Introducing Boorse’s Attempt at a Value Free Account of Health (Disorder, Disease, and Health, part 2)

 

“Health is not unconditionally worth promoting, nor is what is worth promoting necessarily health.” (Boorse, “On the Distinction between Disease and Illness,” p. 60)

 

“The trouble with calling physical or mental or moral excellence health is that it tends to unite under one term a value-neutral notion, freedom from disease, with the most controversial of all prescriptions—the recipe for an ideal human being.” (Boorse, “Health as a Theoretical Concept,” p. 572)

 

In this series of posts, I am exploring philosophical accounts of disease, health, and disorder. My previous post introduced the topic. In this post and the next one, I will examine Christopher Boorse’s highly-influential attempt at a naturalistic, value-free theory of health and disease. According to Boorse’s 1997 restatement of his views, he developed his theory in a single manuscript that covered physical health, mental health, and the concept of biological functions (Boorse 1997, pp. 101-102n1). He then split this manuscript into four separate papers, which appeared between 1975 and 1977. The project was partly funded by the National Institute of Mental Health (NIMH). Accordingly, in today’s post, I will treat the four papers in what I see as their underlying unity, attempting from high altitude to draw out the stakes of the project and the relevant sociohistorical context motivating Boorse’s search for a non-normative definition of health. In the next post, I will analyze in detail the actual account of health and disease as presented in the most significant paper, “Health as a Theoretical Concept” (1977). At a later date, I may discuss the 1997 “Rebuttal on Health” and Boorse’s 2014 “Second Rebuttal on Health” (link), for part of what makes Boorse so unavoidable is the care with which he responds to his critics.

 

When approaching a highly technical and abstract philosophical debate, I find it helpful to begin by considering the larger sociopolitical field from which the debate emanates. Taking ourselves back to the mid-1970s, we find a situation different but not too much so from our own. Consider the following bits of historical background:

 

·       In 1948, in its founding documents, the World Health Organization (WHO) famously defined health thus: “a state of complete physical, mental and social well-being” (p. 16). The WHO states that it is defining health “positively and broadly” and not “negatively” as absence of disease.

·       In 1960-61, the Hungarian-American psychiatrist Thomas Szasz published an article and then a book by the title The Myth of Mental Illness in which he argues that the very notion of mental illness is a kind of fiction, a metaphor without real basis used classify people society sees as problematic. The book became extraordinarily influential both in broader (and highly heterogeneous) anti-psychiatry movements of the 1960s and 1970s and among some members of the ex-patient’s movement, such as Judi Chamberlin.

·       In 1973, the Board of Trustees of the American Psychiatric Association voted, in a highly contentious and politically charged decision, to remove homosexuality from the schedule of psychiatric disorders.

 

All three of these events find discussion in Boorse’s articles. More diffusely, Boorse takes aim at what he sees as a “consensus” among philosophers of his time that health can only be defined evaluatively, that is, in terms of norms regarding what is desirable or not desirable. Although Boorse does not quite spell it out like this, one could say that, on his understanding of the evaluative theory, homosexuality ceased to be a mental disorder in 1973 because the relevant authorities no longer saw it as an undesirable condition—and not, say, because they discovered something more accurate about homosexuality. Along related lines, Boorse is also concerned about what he calls the “psychiatric turn,” or the redescription of ethical problems as psychiatric matters—the attempt to replace morals with medicine (“On the Distinction between Disease and Illness,” p. 49).

 

Viewed as a whole, Boorse’s four papers attempt to develop an objective, value-free account of the distinction between health and disease and defend the traditional negative definition of health as absence of disease. Boorse’s ultimate goal is to secure the concept of mental health from its detractors (“What a Theory of Mental Health Should Be”). His strategy is to explicate the concept of health in “physiological medicine” and “accept the implications of such use in the psychological domain” (p. 62). In short, he embraces the “medical model” (p. 62) of mental health while arguing that critics and promoters alike misunderstand this model. Health is normal species functioning, that is, statistically normal functional ability, given the functional “design” of the organism. Functional design, in turn, can be understood in the purely value-neutral terms afforded by evolutionary theory; it need not raise the specter of natural theology (i.e., “intelligent design” views) or Catholic-Thomistic moralizing about what humans are or are not supposed to do with their bodies.

