Boorse, Christopher – What Is Health and What Is Disease?

Introduction

On my summer mountain trips, my friends and I often discuss topics such as gender, mental disorders, borderliners, the bizarre existence of mass psychogenic illness (or mass hysteria) and so on. I am, however, neither a physician nor a psychiatrist, and I have been reproached that I should therefore not speculate idly without expert knowledge. I took the objection to heart and began to investigate who defines mental disorders, and how, and how it is decided who is healthy and who is ill. Last semester I then completed a course at the Institute of Philosophy and Religious Studies of the Faculty of Arts, Charles University, devoted precisely to the philosophy of psychiatry, and with the two previous articles on Foucault and Szasz I began a series in which I deal with the philosophy of medicine and psychiatry on the basis of what I have learned.

Foucault claimed that mental disorders are labels which the ruling establishment, by means of psychiatry, attaches to people who appear to be an inconvenient and dangerous element disturbing the order of society. Foucault does not deny that mental disorders exist. But because of the close relationship between the judiciary and psychiatry, psychiatry becomes an overly powerful interpretation of an individual’s life and mental functioning. It is precisely on the basis of a psychiatric examination and recommendation that a court decides whether the accused will “merely” go to prison, because they committed the act fully conscious and of sound mind (they were healthy, only morally corrupt), or will go to a psychiatric hospital for treatment, because at the moment of the act they were not mentally healthy. Foucault points out that psychiatrists follow the current social-scientific framework of what society considers a mental disorder and illness, and what is merely a moral failing and a flaw in the character of the convicted. Psychiatrists became experts whose task is to explain to the courts why a given person committed this or that crime. In Foucault’s words, psychiatrists are the executors of society’s mental hygiene.

Szasz was a psychiatrist who wrote many texts in which he argued that mental disorders do not exist. According to Szasz, what we call a mental disorder can in fact be divided into two categories. In the first case, so-called mental disorders are caused by damage to the brain, and if that is so, they are not mental disorders in the strict sense of the word, but a physiological injury or lesion of the brain. In the second case, all the other mental disorders are, for Szasz, “problems in living”, that is, an inability to cope with the complexity of everyday life.

Both authors belong to the so-called antipsychiatry movement, which emerged in the 1960s. The antipsychiatry movement does not call the whole of psychiatry into question, but offers a critical view of: “psychiatric everyday life, the automatisms in the ordinary running of psychiatric hospitals, the thoughtless and simplifying ‘labelling’ of mentally ill individuals with diagnostic categories […] In psychiatric diagnosis the boundaries are blurred and the diagnostic conclusion may be arbitrary; it depends not only on the erudition of the physician, but also on the historical and social understanding of abnormal phenomena, or simply of such manifestations as society labels psychopathological.”^[1] Szasz and above all Foucault believed that psychiatrists do not look for lesions on the body or in the brain, but that in interpreting an individual’s behaviour they have to start from what is considered “normal”. And this “normal” is inevitably defined not within psychiatry itself, but in a wider social-scientific context, in what philosophy calls a “framework” or paradigm and what Foucault specifically called the episteme^[2], that is, the state of a society’s knowledge and understanding, which is historically conditioned by a given cultural and historical epoch.

It is precisely the definitions of, and the argumentative battles over, what society considers normal that are also bound up with what the field of medicine considers a disease (disease, disorder) and what it considers a healthy state (health).

Philosophy and medicine

Philosophical analysis of concepts in medicine may be dismissed as having no contact with the reality of practising medicine, where doctors have no time to philosophise, because they must deal with urgent cases and must act here and now. My view is that medicine, like every field, must have clear rules about what falls within its competence and remit. Philosophical imprecision need not show in the everyday running of the field. A person with a broken leg or in cardiac arrest is intuitively a patient who needs doctors’ help. The imprecision and the lack of grounding show in borderline cases: what about circumcision, say, or breast enlargement? Female circumcision is internationally regarded as an atrocity against humanity. Why is this not the case with male circumcision? Are we internationally misandrous, or is it a historical and cultural accident that the world regards male circumcision as an ordinary medical procedure? How is it possible that the same procedure can be viewed so differently in different places on the planet? And if this happens with one procedure, is it not likely that other procedures we consider ordinary, normal, may come to look like atrocities to us in the future?

If we look at psychiatry, homosexuality was until recently considered a mental disorder. What had to happen for something that used to be treated in psychiatric hospitals to be regarded today as a normal variation of human sexuality? I am not assessing the morality of homosexuality here; I am interested in how the scientific paradigm in psychiatry developed, and what led to its change, such that a human behaviour B1 is considered an illness in one historical phase, while in another phase of history the same behaviour B1 is considered a normal and healthy expression of human behaviour and conduct. In the history of psychiatry we have, for example, drapetomania^[3], as late as the 19th century in the USA. The term was introduced by the American physician Samuel A. Cartwright, who tried in 1851 to explain why enslaved people fled from slavery. With this would-be diagnosis, the American physician interpreted the normal desire for a free life as a mental pathology. Today drapetomania is a textbook example of how science can be abused to legitimise racism and slavery. But the problem remains: if we have no definition of what health is and what disease is, we cannot say unambiguously that one thing is a disease and another a normal expression of healthy behaviour and bodily functioning.

Among the main philosophical contributions to the debate about what health is and what disease is, in medicine as well as in psychiatry, is the article Health as a Theoretical Concept^[4] from 1977, written by the philosopher of medicine Christopher Boorse.

