According to Jerome Wakefield’s harmful dysfunction analysis of medical disorder, the inability of some internal part or mechanism to perform its natural function is necessary, but not sufficient, for disorder. HDA also requires that the part dysfunction be harmful to the individual. I consider several problems for HDA’s harm criterion in this article. Other accounts on which harm is necessary for disorder will suffer from all or almost all of these problems. Comparative accounts of harm imply that one is harmed (...) when one is made worse off, that is, worse off than one otherwise would have been. Non-comparative accounts imply that one is harmed when one is put into some kind of condition or state that is, in some way, bad in itself. I argue that whether harm is construed comparatively or non-comparatively, HDA’s harm criterion is problematic. I tentatively conclude that an analysis of medical disorder should not make use of the concept of harm. (shrink)

One important ethical issue for health promotion and public health work is to determine what the goals for these practices should be. This paper will try to clarify what some of these goals are thought to be, and what they ought to be. It will specifically discuss two different approaches to health promotion, such as, behavior change and empowerment. The general aim of this paper is, thus, to compare the behavior-change approach and the empowerment approach, concerning their immediate goals or (...) aims, and to morally evaluate the strengths and weaknesses of these two goal models, in relation to the ultimate goal of health promotion. The investigation shows that the behavior-change approach has several moral problems. First of all, it is overly paternalistic and often disregards the individual’s or group’s own perception of what is important—something that also increases the risk of failed interventions. Furthermore, it risks leading to ‘victim blaming’ and stigmatization, and to increased inequalities in health, and it puts focus on the ‘wrong’ problems, i.e., behavior instead of the ‘causes of the causes’. It is thereafter shown that the empowerment approach does not have any of these problems. Finally, some specific problems for the empowerment approach are discussed and resolved, such as, the idea that empowering some groups might lead to power over others, the objection that the focus is not primarily on health, and the fact that empowered people might choose to live lives that risk reducing their health. (shrink)

What are the implications of taking seriously Chaïm Perelman's proposition that “definitions are rhetorical”? Efforts to find Real Definitions are dysfunctional to the extent they direct argumentation toward pseudo “is” claims and away from explicit “ought” claims about how words are to be used. Addressing definitional disputes explicitly as propositions ofought rather thanis could put on the agenda the pragmatic concerns of definitional choice that might otherwise remain tacit.

This essay provides an explanation and interpretation of the undertreatment of pain by discussing some of the scientific, clinical, cultural, and philosophical aspects of this problem. One reason why pain continues to be a problem for medicine is that pain does not conform to the scientific approach to health and disease, a philosophy adopted by most health care professionals. Pain does not fit this philosophical perspective because (1) pain is subjective, not objective; (2) the causal basis of pain is often (...) poorly understood; (3) pain is often regarded as a mere symptom, not as a disease; (4) there often are no magic bullets for pain; (5) pain does not fit the expert knowledge model. In order for health care professionals to do a better job of treating pain, some changes need to occur in medical philosophy, education, and practice. (shrink)

In this commentary, I critically discuss the respective views of Gert and Beauchamp–Childress on the nature of so-called common morality and its promise for enriching ethical reflection within the field of bioethics. Although I endorse Beauchamp and Childress’ shift from an emphasis on ethical theory as the source of moral norms to an emphasis on common morality, I question whether rouging up common morality to make it look like some sort of ultimate and universal foundation for morality, untouched by the (...) dialectics of time and reflective equilibrium, was an equally good move. As for Gert’s magisterial conception of common morality, I conclude that certain elements of his system are controversial at best and woefully inadequate at worst. He has a tendency to find in common morality what he himself put there, and his highly restricted conception of duties of assistance strikes this reader as ad hoc, inadequately defended, and unworthy of a project whose goal is to lessen the amount of misery in the world. (shrink)

Accounts of the concepts of function and dysfunction have not adequately explained what factors determine the line between low‐normal function and dysfunction. I call the challenge of doing so the line‐drawing problem. Previous approaches emphasize facts involving the action of natural selection (Wakefield 1992a, 1999a, 1999b) or the statistical distribution of levels of functioning in the current population (Boorse 1977, 1997). I point out limitations of these two approaches and present a solution to the line‐drawing problem that builds on the (...) second one. (shrink)

