As individuals grow older, they usually require assistance with the daily tasks of self-care. This type of assistance, ancillary care, is essential to maintaining the health of those who need these services. In his prudential lifespan account, Norman Daniels includes access to such services making his account an attractive proposal given the current demographic shift. In this paper, I examine the prudential lifespan account through the lens of old age and I focus on the two concepts on which the lifespan (...) account relies. I show that these two concepts, normal species functioning and opportunity cannot buttress Daniels’s lifespan account; at least it cannot do so for older persons. The tensions that I identify in the prudential lifespan account in relation to aging are instructive for the more recent proposals to include aging in a theory of health and health justice. In addition, my analysis allows me to demonstrate that Daniels’s view of opportunity is irreconcilable to capabilities, the latter being more adaptable to the realities of aging. If capabilities appear more promising, it is nonetheless imperative that the specificities of extended care, such as the need for unpaid caregiving, be taken into consideration. (shrink)

Several decades ago, Christopher Boorse formulated an influential statistical theory of normative biological functions but it has often been claimed that his theory suffers from insuperable problems such as an inability to handle cases of epidemic and universal diseases. This paper develops a new statistical theory of normative functions that is capable of dealing with the notorious problem of epidemic and universal diseases. The theory is also more detailed than its predecessors and offers other important advantages over them. It is (...) argued here that statistical theories of biological functions should not be so quickly dismissed. (shrink)

There has been much debate about whether the concept of disease articulated in Boorse’s biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even (...) if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions. (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)

In their paper “Is psychopathy a mental disease?”, Thomas Nadelhoffer and Walter Sinnott-Armstrong argue that according to any plausible account of mental disorder, neural and psychological abnormalities correlated with psychopathy should be regarded as signs of a mental disorder. I oppose this conclusion by arguing that at least on a naturalistically grounded account, such as Wakefield’s ‘Harmful Dysfunction’ view, currently available empirical data and evolutionary considerations indicate that psychopathy is not a mental disorder.

This article considers naturalistic analyses of the concepts of health and disease in light of the possibility of constructing novel living systems. The article begins by introducing the vision of synthetic biology as the application of engineering principles to the construction of biological systems, the main analyses of the concepts of health and disease, and the standard theories of function in artefacts and organisms. The article then suggests that reflection on the possibility of artefactual organisms amounts to a challenge to (...) the functional theories of health and disease proposed by Wakefield and Boorse. More specifically, Wakefield and Boorse's theories are reconstructed as responses to a dilemma concerning how to allow for the ascription of health and disease to artefactual organisms without at the same time opening up the possibility of diseased nonliving artefacts such as cars and computers. It is argued that neither response will enable us to ascribe health and disease to artefactual organisms, because both theories, in order to rule out the possibility of ascribing health and disease to nonliving artefacts, make such ascriptions conditional on having a natural-selection history or being part of a species which has been designed by evolution. (shrink)

Theorists analyzing the concept of disease on the basis of the notion of dysfunction consider disease to be dysfunction requiring. More specifically, dysfunction-requiring theories of disease claim that for an individual to be diseased certain biological facts about it must be the case. Disease is not wholly a matter of evaluative attitudes. In this paper, I consider the dysfunction-requiring component of Wakefield’s hybrid account of disease in light of the artifactual organisms envisioned by current research in synthetic biology. In particular, (...) I argue that the possibility of artifactual organisms and the case of oncomice and other bred or genetically modified strains of organism constitute a significant objection to Wakefield’s etiological account of the dysfunction requirement. I then develop a new alternative understanding of the dysfunction requirement that builds on the organizational theory of function. I conclude that my suggestion is superior to Wakefield’s theory because it (a) can accommodate both artifactual and naturally evolved organisms, (b) avoids the possibility of there being a conflict between what an organismic part is supposed to do and the health of the organism, and (c) provides a nonarbitrary and practical way of determining whether dysfunction occurs. (shrink)

