Concept of disease as an ontological device to shape human existence
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.
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.
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.
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S. Sontag, (1991): Illness as Metaphor and AIDS and Its Metaphors (Paperback), Picador.
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C.E.A. Winslow, (1920):’ The untilled field of public health’, Modern Medicine, 2, pp. 183-191.