Concept of disease as an ontological device to shape human existence
Andres Soosaar
Department of Public Health,
Abstract: Disease and health are conceptual
cornerstones of the framework of all medicine. In different times these
concepts have had different contents, but in all times their role has also been
to express some status of personal human existence and shape its general and
particular forms of individual and collective forms through different wanted or
avoided scenarios of human behavior. A long term solo of biological
reductionism has strengthened the concept of disease as a tool to differentiate
normal and abnormal structure and behavior of human beings. Current symbiosis
of biological reductionism with the trend of stronger social regulation can
rewrite the content of the concept of disease in direction to increase of
external determinism of personal human existence. Philosophical analysis of the
concept of disease can support coherence in the heterogeneous ideological
framework of medicine and help to bind technical side of medicine with
appropriate values.
Introduction
Through all its history medicine has been much more about disease, only
last decades have remarkably changed the social focus from disease to health.
Medicine and physicians have been to deal with abnormal and unwanted human
existence to turn it back to normal or at least better condition. Despite of
long history of hygiene, only now health sciences with different branches and
practices have been massively created and they become to flourish and increase
their influence in all human life. An obvious tendency of modern medicine is its
permanently increasing socialization. It was started with the socialization of
disease from personal feeling or body status to complicated networks of
knowledge, attitudes and interventions of human existence and functioning in
society. This development has turned the conceptual relationship between
disease and health more and more complicated by nature and content. A long lasting
tradition to understand this relationship has been a sharp distinction between
health and disease on the basis of certain estimation and application of some
condition of normality. According to this line of thinking health is taken as
lack of disease or health and disease are conditions with different qualitative
character. In a more quantitative way one can hold that health and disease are
in inverse proportional relationship which means that a person has a constant
amount of health and disease or if there is less disease, the amount of health
is respectively bigger. As mentioned, we
see today strong socialization of content of the concept of health which means
that health is not limited to individual personal human existence, but rather
to be expanded to different connected networks of social activities. These two topics, i.e. quality-quantity issue
in health-disease relationship and social determinism, in the conceptual
development tend also to produce heterogeneities both in the areas of disease
and health. The first issue that health is lack of disease has produced demand
to differentiate and classify numerous abnormal conditions. From other side different
social networks related to health have supported position that health by itself
is also more complicated phenomenon as a simple unified status of wellbeing. Health
and disease are also concepts which promote and reflect simultaneously human
experience and cognitive development. Diseases are very much to do with human
experience in the real social context. Susan Sontag (2001) described numerous
verbal canvases where diseases or rather labels of them (diagnoses) as
metaphors have governed differently sized social groups and whole societies. Usually
these influential labels have got their power over persons and social groups when
people haven’t control over a poor status of human existence or disease.
Diseases loose very much about their metaphorical power if some rational
explanations can get control over them. In philosophy the cognitive development
approach has been developed by Paul Thagard (1997). He stresses just conceptual
development of disease as important label of progress of medicine.
So or otherwise, our entire intellectual development has shown that
health and disease are highly complex concepts with relatively rigid borders
and highly changing and dynamic contents. Despite of their remarkable
heterogeneity and large coverage area of reality, they still work well and unify
efficiently some set of aspects of human
existence.
Properties of the concept of disease
Philosophy is very much about concepts and at the same time there is no
agreement in philosophy how to deal with concepts (Margolis and Laurence,
2006). Numerous different understandings and attitudes about concepts are
lurking around in philosophical minds, respectively those concepts are doing
different job in philosophical research. Situation is especially complicated
with these fundamental concepts which comprise basement of personal or
collective worldview. The concepts of health and disease, I suppose, are in
that sense much easier to manage and put into ontological framework, they have
clear origin from concrete mental and bodily phenomena of a concrete person.
Pain and different feelings of disability have served as an initial impulse to
interact with a suffering person and this interaction has served as permanent
chance to form the understanding of disease and health afterwards. Yes, it is
truly difficult to estimate the exact timing of
birth of health and disease concept, but their coming from the very
everyday life experience seems to be
obvious. Later on, the development of these concepts has been quite well mapped
within history of medicine. At least long time, if completely at all, health
and disease have not been a priori concepts, as it is so typical with some philosophical
concepts. In modern times they are rather in a way generalizations of
reflections on results of empirical research in medicine to turn all
theoretical issues in medicine as coherent as possible to a therapeutically
acting framework of medicine. Specificities and contents in medical conceptual
generalizations are certainly important to differentiate modern scientific
medicine from other alternative and/or more traditional practices of medicine.
