Since Boorse [Philos Sci 44(4):542–573, 1977] published his paper “Health as a theoretical concept” one of the most lively debates within philosophy of medicine has been on the question of whether health and disease are in some sense ‘objective’ and ‘value-free’ or ‘subjective’ and ‘value-laden’. Due to the apparent ‘failure’ of pure naturalist, constructivist, or normativist accounts, much in the recent literature has appealed to more conciliatory approaches or so-called ‘hybrid accounts’ of health and disease. A recent paper by Matthewson (...) and Griffiths [J Med Philos 42(4):447–466, 2017], however, may bear the seeds for the revival of purely naturalist approach to health and disease. In this paper, I defend their idea of Biological Normativity against recent criticism by Schwartz [J Med Philos Forum Bioethics Philos Med 42(4):485–502, 2017] and hope to help it flower into a revival of naturalist approaches in the philosophy of medicine. (shrink)

According to one large family of views, scientific explanations explain a phenomenon (such as an event or a regularity) by subsuming it under a general representation, model, prototype, or schema (see Bechtel, W., & Abrahamsen, A. (2005). Explanation: A mechanist alternative. Studies in History and Philosophy of Biological and Biomedical Sciences, 36(2), 421–441; Churchland, P. M. (1989). A neurocomputational perspective: The nature of mind and the structure of science. Cambridge: MIT Press; Darden (2006); Hempel, C. G. (1965). Aspects of scientific (...) explanation. In C. G. Hempel (Ed.), Aspects of scientific explanation (pp. 331–496). New York: Free Press; Kitcher (1989); Machamer, P., Darden, L., & Craver, C. F. (2000). Thinking about mechanisms. Philosophy of Science, 67(1), 1–25). My concern is with the minimal suggestion that an adequate philosophical theory of scientific explanation can limit its attention to the format or structure with which theories are represented. The representational subsumption view is a plausible hypothesis about the psychology of understanding. It is also a plausible claim about how scientists present their knowledge to the world. However, one cannot address the central questions for a philosophical theory of scientific explanation without turning one’s attention from the structure of representations to the basic commitments about the worldly structures that plausibly count as explanatory. A philosophical theory of scientific explanation should achieve two goals. The first is explanatory demarcation. It should show how explanation relates with other scientific achievements, such as control, description, measurement, prediction, and taxonomy. The second is explanatory normativity. It should say when putative explanations succeed and fail. One cannot achieve these goals without undertaking commitments about the kinds of ontic structures that plausibly count as explanatory. Representations convey explanatory information about a phenomenon when and only when they describe the ontic explanations for those phenomena. (shrink)

This essay replies to critics since 1995 of my “biostatistical theory” of health. According to the BST, a pathological condition is a state of statistically species-subnormal biological part-functional ability, relative to sex and age. Theoretical health, the total absence of pathological conditions, is then a value-free scientific notion. Recent critics offer a mixture of old and new objections to this analysis. Some new ones relate to choice of reference class, situation-specificity of function, common diseases and healthy populations, improvements in population (...) health, the practice of pathologists, “Cambridge changes” in health status, and comparative vs. absolute health concepts. I make no changes in doctrine, except to consider treating “normal aging” as pathological by taking young adults as the standard for all adults. (shrink)

This paper examines what it is for a condition to be a disease. It falls into two sections. In the first I examine the best existing account of disease (as proposed by Christopher Boorse) and argue that it must be rejected. In the second I outline a more acceptable account of disease. According to this account, by disease we mean a condition that it is a bad thing to have, that is such that we consider the afflicted person to have (...) been unlucky, and that can potentially be medically treated. All three criteria must be fulfilled for a condition to be a disease. The criterion that for a condition to be a disease it must be a bad thing is required to distinguish the biologically different from the diseased. The claim that the sufferer must be unlucky is needed to distinguish diseases from conditions that are unpleasant but normal, for example teething. Finally, the claim that for a condition to be a disease it must be potentially medically treatable is needed to distinguish diseases from other types of misfortune, for example economic problems and legal problems. (shrink)

Journal of Social Philosophy, EarlyView.

