Mnoge biološke funkcije dopuštaju stupnjevanje. Na primjer, lučenje određenog hormona u organizmu može biti na višoj ili nižoj razini, u usporedbi s istim organizmom drugom prilikom ili u usporedbi s drugim organizmima. Koje razine funkcioniranja predstavljaju slučajeve disfunkcije; gdje da povučemo crtu? To je kvantitativni problem za teorije disfunkcije i bolesti. Cilj mi je braniti verziju bioloških teorija disfunkcije kako bih se uhvatio u koštac s ovim problemom. Međutim, također ću dopustiti da evaluativna razmatranja uđu u teoriju bolesti. Moj argument (...) se temelji na razlikovanju između biološke i kliničke perspektive. Prema mom mišljenju, bolest je ograničena na slučajeve koji spadaju u granice bioloških disfunkcija. Odgovor na kvantitativni problem ne zahtijeva proizvoljne odluke ili društveno vrijednosne sudove. Stoga se zalažem za nearbitrarnu metodu koja se temelji na činjenicama kako bi se riješio kvantitativni problem. Ipak, nisu sve biološke disfunkcije instance bolesti. Dodavanje kliničke perspektive omogućuje nam da spriječimo potencijalnu preveliku uključenost biološke perspektive, zato što postavlja dodatna ograničenja za određivanje granica bolesti. (shrink)

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

The ethical theories employed in health care today assume, in the main, a modern Western philosophical framework. Yet the diversity of cultural and religious assumptions regarding human nature, health and illness, life and death, and the status of the individual suggest that a cross-cultural study of health care ethics is needed. A Cross-Cultural Dialogue on Health Care Ethics provides this study. It shows that ethical questions can be resolved by examining the ethical principles present in each culture, critically assessing each (...) value, and identifying common values found within all traditions, It encourages the development of global awareness and sensitivity to and respect for the diversity of peoples and their values and will advance understanding as well as help to foster a greater balance and a fuller truth in consideration of the human condition and what makes for health and wholeness. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

It appears that there are two distinct practices within public health, namely health promotion and disease prevention, leading to different goals. But does the distinction hold? Can we promote health without preventing disease, and vice versa? The aim of the paper is to answer these questions. First, the central concepts are defined and the logical relations between them are spelt out. A preliminary conclusion is that there is a logical difference between health and disease, which makes health promotion and disease (...) prevention two distinct endeavours. However, since disease is defined in relation to health, as those kinds of internal processes and states that typically lead to ill health, the difference is smaller than it might appear. Second, in order to answer the practical question whether it is possible to promote health without preventing disease, and vice versa, several kinds of public health interventions are discussed. The conclusion is that while health promotion and disease prevention can be distinguished conceptually, they can hardly be distinguished in practice. Most general measures do both at the same time. (shrink)

Staggering advances in biotechnology within the past decade have given rise to pharmacological, surgical and prosthetic techniques capable of enhancing human functioning rather than merely treating or preventing disease. Bioenhancement technologies range from nootropics capable of enhancing cognitive abilities to distraction osteogenesis, a surgical technique capable of increasing height through limb lengthening. This paper examines whether the use of bioenhancements falls inside or outside the proper boundaries of healthcare, and if so, whether clinicians have professional responsibilities to administer bioenhancements to (...) patients. After explicating two theoretical approaches to the concept of health, one objectivist and the other constructivist, I contend that clinicians' corresponding professional responsibilities hinge on which philosophical account of health is endorsed, and illustrate how the lack of analytic clarity with respect to this concept can lead to defective positions on the place of bioenhancements in healthcare. With this conceptual framework in place, an account of health as a cluster concept that incorporates both constructivist and objectivist components is developed and defended. (shrink)

In this article, I address two objections developed by Kingma against Boorse’s bio-statistical theory of health, the objections that choice of reference classes renders the theory both circular and problematically value-laden. These objections not only apply to the bio-statistical theory of health but also to other naturalistic theories, like the dispositional theory of health. I present three rejoinders. First, I argue that the circularity objection arises from excessive methodological demands. Second, I argue that naturalists can resist the normativist claim that (...) health and pathology are differentiated on the basis of personal or cultural values. Finally, I show that it is possible to justify choices between rival theories of health without the interference of evaluative commitments. With these rejoinders, I conclude that the bio-statistical theory, as well as other naturalistic theories of health utilizing reference classes, is not undermined by Kingma’s arguments. (shrink)

A satisfactory account of the nature of health is important for a wide range of theoretical and practical reasons. No theory offered in the literature thus far has been able to meet all the desiderata for an adequate theory of health. This article introduces a new theory of health, according to which health is best defined in terms of dispositions at the level of the organism as a whole. After outlining the main features of the account and providing formal definitions (...) of ‘health’, ‘healthy’, and ‘healthier than’, I present the main strengths of the proposed account. I argue that the proposed dispositional theory accounts for all paradigm cases of health and pathology, that it circumvents a number of problems faced by rival theories, and that it makes for a naturalistic theory of health with a rigorous metaphysical underpinning. 1Introduction 2The Dispositional Account 3Further Specification of the Dispositional Account 3.1Reference classes 3.2Comparison classes 3.3Which dispositions? 4Advantages of the Dispositional view 5Three Objections and Replies 5.1Objection 1: Counter-examples 5.2Objection 2: Issues with holism 5.3Objection 3: Expediting medicalization 6Final Remarks. (shrink)