Despite of both big differences in theory and practice, vast majority of all
sorts of medicine have in their basic arsenal the concept of disease, and
health, I suppose, too. Such
universality clearly refers to basic nature of these concepts in different
types of medicine and also connects medicine quite strongly to the more general
issue of human existence.
Let me limit my reasoning about the concept of disease here with
scientific medicine which I’m more familiar of and in this paper a concept is
for me a part of mental space which grasps into functioning entity some
phenomenon in mind-reality framework or interface. Someone can ask are health and disease
philosophical concepts at all? My answer is ‘yes’ because at least (i) they are
general, complex, and ontological enough to find place in philosophical work of
conceptual analysis; (ii) they may serve as good examples to apply general
principles of philosophical concept management on some basic entities of an
empirical field, i.e. medicine; (iii) their internal development can in turn
contribute as the case to find some better way to explain theoretically what
concept can be. According to John Searle (1999) there is some division of labor
between philosophical and scientific questions. Philosophical questions are
about big frameworks which we don’t know how to answer systematically, but
after some level of coherence questions about the framework become scientific
problems with their own style and methods to solve. The Searlian approach seems
to work well also in our case of fundamental concepts of medicine.
Important features of concepts are their flexibility, arbitrariness, and
relative character which give to personal and social minds possibility to
change their positions and also take under scope different combinations of
entities and their properties. Along these features the concept of disease has
differently managed basis for some forms of generally unwanted human existence
through history of medicine and despite of numerous attempts we certainly do
not have final formulations of health and disease concepts yet. Only some
decades back some and influential steps to change concepts of health and
disease were done. At first I mean here the World Health Organization
definition of health as “health is a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity” (1946)
and the George L. Engel’s proposal for biopsychosocial model of disease and medicine
(1977). Both these proposals are very much reactions to apparent incompleteness
of purely biological concepts of disease which since the 18th century
have been obtaining more and more dominating position in thinking about
medicine and diseases. Certainly there are several reasons for such
antireductionistic shift at the moment, but complexity of human existence and
independence of this complexity from real structure of a bit stochastic human
intellectual development are again among important reasons of more recent
attempts to change concepts of health and disease. Just in this point it is suitable to claim
that fundamental medical concepts have very much to do with general features of
human existence and its conceptual mapping. These two areas seem to be in
productive mutually interactive relationship which may produce and explain changes
in current concepts of health and disease.
Complexity is a thing which has often bothered human mind and cognition
and a way to avoid or simplify it is to bind or rather reduce a complex
phenomenon in the question to the issue better understood or managed.
Conceptual history of medicine and disease have shown well how certain issue or
dimension has held dominance over other aspects of the whole conceptual
territory of health and disease. At the
same time these basic medical concepts have an obvious feature to be very
practical ones in a sense that their real content has great influence on
thinking and behavior of both medical people and patients. Theoretical and
practical aspects are connected, if disease is taken as an ontological pattern
to bind together some material situation, mental setting and behavioral outcome
in a way that behavior can in turn change existing state of affairs both in the
body-environment interface and mind of a diseased person.
A structure of the concept of
disease
Let us mention here and now some of these different dominants or
dimensions in the concept of disease through different times, but especially
more recent developments of scientific medicine and their connections to the
human existence issue. Through times there have been two different strategies
to understand the health-disease dichotomy of human existence: the first one
deals with ontology with more indicative character or search for independent
measures of pathological existence, another deals with axiology with more
subjunctive character or to search for human behavior how things should be. In
western analytical tradition it is very common to decompose, analyze and purify
parts of whatever composition and the same approach has been used in majority
of different analyses of health and disease. Another typical feature of western
mindset is to reduce, stratify or make sharp difference within a complex issue
to primary, basic or fundamental things and secondary or accompanying things.
The same style is widely followed in discussions about health and disease.
Remember here only the influential work of Boorse (1977) which tried to oppose
value-laden and value-free (statistical biological) explanations of disease.
Despite of an attempt, Boorse could not do that in efficient way to the
complete end and some maneuvers were taken to save general charm and utility of
the health and disease concepts. My approach in this work is much more
synthetic. No question, the useful thing is to analyze and map the concepts of
health and disease, but why not to save and support the complex nature of
health and disease which in turn makes more space and possibilities to human
beings to exist in different sociobiological environments. In my opinion there is no real need to play human
independent ontologies and human values against each other, I would combine
them rather more to be better managed by human mind and knowledge.