If one had to identify the biggest change within the philosophical tradition in the twenty-first century, it would certainly be the rapid rise of experimental philosophy to address differences in intuitions about concepts. It is, therefore, surprising that the philosophy of medicine has so far not drawn on the tools of experimental philosophy in the context of a particular conceptual debate that has overshadowed all others in the field: the long-standing dispute between so-called naturalists and normativists about the concepts of (...) health and disease. In this paper, I defend and advocate the use of empirical methods to inform and advance this and other debates within the philosophy of medicine. (shrink)

Despite the advent of CRISPR, safe and effective gene editing for human enhancement remains well beyond our current technological capabilities. For the discussion about enhancing human beings to be worth having, then, we must assume that gene-editing technology will improve rapidly. However, rapid progress in the development and application of any technology comes at a price: obsolescence. If the genetic enhancements we can provide children get better and better each year, then the enhancements granted to children born in any given (...) year will rapidly go out of date. Sooner or later, every modified child will find him- or herself to be “yesterday’s child.” The impacts of such obsolescence on our individual, social, and philosophical self-understanding constitute an underexplored set of considerations relevant to the ethics of genome editing. (shrink)

What is it to be mentally healthy? In the ongoing movement to promote mental health, to reduce stigma, and to establish parity between mental and physical health, there is a clear enthusiasm about this concept and a recognition of its value in human life. However, it is often unclear what mental health means in all these efforts and whether there is a single concept underlying them. Sometimes, the initiatives for the sake of mental health are aimed just at reducing mental (...) illness, thus implicitly identifying mental health with the absence of diagnosable psychiatric disease. More ambitiously, there are high-profile proposals to adopt a positive definition, identifying mental health with psychic or even overall well-being. We argue against both: a definition of mental health as mere absence of mental illness is too thin, too undemanding, and too closely linked to psychiatric value judgments, while the definition in terms of well-being is too demanding and potentially oppressive. As a compromise, we sketch out a middle position. On this view, mental health is a primary good, that is, the psychological preconditions of pursuing any conception of the good life, including well-being, without being identical to well-being. (shrink)

Jonathan Y. Tsou examines and defends positions on central issues in philosophy of psychiatry. The positions defended assume a naturalistic and realist perspective and are framed against skeptical perspectives on biological psychiatry. Issues addressed include the reality of mental disorders; mechanistic and disease explanations of abnormal behavior; definitions of mental disorder; natural and artificial kinds in psychiatry; biological essentialism and the projectability of psychiatric categories; looping effects and the stability of mental disorders; psychiatric classification; and the validity of the DSM's (...) diagnostic categories. The main argument defended by Tsou is that genuine mental disorders are biological kinds with harmful effects. This argument opposes the dogma that mental disorders are necessarily diseases that result from biological dysfunction. Tsou contends that the broader ideal of biological kinds offers a more promising and empirically ascertainable naturalistic standard for assessing the reality of mental disorders and the validity of psychiatric categories. (shrink)

Christopher Boorse's Bio Statistical Theory (BST) defines health as the absence of disease, and disease as the adverse departure from normal species functioning. This paper presents a two-pronged problem for this account. First I demonstrate that, in order to accurately account for dynamic physiological functions, Boorse's account of normal function needs to be modified to index functions against situations. I then demonstrate that if functions are indexed against situations, the BST can no longer account for diseases that result from specific (...) environmental factors. The BST is impaled on either horn of this dilemma and therefore must be dismissed. (shrink)

The literature on health and diseases is usually presented as an opposition between naturalism and normativism. This article argues that such a picture is too simplistic: there is not one opposition between naturalism and normativism, but many. I distinguish four different domains where naturalist and normativist claims can be contrasted: (1) ordinary usage, (2) conceptually clean versions of “health” and “disease,” (3) the operationalization of dysfunction, and (4) the justification for that operationalization. In the process I present new arguments in (...) response to Schwartz (2007) and Hausman (2012) and expose a link between the arguments made by Schwartz (2007) and Kingma (2010). Distinguishing naturalist claims at these four domains will allow us to make progress by (1) providing more nuanced, intermediate positions about a possible role for values in health and disease; and (2) assisting in the addressing of relativistic worries about the value-ladenness of health and disease. (shrink)

