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WHY BIOETHICS NEEDS THE PHILOSOPHY OF MEDICINE: SOME IMPLICATIONS OF REFLECTION ON CONCEPTS OF HEALTH AND DISEASE

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Abstract

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the “science” of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history, I shall show that it does capture an essential part of modern medical ideology. However, it is also a self-contradictory notion. By making explicit the value desiderata of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice.

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REFERENCES

  1. Caplan A. Does the philosophy of medicine exist? Theoretical Medicine 1992; 13(1): 67–77. Caplan rightly notes that reflection on concepts of health and disease are as close as one can get to a central, boundary-defining problem in the philosophy of medicine (p. 73).

    Google Scholar 

  2. Engelhardt H. The Foundations of Bioethics. 2nd Edition, New York: Oxford University Press, 1996.

    Google Scholar 

  3. Foucault M. The Birth of the Clinic: An Archeology of Medical Perception. Sheridan Smith AM, tr. New York: Vintage Books, 1975.

    Google Scholar 

  4. Temkin O. The Double Face of Janus and Other Essays in the History of Medicine. Baltimore: The Johns Hopkins University Press, 1977; esp. chs. 29–32.

    Google Scholar 

  5. Daniels N. Just Health Care. Cambridge: Cambridge University Press, 1985.

    Google Scholar 

  6. Kass, L. Toward a More Natural Science: Biology and Human Affairs. New York: The Free Press, 1985.

    Google Scholar 

  7. Szasz T. The myth of mental illness. In Silverstein H, ed. The Social Control of Mental Illness. New York: Thomas Y. Crowell Company, 1968.

    Google Scholar 

  8. Leder D. The experience of pain and its clinical implications. In Peset J, Gracia D, eds. The Ethics of Diagnosis. Dordrecht: Kluwer Academic Publishers, 1992.

    Google Scholar 

  9. Cassell, E. The Healer's Art. Cambridge, Massachusetts: MIT Press, 1976.

    Google Scholar 

  10. Toombs, SK. The Meaning of Illness: a Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht: Kluwer Academic Publishers, 1992.

    Google Scholar 

  11. Hesslow G. Do we need a concept of disease? Theoretical Medicine 1993; 14: 1–14; 3.

    PubMed  Google Scholar 

  12. Ibid: 3.

  13. Ibid.

    PubMed  Google Scholar 

  14. Daniels.

  15. Mordacci R. Health as an analogical concept. The Journal of Medicine and Philosophy 1995; 20(5): 475–497.

    Google Scholar 

  16. Lennox J. Health as an objective value. The Journal of Medicine and Philosophy 1995; 20(5): 499–511.

    Google Scholar 

  17. Boorse C. On the distinction between disease and illness. Philosophy and Public Affairs 1975; 5: 49–86.

    Google Scholar 

  18. Boorse C. Health as a theoretical concept. Philosophy of Science 1977; 44: 542–573.

    Google Scholar 

  19. Boorse C. What a theory of mental health should be. Journal of the Theory of Social Behavior 1976; 6(1): 29–48.

    Google Scholar 

  20. Hesslow: note 3.

  21. Snow, CP. The Two Cultures and the Scientific Revolution. Cambridge: Cambridge University Press, 1959.

    Google Scholar 

  22. White, K. The Task of Medicine: Dialogue at Wickenburg. Menlo Park, California: The Henry J. Kaiser Family Foundation, 1988.

    Google Scholar 

  23. Khushf G. Expanding the horizon of reflection on health and disease. The Journal of Medicine and Philosophy 1995; 20(5): 461–473.

    Google Scholar 

  24. Hesslow: note 4.

  25. This would explain why Hesslow seems willing to accept the Boorsian concept, even though he acknowledges that there are “serious difficulties” with it; Hesslow: note 2.

  26. Foucault.

  27. Engelhardt H. Comments on Wulff's ‘The causal basis of the current disease classification.’ In Nordenfelt L, Lindahl B, eds. Health, Disease, and Causal Explanations in Medicine. Dordrecht: D. Reidel Publishing Company, 1984.

    Google Scholar 

  28. Engelhardt H. Clinical problems and the concept of disease. In Nordenfelt L, Lindahl B, eds. Health, Disease, and the Causal Explanations in Medicine. Dordrecht: D. Reidel Publishing Company, 1984.

    Google Scholar 

  29. Engelhardt H. The disease of masturbation: values and the concept of disease. Bulletin of the History of Medicine 1974; 48: 234–248.

    Google Scholar 

  30. Engelhardt HT. Ideology and etiology. The Journal of Medicine and Philosophy 1975; 1(3): 256–268.

    Google Scholar 

  31. Agich G. Disease and value: a rejection of the value-neutrality thesis. Theoretical Medicine 1983; 4: 27–41.

    Google Scholar 

  32. Agich G. The question of technology in medicine. In Skousgaard S, ed. Phenomenology and the Understanding of Human Destiny. The Center for Advanced Research in Phenomenology and the University Press of America, 1981.