Overdiagnosis and disease are related concepts. Widened conceptions of disease increase overdiagnosis and vice versa. This is partly because there is a close and complex relationship between disease and overdiagnosis. In order to address the problems with overdiagnosis, we may benefit from a closer understanding this relationship. Accordingly, the objective of this article is to elucidate the relationship between disease and overdiagnosis. To do so, the article starts with scrutinizing how overdiagnosis can explain the expansion of the concept of disease. (...) Then it investigates how definitions of disease address various challenges of overdiagnosis. The article specifically investigates recent attempts to clarify the relationship between the concepts of disease and overdiagnosis. Several shortcomings are identified and lead to a closer analysis of overdiagnosis in the diagnostic process. Contrary to recent contributions to the field, it is argued that cases of overdiagnosis are not cases of disease. They are non-verified labelling of disease. It is revealed how overdiagnosis establishes an unwarranted link between indicative phenomena, such as polyps or cell changes, and harm, and thereby generates a link to disease. One implication of this study is that we should stop attributing disease language to indicative phenomena. That is, we should stop calling it “cancer screening” when we are actually searching for polyps. Another implications is that we should strive for scientific progress in differentiating phenomena that are of negative value to us from those that are not. In overdiagnosis we diagnose something that is not disease: it is over-diagnosis. (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)

The breadth of themes addressed in this issue of the Journal of Medicine and Philosophy is striking. These articles brim with some of the most foundational questions one can ask in bioethics and the philosophy of medicine: Under what circumstances might we risk some harm in pursuit of a greater good? In the setting of experimental therapies, how should we weigh the potential risk and benefit for an individual patient against the broader potential benefit realized for society as a whole? (...) How might we consistently differentiate health from pathology? Under what circumstances might we say that a human being has died? Does acknowledging particular things as good generate duties? Duties for whom and enforced by whom? These articles share a preoccupation with foundational questions that must be addressed in any sound bioethics curriculum, and they make clear that our answers to these questions are not simply theoretical but manifest in policy and in practice. (shrink)

1 Overview of the problem2 Situationally Specific Normal Functioning and Capacities3 Kingma’s Criticism4 How Normal Responses can be Pathological5 Too Many Pathologies?6 Conclusions.

This essay argues that what is central to Christopher Boorse’s biostatistical theory of disease as statistically subnormal part function (BST) are comparisons of the “functional efficiency” of parts and processes and that statistical considerations serve only to pick out a healthy level of functional efficiency. On this interpretation, the distinction between health and pathology is less important than comparisons of functional efficiency, which are entirely independent of statistical considerations. The clarifications or revisions of the BST that this essay offers are (...) friendly amendments that render moot some of the most prominent criticisms of Boorse’s account. (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)

Some ‘naturalist’ accounts of disease employ a biostatistical account of dysfunction, whilst others use a ‘selected effect’ account. Several recent authors have argued that the biostatistical account offers the best hope for a naturalist account of disease. We show that the selected effect account survives the criticisms levelled by these authors relatively unscathed, and has significant advantages over the BST. Moreover, unlike the BST, it has a strong theoretical rationale and can provide substantive reasons to decide difficult cases. This is (...) illustrated by showing how life-history theory clarifies the status of so-called diseases of old age. The selected effect account of function deserves a more prominent place in the philosophy of medicine than it currently occupies. _1_ Introduction _2_ Biostatistical and Selected Effect Accounts of Function _3_ Objections to the Selected Effect Account _3.1_ Boorse _3.2_ Kingma _3.3_ Hausman _3.4_ Murphy and Woolfolk _4_ Problems for the Biostatistical Account _4.1_ Schwartz _5_ Analysis versus Explication _6_ Explicating Dysfunction: Life History Theory and Senescence _7_ Conclusion. (shrink)

Christopher Boorse’s bio-statistical theory of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, (...) it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST’s binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article’s central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology—alongside physiology—in defining health. (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)

In this paper, I argue for a new way to understand the integration of facts and values in the concept of mental disorder that has the potential to avoid the flaws of previous hybrid approaches. I import conceptual tools from the account of procedural objectivity defended by Helen Longino to resolve the controversy over the definition of mental disorder. My argument is threefold: I first sketch the history of the debate opposing objectivists and constructivists and focus on the criticisms that (...) led to the emergence of the debate. Second, I offer a reconstruction of the “Natural Function Approach” argument to make explicit an unsound assumption underlying this approach. The reconstruction will allow me to show that the NFO’s argument depends on the ideal of value-free science that I will criticize. Then I propose an alternative ideal for psychiatry: social objectivity. I argue that the concept of mental health should be seen as “socially objective” rather than value-free, moving the debate towards the social procedures by which the definition is produced rather than the normative and factual content of its definition. (shrink)

