As a part of a research project on Dignity and Older Europeans Programme) I explore in this paper a set of notions of human dignity. The general concept of dignity is introduced and characterized as a position on a value scale and it is further specified through its relations to the notions of right, respect and self-respect. I present four kinds of dignity and spell out their differences: the dignity of merit, the dignity of moral or existential stature, the dignity (...) of identity and the universal human dignity. Menschenwürde pertains to all human beings to the same extent and cannot be lost as long as the persons exist. The dignity of merit depends on social rank and position. There are many species of this kind of dignity and it is very unevenly distributed among human beings. The dignity of merit exists in degrees and it can come and go. The dignity of moral stature is the result of the moral deeds of the subject; likewise it can be reduced or lost through his or her immoral deeds. This kind of dignity is tied to the idea of a dignified character and of dignity as a virtue. The dignity of moral stature is a dignity of degree and it is also unevenly distributed. The dignity of identity is tied to the integrity of the subject's body and mind, and in many instances, although not always, also dependent on the subject's self-image. This dignity can come and go as a result of the deeds of fellow human beings and also as a result of changes in the subject's body and mind. (shrink)

Contemporary philosophy of health has been quite focused on the problem of determining the nature of the concepts of health, illness 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 atom, metal and rain are value-free and descriptive. To say that a person has a certain disease or that he or she is unhealthy is thus to objectively describe this person. On (...) the other hand it certainly does not preclude an additional evaluation of the state of affairs as undesirable or bad. The basic scientific description and the evaluation are, however, two independent matters, according to this kind of theory. Other philosophers claim that the concept of health, together with the 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. A statement that he or she is healthy does not merely imply certain scientific facts regarding the person’s body or mind but implies also a (positive) evaluation of the person’s bodily and mental state. My task in this paper will be, first, to present the two principal rival types of theories and present what I take to be the main kind of reasoning by which we could assess these theories, and second, to present a deeper characterization of the principal rival theories of health and illness. (shrink)

One INTRODUCTION 1. Background The theory of the nature of health and disease, or of the concepts of health and disease, has been central in modem ...

The basic work for this book was carried out during the spring of 1989 in Edinburgh, where I had been granted a research position at The Institute for Advanced Studies in the Humanities. I should like to express here my indebtedness to the Institute for the opportunity thus afforded me. I should also like to say how very grateful I am for the stimulating conversations I had there with Professor Timothy Sprigge and Dr. Elizabeth Telfer. Dr. Telfers’s own treatise Happiness (...) has been a major influence on my view of the questions involved. The basic view of health and illness presented in this book is more fully set out in my On the Nature of Health. As in the case of my previous larger projects, I have received a great amount of support and may wise comments from Professor Ingmar Pörn, Helsinki. Three Danish experts – Anton Aggernaes, Erik Ostenfeld and Peter Sandøe – have made valuable comments. Professor Heng ten Have, Nijmegen, has improved my reading of the philosophy of Jeremy Bentham. I should also like to thank my colleagues at the Department of Health and Society, University of Linköping, for helping me to avoid a number of the pitfalls that can so easily stumble into when it comes to a treatise like this. Especially I should like to mentioned Per-Erik Liss, Ingemar Nordin and Bo Petersson, all three of whom have read and commented on the entire manuscript. A Swedish version of this book, Livskvalitet och hälsa, came out in 1991. I have been made quite a number of corrections and additions, one type of addition being replies to critical points made in reviews of the Swedish version. I should like to thank Malcolm Forbes for valuable help putting my English into publishable condition. Linköping, May 1993 Lennart Noredenfelt. (shrink)

Discussion about a dignified death has almost exclusively been applied to palliative care and people dying of cancer. As populations are getting older in the western world and living with chronic illnesses affecting their everyday lives, it is relevant to broaden the definition of palliative care to include other groups of people. The aim of the study was to explore the views on dignity at the end of life of 12 elderly people living in two nursing homes in Sweden. A (...) hermeneutic approach was used to interpret the material, which was gathered during semi-structured interviews. A total of 39 interviews were transcribed. The analysis revealed three themes: (1) the unrecognizable body; (2) fragility and dependency; and (3) inner strength and a sense of coherence. (shrink)

This book presents a unique examination of mental illness. Though common to many mental disorders, delusions result in actions that, though perhaps rational to the individual, might seem entirely inappropriate or harmful to others. This book shows how we may better understand delusion by examining the nature of compulsion.