Recently, concerns have been raised about the phenomenon of ‘overdiagnosis’, the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises ques- tions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue (...) that ‘disease’ should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are ‘borderline’ cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a pre ́cising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient. (shrink)

Christopher Boorse’s biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield’s harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse’s (...) central argument for the sufficiency claim, the “pathologist argument,” which takes pathologists’ intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion. (shrink)

I argue for a conception of health as a person's ability to achieve or exercise a cluster of basic human activities. These basic activities are in turn specified through free-standing ethical reasoning about what constitutes a minimal conception of a human life with equal human dignity in the modern world. I arrive at this conception of health by closely following and modifying Lennart Nordenfelt's theory of health which presents health as the ability to achieve vital goals. Despite its strengths I (...) transform Nordenfelt's argument in order to overcome three significant drawbacks. Nordenfelt makes vital goals relative to each community or context and significantly reflective of personal preferences. By doing so, Nordenfelt's conception of health faces problems with both socially relative concepts of health and subjectively defined wellbeing. Moreover, Nordenfelt does not ever explicitly specify a set of vital goals. The theory of health advanced here replaces Nordenfelt's (seemingly) empty set of preferences and society-relative vital goals with a human species-wide conception of basic vital goals, or ‘central human capabilities and functionings’. These central human capabilities come out of the capabilities approach (CA) now familiar in political philosophy and economics, and particularly reflect the work of Martha Nussbaum. As a result, the health of an individual should be understood as the ability to achieve a basic cluster of beings and doings—or having the overarching capability, a meta-capability, to achieve a set of central or vital inter-related capabilities and functionings. (shrink)

If one had to identify the biggest change within the philosophical tradition in the twenty-first century, it would certainly be the rapid rise of experimental philosophy to address differences in intuitions about concepts. It is, therefore, surprising that the philosophy of medicine has so far not drawn on the tools of experimental philosophy in the context of a particular conceptual debate that has overshadowed all others in the field: the long-standing dispute between so-called naturalists and normativists about the concepts of (...) health and disease. In this paper, I defend and advocate the use of empirical methods to inform and advance this and other debates within the philosophy of medicine. (shrink)

If one had to identify the biggest change within the philosophical tradition in the twenty-first century, it would certainly be the rapid rise of experimental philosophy to address differences in intuitions about concepts. It is, therefore, surprising that the philosophy of medicine has so far not drawn on the tools of experimental philosophy in the context of a particular conceptual debate that has overshadowed all others in the field: the long-standing dispute between so-called naturalists and normativists about the concepts of (...) health and disease. In this paper, I defend and advocate the use of empirical methods to inform and advance this and other debates within the philosophy of medicine. (shrink)

Since Boorse [Philos Sci 44(4):542–573, 1977] published his paper “Health as a theoretical concept” one of the most lively debates within philosophy of medicine has been on the question of whether health and disease are in some sense ‘objective’ and ‘value-free’ or ‘subjective’ and ‘value-laden’. Due to the apparent ‘failure’ of pure naturalist, constructivist, or normativist accounts, much in the recent literature has appealed to more conciliatory approaches or so-called ‘hybrid accounts’ of health and disease. A recent paper by Matthewson (...) and Griffiths [J Med Philos 42(4):447–466, 2017], however, may bear the seeds for the revival of purely naturalist approach to health and disease. In this paper, I defend their idea of Biological Normativity against recent criticism by Schwartz [J Med Philos Forum Bioethics Philos Med 42(4):485–502, 2017] and hope to help it flower into a revival of naturalist approaches in the philosophy of medicine. (shrink)

The paper engages Christopher Boorse’s Bio-Statistical Theory. In its current form, BST runs into a significant challenge. For BST to account for its central tenet—that lower-level part-dysfunction is sufficient for higher-level pathology—it must provide criteria for how to decide which lower-level parts are the ones to be analyzed for health or pathology. As BST is a naturalistic theory, such choices must be based solely on naturalistic considerations. An argument is provided to show that, if BST is to be preserved, such (...) parthood choices are based on non-naturalistic considerations. We demonstrate that even when parthood choices are based on the best way to preserve BST, there are counterintuitive results which bring the central tenet of BST into question. (shrink)

Individual autonomy is a prominent value in Western medicine and medical ethics, and there it is often accepted that the only way to pay proper respect to autonomy is to let the patients themselves determine what is good for them. Adopting this approach has, however, given rise to some unwanted results, thus motivating a quest for an objective conception of health. Unfortunately, the purportedly objective conceptions of health have failed in objectivity, and if a conception of health is not acceptable (...) for all agents, the threat of offending the patients’ autonomy arises. This article sketches an objective conception of health that is able to respect individual autonomy. (shrink)

