Skip to main content
Log in

On illness, disease, and priority: a framework for more fruitful debates

  • Scientific Contribution
  • Published:
Medicine, Health Care and Philosophy Aims and scope Submit manuscript

Abstract

The distinction between ‘disease’ and ‘illness’ has played an important role in the debate between naturalism and normativism. Both employ these notions, yet disagree on whether to assign priority to ‘disease’ or ‘illness’. I argue that this discussion suffers from implicit differences in the underlying interpretations: While for naturalists the distinction between ‘disease’ and ‘illness’ is one between a descriptive and a prescriptive notion, for normativists it is one between cause and effect. This discrepancy is connected to different interpretations of priority, which also tend to be conflated in the debate. I disambiguate these different usages and develop a distinction between ‘disease’ and ‘illness’ that is theoretically neutral with regard to naturalism or normativism. Moreover, I propose a concept of heuristic priority that could serve as a common focus. This framework can avoid common confusions by providing a shared terminology and thereby help to make debates on disease-concepts more fruitful.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

Notes

  1. I will use ‘ailment’ as an umbrella-term for ‘illness’ and ‘disease’; cf. “A two-level distinction of ailments” for further elaboration.

  2. By contrast, Wakefield (1992) employs an etiological, evolutionary notion of function in his hybrid account of mental disorder as harmful dysfunction. It is, however, equally debatable whether he thereby achieves his aim to make ‘dysfunction’ a value-free notion (cf., e.g., Lilienfeld and Marino 1995). Wakefield does not use the notions of ‘disease’ and ‘illness’; however, his distinction between a dysfunction and its harmful consequences might be interpreted to mirror the distinction between ‘disease’ and ‘illness’ in both regards (i.e., as distinguishing a cause from its effects as well as a descriptive and normative part). Yet, since Wakefield does not make this explicit, I will not discuss his account in detail here.

  3. Later, he modified his position and claimed ‘illness’ to be purely descriptive, too, given when “pathological processes rise to a systemic level that produces global incapacitation of the whole organism” (Boorse 1987, p. 365). I will adhere to his earlier distinction, as this has played a shaping role in the debate. Also, Boorse’s redefinition does not deny the existence of a normative level of medical ailments, but rather renames it with terms such as therapeutic normality. Moreover, I find it highly doubtful whether it is possible to define “systemic incapacitation” in a way that does not rely on evaluations of the severity of suffering or the importance of abilities (and Boorse does not elaborate any argument that it could).

  4. Logical priority (i.e., considering a to be a necessary condition for b) is thus a particularly strong version of conceptual priority (presuming a in the definition of b); cf. also “A two-level distinction of ailments”.

  5. Note that this does not imply, neither for Boorse nor logically, that such conditions do not merit any therapeutic or medical help (even if it might in practice impact questions of medical and social treatment).

  6. This does not mean that there cannot be any descriptive aspects in ascribing (ill) health. As Nordenfelt puts it, the standard to be set is at least partly normative; but judgements made on whether a normative standard is achieved can be descriptive (Nordenfelt 1987, 80; 2001; 103ff.). Yet, if the notions of illness and disease are defined with regard to a normative standard, they are certainly not value-free. However, this does not make respective ascriptions of health or disease arbitrary. For Nordenfelt, vital goals are somewhat relative to individual human beings. Schramme (2007) criticises that this would lead to counterintuitive judgements if one’s vital goals are either too ambitious or too moderate: If I aim to be a top athlete, I may very well be ill all my life; if I just aim to be able to scratch my nose, I could stay healthy for a long time. I cannot discuss this in detail, but Nordenfelt’s conception is not one in which what is a vital goal is a completely open choice. Vital goals are required to contribute to a person’s long-term, real happiness; this requirement is intended to rule out counterproductive and trivial goals (cf. Nordenfelt 1987, 90ff.).

  7. This definition of ‘disease’ (types) as typically causing ‘illness’ (tokens) leaves the former concept somewhat underdetermined, as it does not specify what kind of internal state or process typically interfere with one’s ability to achieve the vital goals. Here, Nordenfelt’s account could perhaps be complemented by an account of dysfunction.

  8. Moreover, what conditions can be considered as having a real potential for medical help is contingent on the state of knowledge as well as broader societal context. Cooper (2002) makes the important point that a future medical treatment need not only be possible in a technical sense, but also with regard to social acceptability. The class of medical conditions will therefore not necessarily grow bigger and bigger as medical science progresses, as not everything that can be done should be done.

  9. The term “level” here is not to be understood as implying a hierarchical relation.

References

  • Agich, G. 1983. Disease and Value: A Rejection of the Value-Neutrality Thesis. Theoretical Medicine 4, 27–41.

  • Agich, G. 1997. Toward a Pragmatic Theory of Disease. In What is Disease? eds. J. M. Humber, and R. F. Almeder, 221–246. Totowa: Humana Press.

