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On the Downplay of Suffering in Nordenfelt’s Theory of Illness

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A Reply to this article was published on 03 July 2013

Abstract

In his influential theory of health Nordenfelt bases the concepts of health and illness on the notions of ability and disability. A premise for this is that ability and disability provide a more promising, adequate, and useful basis than well-being and suffering. Nordenfelt uses coma and manic episodes as paradigm cases to show that this is so. Do these paradigm cases (and thus the premise) hold? What consequences does it have for the theory of health and illness if it they do not? These are the key questions in this article, which first presents the relationship between pain and disability in Nordenfelt’s theory and the paradigm cases he uses to argue for the primacy of disability over pain. Then, Nordenfelt’s concepts of illness are outlined, highlighting its presumptions and arguments. The main point is that if you do not have an action-theoretical perspective, it is not obvious that disability is the core concept for illness. The compelling effect of the paradigm cases presupposes that you see ability as the primary issue. To those who do not share this presumption, people in coma may not be ill. There are alternative well founded arguments for the primacy of first person experiences for the concept of illness. Hence, we need better arguments for the primacy of disability over first person experiences in illness, or first-person experience should be more primarily included in the concept of illness.

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Notes

  1. In this paper I refer to both pain and suffering without defining these terms or clarifying their distinction. This is because I will use the terms as they are used in the work of Lennart Nordenfelt. My perspective and concern in this article is the downplay of first-person experiences. Pain and suffering are such first-person experiences. I could of course have referred to first-person experiences throughout the article, but I think that this would reduce the readability, as Nordenfelt uses the terms pain and suffering himself. Hence, I stick to his terminology.

  2. Nordenfelt also refers to a “semantic bond” between suffering and behavior, and refers to Wittgenstein (para. 580 in Philosophical Investigations) [23] in order to underline that suffering is well taken care of by the philosophy of language.

  3. Nordenfelt’s argument for the primacy of illness over pain and suffering follows the same pattern as his argument for the primacy of illness over disease. The empirical argument goes as follows. Pain causes disability, but disability does not necessarily cause pain. Therefore, disability is (partly) independent of pain. Correspondingly, disease causes illness, but illness does not necessarily cause disease. Therefore, illness is (partly) independent of disease. The logical argument goes like this: Pain is not a necessary condition for disability. Hence, disability is more basic for illness than pain. Correspondingly, disease is not a necessary condition for illness. Hence, illness is more basic than disease. These arguments are criticized below.

  4. Although Nordenfelt’s basic view is that “ultimately the subject should decide about the content of the set of viatal goals” [23, p. 104], he argues that “almost no human being can wholly understand the nature of this welfare” [23, p. 105].

  5. Nordenfelt’s solution can be to argue that many individuals do not consider their deafness to reduce their ability to realize their vital goals, given standard and acceptable circumstances, and that they are therefore not ill. However, this contradicts his statement that deafness is illness (without suffering) [23, p. 81]. Moreover, as long as Nordenfelt admits that the deaf person’s assessment can be wrong due to “epistemic shortcomings” [23, p. 105], the balancing between the subjective and “objective” view remains unresolved. The person with a manic episode is, if we take Nordenfelt’s assertion that the subjects themselves are the experts (ibid, p. 105), healthy, and hence not ill. Still Nordenfelt insists that the person (with the manic episode or being deaf) is ill (see also below).

  6. Says Nordenfelt: “[D]isability covers the cases that suffering does not. This is obvious with coma, deafness, and paralysis.” [23, p. 81].

  7. As Nordenfelt points out: It is “not up to the health-care personnel to decide whether the patient is healthy or not. This evaluation is, as I have claimed, to be made by the patient.” [23, p. 106]. The task of the health care personnel is to decide what action is warranted.

  8. What about the other paradigm case Nordenfelt mentions, manic episodes? The person does not suffer, but is disabled, according to Nordenfelt. However, considering the person as disabled presupposes a social perspective and not a first person perspective. The person may very well find himself being at the peak of his abilities. Hence, it is not obvious that the case of manic episodes works as an example of disability without suffering.

  9. Phantom pain also provides an interesting case for studying the relationship between pain and disability. A person lacking an arm (and with a well-functioning prosthesis) who experiences phantom pain, certainly feels the pain, but the pain in the arm does not result in any disability in the arm, as the arm does not exist.

  10. Please note that the fact that the athlete is exposed to pain by his own will in order to obtain a goal is not relevant here. It is not argued here that the athlete is ill either, as pain is not a sufficient condition for illness. The point here is only that pain does not a necessary lead to disability.

  11. Moreover, the quadriplegic person may not be in pain or suffering with regards to physical sensation, but the person may certainly be significantly bothered and plagued.

  12. In both cases one may obtain subjectivity and relativism, as indicated above.

  13. May it be that “necessary” in the argument that disability is a necessary condition for illness means non-redundant, and not irreplaceable (sine qua non)? Would it then make sense to say that disability is a necessary condition for illness? I guess it would be easier to argue that disability is a non-redundant condition for illness: although many other things can also result in illness, but when they are absent and disability is not present, illness will not occur. Although this opens up for other perspectives, it still ties illness to disability in ways that are countered by the given examples, and to many may appear counterintuitive (not experiencing your own illness) and it reduces people’s possession of their own life.

  14. Supplementing Nordenfelt’s arguments against the primacy of suffering, one could of course add that suffering and pain are elusive concepts that will be of little value in theoretical and practical perspectives.

  15. I am certainly no exception, when I interpret the cases discussed in this paper as persons being ill when they suffer or are in pain.

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  1. Department for Health, Technology and Society, Gjøvik University College, Gjøvik, Norway

    Bjørn Hofmann

  2. Centre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway

    Bjørn Hofmann

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Hofmann, B. On the Downplay of Suffering in Nordenfelt’s Theory of Illness. Health Care Anal 21, 283–297 (2013). https://doi.org/10.1007/s10728-013-0255-2

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