For the next, I try to describe some positions from different sectors or
levels of human reality on disease both in direction of values and missing them
which, I hope, can contribute to the whole content of the concept of disease. The areas of human reality, taken into account
here, are traditional personal and social realms of human existence which we
are very much ready to accept and follow. Despite of numerous theoretical and
empirical attempts to simplify personal existence to unified grounds, it still
holds clear distinction of body and mind which also has crucial importance for
medicine and its internal development. Despite of some important skills and authority,
abilities of personal mind (sic!) to recognize and rule directly its unified
kingdom of a person are still quite limited which is again an important (pre)condition for
medical activities. This consideration may have some paradoxical sound in the
context of medicine. Some usual attitude is that the healthy human being is a
creature with high potential and diseases can reduce that potential to various
limitations with different grade. Human
beings have invented ways to get over given natural mental limitations via different
types of social reflections and interactions using common formats for
experience. Medicine has been an important area in this enterprise, it has
revealed an increasing variety of more as naturally limited situations of human
existence and has found tools and ways to turn many of those conditions back to
usual or normal or wanted condition. Thus medicine has been and will be very
much about structure and functioning of human organism and possibilities to
steer it. At the some basic ontological level the way of existence which we
call biological is in modern times taken as any other form of bodily existence.
In fact that existence has not any norms or values derived from norms. All ways
and scenarios of that existence which are possible happen may happen by itself,
i.e. in accordance of its structure and governing principles. Someone may
oppose to that position saying that it is possible to think about the preferred
scenarios of life which are based on duration and maintenance of biological
existence. Yes, why not, but age and survival of a living creature are rather
results of appropriate selection among possibilities and not results of having
very special or unique ontological processes per se. Questions is much more in
organization of processes than in some critical processes themselves. Thinking
about modern medicine, it is taking more and more aggressive character to
perform these needed selections, especially with the structure of the organism,
to shape human existence in a certain way. An important step of this
development is connected to possibilities to intrude into genetic setup of
cells which has potential to remove completely from the playground so called “the
natural course of biological events” and open many new possibilities to redesign
almost all forms of biological existence. In the context of the concept disease
just mentioned huge increase of genetic and cellular freedom is challenging the
existing understanding and classification of diseases as deviation from certain
normal or natural condition. Temple et al. (2001) have predicted necessary
changes in the concept of disease in the genomic era. They stress that instead
of really existing labels of any disease, the risk to get any disease or
potentiality of certain form of existence will take priority in defining of
disease. Current situation is truly such that understanding of biological
structure is deeply changing both in details of structure and directions of
being, but medicine and society as whole tend to hold the landscape of diseases
which is based on more coarse-grained structure or integrity of the human
organism. An increasing conflict between knowledge based conjectures and
existing social reality can promote changes in current understanding of
disease, health and medicine in general. Such shift has very much to do with
modality issue in theoretical and more applied philosophy to fill these
modalities with some rational and teleological content. Medicine has very much
been a field of causal relations and current rise of modality issue can change
the existing positions of causation in medicine. A classical approach of
causation in medicine has long time been the idea that diseases are some
arbitrary endpoints of causal chains or rather networks (pathogenesis) from
certain initial state of affairs (etiological factor- diseased organism
interaction) and sharp differentiation of external and internal aspects of
pathogenesis . This approach as the framework seems to be good also today, but
causal connections within a framework of a disease tend to get more complicated
form with different types of causal connections without strong self-limitation
to one-way rigid determinism. As everywhere, causality and understanding of it
serve also medicine with rational basis of behavior to treat diseases.
Despite of great importance of rapid and long term personal conscious
experience in medicine in all times, modern medicine has remarkably changed
traditional attitudes to the role of personal conscious mind in medical theory
and practice. The increasingly fine-grained knowledge of human body structure
and functioning has decreased the role of the patient’s mind and its contents
in medical decision making process. Yes, some contents of consciousness (pain,
certain sensory images etc) strongly initiate some behavior towards diseases
and medicine, but medical people tend to trust less these contents in their
professional activities and believe more in results of different objective
physical and chemical diagnostic methods and devices. At the same time modern
definitions of health as the status of complete personal well-being are mostly
based some satisfying mental condition which may vary in great extent from
person to person. So we see an interesting trend in relations between
subjectivity and health-disease dichotomy. If earlier disease had somehow more
subjective character and health rather objective status, then now things tend
to be in the opposite way.
