• Mary Ann G. Cutter
Part of the Philosophy and Medicine book series (PHME, volume 81)


This work examines disease (ME disese,Ofr desaise,disease; des-priv., + aise,ease; L. dis- priv., and esse, to be). 1 The central thesis of this analysis is that our understanding of disease is contingent on commitments2 to three types of presuppositions: metaphysical (which establishes the nature of reality), epistemological (which establishes how we know what we know), and axiological (which establishes what and how we value). The interplay among these three types of commitments makes disease both theory-laden and evaluative. This means that it is also best understood as context-dependent. Put another way, the term “disease” refers to descriptions of pathological processes abstracted from individual physiological processes that afflict individuals in the human species, bring patients to the attention of health care professionals, and serve as treatment warrants. Given this multidimensional character of disease, we can expect different understandings and responses to particular diseases.


Gross Domestic Product West Nile Virus Severe Acute Respiratory Syndrome Equal Employment Opportunity Commission Disease Concept 
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Chapter Endnotes

  1. 1.
    For an introduction to discussions regarding concepts of disease, one might start with the best guide to the literature, Caplan et al. (eds.) (1981), which unfortunately is no longer in print. For helpful overviews of key debates, see Caplan (1993, 1997), “Health and Disease” (Reich, 1995, pp. 1084–1113), Reznek (1987), Wulff et al. (1986, esp. Ch. 6), Aronowitz (1998), Nordenfelt and Lindahl (eds.) (1984, esp. Appendix, pp. 151–173), Engelhardt, with Erde (1980), Engelhardt (1996, Ch. 5), and Sigerist (1943).Google Scholar
  2. 2.
    By commitments, I mean that which is explicitly or implicitly presupposed in one’s analysis. One of the jobs of philosophers is to uncover and make explicit such commitments.Google Scholar
  3. 3.
    Colorado Revised Statute 10–3–1104.7 limits the use of genetic testing information by insurers. The statute defines genetic testing as a direct laboratory test of human DNA, RNA, or chromosomes used to identify the presence or alterations in genetic material associated with illness or disease. The statute applies to entities that provide health, group disability, and long–term care insurance and are within the Colorado Insurance Commission’s jurisdiction. The covered entities are prohibited from seeking, using, or keeping genetic information for any underwriting or nontherapeutic purposes. Violation of the act is an unfair insurance practice subject to Insurance Commission sanctions. The statute provides a private right of action for individuals injured by wrongful use of genetic information, with both legal and equitable remedies available. Additionally, the prevailing party may recover attorney fees. See Cutter (1998) and Fox (1995). For an overview of other state statutes, see Hudson et al. (1995) Statutes prohibiting the use of genetic information by insurers became moot with the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104–191). Public Law 104–191 makes it illegal to count genetic disposition to disease as a pre–existing condition in group insurance policies. HIPAA limits the ability of group health insurers to deny coverage based on “preexisting” conditions. Under the law, these insurance plans may deny insurance based on a preexisting condition only when medical advice, diagnosis, care, or treatment, was recommended or received within the six–month period before enrollment. Most unexpressed genetic conditions would not meet this insurance exclusion requirement. Moreover, HIPAA explicitly protects people seeking presymptomatic genetic testing. It does so by forbidding group plans from denying insurance based on genetic information when the person has not been diagnosed with the genetic condition. This creates an important distinction. Someday it may be possible to undergo genetic testing for depression. Doctors mayrecommendpreventivetreatmentstopeoplewithdepression but HIPAA would stop an insurance company from using the recommendation as evidence of a preexisting condition. Thus, HIPAA greatly reduces the risk of genetic discrimination by health insurance companies.Google Scholar
  4. 4.