In a time when we as a society are in the process of deciding what our basic rights to health care are, it is critically important for us to have a full and complete understanding of what constitutes health. We argue for an analysis of health according to which certain states are healthy not in themselves but because they allow an individual to reach actual goals. Recognizing that the goals of an individual considered from the point of view of biology (...) and the goals of the same individual considered as an agent in the world might be different, we introduce a distinction between the health of an individual qua organism and the health of an individual qua person. We then argue that this distinction characterizes the evaluations made by patients and healthcare providers better than the widely discussed distinction between disease and illness. (shrink)

This paper develops an instrumentalistic argumentagainst an eliminativist approach to using the folkconcept of pain in clinical medicine and draws someimplications for biomedical theories of pain. Thepaper argues that the folk concept of pain plays afundamental role in several aspects of clinicalmedicine, including the diagnosis and treatment ofdiseases and symptoms, relieving human suffering, andthe doctor-patient relationship. Since clinicians mustbe able to apply biomedical theories of pain inmedical practice, these theories should not stray toofar from pain's clinical realities. Biomedicaltheories of pain (...) should at least incorporate an analogof the folk concept of pain, even if this concept isrevised in light of scientific advances. (shrink)

The disease debate in philosophy of medicine has traditionally been billed as a debate over the correct conceptual analysis of the term “disease.” This paper argues that although the debate’s participants overwhelmingly claim to be in the business of conceptual analysis, they do not tend to argue as if this is the case. In particular, they often show a puzzling disregard for key parameters such as precise terminology, linguistic community, and actual usage. This prima facie strange feature of the debate (...) points to an interesting and potentially instructive hypothesis: the disease debate makes little sense within the paradigm of conceptual analysis but makes good sense on the assumption that pathology is a real kind. (shrink)

In a Ulysses contract, A gets B, at t1, to agree (i) to act at t2 in such a way that A is made to abide by her own earlier intentions and (ii) to ignore A’s later attempt to rescind the authorization. But why does A’s will at t2 lack the authority it had at t1? This article makes the case that a person has authority to enter a Ulysses contract only insofar as her expressed will at t1 is a (...) better expression of the values that remain attributable to her at t2 than is her expressed will at t2. (shrink)

This paper offers a philosophical analysis of the connection between mental disorder and suicide risk. In contemporary psychiatry, it is commonly suggested that this connection is a causal connection that has been established through empirical discovery. Herein, I examine the extent to which this claim can be sustained. I argue that the connection between mental disorder and increased suicide risk is not wholly causal but is partly conceptual. This in part relates to the way suicidality is built into the definitions (...) of some psychiatric diagnoses. It also relates to the broader normative assumption that suicidal behavior is by definition mentally disordered behavior. The above has significant epistemological implications, which I explore. I propose that the claim that suicide is connected with mental disorder cannot be justified solely by appealing to empirical evidence but also warrants a justification on conceptual and normative grounds. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Ethical and legal discourse pertaining to the ability to consent to treatment and research in England operates within a dualist framework of “competence” and “capacity”. This is confusing, as while there exists in England two possible senses of legal capacity – “first person” legal capacity and “delegable” legal capacity, currently neither is formulated to bear a necessary relationship with decision-making competence. Notwithstanding this, judges and academic commentators frequently invoke competence to consent in discussions involving the validity of offering or withholding (...) consent as a synonym for legal capacity to consent. I argue that this gives rise to a conflation, jeopardising clarity and consistency in law. This is somewhat less problematic in instances of “first-person” legal capacity that are heavily informed by criteria for decision-making competence than in the second sense of legal capacity, which is qualitatively different from decision-making competence, or with first-person legal capacity when defined in different terms from competence. The paper concludes by proposing that the soundest resolution to this problem is by making decision-making competence a necessary and sufficient condition of first-person legal capacity, affording a more scrupulous distinction between the two different forms of legal capacity that exist. (shrink)

The terms “health promotion” and “disease prevention” refer to professional activities. But a “health promoter” has also come to denote a profession, with an alternative agenda compared to that of traditional public health work, work that by some is seen to be too medically oriented, too reliant upon prevention, risk-elimination and health-care. But is there really a sharp distinction between these activities and professions? The main aim of the paper is to investigate if these concepts are logically different, or if (...) they are just two extremes of one dimension. The central concepts, health promotion and disease prevention, are defined, and it is concluded that health promotion and disease prevention are logically distinct concepts, although they are conceptually related through a causal connection. Thus, logically, it is possible to promote health without preventing disease, even if this is not so common, in practice, but it is not possible to prevent disease without promoting health. Finally, most health promoting interventions target basic health, not manifest health, and often also thereby reduce future disease. (shrink)

