Christopher Boorse’s Biostatistical Theory of Health has been the main contender among naturalistic accounts of health for the last 40 years. Yet, a recent criticism of this theory, presented by Elselijn Kingma, identifies a dilemma resulting from the BST’s conceptual linking of health and statistical typicality. Kingma argues that the BST either cannot accommodate the situation-specificity of many normal functions (e.g., digestion) or cannot account for many situation-specific diseases (e.g., mountain sickness). In this article, we expand upon with Daniel Hausman’s response to Kingma’s dilemma. We propose that recalling Boorse’s specification that health is an intrinsic property of its bearers and explicating this intrinsic property in relation to the concept of homeostasis can illuminate how proponents of naturalistic accounts of health should deal with the situation-specificity of normal functions. We argue that beyond what Boorse and Hausman have delineated, the situation-specificity of normal function cannot be fully captured in a simple dichotomy between normal and abnormal environment or between relevant and irrelevant situations. By bringing homeostasis to the fore of the analysis of health, we set out a richer picture of what the various situations that affect living organisms’ functional performance can be. Accordingly, we provide a broader classification of these various situations which, we contend, better accounts for the main intuitions that philosophers of medicine have sought to accommodate than previous naturalistic theories of health.
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We removed the environmental clause from this third component of Boorse’s statement because he himself removes it in response to some criticism [1, p. 86]. However, he does add some specifications to meet the challenge posed by environmental diseases [1, p. 84], which we will discuss in the next subsection, “A dilemma for the BST.”
Like Hausman [4, p. 657n1], we keep with Kingma’s use of “paracetamol,” the British word for what North Americans call “acetaminophen.”
Here, we adopt Hausman’s [4, p. 661] interpretation of Boorse’s normal environment clause, which, we think, better reflects what Boorse presumably meant. Boorse’s own statement is: “a statistically species-subnormal function… is pathological if it results from an environmental factor outside an arbitrarily chosen central statistical range of that factor in the environments where the species lives” [1, p. 84].
We leave aside Kingma’s spermatozoon example as it becomes irrelevant in the light of Hausman’s interpretation of Boorse’s normal environment clause (see footnote 5).
These two possibilities are normal environments specified as non-adverse and as natural environments.
As Kingma notes, it is a requirement that normal environments be specified in a naturalistic way if, as Boorse wishes, the BST is to remain a naturalistic account of health.
For concision, we speak of non-performance in a broad sense which includes not only absence of performance but also underperformance, which, for Boorse, itself includes what some often call “overperformance” (cf. Boorse [10, p. 371]).
However, we do not follow Garson and Piccinini’s solution to the situation-specificity problem in terms of “non-negligible contribution to survival or inclusive fitness.” See the third section’s “Homeostasis, Survival, and Design” for our stance on the relation between health, reproduction, and evolutionary fitness.
For Boorse too, what legitimates the appeal to the notion of design is the effect of “normalizing selection,” which, on shorter-than-evolutionary time-scales, maintains some significant degree of uniformity among members of a species (see [2, p. 557]). In the third section’s “Homeostasis, Survival, and Design,” we discuss the relation between designs of reference classes and evolutionary factors.
We follow Ananth, and take as indications of Boorse’s acknowledgment of homeostasis as a constituent of health his statement that “obviously, no fact is more pervasive than what is often called the ‘dynamic equilibrium’ of normal physiology: the normal functional variation within organisms acting and reacting to their environment,” and that “though I did not stress the dynamism of normal physiology in presenting the BST, I always assumed it” [7, pp. 36–37].
Ananth takes this characterization from Seidel .
For Ananth, homeostasis acquires its role as a component of health from its being a product of natural selection and from its contribution to an organism’s survival and reproduction [7, pp. 194–196]. Here, he is sensitive to a remark made by Bechtel that some basis must be given for “why any premium should be placed on maintaining a system at its homeostatic equilibrium point,” and builds on Bechtel’s suggestion that evolution provides such a basis [25, p. 151]. Hence, Ananth argues that what provides grounds for defining health in terms of homeostasis is the fact that living organisms’ tendency to achieve homeostasis has an evolutionary origin and that such tendency, in turn, contributes to their propensity to survive and reproduce. It seems to us that such reasoning conflates conceptual and causal analysis. The fact that homeostasis has an evolutionary origin does not imply that it gains its conceptual relevance to the definition of health from this origin. In the same way, the fact that, by and large, the achievement of homeostasis by organisms contributes to their species’ ability to persist and evolve does not imply that homeostasis is a component of their health in virtue of this contribution. The basis for a conceptual analysis of health in terms of homeostasis (or any other notion) should be found, not (to paraphrase Bechtel) in some premium placed on evolution, but in the analysis’s ability to account for the careful terminological practice of medical theoreticians.
Bechtel acknowledges this objection as a problem which confronts the evolutionary account of health he is proposing.
On Ryle’s example and Boorse’s treatment of it, see Ananth’s [7, pp. 25–27] illuminating discussion.
Related yet not identical because the organizational theory ties the idea of self-maintenance to that of organizational closure which requires that function bearers be both maintained by and contributing to the maintenance of the organized entity they are part of. See Mossio and Bich  on the relation between homeostasis and organizational theories of function, and Holm [33, 34] for an organizational account of health inspired from Mossio and colleagues’ work.
Although see Saborido et al.  for a review of attempts to account for reproduction under organizational theories of functions and an original proposal.
Such grounding of the appeal to design in past natural selection has led some to suggest that Boorse’s account of health comes close to defining health in terms equivalent to Millikan and Neander’s etiological account of proper function (e.g., Giroux [8, p. 81]) or to Godfrey–Smith’s recent selective history account (see Krohs [30, p. 131]).
Note however that the consequences of such abandonment would reach far beyond the philosophy of medicine, for as Krohs emphasizes, notions of design and types still hold important roles in many contemporary biological research programs [30, pp. 132–133].
Considering overwhelming situations as pathologies would be inconsistent, for they are just extreme cases of challenging situations, and challenging situations are intuitively not diseases.
Our distinction between what challenges the homeostatic maintenance of a function and what affects negatively the ability to maintain it has some familiarity with a possibility rejected by Kingma [3, p. 253] to demarcate normal functions from pathologies through a contrast between slow (or impossible) and quick reversibility. Our approach however, although it implies differences concerning the time required for the performance to be reestablished, does not define healthy and pathological states solely in temporal terms. Thus, we think, it handles Kingma’s counterexamples to the reversibility/irreversibility demarcation criterion.
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The authors would like to thank Matteo Mossio, Ghyslain Bolduc, two anonymous referees, and the attendees at the 2013 Philosophy of Medicine Roundtable, the 2014 Philosophy of Biology Consortium, and the Symposium—Controverses et renversements conceptuels dans les sciences du vivant for helpful comments on previous versions of this article. The authors also thank O’Neal Buchanan and Daniel Kim for kindly editing their written English. The research for this article was partly supported by grants from the Fonds de la recherche du Québec—Société et Culture (FRQ-SC), the Centre interuniversitaire de recherche sur la science et la technologie (CIRST), and the Groupe de recherche sur la normativité (GRIN).
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Dussault, A.C., Gagné-Julien, A. Health, homeostasis, and the situation-specificity of normality. Theor Med Bioeth 36, 61–81 (2015). https://doi.org/10.1007/s11017-015-9320-1
- Normal function
- Christopher Boorse
- Elselijn Kingma