    In March, 1995, the Equal Employment Opportunity Commission (EEOC) (1995) released new Americans with Disabilities Act defining disability. Disability now applies to individuals who are subject to discrimination in the workplace on the basis of genetic information predisposing them to illness, disease, or other disorders.Google Scholar
  5. 5.
    This is not to suggest that the choices are always rational. As this study shows, the forces contributing to how disease is understood and undertaken are varied and complex.Google Scholar
  6. 6.
    In the United States, nearly one out of every seven dollars is spent on some form of health care. In 1998, this amounted to approximately 13.6 percent of the gross domestic product (GDP), or $4,178 per capita. By way of comparison, health care in Canada, Germany, Belgium, and Austria in 1998 respectively represented 9.5, 10.6, 8.8, and 8.2 percent of each country’s GDP, or approximately $2,312, $2,424, $2,081, and $1,968 per capita (Organization for Economic Cooperation, 2000). In the United States, this figure continues to increase, despite the attempt by managed care to contain costs.Google Scholar
  7. 7.
    Reductionism occurs when all laws of the “whole” (or more complex situations) can be deduced from a combination of the laws of the simpler or simplest situation(s) and either some composition laws or laws of coexistence (Audi, 1995, p. 492).Google Scholar
  8. 8.
    New knowledge in genetics now enables us to distinguish between pre-existing clinical conditions and existing ones, and to predict the occurrence and severity of genetic disease. Anticipation, for example, allows clinicians to forecast the onset and severity of clinical conditions, giving rise to the terms “sub-clinical events” and “asymptomatic illness.” These and other considerations are taken up in Biological Sciences Curriculum Study (1996, 1997 ).Google Scholar
  9. 9.
    Metaphysics (Gr. meta to physika,after those things relating to external nature, after physics) is the philosophical investigation of the nature, constitution, and structure of reality. In this analysis, the emphasis is on the nature of disease, and the question “What is disease?”Google Scholar
  10. 10.
    Epistemology (Gr. episteme,knowledge, + logos,discourse) is the study of knowledge and justification. In this analysis, the emphasis is on how we know disease and the relation between the knower and known.Google Scholar
  11. 11.
    Although the distinction between rationalism and empiricism is historically suspect, it provides a useful way to talk about major camps of thought in philosophy and medicine.Google Scholar
  12. 12.
    Axiology (Gr. axios,worthy, + logos,discourse) is the study of values, or a branch of philosophy dealing with the nature and types of values.Google Scholar
  13. 13.
    The debate is not whether disease is contextual but rather how. This is because the resolution of the previous debates preempts a non-contextual view of disease.Google Scholar
  14. 14.
    Recommended discussions include Pellegrino and Thomasma (1981), Englehardt (1996), McElhinney (1981), and Bickel (1986).Google Scholar
  15. 15.
    See Wartofsky (1975, 1976, 1977, and 1992).Google Scholar
  16. 16.
    Much, of course, has changed. In the Ancient times, philosophy was concerned with wisdom, understood as the highest form of truth. This continued through the Medieval period and complemented the search for God’s truth. The Modern period holds that reason will deliver answers to our questions, and postmodemity calls into the question the possibility of truth. Nevertheless, there remains a search for wisdom, albeit a changed notion.Google Scholar
  17. 17.
    For more on human limitations, see Chapters 3, 4, 6, and 8.Google Scholar
  18. 18.
    What constitutes “progress” is anything but simple. See Lakatos (1970), Laudan (1977), and Gutting (1980).Google Scholar
  19. 19.
    There is a rich and complex history of philosophical reflection concerning medicine reaching back to the beginnings of Greek philosophy. These can retrospectively be recognized as part of philosophy of medicine. Nevertheless, it was not until the nineteenth century that the expression “philosophy of medicine” gained currency (Schaffner and Engelhardt, 1998, p. 265). Also see Jonsen (1998) and Stevens (2000).Google Scholar
  20. 20.
