IV. 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?

The ens morbi

The history of medicine is replete with talk of clinical findings constituting an ens morbi (disease entity). Disease entities have been conceived of as metaphysical entities, clinical entities, pathological entities, etiological entities, and genetic entities. These ways of considering diseases generated a significant dispute in the nineteenth century between those who held that disease entities (and the classifications within which they are understood) identify realities in the world and those who held that disease classifications are at best distinctions imposed on reality to achieve certain goals (e.g., of diagnosis, therapy, and prognosis). The first were termed ontologists, while those who took a more conventionalist, instrumentalist, or nominalist position were termed physiologists. This distinction appears to have been articulated in 1828 by Françlois-Joseph-Victor Broussais (1772–1838), who denounced ontological accounts of disease (1821). Carl Wunderlich (1815–1877), Ernst von Romberg (1865–1933), Alasdair MacIntyre, Samuel Gorovitz, and others have, in various ways, taken positions in sympathy with Broussais.

Ontological theories have held that disease terms or classifications name things in the world. Though Broussais had directed his criticisms against clinical classifications, disease ontologists can be taken to include any who perceived diseases as entities, including metaphysical views advanced by individuals such as Paracelsus (1493–1541), who held that diseases are specific entities that arise outside the body.

Disease entities have also been understood as clinical realities, or as recurring constellations of findings. Thomas Sydenham (1624–1689), in classifying disease entities, construed them as enduring types and patterns of symptoms: "Nature in the production of disease is uniform and consistent; so much so, that for the same disease in different persons the symptoms are for the most part the same; and the selfsame phenomena that you would observe in the sickness of a Socrates you would observe in the sickness of a simpleton" (p. 15). It is within such a view of disease that one can speak of a person having a typical case of typhoid. Such language expresses the view that there is a central identity for a disease that is its essence, or type. One can therefore classify diseases by type, as well as speak of instances of a disease as approximating a typical case. Within this understanding, one can also talk of typical cases as rare: "One rarely sees a typical case of secondary syphilis." Patients embody clinical realities where typical means the full and complete expression of a disease, or an ideal type, but not necessarily its usual expression. It was against this genre of account that Broussais spoke.

Etiological accounts, like metaphysical views, focused on the cause of the disease as the disease entity, but regarded disease entities as empirical, and usually infectious, agents. Rudolf Virchow (1821–1902) characterized this view as "ontological in an outspoken manner" (p. 192). Virchow considered this understanding of disease entities to rest on a confusion between a disease and its cause. "The parasite," he wrote, "was therefore not the disease itself but only its cause"(p. 192). The confusion of the disease with its cause led to a "hopeless, never-ending confusion, in which the ideas of being (ens morbi) and causation (causa morbi) have been arbitrarily thrown together, [and] began when microorganisms were finally discovered" (p. 192). The mature Virchow embraced a view of disease entities grounded in pathological findings, and he held that a disease entity is "an altered body-part, or, expressed in first principles, an altered cell or aggregate of cells, whether tissue or organ" (p. 192). Further, "this conception is expressly ontological. That is its merit, not its deficiency. There is in actuality an ens morbi, just as there is an ens vitae (life force); in both instances a cell or cell-complex has the claim to be thus designated" (p. 207).

Genetic accounts can also interpret the disease entity as an empirical reality, to be found in genetic abnormalities (Anderson; Fowler, et al). The promise of somatic-cell gene therapy raises the question of a disease entity once again. That is, does the disease exist in the genetic structure, or is the structure the cause of the disease?

Current uses of the term disease in standard nomenclatures and nosologies (classifications) have a predominantly nonontological character. A conventionalist view allows one to choose, for example, whether one wishes to treat tuberculosis as an infectious, genetic, or environmental disease (recognizing that all three sorts of factors contribute to the development of tuberculosis), based on which variables are most easily manipulated. One may decide that it would be best to treat tuberculosis as an infectious disease because little is known about the inheritance of resistance against tuberculosis, or because any eugenic programs to eliminate tuberculosis would be very slow in taking effect. It may also be seen as an environmental disease that is brought about by socioeconomic conditions such as housing, food, and other such factors. It is meaningless to ask whether such a definition of disease is true or false, only whether it is useful (Wulff).

