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by Lennart Nordenfelt with contributions by George Khushf and K. W. M. Fulford
Rodopi, 2001
Review by Patricia Ross, Ph.D. on Dec 5th 2002

Health, Science, and Ordinary Language

            Health, Science and Ordinary Language is an examination of theories of health and disease, in general, and in particular, the rift that exists between medical or biostatistical theories, on the one hand, and normative theories, on the other. The book is divided into two parts.  The first, written by Lennart Nordenfelt, and occupying more than two-thirds of the book, critically examines four contemporary theories of health, disease and illness with an eye toward uncovering the implicit and explicit purposes of these theories.  By focusing on these things, Nordenfelt aims to show the ways in which three of these theories fail and why the fourth, his own radical Reverse Theory of medical concepts, succeeds.  The second part of the book includes two commentaries; one entitled "What Is at Issue in the Debate about Concepts of Health and Disease?  Framing the Problem of Demarcation for a Post-Positivist Era of Medicine" by George Khushf and the other, "Philosophy into Practice:  The Case for Ordinary-Language Philosophy" by K. W. M. Fulford.

            Part I begins with an examination of what has become the locus classicus of such discussion, Christopher Boorse's biostatistical theory of disease.  Nordenfelt ascribes four goals to Boorse: (1) developing a descriptive theory; (2) detailing what doctors mean by health and disease; (3) characterizing the pathological notion of disease; and (4) accounting for the notion of health and disease in medical classification.  By providing examples of conditions recognized as diseases or disorders in the ICD and DSM, Nordenfelt argues that Boorse's biostatistical theory fails to achieve each of the goals it sets for itself.

            Nordenfelt then tackles Lawrie Reznek's alternative medical theory of disease.  While scientific methodology remains essential to this theory, Reznek claims that it is not sufficient for identifying diseases.  Some notion of harmful consequences must be incorporated into the scientific account.  But Reznek's theory, too, falls short of adequate according to Nordenfelt.  For while this theory does improve upon Boorse, insofar as it recognizes that biological malfunction, alone, is incapable of capturing the concept of disease as it is currently understood, the notion of harm that Reznek uses to supplement this scientific theory is inadequate.  According to Nordenfelt, Reznek relies upon a concept of goodness that is too broad for the purposes that it is to serve. Understanding harm in terms of an impediment to a good or worthwhile life leads to the inclusion of too many bodily and mental states currently not recognized as diseases or disorders.

            This brings us to the last two contemporary theories of disease and health, which Nordenfelt labels reverse theories.  The label comes from the fact that such theories maintain that illness must be identifiable first, prior to saying that a disease has been found.  If one cannot identify illness, there will not be any reason for looking for diseases.  K. W. M. Fulford begins development of his theory by considering the ordinary use of the notion of illness.  Given a belief that such concepts are not necessarily specifiable in strictly scientific terms, Fulford resists any approach that entails eliminating the ordinary language concepts in favor of strictly scientific definitions.  Scientific work may supplement or make clearer our ordinary language concepts but should not be thought to replace them.

            Nordenfelt's own reverse theory of disease, similar in kind to Fulfordís theory, nevertheless starts from a belief that Fulford has not been radical enough in formulating his theory. Nordenfelt, like Fulford, maintains that an adequate theory of disease presupposes an adequate theory of illness.  But unlike Fulford, Nordenfelt goes one step further and argues that an adequate theory of illness presupposes an adequate theory of health.  Thus, the starting point in understanding disease and disorder is a theory of health.  Nordenfelt goes on to explain just how such a theory not only solves the problems encountered by Boorse, Reznek and Fulford, and accounts for our ordinary use of disease and disorder, but also addresses concerns about the relationships among health concepts, between human health and the health of other living beings, between mental and somatic health, between health and the environment and, lastly, of the place of health concepts in science.

            In Part II of Health, Science and Ordinary Language, we are presented with two commentaries.  The first, by George Khushf, is an in-depth, scholarly piece that situates the four theories considered in Part I within a broader context.  Khushf first considers our common sense notions of health and disease, as well as our biomedical notions, and examines the relationship between them.  This is intended to provide insight into how more general problems that arise in the relationship between science and the activities of individuals and society are reflected in this domain.  He also situates modern biomedicine within a positivistic notion of science, and this medical positivism within the broader context of philosophy of science. The first context explains why medicine separates theoretical from practical problems.  The second explains why only epistemic concerns play a role in science.  Values, being non-epistemic, are to be avoided in science.  From the point of view of this detailed contextual backdrop, Khushf then examines the current debate.  In his argument, he shows why it is time to stop treating Boorse as the starting point for discussions of disease and health.  Further, only by eliminating the divide between the epistemic and values will it be possible to progress in this area.  Khushf maintains that Fulford and Nordenfelt bring the discussion to this level and provide us with a foundation from which to proceed.

            The second commentary, K. W. M. Fulford considers some of the changes that have occurred in psychiatry within the last decade.  In detailing these changes, he argues that the role of philosophy has been significant and important. Far from looking upon these influences as suspect, they should be encouraged and nurtured.  Conceptual development must take place in unison with empirical development.

            Health, Science and Ordinary Language is a contribution to the current philosophical discussion of the concept of health and disease, but I find myself at a loss to say exactly what the contribution is.  I find the standard book-reviewer's question -- What is the intended audience of this book? -- difficult to answer.  The discussion in Part I of the four theories of disease requires a good deal of background knowledge to fully understand what is being discussed.  One couldn't present the book to a seminar on concepts of disease and disorder without first providing a good deal of background. And after providing that background, students would most likely not find much new of interest in the coverage presented in Part I.  Moreover, the book fails to address a number of important theories on the topic.  The purpose seems to be to enter a particular sub-debate within the larger debate on concepts of disease and disorder.  Thus, it is also narrow in its scope. Finally, the two parts of the book are disjoint, lending an overall lack of coherency to the project.  While each of the commentaries warrants being published independently and, perhaps, somewhere more visible, neither seems particularly engaged in what, in particular, has been discussed in Part I.  Thus I would recommend Health, Science and Ordinary Language as a core component around which to develop a course, or as reading for someone already fairly well familiar with contemporary debates on health and disease, looking to think a bit more about the particular debate at issue.

 

© 2002 Patricia Ross

 

Patricia Ross Ph.D., is an independent researcher and resident fellow of the Minnesota Center for Philosophy of Science. Her research and writing focus on foundational issue in medicine, psychiatry and psychology. Currently, she is examining the concept of disorder as it is employed in psychiatry and psychology, work that is supported by a National Science Foundation grant. She has a continuing interest in the ways in which scientific research is interpreted and used in formulating policies and protocols.