Care and Cure

An Introduction to Philosophy of Medicine

The University of Chicago Press

Contents

HEALTH

1.1 SUMMARY

Health is one of the primary concerns of medicine. Many philosophical accounts of health blur together analyses of the concept of health with analyses of the concept of disease. However, it is useful to discuss the two concepts separately, though obviously there are significant connections between them. In this chapter we focus on health and in the next chapter we focus on disease.

The concept of health can be analyzed on several dimensions. Some people take health to be simply the absence of disease. Others take health to be something more than merely the absence of disease, such as the ability to flourish in various respects. The former view can be called neutralism, since being healthy on this view is a neutral state, or a state of no disease. The latter view can be called positive health, since being healthy on this view involves something beyond mere freedom from disease.

Another important dimension to the concept of health is the role of the patient in determining whether or not she is healthy. Some people hold that it is only objective facts about a person that determine whether or not that person is healthy. Others hold that the way a person feels about her state, regardless of objective facts about that state, determines whether or not that person is healthy. The former view is sometimes called objectivism because whether or not a person has a disease is supposed to be an objective fact about nature. The latter view, in contrast, can be called subjectivism because it is the subject's (that is, the patient's) assessment of her state that matters.

Finally, a related dimension to the concept of health is the role of normative considerations in determining whether or not a state is healthy. One view, called naturalism, holds that health is a state that depends only on natural (biological or physical) facts. A competing view, called normativism, holds that health is a state that depends on evaluative (normative) considerations. This chapter describes these various debates about the nature of health and assesses the leading positions about them.

There are various standards that philosophical accounts of concepts such as health and disease can employ. One standard is descriptive, which requires analyses of concepts to track various sorts of descriptive facts about a concept, such as the way the concept was used in history, or the way it is typically used today, or intuitions that we have about its proper usage. Another standard is prescriptive, which requires analyses of concepts to align with moral and political views about how we want the world to be and how we think the concept in question can contribute to this. Below we see how these two standards can reach different verdicts about an important concept like health.

1.2 NEUTRALISM AND NATURALISM

Health, according to neutralism, is simply the absence of disease. This is sometimes considered a "negative" conception of health, as opposed to a "positive" conception of health that holds that to be healthy one must have more than merely a body free of disease. If health is simply the absence of disease, then one might wonder what a disease is. The concept of disease is controversial — I leave the discussion of disease until chapter 2.

To articulate the negative conception of health associated with neutralism, consider its opposite. Here is one of the most prominent definitions of health, the positive definition of health written into the constitution of the World Health Organization: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Since this definition explicitly claims that health is not merely the absence of disease, it is non-neutral. It is a "positive" conception of health because it holds that there is something to health that goes beyond the neutral state of not having any diseases. A neutral conception of health denies this. Neutralism holds that to be healthy merely requires one not to have diseases.

To illustrate the difference between neutralism and a positive conception of health, consider two people, Lila and Elena. Neither has any diseases. But Lila grew up in a poor family, received a substandard primary education, and has few loving, supportive relationships, whereas Elena grew up in a well-off family, received an excellent primary education, and has many loving, supportive relationships. Lila ends up working in a physically taxing menial job where there are few people she can develop meaningful friendships with. She does not have time or energy to foster hobbies. Over the years Lila develops a bitterness toward her unfair circumstances and becomes hostile and unsocial. Elena, on the other hand, ends up working in a rewarding profession, meeting many interesting and friendly colleagues. Her increasing wealth affords her time and resources to foster playful and stimulating hobbies. Over the years Elena develops a deep satisfaction with her life.

Neutralism holds that Lila and Elena are equally healthy. Since neither of them has any diseases, and since neutralism holds that health is simply the absence of disease, both are healthy. Notice the appeal to well-being in the definition of health from the World Health Organization. If you think that Elena is healthier than Lila, in virtue of the fact that Elena's overall well-being is better than Lila's, then you might be drawn to a positive account of health. But if you think that they are equally healthy, because they are both disease-free, then you might be drawn to neutralism. Neutralism is closely aligned with another view about health, called naturalism.