Similarly to other accounts of disease, Christopher Boorse’s Biostatistical Theory (BST) is generally presented and considered as conceptual analysis, that is, as making claims about the meaning of currently used concepts. But conceptual analysis has been convincingly critiqued as relying on problematic assumptions about the existence, meaning, and use of concepts. Because of these problems, accounts of disease and health should be evaluated not as claims about current meaning, I argue, but instead as proposals about how to define and use (...) these terms in the future, a methodology suggested by Quine and Carnap. I begin this article by describing problems with conceptual analysis and advantages of “philosophical explication,” my favored approach. I then describe two attacks on the BST that also question the entire project of defining “disease.” Finally, I defend the BST as a philosophical explication by showing how it could define useful terms for medical science and ethics. (shrink)

We sketch a novel and improved version of Boorse’s biostatistical theory of functions. Roughly, our theory maintains that (i) functions are non-negligible contributions to survival or inclusive fitness (when a trait contributes to survival or inclusive fitness); (ii) situations appropriate for the performance of a function are typical situations in which a trait contributes to survival or inclusive fitness; (iii) appropriate rates of functioning are rates that make adequate contributions to survival or inclusive fitness (in situations appropriate for the performance (...) of that function); and (iv) dysfunction is the inability to perform a function at an appropriate rate in appropriate situations. Based on our theory, we sketch solutions to three problems that have afflicted Boorse’s theory of function, namely, Kingma’s ([2010]) problem of the situation-specificity of functions, the problem of multi-functional traits, and the problem of how to distinguish between appropriate and inappropriate rates of functioning. (shrink)

Christopher Boorse’s biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield’s harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse’s (...) central argument for the sufficiency claim, the “pathologist argument,” which takes pathologists’ intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion. (shrink)

This paper reviews the debate on the notion of biological function and on functional explanation as this takes place in philosophy. It describes the different perspectives, issues, intuitions, theories and arguments that have emerged. The author shows that the debate has been too heavily influenced by the concerns of a naturalistic philosophy of mind and argues that in order to improve our understanding of biology the attention should be shifted from the study of intuitions to the study of the actual (...) practice of biological inquiry. (shrink)

Our concept of disorder is changing. This causes problems for projects of descriptive conceptual analysis. Conceptual change means that a criterion that was necessary for a condition to be a disorder at one time may cease to be necessary a relatively short time later. Nevertheless, some conceptually based claims will be fairly robust. In particular, the claim that no adequate account of disorder can appeal only to biological facts can be maintained for the foreseeable future. This is because our current (...) concept of disorder continues to be laden with ethical and political values in multiple ways. (shrink)

This essay develops an account of health, the functional efficiency theory, which derives from Christopher Boorse's biostatistical theory. Like the BST, the functional efficiency theory is a nonevaluative view of health, but unlike the BST, it argues that the fundamental theoretical task is to distinguish levels of efficiency with which the parts and processes within organisms and within systems within organisms function. Which of these to label as healthy or pathological is of secondary importance. Because the statistical distributions that Boorse's (...) account relies on are distributions of functional efficiency, the functional efficiency theory arguably complements rather than challenges the BST. (shrink)

In recent years, neuroscience has been a particularly prolific discipline stimulating many innovative treatment approaches in medicine. However, when it comes to the brain, new techniques of intervention do not always meet with a positive public response, in spite of promising therapeutic benefits. The reason for this caution clearly is the brain’s special importance as “organ of the mind”. As such it is widely held to be the origin of mankind’s unique position among living beings. Likewise, on the level of (...) the individual human being, the brain is considered the material substrate of those traits that in combination render each person unique. In view of this preeminent significance of the brain, it is understandable that, in general, interventions into the brain are considered a delicate issue and that new techniques of intervention are scrutinised with particular care. However, in doing so it is important not to go to the opposite extreme and shy away from promising new therapeutic approaches for debilitating disorders of the brain. With respect to the new techniques of brain intervention a broad interdisciplinary perspective is required to discern irrational fear from justified concern. Hence, the Europäische Akademie established a project group consisting, on the one hand, of experts from different fields of medicine who have got first-hand experience of applying the techniques at issue and, on the other hand, of philosophers and a legal expert. The task of this team was to review the state of the art with respect to each single technique of intervening in the brain, to indicate future developments, and to address the ethical and legal issues common to all of them. The project’s outcome is the book at hand. (shrink)

