Health, Illness and Disease

Philosophical Essays

Havi Carel, Rachel Cooper

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317544852
• Edition: 1
• Topic: Philosophie
• Subtopic: Histoire et théorie de la philosophie

What counts as health or ill health? How do we deal with the fallibility of our own bodies? Should illness and disease be considered simply in biological terms, or should considerations of its emotional impact dictate our treatment of it? Our understanding of health and illness had become increasingly more complex in the modern world, as we are able to use medicine not only to fight disease but to control other aspects of our bodies, whether mood, blood pressure, or cholesterol. This collection of essays foregrounds the concepts of health and illness and patient experience within the philosophy of medicine, reflecting on the relationship between the ill person and society. Mental illness is considered alongside physical disease, and the important ramifications of society's differentiation between the two are brought to light. Health, Illness and Disease is a significant contribution to shaping the parameters of the evolving field of philosophy of medicine and will be of interest to medical practitioners and policy-makers as well as philosophers of science and ethicists.

PART I

CONCEPTS OF HEALTH AND DISEASE

1. THE OPPOSITION BETWEEN NATURALISTIC AND HOLISTIC THEORIES OF HEALTH AND DISEASE

Lennart Nordenfelt

INTRODUCTION: TWO THEORIES OF HEALTH

A central problem in the philosophy of health is to adequately characterize the notions of health and disease and at the same time to establish the nature of the relation between these notions. Are the two notions completely tied to each other, so that health is the total absence of disease, or is there a much looser connection? Is health something over and above the absence of disease? Is health even compatible with the existence of disease?

We seem to have varying intuitions in this regard. We seem also inclined to interpret health slightly differently in different contexts. I have discussed these issues in earlier publications (Nordenfelt 1987/1995, 2000, 2001, 2007). In this chapter I wish to continue this discussion by raising some crucial points that have recently come to the fore. I will advance and scrutinize certain arguments for and against some central current theories in the philosophy of health. In order to do this I have to present these theories as clearly and concisely as I can.

I will present two theories of health: a biostatistical theory of health (BST) and a holistic theory of health (HTH). The clearest version of the BST has been proposed by the American philosopher Christopher Boorse, first in 1977 and later in a more developed presentation in 1997. The HTH has appeared in several versions, presented by authors such as Caroline Whitbeck (1981), Ingmar Pörn (1993), K. W. M Fulford (1989) and myself (1987/1995). The theory of Fredrik Svenaeus (2000b) has strong affinities to the HTH but does not have the same emphasis on the notion of ability. In order to simplify matters for my present purpose I will present my own version of the HTH.

Observe that my formulations in the following are not direct quotations. This holds in particular for my presentation of the BST. I have chosen to reformulate the ideas somewhat (keeping the semantic content intact) in order to see more easily the similarities and differences between the two types of theories.

Christopher Boorse’s BST (1977; 1997) can be formulated in the following way:

A is completely healthy if, and only if, all organs of A function normally, i.e. if they, given a statistically normal environment, make at least their statistically normal contribution to the survival of A or the reproduction of A.

The concept of disease in the BST can be formulated in the following way:

A has a disease if, and only if, there is at least one organ or other part of A that functions subnormally (i.e. does not make its statistically normal contribution to the survival or the reproduction of A) given a statistically normal environment. The disease is identical with the subnormal functioning of the organ or other part.

Observe that the term “disease” is here used in an inclusive sense, covering also injuries and defects. Some authors prefer the term “malady” for this generic concept.)

The characterization of health given in my version of the HTH (1987/1995; 2001) is the following:

A is completely healthy if, and only if, A is in a bodily and mental state such that A has the ability, given standard or otherwise reasonable circumstances, to realize all his or her vital goals.

The concept of disease (or malady) given in my version of the HTH is:

A has a disease if, and only if, A has at least one organ or other bodily part that is involved in such a state or process as tends to reduce the health of A. The disease is identical with the state or process itself.¹

Let me make three brief comments on these latter definitions. First, observe that the criterion of health is compound in the following sense. Health is not identical with a certain kind of ability. The criterion says: A is in a bodily and mental state which is such that A has an ability to realize vital goals. For instance, A’s physiological condition is adequate and A is feeling well, and thus A is able to realize his or her vital goals. Second, “vital goal” is a technical concept in the sense that people’s vital goals are not completely identical with their intentionally chosen goals. The class of a person’s vital goals is the class of conditions that are such that the fulfilment of them is necessary for the person’s long term minimal happiness. Thus all people, including babies, persons with dementia and others who do not consciously set any goals in life, have vital goals. Third, the phrase “tends to reduce the health of A” is selected because not all diseases actually do compromise health in the holistic sense of being able to realize vital goals. Some diseases are aborted; that is, they disappear before they have influenced the person as a whole. Others are latent; yet others are so trivial that they are never recognized by their bearer (for comprehensive discussions of all these conditions, see Nordenfelt 1987/1995 and, in particular, 2001).