If it is true that health is a priority objective of medicine, then medical practice can only be successful if the meaning of the term “health” is known. Various attempts have been made over the years to define health. This paper proposes a new definition. In addition to current health concepts, it also takes into account the distinction between specifically human health and health as the absence of disease and illness—i.e. small health. The feeling of leading a life that makes (...) sense plays a key role in determining specifically human great health. (shrink)

Despite the longstanding debate on definitions of health and disease concepts, and the multitude of accounts that have been developed, no consensus has been reached. This is problematic, as the way we define health and disease has far-reaching practical consequences. In recent contributions it is proposed to view health and disease as practical- and plural concepts. Instead of searching for a general definition, it is proposed to stipulate context-specific definitions. However, it is not clear how this should be realized. In (...) this paper, we review recent contributions to the debate, and examine the importance of context-specific definitions. In particular, we explore the usefulness of analyzing the relation between the practical function of a definition and the context it is deployed in. We demonstrate that the variety of functions that health and disease concepts need to serve makes the formulation of monistic definitions not only problematic but also undesirable. We conclude that the analysis of the practical function in relation to the context is key when formulating context-specific definitions for health and disease. At last, we discuss challenges for the pluralist stance and make recommendations for future research. (shrink)

This paper explores causation in the context of health care practice, in particular, primary care. Causation in health care is necessarily premised on the concepts of disease and illness and the ways they are deviations from health. The paper reviews and broadly categorises concepts of illness most commonly found in the literature in terms of the biomedical, biopsychosocial, and agency models. It is argued that although each model has its place in the gamut of health care practice, primary care implicitly (...) or explicitly uses an agency model most frequently. By explicitly acknowledging the role that patients’ values and expectations have in utilising their physiological, psychological and social capacities to live their lives, clinicians can gain a clearer understanding of how a situation has come about and why it has become a health problem for the patient. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ambiguities of Mild Cognitive ImpairmentTim Thornton (bio)Keywordsclassification, disease, mild cognitive impairment, normative, valuesCorner and Bond's paper (2006) raises some key ethical questions about the classification and diagnosis of mild cognitive impairment (MCI). In this commentary, I wish to revise some of the general issues about the classification of mental disorder raised by this particular classificatory concept. The central issue raised is the connection between the pathologic status of (...) a condition and what I term the plain facts about the frequency and nature of its symptoms.There are a number of ethical questions raised by applying the label of MCI. Centrally, perhaps, is the concern, illustrated by the case vignettes, that a diagnosis carries negative repercussions that might outweigh the more narrowly medical advantages of an early diagnosis. But although that concern may be appropriate, such ethical complications are a danger of any psychiatric classification or diagnosis, even the most well grounded. Any psychiatric diagnosis can carry a danger of stigma, for example.What seems to make such ethical concerns more serious in this case—at least to a philosopher outsider—is the implicit further concern that MCI is not a real, objective, or, to use a more medical term, valid category or classification. If it is not valid, then any negative connotations of the diagnosis will not be outweighed by medical technological achievements. In other words, the further ethical issues are given much greater weight if the question of validity is not satisfactorily resolved.The question of the reality, objectivity, or validity of MCI can be divided into two issues:1. Is MCI a real, objective, or valid feature of psychological phenomenology?2. Is MCI a real, objective, or valid psychological illness, disease, or pathology?A condition might be a real, objective, or valid feature of psychological phenomenology without being a real illness. It might be some other aspect of human living. Szasz (1960) suggests that this is the case with mental illness (he might more properly say "so-called mental illness") as a whole. But, less controversially, the unusual ability to calculate, mentally and in a flash, the date of future Easter Sundays is a genuine feature of human living—some people possess the ability even if most do not—without either it, or its lack, being an illness. Being real as an illness is a very specific kind of being. It is this, I suggest, that raises difficulties in the case of MCI by contrast with the easier question of whether something is a genuine feature of human living in some other way. [End Page 21]From "normal" and "normative" to "correct" and "incorrect"Corner and Bond (2006) usefully suggest that the question of whether MCI is real is made more difficult by an ambiguity in the sense of the word normal. They suggest that although "physiologic and cognitive decline is assumed to be a normal experience" this still leaves "boundary problems" about "distinguishing normal aging from disease" (Corner and Bond 2006, 3–4). Thus, if the symptoms of MCI are continuous with the ordinary phenomena of physiologic and cognitive decline, then they might also be merely normal. But this does not settle the status of MCI because normal can mean either "normative, that is, usual; or it can mean nonpathologic" (Corner and Bond 2006, 4).On the assumption that MCI is at least continuous with phenomena that are normal, then its symptoms might be normal in the sense of usual but nevertheless pathologic: an inevitable illness. Or they might be usual and nonpathologic, that is, merely a feature of aging that, although regrettable, lacks the connotations of illness (e.g., the appropriateness, if not the possibility, of treatment). (In principle on the assumption in play—that the symptoms of MCI are normal—they might be unusual but nonpathologic akin, for example, to an improved ability to solve crosswords with age that might affect a small lucky proportion of the population. Perhaps such a crossword puzzler might be reassured by their doctor: "Well that is very unusual but there is no need to worry: it is not a symptom of any illness. You are perfectly normal.")Thus the question "Is MCI normal... (shrink)