This paper criticizes Jerome Wakefield’s harmful dysfunction analysis of disorder by arguing that the conceptual linkage it establishes between the medical concepts of health and disorder and the prudential notions of well-being and harm makes the account inapplicable to nonsentient organisms, such as plants, fungi, and many invertebrate animals. Drawing on a previous formulation of this criticism by Christopher Boorse, and noting that Wakefield could avoid it if he adopted a partly biofunction-based account of interests like that often advocated in (...) the field of environmental ethics, I argue that integrating such an account of interests into the HDA would generate serious concerns. Specifically, it would make dysfunction sufficient for disorder and so reestablish between dysfunction and disorder precisely the kind of sufficiency relation that harm-requiring accounts of disorder strive to avoid; blur the line between the HDA’s dysfunction and harm components and, in so doing, deprive the HDA of its alleged main advantage over monistic dysfunction-based accounts of disorders like Boorse’s; and tie the HDA to an understanding of harm that is in itself problematic. I argue that these three concerns, and the dilemmas they generate, rob the HDA of much of its prima facie appeal, ultimately indicating that a satisfactory account of disorder should most likely eschew all references to prudential notions of well-being and harm. (shrink)

Christopher Boorse’s Biostatistical Theory of Health has been the main contender among naturalistic accounts of health for the last 40 years. Yet, a recent criticism of this theory, presented by Elselijn Kingma, identifies a dilemma resulting from the BST’s conceptual linking of health and statistical typicality. Kingma argues that the BST either cannot accommodate the situation- specificity of many normal functions or cannot account for many situation-specific diseases. In this article, we expand upon with Daniel Hausman’s response to Kingma’s dilemma. (...) We propose that recalling Boorse’s specification that health is an intrinsic property of its bearers and explicating this intrinsic property in relation to the concept of homeostasis can illuminate how proponents of naturalistic accounts of health should deal with the situation- specificity of normal functions. We argue that beyond what Boorse and Hausman have delineated, the situation- specificity of normal function cannot be fully captured in a simple dichotomy between normal and abnormal environment or between relevant and irrelevant situations. By bringing homeostasis to the fore of the analysis of health, we set out a richer picture of what the various situations that affect living organisms’ functional performance can be. Accordingly, we provide a broader classification of these various situations which, we contend, better accounts for the main intuitions that philosophers of medicine have sought to accommodate than previous naturalistic theories of health. (shrink)

Boorse’s biostatistical theory states that diseases should be defined in ways that reflect disturbances of biological function and that are objective and value free. We use three examples from contemporary medicine that demonstrate the complex issues that arise when defining the boundaries of disease: polycystic ovary syndrome, chronic kidney disease, and myocardial infarction. We argue that the biostatistical theory fails to provide sufficient guidance on where the boundaries of disease should be drawn, contains ambiguities relating to choice of reference class, (...) and is out of step with medical processes for identifying disease boundaries. Although proponents of the biostatistical theory might regard these practical issues as irrelevant to the aim of providing a theoretical account of disease, we take them to indicate the need for a theoretical account that is adequate for current needs—including limiting new forms of medicalization that are driven by the identification of disease based on dysfunction. Our processes for determining the boundaries for disease need to recognize that there is no value-free method for making these decisions. (shrink)

The Linda paradox is a key topic in current debates on the rationality of human reasoning and its limitations. We present a novel analysis of this paradox, based on the notion of verisimilitude as studied in the philosophy of science. The comparison with an alternative analysis based on probabilistic confirmation suggests how to overcome some problems of our account by introducing an adequately defined notion of verisimilitudinarian confirmation.

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)

Scientists, philosophers, and even the lay public commonly accept that schizophrenia stems from a biological or internal ‘dysfunction.’ However, this assessment is typically accompanied neither by well-defined criteria for determining that something is dysfunctional nor empirical evidence that schizophrenia satisfies those criteria. In the following, a concept of biological function is developed and applied to a neurobiological model of schizophrenia. It concludes that current evidence does not warrant the claim that schizophrenia stems from a biological dysfunction, and, in fact, that (...) unusual neural structures associated with schizophrenia may have functional or adaptive significance. The fact that current evidence is ambivalent between these two possibilities (dysfunction versus adaptive function) implies that schizophrenia researchers should be much more cautious in using the ‘dysfunction’ label than they currently are. This has implications for both psychiatric treatment as well as public perception of mental disorders. (shrink)