Naturalism about health holds that health is a value-free concept. In other words, health, according to a naturalist, depends only on physical facts (or biological, or physiological, or any other natural facts). In order to accommodate mental health, some naturalists include psychological facts among those that are deemed pertinent to assessing whether or not a person is healthy. The most prominent naturalist account of health is Boorse's "biostatistical theory" of health, developed in the 1970s, in which naturalism is aligned with neutralism. To be healthy, on this account, is to have statistically normal biological functions: one's physiological parts and processes must operate with at least typical efficiency. A reference class must be specified in order to determine what typical efficiency is for a particular person, and on Boorse's account the appropriate reference class is a person's age group of a sex of a species. So, to assess the efficiency of my kidney I measure its ability to regulate electrolyte levels and remove organic waste from my blood, and I compare this with that of kidneys of other males in my age group.

Reference classes are necessary on this account because people have a wide variability in physiological functioning. Suppose Sara, an adult female, has normal levels of estrogen for an adult female. If Joe, an adult male, had the same estrogen level as Sara, then Joe would have dysfunctional physiology (and so would be diseased according to a naturalist account of disease — chapter 2). Similarly, if Mary is an infant female and had the same estrogen level as Sara, there would be a problem with Mary's physiological functioning. So to assess normal functioning, naturalism needs appropriate reference classes.

If we use inappropriate reference classes then we will make erroneous judgments of health. If we demarcate reference classes according to whether or not people are heavy alcohol consumers, then the normal range for liver functioning in this group will be worse than for nondrinkers. Suppose Ian is a heavy drinker, and we want to assess his health. If we compare the functioning of Ian's liver to that of other heavy drinkers, his liver functioning will appear normal. If we compare the functioning of Ian's liver to that of nondrinkers, his liver will appear to be dysfunctional. Determining whether Ian's liver functions with typical efficiency depends on the choice of reference class with which we compare the functioning of Ian's liver.

What makes a reference class appropriate? Recall that Boorse demarcated reference classes by sex and by age. What makes these factors appropriate for demarcating reference classes is that we know, on the basis of background theoretical considerations, that particular physiological functions differ depending on sex and age. But we also know, on those very same background theoretical considerations, that various physiological functions differ according to all sorts of features of different kinds of people. For example, we know that people with type 1 diabetes are unable to produce insulin, but it would be absurd to demarcate reference classes according to whether or not people have type 1 diabetes (one unacceptable consequence of such a demarcation would be that people with type 1 diabetes would automatically be deemed healthy because the efficiency of their pancreases at producing insulin would be compared with that of other people with type 1 diabetes). A standard problem that is raised for naturalistic accounts of health (and disease) is that nature itself does not demarcate groups of people into reference classes. Instead, we need to import background knowledge and evaluative content into determining the right reference classes to assess people's health. Thus, naturalism about health cannot be purely "natural."

The biostatistical theory of health is based on a notion of normal function, and thus, in addition to requiring reference classes to determine normality, it also requires an explication of the notion of function. We will leave this until chapter 2, where we study naturalism about disease (which is closely aligned to naturalism about health).

I noted that naturalism includes psychological facts as relevant to determining health. But at a fundamental level, most people hold that Cartesian dualism is untenable (this is the view that there are two distinct kinds of substances in the world: mental and physical). Most people are physicalists, who hold that the world is composed only of physical things. So talk of psychological facts is best understood as shorthand for physical facts that perhaps remain undiscovered. At first glance some aspects of medicine can seem committed to dualism — we'll see this in chapters 5 and 12.

1.3 WELL-BEING AND NORMATIVISM

Above I gave the definition of health from the World Health Organization as an illustration of a positive conception of health. A positive account of health, as opposed to neutralism, holds that to be healthy involves more than merely being free of diseases. Being healthy, on this account, requires the possession of various capacities, such as the ability to enjoy physically active endeavors and the ability to develop meaningful friendships. Of course, one's well-being is usually mitigated if one has a terrible disease, such as cystic fibrosis, and so absence of disease is an important (though neither necessary nor sufficient) component of one's well-being. A theory of positive health holds that the concept of health is similar to the concept of well-being. How compelling is a theory of positive health? Should we be neutralists about health, or rather, should we hold a theory of positive health? Is health distinct from well-being?

Well-being is itself a tricky notion. There are several leading accounts of well-being. One theory of well-being holds that a person is doing well if they are able to achieve their goals. Another theory holds that a person is doing well if they have certain basic capacities. Yet another theory holds that a person is doing well if they feel satisfied with their state. Most theories of well-being, obviously, require more than mere absence of disease.