There are several strategies to promote health in individuals and populations. Two general approaches to health promotion are behavior change and empowerment. The aim of this article is to present those two kinds of strategies, and show that the behavior-change approach has some moral problems, problems that the empowerment approach (on the whole) is better at handling. Two distinct ‘ideal types’ of these practices are presented and scrutinized. Behavior change interventions use various kinds of theories to target people’s behavior, which (...) they do through information, persuasion, coercion and manipulation. Empowerment is a collaborative method where those ‘facilitated’ participate in the change process. Some ethical problems with the behavior-change model are that it does not sufficiently respect the right to autonomy of the individuals involved and risks reducing their ability for autonomy, and that it risks increasing health inequalities. Empowerment, on the other hand, respects the participant’s right to autonomy, tends to increase the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities. A drawback with this approach is that it often takes longer to realize. (shrink)

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to (...) publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues. (shrink)

Health-related quality of life is the ultimate general goal for medicine, health care and public health, including health promotion and health education. The other important general goal is health-related welfare. The aim of the paper is to explain what this means and what the consequences of these assumptions are for health work. This involves defining the central terms “health”, “quality of life” and “welfare” and showing what their conceptual relations are. Health-related quality of life has two central meanings: health-related well-being, (...) which constitutes quality of life, and health as ability, which contributes causally to quality of life. Four meanings of health-related welfare are put forward: general well-being, health as ability, other inner properties of the individual, and external factors. States and processes covered by these categories contribute causally to health-related quality of life. Finally, using these distinctions, some more specific goals for medicine and health care, on the one hand, and for public health and health promotion, on the other, are outlined. In the former fields work is primarily directed towards changing the health-related quality of life of the individual through direct measures, “manipulating” the individual, whereas public health work and health promotion primarily use indirect measures and further health through various sorts of health-related welfare changes, e.g. through changing the environment. (shrink)

Nurses are increasingly realising that they can offer relevant information and participate in decision-making involving ethical issues. However, inter-professional communications are frequently inadequate, and do not permit exchange of opinions. The consequences are often frustrating and upsetting for nurses whose care is affected by others' policies. This paper explores these issues using some clinical examples.

A diagnosis of schizophrenia is often taken to denote a state of global irrationality within the psychiatric paradigm, wherein psychotic phenomena are seen to equate with a lack of mental capacity. However, the little research that has been undertaken on mental capacity in psychiatric patients shows that people with schizophrenia are more likely to experience isolated, rather than constitutive, irrationality and are therefore not necessarily globally incapacitated. Rational suicide has not been accepted as a valid choice for people with schizophrenia (...) due in part to a belief that characteristic irrationality prevents autonomous decision-making. Since people with schizophrenia are often seen to lack insight into the nature of their disorder, both psychiatric and ethical perspectives generally presume that suicidal acts result directly from mental illness itself and not from second-order desires. In this article, I challenge notions of global irrationality conferred by a diagnosis of schizophrenia and argue that, where delusional beliefs are unifocal, schizophrenia does not necessarily lead to a state of mental incapacity. I then attempt to show that people with schizophrenia can sometimes be rational with regard to suicide, where this decision stems from a realistic appraisal of psychological suffering. (shrink)

Jerome Wakefield criticizes my biostatistical analysis of the pathological—as statistically subnormal biological part-functional ability relative to species, sex, and age—for its lack of a harm clause. He first charges me with ignoring two general distinctions: biological versus medical pathology, and disease of a part versus disease of a whole organism. He then offers 10 counterexamples that, he says, are harmless dysfunctions but not medical disorders. Wakefield ends by arguing that we need a harm clause to explain American psychiatry’s 1973 decision (...) to declassify homosexuality. I reply, first, that his two distinctions are philosophic fantasies alien to medical usage, invented only to save his own harmful-dysfunction analysis (HDA) from a host of obvious counterexamples. In any case, they do not coincide with the harmless/harmful distinction. In reality, medicine admits countless chronic diseases that are, contrary to Wakefield, subclinical for most of their course, as well as many kinds of typically harmless skin pathology. As for his 10 counterexamples, no medical source he cites describes them as he does. I argue that none of his examples contradicts the biostatistical analysis: all either are not part-dysfunctions (situs inversus, incompetent sperm, normal-flora infection) or are indeed classified as medical disorders (donated kidney, Typhoid Mary’s carrier status, latent tuberculosis or HIV, cherry angiomas). And if Wakefield’s HDA fits psychiatry, the fact that it does not fit medicine casts doubt on psychiatry’s status as a medical specialty. (shrink)

Savulescu maintains that our paper, which encourages clinicians to honour requests for "inappropriate treatment" is prejudicial to his atheistic beliefs, and therefore wrong. In this paper we clarify and expand on our ideas, and respond to his assertion that medicine, ethics and atheism are objective, rational and true, while religion is irrational and false.