Biological dysfunction is regarded, in many accounts, as necessary and perhaps sufficient for disease. But although disease is conceptualized as all-or-nothing, biological functions often differ by degree. A tension is created by attempting to use a continuous variable as the basis for a categorical definition, raising questions about how we are to pinpoint the boundary between health and disease. This is the line-drawing problem. In this paper, we show how the line-drawing problem arises within “dysfunction-requiring” accounts of disease, such as (...) those of Christopher Boorse and Jerome Wakefield. We then provide several detailed examples to establish that biological dysfunction cannot provide a boundary. We examine potential ways of resolving the line-drawing problem, either by dropping one of the claims that generates it, or by appealing to additional criteria. We argue that two of these options are plausible, and that each of these can be applied with regard to different diseases. (shrink)

A common epistemological assumption in contemporary bioethics held b y both proponents and critics of non-traditional forms of cognitive enhancement is that cognitive enhancement aims at the facilitation of the accumulation of human knowledge. This paper does three central things. First, drawing from recent work in epistemology, a rival account of cognitive enhancement, framed in terms of the notion of cognitive achievement rather than knowledge, is proposed. Second, we outline and respond to an axiological objection to our proposal that draws (...) from recent work by Leon Kass (2004), Michael Sandel (2009), and John Harris (2011) to the effect that ‘enhanced’ cognitive achievements are (by effectively removing obstacles to success) not worthy of pursuit, or are otherwise ‘trivial’. Third, we show how the cognitive achievement account of cognitive enhancement proposed here fits snugly with recent active externalist approaches (e.g., extended cognition) in the philosophy of mind and cognitive science. (shrink)

Dominant views about the nature of health and disease in bioethics and the philosophy of medicine have presumed the existence of a fixed, stable, individual organism as the bearer of health and disease states, and as such, the appropriate target of medical therapy and ethical concern. However, recent developments in microbial biology, neuroscience, the philosophy of cognitive science, and social and personality psychology (Ickes...

According to recent approaches in the philosophy of medicine, biomedicine should be replaced or complemented by a humanistic medical model. Two humanistic approaches, narrative medicine and the phenomenology of medicine, have grown particularly popular in recent decades. This paper first suggests that these humanistic criticisms of biomedicine are insufficient. A central problem is that both approaches seem to offer a straw man definition of biomedicine. It then argues that the subsequent definition of humanism found in these approaches is problematically reduced (...) to a compassionate or psychological understanding. My main claims are that humanism cannot be sought in the patient–physician relationship alone and that a broad definition of medicine should help to revisit humanism. With this end in view, I defend what I call an outcomes-oriented approach to humanistic medicine, where humanism is set upon the capacity for a health system to produce good health outcomes. (shrink)

In this article, I argue that depression and suicide are natural kinds insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. In particular, depression and suicide are neurobiological kinds characterized by disturbances in serotonin functioning that affect various brain areas (i.e., the amygdala, anterior cingulate, prefrontal cortex, and hippocampus). The significance of this argument is that the natural (biological) basis of depression and suicide allows for reliable projectable inferences (i.e., predictions) to be made about (...) individual members of a kind. In the context of assisted suicide, inferences about the decision-making capacity of depressed individuals seeking physician-assisted suicide are of special interest. I examine evidence that depression can hamper the decision-making capacity of individuals seeking assisted suicide and discuss some implications. (shrink)

Externalist theories hold that a comprehensive understanding of mental disorder cannot be achieved unless we attend to factors that lie outside of the head: neural explanations alone will not fully capture the complex dependencies that exist between an individual’s psychiatric condition and her social, cultural, and material environment. Here, we firstly offer a taxonomy of ways in which the externalist viewpoint can be understood, and unpack its commitments concerning the nature and physical realization of mental disorder. Secondly, we apply a (...) strongly externalist approach to the case of Autistic Spectrum Disorder, and argue that this condition can be illuminated by appeal to the hypothesis of extended cognition. We conclude by briefly considering the significance this strongly externalist approach may have for psychiatric practice and pedagogy. (shrink)

Moral psychology investigates human functioning in moral contexts, and asks how these results may impact debate in ethical theory. This work is necessarily interdisciplinary, drawing on both the empirical resources of the human sciences and the conceptual resources of philosophical ethics. The present article discusses several topics that illustrate this type of inquiry: thought experiments, responsibility, character, egoism v . altruism, and moral disagreement.

