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Medicine, Health Care and Philosophy

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01.02.2010 | Scientific Contribution

The concept of disease—vague, complex, or just indefinable?

verfasst von: Bjørn Hofmann

Erschienen in: Medicine, Health Care and Philosophy | Ausgabe 1/2010

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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.

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.

Banja, J.D. 1997. Defining disease: Praxis makes perfect. In What is disease?, ed. J.M. Humber and R.F. Almeder, 247–268. Totowa, NJ: Humana Press.

Boorse, C. 1997. A rebuttal on health. In What is disease?, ed. J. Humber and K. Almeder. Totowa, NJ: Humana Press.

Brown, W.M. 1985. On defining ‘Disease’. Journal of Medicine and Philosophy 10: 311–328.PubMed

Brülde, B., and P. Tengland. 2003. Hälsa och sjukdom - en begreppslig utredning. [Health and disease–a conceptual exploration] Studentlitteratur, Lund

Burge, T. 1992. Philosophy of language and mind: 1950–1990. The Philosophical Review 101: 3–51.CrossRef

Burge, T. 1996. Individualism and the mental. In The twin Earth Chronicles, ed. A. Pessin and S. Goldberg, 125–142. New York: M.E. Sharpe.

Clouser, K., C. Culver, and B. Gert. 1997. Malady. In What is a disease?, ed. J. Humber and R.F. Almeder, 173–217. Totowa, NJ: Humana Press.

Elliot, C. 1999. A philosophical disease: Bioethics, culture, and identity. London: Routledge.

Engel, G. 1960. A unified concept of health and disease. Perspectives in Biology and Medicine 3: 459–485.PubMed

Engelhardt, H., and S. Spicker. 1975. Evaluation and explanation in the biomedical sciences. Dortrecht: Reidel.

Engelhardt, H., and K. Wildes. 1995. Health and disease—philosophical perspectives. In Encyclopedia of bioethics, ed. W.T. Reich, 1101–1106. New York: MacMillan.

Engle, R.L., and B.J. Davis. 1963. Medical diagnosis: Present, past, and future. I. present concepts of the meaning and limitations of medical diagnosis. Archives Internal Medicine 112: 512–519.

Fischer, E.P. 1995. How many genes has a human being? The analytical limits of a complex concept. In The human genome, ed. E.P. Fischer and S. Klose, 223–256. Munich: Piper.

Fleck, L. 1986. Some specific features of the medical way of thinking. Boston Studies in the Philosophy of Sciences 87: 39–46.

Fulford, K. 1989. Moral theory and medical practice. Cambridge: Cambridge University Press.

Hesslow, G. 1993. Do we need a concept of disease. Theoretical Medicine 14: 1–14.CrossRefPubMed

Hofmann, B. 2001. Complexity of the concept of disease as shown through rival theoretical frameworks. Theoretical Medicine and Bioethics 22: 211–237.CrossRefPubMed

Hofmann, B. 2002. On the triad disease, illness and sickness. Journal of Medicine and Philosophy 27: 651–674.CrossRefPubMed

Hofmann, B. 2003. On the utility of the concept of disease. Tidsskr Nor Laegeforen 123: 1398.

Hofmann, B. 2008. What is disease? (in Norwegian). Oslo: Gyldendal Akademisk.

Jaspers, K. (ed.) 1913/1973. Die Begriffe Gesundheit und Krankheit. In Allgemeine psychopathologie, 651–711. Berlin: Springer.

Jensen, U.J. 1983. Sygdomsbegreber i praksis: Det kliniske arbejdes filosofi og videnskabsteori. Copenhagen: Munksgaard.

Kendell, R. 1975a. The concept of disease and its implications for psychiatry. British Journal of Psychiatry 127: 305–315.CrossRefPubMed

Kendell, R. 1975b. The role of diagnosis in psychiatry. Oxford: Blackwell Scientific Publications.

