This is the third post in a series on philosophical debates about the nature of disease and health. I am especially interested in the ramifications of this debate for how we think about the notion of mental health. In the last post, I examined what I saw as the broader sociopolitical stakes of the debate for the chief representative of the “naturalist” or “objectivist” school of thought, Christopher Boorse. This post will summarize Boorse’s account of health, which he calls the biostatistical theory (BST). I will focus principally on “Health as a Theoretical Concept” (1977) and will not discuss his later replies to critics here.
The broad position Boorse is defending is follows: Attributions
of health are value-neutral and empirical. Whether someone is healthy or not is
an objective matter, independent of personal or social values or judgments.
This broad position is characteristic of naturalism about
health. It is worth spending a bit of time unpacking it. After all, the
aforementioned position may seem obvious, even trivial. Who ever thought
otherwise?—as Intro to Philosophy professors love to say. I go to the doctor, a
test or examination is performed, and then I am informed whether and with what
I am sick. The doctor’s values and my own may come into play in the course of
treatment, but it hardly makes sense to say that the determination that I am
sick depends on values. We might call this view “naïve naturalism.” It is
doubtless quite common.
Naïve naturalism is vulnerable along several fronts. For one
thing, what happens when the test or examination is inconclusive, fails to
yield results, or leads to differences of opinion among experts—and yet there
are still “symptoms,” whatever those may be? Indeed, this model fits mental
disorders quite poorly (but also syndromes diagnosed clinically, diagnoses of
exclusion, medically unexplained symptoms, etc.). Patients with mental
disorders sometimes demand brain scans or other physical confirmations of their
condition. These cannot be provided at present. But there is a more serious
problem with naïve naturalism, for it fails to clarify what it is about certain
test results that indicates disease or health. After all, sometimes people go
to the doctor and discover from a test that they are pregnant. Sometimes, they
discover that they have a non-pathological anatomical abnormality.
It is at this point that the appeal of anti-naturalism—of
what is commonly called “normativism” or “evaluativism” in the debate—begins to
show itself. For one might think that what makes some conditions abnormalities
or non-pathological conditions that doctors still can help with versus diseases
is that the latter are undesirable in a special kind of way. (“A special
kind of way,” of course, because some people do not desire their pregnancies.)
To borrow a distinction from a recent article by Shane Glackin, what makes a
certain constitution have the status of disease or disorder is the
additional claim that the constituted condition in question is of disvalue. In
plainer English, when we say, “John has a disease,” we are in effect saying
that something is going on biologically with John AND that whatever is going on
is BAD. Normativists branch off here along a thousand different paths depending
on what they take the locus of value-determinations to be—bad in the
eyes of society (whatever that is), bad in the eyes of the patient, bad
in the eyes of the clinician, and so on.
I should add here in passing that the contemporary debate
between naturalism and normativism often draws explicit analogies with a debate
in meta-ethics around prescriptivism,
which is the view that moral statements do more than describe—they express
prescriptions. When I say that a situation is unjust, I am not (merely)
describing a situation; according to the prescriptivists, I am doing something
in addition, such as enjoining, expressing commitments to act a certain way, etc.
Perhaps something similar holds when I attribute health or disease to someone.
Having tried to make normativism plausible, I will now
consider why it also brings discomfort. Whose values? Which values? one reasonably
wonders. And normativism seems to have some absurd consequences, such as the
consequence that I could be cured of my disease if the values in question—my society’s,
my own, and so on, depending on my brand of normativism—change. Or maybe I just
need to cross the border. And the worries I discussed in the previous post
intrude, namely, worries about the pathologization of socially marginalized
identities (consider the pathologization of homosexuality or the
psychiatrization of political dissent in the Soviet Union) and worries about the
confusion of health with moral values, with the summum bonum or eudaimonia
or the highest good for humankind.
The appeal of naturalism is that it dispenses with the potential arbitrariness of normativist accounts of disease and health. It dispenses with the fundamental problem for normativism, which is explaining why some bad things are disease and other bad things are vice, wickedness, ugliness, misfortune, and so on. But the challenge for naturalism itself is to give an account of the passage from constitution to status mentioned above. Normativists can say that what makes some constitutions have the status of disease/disorder is that they are bad, that they are disvalued. Naturalists have to find some other way to explain how some constitutions qualify as diseases or disorders.
Boorse’s solution to this challenge is to appeal to a purportedly
value-free, mind-independent concept of biological functions (“Health as a
Theoretical Concept,” pp. 554-563). Health is biological normality. Biological
normality is normal functioning. Normal functioning can be determined
empirically, without reference to values, through an account of the functional
design of a species. A value-free analysis of the concept of functions yields
the result the functions are contributions to goals. Organisms are
hierarchically organized systems of goals; from the perspective of physiology,
drawing on evolutionary theory, the goals of survival and reproduction are at
the top of this hierarchy, so the success or failure of functioning in the
parts can be determined by the contribution of those sub-systems to survival
and reproduction. For example, the function of the heart is to pump blood, not
to produce the sound of heartbeats, says Boorse. The heart can perform this
function well or poorly. Evolution, despite bringing about changes in the
long-term, yields, in the short term, something like an average species design,
which can be empirically derived through statistics—but not by purely
statistical means, since that would yield the absurd result that if everyone
had heart disease, heart disease would not be a disease. We need an account,
rather, of what normal species functioning looks like, an “empirical ideal” (p.