    Google Scholar 

  • Bergner, R. M. 1997. What is Psychopathology? And so What? Clinical Psychology: Science and Practice 4: 235–248.

    Google Scholar 

  • Boorse, C. 1975. On the Distinction between Disease and Illness. Philosophy and Public Affairs 5: 49–68.

    Google Scholar 

  • Boorse, C. 1976a. Wright and Functions. Philosophical Review 85: 70–93.

    Article  Google Scholar 

  • Boorse, C. 1976b. What a Theory of Mental Health should be. Journal for the Theory of Social Behaviour 6: 61–84.

    Article  Google Scholar 

  • Boorse, C. 1977. Health as a Theoretical Concept. Philosophy of Science 44: 542–573.

    Article  Google Scholar 

  • Boorse, C. 1987. Concepts of Health. In Health Care Ethics: An Introduction, ed. D. VanDeVeer, 359–393. Philadelphia: Temple University Press.

    Google Scholar 

  • Boorse, C. 1997. A Rebuttal on Health. In What is Disease? eds. J. M. Humber, and R. F. Almeder, 3–134. Totowa: Humana Press.

    Google Scholar 

  • Cooper, R. 2002. Disease. Studies in History and Philosophy of Biological and Biomedical Sciences 33: 263–282.

    Article  Google Scholar 

  • Douglas, H. 2000. Inductive Risk and Values in Science. Philosophy of Science 67: 559–579.

    Article  Google Scholar 

  • Engelhardt, T. 1976. Ideology and Etiology. Journal of Medicine and Philosophy 1: 256–268.

    Article  Google Scholar 

  • Ereshefsky, M. 2009. Defining ‘Health’ and ‘Disease’. Studies in History and Philosophy of Biological and Biomedical Sciences 40: 221–227.

    Article  Google Scholar 

  • Fulford, K. W. M. 1989. Moral Theory and Medical Practice. Cambridge: Cambridge University Press.

    Google Scholar 

  • Hesslow, G. 1993. Do we Need a Concept of Disease? Theoretical Medicine 14: 1–14.

    Article  Google Scholar 

  • Hyman, S. E. 2010. The Diagnosis of Mental Disorders: The Problem of Reification. Annual Review of Clinical Psychology 6: 155–179.

    Article  Google Scholar 

  • Kingma, E. 2007. What is it to be Healthy? Analysis 67: 128–133.

    Article  Google Scholar 

  • Lilienfeld, S. O., and L. Marino. 1995. Mental Disorder as a Roschian Concept: A Critique of Wakefield’s “Harmful Dysfunction” Analysis. Journal of Abnormal Psychology 104: 411–420.

    Article  Google Scholar 

  • Murphy, D. 2006. Psychiatry in the Scientific Image. Cambridge: MIT Press.

    Google Scholar 

  • Nordenfelt, L. 1987. On the Nature of Health: An Action-Theoretic Approach. Dordrecht: Reidel.

    Book  Google Scholar 

  • Nordenfelt, L. 1993a. On the Relevance and Importance of the Notion of Disease. Theoretical Medicine 14: 15–26.

    Article  Google Scholar 

  • Nordenfelt, L. 1993b. Concepts of Health and Their Consequences for Health Care. Theoretical Medicine 14: 277–285.

    Article  Google Scholar 

  • Nordenfelt, L. 2001. Health, Science, and Ordinary Language. Amsterdam: Rodopi.

    Google Scholar 

  • Nordenfelt, L. 2007a. The Concepts of Health and Illness Revisited. Medicine, Health Care and Philosophy 10: 5–10.

    Article  Google Scholar 

  • Nordenfelt, L. 2007b. Establishing a Middle-Range Position in the Theory of Health: A Reply to My Critics. Medicine, Health Care and Philosophy 10: 29–32.

    Article  Google Scholar 

  • Schramme, T. 2007. A Qualified Defence of a Naturalist Theory of Health. Medicine, Health Care and Philosophy 10: 11–17.

    Article  Google Scholar 

  • Tsou, J. Y. 2015. 2015. DSM-5 and Psychiatry’s Second Revolution: Descriptive vs. Theoretical Approaches to Psychiatric Classification. In The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel, eds. S. Demazeux, and P. Singy, 43–62. Dordrecht: Springer.

    Google Scholar 

  • Wakefield, J. M. 1992. The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values. American Psychologist 47: 373–388.

    Article  Google Scholar 

  • Wright, L. 1973. Functions. Philosophical Review 82: 139–168.

    Article  Google Scholar 

Download references

Acknowledgements

I want to thank Sean Valles for providing helpful comments on an earlier version of this paper, as well as Najko Jahn and Alfons Bueter for their support and inspiration.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Anke Bueter.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bueter, A. On illness, disease, and priority: a framework for more fruitful debates. Med Health Care and Philos 22, 463–474 (2019). https://doi.org/10.1007/s11019-019-09886-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11019-019-09886-7

Keywords

Navigation