Philosophical Perspectives

Concepts of health and disease—as well as of sickness, wellness, deformity, disability, dysfunction, and disfigurement—direct social energies. They inform medicine and healthcare policy regarding what is wholesome, what is to be avoided, and what is to be treated—all else being equal. Concepts of health and disease either directly or indirectly describe, evaluate, and explain reality and help to assign social roles. Decisions about the meaning and scope of concepts of health and disease profoundly influence the character of healthcare. For example, if alcoholism, homosexuality, menopause, or aging are considered diseases, then medical treatment, resources, and research will be focused on treating them. These concepts therefore become the focus of public-policy debates, and they may conceal value judgments that should be treated more explicitly as bioethical issues.

Diseases and sicknesses are usually distinguished from sins, crimes, and social problems in that they are not directly under the control of the will and are explainable, predictable, and (usually) treatable by an appeal to somatic or psychological laws, generalizations, and associations. Pains that are directly under one's own control or that of others (e.g., the pain from standing on one's own foot), difficulties of a moral sort (e.g., being blameworthy), problems of a spiritual sort (e.g., refusing to repent for one's transgressions), or legal disabilities (e.g., being a convicted felon) are thus contrasted with states of disease or illness. This contrast discloses a boundary between disparate human practices (e.g., blaming the immoral, convicting felons, exorcising demons, treating diseases), and the criteria used to distinguish between any of these practices will vary from culture to culture and shift within the history of a particular culture. In addition, the line between medical and other problems is, in part, a function of the competencies of those making the judgment. Diseases and illnesses are what medicine treats.

Illnesses and diseases are generally identified because they involve a failure of function, a pain that is considered abnormal (compare the pain of teething with that of migraine [King]), a deformity, or the threat of premature death. Insofar as judgments regarding proper function, normal pain, correct human form, and normal span of life can be made without reference to culture-dependent values, concepts of disease will not depend on social norms of proper human function. The same can be said with regard to concepts of health. Though much is said regarding healthcare, health, and wellness, one may question whether such notions can be understood only in positive terms. The positive concepts of health must be understood in relation to the absence of particular dysfunctions, pains, or deformities, and there may be numerous concepts of human well-being and exemplary function (Boorse,1975). It is also difficult to provide a positive account of health and well-being that will not include concepts of economic, political, and social health. For example, the World Health Organization's 1958 definition of health as a "state of complete physical, mental, and social well-being" (WHO, p. 459) has been criticized for being too broad and ill defined to guide the formation of health policy (Callahan). The philosophical literature, aside from addressing these difficulties with concepts of health, has focused mainly on concepts of disease and illness.

Philosophical concerns regarding concepts of health and disease can be organized under six questions:

1. Are disease entities to be discovered or are they and their classifications instrumental constructs that are created to achieve certain ends?

2. How do explanatory models shape the boundaries between health and disease and determine the meaning of disease?

3. What values shape concepts of health and disease, and to what extent are these culturally determined?

4. Is the definition of mental disease and health different from that of somatic (or physical) disease and health?

5. Do concepts of animal disease function in the same way as concepts of human disease?

6. How can concepts of health and disease be used for overt political and social ends?

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