There are great health disparities in the world today, both between countries and within them. This problem might be seen as related to the access to various kinds of capabilities. It is not fully clear, however, what the exact relation is between health and capabilities. Neither Amartya Sen nor Martha Nussbaum has explicitly formulated a theory of health to go with their theories of capabilities. This paper attempts to present a clarification of the conceptual relation between health and capabilities. Health, (...) it is argued, should be seen as a holistic multi-dimensional phenomenon, made up of basic abilities and subjective well-being, and of fundamental states and processes. Using this theory, the paper shows how health is related to Nussbaum’s ten capabilities. It is argued that health, in the senses described, is a necessary part of all ten capabilities. Moreover, some of the capabilities on Nussbaum’s list, such as thinking and imagining, and practical reasoning, refer to health. Finally, it is shown that even though health is part of all capabilities, health cannot itself primarily be seen as a capability. An acceptable degree of health is required as a functioning for any theory of human flourishing to be reasonable. (shrink)

The concept of ‘empowerment’ is used frequently in a number of professional areas, from psychotherapy to social work. But even if the same term is used, it is not always clear if the concept denotes the same goals or the same practice in these various fields. The purpose of this paper is to clarify the discussion and to find a plausible and useful definition of the concept that is suitable for work in various professions. Several suggestions are discussed in the (...) paper, for example control over life or health, autonomy, ability, self-efficacy, self-esteem, and freedom, and it is concluded that there are two plausible complementary uses, one as a goal and one as a process or approach. Empowerment as a goal is to have control over the determinants of one’s quality of life, and empowerment as a process is to create a professional relation where the client or community takes control over the change process, determining both the goals of this process and the means to use. (shrink)

The starting point for the contemporary debate about theories of health should be the holistic theory of Lennart Nordenfelt, claims George Khushf, not the refuted theory of Christopher Boorse. The present paper is an attempt to challenge Nordenfelt and to present an alternative theory to his and other theories, including Boorse’s. The main problems with Nordenfelt’s theory are that it is relativistic, that it leads to counter-intuitive results as to what goals can count as healthy, that it focuses on the (...) wrong kind of abilities, that it makes measuring health extra difficult, and that it does not give us a sufficient account of health, at most a necessary one. The alternative theory proposed is two-dimensional. First, health is to have developed the abilities and dispositions that members of one’s culture typically develop, and be able to use them, in acceptable circumstances; and second, health is to experience positive moods and sensations, the kinds that have internal causes. The theory solves the problems attached to Nordenfelt’s theory by not being individual relativistic, by eliminating the goals in the definition, by giving an alternative interpretation of “ability,” by making health easier to measure, and by adding the dimension of well-being that, together with health as ability, not only gives us a necessary, but also a sufficient, account of health. (shrink)

There are several strategies to promote health in individuals and populations. Two general approaches to health promotion are behavior change and empowerment. The aim of this article is to present those two kinds of strategies, and show that the behavior-change approach has some moral problems, problems that the empowerment approach (on the whole) is better at handling. Two distinct ‘ideal types’ of these practices are presented and scrutinized. Behavior change interventions use various kinds of theories to target people’s behavior, which (...) they do through information, persuasion, coercion and manipulation. Empowerment is a collaborative method where those ‘facilitated’ participate in the change process. Some ethical problems with the behavior-change model are that it does not sufficiently respect the right to autonomy of the individuals involved and risks reducing their ability for autonomy, and that it risks increasing health inequalities. Empowerment, on the other hand, respects the participant’s right to autonomy, tends to increase the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities. A drawback with this approach is that it often takes longer to realize. (shrink)

One important ethical issue for health promotion and public health work is to determine what the goals for these practices should be. This paper will try to clarify what some of these goals are thought to be, and what they ought to be. It will specifically discuss two different approaches to health promotion, such as, behavior change and empowerment. The general aim of this paper is, thus, to compare the behavior-change approach and the empowerment approach, concerning their immediate goals or (...) aims, and to morally evaluate the strengths and weaknesses of these two goal models, in relation to the ultimate goal of health promotion. The investigation shows that the behavior-change approach has several moral problems. First of all, it is overly paternalistic and often disregards the individual’s or group’s own perception of what is important—something that also increases the risk of failed interventions. Furthermore, it risks leading to ‘victim blaming’ and stigmatization, and to increased inequalities in health, and it puts focus on the ‘wrong’ problems, i.e., behavior instead of the ‘causes of the causes’. It is thereafter shown that the empowerment approach does not have any of these problems. Finally, some specific problems for the empowerment approach are discussed and resolved, such as, the idea that empowering some groups might lead to power over others, the objection that the focus is not primarily on health, and the fact that empowered people might choose to live lives that risk reducing their health. (shrink)