In this paper we focus on some new normativist positions and compare them with traditional ones. In so doing, we claim that if normative judgments are involved in determining whether a condition is a disease only in the sense identified by new normativisms, then disease is normative only in a weak sense, which must be distinguished from the strong sense advocated by traditional normativisms. Specifically, we argue that weak and strong normativity are different to the point that one ‘normativist’ label (...) ceases to be appropriate for the whole range of positions. If values and norms are not explicit components of the concept of disease, but only intervene in other explanatory roles, then the concept of disease is no more value-laden than many other scientific concepts, or even any other scientific concept. We call the newly identified position “value-conscious naturalism” about disease, and point to some of its theoretical and practical advantages. (shrink)

In addressing the question of what mental health is we might proceed as if there is a single phenomenon – mental health – denoted by a single overarching concept. The task, then, is to provide an informative analysis of this concept which applies to all and only instances of mental health, and which illuminates what it is to be mentally healthy. In contrast, mental health pluralism is the idea that there are multiple mental health phenomena denoted by multiple concepts of (...) mental health. Analysis and illumination of mental health may still be possible, but there isn’t a single phenomenon or concept to be analysed in addressing the question of what mental health is. The question of pluralism has been overlooked in the philosophy of mental health. The discussion to follow is an attempt to get us to take mental health pluralism seriously. To that end, in this essay I have three primary goals: (1) to give a precise account of what mental health pluralism is, (2) to show that the question of pluralism should not be neglected in debate about what mental health is, and (3) to argue for mental health pluralism. I also draw out some implications of this discussion for philosophy, science, and psychotherapy. (shrink)

This article presents the framework Capability Sensitive Design (CSD), which consists of merging the design methodology Value Sensitive Design (VSD) with Martha Nussbaum's capability theory. CSD aims to normatively assess technology design in general, and technology design for health and wellbeing in particular. Unique to CSD is its ability to account for human diversity and to counter (structural) injustices that manifest in technology design. The basic framework of CSD is demonstrated by applying it to the hypothetical design case of a (...) therapy chatbot for mental health. By applying CSD to a design case, the merits of this new framework over the standard VSD approach become apparent. Also, the application demonstrates what a technology design would look like when attention is paid to capabilities right from the start of the design process. (shrink)

This special issue aims to explore and investigate a new subfield, namely experimental philosophy of medicine. Whereas experimental philosophy is relatively new on the philosophical block, some of its takes and findings have already shaped central debates in ethics, philosophy of action, philosophy of language, and epistemology. Interestingly, the approach of this program was for a long time almost wholly ignored within bioethics and philosophy of medicine—although this seems to have changed somewhat recently. In this introduction, we briefly sketch the (...) program of experimental philosophy and how it can be used to shed philosophical light on issues in the philosophy of medicine. (shrink)

On one influential view, the problems that should attract medical attention involve a disorder, because the goals of medical practice are to prevent and treat disorders. Based on this view, if there are no mental disorders then the status of psychiatry as a medical field is challenged. In this paper, I observe that it is often difficult to establish whether the problems that attract medical attention involve a disorder, and argue that none of the notions of disorder proposed so far (...) offers a successful demarcation criterion between medical and non-medical problems. As an illustration, I consider why delusions are considered pathological and whether they attract medical attention in virtue of being pathological, where ‘pathological’ stands for ‘being caused by a disorder’. Although there are several promising answers to what makes delusions pathological, available accounts of the pathological nature of delusions fail to distinguish delusions from other irrational beliefs that are not typically thought of as pathological; and cannot explain why delusions typically attract medical attention whereas other irrational beliefs do not. (shrink)