Kendell, R. 2002. The meaning of disease. BMJ 324: 7342.

King, L. 1984. Medical thinking. Princeton, NJ: Princeton University Press.

Kripke, S. 1982. Wittgenstein on rules and private language. Oxford: Blackwell.

Locke, J. 1690. An essay concerning human understanding II. London.

Nordby, H. 2003. Doctor–patient-interaction is non-holistic. Medicine Health Care and Philosophy 6: 145–152.

Nordby, H. 2004. The importance of knowing how to talk about illness without applying the concept of illness. Nursing Philosophy 5: 30–40.CrossRefPubMed

Nordby, H. 2005. Vague concept of disease in the physician-patient relations. Tidsskr Nor Laegeforen 125: 765–766.PubMed

Nordby, H. 2006. The analytic-synthetic distinction and conceptual analysis of basic health concepts. Medicine Health Care and Philosophy 9: 169–180.CrossRef

Nordenfelt, L. 1987. On the nature of health. Dordrecht: Kluwer Academic Publishers.

Peacocke, C. 1992. A study of concepts. Cambridge, MA: M.I.T Press.

Quine, W. 1953. From a logical point of view. Harward: Harward University Press.

Rosenberg, R. 1991. Some themes from the philosophy of psychiatry: A short review. Acta Psychiatrica Scandinavica 84: 408–412.CrossRefPubMed

Sadegh-Zadeh, K. 1980. Toward metamedicine. Editorial Metamedicine 1: 3–10.

Schlobach, S., M. Klein, and L. Peelen. 2007. Description logics with approximate definitions precise modeling of vague concepts. In Proceedings of the 20th International Joint Conference on Artificial Intelligence (IJCAI 2007), ed. M.M. Veloso, 557–562. AAAI Press.

Sedgwick, P. 1973. Illness–mental and otherwise. The Hastings Studies Center Studies 3: 19–40.CrossRef

Smith, R. 2002. In search for «non-disease». BMJ 324: 883–885.CrossRefPubMed

Sorensen, R. 2001. Vagueness and contradiction. Oxford: Oxford University Press.

Stempsey, W. 1999. Disease and diagnosis: Value-dependant realism. Dordrecht: Kluwer.

Stempsey, W. 2006. Emerging medical technologies and emerging conceptions of health. Theoretical Medicine and Bioethics 27: 227–234.CrossRefPubMed

Sundström, P. 1987. Icons of disease: A philosophical inquiry into the semantics, phenomenology and ontology of the clinical conceptions of disease. Linköping: Linköping University.

Sundström, P. 2001. Disease: The phenomenological and conceptual center of practical-clinical medicine. In Handbook of phenomenology and medicine, ed. S. Toombs, 109–126. Dordrecht: Kluwer Academic Publishers.

Toon, P. 1981. Defining “disease”—classification must be distinguished from evaluation. Journal of Medical Ethics 7: 197–201.CrossRefPubMed

Wells, H. (ed.) 1908. The classificatory assumption. In First and last things. London: Constable.

Wierzbicka, A. 1996. Semantics, primes and universals. Oxford: Oxford University Press.

Williams, B. 1985. Ethics and the limits of philosophy. Cambridge, MA: Harvard University Press.

Williamson, T. 1994. Vagueness. London: Routledge.

Worall, J., and J. Worall. 2001. Defining disease: Much ado about nothing? Analecta Husserliana 72: 33–55.

Zajicek, G. 1995. Normative medicine. Medical Hypotheses 45: 331–334.CrossRefPubMed

Titel: The concept of disease—vague, complex, or just indefinable?
verfasst von: Bjørn Hofmann
Publikationsdatum: 01.02.2010
Verlag: Springer Netherlands
Erschienen in: Medicine, Health Care and Philosophy / Ausgabe 1/2010
Print ISSN: 1386-7423
Elektronische ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-009-9198-7

Springer Medizin

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