Diseases as Clinical Findings and Explanatory Accounts

Many people take the term illness to identify a subjective experience of failed function, pain, distress, or unwellness. Disease, in contrast, is then an explanatory concept, or part of an explanatory account (Boorse, 1975). Or one might identify illnesses as constellations of signs and symptoms and diseases as illnesses joined to disease models or explanations, where the content of the illness is augmented by the phenomena found on the basis of a disease model. But to recognize a state of unwellness as a state of disease is already to have begun to explain it and to recast the meaning of the findings within an interpretive context. A constellation of phenomena is held to be recurrent, and if such a constellation of phenomena is encountered again in the future, it can be identified. A specific set of symptoms, for example, can be identified as a case of chronic fatigue. Diagnoses of syndromes, of recurrent patterns of signs and symptoms, allow predictions to be made (prognoses) as well as the management of outcomes (therapy). Such predictions and attempts at therapy can succeed even in the absence of causal explanations.

During much of its history, medicine has been concerned with classifying patterns of signs and symptoms so that they can be recognized in the future with greater ease. Thomas Sydenham's classic Observationes medicae (1676) suggested classifying diseases in definite species, following the methods of botanists in classifying plants. His work was followed by Carolus Linnaeus's Genera morborum in auditorum usum (1759), François Boissier de Sauvages de la Croix's Nosologia methodica sistens morborum classes juxta Sydenhami mentem et botanicorum ordinem (1763), and William Cullen's Synopsis nosologiae methodicae (1769). These classifications functioned without causal explanations, though these were also given. Such medical descriptions and explanations at a clinical, phenomenological level are still employed whenever a new illness is identified for which a causal explanation is not yet forthcoming. For example, acquired immunodeficiency syndrome (AIDS) was first identified as a clinical, phenomenological entity.

Medicine also explains health and disease by relating what is observed via general laws of physiology, anatomy, psychology, genetics, and so forth to other phenomena. The result is a two-tier account of diseases. The first tier is that of the observed constellations of phenomena, such as a clinical description of yellow fever. The second tier is that of a model advanced within the laboratory medical sciences to explain the observed clinical phenomena, such as an explanation of the clinical findings in yellow fever in terms of the effects of a group B arbovirus (a group of viruses transmitted by mosquitoes and ticks) that causes the death of essential cells in the liver.

The laws of pathophysiology (the physiology of disordered function) and pathopsychology (the psychology of mental disease) relate new phenomena to the original clinical constellations of signs and symptoms. Some of these phenomena are then recognized as the causes of the illness. The concept of disease thus comes to identify disease models that support the search for unnoticed causal factors and expressions of disease. For example, Giovanni Battista Morgagni (1682–1771) in his De Sedibus et causis morborum per anatomen indagatis (1761) correlated clinical observations with postmortem findings, and Philippe Pinel (1745–1826) incorporated anatomical considerations into his Nosographie philosophique (1798), producing nosologies that embraced not only clinical observations, but anatomical considerations as well. This change in focus was strengthened when Marie-François-Xavier Bichat (1771–1802) argued that constellations of symptoms and signs could be explained in terms of underlying pathological processes. According to Bichat, medical advances are best achieved through autopsies (Foucault). This shift to the study of pathological findings as a way to explain clinical observations was then supplemented by accounts drawn from microbiology, endocrinology, biochemistry, genetics, and other fields, producing contemporary explanations of illnesses.

In the process of moving from accounts of illness that were predominantly clinical observations to accounts based on observable illnesses of the anatomy, the meanings of diseases were altered. Individuals who once were thought to die of acute indigestion were now understood to die of a myocardial infarction. The meanings of the phenomena observed (e.g., clinical signs and symptoms) were reinterpreted in terms of disease models. As a result of this recasting, medical complaints often came to be considered legitimate only to the extent that they had a demonstrable, underlying pathophysiological or pathoanatomical lesion.

Health and Diseases: Discoveries or Cultural Inventions?

If certain physiological and psychological functions can be identified as natural or essential to humans, then their absence can be used to define disease states. Leon Kass and Christopher Boorse have argued that one can specify those functions that are integral to being human, and thus secure accounts of disease that are not relative to a particular culture or set of values. Such understandings of health and disease could then be used to sort out essential from nonessential (if not proper from improper) applications of medicine. However, such naturalistic views may depend on particular understandings of what is natural. Others appeal to an evolutionary account of what should count as species-typical levels of species-typical functions appropriate for age and gender (Boorse 1976).

