Documente Academic
Documente Profesional
Documente Cultură
Editors
H. Tristram Engelhardt, Jr., Center for Ethics, Medicine, and Public Issues, Baylor
College of Medicine, Houston, Texas and Philosophy Department, Rice
University, Houston, Texas
Stuart F. Spieker, Center for Ethics, Medicine, and Public Issues, Baylor College of
Medicine, Houston, Texas
Associate Editor
Kevin W. Wildes, SJ., Department of Philosophy, Georgetown University,
Washington, D.C.
Editorial Board
George J. Agieh, School of Medicine, Southern Illinois University, Springfield, Illinois
Edmund Erde, University of Medicine and Dentistry of New Jersey, Camden, New
Jersey
Patricia A. King, J.D., Georgetown University Law Center, Washington, D.C.
E. Haavi Morreim, Department of Human Values and Ethics, College of Medicine,
University of Tennessee, Memphis, Tennessee
The titles published in this series are listed at the end of this volume.
LENNARTNORDENFELT
Department ofHealth and Society,
Linköping University,
Linköping, Sweden
ON THE NATURE
OFHEALTH
An Action-Theoretic Approach
ISBN 978-0-7923-3470-5
ACKNOWLEDGEMENTS x
INTRODUCTION Xl
NOTES 175
BIBLIOGRAPHY 193
SUPPLEMENTARY BIBLIOGRAPHY 200
INDEX 201
Lennart Nordenfelt
ix
ACKNOWLEDGEMENTS
x
INTRODUCTION
GENERAL INTRODUCTION
interpreted to be, on the one hand, the functions of the microscopic parts
of the body, or, on the other hand, the gross functions of the major organs.
Both of these extreme alternatives can yield counterintuitive consequences.
(2) The BST faces a number of difficulties when we consider more closely
the dynamic interaction between an organism and environmental change
pertaining to the organism.
As a consequence ofthis discussion it is argued that our ordinary (as well
as scientifically medical) conceptions of disease cannot be entirely formed
according to a biostatistical model. Considerations concerning pain and
disability are obviously crucial. This conclusion provides good reasons for
considering a theory where pain and disability play an essential role viz.
a theory constructed from a holistic perspective.
The purpose of Chapter three is to provide and defend a holistic theory
of health, which is mainly intended to apply to human beings, although
some applications to non-humans are also made. The key concept in this
theory is the concept of ability, which is therefore given a substantial
analysis within the framework of modern action-theory. The main stages
in this analysis are the following:
The traditional distinction between ability and opportunity for action is
made. A combination of ability and opportunity constitutes what is here
called practical possibility: it is practically possible for a person to perform
an action if, and only if, he is both able and has the opportunity to perform
it.
Ability is defined as that kind of possibility for action which is determin-
ed by factors internal to the agent's body or mind. The specification of an
ability must, however, always presuppose a situational background. It is
argued that, when this background is not explicitly stated, there is a tacit
presupposition of a set of "standard circumstances".
What counts as standard circumstances will, however, vary from place
to place and from society to society. As a result, a person with a particular
physical and mental make-up may be able to perform a required action in
one environment but not in another. This implies an important relativi-
zation in the case of the notion of ability. A fortiOri, this also applies to the
notion of health.
This relativization is in one important respect reduced by the intro-
duction of the concept pair first-order ability and second-order ability. The
idea here is the following: a person may be unable (in the immediate,
first-order, sense) to perform a certain action, but still have a second-order
ability to perform it. This then means that he will, given that he undergoes
INTRODUCTION xv
adequate training and exercise, obtain the first-order ability to perform the
action in question. It is argued that the ability involved in health is of the
second-order kind.
After these preliminaries the fundamental task of the book is formulated
in the following terms: what is the set of goals, and by whom are they set,
which define the abilities that constitute health? This required set of goals
is designated the vital goals of man. Two important proposals for defining
the vital goals are given and discussed in some detail.
(a) The vital goals of man can be deduced from his basic needs (the
need-theory).
(b) The vital goals of man are identical with the goals that he
himself sets during the course of his life (the subject-goal
theory).
The first proposal is found to be too weak; the second is found to be both
too weak and too strong. Some improvements of the two proposals are
considered.
The major suggestion of the whole essay is then introduced: the vital goals
of a human being are. goals whose fulfillment is necessary and jointly
sufficient for the minimal happiness of their bearer. This is the tenet of what
is here to be called the welfare theory ofhealth. (In the case of humans welfare
is identified with happiness.)
The concept of human health is thus connected with the concept of
happiness. Health is in itself, however, neither sufficient nor necessary for
happiness. Health is a person's ability, in standard circumstances, to real-
ize his minimal happiness. It is not sufficient for happiness since, if circums-
tances are not standard, for instance in cases of accident or war, health
need not result in happiness. Nor is health necessary for happiness, since
the vital goals of an ill yet happy person can to a great extent be fulfilled
by people other than the person himself, for instance relatives and others
taking care of him.
The qualifying concept of minimal happiness is introduced and defended
in the context of an analysis of happiness. Happiness is presented as a
multidimensional concept ranging from a very high degree (along some
dimensions one can even speak of complete happiness) to a very low
degree. It is argued that the vital goals of man are conceptually connected
to some minimal degree of happiness to be decided upon by evaluation.
The concept of health thus derived is not theoretically decidable in the
following sense: the analysis of the concept is not sufficient to establish an
XVI INTRODUCTION
ity is a disease (or impairment) only given very special provisos: (i) repro-
duction is an indisputable vital goal, (ii) the homosexual does not merely
choose not to reproduce, but is also unable - for physical or mental reasons
- to reproduce. The latter proviso, obviously, is not generally true.
Finally, the welfare concept of health is applied to the realm of non-
humans. It is argued that the welfare concept of health is applicable also
to the non-human living world. With the higher animals both the ideas of
ability and happiness can be retained. To the lower animals and the plants
the concept can only be extended through analogy. It is, however, disputed
that health in lower animals and plants should be identified simply with
normal probability of survival and reproduction. Health, in these cases, can
also be understood in terms of usefulness: a corn plant is healthy if it
contributes, given standard circumstances, in an expected way to certain
goals and ultimately to the happiness of its cultivator.
CHAPTER ONE
such a consensus presently exists, over and above the application of the
notion to certain obvious diseases.
In sum, there seem also to be urgent practical needs - in addition to the
general philosophical and scientific ones - for correctly characterizing
health and disease.
(3) What is the relation between human health and the health of
other living beings?
Most health-concepts seem to be applicable to other living beings, ani-
mals as well as plants. A dog can be healthy and can acquire diseases and
injuries; so can a cauliflower. It is plausible to assume that these appli-
cations of health-concepts are not radically different from their uses in the
human case. A reasonable theory of health should be able to account for
the similarities as well as the differences between human health and the
h~alth of animals and plants.
The science of medicine has as its subject matter the phenomena repre-
sented by the health-concepts.This raises a number of theoretical questions
concerning the nature of these concepts. What kind of qualities do they
refer to? Are they purely biological; or are they biostatistical or perhaps
anthropological; or do they belong to a number of different spheres?
To this can be added a more radical question: are the health-concepts
basically descriptive, scientific, concepts or are they basically evaluative?
What is the point in talking about "positive" and "negative" health-con-
cepts? Do they indicate some kind of evaluation? What is the nature of this
evaluation and to what extent is it compatible with a science of medicine?
which can be structured in many different ways, and a language which can
be used in many different ways. There are certain ways of structuring the
world and of using the language which are currently dominant. But nothing
in principle prevents us from changing them.
According to this view, to define concepts such as health or disease is
not to find the true nature of these phenomena (there is no such true nature)
but to determine a particular way of using language. This way may be
currently accepted or newly stipulated.
Within nominalism one can find two important but diverging tendencies.
One of these is the exact opposite of Aristotelian essentialism. It denies not
only that the world has a natural organization, but also that language has
any clearly definable uses.And, at least according to some advocates, it
even denies the desirability oflanguage's having a clearly definable use. This
position will be called the strong version of nominalism. 7
A different nominalist position is the following: It is indeed a convention-
al affair how we structure the world. It is dependent on our ways oflooking
at things and on our particular purposes. On the other hand, our use of
language is not completely arbitrary. A presupposition of efficient commu-
nication between individuals is that they structure the world and use
language in almost identical ways. Since communication seems to be rather
efficient in most societies, it is a reasonable hypothesis that there is a fairly
definite structuring of the world and use of language within them. This
structure and language use can be defined. For example, we can define how
the terms "health" and "disease" are used in the Anglo-American society.
This is, according to this' version of nominalism, one reasonable interpre-
tation of the phrase "to define the concepts of health and disease".
If it were to turn out that part of a particular language use is unclear and
difficult to define - which in fact implies that communication must be
ineffective - then a nominalist of this persuasion would not hesitate to make
an explication of the notions involved. Nor would he hesitate to recommend
making certain changes (often simplifications). In contrast to the nominal-
ist of the strong persuasion, he finds clear definitions desirable.
The philosophy to be followed and defended in this essay will be of the
latter form, and will be called weak nominalism. According to this view,
then, there is a fairly definite use (or interrelated uses) of the term "health"
and its relatives. This use (or uses) determines the concept of health to be
analysed in this essay.
But if this is our position, how should we explain the following phenom-
ena?
8 CHAPTER 1
the first society. Hence, C is judged to be in health. B looks upon him from
the other perspective. Hence, C is judged to be disabled, to be ill.
Here again, A and B may share the same concept of health, the difference
between them lying in their application of the concept in different contexts.
Our list of explanations of disagreements between people who make
judgments about health can be lengthened. A more complete discussion of
some of these aspects will be found in Chapter five, section 1: On the relation
between health and society. The purpose of this discussion was merely to
present and critically analyse a set of arguments to the effect that there is
a great multiplicity of concepts of health.
Legitimately refusing to accept such arguments, however, does not prove
that there is only one "true" notion of health. This is not the standpoint
taken in this essay. There is no Aristotelian species called "health"; what
there is, is a use (or a number of related uses) of the term "health". The
assumption is made, however, that this use (these uses) is consistent
enough to allow a characterization and an explication.
Such a characterization can be performed in slightly different ways and
with slightly different purposes. One way is to make a detailed sociolinguis-
tic study and try to pinpoint similarities and differences in various
subcultures. It would be of interest to trace these subcultures, see how
influential they are, and try to describe the technical concepts of health and
disease which they employ. But such a pursuit could not substitute the kind
of project envisaged in this essay.lO
The present project is more traditionally philosophical; its purpose is to
find a core element in prevalent uses ofthe term "health", and try to develop
it in such ways that it will become coherent and useful for scientific
purposes. The aim is not merely one of lexicography, but also of logical
reconstruction: to sharpen the borders of the concept of health. The con-
cept will thus be influenced by the process of analysis. Thus there is an
element of stipulation in the present program, though the basis is an already
existing concept of health.
following: How does this person feel? What is he able to do? Can he
function in a social context?
From the second perspective one directs one's attention to particular
parts of the human organism and considers their structure and function.
One asks questions such as: Is this organ normal? What is the pulse rate
of this man? What does the tissue of the liver look like? What capacity do
the lungs have?
The first perspective, which focuses on the human being as a whole, will
here be called a holistic perspective. A study pursued from this perspective
will use concepts borrowed from ordinary language, psychology, anthro-
pology or sociology. Examples of such concepts are those of well-being,
pain, depression, ability, adaptability, disability and handicap. II
The second perspective, which concentrates on the parts of the orga-
nism, will here be called an analytic perspective. A study pursued from this
perspective will use mainly biological, chemical and statistical concepts. It
will involve inspecting organs and tissues, studying their functioning and
measuring their rate of change, as well as calculating the relative frequency
of the values obtained. 12
What are the ,sources of these two perspectives and why do they both
have a prominent place in our thinking? The source of the first perspective
is obvious. The ordinary human being is primarily interested in the holistic
facts. How do I feel today? Has my pain gone? Can I go to work? What
matters to him are the realities about his whole person. The detailed
functioning of a particular organ is interesting only ifit substantially affects
his whole person in a positive or negative way. The key question for the
ordinary man is: am I healthy or not?
The source of the second perspective is the art and science of medicine.
Medicine has a task: to eliminate disease and restore the health of those
who seek its help. In order to accomplish this, medicine must acquire
knowledge about the mechanisms behind the phenomena of health and
illness. To obtain this knowledge the physician must make detailed investi-
gations involving the smallest accessible parts of the human body. As a
result, his concentration is fixed on particular internal phenomena. A key
question from this perspective is: what is the nature of this disease?
The two perspectives clearly do not exclude one another. In fact, one
cannot view the health-disease dimension from but one of these perspec-
tives alone. The ordinary man surely understands that there is an organic
(and mental) background which is responsible for his state of health. He
understands that his body is like a piece of intricate machinery which can
SOME BASIC ISSUES 13
function well or go awry. In the first case the result is health, in the second,
illness; and the particular malfunction is a disease.
Conversely, the practising physician is highly aware of the holistic pers-
pective. The call for help comes from a person who claims that he is ill; and
the physician's task does not end until health (viewed from the holistic
perspective) is restored.
It is also clear that any serious theory of health and disease must take
both perspectives into account. The holistic phenomena of health and
illness must be properly treated, as must the analytic phenomena of dis-
eases and impairments; moreover, there must be a clear account of the
relation between the two worlds: how, for instance, is a disease related to
the general state of a person's health?
While acknowledging this, it will be argued here that most theories of
health - perhaps all plausible ones - basically stem from one of the two
perspectives. That this is a reasonable claim can be seen from the following.
It is a plausible supposition that health and disease are in some sense
conceptually related. It is not only a matter of empirical fact that diseases
affect our health. If a certain "disease" had no consequences for anybody's
health, we would stop calling it a disease. That the two concepts are
conceptually related thus means that one can be defined (at least partially)
in terms of the other.
For such a definition to be articulated, one of the concepts must be
chosen as more basic than the other. If health is chosen as the basic
concept, the concept of disease should be defined in its terms, for instance,
as a phenomenon which compromises health. But, then, health could not
itself be defined in terms of disease - that would be circular. For the
primary characterization of health we would have to find a set of concepts
not containing the concept of disease. The most natural set would be found
among those used in the holistic perspective, for instance: a man is healthy
if he feels well and can perform his social functions.
Conversely, if disease is chosen as the basic concept, it cannot be defined
in terms of health (or illness). Here, then, the most natural set of concepts
in terms of which to define it will be found among the ones used in the
analytic perspective, for instance: a disease is the abnormal functioning of
a bodily organ.
J'he main role of the perspectives in the formation of a theory of health
and disease then is to aid one in selecting one of the concepts as basic.
Moreover, the perspective chosen provides the conceptual background for
the basic concept of the theory. But a theory formed from one of the
14 CHAPTER 1
Also on the modern bio-medical platform one can find the dual - and
essentially unclear - view of normality, combining descriptive and norma-
tive issues. There is today a marked drive towards using statistical
normality as the basic concept, but few presentations do not at the same
time employ evaluative terms in characterizing the normal functioning of
a human body.16
In contrast to this prevalent unclarity there is one forceful modern
attempt to formulate a conception of health and disease in terms ofbiologi-
cal norms where the interpretation is unambiguous. According to this
conception the biological norms are related to certain natural goals (for
instance the goal of survival). These goals are not attributed to the body
from the outside - they are not goals according to which the body should
function - but belong to the internal constitution of the body. Scientists can
detect what these goals are by inspecting a large sample of human beings,
by making a biostatistical analysis. These are the essential tenets of a theory
presented by the American philosopher Christopher Boorse in his signifi-
cant articles ([13]), ([14]) and ([15]). This theory will from now on be called
the biostatistical theory (BST).
AN ANALYTIC THEORY OF HEALTH 17
The concept of a goal will playa central role in the following discussion.
It has its place both in some analytic theories and, very clearly, in holistic
theories. The term "goal" has two rather different senses, however, both of
which are important in the analysis of health.
In its m.ost general sense the term "goal" refers to a state of affairs which
is the end of some sequence of events, be they natural events or actions.
But this general interpretation can be specified in two ways. Thus one can
speak of an ideal goal set by somebody, normally a human being or some
collection of human beings. This notion is tied to such concepts as 'in-
tention' and 'desire'. If a person intends to realize a state of affairs then this
state of affairs is an ideal goal of his. Alternatively, one can consider a
factual goal, by which we mean a state of affairs that an entity has, as a
matter of fa.ct, a tendency to approach.
A quite precise illustration of this latter notion can be collected from
modern molecular biology. The general idea here is the following: in the
genes of an organism there is an encoded program, which steers the
development of the organism towards a specific phenotype. The program
is connected with steering mechanisms in such a way that, given a set of
possible environments (excluding the most extreme ones), there are causal
mechanisms to effect the evolution of the phenotype. 17
In general we shall say that an organism 0 is goal-directed in this sense
if, and only if, the following conditions hold:
o includes or is connected with a program which assigns a set of goals,
and a set of steering mechanisms, such that the steering mechanisms
constantly keep 0 oriented towards one of its goals.
The notion of goal assumed in the biostatistical theory of health (BST)
is the notion of a factual goal. 18
The realization of a goal, whether ideal or factual, involves a process or
an activity of some kind. If the goal is very general or far-reaching, its
realization may presuppose a very long process involving a number of
stages. These stages constitute subgoals of the main goal.
There may be alternative sets of subgoals for one and the same ultimate
goal. This means, on the one hand, that in a particular situation there may
be different ways of realizing the ultimate goal. One can, for instance, travel
to New York from Stockholm via either Copenhagen or Oslo.
But it means, on the other hand, that different situations may require
different subgoals for the realization of one and the same ultimate goal. For
18 CHAPTER 2
In introducing his theory Boorse explicitly aligns himself with the ancient
medical tradition that culminated in Galen. Boorse here quotes the medical
historian Temkin:
Such a concept of health and disease rests on a teleologically conceived biology. All parts of
the body are built and function so as to allow man to lead a good life and to preserve his kind.
Health is a state according to Nature, disease is contrary to Nature. ([130], p. 398).
and should not be, any more value-laden than the concept of somatic
health.
Mental health must be a constellation of qualities displayed in the standard functional
organization of members of our species. Only empirical enquiry can show whether normal
human beings have an even temper, engage in socially considerate behaviour, and advance
the species -or make love with 'dignity and decency' ([14], p. 70).
It is only when we use the "evaluative" member of the concept pair that
we can infer that the designated state is undesirable.
The concise definition of illness proposed by Boorse is the following: A
disease is an illness only if it is serious enough to be incapacitating, and
therefore is (i) undesirable to its bearer (ii) a title to special treatment and
(iii) a valid excuse for normally criticizable behavior. 21 According to this
definition there can certainly be diseases which are not illnesses. Boorse
allows for "lanthanic" (hidden) diseases (to borrow a term from Alvin
Feinstein), and he allows for early stages of diseases, where these have not
yet turned into illnesses.22
On the other hand, on Boorse's conception all illnesses are diseases. A
person can be ill only if he is diseased. This shows that the BST still rests
on the analytic platform. Illness (on the level of the whole person) is
partially defined in terms of disease, while the concept of disease is not tied
to the state of health of the whole person. Rather, as we have seen, it is
tied entirely to the subnormal functioning of some bodily part.
not identify disease with every kind of deviance from normal values.
Disease is present only when an organ functions at a subnormal level.
The conception of subnormality is important since there are many bodily
and mental deviances which we are inclined to call supernormal and which
could hardly be called diseases. High intelligence is perhaps the most
celebrated example. But if the function of an organ (or a mental faculty)
is not connected to the attainment of a certain known goal, we will be
unable to make judgments concerning sub- or supernormality. For example
the mere observation that an organ, say a gland, "produces" more than
average will not suffice to say that it superproduces. Overproduction can
be countereffective and even prevent the attainment of the gland's particu-
lar goal, or have a generally negative influence on the life of the organism.
In the spirit of the BST we could define supernormal functional ability
in the following way: An organ functions supernormally, if and only if it is
more effective than the statistical average in attaining its particular goal,
provided that this efficiency does not have side effects which are negative
with respect to this goal.
In order to assess the BST we must look more closely at the notion of
a function. Let us consider the following questions:
(i) What is the exact nature of a function? How is the concept of
function to be distinguished fromJunctional ability andJunctional
peiformance?
(ii) What kinds of entities are bearers of functions? Are functions
restricted to what is commonly called organs and mental fa-
culties? Or do all parts of the body, however minute, have
functions?
(i) In Boorse's text there are a number of related concepts: function,
functioning, and functional ability. These are not all explicitly defined,
although the context often helps us to understand them. For our discussion
we need more precise definitions of these concepts.
Function can be characterized in the following way:
Organ 0 has a function Fg if, and only if, 0 is directed towards
a goal G (in the factual sense defined on p. 17 ).
For the purpose of the BST we also need the following more complicated
characterization:
AN ANALYTIC THEORY OF HEALTH 25
The notion offulfillment requires a comment. It could mean that the work
of 0 is a causally sufficient condition in C for the realization of G. Now,
the locution normally used in Boorse's texts is that an organ contributes to
the realization of a goal (presumably one of the ultimate goals of survival
or reproduction). This fact need not raise any theoretical problem. If an
organ contributes to the realization of an ultimate goal G, then it must, in
the circumstances, be causally sufficient for some subgoal of G. That 0
fulfills its function could then mean that it provides sufficient conditions for
a subgoal of G.
Could we then not choose the subgoal as the goal of the organ? As we
shall see in the following discussion there is a difficulty connected with such
a choice. It may be that, depending on the circumstances, the organ aims
for slightly different subgoals in its causal contribution to the attaining of
26 CHAPTER 2
the ultimate goal. The goal of the organ (understood as the kind of state
for which the organ is a causally sufficient agent) must then be described
as a set of goals related to a corresponding set of circumstances.
That a particular organ, or some other part of the body, has a function
or a functional ability says very little about the actual work performed by
the organ, i.e. its functional performance. The sort of performance required
depends on the organ's place in the internal environment, in particular on
what the other organs do and what happens to them. But it also depends
on the external situation, that is, on the external pressures placed on the
body.
It is important to notice that the intensity of functional performance can
also vary greatly in what we might call standard circumstances. Some
organs have continuously to perform near their maximum in order for their
goals to be realized. The heart must pump continuously in order to fulfill
its function; the lungs must exchange gases continuously. But, in contrast,
the stomach and the thigh muscles are used only intermittently. Some parts
of the body are used in a goal-directed way only very rarely. The adipose
tissue of a normal man will release its triglycerides into the metabolism only
when there is a significantly low input (or low uptake) of nutrients into the
organism.
The abstract message here is the following: Certain bodily goals (or
subgoals) are such that they require for their achievement or maintenance
continuous hard work by the bodily parts responsible for these goals. Other
goals can be achieved or maintained by occasional measures. Still other
goals only very rarely require any work by a particular part of the body.
