Health & Disease: Are We Making Diagnoses Without Clear Definitions?

I expected my first philosophy class to be filled with obscure words and concepts-I pictured us all sitting in a circle, debating our morals and pondering the complexity of our life choices. I was extremely relieved when our first class focused on only one word: “disease.” Our professor asked us to define disease—a task I thought would be easy—but I soon realized was quite complex. My immediate thought was that a diseased state was simply the opposite of health, but then I realized I couldn’t come up with an exact definition of health either. Like many of the students in the class, I was taken aback by my inability to define either term: as a student aspiring to work in healthcare, I never questioned my intuitions about what health and disease are. 

As it turns out, the definitions of disease and health are hotly contested topics even today. For example, people who believe that disease is simply a malfunctioning of normal bodily function are known as naturalists. Christopher Boorse, a famous naturalist, stated that for something to qualify as a disease, this normal bodily function should be important for survival and reproduction and statistically abnormal in a class of organisms (Boorse, 1976a, p. 30). Under naturalism, something like eczema would qualify as a disease: it impairs the proper functioning of the skin and is also statistically abnormal. However, having red hair does not qualify as a disease because although it is statistically abnormal, it does not impair any function necessary for survival or reproduction.

While this theory appears to line up with our intuitions at first glance, there are a few problems with naturalism. One of the main issues is with the criteria of statistically abnormal as a qualifier for disease. For instance, dental caries or cavities impair proper functioning but are not statistically abnormal (Cooper, 2002). Thus, dental caries is not a disease under naturalist theory, even though most people would believe it to be. The second problem with naturalism concerns the idea of normal bodily function and how it relates to survival and reproduction. Something such as generalized anxiety disorder could be considered evolutionarily advantageous to maintain alertness, so anxiety wouldn’t be considered an impairment of bodily function and thus not a disease (Cooper, 2002). Evidently, this perspective contradicts the many advances made in validating mental health diagnoses, which calls into question how accurate a naturalist account of disease is. 

Many critics of naturalism fall under a different school of thought known as normativism. Normativists believe that disease can be defined through the societal norms surrounding them. A famous account of normativism written by Cooper describes the criteria for disease as the following: if the condition is considered by the patient as a bad thing to have, if it is considered unlucky to have by society generally, and if it is potentially medically treatable (Cooper, 2002). Through this perspective, we can see how something like dental caries—which failed to qualify as a disease through a naturalist lens—meets the criteria for normativism. The patient definitely considers having a cavity a bad thing, society also believes dental caries to be unsuitable, and there are medical treatments for it. In this way, normativism seems promising for its ability to recognize the intersectionality between societal beliefs and health.

However, the main issue with normativism is its subjectiveness, especially around the criteria of luck. Take the case of intersex people: in Western culture, intersex people are certainly seen as unlucky; they are often outcasts and face discrimination—definitely not in a better state than others. However, this stigma does not appear in some other cultures. For example, in some parts of India, intersex people are part of a community called “hijras.” Hijras actually played a role in ancient Hinduism and are believed to possess special abilities, often blessing weddings and babies (Lal, 1999). If we follow Cooper’s claim of considering other people to be in a better state as telling of their luck, then hijras would actually be considered extremely lucky because of their special powers. The difference in perception of intersex people as being better off in Indian culture yet worse off in Western culture means that Cooper’s claim is unable to provide an absolute answer as to whether intersex people are considered lucky.

Unfortunately, the standardized global healthcare response to the intersex condition is to advocate for and perform surgeries to ensure that the genitalia corresponds with the assigned sex. In many cases, the decision to perform these surgeries, such as shaving down the clitoris, is made early on in infancy; however, these surgeries can impair sexual function, sexual pleasure, and even can cause chronic pain (Chase, 1998).  It appears that in the process of medically invasive intersex surgeries to resolve a condition that may loosely be considered unlucky to some, patients actually suffer more. The danger in utilizing Cooper’s interpretation of luck is that medical practices in the case of intersex people are being informed by an incomplete diagnosis of the condition as a disease.

Clearly, there are flaws in both naturalist and normativist perspectives. However, some philosophers suggest that these two schools of thoughts are not at the opposite ends of a spectrum-rather they can coexist in a type of matrix, as shown below. 

Through this matrix, health is seen as something that can be described based on how objective or subjective it is while comparing the value laden judgment attached to it. In this way, naturalism is seen as something both objective and independent of value while normativism is subjective and value-dependent. Broadbent argues that we can see health as a secondary property: something subjective yet also value independent. In this view, health is not something objectively right with the body (like naturalism would suggest) but it also is not value-dependent (like normativism promotes) because it does not rely on societal norms. Importantly, health is not something that can be seen but that doesn’t mean that it cannot be defined as a secondary property (Broadbent, 2019).

Although there is no definitive definition of health and disease, the lack of clarity surrounding what qualifies as a disease has greater repercussions. For example, how do insurance companies decide what conditions are diseases and thus covered compared to conditions that are not? Are these decisions based on  naturalism, normativism, or another school of thought entirely? More importantly, how do we have standardized treatment plans if there’s a dispute on whether conditions are even diseases? 

As future healthcare professionals, we often take for granted that we know what health and disease are. Taking a closer look at our own experiences and challenging our beliefs might show us that these concepts are far more complex than we imagined. Nevertheless, these are important questions to consider in order to become a more informed and competent healthcare professional. 

References: 

Boorse, C. (1976a). What a theory of mental health should be. Journal of Social Behavior, 6, 61-84

Broadbent, A. (2019). Health as a secondary property. The British Journal for the Philosophy of Science, 70(2), 609–627. https://doi.org/10.1093/bjps/axx014  

Chase, C. (1998). Surgical progress is not the answer to intersexuality. The Journal of Clinical Ethics, 9(4), 385-392. https://doi.org/10.1086/JCE199809407   

Cooper, R. (2002). Disease. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences, 33(2), 263–282. https://doi.org/10.1016/s0039-3681(02)00018-3 

Lal, V. (1999). Not This, Not That: The Hijras of India and the Cultural Politics of Sexuality. Social Text, 61, 119–140. http://www.jstor.org/stable/488683