In this paper I develop a phenomenology of falling ill by presenting, interpreting and developing the basic model we find in Jean-Paul Sartre’s Being and Nothingness ( 1956 ). The three steps identified by Sartre in this process are analysed, developed further and brought to a five-step model: (1) pre-reflective experience of discomfort, (2) lived, bodily discomfort, (3) suffered illness, (4) disease pondering, and (5) disease state. To fall ill is to fall victim to a gradual process of alienation, and (...) with each step this alienating process is taken to a new qualitative level. Consequently, the five steps of falling ill have not only a contingent chronological order but also a kind of logical order, in that they typically presuppose each other. I adopt Sartre’s focus on embodiment as the core ground of the alienation process, but point out that the alienation of the body in illness is not only the experience of a psychic object, but an experience of the independent life of one’s own body. This facticity of the body is the result neither of the gaze of the other person, nor of a reflection adopting the outer perspective of the other in an indirect way, but is a result of the very otherness of one’s own body, which addresses and plagues us when we fall ill. I use examples of falling ill and being a patient to show how a phenomenology of falling ill can be helpful in educating health-care personnel (and perhaps also patients) about the ways of the lived body. (shrink)

In this paper I develop a phenomenology of falling ill by presenting, interpreting and developing the basic model we find in Jean-Paul Sartre's Being and Nothingness. The three steps identified by Sartre in this process are analysed, developed further and brought to a five- step model: pre-reflective experience of discomfort, lived, bodily discomfort, suffered illness, disease pondering, and disease state. To fall ill is to fall victim to a gradual process of alienation, and with each step this alienating process is (...) taken to a new qualitative level. Consequently, the five steps of falling ill have not only a contingent chronological order but also a kind of logical order, in that they typically presuppose each other. I adopt Sartre's focus on embodiment as the core ground of the alienation process, but point out that the alienation of the body in illness is not only the experience of a psychic object, but an experience of the independent life of one's own body. This facticity of the body is the result neither of the gaze of the other person, nor of a reflection adopting the outer perspective of the other in an indirect way, but is a result of the very otherness of one's own body, which addresses and plagues us when we fall ill. I use examples of falling ill and being a patient to show how a phenomenology of falling ill can be helpful in educating health-care personnel about the ways of the lived body. (shrink)

In this paper I explore health and illness through the lens of enactivism, which is understood and developed as a bodily-based worldly-engaged phenomenology. Various health theories – biomedical, ability-based, biopsychosocial – are introduced and scrutinized from the point of view of enactivism and phenomenology. Health is ultimately argued to consist in a central world-disclosing aspect of what is called existential feelings, experienced by way of transparency and ease in carrying out important life projects. Health, in such a phenomenologically enacted understanding, (...) is an important and in many cases necessary part of leading a good life. Illness, on the other hand, by such a phenomenological view, consist in finding oneself at mercy of unhomelike existential feelings, such as bodily pains, nausea, extreme unmotivated tiredness, depression, chronic anxiety and delusion, which make it harder and, in some cases, impossible to flourish. In illness suffering the lived body hurts, resists, or, in other ways, alienates the activities of the ill person. (shrink)

A large slice of contemporary phenomenology of medicine has been devoted to developing an account of health and illness that proceeds from the first-person perspective when attempting to understand the ill person in contrast and connection to the third-person perspective on his/her diseased body. A proof that this phenomenological account of health and illness, represented by philosophers, such as Drew Leder, Kay Toombs, Havi Carel, Hans-Georg Gadamer, Kevin Aho, and Fredrik Svenaeus, is becoming increasingly influential in philosophy of medicine and (...) medical ethics is the criticism of it that has been voiced in some recent studies. In this article, two such critical contributions, proceeding from radically different premises and backgrounds, are discussed: Jonathan Sholl’s naturalistic critique and Talia Welsh’s Nietzschean critique. The aim is to defend the phenomenological account and clear up misunderstandings about what it amounts to and what we should be able to expect from it. (shrink)

In this paper, I argue that disabled people have a right to assistive technology, but this right cannot be grounded simply in a broader right to health care or in a more comprehensive view like the capabilities approach to justice. Both of these options are plagued by issues that I refer to as the problem of constriction, where the theory does not justify enough of the AT that disabled people should have access to, and the problem of overextension, where the (...) theory cannot adequately identify an upper limit on the AT that people have a right to. As an alternative to these justificatory frameworks, I argue that disabled people are owed access to AT at the expense of nondisabled people as a matter of compensatory justice. That is, I defend the position that disabled people are owed AT as part of due compensation for the harms they experience from being disadvantaged by society’s dominant cooperative scheme and the violation of their right to equality of opportunity that such disadvantage entails. I also propose a method for identifying an upper limit to what this right to AT requires. In this way, I argue that compensatory justice avoids both the problem of constriction and the problem of overextension. (shrink)

Definition of the problemAdvance directives involve evaluative assumptions about the further course of one’s life that can be more or less appropriate and thus call for ethical reflection. This contribution focuses on the basis and criteria of such assumptions. We argue that considerations regarding the temporal structure of a good life constitute a particularly relevant perspective in this context.ArgumentsEmpirical studies on the individual composition of advance directives point to the important role of personal values and life plans that can change (...) over time. Therefore, we first contextualize advance directives from the perspective of an ethics of the good life and then discuss their implications with regard to different levels of temporality, comprising fundamental parameters of human existence in time, cultural models of the life course, as well as narratives of the individual trajectory of life.ConclusionConceptions of a good life and its temporal structure represent an important perspective for drafting and interpreting advance directives. Their consideration provides a more nuanced understanding of the evaluative implications of advance care planning. This can benefit individual patients, service providers, as well as policy makers. (shrink)

