Abstract
This paper seeks to develop a theory of health that aligns with the shift in contemporary medical practice and research toward a temporally extended epidemiological view of health. The paper describes how such a theory is at the core of life course based approaches to health, and finds theoretical grounding in recent work in the philosophy of biology promulgating a process theory of life.
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This paper does not analyze the terms of health and disease (as Boorse’s BST attempts), rather, as Lemoine (2015) suggests, it offers a theoretical understanding of what health is, as it emerges from a particular scientific research program, and refines it based on a view in theoretical biology (for further discussion of this “naturalistic turn” see Sholl & Okholm, 2021). A prime example of this “bottom up” approach, taking research in aging as its starting point, was recently offered by Sholl (2021) in this journal. The present paper, though developed too early to fully benefit from his insights, comes to conclusions that are in many ways parallel, and hopefully it can be read in dialogue with his general approach and call to “let a thousand theories bloom” (p.44).
Giroux (2015) notes that Schwartz mistakenly conflates a physiological marker or indicator with the function/dysfunction itself.
Other examples of disease precursor risk factors not discussed by Schwartz might include certain precancerous lesions or polyps. As with stage 1 hypertension and high cholesterol, the preventative treatment for these may be similar or identical to treatments for the actual disease states such as excising potentially cancerous growths.
Schwartz’s neglect of Boorse’s own attempt to explain preventative treatment is perplexing.
To be clear, at a theoretical level the BST will make use of longitudinal measures in order to determine what counts as a significant loss of functional efficiency. A cross sectional survey of a population will only reveal the distribution of a given measure of functional efficiency; it will not tell you what level of loss of efficiency actually results in a loss of biological fitness in terms of survival or reproductive success (Boorse takes these to be the primary goals that organisms have evolved to accomplish); for this, longitudinal data is needed.
LCE and LCHD can be viewed as parallel research clusters (the former centered in the UK, the latter in the USA) but a full discussion of how they intersect and differ is beyond the scope of this article. A textbook framing the LCE approach to chronic disease was published in 1997 (Kuh & Ben-Shlomo, 1997) and a highly-cited article describing the emerging research program was published in 2002 (Ben-Shlomo & Kuh, 2002). That same year the LCHD cluster published its own programmatic outline (Halfon & Hochstein, 2002) and about fifteen years later each group sought to consolidate the state of the field and vision for the future of the research program; for LCE, a special issue of the International Journal of Epidemiology (Volume 45, Issue 4, 2016) and for LCHD an edited volume (Halfon et al. 2018). I focus more on LCHD due to the degree of conceptual framing it offers.
This image of an emerging state of constant health surveillance and risk assessment is, to say the least, problematic, but the subject for a different discussion.
Morgan argues that one can arrive at a similar view proceeding from substance ontology, in which living systems are likewise “temporally extended, dynamic, ecologically dependent, and have vague boundaries” (Morgan, 2021, p. 13). Although he convincingly shows that advocates of process ontology overstate the inflexibility of various explications of substance ontology and the intractability of attendant metaphysical puzzles, none of this undermines what I understand to be their central claim, that ‘process’ is a better fit for characterizing the essential nature of living organisms. Indeed, to a large extent, what contemporary process ontology attempts to counter is not a sophisticated version of substance ontology, but a ‘folk’ substance ontology that carried over into the life sciences from other scientific domains. Such ontological presuppositions can profoundly change how one characterizes, for example, ‘development’ (Fabris, 2018). For present purposes the more salient consideration is what ontological claims are reflected in the relevant biomedical theories and frameworks. Here, the life course frameworks are marked by a shift toward an underlying processual understanding of the organism and health. Still I am sympathetic to modesty when it comes to claims about what really exists, and for those so inclined, Pradeu argues that the processual view ought to be understood as an epistemological viewpoint while remaining agnostic on ontology (Pradeu, 2018).
Morar and Skorburg (2018), while not proceeding from a processual view, offer a similar rejection of strict individuation (in part based on the integral importance of the microbiome) and explore the implications of their theory of “extended health”. The implications of the microbiome for our understanding of health has also been addressed by Inkpen (2019).
Schwartz struggles with some of the counterintuitive implications of the definition of a disease changing based on changes to the reference class over time. Compared to traditional hunter‐gatherer societies everyone today is at higher risk of cardiovascular disease, but we would not want to say that nearly everyone harbors a dysfunction and therefore is diseased (2008, p. 328). This problem is easily avoided once we conceptualize health beyond the mere absence of disease and can talk about relative states of healthy and less healthy. This, along with other considerations motivates Schroeder’s (2013) argument that health is a comparative concept, which is fully compatible with the theory of health I describe here.
