Flourishing

Health, Disease, and Bioethics in Theological Perspective

Neil Messer

• Éditeur: Eerdmans
• Année: 2013
• ISBN:
  9781467440554
• Sujet: Theologie & Religion
• Sous-sujet: Christliche Theologie

We use such words as "health, " "disease, " and "illness" all the time without stopping to consider exactly what we understand by them. Yet their meanings are far from straightforward, and disagreements over them have important practical consequences in health care and bioethics.In this book Neil Messer develops a distinctive and innovative theological account of these concepts. He engages in earnest with debates in the philosophy of medicine and disability studies and draws on a wide array of theological resources including Barth, Bonhoeffer, Aquinas, and recent disability theologies.By enabling us to understand health in the wider perspective of the flourishing and ultimate destiny of human beings, Messer's Flourishing sheds new light on a range of practical bioethical issues and dilemmas.

CHAPTER 1

Philosophical Accounts of Health, Disease, and Illness

Introduction

The meanings of “health,” “disease,” and related concepts have been extensively debated in the philosophical literature over several decades.¹ These debates have at times become both lengthy and intricate. Even when they are not at their most accessible, it is nonetheless important for the purpose of this book to attend to them in a certain amount of depth, because they offer accounts and insights and raise issues with which the theological treatment being developed here must engage. It is the purpose of this chapter to survey a representative sample of philosophical discussion in enough detail to identify the key insights and questions that emerge.

It will be helpful to keep in mind some of the main questions in play in these debates, questions that will emerge at intervals during the following survey of the various accounts. In particular:

1. How narrow or broad a range of human goods is included in “health” and related concepts?

2. What is the relationship between health and other human goods?

3. Which aspects or components of the health concepts are: (a) value-free, and which value-laden; (b) objective, and which subjective; (c) universally human, and which relative to individuals’ lives and circumstances or to social and cultural contexts? These oppositions are related, and are sometimes conflated in discussions of health, but they are distinct. For example, it often seems to be taken for granted that if an account of health incorporates evaluative judgments about good or harm, it will also be subjective and relative to context; but Martha Nussbaum’s critique of Amartya Sen’s “capability” approach, quoted below,² suggests the possibility of an account of health, rooted in an Aristotelian notion of human flourishing, that would be “value”-laden, yet also objective and universally human in at least some of its elements.

4. Should health be understood teleologically, and if so, what will a teleological account entail?

The World Health Organization Definition³

Discussions of health and disease frequently begin with the well-known definition of health in the Preamble to the World Health Organization (WHO) Constitution of 1948: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”⁴ The Preamble claims that the “enjoyment of the highest attainable state of health” is a fundamental human right and that “the health of all peoples is fundamental to peace and security.”⁵ As Daniel Callahan observes, the historical context in which the WHO Constitution was drafted helps to explain the grandiose vision expressed in this definition.⁶ The WHO was formed in the aftermath of the Second World War, in the context of “a conviction that health was intimately related to economic and cultural welfare”⁷ (which was in turn essential for the preservation of peace), and a powerful confidence in the potential of scientific medicine. A statement of Dr. Brock Chisholm, the first director of the WHO, captures the mood nicely:

The world is sick and the ills are due to the perversion of man; his inability to live with himself. The microbe is not the enemy; science is sufficiently advanced to cope with it were it not for the barriers of superstition, ignorance, religious intolerance, misery, and poverty. . . . These psychological evils must be understood in order that a remedy might be prescribed, and the scope of the task before the Committee [charged with drafting the WHO Constitution] therefore knows no bounds.⁸

The WHO definition captures some important insights and intuitions. It gives an account of why health matters for human well-being: as Callahan puts it, “the intimate connection between the good of the body and the good of the self, not only the individual self but the social community of selves.”⁹ It articulates the insight that health is a necessary condition for the realization of many other human goods and goals, and the intuition that it is not fully described by the absence of disease states or the deviation of biological functions from statistical norms.

However, as an attempt to define health in a way that can inform practice and moral discernment in health care, it has some serious — and by now well-known — problems and drawbacks. One is its vagueness: the denial that health can be defined without remainder as the absence of disease requires the introduction of another term by which to define it. The term chosen by the WHO is “well-being,” but this is if anything even less well-defined and more contested than “health,” so it offers little by way of conceptual clarification.¹⁰ Another problem is the idealizing character of the definition: by identifying health with complete well-being, it tends to make the pursuit of health a never-ending quest for an unattainable goal, and the assertion of a human right to “the highest attainable state of health,” so defined, could turn out to be so over-ambitious as to be vacuous.¹¹

A third problem with the WHO definition is its all-embracing character, which if pushed to its conclusion would tend to medicalize every area of human life. Callahan points out that by assimilating all human well-being to the concept of health, the WHO definition “by implication . . . makes the medical profession the gatekeeper for happiness and social well-being,”¹² potentially placing awesome power in the hands of health care professionals and a weighty responsibility on their shoulders. Two contrasting but interrelated dangers follow from this.¹³ First, if all suffering and disorder (including social disorder) is classified as a problem of health, it comes to seem plausible to place anyone who contributes to such disorder (which probably means all of us, to a greater or lesser extent) in a sociological “sick role,” in which one is not held morally responsible for behavior normally considered reprehensible. Therefore, if the language of health and sickness is stretched to include social and communal disorder, it may become difficult to speak of our own or others’ moral responsibility for the well-being of our community and world. The second danger is the other side of the same coin: if health is understood in such a wide-ranging way, it becomes crucial for the survival and well-being of a society that all of its members are “healthy” in this comprehensive sense. A “tyranny of health” could then develop in which health becomes a moral and societal obligation, and a society through its health professionals adopts highly coercive policies towards those judged to be “sick.” Callahan considers such re-description of social deviance or misbehavior as forms of sickness to be a contributory factor in the abuses of psychiatry and the over-prescribing of psychiatric drugs long criticized by “anti-psychiatrists” such as Thomas Szasz.¹⁴