What is the relationship between health and well-being? Most people agree that health is intimately related to well-being. There are three ways in which health might relate to well-being. Health might promote well-being: for example, being healthy allows one to maintain stable employment, which itself promotes various aspects of well-being. Or, health might in part constitute well-being: for example, reducing the symptoms of a headache increases my health and also, at the same time, increases my well-being because being pain-free is in part constitutive of well-being. Or, health might just be a kind of well-being: this is suggested by the World Health Organization definition of health noted earlier. Which of these is correct?

The two first possibilities appear modest and are almost certainly true. We have very good reason to think that being healthy can cause improvements in well-being. Healthy people are more likely to have rewarding social relationships, maintain stable employment, and achieve other important life goals. On any conception of well-being (goal satisfaction, state satisfaction, or capacity maintenance, to name the dominant theories), health contributes to well-being.

Beyond this causal relation, at least sometimes health can partly constitute well-being. I might have the goal of being disease-free, in which case satisfaction of that goal simultaneously renders me healthy and, on the goal-satisfaction account of well-being, contributes to my well-being. But this constitutive relation between health and well-being is fragile. Suppose I have type 1 diabetes and thus suffer from a serious disease that mitigates my health, and yet I am able to satisfy all of my life goals; on the goal satisfaction account of well-being, then, my health suffers but my well-being does not. So it's probably not universally true that health partially constitutes well-being. But it is at least sometimes true.

What about the stronger possible relation between health and well-being? Is health simply a kind of well-being? This is what a positive theory of health seems to require and what neutralism about health denies.

Let's return to the story of Lila and Elena. Are they equally healthy, on the basis of the fact that neither has any diseases? Or is Elena healthier than Lila, on the basis of the fact that many aspects of Elena's life are superior to Lila's? As we saw in the previous section, neutralism holds that Elena and Lila are equally healthy. But on a positive account of health, Elena is healthier than Lila.

As noted above, a popular conception of positive health and well-being is based on goal satisfaction. On such an account, people are healthy to the extent that they are able to achieve their goals. Suppose a primary life ambition of both Elena and Lila is to become a successful writer — thanks to the way her life has gone Elena is able to achieve this goal while Lila is not, and so according to a positive conception of health, Elena is healthier than Lila. There are several problems with such a view. One is that people might have unrealistic goals. Suppose one of my goals is to be an Olympic marathon runner. Since I am not achieving this goal, the goal satisfaction account of positive health holds that I am unhealthy. Conversely, people might have trifling goals. Suppose a person's goal is merely to live another day. That person could suffer from severe physiological problems and yet readily achieve her goal, day after day, and thus be deemed healthy on this account.

How are we to referee between neutralism and positive health? One approach is to determine which view is more closely aligned with our intuitions and with our linguistic habits. This would be to hold the two conceptions to a descriptive standard: on such a standard, the best conception of health is that which more closely tracks the descriptive facts about our intuitions and linguistic practices. On this standard, neutralism is likely to fare better. Another approach is to determine which view is more closely aligned with the way we want society to be and the kinds of lives we hope for people. This would be to hold the two conceptions to a prescriptive standard: on such a standard, the best conception of health is that which more closely tracks one's prescriptive views about how society ought to function and what aspects of our lives are valuable. On this standard, a positive account of health is likely to fare better.

A challenge for a positive conception of health is that the value-laden goals associated with positive health might be better construed as issues that are pertinent to society at large, rather than specifically to medicine. Since health is supposed to be a central concept in medicine specifically, one might hold that we should restrict our evaluation of various conceptions of health to standards that appeal only to medical issues. (Of course, the term "health" is sometimes used in nonmedical contexts, as with phrases like "the health of the economy" or "a healthy relationship," but these extensions of this medical concept into nonmedical domains are metaphorical.) Elena might be better off than Lila, but the respects in which she is better off are nonmedical, since neither needs treatment from physicians. We might wish that Lila's life would go better in many respects, but — goes this response — there is no respect in which Lila's health could be better, since she has no diseases. The ways in which Lila's life could improve involve education, labor, and social issues, and not medical issues. Positive accounts of health overextend the domain in which the concept of health properly applies.