  33. Agich G. Evaluative judgement and personality disorder. In Sadler J, Schwartz M, Wiggens O, eds. Philosophical Perspectives on Psychiatric Diagnostic Classification. Baltimore: Johns Hopkins University Press, 1994.

    Google Scholar 

  34. Reznek, L. The Nature of Disease. London: Routledge, 1987.

    Google Scholar 

  35. Reznek L. Dis-ease about kinds: reply to D'Amico. The Journal of Medicine and Philosophy 1995; 20(5): 571–584.

    Google Scholar 

  36. Nordenfelt, L. On the Nature of Health. Dordrecht: D. Reidel Publishing Co., 1987.

    Google Scholar 

  37. Nordenfelt L. On the relation between biological and social theories of health: a commentary on Fulford's praxis makes perfect. Theoretical Medicine 1993; 14: 321–324.

    Google Scholar 

  38. Nordenfelt L. On the relevance and importance of the notion of disease. Theoretical Medicine 1993; 14: 15–26.

    Google Scholar 

  39. Pellegrino E, Thomasma, D. A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions. New York and Oxford: Oxford University Press, 1981.

    Google Scholar 

  40. Khushf G. Post-modern reflections on the ethics of naming. In Peset J, Gracia D, eds. The Ethics of Diagnosis. Dordrecht: Kluwer Academic Publishers, 1992.

    Google Scholar 

  41. Fulford K. Praxis makes perfect: illness as a bridge between biological concepts of disease and social conceptions of health. Theoretical Medicine 1993; 14: 305–320. Fulford develops illness as the bridge. Disease is placed on one of the sides that is bridged. While I am sympathetic to many of the concerns developed in Fulford's analysis, I will argue that disease itself is already a bridge concept, and thus cannot be accounted for in terms of biomedical theory alone. This is the import of Hesslow's analysis.

    Google Scholar 

  42. Those familiar with Hegel's thought will recognize a similarity between my account of the history of medicine and Hegel's account of the history of philosophy. My criticisms of the speculative and empirical stages will also be informed by Hegel's criticisms of the first and second attitudes of thought toward objectivity. My assessment of the dialectical period (the clinic-laboratory dialectic), as well as the role given to conceptual clarification in the further development of medicine, has also benefitted from Hegel. For an overview of these themes, see Hegel, GWF. Hegel's Logic. Wallace W, trans. Oxford: Oxford University Press, 1975.

  43. For an overview of some of the issues, see ten Have H, Kimsma G, Spicker S. The Growth of Medical Knowledge. Dordrecht: Kluwer Academic Publishers, 1990.

  44. This same qualification would need to be given in a much more detailed historical account, as well. Thus a historian of the stature of Owsei Temkin can note, as he begins his historical overview of concepts of health and disease: “any order can be achieved only be neglecting innumerable details, by paradigmatic use of relatively few opinions and practices, and by admitting that a different point of view may show a different panorama.” Temkin: 419.

  45. On the externalist/internalist distinction and medical historiography, see Wallace E. Psychiatry and its nosology: a historico-philosophical overview. Sadler J, Wiggins O, Schwartz M, eds. Philosophical Perspectives on Psychiatric Diagnostic Classification. Baltimore and London: The Johns Hopkins University Press, 1994: 16–86.

  46. Ackerknecht E. A Short History of Medicine. Baltimore and London: Johns Hopkins University Press, 1982: 66.

    Google Scholar 

  47. Ibid.

    Google Scholar 

  48. Burns G. The nonnaturals: a paradox in the western concept of health. The Journal of Medicine and Philosophy 1976; 1(3): 202–229.

    Google Scholar 

  49. Ibid.

    Google Scholar 

  50. Similar ideas associating the “unnatural” and loss of vitality persisted well into the current century. For a good example, see Engelhardt, 1974.

  51. As Hegel notes (1975: 48), the speculative period worked with a metaphysic that ”took the laws and forms of thought to be the fundamental laws and forms of things. It is assumed that to think a thing was the means of finding its very self and nature.” There is thus little skepticism regarding the general theoretical framework, and a considerable tendency to dogmatism (p. 52). It is this tendency in the Middle Ages that leads to Ackerknecht's harsh appraisal of Medieval medicine (ch. 8).

  52. Khushf, 1992.

  53. Sanchez-Gonzalez M. Medicine in John Locke's philosophy. The Journal of Medicine and Philosophy 1990; 15: 675–695.

    Google Scholar 

  54. Faber K. Nosography in Modern Internal Medicine. New York: Paul B. Hoeber, Inc., 1922: part I.

    Google Scholar 

  55. Sanchez-Gonzalez. For a more detailed discussion of the relation between Locke and Sydenham, see Romanell P. John Locke and Medicine. New York: Prometheus, 1987.