This observation has some impact on our understanding of the locution
"statistically typical efficiency". It is rather easy to understand what is
meant by statistically typical efficiency in the case of the heart and the
lungs. It means the typical continuous cardiorespiratory work (say a pulse
rate between 50 and 70 and a respiratory frequency between 10 and 30).
But some other bodily parts, like the stomach, the muscles or the adipose
tissue need not, at a particular moment, perform at all, at least not in
relation to the particular goals that we are studying. (It is not denied here
that in every living cell there is some activity going on.) The statistically
typical efficiency may manifest itself in rest.
The question is then: how could this organ be differentiated from one
which does not fulfill its goal? Such an organ could presumably also be in
a state of non-activity. The obvious and plausible answer is that we can
detect the "bad" organ by placing the organism in such a situation that
AN ANALYTIC THEORY OF HEALTH 27
o performs its function. Assume now that 0], ... , Os are severely damaged
or completely removed. This fact mayor may not result in a change on the
28 CHAPTER 2
level of O's activity. Experience shows that there need not be a negative
result on the level of the whole organ. There may be two explanations of
this. 0 may have an overcapacity with respect to its function; or the
remaining parts may be able to compensate for the loss through increased
activity.
An example of this phenomenon is the following. A liver has been
damaged by a long period of excessive alcohol consumption, and a
substantial portion of it is no longer functioning. Still, the liver as a whole
can fulfill its main functions, such as glycogen synthesis and purification of
the blood, in the required way. Thus, on our present interpretation of the
BST, the damage to the organ is not an indication of disease.
The damage may make itself felt in certain kinds of situations, however,
where the organ is put under stress. But we certainly know of people who
have organs which function adequately in spite of considerable damage.
Thus we cannot ascribe diseases to such people, for instance the disease
of liver cirrhosis, until this phenomenon manifests itself in a disturbance
of the organic function.
Consider now the second extreme alternative. We move very far down
on the hierarchy of biological levels. Assume that we stop at the level of
cells. Assume also (which is at present quite utopian) that we have a reliable
mapping of the functions of all individual cells. We shall then say that health
obtains in the organism when all cells fulfill their functions. Otherwise there
is at least one disease.
The consequences of such a view are extremely counterintuitive. The
existence of a single cell not fulfilling its functions is sufficient for the
existence of disease and thereby the non-health of the whole person. We
all have a great number of cells which are dying or malfunctioning. Hence,
we would all be ill.
The BST is not satisfactory under either interpretation. It seems then
that we must aim at finding an intermediary level offunction analysis which
is subtle enough to detect "obvious but silent malfunctioning", but not so
subtle as to include the odd single cell. The BST has not given an account
of how this is to be done. An answer in the spirit of the BST might be the
following. For the assessment of health we should scrutinize such func-
tional abilities the suppression of which endangers survival or the ability
to reproduce. This means that we should try to find functional abilities
which are more or less irreplaceable in their causal contribution to survival
and reproduction. This would presumably put us on a fairly high level of
biological integration, roughly on the level of gross functions.
AN ANALYTIC THEORY OF HEALTH 29
But how could we then face the problem of the "obvious malfunctioning"
of parts of otherwise well functioning organs? A state of affairs which would
disturb a particular functional ability in most human beings, need not
disturb it in a certain individual. Still, we might want to say that that
individual has a particular disease. In order to handle this we must change
the categorical characterization of disease within the BST ("a disease is a
state which interferes") to something like the following: a disease is a state
which tends to interfere (or which with a high degree of probability inter-
feres) with an organ's functional ability. (This answer is in line with our own
positive account of the concept of disease, see Chapter four, se(!tion 1:
Maladies.)
So far we have treated the BST in a fairly benevolent way. Our
observations have forced us to make some definitions more precise than
they are in Boorse's texts. We have also suggested some minor amend-
ments which we suspect to be in the spirit of the BST. The criticisms
advanced so far do not suggest a radically different analysis of health. We
turn now to what we consider to be a major defect of the BST.
This observation does not imply that we could never identify diseases
using the BST. An individual can very well react in a way which is not
species-typical. He may become infected where other members of the
species would not. His response might also bear no relation to the ultimate
goals of survival and reproduction. Cancer seems to be a cluster of diseases,
in which the defence system of the body has broken down; certain species-
typical functional abilities no longer exist.
However, the fact that certain instances of diseases can be viewed as
species-typical responses to a particular strain creates a problem for the BST
view of disease. What has gone wrong? Can we suggest an amendment?
Let us first ask: why do we, in ordinary language and according to
medical custom, view infections as diseases? The answer is simple: in-
fections are painful; they cause fever with fatigue as a frequent conse-
quence; both fever and fatigue disable us; we are unable to do the things
we normally want to do.
Facts such as these are involved in Boorse's characterization of illness.
But for reasons of principle he cannot use them in his definition of disease.
(Boorse's concept of illness presupposes his concept of disease. See our
presentation in Chapter two, section 3.) But perhaps the viewing of in-
fections as illnesses can help us give an alternative account within the
framework of the BST. If there is illness there ought to be some subnormal
function; some organ ought not contribute in its usual way to the ultimate
goals of a particular human being. Perhaps, then, the situation should be
described as follows: an infection involves a species-normal response to a
certain kind of external attack on the body. But the infection may depress
the functional ability of other organs which are not primarily affected by
it. If so, the infection would be a disease according to the BST.
(Against this one could not argue as follows: the functional ability of the
non-infected organs can be species-typical given the difficult internal envi-
ronment; hence, there would be no disease. This move would not do,
according to the BST. A disease is precisely such an internal environment
which depresses the functional ability of some organ in relation to the
individual's external environment.)
Consider this defence.
(i) The BST argument here presupposes that diseases can be clearly
anatomically isolated. Some organs and some functions are involved in the
disease. Others are external to the disease but are affected by it. This is
certainly a plausible idea with some diseases. But is it plausible with all
diseases? What about influenza? Can we distinguish there between those
32 CHAPTER 2
organs and tissues which are involved in the disease, and those which are
only affected by it?
(ii) The BST-argument presupposes that illness as generally understood
must be caused by some subnormal function, and moreover that the sub-
normal function which is responsible for illness must be subnormal relative
to the ultimate goals of survival and reproduction.
Let us study this important presupposition in some detail. Consider first
the pain which arises from the site of the infection. In what sense does this
pain involve subnormal functional ability? What does the pain consist or!
Its organic basis is a chemical irritation, caused by pathogenic toxins, of
certain pain-receptors. This may involve the local destruction of some
neural cells. But the "gross function" of the pain consists in the sending of
a message from the damaged locus to the brain. And does this message
indicate any subnormal functional ability? If the organ giving rise to pain
is functioning at a subnormal level, is it subnormal in relation to the goal
of survival? The answer to the latter question seems clearly to be in the
negative. If moderate pain can be related at all to survival it seems rather
to be contributory to survival. The pain can induce the individual to take
steps to prevent a dangerous development of the disease.
Consider, secondly, the disability which may result from the pain, or
from other sources, for instance from high fever. Should we say that the
organic work responsible for this disability necessarily constitutes subnor-
mal functional ability vis-a-vis the goal of survival? Is, for instance, fever
always a subnormal contribution to survival? Our evidence clearly says no.
Fever may efficiently support the defensive mechanisms of the body in
exterminating the invading microbes. Therefore, it is an adequate response,
precisely with respect to the goal of survival.
But what if we should say that the disability itself constitutes subnormal
functional ability in relation to the goal of survival? This will not do. The
disability of the whole person is not a subnormal functional ability of an
organ. Thus the general disability cannot be a candidate for disease within
the framework of the B ST.
Illness, in the ordinary sense of the word, implying pain or disability, may
be due to species-typical reactions involving the execution of normal
functional ability given a certain set of circumstances. Thus illness, as
normally understood, may be due to other things than disease as conceived
on the BST.
This observation points to what is perhaps the most serious weakness
of the BST. The BST has restricted itself, at least so far as somatic health
AN ANALYTIC THEORY OF HEALTH 33
Concluding Remarks
1. AN ACTION-THEORETIC APPROACH
35
36 CHAPTER 3
and 'disability' are better candidates than 'pain' and 'suffering' and their
opposites.
Not all bodily movements are actions. Actions are such movements or
behaviour which are under our control and influenced by our will. In
philosophical terminology it is often said that actions constitute intentional
behaviour. To shake one's hand or to nod one's head is an action only if
the agent intends to do so.
Actions are normally not performed merely for their own sake. They are
typically parts of an agent's plan to reach certain goals, instruments in the
process of his forming his life.
This aspect of actions, the fact that they are to a great extent forward-
looking and goal-related, is mirrored in our way of conceptualizing many
individual actions. It is mirrored in what will here be called the stratification
of actions. 28
the standard case the basic action involves just the (intentional) movement
of a part of the body. (Under special circumstances the basic action can
also be constituted by omitting to move a part of one's body).
The chain of actions indicated here may be said to be generated by the
basic action. The basic action of moving one's finger generates the action
of pulling the trigger, which in its turn generates the action of shooting the
tyrant, etc.
Is there, then, a last member of the chain of generated actions? Now this
question cannot be answered a priori. It seems one cannot draw a limit for
conceptual reasons. It depends in the single case on how much is included
in the agent's intention. If the coup d'etat actually was the final purpose of
the revolutionary (which may be a plausible hypothesis), then it is the last
element of the generated chain of actions in question.
What then is the nature of the process of generation itself? What does
the expression "by doing" signify? This has been debated and quite
thoroughly analysed in recent action theory. One of the most influential
discussions is in Goldman [47].He distinguishes between four kinds of
"level generation" as he calls it: (a) causal, (b) conventional, (c) simple, and
(d) augmentative?O
The first two kinds are the most important and exhaust the vast majority
of existing types of action-generation. Let us consider their nature in more
detail.
First, causal, generation. Here there is a causal relation, but it does not
obtain between the actions in the chain, but rather between an action of
a lower level in the chain and the endstate of an action of a higher level. So
in the case of killing the tyrant by shooting him, it is improper to say that
the shooting is a cause of the killing; the shooting is a cause of the fact that
the tyrant is dead, i.e. the ends tate of the action of killing.
To summarize: when it is true to say that a person F-s by G-ing, and the
generation involved is causal, then the endstate of F-ing is caused by the
G-ing.
In the case of conventional generation, the generation is effected by
conventional stipulation. There is a socially determined rule, which says
that when a certain action occurs in a particular context it should count as
some other action. Examples: lifting one's hat when meeting another
person counts as greeting him; making certain laryngal noises in appropriate
sequences can count as performing actions of speaking; signing a document
in the presence of a bank-official can count as numerous actions, for
example: making an agreement, receiving a loan, or buying a house; the
TOWARDS A HOLISTIC THEORY OF HEALTH 39
The question now is: is the basic action also necessary for these results? The
answer to this is that it varies.
In the case of ordinary causation a cause (including a basic action) is
rarely strictly necessary for its effect. There are often alternative ways of
achieving a certain end. In order to realize a revolution the death of the
tyrant need not be necessary; in order to kill the tyrant it is not necessary
to shoot him; and so on.
In the case of human action it is not only important to determine whether
a basic action is necessary as a matter of fact. In many contexts, for
instance in explanation, it is of greater importance to know whether the
agent himself considers an action necessary for a certain result. If he does,
for him there is only one way to bring about that result.
In the case of conventional generation, a relation of necessity between
a basic action and its effects need not be a rarity. The reason is that it can
always be stipulated. We can always stipulate that the only way in which
A can make a will is by signing a particular kind of document. We can
stipulate that the only way that Sweden can declare war is by the prime
minister's putting his signature to a government decision.
In the previous section we saw how a basic action can generate actions
of higher levels. In the following such generated actions will be called
accomplishments. The chain of actions related by causal or conventional
generation, from the basic action to the final accomplishment, will be called
an action-chain.
Many of our ordinary actions turn out to be accomplishments within this
theoretical framework. Further reflection shows, however, that most of
them entail more than just a basic action plus the course of nature or
convention. This simple structure presupposes that there is an opportunity
for action. Consider the case of the revolutionary. A precondition for his
creating a revolution in the way depicted by the action-chain is that he puts
himself in a position to shoot the tyrant. He must obtain a gun, and
transport himself to a place within shooting distance of the tyrant. The
accomplishment of creating a revolution by killing the tyrant, then, pre-
supposes previous actions and these actions are themselves normally
accomplishments. Such is the case with "obtaining a gun" and "travelling
to the tyrant's home". These previous accomplishments can, however, all
TOWARDS A HOLISTIC THEORY OF HEALTH 41
as (a) logical possibility (nine can be divided by three) (b) epistemic possi-
bility (for all I know, he can be thirty years of age) (c) physical possibility
(men cannot survive without oxygen) (d) ability (John can learn Russian)
(e) authority (this university can issue Ph.D degrees) (0 opportunity (Peter
can cross the road now). 34
Ifwe limit ourselves to human beings and their relations to actions, we
could take at least the last three interpretations into account; when we say
that A can perform F we might mean either: A has the ability to perform
F, A has the authority to perform F, or A has the opportunity to perform
F - or some combinations of these. For purposes of the present discussion
it is particularly important to distinguish between a person's ability and his
opportunity to perform F. (We shall in the following pay rather little attention
to the notion of authority. First, it is of only marginal interest in the
philosophy of health. And second, for many theoretical purposes authority
can be viewed as a conventional circumstance, as a kind of opportunity.)
When a person has both the ability and the opportunity (including
authority) to perform a particular action, then he can perform it in a strong
sense of the word. This strong sense of "can" will here be called practical
possiblity.
How should these concepts be defined? There are at least two main ways
of characterizing concepts of possibility. According to the first - the more
traditional - possibility-concepts are defined conditionally, in analogy to
dispositional properties. For example, "It is practically possible for A to
swim", means that, if A tries to swim, then A succeds in swimming. Like-
wise, "A has the ability to swim", means that, if A tries to swim, and there
is an opportunity for him, then A succeds in swimming. On the second way,
possibility concepts are defined in terms of possible-world semantics. "A
has the ability to swim", then simply means: in some circumstances A
SWIms.
Both of these suggestions have their merits and shortcomings. For
substantial discussions about them, see [6] and [64].35 In the present
context we shall not take a stand on this issue. We shall not propose a
definition of practical possibility or ability. For the purposes of this essay
it suffices to provide a test for the application of the two concepts. This test
is founded on the traditional analysis of practical possibility. We can
ascertain whether it is practically possible for a person to F, by letting him
try to F. From a test where A tries to F and succeeds in F-ing, we shall
conclude that it is practically possible for A to F.36
TOWARDS A HOLISTIC THEORY OF HEALTH 43
These, then, are the background conditions for the practical possibility
of performing a basic action. Consider now the complex actions,
accomplishments and activities.
By definition, the performance of an accomplishment requires the
performance of some basic action. A second obvious requirement is that
the accomplishment can in fact be generated. (Note that this may depend
partly on the agent in question.) A third requirement is that the agent know
that there is a situation which constitutes the opportunity to generate the
accomplishment in question. This entails either that he has some causal
knowledge, i.e. knows what happens, given a particular basic action in a
particular situation, or that he has some conventional knowledge, i.e.
knows of a particular action-generating rule and what it says about the
required circumstances. (In some cases both kinds of knowledge may be
presupposed ).
We shall now collect these requirements (together with the ones noted
above) into one schema. The following symbols will be used: Ace for
accomplishment, Act for activity, B for basic action, 0 for opportunity and
S for action-sequence.
set of abilities with regard to his basic actions. If it appears that a person
cannot move out of his bed, or if it appears that he cannot talk or that he
does these things with extreme difficulty, then we can immediately con-
clude that he cannot enter a particular training program, and that he cannot
do this for reasons internal to his body or mind.
Our general conclusion is that the ability involved in health is an ability
of the second-order kind. To be healthy is to have, at least, a second-order
ability to perform a certain set of actions. To be ill is to have lost or, in
general, to lack one or more of these second-order abilities.
The most difficult task in our characterization of health still remains: how
are we to specify the set of actions that a healthy person must be able to
perform?
In approaching this problem we shall first somewhat alter our manner
of speaking. Instead of talking about a set of actions that an agent must
be able to perform, we shall assume that there is a set of goals which the
healthy person must be able to achieve. This does not involve a radical
change in our philosophy. It is merely a simplification of our mode of
speech. By concentrating on (ultimate) goals, we can avoid giving a long
enumeration of sp~cific actions. Moreover, we are not forced to make
difficult decisions about the level at which action-concepts should be
specified.
It is plausible to believe that whatever the adequate answer to the
question of health should be, it will be an answer on an abstract level, which
can be summarized in terms of certain general goals. The question to be
put should rather be formulated in the following terms: what are the goals
that a healthy person must be able to realize through his actions?
In Chapter two, section 2, a basic analysis of the concept of goal was
presented. The distinction was made there between factual goals and ideal
goals. In our discussion of an analytic theory of health the notion of a
factual goal was employed. In the discussion to follow we shall speak in
terms of ideal goals and in terms of relations between actions and goals.
Let us then look into the logical relations between actions and goals. A
first assumption is that the realization of a goal requires the performance
of at least one action. If the goal is general and abstract it normally requires
a sequence of actions, i.e. an activity.
54 CHAPTER 3
The relation between an action and its goal may be internal or external. 39
The difference is easily seen given our analysis of actions above. We say
that the relation between an action and its goal is external if the goal is a
causal or conventional consequence of the action. The relation is internal if
it follows logically from the fact that the action has been performed, that
the goal has been reached. For example, the relation between working hard
and passing an exam is external. Passing an exam is a causal consequence
of working hard, but it is not a logical consequence of working hard. The
relation between killing Smith and the death of Smith is however internal.
If Smith has been killed it follows logically that Smith is dead.
We see then that the way human action is conceptualized is crucial for
the nature of the relation. One and the same sequence of events can be
looked upon as either an action causing a goal (stabbing Smith causing the
death of Smith) or as an action entailing a goal (kill,ing Smith entailing the
death of Smith).
It is important to be conscious of these features for the following reason.
The reaching of a goal can be conceived of as, simply, the performing of
an action. However abstract a goal we choose to consider, we can always
construct an action-concept entailing it.
It can now more easily be seen that the goal-mode of discourse is just
a variant of the action-mode of discourse. Many of the conclusions drawn
from the analysis of actions can be transferred to the analysis of goal-attain-
ment.
When goals are far-reaching or abstract the process of reaching them is
normally divided into a sequence of actions (an activity). The endstate of
each member of the activity sequence can be viewed as a subgoal. In the
extreme case, the attainment of a goal requires the realization of a very
specific set of subgoals in a particular order.
As was observed with activities, however, most goals can be realized
through a great number of alternative routes. Different circumstances may
constitute opportunities for different actions in realizing the same goal. In
circumstance C I action HI may be necessary for realizing goal G. In C2
actions H2 + HI may be necessary for realizing G.
But also one and the same circumstance may provide an opportunity for
distinct actions leading or contributing to G. In such a case neither of them
is necessary for G. Normally, one can get food for the day in many different
ways. One may go out in the woods and pick blueberries, buy food in a
shop, or visit a restaurant. Many persons have the opportunity of perform-
ing these different actions at anyone time.
TOWARDS A HOLISTIC THEORY OF HEALTH 55
Introduction
The concept of need is at least as involved and loaded with ideology as the
concept of health itself. The idea of a basic human need has a central place
in political theory and political debate. It is among the key concepts in the
thinking of men such as Rousseau, Mill and Marx. It is one of the most
frequently used concepts in day-to-day political discussion; many social
reforms have been motivated by reference to the needs of the population.
These facts motivate much caution in the analysis ofthe concept of need.
Moreover, there are certain linguistic reasons for being cautious when
discussing needs. There are difficulties in making exact translations of the
term "need"; for example it does not have exact equivalents in German or
the Scandinavian languages. In some contexts, "need" can be substituted
by "want", but the German "Bediirfnis" could seldom be substituted by
"WUnsch", nor could the Swedish "behov" be substituted by "onskan".41
The analysis to follow here does not pretend to be a contribution to
comparative linguistics, nor to answer the question of what the basic
58 CHAPTER 3
human needs are. Instead, its primary aims are the following: first, to reveal
a fundamental sense of need (viz. necessary condition for the realization
of a goal), and second, to investigate if there is' a particular interpretation
of 'need' which can serve the purpose of clarifying the concept of health.
The main conclusion of the chapter is that the most favoured interpretation
of a basic human need does not serve this purpose.
In this sense it is certainly not only humans that can have needs. All
entities to which it is sensible to ascribe goals can have needs. A plant needs
chlorophyll to survive and a machine may need oil to work.
The number of needs pertaining to an individual, in this sense, could be
very great. As long as the individual has at least one goal it is strictly
speaking infinite. The reason for this is the transitivity of the relation of
being a necessary condition for something. A necessary condition for a
necessary condition for G is, ipso facto, a necessary condition for G. IfJohn
needs a torch to find the hammer which he needs for repairing his house,
then the torch (or finding the torch) is also a need for John. And since all
series of events are infinitely divisible the number of needs must turn out
to be infinite.
To this fact we shall add a complication. Needs or necessary conditions
are dependent on background situations. It may be necessary for John to
have a hammer in a given situation in order to repair his house. But in a
different situation, where Steve does the hammering, John does not need
a hammer. Therefore, needs in this general sense may vary over time
depending on situational change.
We return now to our initial question about the ontology of needs and
the different ways of expressing the existence of needs. Given the general
sense of needs analysed above the two locutions "A has a need of y" and
"y is a need for A" should have the same analysis. They are both, according
to the analysis, elliptic formulations of the following proposition: There is
a goal G and a situation S so that y (or using y) is a necessary condition
for A in S in order for A to attain G. More simply put, y is a need for A
in S to reach G. This is the four-place expansion of the locution. But what
about ontology? Where is the need? In what sense does the need exist?
If need means "necessary condition" then that which constitutes the
necessary condition is the need. In the case of John's repairing his house,
the hammer or, more strictly put, the use of the hammer, is the need.
In the general sense, then, a need is not a bodily state of a person; it is
rather any kind of state or event, in which the person mayor may not be
involved, which is a necessary condition for the person's attaining a goal. 42
psychological reality; Maslow assumes that for all basic needs there are
physiological and psychological mechanisms which trigger off some be-
havior on the part of the individual to realize a certain goal. For instance,
hunger is associated with (or even identified with) a certain physiological
mechanism which triggers off food-seeking behaviour.
Given this idea one can see how it can be plausible to identify needs with
bodily states. The bodily states are the biological drives.
The idea that biological drives can be identified with needs forces us to
make a distinction between two referents of the term "need". This was in
fact evident already in our introduction where we noted the following two
kinds oflocutions, "A has a need ofy" and "y is a need for A". In our abstract
discussion about needs we let y be the referent of the term "need". Using
a hammer was a need for John in order to repair the house. But when we
say that John needs a hammer in order to repair his house, the need is not
identified with the hammer. The need is rather something located within
John's body or mind.