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 main purpose of this paper is to clarify some senses of dignity that are particularly relevant for the treatment and care of the elderly. I make a distinction between two quite different ideas of dignity, on the one hand the basic kind of dignity possessed by every human being, and on the other hand the dignity which is the result of a person's merits, whether these be inherited or achieved. Common to both these ideas is that having a dignity (...) entails having a set of rights, in the case of basic dignity the set of rights which we call human rights, the rights which the United Nations, among others, has tried to determine. The dignities of merit also provide some rights, although normally rights with limited scope covering, for instance, a professional area. This observation gives my preliminary answer to the fundamental question of what distinguishes dignity from other high values that could be attached to humans. I discuss further a kind of value that might be mistaken for a kind of dignity, viz. what I call public status. This status is to be distinguished from social status (the status of e.g. kings, governors, and officials) that I take to be a proper dignity of merit. The public status is the status gained solely via public perception and not directly via any merits on the part of the dignified. Finally, I turn to the topic of the dignity of the elderly and try to determine whether there is some dignity peculiar to the elderly, and which is over and above the basicMenschenwrde. My two preliminary proposals are the following: the elderly have a dignity of wisdom and they have a highly general dignity of merit, which results from their life-long efforts and achievements, and for this they deserve our gratitude. (shrink)

People with dementia have previously not been active participants in research, with ethical difficulties often being cited as the reason for this. A wider inclusion of people with dementia in research raises several ethical and methodological challenges. This article adds to the emerging debate by reflecting on the ethical and methodological issues raised during an interview study involving people with dementia and their spouses. The study sought to explore the impact of living with dementia. We argue that there is support (...) for the inclusion of people with dementia in research and that the benefits of participation usually far outweigh the risks, particularly when a `safe context' has been created. The role of gatekeepers as potentially responsible for excluding people with dementia needs further consideration, with particular reference to the appropriateness of viewing consent as a primarily cognitive, universalistic and exclusionary event as opposed to a more particularistic, inclusive and context relevant process. (shrink)

This paper constitutes a defence of the basic philosophical enterprise of characterising concepts such as disease and health, as well as other medical concepts. I argue that these concepts play important roles, not only in medical, but also in other scientific and social contexts. In particular, medical decisions about health and diseasehood have important ethical, social and economic consequences. The role played is, however, not always a rational one. But the greater is the need for a reconstruction of this network (...) of concepts for the purpose of efficient and rational communication. (shrink)

Bengt Brülde in his article ``The Goals of Medicine. Towards a Unified Theory'' has proposed a normative theory of the goals of medicine within which the concept of quality of life plays a crucial role. In Brülde's analysis, however, the very concept of medicine is deliberately left quite vague and it is therefore difficult to see how the goals of medicine are related to the goals of closely allied enterprises such as health promotion and social welfare. In this reply I (...) therefore propose an analysis of these related conceptual areas. I do this mainly in two respects. Following the nomenclature in a previously published article I propose a systematic conceptual framework for all varieties of health enhancement and distinguish different notions of medicine within this framework. A consequence of this analysis is, for instance, that the means and also the immediate goals of medicine in its broadest sense are more diversified than the means and immediate goals of medicine in its narrowest sense. From this position I expand the topic further by comparing medicine and health enhancement with social welfare and try to trace the basic features between – as well as the common properties of – these different enterprises. (shrink)

This paper constitutes a defence of the basic philosophical enterprise of characterising concepts such as 'disease' and 'health', as well as other medical concepts. I argue that these concepts play important roles, not only in medical, but also in other scientific and social contexts. In particular, medical decisions about health and diseasehood have important ethical, social and economic consequences. The role played is, however, not always a rational one. But the greater is the need for a reconstruction of this network (...) of concepts for the purpose of efficient and rational communication. (shrink)

This paper contains an attempt at constructing a semantic framework for the field of health enhancement. The latter is here conceived as an extremely general category covering the whole area of health care and health promotion. With this framework as a basis I attempt to define the place of medicine within the enterprise of health enhancement. I finally indicate some normative issues for the future, in particular problems and possible developments for medicine as a species of health enhancement.

This paper contains an attempt at constructing a semantic framework for the field of health enhancement. The latter is here conceived as an extremely general category covering the whole area of health care and health promotion. With this framework as a basis I attempt to define the place of medicine within the enterprise of health enhancement. I finally indicate some normative issues for the future, in particular problems and possible developments for medicine as a species of health enhancement.

