This post marks my fifth on the concept of health. Here I will look at two texts by Quill Kukla on the topic. These are not the only texts I could have selected; Kukla is dazzlingly prolific across a wide range of topics from gender to sexual violence to bioethics to philosophy of language. I have taken these two pieces as exemplary of a certain tendency in Kukla’s thinking, but my choice perhaps comes at the expense of looking at their more “applied” work.
As the title suggests, Kukla is a pragmatist. I mean two
things by this. First, Kukla draws on the philosophical tradition of American
pragmatism, classically associated with Peirce, William James, and Dewey, and
more recently revived by Rorty, Brandom, and others. It’s a complex
inheritance, to be sure, but, to simplify a great deal for my purposes here, I
think this is the main point. Pragmatists about the meaning of concepts say
that what a concept means has to do fundamentally with how we use it. If we
want to explicate the concept of health, then, we have to know what purposes we
put the concept to, what follows (practically as well as logically) from
applying it. To make sense of health, we should look at statements like
the following: “Alcoholism is a health condition, not a moral weakness.” Now,
whether or not we agree with this statement, we can understand it, and to
understand it would seem in no small part to understand what follows—what
we ought to think and do if the statement is true.
In short, for Kukla, it is not a matter of laying out necessary
and sufficient conditions for the concept of health. It is a matter of
clarifying what we do when we bring a domain of experience under the aegis of
health, so to speak, and when such a bringing-under is justified.
I will now look at the two texts in chronological order. I
will discuss in the second one in the companion post.
I. “Medicalization, ‘Normal Function,’ and the Definition
of Health” (2014)
In “Medicalization, ‘Normal Function,’ and the Definition of
Health” (2014),
Quill Kukla (writing as Rebecca Kukla)* considers the relationship between debates
about the definition of health and projects of social justice. They are
engaging here with Norman Daniels, among other bioethicists, who at one point
attempted to draw on Boorse’s value-free definition of health in order to
develop a Rawlsian argument for why health matters for social justice.
(If my memory is right—I read a lot of this material over a
decade ago in a bioethics course—Daniels worked with the Obama Administration
on the Affordable Care Act. I also recall that he later abandoned the attempt
to ground his project in a Boorsian definition of health. However, I could be
wrong about all of this, as I haven’t had time to look it up again.)
One might simply assume without argument that health matters
for social justice. But why, and to what extent? What, for example, should be
covered by an ideal universal health insurance system? And to what extent does
social justice require remediating health inequalities, perhaps by addressing
the social determinants of health? An account is needed of why it is good to
address health problems. At the same time, back behind that account, we also
need to know what a health problem is in the first place. It cannot just be
something doctors deal with, as we have already seen. There are all sorts of
limit cases one can bring up here. Kukla discusses social advantage and
disadvantage attaching to breast size or height. Kukla considers different
causes of shortness, and so on (pp. 521-22).
As Kukla sees it, the problem with both naturalism and
social constructivism about health (this is the contrast they draw, rather than
naturalism versus normativism) is that neither position explicates the
relationship between the health concept and projects of social justice. Boorse’s
naturalism is vulnerable to the sorts of objections I have already mentioned,
but, even if it were to succeed, it would leave the concept of health so
value-neutral that we would have a hard time clarifying why health matters
ethically and politically (p. 517). (Indeed, Boorse acknowledges and even wants
this consequence; he stresses that a consequence of his view is that diseases
should not always be treated or regarded as bad and that medical treatment
should sometimes be applied for conditions that are not diseases.) As for
social constructivism, or the view that some conditions and experiences come to
be medicalized through a complex social process, it makes the normative
implications of medicalization relative to a particular culture or moment, so
that we are left with the unpleasant consequence that homosexuality just was a
disease prior to 1973 and then it was not—and all that we can say about the
matter is that the terms of medicalization changed, not that we came closer
to getting things right (pp. 518-519).
For Kukla, this choice between naturalism and constructivism
is a false one. It ignores the possibility that health is an institutional
category, like “voting,” “paycheck,” or “student”:
“The existence of such things is
thoroughly dependent upon elaborate social institutions, and to be such a thing
is to be embedded in these institutions in the right way. You can’t be a
convict without a legislative, justice, and penal system. Nothing counts as a
paycheck without elaborate labor and economic institutions. And yet, things
don’t become or cease to be convicts or paychecks just because we choose to
classify or declassify them in that way. Being either one has definite
empirical consequences and preconditions.” (p. 525)
This is the pragmatism I mentioned before, although I would
add that I think treating health as an institutional category is entirely
compatible with a certain version of social constructivism. Basically, the
contention here is that concepts are governed by interlocking complexes of
practices and institutions. A certain piece of paper becomes a paycheck. It
does not become a paycheck because I or even any particular collectivity willed
it to be so. It does not cease to be a paycheck because I refuse to recognize
it as such. (This is a similar point to the one Paul Taylor makes about the
concept of race in Race: A Philosophical Introduction.)
It is important to note that we can get things right or
wrong about institutional categories. I can assert that something is a touchdown
when, in fact, it is not. But we can also meaningfully argue about what should
or should not be treated as belonging to any particular institutional category.
Games of all sorts offer great illustrations of this. As video recording
technologies change, for example, it becomes meaningful to debate the criteria governing
what makes something a touchdown. In short, Kukla can treat health as an
institutional category and also contend that some things should or should not
be regarded as health conditions—and, incidentally, “health condition” is their
more capacious concept beyond illness or disease.
Here is what Kukla concludes:
“A condition or state counts as a
health condition if and only if, given our resources and situation, it would be
best for our ‘collective’ wellbeing if it were medicalized—that is, if health
professionals and institutions played a substantial role in understanding,
identifying, managing and/or mitigating it. In turn, health is a relative
absence of health conditions (and concomitantly a relative lack of dependence
upon the institutions of medicine).” (p. 526)
In short, there is a normative bite here. Health conditions
are not just whatever our society has medicalized—whatever medical
professionals and institutions have taken over. They are what our society should
medicalize. Some things that are medicalized should perhaps not be (Kukla
gives some examples of controversial items, which I will avoid discussing here).
Some things that are not medicalized now perhaps should be. All of this depends
on the other things we can do—on our capacities, technological and
otherwise (p. 527). (There is a certain resonance here with the insights of
Kramer in Listening to Prozac: our pharmaceutical capacities modify what
we come to regard as disordered, and that is sometimes OK and sometimes not.)
Of course, the obvious problem here is that we have little
idea and even littler consensus about what is best for our collective
wellbeing. But that might be a bullet we have to bite.
Notes
*On their website, Kukla asks that their pre-2020 papers be cited this way (https://www.quillrkukla.xyz/).
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