Concepts of Disease and Health

This is perhaps the most important area of research in philosophy of biology for bioethics. Arthur Caplan explains it as follows:

It may strain credulity to believe that the analysis of concepts such as health, disease, or normality can shed light on the ethical and policy issues associated with the vast amounts of new knowledge being generated by the human genome project and related inquiries in biomedicine. However credulity must be strained. The focus of attention qua philosophy tends to be on who owns the genome or whether an insurance company can boot you off the rolls if you are at risk of succumbing to a costly disease. But this is not really where the ethical and philosophical action is with respect to the ongoing revolution in genetics. (p. 128)

There are two important distinctions that must be understood in the debates over concepts of disease. First, there is a distinction between ontological and nominalist concepts of disease. On the ontological (realist) view of disease, diseases are real entities that exist in the world. Nosologies represent a true classification of the world—they carve nature at the joints. The paradigm diseases on this view would be either discrete disease causing agents that are at the same time identified as the diseases themselves or as discrete lesions. Thus, poliovirus is not the cause of poliomyelitis, it is poliomyelitis.

In contrast, the nominalist about disease would appeal to the old saying, "there are no diseases, only sick people." On this view, nosologies are merely conventional systems of classification. They may have a great deal of practical value, but they are not in any meaningful sense true descriptions of reality. In some cases we classify diseases based on the pathogen that causes the disease. In other cases we classify based on the signs and symptoms. In others we focus on the organ system that is damaged, regardless of the causes or the symptoms. Thus, the nominalist would use the current lack of unity in the organization of our taxonomy of diseases as support for the view that it is merely a conventional (and somewhat arbitrary) system. Realists would respond by appealing to the role of disease in medical science and point to similar problems with other taxonomic systems in science that are nonetheless regarded as capturing reality.

One of the arenas where this debate has been most heated has been over the issue of the status of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in all of its versions. The fact that there are so many changes in the different versions of the DSM can be interpreted either as an indication that the classification scheme is merely a convention, or that the science of psychiatry is progressing (as any science does).

The second related distinction in debates over the concept of disease is over the role of values in the development of the nosologies. For the non-normativist, the starting point for understanding disease is to understand species typical functioning. Disease is malfunction of the organism, a failure to function as organisms are designed to do. To understand disease, one needs only to understand physiology. The concepts are the same in humans as in understanding disease in nonhuman organisms. Therefore, (non-scientific or epistemological) values play no role in the development of the classification and understanding of disease (Boorse).

In contrast, normativists believe that identifying a condition as a disease is a value-laden exercise. To say that a condition is a disease is to say something about what we value. Labeling something as a disease is a way of signaling the undesirability of the state. Normativists appeal to many examples that illustrate the way social values seem to permeate nosology. The early versions of the DSM identified homosexuality as a disease. The tendency of some slaves to attempt to escape was identified as a disease in the United States in the nineteenth century. Foot binding in Japan produces a condition that would be recognized as a disease in many parts of the world, but is seen as normal in Japan. Normativists deny that an account of disease solely in terms of species typical functioning can work. It is normal in some sense for humans to develop osteoarthritis in old age, normal for teeth to decay, normal to develop many ailments at advanced age. Yet medicine is committed to these things as disease. In fact age itself may be conceived of as both normal and a disease (Caplan et al.).

Finally, there is a dispute over the meaning of health. Non-normativists tend to think of health as the absence of disease. In that case, an organism is functioning within the normal parameters of its species at its age. In contrast there are those who adopt a much broader concept of health. On this view health is not the mere absence of disease, but is the full flourishing of a person in multiple dimensions, including psychological, economic, physical, and social well being. These different conceptions of health and disease lead to very different views about the obligations of medicine towards society, the scope of the medical field, and the nature of medical care.

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