It is obvious that the philosophy of identifying needs with biological
drives is based on the latter mode of speech. When we identify the need
of food with a physiological drive, it is not the food which is the drive but
the hunger; similarly, when we identify the need of safety with a drive within
a person's body or mind, it is not the safety which is the drive but some
safety-seeking tendency within the person.
This important distinction between a drive and its object is obscured by
the drive-philosophers themselves, since they sometimes also refer to the
objects (such as safety, love and esteem) as needs. But even if this dis-
tinction between bodily state and object is well made, it does not seem
advisable to "identify" needs with particular bodily states. It is important
to be able to say that a person has the basic need at all times. The drives,
however, do not appear at all times. They appear only when there is a lack,
when the needs are not fulfilled. Everybody has a need of food. It is,
however, only hungry people who have a physiological drive which triggers
food-seeking behaviour.
Still, the existence of drives certainly is important for the identification
of the basic needs.The idea is the following: wherever we can find a
physiological or psychological drive, universal or almost universal to all
mankind, which triggers behaviour in the direction of a certain object, when
this object is not already present, then we are dealing with a basic need.
The problem of what the basic needs are could then, in principle, be solved
by empirical biology and empirical psychology.
62 CHAPTER 3
Knut Erik Tran0Y [131] suggests a similar, although more complex, charac-
terization of his concept of a vital need.
N is a vital need for a, if and only if the following four conditions are fulfilled.
TOWARDS A HOLISTIC THEORY OF HEALTH 63
Let us now observe that we have two kinds of sufficient criteria for singling
out the basic needs. First, we have the drives, universal, or almost univers-
al, to all mankind; secondly, we have the idea that the objects of the drives
are necessary conditions for survival and health. It might seem that these
criteria could support each other; they are, however, also in potential
conflict. There may be tendencies, almost universal to mankind, which do
not go in the direction of maintaining health. In such a case what would
be the decisive criterion? Ifwe decide that the attainment of the goal, viz.
health, is the ultimate criterion we could characterize the concept of a
human need in the following way: Any state of affairs that is necessary for
the individual's survival or health is a basic need for him (irrespective of
the existence of drives within him, be they universal or individual).45
Health and Need: On the Circle of Health
It is not our task to judge Maslow's theory of needs or any other theory
of human or vital needs. Certain basic conceptual difficulties have, howev-
er, already appeared.
Our main task is to decide if a theory of this kind can be of any use in
the endeavour of characterizing health. The initial suggestion was the
following: A person A is in health if, and only if, he has the ability, given
standard circumstances, to fulfill his basic needs.
Given the above analysis, this suggestion can be translated into: A is
healthy if, and only if, he has the ability, given standard circumstances, to
fulfill certain necessary conditions for his survival or his health. It is
immediately seen that this characterization contains the terms "health"
("healthy") in two places. First, in the analysandum; and second, in the
analysans. The conclusion, then, is that this characterization is empty or
almost empty.46
An alternative which suggests itself, in order to avoid this circularity, is
to drop the criterion of health in the definition of need. A human need is,
then, simply a requisite for the survival of the individual (with the possible
addition of the survival of the species). A healthy man can, in standard
circumstances, see to it that he satisfies his physiological needs.
64 CHAPTER 3
This may look like a very weak suggestion. Would not also the majority
of unhealthy persons fulfill such minimal requirements of health?
But the suggestion is not so implausible when we analyse what must be
packed into the locution "in standard circumstances". The standard cir-
cumstances include the environmental and cultural background. This
background dictates what are the possible and, from a legal point of view,
proper means for maintaining survival.
In a highly regulated Western society most people cannot (without
special permission) simply go fishing and collecting berries and vegetables
in order to survive. In most circumstances the only proper way to get food
for the day is to purchase it. This in its turn presupposes funds. The
standard way of obtaining funds is to get a job.
Therefore, normally, the fulfillment ofa professional role is, in a Western
society, a requisite for satisfying one's basic physiological needs. An alter-
native is that one, as a spouse, is supported by a working man or woman.
But this could very well be seen as a contribution to the latter's professional
role.
A consequence of this analysis is that the suggested definition of health,
in terms of the fulfillment of needs, comes closer to our intuitions. Since
professional life in a Western society entails the performance of complicat-
ed actions, one is often obliged to enter into an involved series of actions
in order merely to survive. Therefore, indirectly the goal of survival will
entail a set of other subgoals, which are in a sense more advanced.
Consider the following facts. The mere process of applying for a job
requires a number of measures. You must be able to contact an employer;
you must be able to make yourself understood; you must be able to fill in
certain forms. In addition to this you must be able to perform the actions
required by the job itself.
Understood in this sense the goal of survival requires a good deal; and
it may even square quite well with ordinary medical practice. A key-cri-
terion of health in medical practice, not least for purposes of health insu-
rance, is that the individual can perform his own professional task in an
efficient way.
We notice now how our analysis of the relation between health and the
fulfillment of needs takes us away from the simple biological platform
suggested by the modern need-theorists. Health becomes a society-related
notion, because, implicitly, society determines the subgoals to be achieved
in order to survive. Moreover, these subgoals can vary a good deal depend-
ing upon the particular society and profession.
TOWARDS A HOLISTIC THEORY OF HEALTH 65
Introduction
The idea that a subject's health is identical with his ability to realize the
goals set by himselfis a promising approach suggested recently, and inde-
pendently, by two analytic philosophers, Caroline Whitbeck and Ingmar
porn. 47 In addition to a definition along these lines, they also provide a
framework for relating the notions of disease, defect and impairment to the
notion of illness. A detailed discussion and defense of this framework is to
be found in [140].
Consider first the central passages in Porn's and Whitbeck's presen-
tations of this idea. Porn says:
Health is the state of a person which obtains exactly when his repertoire is adequate relative
to his profile of goals. A person who is healthy in this sense carries with him the intrapersonal
resources that are sufficient for what his goals require of him. This does not mean, however,
that he will realize all of his goals, for his powers to act are determined not only by his
repertoire but also by the external factors making up his opportunities for action-factors over
which he does not always have control ([991, p. 5).
have great abilities, but they may also be aware of the possibility that these
may cease to exist. Therefore, they set their goals with a considerable
margin of safety. This cautious way of planning life is certainly not a
man.ifestation of illness. According to this reasoning the equilibrium thesis
will in the subsequent discussion be interpreted in the following way: health
obtains when a person has, at least, the ability required for realizing his
goals.
(It will be conceded in Section 7 that there are cases when a person sets
too low goals for himself and that this may indeed be a sign of illness. It
is, however, in our view a mistake to claim that there is illness as soon as
there is disequilibrium in Porn's sense.)
Note, thirdly, a subtle difference in the ontological characterization of
health by the two theories. For Porn health is the relation which holds when
a person's ability is adequate to his goals. To Whitbeck health is the
person's capacity to act supportively in rel~tion to his goals.
From an ontological point of view there are good reasons in support of
Porn's view. To say that health is a relation is to underline the essential
relational character of the concept of health. For most purposes this
difference of expression is, however, unimportant. As long as the theories
agree on the truth-conditions for health-statements, which in both cases
contain references also to goals and circumstances, then the difference will
have little practical import. In the following, we shall sometimes, for the
sake of simplicity, use locutions to the effect that health is the ability to
reach one's goals.
A person has the highest degree of health if he can fulfill all his vital goals
in all kinds of situations. But since one can always conceive of new and
more demanding situations, there can in practice be no such thing as a
highest degree of health.
Observe an interesting complication here. In our characterization of
ability as used in the context of health we have presupposed as a standing
background some set of standard circumstances. Now in this argument
Whitbeck does not make such a presupposition. Instead she counts on
there being indefinite variations of the circumstances and measures health
in accordance with these variations. Is it possible, given our approach, to
acknowledge this dimension of health?
Two points should be made regarding this issue. First, in one interpre-
tation, Whitbeck's dictum is not reasonable. If we say generally that a
person's health is greater the more kinds of situations he can handle in
realizing his vital goals, then the conceptual difference between health and
pure strength will be blurred. Assume, for instance, that in a particular
situation one has to be able to lift a heavy weight in order to realize a goal.
A physically very strong person may succeed in doing this. But are we
inclined to say that he is healthier for this reason? No, we are not.
But given a different interpretation we can also acknowledge a di-
mension of health in the direction envisaged by Whitbeck. We can, if we
mean by different situations different sets of standard circumstances, for
instance as provided by different cultures. A person who is adaptable in the
sense that he can reach his vital goals in a great many standard environ-
TOWARDS A HOLISTIC THEORY OF HEALTH 69
ments could be said to be healthier than one who is less adaptable. Adapta-
bility is one kind of strength, but a kind which is closer to our ordinary
notion of health.
If health is a graduated concept, what becomes of its complement:
illness? Is there such a thing as illness or are there only varying degrees of
health? Whitbeck does not explicitly discuss this matter. It is obvious,
though, that she does not identify illness with lack of health in the way Porn
does. "Illness" is a term seldom used in Whitbeck's text. The following
quotation seems to indicate that Whitbeck wishes to restrict "illness" to the
context of disease.
Ifit [a disease] precedes all symptomatic episodes (episodes of illness or acute episodes), then
the disease at that stage is alternatively termed "sub-clinical". Now it is clear that during the
subclinical phase of a disease there will be no ill (or symptomatic) person to treat ([140], p.
215).
Before being able to analyse these problems properly we must give a more
precise interpretation to the notion of setting a goal for oneself.
Let us first observe that the two authors under discussion abstain from
giving precise interpretations. Porn discusses abstractly in terms of an
agent's profile of goals. There is only a short passage in which he indicates
that the goals are determined by the agent's faculty of will ([99], pp. 7-8).
Whitbeck uses quite different expressions in her characterization. We
have previously quoted the terms "goals, projects, and aspirations". In
another context we encounter "Therefore, the notion of health is closely
associated with the notions of autonomy, with the ability to act to achieve
one's purposes ... " ([141], p. 616).
The common and quite vague platform here is simply the following: A
goal set by a person is a state of affairs which the person wants to become
the case. In order to give a plausible interpretation of this idea we must,
however, make a fundamental distinction. We shall distinguish between
wants in a wider sense and wants - or intentions - in a narrower sense.
Most people have wants (we sometimes call them idle wishes) which are
completely unrealistic, and these people are also aware that they are
unrealistic. Somebody might wish that he were the world champion in a
branch of sports or that he could travel round the world; but he knows that
he cannot realize these wishes. As a result these goals do not affect his
conduct; he does not make any preparations in order to realize them. Such
goals are not goals in the narrow sense which we have in mind here.
Goals in the narrow sense are goals which w~ act upon unless prevented
from doing so. They are goals which we have decided or intended to realize.
(The two expressions "deciding" and "forming an intention" will here be
regarded as synonymous.)49
It may be contended that there is an intermediate position between
wants and intentions. A person may decide to try to perform an action
without really believing that he can succeed. (The minimal epistemic re-
quirement here is something weaker, viz.: it is not the case that he believes
that he cannot perform the action (or reach the goal).) A decision to try
is, indeed, a way of setting a goal which has a direct influence on conduct.
The important distinction to be proposed here then is the one between
wanting, on the one hand, and deciding (intending), or deciding (intending)
TOWARDS A HOLISTIC THEORY OF HEALTH 73
to try, on the other hand. We shall say that a person has set a goal for
himself only if he has decided (intends) to reach a goal, or has decided
(intends) to try to reach a goal. A goal set in this sense will be called an
intended goal. 50
(a) The case of the unrealistic person. Consider now the first item in our list
of problems. Should all normally-equipped persons, who happen to set a
number of unrealistic goals for themselves, be considered to have a low
degree of health?
Prima facie, on the SG-theory, the person who aims for the stars is not
healthy. Given our present conceptual background, we can, however, qual-
ify this judgment. A person who aims for the stars may only want to reach
the stars. He may be perfectly aware that the project is unrealistic and not
act in accordance with it. His goals are therefore not real goals in our sense.
Accordingly, this case of aiming for the stars is compatible with health.
It may also be the case that a person aims for the stars under the explicit
assumption that certain favourable opportunities should arise. Such a
person has set a hypothetical goal. If the favourable opportunities never
arise and the agent fails to reach his goals, this does not indicate lack of
health.
The case of non-health to be described must presuppose the following:
(1) A has an intended goal G (i.e. A has set the goal G) (2) A has set the
goal G under the assumption that situation S obtains (3) S obtains and A
tries to bring about G (4) A fails to bring about G in S.
Do all cases fulfilling conditions (1 )-( 4) fulfil a set of sufficient conditions
for our intuitive notion of non-health? Are all people with ambitions that
are too high, ill? A positive answer to such a question would still seem
paradoxical if the ambitious man is an extremely vital person, who
succeeds in accomplishing a good deal.
Before accepting the ambitious and vital but unrealistic person as a
counterinstance to the SG-theory, we might want to introduce a new
qualification. It seems to be essential to assess the extent to which the agent
is justified in believing that a particular goal is attainable. If he is justified
in such a belief, and if he is justified in his particular beliefs concerning
means to ends, then we would not consider his goals to be unrealistic. Nor
would he be a candidate for being ill.
74 CHAPTER 3
If the agent is unjustified, on the other hand, either concerning the whole
project, or concerning particular parts of the project, then he may be
considered to lack realism and judgment. The crucial question is, then,
whether such a lack is a sufficient criterion of illness.
A balanced answer to such a question must also take the following into
account: in giving the general assessment that a person is ill, we certainly
do not just consider one particular goal and the person's adequacy or
inadequacy vis-a.-vis that goal. We must find out whether or not equilibrium
obtains with respect to the whole range of goals that a person has set for
himself. In such a general assessment, the outcome concerning one or a few
parameters will have little influence.
A person whom we, on intuitive grounds, consider to be vital and
ambitious will most probably perform well with regard to many of his goals
(perhaps most of his goals in his private life), although he may be unrealistic
concerning some other projects (e.g. his professional ones).
This qualification, however, does not explain away the following conse-
quence of the SG-theory. A person who has set high goals for himself and
is in general unrealistic in judgments about his ability to reach these goals
has a low degree of health. This consequence indicates in a salient way that
illness on this theory may have little to do with disease as normally un-
derstood. A combination of a low degree of intelligence and an unfavour-
able character trait may be sufficient for considering the person ill.
Let us summarize our discussion about the unrealistic person. A person
who is not justified in believing that a particular state of affairs is attainable
and still makes this state an intended goal of his, is unrealistic with respect
to this goal. If such lack of realism obtains with regard to most of his
intended goals then he has, according to the SG-theory, a low degree of
health.
This conclusion is probably controversial. In our opinion it is, however,
not obviously counterintuitive. In fact, we shall incorporate this element of
realism in our own positive account of health.
The following three arguments, however, seem to be fatal for the SG-
theory, unless the theory is considerably qualified.
(b) The case of the person with very low ambition. Does a person with very
low ambition and very few goals - which he can easily achieve - automati-
cally have a high degree of health? Does the man who is dying, and who
is - intuitively speaking - a very sick man, but who has become resigned
TOWARDS A HOLISTIC THEORY OF HEALTH 75
important aim of his, for instance that of performing his professional role
properly. If his consumption is excessive and enduring the result of his
decision will even damage his body or mind.
It seems counterintuitive to say that all kinds of irrational and counter-
productive goals, just because they are intended, should have the status of
vital goals. Must we not have some minimal requirement concerning the
"quality" of the goal?
This question will be given a detailed answer within the framework of
the welfare theory of health. (See Section 8 in this chapter.)
Let us recollect our main conclusions from the analyses of the two propos-
als on the vital goals of man.
The vital goals as determined by our basic needs: Prima facie merits
(i) This concept is a candidate for being a universal concept of
health. It is not necessarily restricted to human beings. If there
is some sense in talking about basic needs of humans there
ought to be sense in ascribing basic needs to animals and plants
as well.
(ii) It seems to admit a uniform application to all human beings. If
the basic needs are general, it seems not to be necessary to
TOWARDS A HOLISTIC THEORY OF HEALTH 77
tant elements from both of them. The key notion in this conception is
welfare; in the case of humans welfare will be equated with happiness.
Happiness should then be understood as a technical ,?oncept covering more
ground than does the ordinary concept of happiness.
The general idea is the following: The vital goals of man are those whose
fulfillment is necessary and jointly sufficient for a minimal degree of wel-
fare, i.e. happiness. To be healthy, then, is to have the ability to fulfill those
goals which are necessary and jointly sufficient for a minimal degree of
happiness. Observe, however, that this implies neither that health is suf-
ficient for minimal happiness, nor that it is necessary. Health is not suf-
ficient, since the ability to fulfill one's vital goals does not imply that one
actually fulfills them. And health is not necessary, since the vital goals can
be fulfilled by other means, for instance by the actions of someone else.
To relate health to happiness is to give credit both to the need-theory
and the SG-theory. In a way it could be seen as a new way of specifying
the goals of needs. Instead of relating needs to survival and health we now
propose to relate them to happiness. Our suggestion also includes essential
elements from the SG-theory. As we shall see in the subsequent analysis,
happiness is conceptually related to the fulfillment of the agent's goals. It
is important to note, however, that not all intended goals fulfill the require-
ments of being goals in the welfare sense. Moreover, there are some goals
in the welfare sense which are not goals aimed at by the agent himself.
Is, then, the question of what the vital goals of man are a theoretically
decidable question? Can any empirical investigation completely determine
this? Superficially, it may seem so. If the fulfillment of the vital goals is
necessary and jointly sufficient for minimal happiness, then our task must
be to inquire what happiness requires. What does Jones need to be happy,
and what does Smith need? The investigation may involve very difficult
methodological problems, but it seems, in principle, to be a theoretically
decidable question.
Our reply to this will be the following: the question of what the vital goals
are is only partially theoretically decidable. Roughly, it is decidable to the
extent that a modified SG-theory is correct. We can determine the vital
goals by theoretical means to the extent that they are identical with the
goals set by the agent himself.
The welfare-theory of health to be proposed here means, however,
precisely that this cannot be the whole story. The question of what consti-
tutes "real" happiness, as well as a minimal degree of such, can only be
answered by a primary evaluation; it is not a question of science. Consider
TOWARDS A HOLISTIC THEORY OF HEALTH 79
the following problem: a person with very low intelligence and a low degree
of vitality sets very few and primitive goals. Assume that he is able to fulfill
these goals and that the situation actually permits their fulfillment. From
the point of vie.w of mere goal-satisfaction this person is then a happy
person.
It may, however, be contended that this is not enough. "Real" happiness
presupposes a minimum of complexity and subtlety. A person who fulfills
a very small and primitive set of goals does not fulfill the requirements of
minimal human welfare, minimal human happiness. Thus, ifhis abilities do
not supersede the ability to fulfill his primitive goals, then he cannot be
healthy.
The problem here cannot, we believe, be solved by scientific means. It
can only be solved by a decision founded on an evaluation of what should
constitute minimal human happiness. Let us call this an evaluation of
welfare. It is, as far as we can see, an evaluation sui generis. It should, for
instance, be kept distinct from moral evaluation. An evaluation of welfare
does not require that the vital goals have any particular moral status. The
vital goals are primarily egocentric. They are goals the fulfillment of which
gives the agent himself satisfaction. This is certainly compatible with the
goals, being moral goals; but it is also compatible with their not being so. 51
The tr.eory which we propose has profound consequences for the philo-
sophy of health. A conceptual analysis cannot once and for all settle what
the vital goals of health are. It can bring us precisely to the point we have
reached in our discussion. It can tell us that the ultimate specification of
the vital goals must be left to an evaluation of welfare.
The basic conception of health offered by the welfare-theory is the
following:
A is healthy if, and only if, A is able, given standard circums-
tances in his environment, to fulfill those goals which are neces-
sary and jointly sufficient for his minimal happiness.
Depending on one's platform of values these vital goals can be specified
in a number of ways. In this sense we can get a family of concepts of health
consistent with our basic theory. The theory itself cannot decide which
concept is to be preferred.
The important question, then, is: can anybody make this primary eval-
uation of welfare? Can we live with a great number of characterizations of
happiness and thus a great number of characterizations ofhealth? Such an
idea might seem disastrous to the science of medicine and the general
80 CHAPTER 3
enterprise of health care. We shall say more about this later but let us now
just offer the following words of caution.
Evaluation is not a fortuitous affair. It should be made with the same care
and rigour as the making of a scientific investigation. Moreover, once the
basic evaluations of what constitutes a minimally happy life have been
made, then this has strictly logical implications for the particular appli-
cations of the terms "health" and "illness" in individual cases. Once a
speaker has made an evaluation, he cannot rationally change criteria from
one application of "health" to another.
Secondly, evaluations do not simply appear from nowhere; they are
formed in social settings. People within the same culture will tend to make
the same basic evaluations concerning the good life from a welfare point
of view. This will in most cases result in a great deal of intersubjectivity in
judgment. There will automatically be some common ground for "consen-
sus"-discussions about minimal and desirable degrees of welfare.
Thirdly, and as a continuation of the last statement, welfare evaluations
can be made explicit, and as in political affairs, be decided upon. In fact,
this is partly being done - although normally implicitly - in the social
policies of different countries. By legislating on social and medical matters
a government declares what it considers to be desirable and what minimal
levels of welfare it would tolerate without intervention. This amounts to,
among other things, specifying what it considers to be the border between
health and illness. (From now on the term "illness" will be used consistently
as the term contradictory of "health". This means that we follow the
proposals of Porn's in this respect. For a further discussion of the notion
of illness, see Chapter four, section 1).
Fourthly, there is a secondary use of the terms "health" and "illness"
which is not evaluative. This is when we ascribe health to somebody against
the background of a standard previously decided upon. Perhaps this is what
most of us do most of the time. We may presuppose some technical concept
of health or we may base our statement on what we take to be society's
judgment about the minimal limits of happiness. If we do the latter we are
not the evaluators; we make theoretical applications of standards given by
others who are the primary evaluators.
Considerations such as these will enable us to see that the enterprise of
health care is not really in danger. In order to see that medicine can remain
a science we shall have to make some further reflections based on an
analysis of the concepts of disease and impairment and similar concepts,
as will be undertaken below.
TOWARDS A HOLISTIC THEORY OF HEALTH 81
In modern times the concept of happiness was radically refashioned by being given a subjective
colouring. It ceased to be described as possession of goods but as a subjective sense of
gratification. A life is a happy one if we are satisfied with it, and it is the man satisfied with
his life who is qualified as happy. Whether or not he possesses goods and of what kind they
are makes no difference. As long as he is content he is happy ([127], p 33).
relation between an emotion and its objects is not a purely contingent fact.
A person loved or hated must, for conceptual reasons, have certain charac-
teristics or have a certain relation to the subject in order to be at all loveable
or hatable.