In contrast, Joseph Margolis, H. Tristram Engelhardt, and others have argued that definitions of disease and health depend on sociological, culturally determined value judgments, and that these definitions can be understood only in terms of particular cultures and their ideologies (Margolis). A value-free account of disease cannot be given, some have argued, because diseases are defined not by their causes, but by their effects (Resnek)—and their effects gain significance within a cultural context. K.W.M. Fulford has also indicated deeply hidden but still crucial evaluative elements in medicine. He has done this through a linguistic-analytic examination of how disease language appears to be value-free, while still entailing values, with the result that controversies in medical health are engendered where relevant values are sufficiently diverse. Fulford also argues that part-function analysis, which focuses on the proper function of each part of the body, fails with psychotic mental disorders where the rationality of the person as a whole is disturbed. Others have explored the nature of disease through the use of action theory and by placing concerns about disease and illness within the larger holistic context of health (Nordenfeldt, 1995, 2001). Still others ground disease language in a notion of malady dependent on the universal features of human rationality, thus eliminating culture as a factor (Clouser).

The view that the concepts of health and disease are culturally determined has been supported by feminist writings on healthcare. Many authors have pointed out that the practice of medicine has had an androcentric (masculine) focus, that women's issues have largely been ignored, and that experiences reported by women that could not be documented have been treated as invalid (Rosser; Oakley).

Partisans of the view that social and cultural ideas influence concepts of health and disease stress that a definition of disease tied to evolution makes disease concepts dependent on particular past environments and past adaptations. Successful adaptation must always be specified in terms of a particular environment, including a particular cultural context. A culture-dependent account of concepts of health and disease need not deny that there will be great similarities as to what will count as diseases across cultures, for certain symptoms and conditions will probably be understood as diseases in most cultures. Supporters of a value-infected, culture-dependent account of disease have argued that those who would attempt a purely evolutionary account of disease have not reconstructed the practice of medicine, but rather some practice of characterizing individuals as members of particular biological species (Engelhardt, 1975). The practice of medicine, in this view, depends on culturally constructed understandings of health and disease.

How one understands health and disease will in turn influence how one conceptualizes medical practice. Henrik Wulff has argued that an exclusively biological or empirical model of illness contributes to paternalistic medical practice, for if concepts of health and disease can be fully understood in biological terms, then there may be no need to assign the patient an active role in the decision-making process. If, however, determinations of health and disease are not just empirical concepts, but are also related to cultures and values, the patient will have a more active role in determining the burden of the disease and the extent of treatment.

The conceptualization of medicine will certainly be influenced by developments in genetic research, which hold the promise not only to correct diseases in patients, but to prevent them in future generations of patients (Anderson; Zimmerman). Thus, as the capacities of genetic medicine increase, preventive medicine will expand. Somatic and germ-line therapies will also be affected as choices are made about which genetic variances should be treated as disease abnormalities (e.g., homosexuality, alcoholism, shortness of stature).

Physical, Mental, and Social Diseases

It has been argued that only somatic diseases are legitimately diseases, while mental diseases are problems with living (Szasz). Following similar lines of argument, individuals have contended that enterprises such as psychotherapy are tantamount to applied ethics (Breggin), or that the cure of somatic disease constitutes the prime goal of medicine (Kass).

In response, some argue that such stark dichotomies or dualisms fail to offer satisfactory accounts of reality. If mental life is dependent on brain function, then all mental diseases can, in some sense, be tied to physical pathology or abnormal anatomy. For example, depression can be presumed to be dependent on a neurophysiological substrate, and thus, in principle, is open to pharmacological treatment. If one views diseases as explanatory models for the organization of signs and symptoms, then it does not matter whether the signs and symptoms identify physiological states ("I have a rash") or psychological states ("I feel depressed"). Nor does it matter whether models employed to correlate these phenomena are pathophysiological or psychological. Most accounts of disease will, in fact, mingle physical and psychological symptoms. As a consequence, one may come to view distinctions among somatic, psychological, and social models of disease in terms of pragmatic needs—of accenting the usefulness of particular modes of therapeutic intervention. One may even advance sociological models of disease, construing diseases primarily in terms of social variables and giving secondary place to the pathophysiological.