The presented versions of the BST and the HTH are clearly quite different theories of health. The differences can be summarized thus:

(a) In the BST health is exclusively a function of internal processes in the human body or mind and their relation to reproduction and survival. In the HTH health is a function of a person’s abilities to perform intentional actions and achieve goals.

(b) In the BST health is a concept to be defined solely in biological (or perhaps also psychological) and statistical terms. In the HTH the concept of health presupposes extra-biological concepts such as “person’, ”intentional action“ and ”cultural standard’!

(c) In the BST health is identical with the absence of disease. In the HTH health is compatible with the presence of disease. The concept of disease is, however, logically related to the concept of ill health also according to the HTH. A disease is defined as a state or process that tends to negatively affect its bearer’s health.

My procedure in the following will involve advancing some critical arguments against both these basic positions in the philosophy of health. My arguments will mainly be directed against the HTH. This means that I will put my own view of health and disease to severe tests; that is, I will perform a piece of self-criticism in the Popperian sense. However, I will first raise a criticism against the BST with regard to its criterion of survival. I consider it counterintuitive to connect the concept of health so completely to the concept of survival. Second, I will raise a criticism against the HTH to the effect that its concept of health is too expansive. Third, I will discuss two conditions whose status as diseases has been disputed and briefly analyse how the HTH can handle these disputed cases. Fourth, I will discuss the relationship between human and animal health and illness. It is often maintained that the BST is the only viable theory of the two when it comes to characterizing the health and disease of non-human animals. Finally I will conclude that the HTH in my version can satisfactorily answer these criticisms.

ON PROBABILITY OF SURVIVAL AS A KEY CRITERION OF HEALTH: A CRITICISM OF THE BST CONCEPT OF DISEASE

In the BST definition, a disease is constituted by the subnormal function of an organ or some other bodily part. This entails that the organ or bodily part in question does not make its statistically normal contribution, given a statistically normal environment, to the survival of the individual or the species (for the sake of simplicity I will here only discuss the case of the survival of the individual).

It is not altogether easy to interpret this criterion. And in particular it is not easy to measure it. How do we know that a certain organ does not contribute to survival with statistically normal efficiency? It is clearly not sufficient to say – and this is a common misunderstanding of the BST – that the function of the organ happens to fall outside a statistically normal scope. The pulse of an athlete, for instance, can be abnormally low, say thirty-five beats per minute. His or her pulse is then well below the normal frequency scope, which lies between sixty and eighty beats a minute. However, we would clearly say that the function of the athlete’s heart is perfect. The function is indeed supernormal in that, as we believe, it makes more than a normal contribution to the survival of its bearer.

I will here leave the problem of measurement aside and in my discussion use the following interpretation of the BST analysis of disease. I will propose that a person who has a disease has a slightly lower probability of survival than the completely healthy person. Through the dysfunction it involves, the disease lowers the probability of the bearer’s survival. Of course, this does not mean that every instance of a disease is life-threatening. It can only mean that there is a marginal reduction of the bearer’s probability of survival (for the sake of simplicity I leave out the criterion of reproduction here).

The traditional understanding of this idea is that a disease reduces the probability of survival solely via the body’s physiology and biochemistry. Through the dysfunction of the organ in question the function of the whole body (or mind) is becoming weaker. As a result the body (or mind) becomes vulnerable to more fatal processes that in the end might lead to premature death. Many diseases (in particular infections, but also cardiovascular diseases and endocrine diseases) have such known complications. A mild infection can develop into serious meningitis or a general sepsis that may be fatal. Angina may develop into a myocardial infarction, diabetes may give rise to a stroke, and so on. Such examples, then, give the basic idea concerning probability of survival some plausibility.

It seems, however, much less plausible to generalize this intuition to cover all kinds of such diseases as are conventionally accepted as such. Not all diseases, in particular not the ordinary trivial ones like headache or eczema, or injuries like a bruised leg, really lower the probability of survival. And, if so, in what terms could we understand such a probability?