Let us consider the case of hatred more closely. Jones is said to hate
Brown. The following is true about Jones: he knows that Brown has helped
him in major matters throughout his whole life. He also believes that Brown
has sympathetic feelings towards him. He is not irritated by any particular
fact about Brown. He does not feel inferior to him. Given these facts we
must doubt the statement that Jones hates Brown. Brown is not the kind
of man that could be hated by Jones. Brown is not a proper object of hatred.
Our doubt about ascribing, or even our refusal to ascribe, hatred to Jones
does not depend on any external inspection of Jones involving, say, his
emotional behaviour. We draw our conclusion solely on premises describ-
ing the alleged object of a particular emotion of hatred. Brown is an object
of hatred from the point of view of Jones only if Jones believes that Brown
has contributed, or is about to contribute, to creating a state of affairs
which is highly negative for Jones. Without this prerequisite a case of
hatred cannot occur. (Observe that Jones' belief can, of course, be false.
Still, there must be a belief of this kind.)
The kind of abstract object, defined by a set of characteristics and
relations, delimiting the class of possible objects of hatred will in the
following be called the formal object of hatred. For all emotions there is a
corresponding formal object. 56
The distinction between moods and emotions is somewhat complicated
by the fact that certain mental concepts seem to occupy an ambiguous
position between the two. A typical example is depression. According to
authoritative judges there are depressions which are object-less, i.e. not
directed at any particular fact in the external or internal situation. On the
other hand certain instances of depression have an obvious object, a fact
which the subject is depressed about. An important question here is wheth-
er this really indicates that there are two completely different kinds of states
called depression, or, whether they have something important in common
motivating the identical label. If they have something in common, which
it is plausible to assume, the only candidate seems to be the experiential
state itself (or parts of it), the feeling of being depressed. The mood of
depression is characterized by a feeling of suffering; the emotion of de-
pression is partly characterized by an identical, or similar, feeling of suffer-
ing.
84 CHAPTER 3
taking part in a particular activity. Still, we could very well label these
mental states states of happiness.
There is an argument for the emotion-hypothesis here too. It runs as
follows: when for instance you are listening to a tune which makes you
happy there are two things which occur simultaneously. You realize that
there is here a desirable goal, viz. listening to this tune, and this goal is
immediately achieved. (For an idea in this direction, see [81], pp. 5-6.)
This analysis may be a plausible one for certain cases of very salient and
normally quite short-term pleasures such as the ones we have described.
The analysis is much more doubtful, however, when we consider the mild
pleasures of being active and continuously having new experiences, i.e., of
living a rich life. The subject "feels well" - arid this may be an enduring state
of mind - but he may not be conscious of the sources of his happiness,
which may be quite complex. Thus he may not be able to form any object
the materialization of which is desirable to him. Indeed, there need not be
such an object. (That there are cases of objectless feelings of well-being
becomes even clearer when we incorporate infants and the higher animals
among the subjects of happiness.) In the theory to be proposed here it will
therefore be assumed that there are objectless states of happiness, viz.
moods of happiness. Like emotions these can be both short- and long-term.
Observe that there may be important relations between a mood and an
emotion of happiness. First, the fact that a subject is in a happy mood can
be the object of the same person's emotion of happiness. When one is happy
about one's whole life-situation, the life-situation would include an enduring
mood of happiness. An enduring mood of happiness certainly contributes
to the realization of many wants, not least to the appreciation of this
realization. Contrariwise, a mood of happiness is dependent on some
degree of emotional happiness; a mood of happiness would be disturbed
or even disrupted by emotional unhappiness.
conceptually required that happiness last for a long period. Thus Aristotle
says: "One swallow does not make spring, nor does one fine day; and
similarly one day or a brief period of happiness -does not make a man
supremely blessed and happy" ([3], 1.7.).
What are the conclusions to be drawn from this list of dimensions of
happiness? Does happiness then have an upper limit? Is there anything to
be called complete or total happiness? Theoretically a man can be com-
pletely happy or satisfied in the sense that all his wants have been satisfied.
In a sense completeness can also pertain to the dimension of duration. If
happiness lasts all through life, then happiness is complete from a temporal
point of view. (This completeness can, however, be somewhat spurious in
the case where life is very short.) Perhaps also frequency can be complete,
in the sense that there are no intervals, the feeling of happiness is contin-
uous. For dimensions such as richness and intensity there do not seem to
be any theoretical limitations. The limitations that there are, are psycholog-
ical, individual ones. A particular individual cannot appreciate more than
a certain amount of richness and intensity in experience.
A second and for the purposes of this essay more important conclusion
is the following: along all dimensions there is, or can be judged to be, a
lowest degree of happiness, below which there is no happiness at all. If the
pleasure is poor in variety and intensity, if there is a negative balance, so
that suffering dominates, then the person in question is not to be described
as happy.
On the Relation Between Health and Happiness
We have noticed in our analysis that the formal object of happiness-as-an-
emotion is the realization of the subject's goals. This fact is important in
the following two ways. First, it immediately shows an important link
between health and happiness. Health is, roughly, one's ability to fulfill
one's goals. Happiness (as an emotion) is a state which arises as a conse-
quence of goal-fulfillment. Thus, health must be an important contributor
to happiness. Second, this discovery constitutes, however, a theoretical
problem. We are still searching for a definition of a vital goal, and conjec-
turing that the concept of happiness could provide a basis for such a
definition. Now, in the analysis of the emotion of happiness, in terms of its
formal object, we come up with the notion of a goal. Have we then come
full circle?
We shall argue that there is no vicious circle here. Let us first specify
what kind of goal is presupposed in the characterization of the formal
TOWARDS A HOLISTIC THEORY OF HEALTH 89
object of happiness. "Goal" does not mean the same as "vital goal". It is
instead a state of affairs in general wanted by the subject. It need not be
an intended goal. Remember that that goal-realization which contribute.s
to happiness need not be performed by the agent himself. One may be
happy about receiving a gift which one has wanted to have for some time.
Or one may be happy about the good weather which one has been longing
for. It is impossible to intend to attain such states of affairs. Still, when they
occur one may be happy about them and they may contribute to one's
general state of happiness.
We can draw one important conclusion from this reasoning. Happiness
depends on much more than health. A high degree of happiness presup-
poses, in addition to health, good fortune. The course of events, be they
political, social or natural, must be in general supportive of the subject's
plans and purposes. But how then should the relation between health and
happiness be characterized? Our answer is that health is related to some
minimal degree of happiness on the part of the subject. 62 A person's vital
goals constitute the set of goals necessary and together sufficient for a
person's minimal degree of happiness. The vital goals thus constitute a
subset of a person's goals. A further characteristic of this subset is that it
must contain goals which are all in principle attainable through the person's
actions. The vital goals could therefore all be intended by the agent, but they
need not be, since the agent need not know - or need not consider - what
is required for his minimal happiness.
Let us illustrate this contention by considering the dimension of time. A
reasonable claim is that a momentary pleasure is not ipso facto an instance
of minimal happiness. Moreover, the fact which creates the momentary
pleasure may block the realization of long-term minimal happiness. Still,
many agents decide to opt for the momentary pleasure and - consciously
or unconsciously - abstain from realizing a necessary condition for long-
term happiness.
We shall consider this case of counterproductivity more fully in the next
section. Let us here confine ourselves to a simple illustration. A person aims
to acquire a bag of his favourite sweets. He achieves this and as a result
he derives some temporary pleasure. A later consequence of this, however,
is that his stomach starts aching and his general well-being is reduced for
a period which is much longer than the duration of the pleasure connected
with eating the sweets. In a case like this the aim of acquiring the sweets
is not a vital goal' of the person in question. It is not a necessary condition
of minimal happiness, since minimal happiness requires some duration.
90 CHAPTER 3
What are the vital goals over and above the basic ones? Here the
SG-theory gives the fundamentally correct answer. There are, however,
some important exceptions to it and we shall consider the most important
of these in the following.
(i) The case of intended goals which have been formed under
compulsion.
A subject is sometimes not free in setting one of his goals. He has been
forced or compelled to do so. Is a goal which is formed in such a way
automatically one of his vital goals? In answering this question we shall
consider some different cases of compulsion: first, compulsion in the sense
of internal prevention of deliberation.
This kind may have a number of varieties. The most important of these
is perhaps the case of the irresistible desire. We mean here a desire such that
the subject cannot think of anything else; his ability to weigh between
possible competing goals is blocked. The drug-addict and the alcoholic are
typical examples of subjects with, as we believe, irresistible desires. We
view them, at least in the extreme cases, as being compelled to consume
drugs or alcohol.
A quite different kind of compulsion, which is also relevant for the
theory, can be illustrated by the example of the gunman. A person threaten-
ed with a gun can be forced to perform a wide variety of actions; he can
be forced to perform things highly damaging to himself. And when he is thus
forced he is also forced to decide to perform these actions. This is com-
pulsion in the form of an external threat. What is the logical mechanism
behind this kind of compulsion? The person who is forced is placed in an
extremely grave situation. Unless he does what the gunman tells him he
risks losing his life. This means that his most central vital goal is threatened.
If the gunman is efficient there is, given the situation, only one way of
TOWARDS A HOLISTIC THEORY OF HEALTH 93
maintaining survival; the gunman must be obeyed; the victim must decide
to follow his order.
This is then a highly rational decision; obeying the gunman is acting in
the light of one's most central vital goal. But, as soon as the threat disap-
pears, when a normal situation obtains, the decision and the action may
seem highly counterproductive. It does not reflect what the agent basically
wants and therefore does not create any happiness on his part.
Our conclusion concerning these cases is obvious: a decision which has
been compelled, either in the internal or the external sense, does not, ipso
facto, reflect a vital goal. The purchase of drugs is not a vital goal of the
drug-addict simply because he actually intends to do so. Nor is the burning
down of a person's house a vital goal of his simply because a gunman has
forced him to do so.
It is, on the other hand, theoretically possible that one is forced to
perform an action which is in accordance with one's vital goals. An intend-
ed goal formed under compulsion may be identical with a vital goal. What
makes a goal a vital goal here is not whether it has been intended or not.
The touchstone is whether minimal happiness in the long run will be
created.
(ii) The case of counterproductive goals
It is possible to intend to realize a particular goal, which does not create
happiness, but rather unhappiness, in the long run, without having been
compelled to form this intention. For such a goal we shall, in general, use
the label counterproductive goal. The counterproductivity can, however, be
of different kinds, from which we must draw different conclusions. Consid-
er first the case of accidental counterproductivity.
A person decides to build up a business, for instance to open a booksell-
er's shop. He succeeds in doing so, but after a while the business fails. It
has to be closed down and the owner goes bankrupt. The situation has
brought him unhappiness in the long run. Still, he has succeeded in realiz-
ing one of his intended goals, and this goal was not formed under com-
pulsion. Should we then say that opening the bookseller's shop was not a
vital goal for this man? No, we cannot draw this conclusion. One cannot
require from a vital goal that it must according to causal laws lead to
happiness in the long run. Other events may always occur to destroy the
effects of the realization of the vital goals.Thus the relation between a vital
goal and happiness must be formulated in a more careful way. A vital goal
of A is not a state of affairs which necessarily contributes to the minimal
94 CHAPTER 3
and we would therefore never be able to judge what the vital goals of man
are.
The question of whether something is a vital goal must therefore depend
on some judgment about the probable relation between the realization of
the goal and the creation of happiness. This judgment can be made by the
agent himself, but it can also be made by external observers. Whose
judgment is to be followed?
Let us here separate the empirical problem from the evaluative problem.
Relevant empirical issues are, for instance, the following: is a certain state
of affairs stable or is it likely to disappear soon (example: does the business
aimed for have good prospects or is it likely to go bankrupt soon); does an
alleged vital goal stand in conflict with another high priority goal of the
agent; has the agent been forced to make a particular decision?
In these empirical matters anybody - the agent, as well as the external
observer - can be both right and wrong. In particular, the agent can be
wrong and the external observer be right. It is therefore quite possible for
an agent not to be aware of what his vital goals are.
In the standard cases the agent is more likely to be right than is an
external observer. The reason for this is that the agent has direct access
to more relevant information than the external observer has. Unless the
agent is highly irrational he will know much more about his own hierarchy
of goals than the external observer does; he is normally also a better judge
as to whether a decision has been formed under compulsion or not.
But as we have claimed, the judgments in this area are not only empirical
in nature. In particular, the question of whether a person's state of happi-
ness satisfies the conditions of being minimal "real" happiness is basically
not an empirical question. A subject may accept a certain condition and
say that he is happy enough; an external observer may question this,
perhaps on the ground that the conditions for happiness are so poor or on
the ground that the behaviour displayed by the agent is unconvincing.
This conflict of opinion is theoretically unsolvable unless the agent and
the external observer have together made some common decision about the
criteria for the existence of minimal "real" happiness. If they have agreed
on such criteria and been able to formulate them in intersubjectively
verifiable terms, then they have transformed the evaluative issue to a
theoretically decidable one.
TOWARDS A HOLISTIC THEORY OF HEALTH 97
in some degree of illness, the degree depending upon the number and to
some extent the nature of the unfulfilled vital goals.
If health is interpreted as a dimensional concept the degree of optimal
health should be equated with the state described above simply as absolute
health. The idea of optimal health requires in turn some minimal degree of
health. This forces us again to make a decision. We must consider some
partial fulfillment of some goals to be minimally satisfactory, or we must
consider some goals as being less indispensable than others.
There is nothing in our analysis which forces us to decide in favour of
either of the two interpretations. A purely linguistic study would give the
answer that both the absolute and the dimensional discourses exist.
The English language, like many other languages, permits both the
locutions "complete health" and "optimal health". To speak of complete
health implies an absolute notion of health. Every state of incomplete
health is not really a state of health but a state of illness. Talking about
optimal health implies, as we have said, different stages of health which are
all stages of "real" health.
It seems as though the two discourses occur in different contexts. The
idea of health in an absolute sense (the idea of complete health) is favoured
in policy documents (including the famous document of the WHO).65 When
a policy document highlights the health of people as a goal, the goal
certainly is complete health (or, given the other conception, optimal
health).
The idea of health as a dimensional concept is much more natural in the
pragmatic context of actual health care. The health-care system is forced
to take care of the most severe instances of illness. It must, therefore, make
pragmatic decisions in many cases as to when a patient is fit enough to
leave the system. The border thus drawn could be said to be that of a
minimal degree of health, which is indeed far from what everybody would
consider to be optimal health.
Observe now that there is a further important way to interpret the idea
that health is a dimensional concept. This is by dropping the relativization
of health to one particular environment. Instead of saying that A can fulfill
his vital goals merely in E, we can contend that A can fulfill them in a great
number of standard environments E 1 .•• En. In the latter case A has a higher
TOWARDS A HOLISTIC THEORY OF HEALTH 99
degree of health than in the former case. Optimal health, on this interpre-
tation, occurs when the subject is able to realize his vital goals in all
standard environments.
This observation calls for the introduction of a new notation. Health-
ascriptions which are tied to a particular environment should be explicitly
noted as "A is in health" or "A is in health EJ ••• En". The absolute statement,
"A is in health", should then - strictly speaking - be reserved for a person's
ability irrespective of standard environment.
The absolute variant of health ascriptions is not merely of academic
interest. We are sometimes interested in the degree of a person's adaptabili-
ty to different cultures and environments. Ifhe has a high degree of adapta-
bility he has a high degree of health in this sense.
Note that adaptability does not merely depend on the person's psycho-
physical strength. Adaptability is also a matter of realism: to what extent
is the subject prepared to change his ambitions, to reformulate them in the
light of a new environment. If the subject is adaptable in this sense some
lack of psychophysical strength can be compensated for and the equilib-
rium between abinty and vital goals can remain.
Observe the consequences of this for the idea of curing a person who is
ill. The process of curing normally implies the manipulation of some ability-
grounding factors, typically parts of human anatomy or physiology. But
given our present observation we can see how curing can be effected by the
manipulation of a person's ambitions (presupposing, of course, that the
ambitions are not reduced to a level under which no "real" happiness is
possible).
of the kind such that its fulfillment, ceteris paribus, is necessary for the
minimal happiness of the agent. This may be so, for example, because the
fulfillment of this will stands in conflict with the realization of some higher
order goal in the hierarchy of the agent's preferences.
But an unrealistic goal may be a vital goal. It may be the case that a
person sets an unrealistic goal of a high-priority kind. It need not be set
under compulsion and it need not stand in conflict with any higher priority
goal of the agent. Thus, the character of the agent may be such that the
realization of this goal is a necessary condition for his minimal happiness.
If now the lack of realism is genuine so that the agent does not even have
a second-order ability to reach this goal, then the conclusion must be that
he is ill to some degree. This conclusion can be derived directly from our
own conception of health. The agent is ill because of his lack of ability to
fulfill one of his vital goals. We need no extra supposition about defective
wills.
This conclusion does not mean that we should ignore unrealistic wills.
The agent's lack of ability certainly depends on his unrealistic will. The
unrealistic will is what compromises his health in this case. It is therefore
a candidate for being a mental disease.
(c) The sense of a "mad" will. Certain human beings want to do things
which are highly unusual; they may want to climb Mount Everest, for
example, or sail around the globe in a mini-boat. Sometimes the objects of
these wants will even have the status of vital goals for these persons. Would
we say that the existence of such unusual wills are ever sufficient conditions
for the occurrence of illness? Our theory gives a very definite answer. The
fact that a person's goals in general, or vital goals in particular, are unusual
is never in itself a sign of illness.
Sometimes, however, the pursuing of an unusual goal- as is certainly the
case in pursuing many usual goals - can create illness. This can be done by
means of two very different mechanisms. The first mechanism is the simple
causal one, which entails the pursuit of a certain goal damaging the agent's
mind or body so that his basic abilities are reduced. The other mechanism
involves the pursuit of the goal in a way which so absorbs the agent's
attention and energy that he is unable to fulfill some of his other vital goals.
Observe that this general reasoning also applies to such an extreme will
as the will to take one's own life. The having of this will does not in itself
entail illness. A difference from most other cases of mad wills is, however,
the following: the goal of taking one's own life can never become a vital goal.
Observe our definition of a vital goal. The satisfaction of a vital goal is a
102 CHAPTER 3
Can two vital goals come into conflict with each other? Or is a conflict
necessarily a sign that one of the two is not a vital goal? We have given a
TOWARDS A HOLISTIC THEORY OF HEALTH 103
The general conclusion thus is that two vital goals cannot be genuinely
in conflict with each other.
1. MALADIES
ing to the ear muscles would almost never be discovered and would not
even, we should argue, be deemed a disease or a defect. In the example
described, however, there is a case for speaking of a culture-bound disease
due to a culture-specific vital goal.
We shall now suggest the following characterization of the notion of
disease:
D is a disease-type in environment E if, and only if, D is a type
of physical or mental process which, when instanced in a person
Pin E,would with high probability cause illness in p.70
The above concerns the notion of disease, which has been chosen as a
paradigm notion among the maladies. However, almost everything in the
preceding analysis can be seen also to be valid for the other maladies:
impairments, injuries and defects. The essential difference between them
has to do with their ontological status?!
Impairments are mostly taken to be state-like entities, and are not, like
processes, continually variable. In the International Classification of Impair-
ments, Disabilities, and Handicaps (ICIDH) [144] an impairment is said,
normally, to refer to the endstate of diseases, to what remains after the
disease-process has terminated. According to the view of the ICIDH, an
impairment is also an "exteriorized" state of affairs, a state which has
become obvious and which is normally also a problem for its bearer. 72
Both Porn and Whitbeck suggest that an injury constitutes a change (cf.
our notion of event in the Appendix). 73 As we see it, "injury" can receive
either of two interpretations; according to the first, injury is a mental or
bodily state; a way of distinguishing an injury from an impairment - which
seems defensible from the point of view of ordinary linguistic usage - is to
reserve the term "injury" for states caused externally. According to the
second interpretation, an injury is a change; by using the term "injury" one
then focuses on the moment of incidence when the injury, as a state, is
induced in the mind or body.
By a defect is typically meant a mental or bodily state of affairs which
is congenital.
A possible reconstruction of this conceptual apparatus for technical
purposes, then, is the following:
A disease is a bodily or mental process which tends to com-
promise health.
ON THE FACTORS WHICH COMPROMISE HEALTH 109
lar when all the disabilities involved in an illness arise from the same
disease.
The conceptual suggestion made here provides, in principle, a sharp
distinction between illness and disease. Illnesses are typically effocts of
diseases and not identical with them. This scheme has important conse-
quences for the field of mental pathology. In fact, most mental "diseases"
would turn out as illnesses in our terminology. The objects of psychiatric
classification are primarily clusters of disabilities, such as disabilities to
think coherently, to communicate, to socialize, etc. The real mental diseases
must be found among the causes of these disabilities.74
The conception of maladies presented here calls for a reconsideration of
the concept of health. In particular, a distinction could be made between
some different senses of ,health' which would do justice to some prevalent
medical intuitions concerning the notion.
In our main analysis we delimited a concept of health which was not
obviously a medical concept. Illness was defined as being due to internal
psycho-physical causes, but not necessarily to disease or to any other kind
of malady. The concept was deliberately kept open on this point.
To this general discourse on health we shall now add the specifically
medical one. According to it, the notion of health is typically tied to the
notion of malady in general, and the notion of disease in particular.
We are now in the position to clarify our discourse by introducing at least
two more narrow technical concepts of illness.
Maladies are the most typical internal factors which compromise health.
But we have not excluded other factors. There may be other phenomena
internal to a subject which can compromise his health. The important
question is then: are there other typical internal compromisers of health
and, if there are, how are they to be distinguished from maladies? We shall
consider this question by analysing some phenomena which constitute
classical test cases in the philosophy of health: (1) old age or senility, (2)
pregnancy and (3) grief (together with some other negative emotions).
Consider first the degenerating process of old age. Prima facie it is a
candidate for being a disease: it is a bodily or mental process which tends
to reduce a person's abilities. It has some typical characteristics: it affects
the epidermic cells, which lose their plasticity; it accelerates the process of
atherosclerosis; it accelerates the process of necrosis in the cerebral
tissues.
All these concrete degenerating changes could very well constitute or be
part of pathological changes. Still, old age has traditionally been dis-
tinguished from disease. Why? And how could this be expressed in the
theoretical framework of this essay? The major (pragmatic) reason for a
distinction between old age and disease seems to be that old age is the
inevitable fate of all human beings. In the long run, for reasons of principle,
senility cannot be cured. The "cannot" here is - at least so we believe -
irreversible. It is to be distinguished from what we today call incurable or
chronic diseases. In the latter cases we do not consider it impossible to be
able to cure them at some point in the future.
We do not know the mechanism of senile degeneration in all details.