    The field of philosophy of medicine experiences new growth at the end of the twentieth century. Consider journals such as The Journal of Medicine and Philosophy (inaugurated in 1976), Theoretical Medicine (formally called Metamed, inaugurated in 1979), Medicine, Health Care, and Philosophy, and Kennedy Institute of Ethics (inaugurated in 1991). There are book series, such as Philosophy and Medicine (inaugurated in 1975) and Clinical Medical Ethics (inaugurated in 1991 ), and databases, such as “Bioethicsline,” begun in the 1980s. There are courses with the title of “Philosophy of Medicine” that are offered to students at the undergraduate and graduate level. All of this has transpired since the 1970s.Google Scholar
  21. 21.
    For more on this broad-ranging character of medicine, see Engelhardt (1996, Ch. 5). Also see Engel (1977, pp.129–136), Pellegrino and Thomasma (1981, pp. 58ff), and Veatch ( 1997, p. 5 ).Google Scholar
  22. 22.
    The biopsychosocial model of disease emphasizes that how a disease affects any one individual requires consideration of psychological, social, and cultural factors and stresses individual variability of a disease (Engel, 1977, p. 132).Google Scholar
  23. 23.
    First person refers to the person speaking (e.g., I read). Second person refers to the person spoken to (e.g., You read). Third person refers to a person or thing other than the speaker or the one spoken to (e.g., He/she reads).Google Scholar
  24. 24.
    This account is admittedly general and highlights dominant themes for purposes of illustrating major conceptual shifts in medicine that influence what and how we know in the clinical setting.Google Scholar
  25. 25.
    Postmodernism is a complex set of reactions to modern philosophy and its presuppositions about the nature of reality and how it is known. See Foucault (1972 [1969]), Lyotard (1984 (1979), and Ermarth (1992).Google Scholar
  26. 26.
    Existentialism is a philosophical and literary movement that comes into prominence in Europe, particularly in France, immediately after World War II, and focuses on the uniqueness of each human individual as distinguished from abstract human qualities. See Camus, The Plague (1991) and Sartre, Nausea (1969).Google Scholar
  27. 27.
    Hermeneutics is a type of philosophy that addresses questions of interpretation. See Dilthey (2002 [1910]) and Heidegger (1996 [1927]).Google Scholar
  28. 28.
    Phenomenology is a philosophical tradition developed by Edmund Husserl (1859–1938) (and his followers, emphasizing the description of human experience as directed unto objects, in the sense in which thoughts or wishes have objects, even if unreal ones (“intentional objects”).Google Scholar
  29. 29.
    One might note the explosion of courses in ethnic diversity and gender studies in higher education at the turn of the Third Millennium.Google Scholar
  30. 30.
    This is not to suggest that philosophers of science offer little by way of reflection on disease. One could consider in greater detail the account by Hempel (1965, p. 398) of why Jones contracted streptococcal infection. Then there is Achinstein’s (1983, pp. 74–102) analysis of Dr. Smith’s account of why Bill was overcome by a stomachache. Or consider the syphilis-paresis example offered by Scriven (1959).Google Scholar
  31. 31.
    I am indebted to Harlow Sheidley, Department of History, University of Colorado at Colorado Springs, and Roberto Trevino, Department of History, University of Texas at Arlington, for our discussions of philosophy of history and more specifically the methodology of using historical materials in scholarly analysis (also see Can, 1969; Toews, 1987; Novick, 1988; Harlan, 1989; Elton, 1991).Google Scholar
  32. 32.
    For discussions on clinical classification, see Wulff et al., 1986, Ch. VI.Google Scholar
  33. 33.
    For discussions on of clinical diagnosis, see Murphy (1976) and Wulff (1981b).Google Scholar
  34. 34.
    For discussions on clinical decisionmaking, see Feinstein (1967), Schaffner (1980), and Wulff (1981a, 1981b ).Google Scholar
  35. 35.
    For sustained analyses of health, see Whitbeck (1981), Nordenfelt (1987, 2001), Mordacci (1995), Lennox (1995), and Lafaille and Fulder (1993).Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2003

Authors and Affiliations

  • Mary Ann G. Cutter
    • 1
  1. 1.University of ColoradoColorado SpringsUSA

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