Abstract
The long ongoing and partly heated debate on the concept of disease has not led to any consensus on the status of this apparently essential concept for modern health care. The arguments range from claims that the disease concept is vague, slippery, elusive, or complex, and to statements that the concept is indefinable and unnecessary. The unsettled status of the concept of disease is challenging not only to health care where diagnosing, treating, and curing disease are core aims, but also to the branch of philosophy that tries to clarify concepts. This article discusses three claims about the concept of disease: that it is vague, complex, and that it is indefinable. It investigates (a) what is meant by these claims (b) what their implications are, and (c) whether the claims are sound or not. It is argued that some of the arguments are flawed and miss important points about concept analysis. This does not mean, however, that disease is a clear concept with a crisp definition. It only rules out speculative claims that disease necessarily is vague, complex, and indefinable. It appears at least as hard to show that disease is indefinable as it is to define it.
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Notes
In a relative borderline case the concept (of disease) is clear, but the means to decide whether or not a condition falls in under the concept (i.e. whether it is disease) are incomplete.
Indeed, in many countries the latter two mentioned, CFS and fibromyalgia, are no longer borderline cases.
Example “Disease is a multi-faceted reality, though always with a human being as its carrier and vehicle, and regularly with a professional helper as its interpreter and knower” (Sundström 2001, p. 119).
In the first case I use the term “disease” to explain my behavior (coughing), in the second I use it to claim that the condition described as CFS gives me certain rights, whereas the last case I may use it to characterize bad ethics.
Nordby points out that this presupposes a non-holistic theory of concept possession, and requires an explicit minimal understanding for possessing a concept (Nordby 2003).
Yet another source of concept vagueness may be the normative implication of concepts. In e.g. Locke highlighted the normative implications of concepts, and claimed that “person” is a forensic term (Locke 1690, book 2, Chap. 27, paragraph 26).
I owe this argument to Lennart Nordenfelt.
It is important to notice that the meaning of the term “complex concept” is different in the philosophy of medicine than in analytic philosophy of language, where it usually means a concept composed of existing concepts, e.g. brown dog. In philosophy of medicine “complex concept” is often used to denote a term having many meanings (at the same time). This distinction is not sharp, as the uses are not consistent, see e.g. Fischer (1995) and http://www.janpols.net/Chapter-5/2.2.html.
”Das liegt daran, dass der Begriff der Krankheit kein einheitlicher ist, dass es mehrere Krankheitsbegriffe gibt, und dass alle Krankheitsbegriffe, die wohl prinzipiell scharf gefasst werden können, in der Anwendung auf die Wirklichkeit Grenzfälle und Übergänge zulassen müssen” (Jaspers 1973, pp. 2–3).
The same argument is applied for specific diseases: “Diseases are, in fact, not only multifactorial, but multidimensional, involving genetic, physiological, psychological, and sociological components. The presence of these various components does not merely entail a superimposition of modifying variables upon basic disease structures. Rather, it implies that diseases have a basically relational, not a subject (i.e. substance)-predicate (accident) nature. That is, there is not necessarily a bearer for every disease, a substrate for each type of disease” (Engelhardt and Spicker 1975).
As indicated earlier, the differences between interlocutors are only relative to a common “minimal understanding”.
“Such indefinable terms (‘ethics’, for instance) are among the most fundamental and primitive elements of any natural language” (Tranøy KE. Remembering von Wright. Unpublished manuscript based on: Deontic Logic and Moral Philosophy. Reason, Action and Morality. Memorial Symposium in honor of Georg Henrik von Wright, Åbo May 26–27 2006).
Nordby appears to claim that the circularity of analytic sentences also yields for analytic concepts. Although the premises of this argument may be contested, let us accept this for the sake of the argument.
Another phrasing of the argument is:”We in medicine are always arguing the question whether’there is such a thing as disease’ and what’ the nature of disease’ is, while we have no concept of disease which can form the inter-subjectively controllable basis for such a debate” (Sadegh-Zadeh 1980).
It is quite clear that conceptual analysis in the field of philosophy of medicine has normative intentions (Nordenfelt 1987; Brülde and Tengland 2003). Although theories of disease may start with analyzing concepts of ordinary language, this does not seem to be the end-point. On the contrary, the theories are refined by discussing basic philosophical issues, such as pain, basic needs or reduced welfare, as well as difficult cases, such as fibromyalgia and chronic fatigue syndrome, in order to amount to definitions (with normative implications). Due to this theoretical background and the normative intentions, definitions are seldom verified against ordinary language.
The Woralls’ reason for dismissing the disease concept is that they recognize that it is evaluative, and they want to keep medicine descriptive, clean, and objective for pure scientific intervention: unsullied by social and evaluative aspects. “How could medicine be scientific, if its central notion—that of disease—is shot through with values?” (Worall and Worall 2001). However, how are they to avoid evaluative issues when defining chronic fatigue syndrome, fibromyalgia, and ADD?
Furthermore, Quine’s holism is a holism of verification, and not primarily a holism of meaning. It claims that propositions cannot be verified singly, but only in connection to other claims. It is of course possible to expand the Quinian holism to assessing meanings of terms, but it seems to need more elaboration and justification (than Nordby provides).
And we have to define the limits of “minimal” as for making something an entry in a dictionary.
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Acknowledgement
An earlier draft of this manuscript has been presented at the 22nd European Conference on Philosophy of Medicine and Health Care, European bioethics in a global context, August 21–23, 2008, Tartu, Estonia. I am most thankful to the participants for an open and fruitful discussion on the ambitions, possibilities and limitations of conceptual analysis of disease. I am also grateful to Halvor Nordby for interesting and clarifying discussions.
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Hofmann, B. The concept of disease—vague, complex, or just indefinable?. Med Health Care and Philos 13, 3–10 (2010). https://doi.org/10.1007/s11019-009-9198-7
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DOI: https://doi.org/10.1007/s11019-009-9198-7