Mobile health applications (‘health apps’) that promise the user to help her with some aspect of her health are very popular: for-profit apps such as MyFitnessPal, Fitbit, or Headspace have tens of millions of users each. For-profit health apps are designed and run as optimization systems. One would expect that these health apps aim to optimize the health of the user, but in reality they aim to optimize user engagement and, in effect, conversion. This is problematic, I argue, because digital (...) health environments that aim to optimize user engagement risk being manipulative. To develop this argument, I first provide a brief analysis of the underlying business models and the resulting designs of the digital environments provided by popular for-profit health apps. In a second step, I present a concept of manipulation that can help analyze digital environments such as health apps. In the last part of the article, I use my concept of manipulation to analyze the manipulative potential of for-profit health apps. Although for-profit health can certainly empower their users, the conditions for empowerment also largely overlap with the conditions for manipulation. As a result, we should be cautious when embracing the empowerment discourse surrounding health apps. An additional aim of this article is to contribute to the rapidly growing literature on digital choice architectures and the ethics of influencing behavior through such choice architectures. I take health apps to be a paradigmatic example of digital choice architectures that give rise to ethical questions, so my analysis of the manipulative potential of health apps can also inform the larger literature on digital choice architectures. (shrink)

To be effective, a medical intervention must improve one's health by targeting a disease. The concept of disease, though, is controversial. Among the leading accounts of disease-naturalism, normativism, hybridism, and eliminativism-I defend a version of hybridism. A hybrid account of disease holds that for a state to be a disease that state must both (i) have a constitutive causal basis and (ii) cause harm. The dual requirement of hybridism entails that a medical intervention, to be deemed effective, must target either (...) the constitutive causal basis of a disease or the harms caused by the disease (or ideally both). This provides a theoretical underpinning to the two principle aims of medical treatment: care and cure. (shrink)

Medicalization is frequently defined as a process by which some non-medical aspects of human life become to be considered as medical problems. Overdiagnosis, on the other hand, is most often defined as diagnosing a biomedical condition that in the absence of testing would not cause symptoms or death in the person’s lifetime. Medicalization and overdiagnosis are related concepts as both expand the extension of the concept of disease. They are both often used normatively to critique unwarranted or contested expansion of (...) medicine and to address health services that are considered to be unnecessary, futile, or even harmful. However, there are important differences between the concepts, as not all cases of overdiagnosis are medicalizations and not all cases of medicalizations are overdiagnosis. The objective of this article is to clarify the differences between medicalization and overdiagnosis. It will demonstrate how the subject matter of medicalization traditionally has been non-medical (social or cultural everyday life) phenomena, while the subject matter of overdiagnosis has been biological or biomolecular conditions or processes acknowledged being potentially harmful. They also refer to different types of uncertainty: medicalization is concerned with indeterminacy, while overdiagnosis is concerned with lack of prognostic knowledge. Medicalization is dealing with sickness (sick role) while overdiagnosis with disease. Despite these differences, medicalization and overdiagnosis are becoming more alike. Medicalization is expanding, encompassing the more “technical” aspects of overdiagnosis, while overdiagnosis is becoming more ideologized. Moreover, with new trends in modern medicine, such as P4 (preventive, predictive, personal, and participatory) medicine, medicalization will become all-encompassing, while overdiagnosis more or less may dissolve. In the end they may converge in some total “iatrogenization.” In doing so, the concepts may lose their precision and critical sting. (shrink)

Nineteenth-century medical advances were entwined with a conceptual innovation: the idea that many cases of disease which were previously thought to have diverse causes could be explained by the action of a single kind of cause, for example a certain bacterial or parasitic infestation. The focus of modern epidemiology, however, is on chronic non-communicable diseases, which frequently do not seem to be attributable to any single causal factor. This paper is an effort to resolve the resulting tension. The paper criticises (...) the monocausal model of disease, so successful in the nineteenth century. It also argues that a multifactorial model of disease can only be satisfactory if it amounts to more than a mere rejection of the monocausal model. A third alternative, the contrastive model, is proposed and defended on the grounds that it links the notions of disease and of general explanation, while avoiding the philosophical naiveties and practical difficulties of the monocausal model. (shrink)