(Although there have been notable advances recently, see for instance [22],
[34] and [52]).75 But we do in general believe that there is a special cause,
quite clearly distinguishable from most causes of diseases, which accounts
for this process. A plausible hypothesis is that this cause is to be located
in the genetic code as a specific program determining the life-span of man.
But how should senility be accounted for in our theory of health? There
seem to be two perhaps equally plausible strategies. The first one - suggest-
ON THE FACTORS WHICH COMPROMISE HEALTH 113
Consider now the states of grief, despair andfrustration. One of the criteria
of such negative emotions is that they tend to reduce the subject's general
ability. This reduction is accomplished mainly in two ways. One is that they
cause complete passivity, the kind of state we call depression. Another way
ON THE FACTORS WHICH COMPROMISE HEALTH 115
is that they cause outbursts which in their turn block systematic activity.
These emotions are thus mental states or processes which tend to com-
promise the subject's ability. But are they, ipso facto, maladies?
A cautious answer to this question will again tell us something about the
specification of human vital goals. First we make one distinction. There are
instances of negative moods, in particular of depression, which we believe
to be consequences of underlying impairments or diseases of the subject
himself. Such cases of depression belong to the pathological picture. They
qualify as illnesses.
Negative emotions, however, are responses to situations. Grief is a re-
sponse to a situation which involves a loss of something that the subject
holds dear. Frustration is a response to a situation which prevents the
subject from doing something which he considers to be important.
Emotions are, as we have previously said, directed towards objects and
these objects may be very limited. The loss of a particular physical object
may cause grief; the prevention of a very special course of action may cause
frustration. But although the objects (which are normally identical with the
causes) of these emotions may be very limited they are similar to happiness
in that they may colour the whole personality of the individual. This is why
an emotion may affect the general ability of the subject and thus have
consequences similar to the consequences of diseases.
But why then do we normally refuse to label the negative emotions
"diseases"? A tentative answer runs as follows. In contrast to other mental
categories, emotions are linked to the moral character of their bearers.
Emotions can be justified or unjustified in particular situations. It is highly
morally justified - or even morally commendable - to feel grief when a close
relative has died. Similarly, it is highly morally justified - or even morally
commendable - to feel happiness at the success of a loved one.
In general, emotional sensitivity, i.e. the disposition to have a rich em-
otional life including both positive and negative emotions, must be a goal
for every moral agent. He must prepare himself to become a sensible
person. This involves a disposition for acquiring negative emotions, such
as grief, should the course of events go against his desires. Thus, justified
grief is an indirect consequence of moral education. According to ordinary
intuitions, illnesses do not have such links to adequate moral training.
Although this may explain the common intuitions concerning grief and
some other negative emotions, it does not settle the status of these em-
otions from the viewpoint of the welfare theory of health. How can grief,
116 CHAPTER 4
being a malady. There are, however, good reasons for putting this malady
into a special category. Contrary to the ordinary maladies we believe that
(at least many aspects of) senile degeneration is an inevitable process. Thus
it must have a very special status in medical treatment. Ifwe wish to reserve
the term "medical malady" for such states, events, and processes which are,
in principle, treatable, then senile degeneration is not a medical malady.
(ii) The standard case with pregnancy is that it does not compromise
health. The reason for this is that for most pregnant women the having of
a baby is a vital goal. Pregnancy is a necessary condition for this vital goal.
Thus, pregnancy cannot be a disease.
We did not, however, exclude the case where pregnancy is a cause of
illness. For some women bearing a child is not a vital goal. This does not
give pregnancy the status of a disease. To be a disease a process must
typically cause illness. This is not true of pregnancy.
(iii) Grief, and most other negative emotions, are not maladies. The main
reason for this is that the emotional sensitivity which disposes one for grief
is a precondition for a minimally happy life. Thus the disablement occasion-
ed by grief does not qualify as illness. We speak of illness in certain extreme
cases, when the emotions are exaggerated and prolonged. Then they may
be viewed as an expression of weakness of character, which in its turn is
a candidate for being a malady.
CHAPTER FIVE
But observe that this dependence between the concept of health and a
language-using society is nothing peculiar to the concept of health. It
concerns all concepts as conceived in public languages. In the same sense
the concepts of stone, moon, electron, and animal are society-dependent.
One thing to notice here, though, is that these goals are not always
attainable given the society here and now. The goals of such programs
normally presuppose the effecting of important societal changes. One can-
not therefore immediately interpret these goals as the vital goals characte-
rizing health in society as it is. They may perhaps characterize the vital
goals of tomorrow.
The programs can, however, give a clue to the general dimensions along
which the vital goals may be found. Sometimes the desired goals oftomor-
row can be seen as extensions and further specifications of the vital goals
of today. Consider, for instance, the general dimension of education. Ac-
cording to all political programs, a certain minimal degree of education
belongs to the vital goals of man. What distinguishes the programs and
what distinguishes the situation today from a desired situation tomorrow
is the exact position of a minimal degree of education. Still, the programs
tell us that education and learning as general dimensions belong to the vital
goals of man.
(b) The evaluations of society as a whole. A party's political program may
become the program of a parliament. Some of its aspects may even become
law. When this is the case we have the paradigm of an evaluation made and
codified by society as a whole. The use which we can make of such
programs and laws is analogous to what we said above about programs in
general.
(c) Evaluations and decisions made by health authorities. It could be pre-
sumed that the most direct way to judge what the evaluations of the society
concerning welfare are is to observe the decisions and actions actually
taken by the health authorities. Now this procedure is both direct and
indirect. It is direct in the sense that the actions and decisions of health
authorities really concern what is to be evaluated as health today. It is
indirect, however, in the sense that the health authorities do not normally
formulate the vital goals of man in the way political parties try to. Instead
they make concrete decisions in particular cases. They decide from case to
case whether an individual fulfills the criteria for societal health care. From
these criteria one can only indirectly draw conclusions concerning the vital
goals of the individual.
It is important to note that when we talk about the health authorities we
almost invariably refer to medical health authorities, consisting mainly of
medically-trained personnel. Such authorities tend to use one of our more
narrow notions of health. That is, illness to them is a kind of disability that
124 CHAPTER 5
Let us, however, also consider those untypical cases where society
"offers" health care without the subject's having asked for it. The paradigm
here concerns people who are gravely ill or handicapped for mental rea-
sons. The majority are people whose disability is obvious to everyone
irrespective of ideological background; the disability concerns here such
basic vital goals as being able to take care of oneself, being able to orient
oneself and communicate with others.
There are, however, interesting exceptions to this rule. We have reasons
to suspect that the health-care system in some countries is used to take care
of people who are not handicapped in this obvious sense. The typical
characteristics of the subjects in question are that they do not conform to
certain norms laid down by the state. They may oppose the prevailing
ideology of the state, or they may simply be criminal or immoral.
When such procedures are customary in the health-care system they
become relevant to our conceptual issue. This depends, however, on how
the situation is interpreted by the state and the health-care system in
question. Assume that the situation is interpreted in the following way: the
deviant person under scrutiny is not merely a political opponent. He is
cognitively disabled; he does not understand the important vital goal of
contributing to the x-ist ideology. This cognitive disability must be cured
and he must be attended by medical personnel.
If this is the interpretation, the society in question is still using the
standard concept of health. What is peculiar here is the specification of a
human vital goal in conformity with a particular political ideology.
Consider now a different interpretation: the political opponent is not
considered disabled. He is viewed simply as a nonconformist who is dan-
gerous to the state. The most convenient - and perhaps the most efficient
- way for the state to take care of him is to let the health-care system do
it. This can be done either in a completely pragmatic way without involving
the notions of health and illness, or it can be done by actually extending
the notion of illness to cover cases like these. People who are dangerous
to the state can be defined as being ill.
If the latter procedure is the one which is adopted, then there has indeed
been a conceptual change effected by a society. We have a completely new
notion of health added to the standard notion accepted in all societies. It
can however be doubted whether this redefinition is ever made, since
standard pathological terms are often used to signify the mental states of
the subjects in question. The label "schizophrenia" is a common label
attached to such individuals. And a typical feature of schizophrenia, as this
126 CHAPTER 5
true that health is not an absolute biological concept, but instead a three-
place predicate with argument-places for a standard environment and for
a set of vital goals, the necessity becomes great for further specification and
evaluation. Ifwe want discourse on health to become clear, we must know
what are to be counted as standard circumstances and we must have the
vital goals more exactly specified.
For certain technical health-concepts the request may already have been
satisfactorily met. Consider the specifications made by health insurance
authorities. Here the situation is simplified since there is only one vital goal
in focus. And this goal is quite clear: it is the fulfillment of the subject's
professional role. A person who is unable to fulfill his professional role is
ill from the point of view of health insurance. This is a simple and clear
criterion as well as an individually sensitive one. The professional role does
not mean one and the same thing but very different things to different
individuals.
There are, however, more ambitious attempts to respond to the require-
ment expressed here. Consider, for instance, the previously mentioned
work issued by the WHO, which is a tentative manual for the Classification
of Impairments. Disabilities and HandiCaps (ICIDH) [144]. Admittedly, this
work does not express itself exactly in the terms suggested in this essay.
Nor is its explicit purpose to define health, or to list the vital goals involved
in health. The purpose, however, when properly analysed, is quite similar.
In an attempt to arrive at an exhaustive taxonomy of handicaps the
authors of the ICIDH suggest that every individual living in a modern
society must fulfill a number of roles in order to survive (or at least in order
to survive without direct assistance). These are called survival roles.
If the individual turns out to be more or less unable to fulfill these roles
then he is more or less handicapped. The manual even suggests procedures
for measuring the degrees of handicap along a scale from 0 - 9. We can
illustrate the technique of the ICIDH by describing the survival role of
economic self-sufficiency and the various degrees of handicaps which can
pertain to it. 79
Definition: Economic self-sufficiency is the individual's ability to sustain customary socioeco-
nomic activity and independence. Scale categories: [The text is here highly abbreviated].
o Wealthy
1 Comfortably well-off
128 CHAPTER 5
2 Fully self-sufficient
3 Adjusted self-sufficiency
4 Precariously self-sufficient
Includes: individuals who remain self-sufficient only by virtue of appreciable support from
or dependence on financial or material aid from other individuals or the community ...
5 Economically deprived
Includes: individuals who economically are only partially self-sufficient because their income
or possession of financial or material aid from other individuals or the community meets only
part of their needs ...
6 Impoverished
Includes: individuals who economically are not self-sufficient by virtue of being totally
dependent for financial or material aid on the goodwill of other individuals or the communi-
ty ...
7 Destitute
Includes: individuals who economically are not self-sufficient and to whom support from
others is not available, so that their disability status is further aggravated.
8 Economically inactive
9 Unspecified.
General Consequences
The analysis of health and society presented here has already shown some
obvious consequences of our conception of health for health care and
medicine.
A most crucial element in the analysis is that health is not a purely
biological concept. It is a three-place notion involving evaluations concern-
ing vital human goals; moreover it contains an essential reference to an
environment involving a society. Thus the clarification of the discourse on
health cannot be made merely by improving our biological or broadly
medical conceptual apparatus. As was noted in the previous chapter, there
must be a standing request to each health-care system to specify the basic
vital goals to be adopted in a particular society. These requests are
profound and entail a major demand on the social politics of the governing
bodies in society.
Without such a specification health care and clinical medicine cannot be
a clearly defined enterprise. As a result there may be very different and
unclear ambitions on the part of health-care personnel. Some of them may
interpret their task as consisting only of bringing a particular disease
process to an end; others may include in their task an attempt to rehabili-
tate a subject to a certain level offitness; yet others may include an attempt
to prevent new health risks from occurring, and so on.
But what then are the consequences for clinical medicine in a more
limited sense, and for the science of medicine? By clinical medicine in a
limited sense we mean the enterprise of diagnosing diseases and impair-
ments, treating disease and making prognoses. Is this enterprise affected
in a major way by our notion of health? Does it, for instance, mean that
the physician himself must take part in the procedure of formulating the
vital goals of health?
Our answer is no. The physician could and should remain a technician.
The formulation of vital goals should be in the hands of the individuals
themselves and - concerning certain basic vital goals - in the hands of
politicians and policy-forming health authorities. The clinician and the
medical scientist should instead work in the light of such a well-defined
concept ofhealth. Given a well-defined set of vital goals the clinician can use
his expertise in theoretical judgment: what bodily and mental states are
risk-factors for a subject's ability to realize his given set of vital goals? What
130 CHAPTER 5
states have such a high probability of disablement that we should call them
diseases?
Observe here the clear connection between the bodily and mental states
and disablement. This involves a sharpening of the request to the medical
practitioners. Not any abnormal bodily state is a disease. There is, accord-
ing to the philosophy presented here, no reason to make a bodily state into
a disease just because it functions in some sense abnormally or subnormal-
ly. We should do so only if experience tells us that there is a high probability
of the state's causing disablement in the subject.
The choice of vital goals can, in principle, also affect the set of diseases
and impairments. There may be some cultural variations in deciding what
should be counted as diseases. But, as we have already noticed, it is not
likely that this variation will be very great. The main reason for this is that
most acknowledged diseases and impairments strike their subjects in a
basic and general way. Consider, in particular, all those diseases and
impairments which cause pain and fatigue. Pain (even "local" pain) and
fatigue strike the subject as a whole. These sensations make all kinds of
activities (except perhaps certain kinds of omissions) difficult for him. The
result then is general passivity. Then the exact nature of the vital goals that
the subject should achieve will be of little importance. He will be ill in
whatever culture he finds himself.
When it comes to the stratification of diseases and impairments, when
we deal with particularities of taxonomy, the influence of our philosophy
will be even less. The grounds for the division of diseases and impairments
are not connected with particular vital goals. They concern essentially
anatomical localization or etiology. Out of the 17 main categories in the
International Classification of Diseases (ICD) [143] about 10 are formed
according to the principle of anatomical localization, whereas 2 or possibly
3 are formed according to an etiological principle. These facts are certainly
purely biological (or, in the case of mental diseases, psychological) and will
remain so.
lt is therefore important to stress that the vital goal notion of health is
not a notion which stands in opposition to biological medical research or
to a biological understanding of diseases. The biological order is a necessa-
ry condition for health. Our conception, however, means that health is not
identical with the biological order. We need a set of goals for action in order
to understand what health is. And before we have the goals we cannot be
quite clear about the notion of biological order. As we understand the
notion, biological order is that set of biological functions which, given
ON SOME SOCIETAL AND SCIENTIFIC CONSEQUENCES 131
standard circumstances, makes it possible for the subject to satisfy his vital
goals.
Let us then summarize our general conclusions concerning the conse-
quences of our philosophy for the medical profession:
(i) The determination of what is to be counted as health is not an
exclusively biomedical affair. It is an evaluation of a social and
political character, which should ultimately be decided upon by
central political organs.
(ii) Biomedical work should be pursued against the background of
such political decisions. The medical categories, diseases,
impairments, injuries, etc., should be identified in the light of a
given specification of health.
(iii) A clear definition of health will have a particularly salient effect
on treatment and rehabilitation. If the vital goals of health be-
come explicit, medical personnel- including physicians, nurses,
physiotherapists and occupational therapists - will also know
the goal of their work. The goal is no longer simply the termi-
nation of a particular process of disease; it is the realization of
a particular level of ability on the part of the subject.
A Test Case for Diseasehood: Homosexuality
It might now be of some interest to test the welfare theory of health on some
matter of controversy. In the general political and medical debate the status
of some bodily and mental states has been unclear. The typical cases are
various kinds of deviances, states which express themselves in deviant
behaviour, i.e. criminal, immoral or otherwise undesirable behaviour. Par-
adigm cases are alcoholism, psychopathy and homosexuality. In different
countries and at different times these states have moved in and out of the
sphere of pathology. Alcoholism, at least in its severe forms, has perhaps
come to stay; psychopathy, although hardly ever clearly defined, has per-
haps never been completely out, but its importance as a state of pathology
has varied. Homosexuality is particularly interesting; it has entered and left
many lists of diseases and impairments; it remains in some of them. It has
also been a more or less permanent guest in the criminal codes of different
countries.
In the discussion to follow we shall use homosexuality as our own test
case. We shall try to answer the following questions: On what has one
based, and on what can one base, the idea that homosexuality is a disease?
132 CHAPTER 5
The religious standpoint was for a long time supported in the Western
criminal codes; and as religious authority began to wane secular law took
over the persecution. The death penalty for homosexual acts remained in
most countries until the 19th century, when it was replaced by milder forms
of penalty. Now, in the year 1985, there are a great many places where
homosexuality is no longer a criminal offense. On the other hand public
discrimination of homosexuals often continues, for instance by labelling
homosexuality a pathological condition. 82
The first significant scientific works on homosexuality were those of
Freud. In fact, the psychoanalytic school of thought is still the dominant
school among those who consider homosexuality to be a pathological
condition.
Freud and his followers held it as almost self-evident that a heterosexual
disposition was the normal and natural outcome of a person's psychosexual
growth. Thus, homosexuality was an inversion, a trait due to some stop-
page in the person's development to being a normal adult. 83
According to Freud, however, homosexuality is not a completely unna-
tural condition. In fact, he says, all children experience homosexual phases,
which must be gone through before the completion of their development.
In emphasizing this feature Freud distinguished himself from most of his
predecessors and followers. He opposed the view that homosexuals repre-
sented an extreme form of degeneracy or that they were in general deviant
or disabled. In fact, Freud noticed how many homosexuals were dis-
tinguished members of the society displaying high intellectual and moral
abilities. As a result he rejected the idea that homosexuals should be barred
from membership of psychoanalytic societies. 84
What, then, is the nature of that psycho-biological process which termi-
nates in a homosexual inclination? Consider here Freud's basic ideas on
male homosexuality.85
ON SOME SOCIETAL AND SCIENTIFIC CONSEQUENCES 133
In the beginning there is a young man who has strongly fixated on his
mother. After puberty he changes his attitude; he identifies with his mother
and looks for love-objects whom he can love as his mother loved him. The
male object should be of the same age as himself, when this new phase of
his development starts.
The main causes of this identification with the mother are, according to
Freud, the following: fixation on the mother, which makes it difficult to
transfer affection to other women; fixation on the male organ - a tendency
not to tolerate its absence in a love-object; respect for the father and a fear
of him; thus all rivalry with the father - and with other men - is avoided.
Many of the later psychoanalysts have followed Freud in tracing the
origin of homosexuality to psychosexual development. There are, however,
also important differences. The most influential psychoanalysts, like San-
dor Rado, Irving Bieber and Charles Socarides, consider homosexuality to
be a grave disorder. According to them homosexuality is not simply an
abnormal variant. It is a highly disabling state of affairs connected with
massive fears. Socarides writes:
Homosexuality is a masquerade of life in which certain psychic energies are neutralized and
held in a marginally quiescent state. However, the unconscious manifestations of hate,
destructiveness, incest, and fear always threaten to break through. Instead of union, cooper-
ation, solace, stimulation, emotional enrichment, and a maximum opportunity for creative
interpersonal maturation and realistic fulfillment, there are multiple underlying factors which
constantly threaten any ~going homosexual relationship: destruction, mutual defeat, exploi-
tation of the partner anti the self, oral sadistic incorporation, aggressive onslaughts, and
attempts to alleviate anxiety - all comprising a pseudo-solution to the aggressive and libidinal
conflicts that dominate and torment the individuals involved ([121], p. 119).
The elements of fear and hatred are important also in Socarides' causal
explanation of male homosexuality. The very young boy's fear of his mother
and aggression towards his father (already during the preoedipal phase)
prevents him from separating from his mother and establishing an identity
of his own. As a result he cannot identify his true gender, and retains in
a sense a feminine personality.86
For Socarides there can be no doubt about the pathological status of
homosexuality. Moreover, he claims that most homosexuals, because of
their homosexuality, have other mental diseases as well, such as schizoph-
renia and paranoia. 87
The psychoanalytic theories, although dominant in particular in the
American debate, have no monopoly in explaining homosexuality. There
are also a number of purely biological hypotheses. One of the most favoured
134 CHAPTER 5
universal vital goals; and, are homosexuals in general strictly unable to form
families and have children?
It could seriously be doubted - given some recent empirical investi-
gations - that family-forming and reproduction are universal vital goals.
Moreover, it is simply not true that homosexuals are, in general, unable to
form a family and have children. Thus, there is no support for claiming that
the homosexual inclination (or its causes) is a disease or an impairment.
There are good reasons for believing that family-forming and repro-
duction are vital goals for some homosexuals. There are also good reasons
for believing that many of these - mainly for psychological reasons - have
great difficulties or are even unable to realize these vital goals. These
homosexuals qualify as being ill in our system. But even if the homosexual
inclination is a cause of this illness, we cannot conclude that it is a disease
or an impairment. The reason is that the homosexual inclination does not
cause illness in the majority of its subjects.
On the Notion of Health Outside the Realm of Human Beings
We have noticed at several stages in our discussion that the concept of
health as well as all the malady-concepts have applications outside the
context of human affairs; in fact, they seem to apply to all living beings.
Animals as well as plants can be healthy, have diseases and be impaired.
It is also obvious that the way these concepts are applied to non-human
living beings is closely related to the way they are applied to humans. This
relation is particularly obvious when we compare the diseases and impair-
ments of higher animals with the diseases and impairments of humans. The
nomenclature of pathology is partly identical and otherwise very similar.
Dogs and horses can break legs and have skull fractures; they can be
infected, acquire influenza and common colds; they can have renal and
cardiac troubles and their tissues can be transformed into neoplasms.
Much knowledge about human diseases is in fact acquired through the
study of animal diseases. Current medical ethics still allows some experi-
mentation with animals. Certain knowledge is therefore more easily acces-
sible through the study of animals. But this study of animal disease would
be pointless unless we believed that there was a close conceptual and
empirical connection between animal pathology and human pathology.
But the relation is certainly not restricted to the malady-concepts. There
is an obvious relation also between animal and human health. We say that
a dog or a horse is healthy when it is active and alert, when it expresses
140 CHAPTER 5
joy, when it does the things that we expect and want it to do. All this sounds
rather close to a rough description of human health.
Now, what about plants? When is a flower healthy, and what do its
diseases and impairments amount to? A flower is healthy when it
"flourishes", when it displays vitality, when it grows and develops well. Its
diseases and impairments are all those processes and states within it which
tend to diminish its vitality or even threaten its life altogether.
These elementary observations converge on one conclusion: the health-
concepts of man are not completely distinct from those of animals and
plants. Our observations in fact unambiguously suggest that they are highly
similar and must belong to one and the same family. This raises a criterion
of adequacy for the theorist. As we have said, a good theory of health
should be able to account for the whole family of health-concepts. 97
We observed that the biostatistical conception of health had the advan-
tage of offering a universal notion also applicable to animals and plants.