Distinctions between medical and nonmedical models of therapy, unlike somatic, psychological, and sociological accounts of disease, are often meant to contrast the autonomy of clients in nonmedical therapeutic models with the dependence of patients on healthcare practitioners in medical models. Talcott Parsons characterized the "sick role" as:(1) excusing ill individuals from some or all of their usual responsibilities; (2) holding them not responsible for being ill (though they may be responsible for becoming sick); (3) holding that they should attempt to become well (a therapeutic imperative) and seek out experts to treat their illness. Medical models tend to support paternalistic interventions by healthcare practitioners and to relieve patients of responsibility for directing their own care. Nonmedical models, in contrast, tend to accent the patient's responsibility.

Somatic models of disease may be employed within both medical and nonmedical models of therapy. For example, hypertension may be treated with antihypertensive agents or by enjoining the afflicted individuals to find ways to change their lifestyles with regard to stress, eating patterns, and so on. The same is true of psychological models of disease. Depression can be treated chemotherapeutically or by enjoining individuals to make changes in their ways of living.

As predisposing factors toward particular diseases become better known and easier to control or avoid, individuals are held increasingly responsible for becoming ill, even though they will remain nonresponsible for being ill. A person is not held to be responsible for having bronchogenic carcinoma in the same way that one is responsible for being a willful malingerer. In other words, one cannot be told to stop having cancer, but one can be held responsible for having developed cancer through one's smoking habits. As the impact of lifestyle on the development of diseases becomes clearer, the responsibility of individuals for their health may increase the possible scope of nonmedical models of therapy.

Animals and Disease

If concepts of human illness, disease, and health are, in part, social constrictions, there will be differences between the ways in which diseases are identified for humans and the ways they are identified for other animals. Illnesses and diseases in animals will be judged through the social or cultural criteria of human beings. Pets or domestic animals may be regarded as having disease or being healthy depending on how they are viewed through human purposes and constructs. The diseases or illnesses of those animals that are not pets, however, along with those of plants, may be understood less in terms of human social or cultural criteria and more in terms of generalized knowledge about the species. In the case of animals in the wild, there may not be concern for individual suffering, disability, or deformity, but rather with the general health of the species. Identifying the role human values play in the concepts of animal disease and illness expands the discussion of the ethical treatment of nonhuman animals in bioethics.

The Social Force of Diagnosis

Concepts of disease have been used to impose political judgments. For example, in the United States prior to the Civil War it was proposed that the flight of a slave to the North and the absence of a wholesome inclination to do effective plantation work were diseases for which explanatory accounts and treatments could be provided (Cartwright). Masturbation was once viewed as a serious disease for which castration, excision of the clitoris, and other invasive therapies were employed. Individuals were even determined to have died of masturbation, and postmortem findings "substantiated" this cause (Engelhardt, 1974). In the case of the diseases of slaves, the motivation may have been to protect slaves from punishment. In the case of masturbation, the influence of cultural values on the psychology of discovery was not appreciated.

Historical perspective can increase our awareness that medical practitioners and researchers have tended to "discover" what already was assumed. More recent political uses of disease concepts (e.g., in psychiatry) have been closely connected with repressive goals and political agendas of certain governments. Social employment of disease definitions is often meant to be benevolent, however, such as advocating a view of alcoholism and drug addiction as diseases so as to recruit the forces of medicine to aid in their control. Moreover, such conditions may be termed diseases in order to relieve alcoholics and drug addicts of the social opprobria that attend what is often viewed as immoral behavior.

Summary

Concepts of health and disease shape descriptions of medical reality, convey explanations, advance value judgments, and structure social reality. They influence not only the scope of medicine, but healthcare policy as well. Because they may involve not only moral values but values associated with physical and mental excellence, they raise questions pertinent to both bioethics and the philosophy of medicine. These special concerns regarding medical explanation may sufficiently define a distinctive problem area so as to establish the philosophy of medicine as a field in its own right, despite arguments to the contrary. In any event, the concepts of health and disease, as well as their application, will continue to be the subject of debate in societies that are morally and culturally pluralistic.

h. tristram engelhardt, jr.

kevin wm. wildes (1995)

revised by authors

SEE ALSO: Anthropology and Bioethics; Bioethics, African-American Perspectives; Eugenics: Historical Aspects; Feminism; Lifestyles and Public Health; Medicine, Anthropology of; Medicine, Philosophy of; Medicine, Sociology of; Mental Illness;Women, Historical and Cross-Cultural Perspectives; and other Health and Disease subentries

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