This paper argues for the importance of approaching medicine, as a theoretical science, through values. The normative concepts of benefit and harm are held to provide a framework for the analysis of medicine which reflects the obligations of the doctor-patient relationship, suffices to define the key concept of medical relevance, yields a general necessary condition for the basic concepts of medicine, explains the role of such nonnormative conceptions as discomfort, dysfunction, and incapacity, and avoids the mistakes of other normative approaches (...) which hold that unhealthy conditions are disvaluable or should be treated. Neutralist analyses are criticized, especially those approaching health through proper functioning. (shrink)

The paper contrasts Lennart Nordenfelt’s normative theory of health with the naturalists’ point of view, especially in the version developed by Christopher Boorse. In the first part it defends Boorse’s analysis of disease against the charge that it falls short of its own standards by not being descriptive. The second part of the paper sets out to analyse the positive concept of health and introduces a distinction between a positive definition of health (‘health’ is not defined as absence of disease (...) but in positive terms) and a positive conception of health (health is seen as an ideal). An objection against Nordenfelt’s account is developed by making use of a specific example of an ambitious athlete. It is stated that Nordenfelt’s conceptualisation includes too many phenomena under the umbrella of ill health. An ideal conception of health like Nordenfelt’s is in danger of supporting medicalization. In conclusion, although Nordenfelt’s theory is not altogether rejected and even seen in congruence with Boorse’s account, it is claimed that the naturalistic framework should obtain conceptual priority. (shrink)

The traditional contrast between naturalist and normativist disease concepts fails to capture the most salient features of the health concepts debate. By using health concepts as a window on background notions of medical science and ethics, I show how Christopher Boorse (an influential naturalist) and Lennart Nordenfelt (an influential normativist) actually share deep assumptions about the character of medicine. Their disease concepts attempt, in different ways, to shore up the same medical model. For both, health concepts function like demarcation criteria (...) in the philosophy of science: they mark off the jurisdiction of medical science, and protect it from an inappropriate intrusion of socioeconomic factors, which threaten the integrity of modern medicine. These views are challenged by new developments in healthcare such as managed care and total quality review. To frame the health concepts debate in a way that better captures the issues integral to these new developments, I advance a new way of reading the distinction between weak and strong normativists. Strong normativists are skeptical of the demarcation project, think facts and values cannot be disentangled, and hold that socioeconomic conditions unavoidably influence how pathology is understood. The new health concepts debate should be framed as one between weak and strong normativists, and it concerns how we should respond to the current developments in health care. (shrink)

Social Constructivism about the disease concept has generally been taken to ignore the fundamental biological reality underlying diseases, as well as to fall foul of several apparently compelling objections. In this paper, I explain how the metaphysical relation of grounding can be used to tie a socially constructed account of diseases and their classification to their underlying biological and behavioural states. I then generalize the position by disambiguating several varieties of normativism, including a particularly strong ‘placeholder’ version of social constructivism, (...) and showing that the grounding approach is available to each. I go on to provide what I believe to be the first attempt at a full semantics for disease-talk and disagreement, before using the placeholder to demonstrate on that basis that the most troublesome objections to normativism can be avoided even by very strong versions of the position. (shrink)

Bioethics functions within a world of deep moral pluralism; a universe of discourse debating ethical analysis, public policy, and clinical practice in which a common, generally accepted morality does not exist. While religious thinkers are often approached within a hermeneutic of suspicion for assuming moral standards that cannot be justified in rational terms, secular bioethicists routinely find themselves in exactly the same intellectual predicament. That ethical theory, proposed values, or normative content is secular, that it does not invoke God or (...) any particular religious perspective, does not mean that it is rationally grounded, necessarily true, or universally binding. As the authors in this issue of The Journal of Medicine and Philosophy make clear, this normative reality directly impacts debates regarding concepts of health, illness, and disease, accounts of socially acceptable health-risky behaviors, and the political frameworks that shape public policy. As a result, honest discussion of diverse moral, religious, and political perspectives remains essential in clarifying the intellectual challenges, ethical intuitions, and ideological judgments that shape clinical practice and healthcare policy. Depending on which moral, political, or scientific concepts are guiding bioethical analysis, careful scrutiny will tend to support rather different policies and practices, each of which is likely to be worth careful consideration. (shrink)

