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)

Our goal in this chapter is to draw on empirical work about preference formation and welfare to propose a distinctive form of paternalism, libertarian in spirit, one that should be acceptable to those who are firmly committed to freedom of choice on grounds of either autonomy or welfare. Indeed, we urge that a kind of ‘libertarian paternalism’ provides a basis for both understanding and rethinking many social practices, including those that deal with worker welfare, consumer protection, and the family.

Philosophers have long been interested in a series of interrelated questions about natural kinds. What are they? What role do they play in science and metaphysics? How do they contribute to our epistemic projects? What categories count as natural kinds? And so on. Owing, perhaps, to different starting points and emphases, we now have at hand a variety of conceptions of natural kinds—some apparently better suited than others to accommodate a particular sort of inquiry. Even if coherent, this situation isn’t (...) ideal. My goal in this article is to begin to articulate a more general account of ‘natural kind phenomena’. While I do not claim that this account should satisfy everyone—it is built around a certain conception of the epistemic role of kinds and has an obvious pragmatic flavour—I believe that it has the resources to go further than extant alternatives, in particular the homeostatic property cluster view of kinds. (shrink)

I argue that ductal carcinoma in situ (DCIS), the tumor most commonly diagnosed by breast mammography, cannot be confidently classified as cancer, that is, as pathological. This is because there may not be dysfunction present in DCIS—as I argue based on its high prevalence and the small amount of risk it conveys—and thus DCIS may not count as a disease by dysfunction-requiring approaches, such as Boorse’s biostatistical theory and Wakefield’s harmful dysfunction account. Patients should decide about treatment for DCIS based (...) on the risks it poses and the risks and benefits of treatment, not on its disease status. (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)

Metaphysical presuppositions are important for guiding scientific practices and research. The success of twentieth-century biology, for instance, is largely attributable to presupposing that complex biological processes are reducible to elementary components. However, some biologists have challenged the sufficiency of reductionism for investigating complex biological phenomena and have proposed alternative presuppositions like organicism. In this article, contemporary cancer research is used as a case study to explore the importance of metaphysical presuppositions for guiding research. The predominant paradigm directing cancer research is (...) the somatic mutation theory, in which mutated genes are presumed to be ultimately responsible for explaining carcinogenesis. This reductionistic approach to cancer has been criticised recently, and an organistic approach has been proposed. The article concludes with a discussion of the reciprocal interaction of metaphysical presuppositions and scientific practices for investigating cancer's complex nature. (shrink)

In recent cancer research, strong and apparently conflicting epistemological stances have been advocated by different research teams in a mist of an ever-growing body of knowledge ignited by ever-more perplexing and non-conclusive experimental facts: in the past few years, an 'organicist' approach investigating cancer development at the tissue level has challenged the established and so-called 'reductionist' approach focusing on disentangling the genetic and molecular circuitry of carcinogenesis. This article reviews the ways in which 'organicism' and 'reductionism' are used and opposed (...) in this context, with an aim at clarifying the debate. Methodological, epistemological and ontological implications of both approaches are discussed. We argue that the 'organicist/reductionist' opposition in the present case of carcinogenesis is more a matter of diverging heuristics than a claim about theoretical or ontological (ir)reducibility. As a matter of fact, except for the downward causation claim, which we question, we argue that the organicist arguments are compatible with the reductionist approach. Moreover, we speculate that both approaches, which currently focus on specific entities i.e., genes versus tissues, will need to shift their conceptual frameworks to studying complex arrays of relationships potentially ranging over several levels of entities, as is the case with 'systems biology'. (shrink)

One of the major developments in cancer research in recent years has been the construction of models that treat cancer as a cellular population subject to natural selection. We expand on this idea, drawing upon multilevel selection theory. Cancer is best understood in our view from a multilevel perspective, as both a by-product of selection at other levels of organization, and as subject to selection at several levels of organization. Cancer is a by-product in two senses. First, cancer cells co-opt (...) signaling pathways that are otherwise adaptive at the organismic level. Second, cancer is also a by-product of features distinctive to the metazoan lineage: cellular plasticity and modularity. Applying the multilevel perspective in this way permits one to explain transitions in complexity and individuality in cancer progression. Our argument is a reply to Germain’s scepticism towards the explanatory relevance of natural selection for cancer. The extent to which cancer fulfills the conditions for being a paradigmatic Darwinian population depends on the scale of analysis, and the details of the purported selective scenario. Taking a multilevel perspective clarifies some of the complexities surrounding how to best understand the relevance of evolutionary thinking in cancer progression. (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)

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 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)

After a 50-page outline of the principles of clinical reasoning, over 60 actual cases are detailed that illustrate (and are keyed to) the principles, presenting case records, analysis, and references to literature. For medical students and interns, and their instructors. Annotation copyright Book Ne.

The normal and the pathological are terms used for structures, activities, individual or collective situations proper to living beings and especially to man. The relation of a fact and a norm is its positive or negative value. Can the assessment of behaviours be reduced to noting a necessity? Is a living being's disease a fact similar to universal attraction? The author maintains that diseases are not merely predetermined effects, but are revealing of a normative regulation proper to living beings and (...) man. (shrink)

Christopher Boorse's biostatistical 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)

Since the microbiological revolution, most infectious diseases have been defined and classified according to an etiologic criterion, i.e. the identification of single, external necessary causes (for example, Mycobacterium for tuberculosis). This is not the case with cancer. Not only external necessary causes of cancer have not been identified, but also the morphological classification cannot be based on univocal criteria. Although neoplasia and anaplasia appear to be universal attributes of cancer, these events are only quantitative. Neoplastic growth can be fast or (...) slow (development may take weeks or years), and tissue pathologies are difficult to detect from normal tissue in some cancers but are obvious in others. Common special properties of anaplasia appear to be concealed in the wide range of morphologies. In the absence of a coherent morphological definition, and of external necessary causes (such as bacteria for infectious diseases), a mechanistic definition could be adopted. However, unless molecular biology discovers specific mechanistic steps in carcinogenesis, which indicate the existence of necessary events in carcinogenesis, we cannot adopt a univocal (monothetic) definition of cancer. The alternative is to use a polythetic definition, according to Wittgenstein's model of a long rope twisted together out of many shorter fibres. (shrink)