Abstract
Many scholars have pointed out that defining the concepts “health” and “disease,” which may seem to be nothing more than an abstract, intellectual enterprise, has important practical consequences. These consequences determine how the health care profession is practiced and the manner in which it affects the lives of its clients. In the first place, including someone under the definition of the terms “healthy” or “diseased” has consequences for the way in which we treat that person. Although Parson’s concept of the “sick role” may require modification in light of recent developments in our culture (for exam-ple, there is a growing sentiment that in many cases an individual is responsible for being sick), we still exonerate people from a number of social obligations when they suffer from disease, including employ-ment obligations and responsibilities for behavior.1 As well, we expect those who are exonerated to seek professional help(and increasingly, we expect society to provide them such help). Hence, how we define the concepts of health and disease determines to whom we grant such exonerations.
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Notes and References
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King traces this view back to Sennart in the 17th century.’ Kass, however, takes issue with this claim.’ He points first to etymological considerations, showing that in English as well as in Greek, Latin, Hebrew, and German, the word for health has a distinct heritage from the terms of disease, illness, and sickness. It is unclear, however, what conclusion one should draw from such etymological considerations. For two terms to be complementary, it is not necessary that they were originally understood as complementary. Even if Kass is right and disease was first understood as an invasion of the body and health as a state of proper functioning of the person, it can be discovered later that it is when a person is invaded by disease that the person ceases to function well. This is comparable to the discovery that the morning star is the evening star. What would render this assessment wrong is if there were infringements on the proper functioning of the body that nonetheless did not involve disease. Under this circumstance, one might hold that health care should be concerned only with combating diseases, and not with other dimensions of promoting proper functioning, such as education. But although Kass is interested in re-stricting the domain of the health-care profession, he does not use this argu-ment schema, for he also wants to restrict the concept of health and not apply it to all aspects of human functioning. Thus, the point of his denying the complementarity of the concepts “health” and “disease” is not clear. (Whitbeck, distinguishes the two concepts in a different manner, pointing to a special value-ladenness that arises with the concept disease.)“
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For Sydenham, “a disease ... is nothing more than an effort of nature, who strives with might and main to restore the health of the patient by the elimination of the morbific matter.” Sydenham’s version of the ontological conception is thus clearly the first version, which hypostatizes diseases as logical types, but does not identify them in terms of disease entities that are taken to be the causes of the symptoms.
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The localization spoken of here does not have to be physical localization. Assigning functions a place in a flowchart counts equally as localization as I am using the term.
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Engelhardt offers an interesting suggestion.’ He proposes that for clinical applications, one start not with the notions of “health” and “disease,” but with “clinical problems” that patients present. According to this proposal, the common characteristic of clinical problems would be the fact that they are what patients present and for which they seek treatment. This may, in fact, be the operating criterion in normal practice, but it poses the problem that there may be no limit to what could fall within the domain of health-care workers.
O. Temkin (1963) The Scientific Approach to Disease: Specific Entity and Individual Sickness in Scientific Change: Historical Studies in the Intel-lectual, Social, and Technical Conditions for Scientific Discovery and Tech-nical Invention, from Antiquity to the Present. (A. C. Crombie, ed.) Basic Books, New York.
To this Boerhaave added the complementary definition of disease in terms of the interruption of functions: “The condition of the living body whereby the ability of exercising any one function is abolished, is called disease.’’’
Temkin notes this teleological feature of the physiological attempts to define health and disease, and presents the problem it raises: “The answer (as to whether disease can be defined in terms of departure from normal function) may depend on the biologist’s philosophical orientation. If he [or she] ex-cludes all teleology, he [or she] may . . . believe that health and disease are not scientific terms. If he [or she] does not mind using teleological notions, he [or she] may find it pertinent to pay attention to those states where nature fails in two of its main aims, as Galen had them, assurance of the life of the indi-vidual and of the species. ’’” Later I will argue that the matter is more than one of predilection by showing that there is an objective basis for insisting on a teleological element within biology.