Several philosophers have recently argued that phenomenology is well-suited to help understand the concepts of health, disease, and illness. The general claim is that by better analysing how illness appears to or is experienced by ill individuals—incorporating the first-person perspective—some limitations of what is seen as the currently dominant third-person or ‘naturalistic’ approaches to understand health and disease can be overcome. In this article, after discussing some of the main insights and benefits of the phenomenological approach, I develop three general (...) critiques of it. First, I show that what is often referred to as naturalism tends to be misunderstood and/or misrepresented, resulting in straw-man arguments. Second, the concept of normality is often problematically employed such that some aspects of naturalism are actually presupposed by many phenomenologists of medicine. Third, several of the key phenomenological insights and concepts, e.g. having vs. being a body, the alienation of illness, the epistemic role of the first-person perspective, and the idea of health within illness, each bring with them new problems that limit their utility. While acknowledging the possible contributions of phenomenology, these criticisms point to some severe limitations of bringing phenomenological insights to bear on the problems facing philosophy of medicine that should be addressed if phenomenology is to add anything substantially new to its debates. (shrink)

The basic work for this book was carried out during the spring of 1989 in Edinburgh, where I had been granted a research position at The Institute for Advanced Studies in the Humanities. I should like to express here my indebtedness to the Institute for the opportunity thus afforded me. I should also like to say how very grateful I am for the stimulating conversations I had there with Professor Timothy Sprigge and Dr. Elizabeth Telfer. Dr. Telfers’s own treatise Happiness (...) has been a major influence on my view of the questions involved. The basic view of health and illness presented in this book is more fully set out in my On the Nature of Health. As in the case of my previous larger projects, I have received a great amount of support and may wise comments from Professor Ingmar Pörn, Helsinki. Three Danish experts – Anton Aggernaes, Erik Ostenfeld and Peter Sandøe – have made valuable comments. Professor Heng ten Have, Nijmegen, has improved my reading of the philosophy of Jeremy Bentham. I should also like to thank my colleagues at the Department of Health and Society, University of Linköping, for helping me to avoid a number of the pitfalls that can so easily stumble into when it comes to a treatise like this. Especially I should like to mentioned Per-Erik Liss, Ingemar Nordin and Bo Petersson, all three of whom have read and commented on the entire manuscript. A Swedish version of this book, Livskvalitet och hälsa, came out in 1991. I have been made quite a number of corrections and additions, one type of addition being replies to critical points made in reviews of the Swedish version. I should like to thank Malcolm Forbes for valuable help putting my English into publishable condition. Linköping, May 1993 Lennart Noredenfelt. (shrink)

Is medicalization always harmful? When does medicine overstep its proper boundaries? The aim of this article is to outline the pragmatic criteria for distinguishing between medicalization and over-medicalization. The consequences of considering a phenomenon to be a medical problem may take radically different forms depending on whether the problem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medicalization of subsequent areas of human existence, nor criticizing new medicalization cases just because they are medicalization (...) can be justified. The article: (i) identifies various consequences of both well-founded medicalization and over-medicalization; (ii) demonstrates that the issue of defining appropriate limits of medicine cannot be solved by creating an optimum model of health; (iii) proposes four guiding questions to help distinguish medicalization from over-medicalization. The article should foster a normative analysis of the phenomenon of medicalization and contribute to the bioethical reflection on the boundaries of medicine. (shrink)

The mental realm seems different to the physical realm; the mental is thought to be dependent on, yet distinct from the physical. But how, exactly, are the two realms supposed to be different, and what, exactly, creates the seemingly insurmountable juxtaposition between the mental and the physical? This review identifies and discusses five marks of the mental, features that set characteristically mental phenomena apart from the characteristically physical phenomena. These five marks (intentionality, consciousness, free will, teleology, and normativity) are not (...) presented as a set of features that define mentality. Rather, each of them is something we seem to associate with phenomena we consider mental, and each of them seems to be in tension with the physical view of reality in its own particular way. It is thus suggested how there is no single mind-body problem, but a set of distinct but interconnected problems. Each of these separate problems is analyzed, and their differences, similarities and connections are identified. This provides a useful basis for future theoretical work on psychology and philosophy of mind, that until now has too often suffered from unclarities, inadequacies, and conflations. (shrink)

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)