Changes in subjectivity about health and disease and some bigger
appearance of modality conditions can among other things increase the role of
values as arbitrary rules to follow one or another track among possible worlds
of different medical conditions in which laws of nature perfectly hold. The
arbitrariness just mentioned above has its own limits in social reality which
may or may not differ so much in physical conditions, but scale of social
conditions may vary a lot. These changes in subjectivity and ontological modality
can support justifications of medical ethics principles, especially from
personal point of view. Modern medical ethics is very much as a sort of external
social regulation and a justified personal value perspective helps to soften
rigidity of regulatory medical ethics which by itself supported by general
regulatory mania of modern biomedicine. At the same time modern medical ethics
is very much about autonomy of a patient or research subject which can
certainly highly prioritize and support the subjective and pluralistic approach
to well-being and respectively to health both in general and in concrete cases.
The 20th century raised very much also social involvement
into medicine. If before that medicine were more activity of and between
individual persons (traditionally two), then now it has become more and more to
permanent but changing relationship between a patient and different social
groups or to put it more radically, the patient should be during one case in
numerous different social associations of medicine. Societies gave a great deal
of autonomy to medical professionals to do medicine according their best
understandings and they carry both success and risks of different medical
treatments. According to this rather classical line, the concepts of disease
and health had also personal ontological status among medicals professionals as
authorities to patients, despite of possibility of a society to change
immediate environment around members of this society.
An interesting development in conceptual development of health has been
the birth of public health. There is no such thing as a public disease yet, but
public health is well organized and increasingly influential part of modern
medicine. Charles-Edward Amory Winslow defined the public health in 1920 as "
the science and art of preventing disease, prolonging life and promoting health
and efficiency through organized community effort for the sanitation of the
environment, the control of communicable infections, the education of the
individual in personal hygiene, the organization of medical and nursing
services for the early diagnosis and preventive treatment of disease, and for
the development of the social machinery to insure everyone a standard of living
adequate for the maintenance of health, so organizing these benefits as to
enable every citizen to realize his birthright of health and longevity."
Without getting into deeper comparative analysis of concepts of personal and
public health, they obviously cover different parts of reality which have
connections or overlapping zones, but so or otherwise public health in this
definition is not personal well-being itself and rather serves to this
well-being. Public health is rather oriented set of activities in society to
decrease possibility or avoid completely appearance such forms of personal
human existence which we may call diseases or illnesses. It is also not a summarizing
estimation or description of members’ health of one or another social group
which is better to call the population health or some sort of integrative
epidemiology. The population health has
turned into broad area of quantitative analysis and different studies to
describe and compare different social groups on the basis of different
quantitative statistical labels are performed published in impressively big
amounts all over the world. Often these studies try to say that some societies
are healthier than others and various rankings and top listings are common
expressions of such social health. It is quite difficult and problematic to
take identically personal and social health. They are connected, but not the
same thing by essence. The possibility to unify personal and social health into
one bigger concept seem to need some new arbitrariness or metaphoric
creativity, but still the concept of disease has central place to manage in
medicine and different concepts of health have some secondary position as some
reference status in medical reasoning.
Concluding remarks
The conclusion of this story is the conviction that the concept of
disease is most of all a social instrument to influence or rather shape the
human existence in general and especially in situations where autonomy and
self-confidence of the human being to exist independently are under suspicion.
Real status of medicine should give limits to manage with these situations, but
values and real social circumstances usually determine to what extent possibilities
of medicine will be realized in every concrete case. Has that existence shaping
activity any direction? Two or three possible goals are easy to see – social
amplification of positive emotions of every member of society, stability of a
society itself, and the change of social/biological ratio in human existence in
advantage of social circumstances.
References
C. Boorse, (1977): ‘Health as a Theoretical Concept’, Philosophy of
Science, 44, pp. 542-573.
G.L. Engel, (1977): ‘The Need for a New Medical Model: A Challenge for
Biomedicine’, Science, 196, pp. 129-135.
E. Margolis,
J. Searle, (1999):’The
future of philosophy’, Philosophical Transactions of the Royal Society London (B), 254, pp.
2069-2080.
S. Sontag, (1991): Illness
as Metaphor and AIDS and Its Metaphors (Paperback), Picador.
P. Thagard, (1997): ‘The Concept of Disease: Structure and Change’, Communication and Cognition, 29, pp. 445 - 478.
C.E.A. Winslow, (1920):’ The untilled field of public health’, Modern
Medicine, 2, pp. 183-191.