The subject-goal theory, however, was limited in this respect. A notion of
health based upon the fact that the subject sets goals for himself cannot
be applied to the whole realm of animals, and obviously not to plants. But
what are the qualities of the welfare theory in this respect? How should we
describe the welfare of animals and plants?
Let us first note the very salient analogies which can be drawn between
humans and the higher animals. It is proper to say, for instance, that
monkeys, foxes, dogs and cats have wants and intentions. We can see how
they decide to reach certain goals, such as acquiring food or sheltering their
offspring, and successfully carry out these intentions. We can also see how
some of these goals display some stability. They have the character of
standing goals and particularly important goals. We can also observe what
happens when the animal in question does not succeed in realizing or
maintaining these goals. It expresses aggression or anxiety; it nervously
seeks for alternative routes to realizing the goal; if the preventative factor
is an intruder, it attacks the intruder or flees from it; ifit is some other kind
of physical circumstance it would try to manipulate it or again flee from it.
The analogies with the human case are very salient. Higher animals have
goals similar in certain respects to those of humans. Their behaviour is
systematically directed to these goals. As a result of reaching the goals the
animals express satisfaction in a way partly similar to human expressions
of happiness. And when the goals are compromised, they display emotions,
for instance, anxiety and aggression, in a way similar to humans. The
important difference between humans and animals lies in complexity,
ON SOME SOCIETAL AND SCIENTIFIC CONSEQUENCES 141
variety and richness. Humans can deliberate in a way that animals cannot;
they can decide on the relative importance of goals and consciously form
intentions. Moreover, humans have a much greater variety of goals, far
beyond those connected with survival and reproduction. A far greater
number of things are important to humans than to animals. As a result the
happiness of humans is much richer and far more complex than that of
animals.
Our general conclusion is that the whole welfare-conception of health
(even keeping the identification between welfare and minimal happiness)
can in all its essentials be applied to the higher animals. We can talk in
terms of their ability to reach their vital goals.
But how must we modify our analysis to take in the health of lower
animals and plants? There seem to be three features to consider, two of
which have already been treated in the discussion of the health of infants.
(i) Lower animals and plants do not form intentions,
(ii) Lower animals and plants do not have abilities in the sense
analysed in this essay,
(iii) Lower animals and plants cannot experience happiness.
(i) is a fundamental problem for the SG-theory but it does not disturb the
welfare theory, as was pointed out in the case of infants. The states
necessary and jointly sufficient for a living being's welfare need not be the
objects of his intentions.
(ii) can be met in a way analogous to the solution for infants:
A lower animal or plant LP is in health if, and only if,
the inner constitution and development of LP is such that, given
standard circumstances, the necessary and jointly sufficient
conditions for LP's welfare are fulfilled.
The crucial problem then concerns (iii). How do we determine the welfare
of a lower animal or a plant when there is no criterion of happiness? Two
ideas for the solution of this problem will be suggested here. First, the
welfare of lower animals and plants may be modelled on that of humans
and higher animals. Second, their welfare may be evaluated on the basis
of their efficiency in contributing to human welfare.
The first suggestion amounts to the following: From the happiness
concept of health, in the case of human beings, we can derive a secondary
concept in terms of a certain biological order. There are certain well-known
142 CHAPTER 5
have been cultivated and trained, and their failure is not due to extraordina-
ry circumstances, then these species of life are considered to be ill.
Our reasoning can be summarized. The welfare theory of health is also
a plausible theory from the point of non-human life. First, such notions as
intentions and wants have application to many higher animals; a happiness
criterion can therefore be used also in these contexts. Second, we evaluate
the welfare of animals and plants also on the basis of other criteria. These
criteria may either be completely modelled on the human case or they may
be attributed to nature on the ground of nature's capacity to be, in an
expected way, useful to mankind.
This line of reasoning has revealed the following basic tenet in our
philosophy of health. The concept of health has its fundamental place in
the specifically human discourse. The term "health" is obviously also used
outside the universe of humans. According to our suggestion, however, it
is used there in a parasitic sense. The idea of health can be extended to
cover all animals and plants only by using certain incomplete analogies.
This conclusion constitutes another basic difference between the welfare
theory of health and the biostatistical theory as proposed by Christopher
Boorse.
CHAPTER SIX
In Chapter one, section 2, we listed six basic questions which every good
theory of health should be able to answer. Let us now summarize our own
investigation by letting the welfare-theory answer these questions.
2. What are the logical relations between the concept of health and some other
central humanistic concepts?
Health is defined as an ability-concept. It is, however, easily distinguished
from the concepts of excellence such as those of intelligence, strength, or
talent. Health is the ability to reach a certain basic level, i.e. the level of
145
146 CHAPTER 6
3. What is the relation between human health and the health of other living
beings?
The theory states in its most abstract form that a person's vital goals are
necessary and jointly sufficient for his minimal welfare. The concept of
welfare is applicable to all living creatures, including plants.
For humans and higher animals we have interpreted welfare as happi-
ness. For lower animals and plants we must use some other interpretation.
Our suggestion is that there is an ideal of welfare imposed on lower animals
and plants in analogy with the one used with respect to higher animals and
ourselves. Steady growth, development of potentials and reproduction are
important conditions of our own minimal happiness. We therefore consider
such features as essential criteria for health in, for instance, plants.
We have also suggested that with some animals and plants, in particular
those actually raised and cultivated by humans, we tend to use a notion of
welfare which is parasitic on our own welfare. According to this notion, a
plant or a lower animal is healthy if it fulfills the purposes of the breeder
or cultivator, i.e. some of the goals necessary for his welfare.
Still, ordinary intuitions about mental illness and mental health can be
expressed within the theory: a person is mentally ill if his health has been
compromised by states or processes in his mind. A person is mentally
healthy if there is no mental compromiser of his health (i.e. if he is either
in complete health or ifhis health has been compromised merely by somatic
factors).
standard is, however, essential for the science of rehabilitation and absol-
utely necessary for the general enterprise of health care.
2. GLOSSARY
(ii) Accomplishment
An accomplishment is an action generated by at least one further action.
This generation can be causal or conventional.
(iii) Activity
An activity is a set of actions on the part of an agent A, constituting a
spatio-temporal sequence.
(ix) Malady
M is a type of malady in environment E if, and only if, M is an episode-type
which, when instanced in a person A in E, causes with high probability
illness in A.
In this essay we have so far only spoken of the general concepts of health
and illness and the general malady concepts. We have, for instance, sug-
gested generally that diseases are internal processes such as tend to com-
promise health. However, the medical discourse does not just contain a
general notion of disease; there are also a great number of specific disease
notions, i.e. notions standing for all the various kinds of diseases that there
are, for instance, cancer, tuberculosis, diabetes mellitus and coronary
infarction.
The ontology of these diseases or disease-kinds has been the subject of
a long and interesting debate which has played an important role in medical
thinking. 98 It is customary to characterize this medico-ontological dis-
cussion as a debate between two parties, normally called the ontologists and
the physiologists. Another term for the latter party is "functionalists". Both
parties have a long tradition, but perhaps the physiological school is the
older of the two. The tradition of this school dates back to Hippocrates and
his ideas about the physiology of the healthy and the ill person. The healthy
person was characterized by physiological balance, a balance sustained by
the right mixture of bodily elements, including the bodily humours. A
person who was ill was characterized by an imbalance in these respects.
The various disease labels, which certainly also existed in ancient times,
were then taken to refer to the different ways in which an imbalance could
manifest itself. The disease or illness of melancholia could, for instance, be
identified as the imbalance consisting of too much of the humour black bile
and too little of other humours. 99 (Similarly, according to the modern
physiological way of thinking, diseases could be viewed as different kinds
of disturbances in the ordinary physiological functioning of the body.) 100
In the history of medical ideas "physiologism" often stands for a particu-
lar attitude towards the task of medical classification too. The physiologists
- given their way of viewing diseases - have difficulties in ordering disease
phenomena into clear categories. They are bewildered by the enormous
individual differences; they are struck by the fact that no one case is exactly
151
152 APPENDIX
they abstain from drinking, their mouth becomes parched and their body dry; the viscera seem
as if scorched up; they are affected with nausea, restlessness and a burning thirst; and at no
distant term they expire ([2], p 338).
can appear without the pancreas being involved. Therefore, some of the old
"true" cases of diabetes would be labelled "false" diabetes today.
Nor is the specification of diabetes as a defect in the glucose homeostasis
sufficient to identify it with the modern concept. A disturbance in glucose
homeostasis can be effected by other means. The metabolism of sacchar-
ides depends on many factors outside the pancreas, for instance the endo-
crine glands and the liver. Therefore, not all those disturbances, which look
very much like diabetes clinically, need be "true" instances of the modern
concept of diabetes mellitus.
Nor again are all those cases of deficient glucose homeostasis which are
due to lack of insulin, true instances of diabetes mellitus. The insulin pro-
duction can be blocked by external factors and need not be due to specific
internal failures, which the modern concept - strictly speaking - re-
quires.105 ,106
It appears, then, that the conceptual change which is due to medical
discoveries does not just result in better descriptions of the "same" thing.
This evolution results in an, at least partial, change of the reference-class.
Let us consider this in some detail via a more abstract analysis of the
process.
A disease-species was first identified as a cluster of signs and symptoms.
In the days of pathoanatomy and pathophysiology some causes of these
signs and symptoms were sought in the structure or function of certain
organs. If such changes were found the disease was identified with these
causes. The disease had taken its seat in the organs. Sometimes cellular
biology traced the etiology deeper down in the microbiology of the orga-
nism. If such cellular changes were found, as were likely to have caused
both the dysfunction of the organs and the external signs and symptoms,
the real locus of the disease moved to the cells. But the process can go
further; we may try to look for the external (or internal) cause of the cellular
change. If such a cause is found, this normally has consequences for the
disease-concept. The disease tends. to be etiologically defined, although it
is not normally literally moved to the locus of the external object.
This evolution has a number of conceptual consequences. They can be
described slightly formally in the following way: A particular cause (on the
physiological level) of a cluster of signs and symptoms is found. A former
symptom-disease D is redefined in terms of this cause. It eventually ap-
pears, however, that this cause can account for only a portion of the
manifestations of the sign-symptom cluster. The old disease-species D is
now divided into the new disease-species D and something else which lacks
ON THE ONTOLOGY OF DISEASES 157
a particular cause. For the new D one may find in its turn a cellular cause
or an· external cause, which may give rise to yet another conception of D.
Again these causes can most probably account for only a certain percent-
age of the new D. The new D should, then, in its turn be divided into a
further D and a residue disease which lacks the microscopic or external
causes in question. If such a conceptual split is made over a long period
and in several steps - and if, furthermore, an ancient term is carried over
to connote a modern concept - then we have rich sources for conceptual
confusion. In this case, the reference class formerly denoted by the term
has a rr.uch greater extension than the same term today.
The conceptual development which we have outlined here is the most
typical one. Another important case, though, is the one in which several
kinds of symptoms have been found to have a common cause. This is the
case with the disease of Tuberculosis, where many different symptoms -
earlier viewed as different diseases - were shown to be caused either by
Mycobacterium tuberculus or Mycobacterium bovis. Here instead of a split, we
get a conceptual unification.
What does this story tell us about disease species and the possibility of
characterizing the ontology of diseases? It gives us numerous reasons for
caution.
First, the facts regarding conceptual evolution constitute a good argu-
ment against an Aristotelian view of disease-types. Given the great histori-
cal change described above, it is highly implausible that the terms
"diabetes" or "tuberculosis" represent essences which are given once and
for all. Second, the historical outline implies that a disease as identified at
one time may have an ontology distinct from the disease as identified at
another time.
Returning now to the main issue, what strategy for ontological inquiry
should be chosen?
Let us make two preparations for this discussion, first a pragmatic one,
then a philosophical one. The pragmatic consideration will concern the
already existing terminology used to refer to diseases. The philosophical
consideration will introduce some concepts which might be useful for the
analysis of disease-concepts.
158 APPENDIX
There has always been and must always be a need for medical classifi-
cation and medical definition. This is a sine qua non for medical communi-
cation which, in its turn, is a sine qua non for scientific development.
Medical history has given us a vocabulary of diseases, together with a
variety of classifications of these diseases. Some of these classifications
have for a number of pragmatic reasons become more influential than
others, and have been codified and accepted by medical congresses. A
relatively recent important codification of terminology took place in Paris
in 1948, when different disease-classifications were fused with the Inter-
national Classification of Causes of Death into the International Classification
of Diseases, Injuries and Causes of Death (ICD) [143].
According to this classification there are 17 classes of disease and -
depending on the level of specification - several thousand disease-species
to be subsumed under these classes.
The given classification and its associated vocabulary is not considered
sacrosanct. Modern taxonomists are quite aware of the historical evolution
of the system and have anticipated a revision of this taxonomy once every
decade. There have been three such revisions since 1948.107
What do these classifications tell us? The principal message is that every
term - on the species-level - refers to some internationally accepted dis-
ease-phenomenon. These terms can be used in international medical com-
munication; they can be used in international medical statistics, such as the
statistics on causes of death.
If this international communication and these international statistics are
to be of any value, there must be some common characterization of the
concepts referred to by these disease-labels. And most importantly, these
characterizations or concepts must remain stable as long as no explicit
notice concerning change has been given.
If we admit this much, we admit more than the extreme physiologist
does. We mean that it is essential to be able to speak about disease-species
and tokens or examples of these species. This in its turn presupposes that
there are disease-concepts to be defined. It becomes sensible to ask: what
kinds of entities are the disease-tokens thus characterized? What is their
ontology?
The above historical outline indicated that the classical versions of
ontologism were not good enough. What could we offer instead? Let us here
insert some philosophical considerations by way of preparing the ground.
As we observed, the basic trouble for medical ontology and classification
is that, whatever diseases are, they are not physical objects. The naive
ON THE ONTOLOGY OF DISEASES 159
ontologism, entailing that diseases are parasites invading the body breaks
down for many reasons. First, we know of parasites or invading agents only
in the case of a few types of diseases. Second, and most importantly, it is
absurd to say that the parasite is the disease. Whose disease is the parasite
when it is outside the human body? And what about the state of affairs
remaining when the parasite has left? To say that disease-terms refer to
altered parts of a human body is also to simplify matters. Disease-terms
have a much broader reference than transformed cells or tissues.
The fact that diseases are not physical objects immediately differentiates
medicine from the other biological disciplines. The zoologist and the bota-
nist classify subjects which have definite positions in space and time and
fairly clear-cut boundaries. Another feature which has simplified - although
definitely not solved - definition and classification in these disciplines is the
facts of reproduction. The rule of thumb that only members of the same
species can reproduce has formed the basis for something which could
justifiably be called natural classification.
Such helpful features are absent in medicine. Diseases have no clear
location in space and time; they definitely have no salient boundaries; there
is no analogue to animal reproduction in the case of diseases. (The only
conceivable analogue would be ordinary causation. But although causation
plays an important part in the formation of disease-concepts, it does not
do so in a way analogous to animal reproduction.)
An adequate characterization of diseases thus requires ontological cate-
gories other than that of physical objects. We shall suggest that the fundam-
ental category needed for this purpose is the category of episodes. By an
episode we mean, roughly, something that happens to an object, something
which comes to be, remains, or ceases to be about this object. This ontolog-
ical category thus concerns properties of objects, not the objects them-
selves; and it concerns these properties in a way in which their temporal
aspects are important.
We shall distinguish between three kinds of episodes: states, events and
processes. 108 The basic concept to be introduced is the concept of a state.
It can be viewed as a primitive notion within the theory. A state can,
however, be informally characterized in the following way:
The examples which follow are taken from the well-known Textbook of
Medicine by Paul B. Beeson and Walsh McDermott [9]. In the very careful
characterizations which are given in this book, the attempt is often made
to give concise definitions. Mostly, these are actually called "definitions".
Sometimes other terms are used, for instance, "general considerations".
ON THE ONTOLOGY OF DISEASES 163
Definition: The common cold is a symptom complex caused by viral infection of the upper
respiratory passages. Most precisely, the term applies to a febrile, acute coryza of viral origin.
In the broadest sense, the common cold refers to any undifferentiated upper respiratory
infection. The terms rhinitis, pharyngitis,laryngitis, and "chest cold" are sometimes used to
designate the principal anatomic site of infection. The main difference between the common
cold and other viral or bacterial respiratory infections is the absence offever and the relatively
mild constitutional symptoms and signs (p. 184).
3. Tuberculosis
General considerations
The disease begins insidiously with any of its three cardinal manifestations either alone or in
combination. Tremor usually in one or sometimes in both hands, involving the fingers in a
pill-rolling motion, is the most common initial symptom. This is often followed by stiffness in
the limbs, general slowing of movements and inability to carry out normal and routine daily
functions with ease. As the disease progresses the face becomes "masklike", with a loss of
eyeblinking and a failure to express emotional feeling; ...
Although paralysis agitans is invariably progressive, the rate at which symptoms develop and
disability ensues is extremely variable ...The major neurologic findings are the following:
l. Lack offacial expression ...
164 APPENDIX
5. Postural abnormalities; ... the patient's body has a tendency to fall forward or backward ... (p.
636).
Definition: Acute myocardial infarction is a clinical syndrome resulting from deficient coronary
arterial flow to an area of myocardium with eventual cellular death and necrosis. It is
characterized by severe and prolonged precordial pain similar to, but more intensive than, that
of angina pectoris, and signs of myocardial damage,including acute electrocardiographic
changes and a rise in level of certain serum enzymes. Atherosclerosis oqhe coronary arteries
is the common denominator in the overwhelming majority of patients with acute myocardial
infarction (pp. 1006-1007).
6. Diabetes mellitus
General considerations
between the common cold and other infections. We can ask the question:
is the common cold an infection, or is it caused by an infection?
Before entering more deeply into the ontological considerations let us
first consider the disease-notions emerging from these definitions, mainly
from the point of view of similarities and differences. This procedure can
be made easier by some formal simplifications:
( 1) Pneumococcal pneumonia
An acute bacterial infection of the lungs caused by Streptococcus
pneumoniae.
(3) Tuberculosis
A chronic infection caused by either Mycobacterium tuberculosis
or Mycobacterium bovis.
This short list underlines the pattern found in the historical development
of the modern concept of diabetes mellitus. There is a very strong tendency
to use etiological means in the specification of disease-concepts. A disease
is favourably defined as an X caused by a Y. Later on the disease may be
identified with the Yor preferrably as a Y caused by a Z.
What are then the ontological categories found in our examples? Three
examples refer to infections caused by certain viral or bacterial agents.
Three examples refer to symptom complexes (clinical syndromes) of various
(partly unknown) origin. One example mentions biochemical abnormalities
(alternatively: a disturbance of homeostasis). How should these categories
be viewed? Is there any common feature to be found which could give a
clue to the basic ontology of diseases? These questions will be answered
in this and the following section.
Let us first make a preliminary analysis of the categories mentioned.
What is an infection? By definition, an infection is a series of events
initiated by some microscopic living organism which has entered the hu-
man body and spread toxic substances with the effect that the body re-
sponds with a series of typical measures; for instance, a rise in temperature,
excessive blood flow to the affected part of the body, and production of
antibodies against the toxic substances.
What is a symptom complex or a clinical syndrome? 110 Normally, symp-
toms are defined as features of a disease directly accessible to the bearer.
These features can be of an almost exclusively subjective kind, such as
when they are mental phenomena like sensations and emotions. But they
can also be intersubjective properties. In that case they should be easily
accessible to an external observer without the assistance of any specific
medical observational apparatus; Signs or features which require advanced
apparatus for their detection would not be called symptoms. Paradigmatic
symptoms are changes on the surface of the body, as to figure, colour,
dryness and warmth. Other symptoms are changes in the bearer's ability
to move or perceive. Symptoms, then, are phenomena such as sensations,
emotions, changes on the surface of the human body or changes in human
abilities. A symptom complex is the existence of at least two such symp-
toms, occurring either contemporaneously or in sequence.
Consider, finally, the concepts of 'biochemical abnormality' and 'distur-
bance of homeostasis'. These are difficult since they seem to be, in different
ways, ambiguous. In one sense a biochemical abnormality can amount to
a static property (of an organ, tissue or liquid) which consists in the
existence of abnormally much or abnormally little of certain substances. In
ON THE ONTOLOGY OF DISEASES 167
another sense, the term can refer to a dynamic process of abnormal pro-
duction and evolution of substances on the biochemical level.
The term "disturbance in homeostasis" is also, although differently,
ambiguous. ori the one hand, a disturbance can be a particular momentary
event. Such an event presupposes the existence of a normal, undisturbed,
state or process. In this state or process a change occurs, normally caused
from the outside. This change is the momentary event of disturbance. (Such
a change can be repetitive; there may be a continuous sequence of disturb-
ing events.)
On the other hand, a disturbance could be the episode resulting from
such an initiating (sequence of) disturbing event(s).
What do these analyses of the key concepts tell us? How could we use our
episode concepts to describe them? Consider first the easiest case, in-
fection~. The rough definition which we have given would seem to be
sufficient. An infection is a bodily process with certain typical characteris-
tics, causally triggered by a microscopic living creature. These characteris-
tic changes certainly do not fall under a single dimension. They involve
biochemical changes, changes of temperature, as well as visible external
changes of the body.
There are, however, unifying principles. The principle of a common cause
is obvious: the microbe. The general principle of a single bearer is also
obvious. The infection belongs to a person and terminates outside the
person. Is there a further unifying principle?
There certainly is and this is the principle which gives the process its
status as a disease, in contradistinction to other possible processes
contained in a human body. A further unifying principle is that the elements
of the infection, the individual state-transitions tend to limit the bearer's
abilities, either directly or indirectly by causing pain or other kinds of
suffering.
Let us now proceed to an analysis of symptoms. Do they have a place
in the ontology of episodes? Consider first mental symptoms. In ordinary
parlance we acknowledge such locutions as being in a state of pain or in
a state of depression. We can also experience a stroke of pain or a sudden
pang of anguish. If we consider the situation more deeply this seems to be
quite a proper manner of speaking. To have a mental property is, if the
property remains unchanged, to be in a state. If it changes continuously or
168 APPENDIX
6. SUMMARY
I For useful introductions to the history of the philosophy of health and disease. see [6S). [69).
[8S), [lOS), (108), (128), [129) and [130); concerning antiquity and the middle ages see [9S).
2 For a modern discussion ofthe legal and ethical aspects of involuntary psychiatric hospitali-
zation, see [80). The Swedish regulations relating to the use of force in psychiatry are to be
found in Lagen om beredande av sluten psyldatrisk vdrd i vissa fall (The Act on Mandatory
Institutional Psychiatric Care in Certain Cases.) Swedish Government Official Reports, SOU
1966:293.
3 For a thorough analysis of the procedures and decisions of Swedish insurance authorities
concerning sickness benefits, see [137).
A classical analysis of prewar German illness insurance policies is [SI).
4 The Swedish Public Health Act (Swedish Government Official Reports, SOU 1982:763) is
presented and commented on in (113).