    Google Scholar 

  56. Foucault: chs. 1–2.

  57. Temkin: ch. 30.

  58. Taylor F. The Concepts of Illness, Disease and Morbus. Cambridge: Cambridge University Press, 1979.

    Google Scholar 

  59. Bole T. the neologism ONTOI in Broussais's condemnation of medical ontology. The Journal of Medicine and Philosophy 1995; 20(5): 543–549.

    Google Scholar 

  60. Temkin: 443.

  61. Sanchez-Gonzales: 680–684.

  62. Sydenham T. The Works of Thomas Sydenham, M.D. 2 Vols. Latham RG, trans. London: Sydenham Society, 1848. Quoted in Sanchez-Gonzalez: 680.

    Google Scholar 

  63. Temkin: 443–444. Sanchez-Gonzalez: 688–690.

  64. Khushf, 1992.

  65. Engelhardt, 1996.

  66. Sanchez-Gonzalez.

  67. For a current formulation of this same problem with respect to the inductivism of the DSM and psychiatric nosologies, see Wallace E. What is truth? Some philosophical contributions to psychiatric issues. American Journal of Psychiatry 1988; 145(2): 137–147.

  68. Engelhardt, 1996.

  69. Sydenham–Locke. Anatomie. Dewhurst K, ed. Dr. Thomas Sydenham (1624–1689) His Life and Original Writings. Berkeley: University of California Press, 1966.

    Google Scholar 

  70. Ibid: 85.

  71. Taylor: 13.

  72. Reiser S. Medicine and the Reign of Technology. Cambridge: Cambridge University Press, 1978: ch. 1, esp. 16–22.

    Google Scholar 

  73. Khushf, 1992.

  74. Engelhardt, 1996; Foucault.

  75. Foucault.

  76. Taylor: 12.

  77. Reiser.

  78. Engelhardt, 1996: 216.

  79. Engelhardt H. Goals of medical care. In Bell N, ed. Who Decides: Conflicts of Rights in Health Care. Clifton: Humana Press, Inc., 1982: 55.

    Google Scholar 

  80. Faber: 28.

  81. Engelhardt, 1996.

  82. Foucault.

  83. Cassell; Leder; Toombs.

  84. Canguilhem G. The Normal and the Pathological. New York: Zone Books, 1989.

    Google Scholar 

  85. Pellegrino and Thomasma: 75–76.

  86. Ibid. See also Temkin: ch. 30.

  87. Boorse (1975: 545) argues that the “consensus view” among clinicians and philosophers is a weak normativism. While this may be closer to the truth in philosophy, it is clearly false among clinicians, for whom, since Broussais, a value-neutrality was the orthodoxy. On this, see Canguilhem.

  88. Nordenfelt L. Concepts of health and their consequences for health care. Theoretical Medicine 14(3), 1993:277–285: 281–282.

    Google Scholar 

  89. This is a function that Hegel attributes to thought, and which he develops as his dialectic; Hegel, 1975.

  90. This point is made by Hesslow, when he states that Boorse's concept “captures quite well what medical scientists and practitioners actually mean by the term ‘disease’ ” (p. 3).

  91. Boorse, 1977: 543.

  92. Ibid: 551.

  93. Ibid: 567.

  94. Ibid: 544.

  95. Ibid: 562.

  96. For more extensive criticisms, see Agich G. Disease and value: a rejection of the value-neutrality thesis. Theoretical Medicine 1983; 4: 27–41; also see the next reference.

    Google Scholar 

  97. Goosens W. Values, health, and medicine. Philosophy of Science 1980; 47: 100–115.

    Google Scholar 

  98. Engelhardt, 1996.

  99. Boorse, 1977: 559.

  100. Margolis J. The concept of disease. The Journal of Medicine and Philosophy 1976; 1(3): 238–255; 252.

    Google Scholar 

  101. Gardell Cutter M. Value presuppositions of diagnosis: a case study in diagnosing cervical cancer. In Peset J, Gracia D, eds. The Ethics of Diagnosis. Dordrecht: Kluwer Academic Publishers, 1992.

    Google Scholar 

  102. Boorse, 1977: 560–561.

  103. Hesslow: 11.

  104. Ibid: 12.

  105. Ibid.

  106. Cassell; Pellegrino and Thomasma; Khushf, 1992.

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  1. Department of Philosophy and Center for Bioethics, University of South Carolina, Columbia, SC, 29208, USA

    George Khushf

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Khushf, G. WHY BIOETHICS NEEDS THE PHILOSOPHY OF MEDICINE: SOME IMPLICATIONS OF REFLECTION ON CONCEPTS OF HEALTH AND DISEASE. Theor Med Bioeth 18, 145–163 (1997). https://doi.org/10.1023/A:1005730108133

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