This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

This essay replies to critics since 1995 of my “biostatistical theory” of health. According to the BST, a pathological condition is a state of statistically species-subnormal biological part-functional ability, relative to sex and age. Theoretical health, the total absence of pathological conditions, is then a value-free scientific notion. Recent critics offer a mixture of old and new objections to this analysis. Some new ones relate to choice of reference class, situation-specificity of function, common diseases and healthy populations, improvements in population (...) health, the practice of pathologists, “Cambridge changes” in health status, and comparative vs. absolute health concepts. I make no changes in doctrine, except to consider treating “normal aging” as pathological by taking young adults as the standard for all adults. (shrink)

Osteoporosis, a disease of bone loss associated with aging and estrogen loss, can be crippling but is ‘silent’ prior to bone fracture. Despite its disastrous health effects, high prevalence, and enormous associated health care costs, osteoporosis lacked a universally accepted definition until 1992. In the 1980s, the development of more accurate medical imaging technologies to measure bone density spurred the medical community’s need and demand for a common definition. The medical community tried, and failed, to resolve these differing definitions several (...) times at consensus conferences and through published articles. These experts finally accepted a standard definition at an international consensus conference convened by the World Health Organization in 1992. The construction of osteoporosis as a disease of quantifiable risk diagnosed by medical imaging machines reflects contemporary trends in medicine, including the quantification of disease, the risk factor model, medical disciplinary boundaries, and global standardization of medical knowledge. (shrink)

I argue that ductal carcinoma in situ (DCIS), the tumor most commonly diagnosed by breast mammography, cannot be confidently classified as cancer, that is, as pathological. This is because there may not be dysfunction present in DCIS—as I argue based on its high prevalence and the small amount of risk it conveys—and thus DCIS may not count as a disease by dysfunction-requiring approaches, such as Boorse’s biostatistical theory and Wakefield’s harmful dysfunction account. Patients should decide about treatment for DCIS based (...) on the risks it poses and the risks and benefits of treatment, not on its disease status. (shrink)

In a series of recent papers, I have made three arguments about how to define “disease” and evaluate and apply possible definitions. First, I have argued that definitions should not be seen as traditional conceptual analyses, but instead as proposals about how to define and use the term “disease” in the future. Second, I have pointed out and attempted to address a challenge for dysfunction-requiring accounts of disease that I call the “line-drawing” problem: distinguishing between low-normal functioning and dysfunctioning. Finally, (...) I have used a dysfunction-requiring approach to argue that some extremely prevalent conditions, such as high blood pressure, high cholesterol, and ductal carcinoma in situ, are not diseases, but instead are risk factors. Four of the papers in this issue directly engage my previous work. In this commentary, I applaud the advances these authors make, address points of disagreement, and make suggestions about where the discussion should go next. (shrink)

La possibilité d’une définition naturaliste de la santé et d’une distinction entre le normal et le pathologique qui ne repose pas sur des normes culturelles, sociales ou subjectives est au cœur des débats en philosophie de la médecine. Or le concept statistique de la normalité, fondamental pour une définition objective de la santé, soulève d’importantes difficultés. Christopher Boorse défend une « théorie bio-statistique » qui, en articulant ce concept à une notion non normative de fonction biologique, résoudrait ces difficultés. L’identification (...) de la santé et de la normalité au sens statistique demeure toutefois centrale dans sa définition. Après avoir précisé le rôle que joue la normalité statistique dans la BST, nous dégageons, à partir de l’épidémiologie contemporaine, un certain nombre de problèmes et questions que cette définition naturaliste soulève.The liability for a naturalist definition of health and for a value-free distinction between the normal and the pathological is at the core of discussions on health and disease in philosophy of medicine. But the statistical concept of normality, a central one for any objective definition of health, raises numerous problems. Christopher Boorse argues for a « biostatistical theory » which aims at solving these difficulties by articulating a statistical concept of normality and a non-normative concept of biological function. However the BST is still based on identifying normality and health with the most frequent. After analyzing in details the true role of statistical normality in BST, I will show how results and data from modern epidemiology can be mobilized to reveal several limits and difficulties with respect to this naturalist definition of health and disease. (shrink)

Christopher Boorse’s bio-statistical theory of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, (...) it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST’s binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article’s central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology—alongside physiology—in defining health. (shrink)

In this paper, I will argue that ageing can be construed as disease. First, the concept of disease is discussed, where the distinction is made between two lines of thought, an objectivist and a subjectivist one. After determining the disease conception to be used throughout the argument, it is proposed that senescence could be seen as disease. Three common counterarguments are discussed, none of which appears strong enough to effectively counter the advocated view. In the third section, two potential implications (...) of the view advocated here will be briefly touched upon. These are the quest for a cure or treatment for ageing and the general attitude towards the elderly. It is concluded that, utilizing an objective disease concept, ageing could be seen as a disease. None of the considered counterarguments packs enough of a punch to discard this. The implications are complex and intertwined, but need not be negative. (shrink)

A number of philosophers of medicine have attempted to provide analyses of health and disease in which the role that values play in those concepts is restricted. There are three ways in which values can be restricted in the concepts of health and disease. They can be: (i) eliminated, (ii) tamed or (iii) corralled. These three approaches correspond, respectively, to the work of Boorse, Lennox, and Wakefield. The concern of each of these authors is that if unrestricted values are allowed (...) to infect our concepts of health and disease, then anything could be construed as healthy or diseased. They believe that, if at all possible, such a result should be avoided. Unfortunately, as I argue, this result is unavoidable and such attempts to limit values in these concepts are destined to fail. I argue for this position by showing how each of these three attempts to provide value-restricted analyses of health and disease fail as analyses of the concepts of health and disease and that they fail because of their attempts to restrict the role of values in their accounts. I also show how, despite their best efforts, each of these analyses are, themselves, value-driven and value-laden. This leads to the conclusion that values infect our concepts of health and disease at all levels. (shrink)