In the traditional philosophical debate over different conceptual analyses of “disease,” it is often presupposed that “disease” is univocally definable and that there are clear boundaries which distinguish this univocal category “disease” from the category of “nondisease.” In this paper, I will argue for a shift in the discussion on the concept of “disease” and propose an alternative, pragmatic approach that is based on the conviction that “disease” is not a theoretical concept but a practical term. I develop a view (...) on which our use of the term “disease” is determined by two interacting factors, namely, value-laden considerations about the desirabilty of certain states and discoveries of cause which is/are explanatorily relevant. I show how these factors interact with regard to a taxonomy of kinds of diseases. This pragmatic approach will not lead me to a final definition of “disease,” but will result in a more realistic description of the way we build, use, apply, and change our concept of “disease.” Meanwhile, it is useful as a basis for critical reflection on disease-labeling in medicine. (shrink)

The vagueness or imprecision of ‘the normal’ allows it to be exploited for various purposes and political ends. It is conspicuous in both medicine and athletics; I am going to try to say something about the normal in each of these areas. In medicine the idea of the normal is often deployed in understanding what constitutes disease and hence, as some see it, in determining the role of physicians, in determining what is or ought to be covered by insurance, and (...) in underwriting certain views on social justice. In athletics the use of performance enhancing substances raises different sorts of questions about the normal, especially when it comes to deciding what constitutes an enhancement and which enhancements, if any, are acceptable. (shrink)

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease (...) as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization. (shrink)

It appears that there are two distinct practices within public health, namely health promotion and disease prevention, leading to different goals. But does the distinction hold? Can we promote health without preventing disease, and vice versa? The aim of the paper is to answer these questions. First, the central concepts are defined and the logical relations between them are spelt out. A preliminary conclusion is that there is a logical difference between health and disease, which makes health promotion and disease (...) prevention two distinct endeavours. However, since disease is defined in relation to health, as those kinds of internal processes and states that typically lead to ill health, the difference is smaller than it might appear. Second, in order to answer the practical question whether it is possible to promote health without preventing disease, and vice versa, several kinds of public health interventions are discussed. The conclusion is that while health promotion and disease prevention can be distinguished conceptually, they can hardly be distinguished in practice. Most general measures do both at the same time. (shrink)

I characterize the deductivist ideal of justification and, following to a great extent Toulmin’s work The Uses of Argument, I try to explain why this ideal is erroneous. Then I offer an alternative model of justification capable of making our claims to knowledge about substantial matters sound and reasonable. This model of justification will be based on a conception of justification as the result of good argumentation, and on a model of argumentation which is a pragmatic linguistic reconstruction of Toulmin’s (...) model of argument. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised.Ulysses (...) contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

Patients suffering from mental disorders are often not treated on an equal basis with patients suffering from organic diseases. In Germany, for example, alcohol-dependent patients will be detoxified on a clinical ward to ensure that they survive acute alcohol withdrawal; however, medical insurances often do not cover treatment costs for a therapy for the addictive behavior that underlies the acute alcohol problem. While patients suffering from diabetes mellitus can also display personally harmful choices and, for example, consume sugar although they (...) know that this is detrimental for their health, medical insurances pay for the acute hyperglycemic shock treatment as well as for dietary and medical treatment of the .. (shrink)