Patientenverfügungen und andere Arten gesundheitlicher Vorausverfügungen wie Advance Care Planning und in gewisser Hinsicht auch Vorsorgevollmachten und Betreuungsverfügungen schließen evaluativ gehaltvolle Annahmen und Werturteile über den weiteren Verlauf des eigenen Lebens ein, die sich als mehr oder weniger angemessen erweisen können und daher einer ethischen Klärung und Reflexion bedürfen. Der Beitrag geht der Frage nach den Grundlagen dieser Annahmen und Urteile nach und argumentiert, dass für ihre Analyse eine strebensethische Perspektive auf Vorstellungen eines guten Lebens in der Zeit besonders geeignet (...) ist. Dazu geben wir zunächst einen kurzen Überblick über die empirische Forschung zu Einflussfaktoren bei der Abfassung gesundheitlicher Vorausverfügungen, insbesondere der Bedeutung von individuellen Wertvorstellungen und Lebensorientierungen. Im nächsten Schritt wenden wir uns vor diesem Hintergrund der Bewertung von Lebensqualität im Lebensverlauf zu. Wie sich dabei zeigt, verweisen die betreffenden Werturteile in mehrfacher Hinsicht auf umfassendere Vorstellungen eines guten Lebens und seines zeitlichen Verlaufs. Daher nehmen wir im Anschluss die Frage des guten Lebens in der Zeit in den Blick und arbeiten typologisierend unterschiedliche Vorstellungen heraus, an denen sich die Implikationen der zeitlichen Erstreckung und Verlaufsstruktur guten Lebens für gesundheitliche Vorausverfügungen deutlich machen lassen. Der Aufsatz formuliert so nicht nur wichtige Perspektiven für eine eingehendere empirische Erforschung evaluativer Aspekte der Abfassung gesundheitlicher Vorausverfügungen. Die Klärung der Bedeutung der Zeitstruktur guten Lebens für solche Verfügungen eröffnet auch einen theoretischen Zugang zu den grundlegenden strebensethischen Fragen, mit denen sich die Betroffenen innerhalb des Rahmens des sollensethisch gut begründeten, gesellschaftlich weithin anerkannten und gesetzlich abgesicherten Rechtes auf ein selbstbestimmtes Sterben konfrontiert sehen. (shrink)

The combination of breeding for increased production and the intensification of housing conditions have resulted in increased occurrence of behavioral, physiological, and immunological disorders. These disorders affect health and welfare of production animals negatively. For future livestock systems, it is important to consider how to manage and breed production animals. In this paper, we will focus on selective breeding of laying hens. Selective breeding should not only be defined in terms of production, but should also include traits related to animal (...) health and welfare. For this we like to introduce the concept of robustness. The concept of robustness includes individual traits of an animal that are relevant for health and welfare. Improving robustness by selective breeding will increase (or restore) the ability of animals to interact successfully with the environment and thereby to make them more able to adapt to an appropriate husbandry system. Application of robustness into a breeding goal will result in animals with improved health and welfare without affecting their integrity. Therefore, in order to be ethically acceptable, selective breeding in animal production should accept robustness as a breeding goal. (shrink)

Many philosophers and medical scientists assume thatdisease categories or entities used to classify concrete cases ofdisease, are often defined by disease mechanisms or causalprocesses. Others suggest that diseases should always be definedin this manner. This paper discusses these standpoints criticallyand concludes that they are untenable, not only when `diseasemechanism' refers to an objective mechanism, but also when`mechanism' refers to a pragmatically demarcated part of thetotal ``objective'' causal structure of diseases. As an alternativeto principles that use the concept of disease mechanism (...) oranalogous concepts, a pragmatic approach is suggested anddescribed. This approach has been suggested before, but inproblematic or inadequate versions. This paper proposes a versioncompiled of two ``pragmatic principles'' and shows that they aremuch more adequate than the principle of disease mechanism. Withreference to a case study of a still ongoing internationaldiscussion of various candidates for a classification system formalignant lymphomas, including REAL (Revised European–AmericanClassification of Lymphoid Neoplasms) in which the concept ofdisease mechanism or analogous concepts plays a very small part,it is shown just how pivotal these two pragmatic principles canbe in actual discussions of definitions of diseases. Finally, itis pointed out that with regard to modern philosophy of languageit may, at least in some cases, be problematic to distinguishbetween the two pragmatic principles as they stand. (shrink)

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)