A great number of constructive suggestions for the analysis of the concepts and models treated are presented in this book, which mirrors a current debate within the theory of medicine by covering three central topics: the concepts of health and disease; definition and classification in medicine; and causal explanation in medicine. Among the issues dealt with are: How should the concepts of health and disease be characterized in order to be of relevance to clinical practice? Should we try to define (...) particular diseases in explicit terms? What should be the criteria for selecting causes when explaining disease or death? These problems are treated from various points of view, the contributors being drawn from the fields of clinical medicine, epidemiology, psychiatry, social medicine, philosophy, and history of medicine. (shrink)

This book is a scholarly treatise on the nature of health presented in the form of a dialogue between an inquirer and a philosopher. It attempts to do two things: first, to introduce modern philosophy of health to non-philosophers, in particular to people with a professional relation to health care; and second, to elaborate and specify in some detail the author's holistic theory of health. According to this theory, a person is completely healthy if, and only if, she or he (...) is able to realize all her or his vital goals given reasonable circumstances. This theory is presented by the philosopher in the book, but it is at the same time scrutinized and criticized by the inquirer. Some of the criticisms presented, and to which the philosopher responds, have been put forward in published reviews of the author's earlier works. Towards the end of the book the author demonstrates how his philosophy of health can be applied to related areas, such as the theory of disability, and to modern ethical discussion, such as that concerning prioritization in health care. The book is supplemented with a list of definitions of central concepts and with an annotated bibliography. (shrink)

This article is a reply to Venkatapuram's critique in his article Health, Vital Goals, Capabilities, this volume. I take issue mainly with three critical points put forward by Venkatapuram with regard to my theory of health. (1) I deny that the contents of my vital goals are relative to each community or context, as Venkatapuram claims. There is no conceptual connection at all between standard circumstances and vital goals, as I understand these concepts. (2) Venkatapuram notes that I stop short (...) of filling the framework of vital goals with any content and thereby make my concept of health less concrete. I reply that some vital goals are indeed universal, viz. the ones which are necessary conditions for survival. Many other vital goals are individual and cannot therefore be included in a universal list. (3) Venkatapuram claims that my definition of vital goals is too broad, since it entails that some persons without any disease can be regarded as ill. However, in my understanding health is a relational concept from a state of complete health to a state of maximal illness. In this framework, a minor reduction of a state of complete health does not entail illness. This article also contains a comparison between my theory of health and Martha Nussbaum's theory of capabilities for dignity. (shrink)

This book contains scholarly contributions to several current debates in the philosophy of medicine and health care regarding the nature of health and health promotion, concepts and measurements of mental illness, phenomenological conceptions of health and illness, allocation of health care resources, criteria for proper medical science, the clinical meeting, and ethical constraints in such a meeting.With one exception, the authors in this book are or have been teachers or graduate students at the interdisciplinary Department of Health and Society at (...) Linköping University, Sweden. While all the texts have a philosophical focus, many other disciplines have influenced the choice of specific perspectives. The university backgrounds of the authors range from medicine, psychology, sociology, and religion to philosophy. What binds the authors together is their deep interest in the theory of medicine and in the pursuit of a philosophy of humanistic medicine and health care. (shrink)

In this article I provide an analysis of some salient concepts of dignity. The text is a development of a work which was initiated in the year 2000 in the research programme Dignity and Older Europeans supported by the European Union. The programme was both theoretical and empirical. The empirical part, which was the most comprehensive, consisted of focus-group interviews with health care and social care personnel, elderly persons within health care or social care, and representatives from the general public. (...) The interviews concerned the care of the elderly and attitudes towards the elderly. Some questions concerned how the interviewees conceived the concept of dignity and what they meant by behaviour respectful of dignity in the care of the elderly. Altogether around 1000 focus-group interviews were conducted in seven of the countries involved. The theoretical part of the programme consisted of an analysis of the concepts of dignity based on studies of dictionary entries in six languages as well as previous philosophical analyses of the concept. In the theoretical part of the study there emerged four different concepts of dignity: dignity of merit, dignity of moral standing, dignity of identity and human dignity. Characterizations of these concepts have been presented and developed in several publications, for example Nordenfelt and. In the present article this analysis is taken a step further. I take as a starting point some previous studies, including Schroeder, Sulmasy and my earlier ones, and propose an improvement and clarification of my earlier classification of dignities. At the same time I enlarge the analysis to concern worths in general and how these are attached to entities in general, not just human beings. The four kinds of dignities which I now propose are called: attributed dignity, dignity of inflorescence, dignity of identity and human dignity. (shrink)

This article provides a deeper understanding of how meaning can be created in everyday life at a nursing home. It is based on a primary study concerning dignity involving 12 older people living in two nursing homes in Sweden. A secondary analysis was carried out on data obtained from three of the primary participants interviewed over a period of time (18—24 months), with a total of 12 interviews carried out using an inductive hermeneutic approach. The study reveals that sources of (...) meaning were created by having a sense of: physical capability, cognitive capability, being needed, and belonging. Meaning was created through inner dialogue, communication and relationships with others. A second finding is that the experience of meaning can sometimes be hard to realize. (shrink)