As a reviewer noted, the definition offered by Fabris as maintenance of a “single, fixed steady state” does not reflect how homeostasis is described in the literature, particularly given that many biological systems can function well within a certain range of values (Kotas & Medzhitov, 2015). However, the intent, per Fabris’s understanding of Waddington, is to capture how an organism maintains stability through a developmental course that exhibits a great deal of plasticity.
Both Ananth and Dussault and Gagne´-Julien, without emphasizing a shift in the locus of analysis, similarly turn from an analysis of disease to one focused on health. Both theories, it should be noted, see in Boorse’s own analysis an overlooked underlying theory of homeostasis.
This convergence emerges both from the ‘bottom-up’, as research on aging over the past two decades has been influenced by life course approaches to health and wellbeing (Ben-Shlomo et al., 2016; Hanson et al., 2016; Kuh & the NDA Preparatory Network, 2007), as well as at the theoretical level, where one finds parallels with Waddington’s process-based developmental theory of phenotypes as “temporally extended epigenetic trajectories” (Fabris, 2018, p. 246).
Dussault and Gagne´-Julien (2015), in a parallel manner, incorporate a forward-looking aspect of health by characterizing it in dispositional terms, as does Werkhoven (2019). I favor the term capacity as better capturing a property like health which manifests in different ways under different conditions and at different levels of analysis (e.g. individuals and populations). On the relationship between a process view of life and a dispositional account of causation see Anjum and Mumford (2018).
Morar and Skorburg’s (2018) extended concept of health similarly begins to efface the boundary between the individual, population, and environment. Their suggestion for how to delimit the proper bearer of health relies, in part, on where efficacious biomedical interventions are targeted.
However, as mentioned above, the incorporation of a broader, normative understanding of human goals is also compatible with the LCPT, allowing one to integrate changing reproductive goals and an expanded timeframe of healthy fertility.
References
Alwin, D. F. (2016). Commentary: It takes more than one to tango: Life course epidemiology and related approaches. International Journal of Epidemiology, 45(4), 988–993. https://doi.org/10.1093/ije/dyw108
Ananth, M. (2008). In defense of an evolutionary concept of health: Nature, norms, and human biology. Ashgate Publishing.
Anjum, R. L., & Mumford, S. (2018). Dispositionalism: A dynamic theory of causation. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 61–75). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.001.0001
Ben-Shlomo, Y., Cooper, R., & Kuh, D. (2016). The last two decades of life course epidemiology, and its relevance for research on ageing. International Journal of Epidemiology, 45(4), 973–988. https://doi.org/10.1093/ije/dyw096
Ben-Shlomo, Y., & Kuh, D. (2002). A life course approach to chronic disease epidemiology: Conceptual models, empirical challenges and interdisciplinary perspectives. International Journal of Epidemiology, 31(2), 285–293. https://doi.org/10.1093/ije/31.2.285
Bertolaso, M., & Dupré, J. (2018). A processual perspective on cancer. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 321–336). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0016
Boorse, C. (1977). Health as a theoretical concept. Philosophy of Science, 44(4), 542–573.
Boorse, C. (1997). A rebuttal on health. In J. M. Humber & R. F. Almeder (Eds.), What is disease? (pp. 1–134). Humana Press.
Boorse, C. (2009). Disability and medical theory. In D. C. Ralston & J. H. Ho (Eds.), Philosophical reflections on disability (pp. 55–88). Springer. https://doi.org/10.1007/978-90-481-2477-0_4
Boorse, C. (2014). A second rebuttal on health. The Journal of Medicine and Philosophy, 39(6), 683–724. https://doi.org/10.1093/jmp/jhu035
Boyce, W. T., & Shonkoff, J. P. (2016). Commentary: The course of life and life, of course: A commentary on Ben-Shlomo, Cooper and Kuh. International Journal of Epidemiology, 45(4), 1000–1002. https://doi.org/10.1093/ije/dyw107
Broadbent, A. (2013). Philosophy of epidemiology. Palgrave Macmillan.