What seems to be universal, and that is exactly what the HTH claims, is that there exists, with all diseases, the probability of certain phenomenologi-cal consequences or some limitation of agency. Persons who have a disease are often ill, in the sense of having negative sensations. They do not feel “at home” (to put it as Fredrik Svenaeus does; Svenaeus 2000b), or are disabled. It is true that some people having a disease do not yet have any negative symptoms. On the other hand, it is plausible to say that there is a high risk of their having such symptoms. If there is no risk of suffering or disability at all, it is legitimate to ask what reason there would be for calling the state a disease in the first place.

It seems therefore that we have come up with a reasonable criticism of the basic BST idea of connecting disease to reduced probability of survival. On the other hand there is a point to make here and to be explored in defence of the BST along the following lines. (As far as I know, however, neither Christopher Boorse nor anyone else in the BST camp has ever in fact made this point.) The BST protagonist might claim that a disease always lowers the probability of survival but not necessarily directly by making the body (or mind) vulnerable to other, fatal, biological or mental processes. The disease may lower the probability of survival by disabling the person. Persons who are disabled in vital respects (being blind, deaf or partly paralysed, to take some extreme examples) have difficulty in finding their way and supporting themselves. They may require assistance in order to move around or indeed to obtain such basic commodities as food and shelter. Moreover, they are more vulnerable to accidents of various kinds than if they had been healthy.

One might maintain that this argument also holds for mild diseases such as the common cold. Although the cold in itself may be mild in its disabling consequences, it still often prevents its bearers from performing their normal tasks to some extent. Such consequences entail some, although often very slight, reduction in the probability of survival of these persons, according to the argument I am expounding. Hence there seems to be a case for maintaining that all diseases (or all maladies) increase the probability of death, as the BST maintains.

But again, it is highly debatable whether this is a universal phenomenon. There are many diseases, in particular if we move outside the somatic sector, which have no known fatal complications and which need not in any other sense increase the risk of death. For instance persons with a mild paranoia have a disease, because they are prevented from living a well-balanced life and fulfilling much of their potential. On the other hand these persons may – indeed because of the disease – be highly alerted to risks and thereby become quite careful persons who in a sense have a higher survival potential than ordinary healthy persons.

My conclusion is therefore that even if we improve the arguments of the BST, and include disability among the potential causal factors of death, we cannot satisfactorily sustain the BST concept of disease in this regard.

ON THE SCOPE OF THE CONCEPT OF HEALTH ACCORDING TO THE HTH AND THE BST: THE RISK OF TOO EXPANSIVE A CONCEPT OF HEALTH ACCORDING TO THE HTH

It is frequently claimed that a holistic concept of health such as that of the HTH (also in my version of it) risks being too inclusive and vague. Or, to be more specific, the most acute risk is that the converse concept, ill-health, will include too much. If every person who is somewhat disabled in relation to his or her vital goals turns out to be ill according to the HTH conception, then we might come up with too many sick-listed persons. The HTH concept of health would then turn out to be unreasonable and of little practical use in health care. (I may mention that I have caused worry during two conferences on insurance medicine in Europe where many persons in the audience interpreted my presentations as opening the floodgates and letting in altogether too many conditions among diseases or maladies.)

An interesting version of this criticism has been put forward by the German philosopher Thomas Schramme (2007). He formulates the following crucial purpose for a fruitful theory of health: it should be able to function as a gatekeeper against medicalization. Schramme claims that Boorse’s biostatistical theory of health fulfils this purpose whereas mine doesn’t. For example Schramme says the following:

Consider Lily, an athlete, who struggles, for her whole adult life so far, to become an accomplished high-jumper, but does not succeed … We may agree that it is one of Lily’s vital goals to succeed, because not to succeed means that she is not minimally happy but actually quite angry and sad … Lily is unable to realize at least one vital goal, therefore she is not healthy according to Nordenfelt’s definition.

(Schramme 2007: 14)

Schramme says that we certainly would not call Lily unhealthy in this case. We would only do so if she really suffered from a disease in the ordinary sense of the word. The consequence of the HTH is thus, he says, counterintuitive.

I have already in a reply to my critics (Nordenfelt 2007) given an answer to this argument and I wish now to develop it further. I say first that Schramme presupposes that I consider the concepts of health and illness to be contradictory in the strong sense that wherever we do not have complete health we have some degree of illness. In fact, for me health is a dimension ranging from a state of complete health to a state of complete illness. So, when Lily does not achieve what she has striven for so intensely – and this goal qualifies as a vital goal in my sense – the assessment is not automatically, I claim, that she is ill in the sense that her state of health is on the negative half of the scale. The result is only that Lily’s health is somewhat reduced. Her health is prob...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Contributors
• Introduction
• Part I: Concepts of Health and Disease
• Part II: The Experience of Illness
• Part III: Illness and Society
• Bibliography
• Index