This thesis is about the notions of health and pathology in medical theory. I develop a theory, which defines ‘health’ and ‘pathology’ in a way that solves several problems with earlier suggestions of how to define these terms. I call the theory ‘the disposition profile efficiency theory’, abbreviated ‘the DPE-theory’. According to the DPE-theory, a trait token is healthy, roughly, if and only if all of its dispositions for performing physiological functions are efficient enough. A trait token is pathological, roughly, (...) if and only if at least one of its dispositions for performing a physiological function is not efficient enough. The notion of efficiency, I suggest, is reference class-relative: the efficiency of a trait token’s disposition for performing a physiological function expresses a relation between the trait token and a health standard for the trait token’s bearer’s reference class. The thesis also examines the most discussed theory of health and pathology, “the biostatistical theory” proposed by Boorse. Both the DPE-theory and the biostatistical theory are evaluated against a number of desiderata: the theory should be theoretically sound; only use empirical, statistical, and logical terms; not involve values; be clear; both account for health and pathology as reference class-relative properties, and account for the importance of integration of different physiological functions for health; and have reasonable implications. It is argued that the DPE-theory satisfies the desiderata, and that it does so better than the biostatistical theory. The main contributions of the thesis are the DPE-theory’s models of dispositions, its approach to defining reference classes, its efficiency measure, and its way of drawing the line between high enough efficiencies and too low efficiencies. Other important contributions concern the desideratum about reasonable implications. It is shown how the DPE-theory contributes to solving two much discussed objections directed towards the biostatistical theory, “the problem of common diseases” and “Kingma’s dilemma”. Further, the DPE-theory is used to illuminate discussions about certain types of conditions for which it is contested whether they should count as healthy or pathological. (shrink)

Empowerment is a concept that has been much used and discussed for a number of years. However, it is not always explicitly clarified what its central meaning is. The present paper intends to clarify what empowerment means, and relate it to the goals of health promotion. The paper starts with the claim that health-related quality of life is the ultimate general goal for health promotion, and continues by briefly presenting definitions of some central concepts: “welfare” “health” and “quality of life”. (...) Several suggestions as to what empowerment is are then discussed: autonomy, freedom, knowledge, self-esteem, self-confidence, and control over health or life. One conclusion of this discussion is that empowerment can be seen as a complex goal which includes aspects of the three central concepts welfare, health and quality of life. To the extent that the empowerment goals aimed at are health-related, it is concluded that empowerment is a legitimate goal for health promotion. But empowerment is not only a goal, it can also be described as a process or as an approach. This process, or approach, in a fundamental way involves the participants in problem formulation, decision making and action, which means that the experts have to relinquish some of their control and power. (shrink)

It is commonly thought that mental disorder is a valid concept only in so far as it is an extension of or continuous with the concept of physical disorder. A valid extension has to meet two criteria: determination and coherence. Essentialists meet these criteria through necessary and sufficient conditions for being a disorder. Two Wittgensteinian alternatives to essentialism are considered and assessed against the two criteria. These are the family resemblance approach and the secondary sense approach. Where the focus is (...) solely on the characteristics or attributes of things, both these approaches seem to fail to meet the criteria for valid extension. However, this focus on attributes is mistaken. The criteria for valid extension are met in the case of family resemblance by the pattern of characteristics associated with a concept, and by the limits of intelligibility of applying a concept. Secondary sense, though it may have some claims to be a good account of the relation between physical and mental disorder, cannot claim to meet the two criteria of valid extension. (shrink)

Contemporary philosophy of health and disease has been quite focused on the problem of determining the nature of the concepts of health and disease from a scientific point of view. Some theorists claim and argue that these concepts are value-free and descriptive in the same sense as the concepts of atoms, metal, and rain are value-free and descriptive. According to this descriptive or naturalist line of thought, the notions of health and disease are furthermore related to the idea of a (...) normal or natural function. A bodily organ is healthy insofar as it functions normally, and it is diseased when it does not fulfill its functions. Other philosophers claim that the concept of health, together with other medical concepts, is essentially value-laden. To establish that a person is healthy does not just entail some objective inspection and measurement. It presupposes also an evaluation of the general state of the person. My purpose in this article is to scrutinize the relation between the notion of a natural function, on the one hand, and the concepts of health and disease on the other. In characterizing the notion of a normal function I will follow the classic analysis put forward by American philosopher Christopher Boorse. I will criticize Boorse’s proposal mainly by using arguments from the analysis of ordinary lay and medical language. I ask questions such as: what do we normally mean when we ascribe health or disease to a person? In the end I will recommend an analysis of these and related medical notions, which is unrelated to the notion of a natural function as normally interpreted. (shrink)

The present thesis surveys different philosophical approaches to the nature of delusions: specifically, their ontology. However, since none of the various theories of the nature of delusions succeeds, I argue that there must be something problematic about the form of the analyses commonly offered. My general conclusion is that one cannot characterize delusions without taking away what it is distinctive about them.