Caplan, A. L. (2005). Death as an unnatural process. EMBO Reports, 6(S1), S72–S75. https://doi.org/10.1038/sj.embor.7400435
Daniels, N. (2000). Normal functioning and the treatment-enhancement distinction. Cambridge Quarterly of Healthcare Ethics. https://doi.org/10.1017/S0963180100903037
Dupré, J., & Nicholson, D. J. (2018). A manifesto for a processual philosophy of biology. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 3–45). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0001
Dussault, A. C., & Gagné-Julien, A.-M. (2015). Health, homeostasis, and the situation-specificity of normality. Theoretical Medicine and Bioethics, 36(1), 61–81. https://doi.org/10.1007/s11017-015-9320-1
Fabris, F. (2018). Waddington’s processual epigenetics and the debate over cryptic variability. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 246–263). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0012
Fuller, J. (2018). What are chronic diseases? Synthese, 195(7), 3197–3220. https://doi.org/10.1007/s11229-017-1368-1
Giroux, É. (2015). Epidemiology and the bio-statistical theory of disease: A challenging perspective. Theoretical Medicine and Bioethics, 36(3), 175–195. https://doi.org/10.1007/s11017-015-9327-7
Gray, J. A. M. (2013). The shift to personalised and population medicine. The Lancet, 382(9888), 200–201. https://doi.org/10.1016/S0140-6736(13)61590-1
Griffiths, P., & Stotz, K. (2018). Developmental systems theory as a process theory. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 225–245). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0011
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., … Yeboah, J. (2019). 2018 guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation, 139(25), e1082–e1143. https://doi.org/10.1161/CIR.0000000000000625
Halfon, N., & Forrest, C. B. (2018). The emerging theoretical framework of life course health development. In N. Halfon, C. B. Forrest, R. M. Lerner, & E. M. Faustman (Eds.), Handbook of life course health development (pp. 19–43). Springer. https://doi.org/10.1007/978-3-319-47143-3_2
Halfon, N., Forrest, C. B., Lerner, R. M., & Faustman, E. M. (Eds.). (2018a). Handbook of life course health development. Springer. https://doi.org/10.1007/978-3-319-47143-3
Halfon, N., Forrest, C., Lerner, R., Faustman, E., Tullis, E., & Son, J. (2018b). Life course research agenda (LCRA), version 1.0. In Handbook of life course health development (pp. 623–645). Springer. https://doi.org/10.1007/978-3-319-47143-3_26
Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health, policy, and research. The Milbank Quarterly, 80(3), 433–479. https://doi.org/10.1111/1468-0009.00019
Hanson, M. A., Cooper, C., Aihie Sayer, A., Eendebak, R. J., Clough, G. F., & Beard, J. R. (2016). Developmental aspects of a life course approach to healthy ageing. The Journal of Physiology, 594(8), 2147–2160. https://doi.org/10.1113/JP270579
Hollander, M., Deaton, C., Gibson, I., Kurpas, D., Rutten, F., Hanssen, H., Antonopoulou, M., Dendale, P., & Grobbee, D. E. (2020). The new primary care and risk factor management (PCRFM) nucleus of the European Association of Preventive Cardiology: A call for action. European Journal of Preventive Cardiology, 27(12), 1328–1330. https://doi.org/10.1177/2047487319894107
Hutter, T., Gimbert, C., Bouchard, F., & Lapointe, F.-J. (2015). Being human is a gut feeling. Microbiome, 3(1), 9. https://doi.org/10.1186/s40168-015-0076-7
Inkpen, S. A. (2019). Health, ecology and the microbiome. eLife, 8, e47626. https://doi.org/10.7554/eLife.47626
Izaks, G. J., & Westendorp, R. G. (2003). Ill or just old? Towards a conceptual framework of the relation between ageing and disease. BMC Geriatrics, 3(1), 7. https://doi.org/10.1186/1471-2318-3-7
Jacob, F. (1982). The possible and the actual. Pantheon.
Kotas, M. E., & Medzhitov, R. (2015). Homeostasis, inflammation, and disease susceptibility. Cell, 160(5), 816–827. https://doi.org/10.1016/j.cell.2015.02.010
Kuh, D., & Ben-Shlomo, Y. (Eds.). (1997). A life course approach to chronic disease epidemiology. Oxford University Press.
Kuh, D., the NDA Preparatory Network. (2007). A life course approach to healthy aging, frailty, and capability. The Journals of Gerontology, 62(7), 717–721. https://doi.org/10.1093/gerona/62.7.717
Law, I., & Widdows, H. (2008). Conceptualising health: Insights from the capability approach. Health Care Analysis, 16(4), 303–314. https://doi.org/10.1007/s10728-007-0070-8
Lemoine, M. (2015). The naturalization of the concept of disease. In P. Huneman, G. Lambert & M. Silberstein (Eds.), Classification, disease and evidence (pp. 19–41). Springer.