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The difficulty that exists here has sometimes been obscured by a confu-sion over two senses of normal, one in which it refers to the mean condition, the other in which it refers to the optimal condition. The two are clearly not equivalent. When the development of hospitals in the 18th century made pos-sible the examination of large numbers of individuals, it was thought to be possible to determine a set of norms for the healthy person. For example, the discovery of the thermometer gave rise to the suggestion that there is a normal body temperature for humans, such that deviations from this norm could be taken as a sign of disease. In some cases, the normal condition, in the sense of average may also constitute the correct normative condition, the healthy con-dition. But one can readily acknowledge circumstances in which the prevalent mean would not constitute a health state (e.g., during an attack of the plague). One needs to be careful not to equivocate between these two senses of “nor-mal.” See Grene, who distinguishes not only these two senses but a third as well: being “characteristic for members of the species.”“
Macklin laments the lack of an integrated theoretical perspective, sug-gesting that if there were such, it would offer the foundations for the concepts of health and disease: “There is no general, well-integrated theory of the sort that exists in, say, physics, interconnecting the well-developed fields in medi-cine of physiology, anatomy, pathology, neurology, immunology, etc. with current developments in the biological sciences . . 1TJhe absence of well-confirmed fundamental laws, from which other laws are derivable, and the absence of a systematic, general theory result in the situation that within med-icine itself, there are no clear or precise formulations of the basic concepts of health and disease, and no set of necessary and sufficient conditions for their application.’ ’”
I will focus on those who appeal to a society’s values. Two philosophers who have made the individual’s values central in defining health are Whitbeck and Porn.“,” For Porn, health consists in an equilibrium between and individ-ual’s goals and his or her repertoire of abilities. This makes one unhealthy if one’s goals are unobtainable. Nordenfelt suggests that Whitbeck can avoid this problem because in her otherwise very similar treatment, she introduces the notion of “real goals,” but, as he notes, this raises the question as to how these are to be measured.“ In particular, Nordenfelt suggests that one lands in a circularity when goals are interpreted as needs, for these needs are in turn identified as what is required to maintain health. However, contra Nordenfelt, it does not appear that Whitbeck’s introduction of ”real goals“ was meant to eliminate unobtainable goals, but only to allow us, when we think someone’s goals are irrational, to look for a more ultimate goal. It seems then, that for both Whitbeck and Porn, that one is ill if one has set unobtainable goals, which .certainly seems counterintuitive. Additionally, their approach permits no limits on the domain of health.
J. Margolis (1976) The concept of Disease. Jo. Med. Philos.1, 238–255.
In addition to pointing out that standards are implicit in any judgment, Margolis offers three additional reasons for maintaining that these norms cannot, in any direct way, be “read off” the physical structure of the body: (1) there is not a one-to-one but only a many-many relation between disease condition and localized deficits, (2) many of the processes making for health are molar and not found in localized parts, and (3) the healthy condition of body parts can vary through ranges, and the point in the range that counts as healthy may depend on the current environment the individual is in. The last of these points is the same as that discussed previously and, as I indicated, I will try to make a virtue out of this purported difficulty. The first two do not seem to be particularly telling, since they are objections against a localized conception of a disease entity, not against the view of the defender of the physiological concept that one can determine objectively the health condition of an organism.
T. Lenoir (1982) The Strategy of Life. D. Reidel, Dordrecht, Holland.
C. Bernard (1865) Introduction à I’ etude de la médecine experimentale. Bailliere, Paris. English translation by M. C. Greene, An Introduction to the Study of Experimental Medicine. Dover, New York 1959.
SAC. Bernard (1859) Leçons Sur les Propriétés Physiologiques et les Alterations Pathologiques des Liquides de L’organisme. J. B. Bailliére, Paris.
In terms of this organization, Bernard proposed to account for some of the factors that had led vitalists to posit a vital force. For example, Bichat, a significant early 19th century vitalists, had considered two features of living systems to be indicative of the vital force active within them: their ability to respond to and restore themselves in the face of external stimuli and their indeterminacy in responding to stimuli (expressed by their failure to always respond to the same stimulus in the same way). Bernard showed that both of these features could be explained in terms of the organization found in the internal environment. The response to external stimuli was mediated by compensating mechanisms through which the organism attempted to restore its internal environment to a constant state. The variation in response to similar stimuli resulted from somewhat different internal conditions prevailing at different times (the differences resulting from different compensating mechanisms have been invoked in response to previous stimuli).99,9“ 9’
W. B. Cannon (1932) The Wisdom of the Body. Norton, New York.
Dubos has made a similar point in a different manner: “In the light of these facts it is easier to understand why direct cause-effect relationships often fail to account for the natural phenomena of disease. Each type of insultmicrobial invasion, chemical damage, physiological stimulus, or psychic event-can have many different effects depending upon the state of the recipient individual. On the other hand, any given pathological effect can be the outcome of many varied kinds of insults.’”
W C. Wimsatt (1972) Teleology and the logical structure of function statements, Studies in the History and Philosophy of Science3, 1–80.
L. Wright (1976) Teleological Explanations: An Etiological Analysis of Goals and Functions. University of California Press, Berkeley.
Evolutionary biologists since Darwin have used the term “fitness” am-biguously to refer both to the reproductive success of an entity and to its rela-tion to the environment that makes for that success. Brandon has proposed employing the alternative term “adaptedness” for that which makes for the increased selection of the entity.“ One of the benefits of this terminology is that it reveals that the principle of natural selection is not tautologous.