5 The expression "medical concepts" may seem more natural here. For reasons elaborated
in Chapter four, section I, we wish, however, to reserve this expression for a subset of the
health-concepts.
6 Aristotle's views on definition can be found for instance in his Topies, I 4-6, VI, VII, and
Uffe Juul Jensen. Jensen (60) makes a distinction between two kinds of concepts, viz. concepts
of praxis and ideal concepts.
By an ideal concept he means a concept determined by an explicit definition. If we define
the concept of man as a rational animal, then we have created an ideal concept of man. But,
Jensen contends, few concepts are defined in such a precise way. However, we maintain that
these concepts exist. They exist as concepts of praxis; they exist in the sense that people use
them. This is tantamount to saying that people use certain linguistic expressions according
to certain, often implicit, rules. The concept of 'table' exists in the sense that people use the
word "table" according to well-known linguistic rules.
Now an important idea in Jensen is that the praxis concepts must precede the ideal concepts.
First comes language use; then we can make definitions and formulate ideal concepts.
This distinction lies at the basis of Jensen's program for conceptual analysis. His program
implies that we ought to study praxis-concepts and not ideal concepts. If we are interested
in the concept of health we should pay attention to how we, in our praxis, use the concept.
It is, he contends, much less interesting to study a particular explicit definition, viz. an ideal
concept, and it can even lead us in the wrong direction.
A program of this kind has important consequences, according to Jensen. Since the
conceptual praxis is partly changed over time, and since there may exist several contemporary
forms of praxis, the goal of the program is not to offer one single definition of health, i.e. to
175
176 NOTES
create an ideal concept of health. The goal must instead be to mirror the conceptual
multiplicity and the conceptual development without formulating explicit (iefinitions.
Jensen complains about the fact that much ofthe discussion of the theory of health has been
misguided due to attention being focused on one particular concept of health, what he calls
the "machine-concept" of health. (As a paradigm for this concept he uses some formulations
of the Danish philosopher Alf Ross [107]. Ross' concept is in many ways similar to Boorse's
concept of health, which is discussed at length in Chapter two.)
According to this conception man can be viewed as a machine, a man is healthy if his
"machine" functions like the majority of other "machines" of his kind. He is diseased if the
function deviates from this norm, i.e. is abnormal. (See [60], pp. 142-156.)
This ideal concept, however, has very little to do with praxis, says Jensen. At most it
illuminates parts of praxis, i.e. the praxis of medical doctors oriented towards pure biological
research.
Let us here comment on Jensen's program. We agree with Jensen in the following respects:
(i) The primary object of study are the praxis-concepts of health and disease.
The starting-point for a conceptual analysis is normally a given conceptual praxis (except
for the cases of pure stipulation). Already formulated ideal concepts are of secondary interest.
They would constitute the primary focus of study if we were to write the history of health
theory or a survey of modern health theories.
(ii) The praxis changes; the praxis-concepts of health and disease are changeable.
From these two common platforms Jensen draws, however, a number of conclusions which
differ from ours. Contrary to Jensen we find ideal concepts to have an important place in
conceptual analysis. We endorse the following thesis:
(iii) In some cases ideal concepts are the results of sharp reflection over praxis
concepts; if our goal is to become clear about praxis concepts, it is often
expedient to scrutinize some ideal concepts and compare them with praxis.
Jensen is certainly right in criticizing the naive acceptance of some ideal concept of health
(such as the "machine-concept"). Nevertheless, such concepts may be helpful in conceptual
research. A careful and precise ideal concept is an excellent platform for the further analysis
of existing praxis concepts.
We would like to sharpen this thesis. It is in practice necessary to think against a background
of ideal concepts, be they proposed in the literature or by the analyst himself. Every process
of conceptual analysis must contain tentative characterizations of the concept in focus.
These tentative characterizations are, at least, a kind of partial definition. Thus, they fulfill
the main criteria for being ideal concepts. The process of analysis then proceeds by way of
a criticism of these tentative characterizations. We may show that a certain conceptual praxis
does not agree with the proposed characterization. The latter must therefore be remodelled
in order to incorporate the counterinstance.
(iv) The result of a conceptual analysis should, if possible, be summarized in a
definition. In other words, the result of a successful conceptual analysis is one
(or a number of) ideal concept(s).
NOTES 177
Our program deviates most significantly from Jensen's on this issue. Jensen seems to reject
definitions completely. His main argument against defining seems to be that definitions, in an
illegitimate way, "freeze" reality; they do not do justice to the mUltiplicity and the evolving
nature of concepts. .
We do not accept this argument. The extent to which concepts evolve can be mirrored by
a series of definitions which can capture every step in the change. In a similar way a number
of definitions can mirror the contemporary multiplicity of concepts.
We shall furthermore endorse the following thesis:
(v) The purpose of a conceptual analysis is not only to "mirror" given concepts of
praxis as sensitively as possible. The purpose is also to find fruitful simplifi-
cations, which can sharpen the concepts in their future scientific and technical
contexts.
II There are a great number of authors who have proposed holistic views and holistic theories
of health and disease. Among philosophical works the following could be mentioned: [1), [20],
[33], [36], [38], [48], [99], [140] and [1411. Other important texts expressing holistic views
are [41] and [43].
The theories mentioned are often called non-neutralist since they combine the holistic view
with the idea that health is an evaluative (non-neutral) concept.
12 Christopher Boorse is the clearest and most widely cited representative of an analytic,
neutralist theory of health. His most important works are [13], [141 and [15). Penetrating
critical analyses of his work are (1], [48], (70) and [76].
Well before Boorse a British physician, J.G. Scadding [115), (116) and (117), presented an
analytic definition of disease. Scadding's general definition runs as follows:
A disease is the sum of the abnormal phenomena displayed by a group ofliving
organisms in association with a specified common characteristic or set of
characteristics by which they differ from the norm for their species in such a
way as to place them at a biological disadvantage ([116], p. 877).
This definition is very similar to Boorse's. It even suggests the notion of a species-typical
goal (in the phrase "biological disadvantage").
In Scandinavia the philosopher oflaw, AlfRoss [107] has presented a theory quite similar
to Boorse's. For a critical discussion of Ross, see [60], pp. 159-172.
178 NOTES
13 Lucid expositions of the Hippocratic-Galenic conceptions of health are [95], pp. 127-135,
and [130].
14 The most celebrated revival of the idea of balance is Walter Cannon's masterpiece The
Wisdom of the Body, [21]. This balance is today mostly referred to as bodily homeostasis or
equilibrium.
15 The widely used textbook on pathology by Hopps [57] displays both ideas:
ed in [116]. p. 877:
A disease is the sum of abnormal phenomena displayed by a group of living
organisms ... by which they differ from the norm for their species in such a way
as to place them at a biological disadvantage.
Evaluative notions are particularly common in psychiatric discourse. The well-known
textbook by Redlich and Freedman [103] does not even mention statistical normality in its
characterization of mental diseases or behavior disorders:
What constitutes manifest behavior disorders depends on the culture or value
system. The culture also sanctions those interventions that are referred to as
psychiatric treatment (p. 2).
17 For a more thorough discussion of the notion of biological goals, see [59], pp. 101-124.
18 A similar distinction, expressed in terms of systems of actuality and systems of ideality,
is made in [99]. pp. 3-5.
18 This discussion is found in [15]. pp. 566-567.
20 In a note added to the reprint of [13] in [23] Boorse withdraws some of his statements in
the article:
... the view that illness is disease laden with values ... now seems a mistaken
concession to normativism. Illness is better analyzed simply as systemically
incapacitating disease, hence as no more normative than disease itself(p. 560).
21 It is now common to make some distinction between disease and illness roughly in the way
indicated by Boorse. From our philosophical point of view the differences in interpretation
NOTES 179
The person who can perform the several actions proper to the human body with
ease, pleasure, and a certain constancy. is said to be well; and that condition
of the be dy is termed health. But if he either cannot perform those actions; or
ifhe performs them but with difficulty, pain. and sudden weariness; he is then
said to be ill: and that state of the body is called a disease ([121. I. 2-3).
21 The lOCUS classicus for this kind of position is Ludwig Wittgenstein's paragraph 580 in [1481:
An 'inner process' stands in need of outward criteria.
About this sentence Armstrong [51. p. 55, says the following:
When Wittgenstein speaks of'outward criteria' he means bodily behaviour. The
phrase 'inner process' refers to mental happenings of the sort that. prima/ode,
seem quite different from bodily behaviour: such things as thoughts and sen-
sations. In saying that 'inner processes' stand in need of outward criteria
Wittgenstein seems to be saying that there is a logically necessary connection
between the former and the latter.
Armstrong goes on to conclude that Wittgenstein must identify the 'inner process' with some
behaviour. As a result he is an analytical behaviourist.
Our position, however, is not behaviourist. A sensation like pain is not identical with
pain-behaviour. There is still a conceptual !ink between the concept of pain and the concept
of behaviour. Pain is a mental state which lends to result in certain sorts of behaviour. If we
180 NOTES
identify a mental state as pain we commit ourselves, for conceptual reasons, to predicting a
certain kind of behaviour as well as a certain kind of inability to perform intentional actions.
28 For the term "stratification" see Shwayder's title [118], The Stratification of Behavior.
29 The concept of basic action was introduced by Arthur Danto (28]. The philosophy of basic
action and action-generation essentially adopted here is developed by Goldman [47]. For
similar treatments, see [98], pp. 43-63 and [132]. pp. 8-35.
30 See [47], pp. 20-48.
31 For more elaborate discussions of insufficient causes, see [72], pp. 29-58 and (88]. pp. 24-
34.
32 The terms "accomplishment", "activity", "action-chain", and "action-sequence" have other
references in the case of other authors. The present use of ihese terms was introduced by me
in [90], pp.25-33.
33 An analysis of conventional generation requires a further concept, viz. the concept of
QUChorilY. An authority can be viewed as a "conventional power" attributed to a person or a
corporation. This power may last for a short while, as that of an umpire in a game, but it may
also last for a lifetime, as is the case with most monarchs. For some conventional accomplish-
ments authority is crucial. Only a judge can sentence a criminal; only a doctor can sign a
certificate of illness, and only a priest can administer the Holy Communion.
34 This list of distinctions has been inspired by [64], p. 131.
35 Ayers [6] argues strongly, in particular on pp. 125-144, against a conditional analysis of
published in [90].
38 In later writings I have modified my analysis of the background set of circumstances in the
following way. As the general concept I now propose the concept of accepted circumstances.
By "accepted" I mean that the circumstances are accepted by the person who ascribes ability or
disability to another person. These circumstances may be standard in the sense of being
NOTES 181
commonly accepted in a particular culture but they need not be. For a more complete
introduction of this concept, see the Postscript of this volume, pp. 212-213.
39 The distinction between internal and external outcomes of an action has been well develop-
ed in [15 I), pp. 86-88. The author there introduces the term "result" for the outcome which
is included in the action itself. and "consequence" for an outcome which is excluded from the
action.
40 Cf. the points made by Spicker [123] on the idea of a family-concept of health.
41 For a good philological account of the term "need" and its cognates in other languages.
introduction to Marx's theory of needs is [53]. [7] makes a useful comparison between Marx's
and Maslow's theories of needs.
The main source for the discussion of Maslow's theory is [78]. See, in particular, pp. 35-58.
43 In [77), p. 21 the connection between the concepts of need and health is elaborated even
further:
The concept "basic need" can be defined in terms of the questions which it
answers and the operations which uncovered it. My original question was about
psychopathogenesis. "What makes people neurotic?" My answer ... was, in brief,
that neurosis seemed at its core to be a deficiency disease; that it was born out
of being deprived of certain satisfactions which I called needs in the same sense
that water and amino acids and calcium are needs, namely that their absence
produces illness.
45 Since the present volume was first published Per-Erik Liss [159] has provided a thorough
examination of the notion of health-care need and related notions. Liss [160], Anton Aggernaes
[152] and Torbjorn Mourn [161] trace from various points of view the relations between the
notions of need and quality of life.
46 This conceptual circle was the object of my study in [92]. Some of the arguments advanced
there have been carried over to this chapter.
47 The treatment of Porn's and Whitbeck's theories is wholly based on the texts referred to.
viz. [99], [100), [140] and [141]. [93] contains a short critical discussion of these theories. [19]
is a recently published study relating Whitbeck's theory to Boorse's.
48 In a recent article [166] Porn has developed his theory of health considerably. Some ideas in
his present theory of health-as-adaptedness are presented and commented on in the Postscript of
this volume, pp. 206-208.
49 A more precise analysis of the concepts of intention and want has been given in [86],
We have pain in a tooth or pain in the stomach. But we do not commonly say
that we have pleasure in the mouth, when eating an apple. Pain, as has often
been observed, is much more sensation-like than pleasure. The word "pain" has
analogical uses, which resemble the use of "pleasure" in that they make the word
a value-attribute. But it seems to me right to say that, in its primary sense, "a
pain" refers to a kind of sensation and that "pain" names a sense-quality of
which, however, there are many shades. In this respect "pain" is on a different
logical level, both as compared with the substantive "pleasure" and as compared
with the adjectives "pleasant", "unpleasant", and "painful" (pp. 69-70).
58 Tatarkiewicz [127] writes:
Next, even complete satisfaction does not necessarily add up to happiness.
Satisfaction with particular things, however important - health or an untrou-
bled conscience, success or position - falls short of happiness if it is not
accompanied by other satisfactions. It is then only partial satisfaction; happi-
ness requires total satisfaction, that is satisfaction with life as a whole (p. 8).
59 Observe that Veenhoven [134] takes quite a different standpoint. On her view, happiness
Let us suppose that someone is satisfied with life, desires no change, has enough
money, good health, a loved wife, fine children, interesting work, and that this
is all he wants ... Though the majority will call him "happy", this view could be
questioned if we mean by happiness only that contentment which reaches the
depths of a man's consciousness and touches its innermost fibre (p. 21).
62 Rescher [104] is an important work dealing with many aspects of human welfare. The
conceptual structure developed there is, however, in some respects different from ours. In
other respects there are similar and parallel observations. One such observation concerns the
relation between health and the minimally good life.
184 NOTES
Welfare is only thefoundation of such a life [the good life), not the structure itself.
Physical health, adequacy of resources, and mental and emotional well-being
are enormous - perhaps even indispensable - aids toward a meaningful and
satisfying life, but they are not in themselves sufficient for this purpose. This is
the reason why the components of the good life must extend far beyond the
province of welfare (p. 8).
Observe that the term "welfare" in Rescher's theory denotes certain basic causes of hap pi-
ness. In our theory happiness is the most important variant of welfare.
63 Caroline Whitbeck also attempts a distinction between health and happiness. We doubt,
however. that she succeeds in making it clear. Consider the following passage:
I argue, that to be happy, a person needs to be able to act in ways that serve
many goals, aspirations and projects simultaneously. The opportunity to do so
is a function of at least four things; the range and relative importance of a
person's goals ... ; the person's health ... ; the person's creativity; and the person's
access to resources of all types (social, economic and so forth) ([141), p. 620).
There are certainly important things here with which we agree. We agree that a person's
happiness depends on a number of factors of which health is only one. We also agree that all
the four factors mentioned are of importance for the creation of happiness.
The analysis as it stands gives, however, a very incomplete picture of the nature of happiness.
Moreover. it gives the impression that happiness is a concept very closely linked to health.
Whitbeck's analysis stresses the fact that a happy man needs to be able to act in ways
supportive of his goals. Happiness is presented as an ability-concept; the emotional aspect of
happiness is not mentioned. But ifhappiness is a kind of ability (or highly dependent on a kind
of ability) what would then distinguish happiness from health as understood by Whitbeck (i.e.
the subject-goal view of health)?
The answer seems not to be that the nature of the goals should be different. In both cases
Whitbeck speaks ofthe subject's goals, aspirations and projects. The fundamental difference
is that in order for a person to be happy he must be able to support many goals simultaneously;
this is not required in the case of health.
We shall thus envisage a man who is healthy but who is, according to Whitbeck's criterion,
unhappy. Consider a person with a great number of goals: he intends to perform well at his
job, he wants to take care of his children properly, he wants to go to the theatre once in a
while, he wants to travel to New York very soon, etc. Assume now that this person is
psychophysically capable of realizing each ufthese individual goals. Therefore, he is in health.
He does not, however, manage to complete the whole program within what he himself
considers to be a reasonable time interval. Therefore, he is unhappy.
There are at least two problems with this characterization. First, most goals have a (possibly
implicit) time clause built into them. If one has set oneself a goal one has set it to be realized,
roughly, at some time or within some time interval. When a person intends to pass an
examination. he normally intends to do so within the standard period of time. If a person
intends to get married, he normally intends to do so reasonably soon and not at any odd time
in life.
These considerations are important when we try to assess the state of health of the person
NOTES 185
mentioned above. If he intends to realize all his goals within the coming week and fails to do
so for psychophysical reasons, then we are not entitled to say that he is in complete health
(unless the circumstances were extraordinary). In setting his goals, the person must, of course,
take into account the other goals he has set. In the case of his not grasping his whole profile
of goals and not understanding how unrealistic it is, he then qualifies as a man who is ill given
the subject-goal theory. The contrast between health and happiness is thus blurred.
The contrast between health and happiness, on Whitbeck~s platform, is blurred for yet
another reason: what is to be selected as one goal in contradistinction to many goals is a
completely arbitrary matter. Whatever state we designate as a goal can be subdivided into
many goals. This can be done in at least two ways. First, as we have shown above, every goal
has a (perhaps infinite) number of sub goals. In order to complete an examination one normally
passes a number of tests during the years of study. The passing of every such test can be
counted as a subgoal. Secondly, every ends tate can be divided into its parts. If an examination
consists of three salient final parts, then the passing of every such final part constitutes a part
of the endstate of completing the examination.
In a perfectly clear way, then, the serving of one goal involves the serving of several goals.
What is in one context considered to be one goal is in other contexts many goals. This certainly
also holds conversely. What is in one context considered to be many goals can in another
context be considered to be one. The person who intends to realize many goals during a week,
can be said to have one program to realize. To realize this program is his (single) goal.
We conclude therefore that Whitbeck's account of happiness cannot be adequate. Happiness
and health are distinct categories in a more profound way than her account suggests.
64 Let us parenthetically note that a theory which conceptually connects health with happi-
ness provides a further tool for the analysis of health. It provides a way of dealing with the
typical experiential concomitants of illness, such as suffering and pain, in a direct way.
In order to see this let us consider the relation between happiness and certain negative moods
such as anguish, and negative sensations such as pain. Is happiness compatible with these
mental phenomena?
There are two principal ways in which negative moods and sensations can disturb or even
annihilate happiness. One is direct and the other is more indirect. In the direct way the
negative feeling is so strong or intense that it "totalizes" the consciousness of a subject so that
there is no room for a feeling of happiness. To be able to feel happy it must be possible to
bring one's attention to some fact and contemplate it fairly undisturbed. In states of great pain
and depression this is impossible.
The other, indirect, way of preventing happiness is associated with the formal object of
happiness. Great pain and depression prevent many possibilities of goal-satisfaction, both via
one's own actions and otherwise. Therefore, one's own pain and depression are normally the
object of the emotion of unhappiness. If the depression and pain are great enough, then many
or most of one's goals are impossible to satisfy. Hence, there is a case for general unhappiness.
And general unhappiness must exclude general happiness.
Consider now how this observation could be used for an additional characterization of health
and illness: A is healthy if, and only if, A has the ability, given standard circumstances, to fulfill
his vital goals and A's happiness is not reduced under the level of minimal happiness by a
negative mood or a negative sensation.
Observe that we cannot include negative emotions in this characterization. A negative
186 NOTES
emotion, such as disappointment or grief, can certainly create great unhappiness. But the
unhappiness about the outbreak of a war or about the loss of a close relative is not a criterion
of illness. This problem is discussed in Chapter four, section 2.
65 According to the Constitution o/the World Health Organization health should be defined in
the following way: Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.
This constitution was adopted by the International Health Conference which was held in
New York in 1946 and signed by the representatives of sixty-one countries. The Constitution
is reprinted in [23], pp. 83-84.
66 For a brilliant paper on the concept of mental health which panly seems to follow the same
general path as we do, see Moore [84]. He says:
The central idea behind illness is that of impairment: to be ill is to be impaired
from functioning in some of the wide varieties of ways we think to be normal
(p.51).
A main difference lies, however, in the importance he attaches to the concept of normality.
61The term "malady" has been introduced in the important work by Culver and Gen [27].
The precise definition of this concept is made in the following way:
A person has a malady if and only if he has a condition, other than his rational
beliefs and desires, such that he is suffering or at increased risk of suffering, an
evil (death, pain, disability, loss of freedom or opportunity, or loss of pleasure)
in the absence of a distinct sustaining cause ([27], p. 81).
The internal condition responsible for the evil can be of different kinds. It can be a wound,
a disorder, a defect, an affection and a lesion or a disease ([27], p. 65). Thus a malady is a
concept covering all typical causes of illness in the way we interpret illness.
Culver's and Gert's theory (the CG-theory) is in important respects similar to ours, but there
are also some notable differences. Let us try to collect some of these features.
Similarities:
(i) The CG-theory is holistic. The basic concept in the conceptual apparatus is the concept
of evil pertaining to the person as a whole.
(ii) Maladies are defined as internal states which cause or tend to cause some evil.
Differences:
(iii) The CG-theory is wholly preoccupied with the negative aspect of health, viz. illness and
its causes. One can, however, say that there is an implicit theory of health. This implicit theory
is different from ours, since it seems completely tied to the notion of a malady. Where there
is no malady there is health, according to the CG·theory. We say instead, that this concept
of health is a special instance of a more general case which is not necessarily tied to the absence
of maladies.
(iv) The CG-theory seems to be more general than ours in another respect. The concept
of evil is more inclusive than the concept of disability. As Culver and Gert explicitly say, evil
covers such things as death, pain, disability, loss offreedom or opportunity or loss of pleasure.
We hope, however, that it has become clear from our discussion that the concept of ability
(or disability) has a much more central place than Culver and Gert suggest. Our analysis has
NOTES 187
shown that loss of freedom, or loss of opportunity (when these phenomena are dependent on
internal conditions) cannot be distinct from disability. A condition which causes death or
threatens to cause death must, afortiori, also cause disability. We have previously discussed
the relation between pain (as well as other negative sensations and moods) and disability.
There is a case for maintaining an intimate relationship between these concepts, in the sense
that severe pain must necessarily lead to some disability. Thus. a notion of health based solely
on the concept of disability would be able to cover (almost) equally as much as Culver's and
Gerfs concept of evil with its superficially different special cases.