Matthewson, J., & Griffiths, P. E. (2017). Biological criteria of disease: Four ways of going wrong. The Journal of Medicine and Philosophy, 42(4), 447–466. https://doi.org/10.1093/jmp/jhx004
Mercer, A. J. (2018). Updating the epidemiological transition model. Epidemiology & Infection, 146(6), 680–687. https://doi.org/10.1017/S0950268818000572
Modig, K., Talbäck, M., Torssander, J., & Ahlbom, A. (2017). Payback time? Influence of having children on mortality in old age. Journal of Epidemiology and Community Health, 71(5), 424–430. https://doi.org/10.1136/jech-2016-207857
Morar, N., & Skorburg, J. A. (2018). Bioethics and the hypothesis of extended health. Kennedy Institute of Ethics Journal, 28(3), 341–376. https://doi.org/10.1353/ken.2018.0020
Morgan, W. (2021). Are organisms substances or processes? Australasian Journal of Philosophy. https://doi.org/10.1080/00048402.2021.1931378
Murphy, D. (2021). Concepts of disease and health. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Spring 2021 Edition)
Nicholson, D. J. (2018). Reconceptualizing the organism: From complex machine to flowing stream. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 139–166). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0007
Nicholson, D. J., & Dupré, J. (Eds.). (2018). Everything flows: Towards a processual philosophy of biology. Oxford University Press. https://doi.org/10.1093/oso/9780198779636.001.0001
Omran, A. R. (1971). The epidemiologic transition: A theory of the epidemiology of population change. The Milbank Memorial Fund Quarterly, 49(4), 509–538. https://doi.org/10.2307/3349375
Pradeu, T. (2018). Genidentity and biological processes. In D. J. Nicholson & J. Dupré (Eds.), Everything flows: Towards a processual philosophy of biology (pp. 96–112). Oxford University Press. https://doi.org/10.1093/oso/9780198779636.003.0005
Rattan, S. I. S. (2013). Healthy ageing, but what is health? Biogerontology, 14(6), 673–677. https://doi.org/10.1007/s10522-013-9442-7
Rattan, S. I. S. (2020). Biological health and homeodynamic space. In J. Sholl & S. I. S. Rattan (Eds.), Explaining health across the sciences (pp. 43–51). Springer. https://doi.org/10.1007/978-3-030-52663-4_4
Schramme, T. (2013). ‘I hope that I get old before I die’: Ageing and the concept of disease. Theoretical Medicine and Bioethics. https://doi.org/10.1007/s11017-013-9256-2
Schroeder, S. A. (2013). Rethinking health: Healthy or healthier than? The British Journal for the Philosophy of Science, 64(1), 131–159. https://doi.org/10.1093/bjps/axs006
Schwartz, P. H. (2008). Risk and disease. Perspectives in Biology and Medicine. https://doi.org/10.1353/pbm.0.0027
Sholl, J. (2020). The sciences of healthy aging await a theory of health. Biogerontology, 21(1), 399–409. https://doi.org/10.1007/s10522-020-09872-0
Sholl, J. (2021). Can aging research generate a theory of health? History and Philosophy of the Life Sciences, 43(2), 45. https://doi.org/10.1007/s40656-021-00402-w
Sholl, J., & Okholm, S. (2021). Taking a naturalistic turn in the health and disease debate. Teorema, 40(1), 91–109.
Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., Ramirez, A., Schlaich, M., Stergiou, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). 2020 International society of hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334–1357. https://doi.org/10.1161/HYPERTENSIONAHA.120.15026
Venkatapuram, S. (2013). Health, vital goals, and central human capabilities. Bioethics, 27(5), 271–279. https://doi.org/10.1111/j.1467-8519.2011.01953.x
Werkhoven, S. (2019). A dispositional theory of health. The British Journal for the Philosophy of Science, 70(4), 927–952. https://doi.org/10.1093/bjps/axy003
Acknowledgements
My thanks to all those who have read and commented on this paper, in particular, the guest editors of this issue, Nitzan Rimon-Zarfaty and Mark Schweda, who organized the conference that this special issue grew out of. Jeremy R. Simon offered valuable feedback on an earlier version of this paper, and two anonymous reviewers provided extensive comments, suggestions, and references that improved this paper in many ways. I would also like to acknowledge Fred Gifford for teaching a graduate seminar on the philosophy of medicine in which a section of this paper was first developed.
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Schick, A. Health as temporally extended: theoretical foundations and implications. HPLS 44, 32 (2022). https://doi.org/10.1007/s40656-022-00513-y
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DOI: https://doi.org/10.1007/s40656-022-00513-y