Theorists of health have, to this point, focused exclusively on trying to define a state—health—that an organism might be in. I argue that they have overlooked the possibility of a comparativist theory of health, which would begin by defining a relation—healthier than—that holds between two organisms or two possible states of the same organism. I show that a comparativist approach to health has a number of attractive features, and has important implications for philosophers of medicine, bioethicists, health economists, and policy (...) makers. (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.

How should we define ‘health’ and ‘disease’? There are three main positions in the literature. Naturalists desire value-free definitions based on scientific theories. Normativists believe that our uses of ‘health’ and ‘disease’ reflect value judgments. Hybrid theorists offer definitions containing both normativist and naturalist elements. This paper discusses the problems with these views and offers an alternative approach to the debate over ‘health’ and ‘disease’. Instead of trying to find the correct definitions of ‘health’ and ‘disease’ we should explicitly talk (...) about the considerations that are central in medical discussions, namely state descriptions and normative claims . This distinction avoids the problems facing the major approaches to defining ‘health’ and ‘disease’, and it more clearly captures what matters in medical discussions. (shrink)

The biological sciences employ a concept of normality that must be distinguished from statistical or value concepts. The concept of normality is presupposed in the standard explications of biological functions, and it is crucial to the strategy of explanation by approximations in, for example, physiology. Nevertheless, this concept of normality does not seem to be captured in the language of physics. Thus attempts at explaining the methodological relationship between the biological sciences and the physical sciences by concentrating only on the (...) concept of biological function cannot go very far. An analysis of the concept of normality is also necessary. (shrink)

Ernst Mayr has argued that Darwinian theory discredited essentialist modes of thought and replaced them with what he has called "population thinking". In this paper, I characterize essentialism as embodying a certain conception of how variation in nature is to be explained, and show how this conception was undermined by evolutionary theory. The Darwinian doctrine of evolutionary gradualism makes it impossible to say exactly where one species ends and another begins; such line-drawing problems are often taken to be the decisive (...) reason for thinking that essentialism is untenable. However, according to the view of essentialism I suggest, this familiar objection is not fatal to essentialism. It is rather the essentialist's use of what I call the natural state model for explaining variation which clashes with evolutionary theory. This model implemented the essentialist's requirement that properties of populations be defined in terms of properties of member organisms. Requiring such constituent definitions is reductionistic in spirit; additionally, evolutionary theory shows that such definitions are not available, and, moreover, that they are not needed to legitimize population-level concepts. Population thinking involves the thesis that population concepts may be legitimized by showing their connections with each other, even when they are not reducible to concepts applying at lower levels of organization. In the paper, I develop these points by describing Aristotle's ideas on the origins of biological variation; they are a classic formulation of the natural state model. I also describe how the development of statistical ideas in the 19th century involved an abandoning of the natural state model. (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)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (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)

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)

This paper examines the most influential naturalist theory of health, Christopher Boorse’s ‘biostatistical theory’ . I argue that the BST is an unsuitable candidate for the rôle that Boorse has cast it to play, namely, to underpin medicine with a theoretical, value-free science of health and disease. Following the literature, I distinguish between “real” changes and “mere Cambridge changes” in terms of the difference between an individual’s intrinsic and relational properties and argue that the framework of the BST essentially implies (...) a Cambridge-change criterion. The examination reveals that this implicit criterion commits the BST to the troubling view that an individual could go from being diseased to healthy, or vice versa, without any physiological change in that individual. Two problems follow: the current framework of the BST is ill-equipped to formally embrace Cambridge changes and it is theoretically dubious. The arguments advanced here are not limited to the BST; I suggest they extend to any naturalist claim to underpin medical practice with a value-free theory of health and disease defined in terms of an evolutionary view of biological fitness. (shrink)