(v) The CG-theory stresses the fact that the malady is an internal condition which does
not have a sustaining (normally external) cause. By saying this Culver and Gert are partly
making the same qualification as we are when we speak ofa person's ability, given standard
circumstances. One of their examples concerns a man who is put in jail. He has some loss
of freedom which is due to an external cause. Thus, this loss of freedom does not constitute
a malady ([27). p. 79).
However. there is something odd about this example.lt does not describe any internal
condition of the agent whatsoever. The prevention is completely external, and there would
therefore be no question at all of maladies.
An interesting case would instead be the following: a finger is pricked by a needle which
is kept there. The subject feels pain as long as the needle remains.But here there is not just
an external condition. i.e. the needle's position on the body, but also an internal reaction to
this situation. The needle has actually cone some damage to the tissue and it has irritated the
pain receptors. The damage and the irritation are, however. of the kind that when the needle
is taken away. practically all reactions disappear. Some slight damage to the tissue remains
but it does not affect the bearer in a significant way.
Here we have an example of an internal condition existing as long as an external cause
actually sustains it. Culver and Gert have committed themselves to the view that this relation
entails the internal condition's not being a malady. In our analysis we have not committed
ourselves to this view; nor do we agree with it in general. To us damage is damage even if
it is constantly sustained by an external cause.
68 Our characterization of maladies is essentially in accordance with the one suggested by
Porn and Whitbeck. We shall here summarize their treatments of maladies.
Porn: I therefore think it is correct to characterize impairments, injuries, and diseases
as. respectively, states. changes. and processes of an anatomical, physiological,
or psychological kind which are evaluated as abnormal (poor, weak, etc.)
because of their causal tendency to restrict repertoires and thereby compromise
health ... However, it does not follow ... that a person is ill if he sustains an injury,
is affected by a disease, or is the bearer of an impairment. Owing to the
relational character of illness and the nature of relata, he is ill if and only ifthe
injury, disease, or impairment makes his repertoire inadequate relative to his
profiJe of goals ([99), pp. 6-7).
An important further feature of this theory, which may not seem equally plausible, is the
following: A person may be in very poor health without being affected by diseases, impair-
NOTES 189
ments, or injuries. There may be a kind of process (or other condition) which negatively affects
a particular subject. It does not. however, qualify as a disease (impairment or injury) since
it does not affect what people commonly want to do. For instance. a unique and negative
experience may handicap a particular subject with regard to a particular ability. This ability
is of no importance for most people; it is. however. something that the subject wants to have.
Therefore, he is in bad health. although not affected by disease or any other malady. This
possiblity is also left open in our treatment of health and disease.
69 The example of lactase deficiency is taken from [561. pp. 189-190.
avoid; (4) the aged person, as the sick individual, becomes the one who would
seek the help of the health care establishment ([34], p. 190.)
76 For different treatments of grief in relation to health, see [27] and [32]. Engel [32] holds
that grieffulfills the conditions of being a disease, whereas Culver and Gert [27] argue against
this position. The reasons given by Culver and Gert are, however, different from ours ([27],
pp.95-98).
77 The thesis is most clearly summarized in [148], §243. In the paragraphs which follow there
pp. 230-231.
86 See [121], pp. 118-119 and [122], pp.417-418.
87 See [120], p. 90.
88 [31], p. 199.
89 [31),p.200.
90 See [31), p.198: "For many centuries mankind has been trying to explain the
The genes appear in pairs in an organism. If genes which are paired are identical, then the
organism is called "homozygous", otherwise "heterozygous". Ifin a population of organisms
there are just two kinds of genes which can occupy the two positions, then there are three
possible kinds of combinations, two homozygotes and one heterozygote. Let us illustrate the
combinations in the following way: .1\.110 .1\.12' A~2'
Assume now that A \.1 \ represents a low-reproducing kind of heterosexual. A \.12 is a repro-
ductively very fit heterosexual. And A~2 is a homosexual. Since a person of the .1\.12 type
is highly reproductive, he passes on a certain amount of .12 genes in the new generation, which
necessarily consists of a certain amount of A~2 combinations, viz. homosexuals. Given the
genetic structure this is bound to go on indefinitely. This means that the species design (of
the majority) has in itself secured and necessitated a certain number of homosexuals in each
generation.
The conclusion could then be drawn that the existence of a certain number of homosexuals
is in accordance with the species design. Thus, Ruse concludes, given a Boorsian naturalist
model of health, homosexuality would not qualify as a disease or illness ([109], p. 715).
This reasoning is, however, not obviously correct. Ruse introduces a notion of species design
which is different from Boorse's. Ruse's notion admits that there is more than one ideal type
for the individuals in the species. All the genetically determined types would be ideal or healthy
types. But this is not what Boorse says. The procedure he suggests for determining the species
design (i.e. the model for a healthy human being) is descriptive statistics. The design of the
majority of the population (with respect to each function) defines the criteria of health. Thus.
the properties of the individuals representing the most frequent genetic combination (which
is not the A~1 combination) would constitute the species design as we understand Boorse's
intentions.
93 This was apparently one of the strongest arguments put forward by the Gay Liberation
Front in the American debate. See [8], pp. 67-100. Contrast, however, the contention of
Socarides [121). p. 122:
It is not true that homosexuals who seek treatment represent any special group
or skewed sample. The notion that the only homosexuals who enter therapy are
the "sick" homosexuals is erroneous in that often they are far less masochistic
and self-destructive than their partners or associates, who will not even attempt
any realistic effort to relieve their anguish.
94 See [112]. pp. 1079-1080.
95
See [10], pp. 337.432.
96 (10), pp. 450-457.
97 This general requirement distinguishes us from. for instance, Whitbeck. In [140], p.212,
she explicitly claims that her treatment of disease concerns human disease only.
98 [33]. [36], [58]. pp. 229-247, [66], pp. 165-183. [102] and [128] include good accounts of
the ontological and physiological views on the nature of disease.
99 For a discussion of the Hippocratic views on diseases, see e.g. [128], pp. 634-641.
\00 For a thorough analysis of the physiological thinking among the French medical theorists
time before the nineteenth century. For instance, Sydenham, Sauvages and Cullen all agreed
that diseases were processes. They saw no tension between the reification necessary for
classification and the view that diseases were variable processes [16], pp. 155-162.
102 For an illuminating discussion of Sydenham's views, see [102], pp. 353-369.
103 A principal source for this historical sketch is (96).
104 This summary is based on [96]; about Bernard, pp. 19-20, about Minkowski, pp. 26-27, and
about Banting and Best, pp. 47-61. The modem definition of diabetes mellitus is presented in
[9], p. 1599.
105 A comprehensive description of diabetes mellitus is presented in [9], pp. 1599-1619. The
development of the concept of diabetes mellitus is also discussed in [20], pp. 37-40.
106 This discussion presupposes Cahill's definition above. It appears, however, that the
modern definition may also be a matter of controversy. Papaspyros [96], p. 62, writes as
follows:
Insulin seemed at first to have solved the problem of the treatment of Diabetes
Mellitus. Soon, however, it became clear, that diabetes is not always the result
of insulin-lack. Other factors also, which block or destroy insulin may be
involved. For quite some years we know that the pancreas is not the only cause
of diabetes ...
107 For discussions of the history of modem classifications of diseases, see [89], pp. 13-22 and
[149].
108 The conceptual apparatus summarized here was introduced by me in [87], pp.43-50.
109 For the sake of simplicity we here speak of the causal origin in terms of a single cause.
The reasoning does not, however, depend on this assumption. The etiology may be multifac-
torial. Our thesis, however, presupposes that there is a set of causes determining a process
and thereby partially defining its limits.
110 Cf. Feinstein (44), p. 131, who makes a very sharp distinction between symptoms and signs.
He says:
A symptom is the name given to a subjective sensation or other observation that
a patient reports about his body or its products ... A sign is the name given to
an entity objectively observed by the clinician during physical examination of
the patient.
III Cf. ~lalmgren's discussion about unitary but unidentified etiology in [74], pp. 84-86.
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SUPPLEMENTARY BIBLIOGRAPHY
200
INDEX
201
202 INDEX
INTRODUCTION
able to attain or maintain; in many cases this goal can be identified with a
simple action, e.g., A IS goal is just to be able to perform the action of
walking to the supermarket. And third, one has to identify the
circumstances in which A is assumed to be able to attain or maintain this
goal or perform this action.
Let me now illustrate this. Brown is able to do his own cooking when he is
on his own and is undisturbed. Here in this concrete case of an ability
relation, Brown is of course the person, the goal is the accomplishment of
cooking, and the circumstances include Brown's being on his own and
being undisturbed. This is clearly not a complete description of the required
circumstances, but these are the ones that are made explicit in this case.
It is now very easy to see how a case of disability in general shall be
construed by analogy with this: Brown is unable to do his own cooking
when he is disturbed. We can here detect the same terms in the relation: the
person, the goal, and the circumstances. The difference between ability and
disability can be expressed by the following analysis: When A is able to
reach G in C, then he or she reaches G in C if he or she tries; when A is
unable to reach G in C, then A does not reach G in C if he or she tries.
We can now see how we can use this schema for analyzing all kinds of
ability and disability relations, including the cases where disability
constitutes non-health or illness. We can, for instance, see how we can
express various cases of ability and disability. Smith, for instance, may be
unable to do his cooking in all kinds of circumstances. He then has an
extreme disability with respect to this action. Or he may be unable to do his
cooking in a specified set of circumstances. He is then disabled with respect
to this action in relation to this specified set of circumstances.
HEALTH AS ADAPTEDNESS
From the above it is clear that the success of an action is dependent on three
types of things: the agent with his or her biology and psychology, the nature
of the goal to be attained or maintained, and the nature of the circumstances
POSTSCRIPT 207
Now is there anything wrong with the idea of health as adaptedness? Let me
first focus on the circumstance term in the relation of being adapted. What
is wrong with including the actual set of circumstances in the notion of
health itself?
Is not, for instance, "environment care" very often considered to be an
important element in health work, in what is normally called health
promotion? Does not health promotion involve the provision of
opportunities for various kinds of healthy actions? Does it not involve
measures to purify the air, earth, and water surrounding us? Why should it
then be wrong to include the given set of circumstances surrounding a
person in the characterization of the health of that person?
I shall not dispute the importance of a certain kind of environment care.
I have argued at length elsewhere for the necessity of a diversified effort for
health [162]. It is obvious that environment care has a central place in the
work for health.
The standard kind of environment care, however, is logically different
from the care proposed in the definition of health noticed above. In order to see
this, we must make a distinction between the environment as a cause of
human health or illness, and the environment as a platform for action.
Let me explain. The environment can of course cause diseases in the
human body or mind. That is what toxins of various kinds often do and
what polluted air or water often does. The environment causes a change in
the body of a particular person and this, in turn, reduces the ability of the
person to perform a certain set of actions. We then say that the environment
affects health by causing changes within the person, for instance, by
causing diseases or injuries. Conversely, a person can be cured of a disease
and thereby promoted to a healthier state by purification of the air and
water surrounding him or her.
But this is not what is meant in the definition noticed above. Here the
environment does not play the role of a cause. It plays rather the role of a
platform for action. Let me illustrate. Assume that a man tries to enter his
work-place. He is brusquely prevented from doing so, however, by a number
of pickets, who claim that he is not permitted to enter. He then has no
platform for doing his work. He cannot do his work for external reasons.
This is obviously very different from the case where he cannot do his work
POSTSCRIPT 209
because he has contracted a disease, which mayor may not have external
causes.
The advocate of the notion of health-as-adaptedness-to-a-situation is
forced to hold that the strike case is also a case of non-health. The man who
has lost his platform for work because of a strike is also unhealthy
according to this theory. It is so, at least given the precondition that going
to work is a goal for the man in question. (We can of course imagine cases
where this is not included among a person's goals.)
Is this consequence counterintuitive? Is this consequence a sign that the
notion of health-as-adapted ness is a defective notion of health?
I think that it is obvious that it is very far from the notion of health as it
is used in ordinary language. I think that most of us would say that being
physically prevented is not tantamount to being unhealthy. In observing this
I do not wish to ally myself with the idea that philosophy should terminate
with the subtle analysis of the concepts of ordinary language. I think,
however, that every substantial deviation from ordinary usage should be
founded on sound arguments of some scientific or pragmatic kind.
I believe that there are good scientific and pragmatic arguments for
rejecting this notion. Perhaps the most important argument is that we need
some conceptual variety. It is important to be able to describe the general
idea of adaptedness which is a notion of freedom. When one is adapted one
is free to do the things which are required by one's wants. But I think that it
is also important to single out such an aspect of this freedom as stems from
the individual him or herself and distingush it from the external platform.
Health is by tradition semantically viewed as particularly linked to the
human body or mind. It can indeed be practical to keep this connection. If
we do, it will still be possible to say: this person is completely healthy but
he or she is at this particular moment prevented from doing certain things.
Let us also notice the converse kind of consequence. By providing
opportunities for a person ordinarily called "unhealthy" or "disabled", like
giving a wheelchair to a lame person, one would, according to the notion of
health-as-adaptedness, automatically be improving his or her health. This
cannot be a happy consequence. By calling a lame person who is helped by
a wheelchair a healthy person, we blur the fact that this person has some
basic characteristics which we ought to pay attention to. (From this
semantic point one should not draw the conclusion that it is not up to the
institutions of health care to provide means of assistance. On the contrary
there may be many pragmatic reasons for these institutions to help people
compensate for losses in health. The notion of compensation is not,
however, identical with the notion of restitution or rehabilitation.)
210 POSTSCRIPT
As I have argued here (as well as earlier in the present book), I therefore
suggest a restriction on the circumstance term when I try to describe the
ability that constitutes health and the disability that constitutes non-health
or illness. When one is ill one is not disabled given any set of
circumstances; one is disabled given a rather specific set of circumstances. I
shall shortly return to this issue.
In taking this stance I think that I have some substantial support from
William Fulford, who in his Moral Theory and Medical Practice [155]
provides a very detailed analysis of health and related concepts. One of his
most central statements is that "illness is the failure of action in the absence
of preventive factors or opposition" (p.109). Disablement or failure of
action, given external prevention or opposition, is not then counted as
illness by Fulford.
SO much for circumstances. What about goals? Which are the actions that a
healthy person should be able to perform given a specified set of
circumstances?
Let me here start by offering some comments on Fulford's theory. I wish
to do this because he expresses himself in other terms than the three other
scholars. Fulford does not explicitly talk in terms of goals. He, instead,
consistently uses action-language (or doing-language). Fulford coins the
term "ordinary" doing for the set of doings which is relevant for the
analysis of health.
The concept of "ordinary" doing includes certain intentional actions but
ranges over a broader spectrum from simple functioning to fully conscious
intentional actions. The basic idea seems to be that 'brdinary" doing should
fall somewhere in the middle of this range.
Fulford, however, abstains from providing a systematic analysis of this
notion of ordinary doing. Thereby he also leaves us without a set of explicit
criteria for delineating the set of doings and actions that a healthy person
should be able to perform. Some explication of what he means by ordinary
doing is given in the following:
...the patients who are ill are unable to do everyday things that people ordinarily just get on and
do, moving their arms and legs, remembering... things, finding their ways about familiar places and
so on ([155], p. 149).
A person's optimum state of health is equivalent to the state of the set of conditions which fulfil
or enable a person to work to fulfil his or her realistic chosen and biological potentials. Some of
these conditions are of the highest importance for all people. Others are variables dependent upon
individual abilities and circumstances ([168], p. 61.).
The addition of the word "realistic" is essential for the plausibility of the
notion. The individual may have very unrealistic goals - wanting to
become a Nobel laureate or to win an Olympic gold medal in the high jump.
Assume that he or she is very far from having the resources necessary for
attaining such goals. According to an unqualified theory of health this
individual would then be in a state of non-health. I think this is an absurd
conclusion. So, obviously, does Seedhouse. He qualifies by adding the
clause of realistic chosen goals. (I think that there are also other
qualifications to be made, having to do with distinctions between different
species of will [see this volume, pp. 72-73]. But I shall leave them aside
here.)
But there is a reverse problem which is not explicitly taken care of in
Seedhouse's theory. Nor has it been dealt with by Porn. This is the problem
of the person who does not choose anything at all, the lazybones or the
intellectually very weak person or the person with a very defective will.
If the subject has not chosen any goals at all, or really does not want to
have anything, then he or she can come out as healthy without having any
resources whatsoever. He or she can even have grave diseases or be highly
disabled, at least according to conventional ideas about disablement. But
still the subject can fulfil all his or her chosen goals, since he or she does
not have any such goals or at least only limited ones. This is indeed a
counterintuitive consequence.
If we decide on a subject-oriented notion of health, like Seedhouse's,
Porn's, and my own, we must find reasonable ways to avoid both kinds of
difficulties. We must define a notion of a person's goals which is not simply
identical with, but still related to, what a person wants to do or chooses to
do. My own notion of a vital goal of human beings involves an attempt to
play this theoretical role.
Let me now briefly rehearse my definition of health in the light of the above
commentaries:
A is completely healthy, if and only if A is in a bodily and mental state
which is such that A is able to realize all his or her vital goals, given
accepted circumstances.
I shall briefly elaborate on this definition. Consider first the
circumstance clause.
I criticized the characterisation of health as adaptedness to any situation.
The reason was that we cannot in such a case talk about a person's being
POSTSCRIPT 213
NOTES
1 Fulford at some places refers to the individual's preferences. But in the quotation above he
explicitly talks about what people ordinarily just get on and do.
2 As is indicated in the quotation, Seedbouse also mentions biological goals, but he has informed
me in conversation (April 1992) that in the case of conflict between biological and chosen goals the
chosen goals override the biological ones.
Philosophy and Medicine
1. H. Tristram Engelhardt, Jr. and S.P. Spicker (eds.): Evaluation and Explanation
in the Biomedical Sciences. 1975 ISBN 90-277-0553-4
2. S.F. Spicker and H. Tristram Engelhardt, Jr. (eds.): Philosophical Dimensions
o/the Neuro-Medical Sciences. 1976 ISBN 90-277-0672-7
3. S.P. Spicker and H. Tristram Engelhardt, Jr. (eds.): Philosophical Medical
Ethics: Its Nature and Significance. 1977 ISBN 90-277-0772-3
4. H. Tristram Engelhardt, Jr. and S.F. Spicker (eds.): Mental Health: Philosophi-
cal Perspectives. 1978 ISBN 90-277-0828-2
5. B.A. Brody and H. Tristram Engelhardt, Jr. (eds.): Mental Illness. Law and
Public Policy. 1980 ISBN 90-277-1057-0
6. H. Tristram Engelhardt, Jr., S.P. Spicker and B. Towers (eds.): Clinical
Judgment: A Critical Appraisal. 1979 ISBN 90-277-0952-1
7. S.F. Spicker (ed.): Organism, Medicine. and Metaphysics. Essays in Honor of
Hans Jonas on His 75th Birthday. 1978 ISBN 90-277-0823-1
8. E.E. Shelp (ed.): Justice and Health Care. 1981
ISBN 90-277-1207-7; Pb 90-277-1251-4
9. S.P. Spicker, J.M. Healey, Jr. and H. Tristram Engelhardt, Jr. (eds.): The Law-
Medicine Relation: A Philosophical Exploration. 1981 ISBN 90-277-1217-4
to. W.B. Bondeson, H. Tristram Engelhardt, Jr., S.F. Spicker and J.M. White, Jr.
(eds.): New Knowledge in the Biomedical Sciences. Some Moral Implications
ofIts Acquisition, Possession, and Use. 1982 ISBN 90-277-1319-7
11. E.E. Shelp (ed.): Beneficence and Health Care. 1982 ISBN 90-277-1377-4
12. G.J. Agich (ed.): Responsibility in Health Care. 1982 ISBN 90-277-1417-7
13. W.B. Bondeson, H. Tristram Engelhardt, Jr., S.F. Spicker and D.H. Winship:
Abortion and the Status o/the Fetus. 2nd printing, 1984 ISBN 90-277-1493-2
14. E.E. Shelp (ed.): The Clinical Encounter. The Moral Fabric of the Patient-
Physician Relationship. 1983 ISBN 90-277 -1593-9
15. L. Kopelman and J.C. Moskop (eds.): Ethics and Mental Retardation. 1984
ISBN 90-277-1630-7
16. L. Nordenfelt and B.I.B. Lindahl (eds.): Health, Disease, and Causal Explana-
tions in Medicine. 1984 ISBN 90-277-1660-9
17. E.E. Shelp (ed.): Virtue and Medicine. Explorations in the Character of
Medicine. 1985 ISBN 90-277-1808-3
18. P. Carrick: Medical Ethics in Antiquity. Philosophical Perspectives on Abortion
and Euthanasia. 1985 ISBN 90-277-1825-3; Pb 90-277-1915-2
19. J.C. Moskop and L. Kopelman (eds.): Ethics and Critical Care Medicine. 1985
ISBN 90-277-1820-2
20. E.E. Shelp (ed.): Theology and Bioethics. Exploring the Foundations and
Frontiers. 1985 ISBN 90-277-1857-1
21. G.J. Agich and C.E. Begley (eds.): The Price o/Health. 1986
ISBN 90-277-2285-4
22. E.E. Shelp (ed.): Sexuality and Medicine.
Vol. I: Conceptual Roots. 1987 ISBN 90-277-2290-0; Pb 90-277-2386-9
Philosophy and Medicine
41. K.W. Wildes, SJ., F. Abel, SJ. and J.C. Harvey (eds.): Birth, Suffering, and
Death. Catholic Perspectives at the Edges of Life. 1992
ISBN 0-7923-1547-2; Pb 0-7923-2545-1
42. S.K. Toombs: The Meaning of Illness. A Phenomenological Account of the
Different Perspectives of Physician and Patient. 1992
ISBN 0-7923-1570-7; Pb 0-7923-2443-9
43. D. Leder (ed.): The Body in Medical Thought and Practice. 1992
ISBN 0-7923-1657-6
44. C. Delkeskamp-Hayes and M.A.G. Cutter (eds.): Science, Technology, and the
Art of Medicine. European-American Dialogues. 1993 ISBN 0-7923-1869-2
45. R. Baker, D. Porter and R. Porter (eds.): The Codification of Medical Morality.
Historical and Philosophical Studies of the Formalization of Western Medical
Morality in the Eighteenth and Nineteenth Centuries, Volume One: Medical
Ethics and Etiquette in the Eighteenth Century. 1993 ISBN 0-7923-1921-4
46. K. Bayertz (ed.): The Concept of Moral Consensus. The Case of Technological
Interventions in Human Reproduction. 1994 ISBN 0-7923-2615-6
47. L. Nordenfelt (ed.): Concepts and Measurement of Quality of Life in Health
Care. 1994 ISBN 0-7923-2824-8
48. R. Baker and M.A. Strosberg (eds.) with the assistance of J. Bynum:
Legislating Medical Ethics. A Study of the New York State Do-Not-Resus-
citate Law. 1995 ISBN 0-7923-2995-3