557). Normal species functioning would then be the ability of the given parts
of the organism to perform their functional contributions to survival and
reproduction with at least statistically typical efficiency (abnormality in the
sense of superior functioning is not disease).
To make this account plausible, a few caveats have to be
added. The proper “reference class” for determinations of health cannot
actually be the species as such. We need to take age into account. Failure to
grow is a failure of normal functioning for children but not for adults. And
likewise the reference class needs to take into account the normal changes
involved in the aging process. Sex differences must be considered. (Boorse has
nothing to say about gender, and he mentions race in passing and without much
nuance.)
Boorse has another caveat about environmental injuries (p.
567). Finally, he draws a distinction between disease and illness,
which is his way of accounting for the territory that the normativists want to
claim. Disease is value-free; illness is not. Something is an
illness if it is undesirable to its bearer (i.e., undesirable for the person who
suffers from it) and incapacitating, among several other conditions (“On the Distinction
between Disease and Illness,” p. 61). In short, Boorse captures the common
intuition that health is good, that illnesses are bad, undesirable,
by distinguishing a value-free concept of disease from a value-laden concept of
illness. This distinction allows him to argue that not all diseases are
illnesses, that diseases are not uniformly bad (think of the immunity conferred
by cowpox), that health is not always and everywhere desirable, and that
diseases should not always be treated. In this respect, health is like wealth;
we can define wealth without saying anything about its desirability or
undesirability (“On the Distinction,” p. 54).
In short, Boorse’s argument strategy turns on the claim that
there is such a thing as empirical ideals, ideals that can be used to make
important distinctions without importing value judgments into those
distinctions. The concept of health is rather like the concept of good
mechanical condition (Boorse says “perfect mechanical condition,” but I think
that is not really the point he wants to make):
“Despite appearances, ‘perfect
mechanical condition’ in, say, a 1965 Volkswagen is a descriptive notion. Such
an artifact is in perfect mechanical condition when it conforms in all respects
to the designer's detailed specifications. Normative interests play a crucial
role, of course, in the initial choice of the design. But what the Volkswagen
design actually is is an empirical matter by the time production begins.” (“On
the Distinction,” p. 59)
I think it is easy to see why Boorse’s position is so
compelling. If his arguments are sound, he has managed to free the concept of
health from the threat of arbitrariness while also explaining everything the
normativists tried to explain. He is having his cake and eating it too. To
conclude, I will simply gesture at a few difficulties in the account:
-Although Boorse does think this account applies to mental
health and disorder, and indeed develops in order to defend the concept of mental
health, it is not so clear that his position works in that realm. For Boorse to
be successful, we will need a theory of mental functions similar to the
theory of physiological functions. That may prove problematic. It is also not so
clear that mental disorders involve reductions in the organism’s ability to
perform functions related to survival and reproduction. It is quite possible
that at least some of the conditions listed in the standard diagnostic manuals,
for example, actually are associated with having more children, rather than
fewer. In any case, functional contribution to survival and reproduction seems
like the wrong standard to use. When mental health professionals speak of “functioning”
or “dysfunction,” they usually have something quite different in mind.
-The account runs the risk of vagueness. There is going to
be a lot of line-drawing involved, both as regards how we make decisions about
the relevant reference class for any individual and how we decide at what level
to set the line between species typical functioning and sub-typical
functioning. Vagueness is not inherently a problem. After all, we all mostly accept
that bald people, beards, piles of clothes, and adults exist, even if
reasonable people may disagree about exactly when five o’clock shadow passes
over into beard-ness. Physiological medicine has to deal with this issue all
the time, as when decisions have to be made about criteria for diabetes or
hypertension. The philosophical issue, I think, though, is that these
line-drawing decisions, both with respect to the delimitation of the relevant
reference class and with respect to the border between the normal and the pathological,
might end up inevitably involve reference to values. In that case, Boorse’s
naturalism would end up admitting normativism in through the back door.
I mention this second worry because I think it is also
especially relevant to discussions about mental health and disorder. Consider
the endless debates and controversies around exactly how far to extend the
spectrum in autism spectrum disorder or about the difference between the
boundaries of normal variation in attentiveness versus ADHD. Consider the
debate around the (now former) bereavement exception for major depression or
the problem of major depressive disorder, mild severity level, or the
introduction of the non-diagnostic “personality difficulty” Q-code introduced
in ICD-11 (which I discussed in one of my first posts on this blog). Or
consider the attempt over the last 25 years or so to introduce a new specialty
in psychiatry for adolescents and young adults that would sit between pediatric
psychiatry and adult psychiatry.
Or just consider for a moment the whole question of those social identities
that straddle both the biological and the social—of race and gender, but also
of age. (Cf. https://plato.stanford.edu/entries/feminism-gender/.) And what
about trans people in the Boorsian scheme? If the relevant reference class cannot be determined naturalistically,
and I doubt that it can, then Boorse is at very least in hot water.
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