The paper contrasts Lennart Nordenfelt’s normative theory of health with the naturalists’ point of view, especially in the version developed by Christopher Boorse. In the first part it defends Boorse’s analysis of disease against the charge that it falls short of its own standards by not being descriptive. The second part of the paper sets out to analyse the positive concept of health and introduces a distinction between a positive definition of health (‘health’ is not defined as absence of disease (...) but in positive terms) and a positive conception of health (health is seen as an ideal). An objection against Nordenfelt’s account is developed by making use of a specific example of an ambitious athlete. It is stated that Nordenfelt’s conceptualisation includes too many phenomena under the umbrella of ill health. An ideal conception of health like Nordenfelt’s is in danger of supporting medicalization. In conclusion, although Nordenfelt’s theory is not altogether rejected and even seen in congruence with Boorse’s account, it is claimed that the naturalistic framework should obtain conceptual priority. (shrink)

Mobile health applications that promise the user to help her with some aspect of her health are very popular: for-profit apps such as MyFitnessPal, Fitbit, or Headspace have tens of millions of users each. For-profit health apps are designed and run as optimization systems. One would expect that these health apps aim to optimize the health of the user, but in reality they aim to optimize user engagement and, in effect, conversion. This is problematic, I argue, because digital health environments (...) that aim to optimize user engagement risk being manipulative. To develop this argument, I first provide a brief analysis of the underlying business models and the resulting designs of the digital environments provided by popular for-profit health apps. In a second step, I present a concept of manipulation that can help analyze digital environments such as health apps. In the last part of the article, I use my concept of manipulation to analyze the manipulative potential of for-profit health apps. Although for-profit health can certainly empower their users, the conditions for empowerment also largely overlap with the conditions for manipulation. As a result, we should be cautious when embracing the empowerment discourse surrounding health apps. An additional aim of this article is to contribute to the rapidly growing literature on digital choice architectures and the ethics of influencing behavior through such choice architectures. I take health apps to be a paradigmatic example of digital choice architectures that give rise to ethical questions, so my analysis of the manipulative potential of health apps can also inform the larger literature on digital choice architectures. (shrink)

In decisions about inclusion (or exclusion) of health care services in the benefit package, different interpretations of notions like health, health risk, disease, quality of life or necessary care often remain implicit. Yet they can lead to different benefit package decisions. After a brief discussion of these concepts in definitions of the goals of medicine, the various value-judgements implicit in interpretations of key notions in health care are analysed and conclusions are drawn with regard to the composition of decision making (...) bodies at various levels. It is further argued that such a body needs to discuss the various interpretations of key-notions explicitly in the various phases of a priority-setting procedure so that more consistent choices can be made in health care priority setting. (shrink)

In Europe a process of harmonisation of standards and regulations on genetic testing has started. Public discussion and consultation are recommended, but it is not clear in every European country how the decision making process as regards the further introduction of genetic testing services should be formed. In this paper the usefulness and importance of an overseeing body for genetic screening and testing is founded on four lines of reasoning: analysis of the role of value judgments in the use of (...) the concept of abnormality; a balancing of potential benefits for all parties involved; a balancing of potential disadvantages, and the greater availability of commercial genetic tests in the future. It is further argued that such an overseeing body has advantages for all the interested parties. (shrink)

This paper considers proposals for developing ‘co-productive’ medical partnerships, within the UK National Health Service (NHS), concentrating in particular on the potential problem involved in combining professional and lay conceptions of health. Much of the literature that advocates the introduction of co-productive healthcare partnerships assumes that medical professionals and patients share, or can easily come to share, a common set of beliefs about what is valuable with regard to health interventions and outcomes. However, a substantial literature documents the contestability of (...) the concept of health, particular across professional and lay divides. We suggest that this potential disagreement ought to be taken seriously, and suggest that the prospect of a co-productive NHS in which patients and professionals act in partnership is threatened by the existence of unresolved epistemic differences. We suggest that part of the solution may lie in re-framing this potential disagreement in the terms provided by Engel’s bio-psycho-social account of health, and demonstrate how support for this account can be grounded upon a critical realist foundation. What we call a ‘stratified conception of health’ reveals the potential complementarity between health beliefs which may have at first seemed to be essentially contradictory. We consider some of the practical implications this idea has for conceiving and creating co-productive medical partnerships. (shrink)

The themes of this issue—which include the meaning of our health and disease concepts, the so-called “medical gaze” and its embedded power relations, and the epistemic value of mixing therapy with research—are introduced by reflecting on a case about an infant girl whose head is observed to be somewhat flat.

In this paper I investigate the web-rhetoric of companies offering home-based personal health monitoring to patients and elderly people. Two main rhetorical methods are found, namely a reference to practical benefits and a use of prestige words like “quality of life” and “independence”. I interpret the practical benefits in terms of instrumental values and the prestige words in terms of final values. I also reconstruct the arguments on the websites in terms of six different types of argument. Finally, I articulate (...) a general critique of the arguments, namely that the websites neglect the context of use of personal health monitoring technologies. Whether or not a technology is good depends on the use of the technology by a particular individual in a particular context. The technology is not good–or bad–in itself. I support this critique with a number of more specific arguments such as the risk for reduced personal contact. For some elderly people social contact with care providers is more valuable than the independent living made possible by remote monitoring, for others independence is more important. (shrink)