Wimsatt seems to want to allow his functional analyses to interpret the relation between selection and teleology in either order.“ He supplies the fol-lowing general ”normal form“ for function statements: ”According to theory T a function of behaviour B of item i in system S in environment E relative to purpose P is to do C.“ The purpose value in this statement is to be specified, at least in biological cases, by invoking evolutionary theory. Wimsatt goes on to discuss the evaluative and explanatory role of function statements, and notes that there are cases in which we want to invoke the function statement evaluatively, but not explanatorily. These are cases in which the behavior oc-curs in the current context independently of selection, but is now being se-lected for a certain purpose. In these cases the focus is on currently operating selection forces, but Wimsatt wants to claim also that functional statements lead us to try to explain the current occurrence of the entity as the product of past selection. The explanatory and evaluative endeavors are really much more distinct than Wimsatt indicates: One uses previous selection forces to specify the purpose variable, the other uses current selection forces.
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Another objection of Margolis’ seems simply to be erroneous. He claims: “one only has to imagine the evolution of diseased populations to see that creatures and organs and processes may well be said to function in a certain characteristic way, although on some relevant theory, we should not wish to say that the function of what is in question would then be given by the formu-lation cited.”’ What Margolis does not make clear is whether the “disease” is what enhanced the adaptedness of the organism and thus, provided for its selection. If not, then Wright’s formula has not been satisfied and Margolis’ example does not count against his proposal. If it does, then it is not clear why it is considered a disease. The one possible situation in which it might be con-sidered a disease is when it once enhanced the adaptedness of the organism and is now a detriment (like sickle cell trait). This, however, can be easily handled by the treatment proposed here that reverses the relation between evolution and functions. Within this account, sickle cell trait would count as healthy within an environment of malaria infestation prior to drug treatments, but subsequently to count as a disease.
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In a recent paper, there is a suggestion that Engelhardt may have revised his position, for there he alludes to the view that evolution selects for inclusive fitness, not individual fitness.’ However, he seems to equate inclusive fitness with group fitness, which is only correct for certain special kinds of groups. Moreover, it is not clear that inclusive fitness is not one of the relevant frameworks for assessing health. What many of the sociobiologists who have invoked the notion of inclusive fitness have tried to show is that it could ground some of our social instincts. It may be that our abilities to fulfill these social functions is a relevant criterion in evaluating health.
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In this respect, as in many others, the conception of health I am offering is quite similar to that of Dubos. According to Dubos, health is a matter of being properly adapted to one’s environment. Although he does not emphasize the link with the evolutionary perspective, the notion of adaptation he is using received its natural interpretation in an evolutionary framework. Dubos appeals to what is fundamentally an evolutionary concept of adaptiveness to explain why the conditions making for health may be different in different circumstancesdifferent conditions may be needed to make one adapted to one’s environment. Moreover, Dubos stresses that within this framework one can see why the conditions that count as healthy cannot be permanently fixed. As one’s environment changes, different conditions are needed to make one adapted. In addition to showing how to account for the environmental relativity of health, Dubos raises an important caution as to the limitations of viewing health in terms of being adapted to one’s environment: “The most disturbing aspect of the problem of adaptation is paradoxically that human beings are so adaptable. They can become adjusted to conditions and habits that will even-tually destroy the values most characteristic of human life. If only for this reason, it is dangerous to apply to human beings the concept of adaptability in a pure biological sense.’” Part of what underlies Dubos’ concern can be ad-dressed by employing the generalized evolutionary framework I sketched above. Another part depends on the distinction between long-term and short-term advantage. Biological selection will promote traits that offer a short term focus on the longer term and direct health care to promote long-term adaptation over mere short-term adaptation. This is not something that is pos-sible for most other organisms, but it is within the potential of humans who have the ability to evaluate courses of action in terms of their anticipated long-term consequences.
Confinement of genetics illness to distinct groups is both observed (con-sider Tay Sachs, thalosemia, and sickle cell anemia) and theoretically pre-dicted. It is theoretically predicted since interbreeding is common among mi-norities excluded from the mainstream of the population, whereas interbreeding is common in the majority population. Inbreeding among a pop-ulation in which a recessive gene is already in higher frequency because of past inbreeding results in the more frequent expression of recessive genes. (If one focuses on the genes, rather than the conditions produced by the genes, the evidence suggests that all humans, on average, carry five recessive genes that, expressed would produce the manifestations of genetic disease. How-ever, when the breeding population is large, these recessive genes are almost never expressed.)
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There is mounting evidence that previous determinations of the ‘cost’ of genetic mutations were assessed too severely. One of the emerging concepts of genetics is that genetic diversity per se, where many individuals in a popu-lation carry a high proportion of genetic variants, is itself of great value for species survival. Such variability can assure the constancy of embryonic de-velopment in the face of environmental stresses, and can proffer a certain guarantee of flexibility in the face of environmental change. While there is no way for everyone in a freely marrying population such as ours to become, or remain, heterozygous for any one gene, the survival of the population is rein-forced by many people being heterozygous for different geneshence the im-ponderable difficulty of defining just which particular heterozygous state is desirable or undesirable.
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Bechtel, W. (1985). In Defense of a Naturalistic Concept of Health. In: Humber, J.M., Almeder, R.F. (eds) Biomedical Ethics Reviews · 1985. Biomedical Ethics Reviews. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-441-2_8
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