Furthermore, if the concept of health is made into a theory of everything, an all-embracing account of every aspect of human well-being, then it becomes difficult if not impossible to give an account of a diversity of human goods, goods that in a finite and flawed world might sometimes be in conflict with each other and might need to be ranked in importance. There are many human endeavors, such as caring for needy and suffering people, the struggle for political justice, artistic expression, athletic excellence, and even academic research, which have been considered by some of their practitioners to be worth pursuing even at a heavy cost to physical health, emotional well-being, or personal relationships. It is beside the point whether those athletes who have risked injury for the sake of success, those priests and pastors whose ministries in conditions of squalor and disease have brought them to an early grave, those political activists who have risked liberty, relationships, and sometimes their own lives for their causes, or those martyrs who have counted faithful Christian witness a more important good than the preservation of their bodily life were right to do so.¹⁵ The point is simply that there are such choices, and an account of health which tends to obscure them or render them unintelligible must be considered questionable. While it could be objected that the WHO definition does not make these choices unintelligible because the conflict and ranking of different human goods can be understood as the conflict and ranking of different aspects of “health,” we might then ask what is gained by calling all of this “health.” If “health” is taken to mean everything, it could end up meaning nothing.

A final difficulty with conceptualizing health as a theory of everything is that, while the meaning of “health” is stretched too wide, we are also left with an inadequate notion of “everything.” In other words, the WHO definition not only suggests too wide-ranging a concept of health, but also implies too narrow an account of total human well-being or flourishing. In particular, it has often been criticized for omitting spiritual well-being (to use a rather ill-adapted term) from the picture, notwithstanding later attempts to include spiritual well-being;¹⁶ and indeed, it is hardly surprising if WHO policy documents do fail to give an adequate account of this aspect of human life.

The Biostatistical Model: Christopher Boorse

At the other end of the scale from the WHO definition, and partly in reaction to it, lies the kind of “biostatistical model” most famously associated with Christopher Boorse. In his early work on health Boorse, like Thomas Szasz, has the burgeoning social and political role of psychiatry in his sights.¹⁷ As Bill Fulford notes, Boorse aims to place medical theory on as solid a scientific foundation as possible, drawing a clear distinction between medical practice (which is avowedly and properly value-laden) and medical theory (which should be scientific, objective, and value-free).¹⁸ Boorse attempts to secure the objective, value-free character of medical theory by defining health and disease in terms of statistical normality:

An organism is healthy at any moment in proportion as it is not diseased; and a disease is a type of internal state of the organism which:

(i) interferes with the performance of some natural function — i.e., some species-typical contribution to survival and reproduction, characteristic of the organism’s age; and

(ii) is not simply in the nature of the species, i.e., is either atypical of the species, or, if typical, mainly due to environmental causes.¹⁹

In his early papers, he maintains the distinction between value-free medical theory and value-laden medical practice by means of a distinction between “disease” and “illness,” the additional conditions for the latter being that it is “(i) undesirable for its bearer; (ii) a title to special treatment; and (iii) a valid excuse for normally criticizable behavior.”²⁰ In a 1997 defense of his theory, Boorse retracts this distinction between disease and illness, while continuing to distinguish on more complex grounds between (value-free) medical theory and (value-laden) medical practice.²¹ Others, however, do maintain various forms of a disease/illness distinction, as we shall see.

In contrast to the WHO definition, which is both all-embracing and avowedly normative, Boorse’s biostatistical theory does at least four important things. First, it conceptualizes the domain of health as a particular, limited domain of human experience, and represents an attempt to define the boundaries of that domain as clearly as possible. Second, it offers a way of connecting an understanding of health with the theoretical framework of the biological sciences, namely evolutionary biology. This connection is implicit in the phrase “species-typical contribution to survival and reproduction,” and is drawn out more fully and explicitly by others such as Jerome Wakefield, as will be discussed below.²² Third, in his initial disease-illness distinction and in his later revision of it, Boorse offers one kind of answer to the following questions: which components of an account of health are value-free, which are value-laden, and how are the value-free and value-laden components related to one another? Fourth, it offers one answer to the question, which of the health concepts has conceptual priority? For Boorse, it is “disease,” since “health” is defined in opposition to “disease” and “illness” as a subset of it. These four issues — the ...

Table des matières

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Abbreviations
• Introduction: The Importance of Concepts of Health and Disease
• 1. Philosophical Accounts of Health, Disease, and Illness
• 2. Disability Perspectives: Critical Insights and Questions
• 3. Theological Resources for Understanding Health and Disease
• 4. Theological Theses Concerning Health, Disease, and Illness
• Conclusion
• Bibliography
• Index