 

Although I have presented the four papers as a package deal, it is worth noting that one can accept parts of the project without accepting all of it. One could, for example, accept that the concepts of health and disease do admit of objective, non-normative analysis in physiological medicine but not in psychiatry. One could likewise accept the goal of an objective analysis of disease and health while rejecting or disputing the details of Boorse’s account of biological functions. The most-tightly argued part of this project, “Health as a Theoretical Concept,” only applies to physical health and disease. The reason I have underlined Boorse’s NIMH funding and concern with the concept of mental health, however, is that they bring into view the stakes of the project.

 

What worries Boorse, I think, is the tendency in modern societies for medicine to swallow up morals and for health to be imposed as an absolute value. The problem with the WHO definition of health is that the word “health” takes over the old territory of the ethical problem of the summum bonum, the highest good. See the second quote with which I started this post: “The trouble with calling physical or mental or moral excellence health is that it tends to unite under one term a value-neutral notion, freedom from disease, with the most controversial of all prescriptions—the recipe for an ideal human being” (Boorse, “Health as a Theoretical Concept,” p. 572). Reflection on the highest good, as we find, for example, in Aristotle’s Nicomachean Ethics, requires reflection on rival conceptions of the good and argumentation as to why some goals should be preferred to others. Consider, for example, the question of the relative value of virtue, pleasure, honor, and contemplation in the Nicomachean Ethics. It is characteristic of the human ethical condition that we cannot pursue every apparently good thing, that we must make difficult decisions about what ends are worth pursuing. Calling the highest good “health” obscures this problem and makes it seem as though the problem is simply a technical or a scientific one—to be settled by medical professionals. We must choose between potentially “incompatible excellences” (p. 572).

 

Even if we reject the excesses of the WHO conception of health, Boorse’s view, I take it, is that the very fuzziness of normative conceptions of health lend themselves to the medicalization of moral and political matters, or what he calls the “psychiatric turn”: “one cannot expect to substitute psychiatry for moral debate, any more than moral evaluations can be substituted for psychiatric theory” (“On the Distinction between Disease and Illness,” p. 67). Boorse takes great pains in his four articles to point out the frank tendency of definitions of mental health from his time to conflate mental health with social conformity or conformity with sociocultural ideals.

 

By challenging the normative conception of health, Boorse also wants to challenge the view that health is inherently worth promoting: “Health is not unconditionally worth promoting, nor is what is worth promoting necessarily health” (Boorse, “On the Distinction between Disease and Illness,” p. 60). Boorse is alluding to a very old problem in ethics here, the distinction between intrinsic and instrumental values, or things that are valuable for their own sake versus things that are valuable only insofar as they help us obtain something else of value. It is a distinction that appears in the second book of Plato’s Republic and of course also in Aristotle. We run a great danger when we treat instrumental values as intrinsic values. By analogy, one could argue—many commentators have—that this is the core of Marx’s case against capitalism, that it subordinates the pursuit of intrinsic values to what can only ever be an instrumental value, the accumulation of capital, and thereby creates a state of pervasive alienation. Whether one accepts Marx’s account of capitalism or not, I think the analogy is clear enough: health, much like money, is of merely instrumental worth. But normative conceptions of health muddy this point and thus risk inducing a different kind of alienation—what later writers have called healthism (e.g., Kukla).

 

At this point, I have gone well beyond what Boorse actually says and have probably overstated his positions. What I wanted to show was that a set of ethical concerns, some more frankly stated than others, underpins the project of a value-free conception of health. If we accept these concerns about the medicalization of morals, as I think we largely (but not completely—I will come back to this) should, Boorse’s account of health offers one possible solution. But it may be possible to achieve the same goals—thwarting the confusion of medicine and morals, defending the merely instrumental worth of health—without an objective, value-free definition of health.