This paper contains a brief comparative analysis of some philosophical and scientific discourses on human and animal health and welfare, focusing mainly on the welfare of sentient animals. The paper sets forth two kinds of proposals for the analysis of animal welfare which do not appear in the contemporary philosophical discussion of human welfare, viz. the coping theory of welfare and the theory of welfare in terms of natural behaviour. These proposals are scrutinized in the light of some similar theories (...) dealing with human health and quality of life. My conclusion is that the coping theory and the natural behaviour theory are not in themselves adequate for the characterization of welfare, either for humans or for sentient animals. I contend, finally, that, in the light of the previous discussion, there are good arguments for a particular set of analyses of both animal and human welfare, viz. the ones that are based on the notions of preference satisfaction and positive subjective experiences. (shrink)

In this article I respond to Björn Hofmann’s criticism of some elements in my theory of health. Hofmann’s main objective is to question “Nordenfelt’s basic premise that you can be ill without having negative first-person experiences, and to investigate the consequences of abandoning the premise.” One of Hofmann’s critical points is that my theory of health does not lend voice to the individual. My response is essentially conducted in four steps: (1) I question the aim of conceptual analysis that Hofmann (...) proposes for the analysis of the notion of health. (2) I maintain that my analysis, in spite of Hofmann’s contention, lends voice to the individual. It does so via my notion of subjective illness but also via my notion of vital goal. (3) I argue that conditions, such as coma, paralysis and mania are salient instances of ill health and that these may become neglected if the use of the terms “ill” and “illness” is restricted to instances where negative subjective experiences are present. (4) I rehearse my main arguments for selecting disability as the core element of ill health and respond to Hofmann’s contention that persons who are in great pain can sometimes nevertheless perform perfectly. (shrink)

In this paper I focus on the topic of chronic illness in the context of quality of life. I offer a conceptual explanation of these notions and then try to systematise the various species of suffering connected with chronic illness. Suffering in illness rarely attracts systematic analysis. Part of the reason for this is that the topic is in a way an aspect of common sense. It has an air of self-evidence and seems not to require analysis. However, it is (...) my contention that the nature of human suffering is not at all selfevident. In many ways we know very little about the content and extent of suffering. And, although it may not be sensible to borrow traditional scientific techniques for the study of suffering, we need as much intellectual penetration and rigorous analysis in order to clarify the nature of suffering as for any other scientific investigation. Moreover, there are good reasons for saying that we ought to direct much more of our attention to this humanistic aspect of medicine. We ought to remember that the existence of suffering is one of the main motives, if indeed not the most important motive, for undertaking the medical enterprise. (shrink)

This paper is a reply to an article by Steven Edwards in a previous issue of Theoretical Medicine and Bioethics. In this paper Edwards discusses two types of problems which he finds to be inherent in my theory of disability, mainly as presented in my On the Nature of Health, Kluwer 1995. First, Edwards discerns a tension in my basic definition of health, a tension between my “subjectivistic” and my “objectivistic” aspirations in the definition. Second, he finds that my theory (...) of disability does not allow for a distinction between disability due to illness or injury and disability which has no such (at least not immediate) background. In my answer to Edwards's arguments I claim that his first criticism must be due to a misunderstanding of my intentions. I find his second criticism to be more to the point. It raises important issues in the theory of health which partly concern our interpretation of the notion of illness. Edwards introduces the notion of capacity in order to separate between disability due to illness or injury and disability without such a background. In the last part of my paper I argue that this distinction, however, will not fulfil its purpose. (shrink)

Marcus Tullius Cicero, the great promoter of Greek thought to the Latin world, gives a very detailed presentation of the Stoic philosophy of mind and of mental disorder in his Tusculan Disputations. In an interesting way, this philosophy anticipates the modern philosophical theories of affections or emotions developed by, for instance, R.M. Gordon, which are based on the concepts of belief and desire. According to Cicero, having an affection is the same as having a belief about something which one considers (...) to be good or evil, either in the present or in the future. Cicero develops these ideas about affections within the context of a theory of mental disorder, claiming that all but the mildest affections are in fact species of mental disorder. This paper summarizes Cicero's theory of affection and disorder and indicates its relations to modern thinking in the philosophy of emotion and mental health. (shrink)

This commentary on Sadegh-Zadeh's article 'Fuzzy health, illness and disease,' has its focus on the philosophical background for applying fuzzy logic to medical theory. I concentrate on four issues. First, I contest some of Sadegh-Zadeh's statements on the present state of the theory of medicine, in particular with regard to assumptions ascribed to contemporary theorists. Second, I consider Sadegh-Zadeh's interesting idea that a person can have a disease to varying degrees, from not having it at all to having it completely. (...) I argue that there are difficulties pertaining to the definition of particular diseases, which obstruct the application of this idea. The following two points concern medical semantics and principles for definition in general. I take issue with Sadegh-Zadeh's description of the correct procedure for definition. I also contest his unconditional proposal for a social definition of health, illness and disease. (shrink)