Contemporary philosophy of health and disease has been quite focused on the problem of determining the nature of the concepts of health and disease from a scientific point of view. Some theorists claim and argue that these concepts are value-free and descriptive in the same sense as the concepts of atoms, metal, and rain are value-free and descriptive. According to this descriptive or naturalist line of thought, the notions of health and disease are furthermore related to the idea of a (...) normal or natural function. A bodily organ is healthy insofar as it functions normally, and it is diseased when it does not fulfill its functions. Other philosophers claim that the concept of health, together with other medical concepts, is essentially value-laden. To establish that a person is healthy does not just entail some objective inspection and measurement. It presupposes also an evaluation of the general state of the person. My purpose in this article is to scrutinize the relation between the notion of a natural function, on the one hand, and the concepts of health and disease on the other. In characterizing the notion of a normal function I will follow the classic analysis put forward by American philosopher Christopher Boorse. I will criticize Boorse’s proposal mainly by using arguments from the analysis of ordinary lay and medical language. I ask questions such as: what do we normally mean when we ascribe health or disease to a person? In the end I will recommend an analysis of these and related medical notions, which is unrelated to the notion of a natural function as normally interpreted. (shrink)

The capability approach, originated by Amartya Sen is among the most comprehensive and influential accounts of justice that applies to issues of health and health care. However, although health is always presumed as an important capability in Sen’s works, he never manages to fully explain why health is distinctively valuable. This paper provides an explanation. It does this by firstly laying out the general capability-based argument for health justice. It then discusses two recent attempts to justify why health is distinctively (...) valuable from within a capability framework – these are Sridhar Venkatapuram’s conception of health as the central human meta-capability and, respectively, Norman Daniels’ embrace of the capability metric in his use of Rawls’ principle of fair equality of opportunity. The paper argues that none of these accounts succeed in providing a plausible justification of the value of health. Finally, the paper suggests an alternative more complex justification, closely tied to different but central element of the capability view, that captures the core intuitions of both Venkatapuram and Daniels’ accounts but without being vulnerable to the objections raised against each of them. This, the paper concludes, provides a promising ground on which the capability view on health justice should be founded. (shrink)

This paper will examine a claim that nursing is united by its moral stance. The claim is that there are moral constraints on nurses' actions as people practising nursing and that they are in some way different from both what for now can be called standard morality and also different from the person's own moral views who also happens to be a nurse, hence the defining and unifying factor for nursing. I will begin by situating the claim within the broader (...) area about the need for a definition to state features that are essential to all and only members of its class. This will highlight the fact that there are two distinct types of definition used by authors seeking to find a unity for nursing. One type of definition has to do with goals or purposes given to nursing and the other with ends discovered as nursing. But even if there are ends waiting to be discovered a particular practical concern is how we can have knowledge of them. I will suggest that knowledge by intuition is plausible but that as things currently stand in moral epistemology it will not provide the unifying ground for nursing. Then I will argue that in the latter approach to definition a certain account of human nature has been advanced in order to provide features that are there to be discovered and so not dependent on human beings for the definition or classification. However, such an attempt to define nursing cannot do what is wanted. Rather than the account of human nature grounding morality and doing so for nursing, the account of human nature itself relies upon a prior account of morality. Because of this it loses its supposed ground of unity for the profession. Nursing is not united by its moral stance especially if this is understood in a strong sense as unique moral stance, but as things currently stand in moral epistemology this is not necessarily a bad thing for practitioners or patients. (shrink)

In the last two decades, the term “quality-of-life” has become popular in medicine and health care. There are, however, important differences in the meaning and the use of the term. The message of all quality-of-life talk is that medicine and health care are not valuable in themselves. They are valuable to the extent that they contribute to the quality of life of patients. The ultimate aims of medicine and health care are not health or prolongation of life as such, but (...) preservation or improvement of the quality of life. The primary aims of medicine and health care, such as the prolongation of life, can – but need not always – come into conflict with the ultimate ones: medical treatments do not always benefit a patient. In this article I will, first, summarize the results of my explorations of the use and the meaning of the term “quality-of-life.” The use and the meaning of the term turn out to depend on the contexts of medical decisionmaking in which it is used. I will show that there are at least three different concepts of quality-of-life. Second, I will argue that the different concepts of quality-of-life are not unrelated. They point to different components of and/or conditions for happiness. Third, I will analyze the relation between the three concepts of qualityof-life, health and happiness. (shrink)

The varieties of meaning in which we use the terms illness and health requires that we develope a conceptualization allowing us to maintain a unity between the differences. In fact, the experiences of health and illness are complex ones and they need to be understood in their different levels so that the need for help of patients and their desire for health is adequately faced. At its roots, the experience of illness is that of a threat posed to the unreflective (...) credit given to life in good health. This threat has not only a biopsychosocial dimension, but a moral and sybolic one as well, and it is mainly at this level that illness represents a moral challenge. Contemporary culture seems to be at pains in suggesting a shared set of meanings enabling the patient to give an intersubjectively valid sense of illness, since the only kind of answer offered is a technical one. The symbolic dimension of the notions of health and illness call for a deeper cultural enterprise of looking for a credible sense of illness for our times. (shrink)