Health as a theoretical concept

With his article, Boorse was responding to an unfavourable situation in the psychiatric literature, in which the ideas of the antipsychiatry movement had begun to prevail. If psychiatry is to treat mental illnesses, but at the same time there is no sufficiently rigorous definition of what illness and health actually are, this confronts the field and its practitioners with a problem. At first the problem will show only in marginal cases, but later the philosophical unclarity of the basic notions and concepts may swallow the entire field. So how does medicine define health (and, by extension, disease)? Boorse decided to answer the question by first examining what the medical literature says in general. According to the literature, disease and health can be defined in several ways: on the basis of values; by what doctors treat; by statistical normality; by pain and suffering; by disability and limitation of abilities; by homeostasis; and finally from the perspective of biological adaptation and the function of bodily and mental processes.

(1) Value

People value health and prefer it to disease. That, however, does not help us define health, because there are many undesirable bodily states that medicine does not consider diseases: short stature, lack of strength or stamina, slow reflexes, a lack of physical beauty and so on. We therefore cannot define health on the basis of what is desirable or undesirable. Conversely, some diseases may be desirable. Cowpox saves lives during a smallpox epidemic; short-sightedness saved the lives of some men because they did not have to enter military service; acquired infertility may come as a deliverance to parents with many children.

(2) Treatment by doctors

According to Boorse, the literature sometimes simplifies things by defining health and disease simply like this: whatever doctors treat counts as a disease. But this can be neither a sufficient nor a necessary definition of disease. Circumcision, cosmetic procedures, elective abortions and the like, for example, are procedures performed by doctors, yet no one speaks of them as diseases.

(3) Statistical normality

The literature also interprets normality statistically. On the basis of a selected population sample, it is possible to establish the clinically relevant values of the variables we measure and their normal variation within the given population. Values are then normal if they fall within the normal variation of the measured population. In other words, on a purely statistical interpretation, what is normal and indicates health is what is common in the population.

This approach has several problems. For example, what is not common in the population is not always abnormal. Blood group O or red hair are less common than their alternatives, yet no one would want to claim that people with these traits are abnormal and ill. Conversely, seemingly normal things can be diseases. If almost everyone in a society smokes or lives in a dusty environment and has lung problems, we ordinarily consider such people ill, even though their problems and addictions are statistically common in the population in question. Another example is atherosclerosis, which is a very common disease of the arteries.

Statistical frequency can be neither sufficient nor necessary for defining what is normal and healthy.

(4) Pain, suffering, discomfort

Another possible way of defining disease is by what causes us pain and discomfort. Many natural human bodily processes are accompanied by pain – childbirth, menstruation, teething – without our considering these processes diseases. Conversely, we know of many diseases that are not accompanied by a subjective experience of pain and suffering. A tumorous lesion, for instance, is a disease that may manifest itself for a long time without any pain.

(5) Disability / limitation of abilities

Disease usually brings with it indisposition and a limitation of abilities. Not every indisposition and limitation of our abilities is a disease, however. Childbirth or fever are limiting bodily states, but they belong among the natural and normal bodily processes; their absence at the expected moment, on the contrary, could be a pathological phenomenon and a disease.

(6) Homeostasis

The literature further mentions the process of homeostasis. Homeostasis is the maintenance of a constant internal environment of the organism (e.g. constant temperature, pH, ion concentration, etc.). It is necessary for the normal activity of the organism.^[5] Homeostasis is not a suitable indicator of health, because many natural processes of the body are designed precisely to disrupt homeostasis: growth, pregnancy, movement, perception. These processes end up disrupting the constancy of the internal environment; it is precisely because homeostasis is disrupted as a matter of daily routine that we, as organisms, are flexible and able to adapt to changes in our surroundings. While diseases disrupt homeostasis, a disruption of homeostasis cannot automatically be taken as a sign of disease.

(7) Adaptation

From the point of view of biology, the traits and abilities of an organism are adaptations to its environment. Several authors in the philosophy of medicine began to use precisely the concept of biological fitness to define what health is. The classic Darwinian view of biological fitness rests on success in genetic reproduction. Boorse objects that adaptation and fitness defined this narrowly cannot be good indicators of health: it rarely holds that the more children a person has, the more “healthy” they are. Given how demanding parenthood is, we would be tempted to say that the opposite is true. In some kinds of environment, having fewer children seems to be the more useful strategy for survival. If the environment is inhospitable and life is costly in both time and money, people choose to have fewer children and invest their limited resources in a smaller number of them. On the other hand, if a person in an inhospitable environment can afford to have more children who survive and have enough resources to live on, that is a strong indicator of good adaptation. Some abilities and bodily dispositions are suitable only in a particular environment. A well-known example is sickle cell anaemia (sickle cell disease). Sickle cell anaemia and malaria are genetically and evolutionarily linked. People with sickle cell trait (carriers – HbAS) are naturally protected against severe forms of malaria, which gives them a survival advantage in malarial regions, for example in the countries of West Africa. From the opposite angle, there are abilities, such as mathematical or linguistic ones, which provide an adaptive advantage and, in today’s environment of modern Western society, lead to a higher likelihood of reproductive fitness, yet we do not consider an average or below-average level of them a disease (down to a certain level). Myopia in some environment far from civilisation, where glasses or contact lenses do not exist, is a serious problem for survival, whereas anywhere in Europe it is no problem at all; indeed, for various reasons myopia may even be taken as a reproductive advantage, thanks to its association with the image of an intellectual and a clever person.

The fact is, then, that we must judge how advantageous a given adaptation is, and not only for reproductive fitness, in relation to a specific environment. Which is nothing new for biologists; adaptations always evolve relative to the given environment in which the organism lives. The longer an organism lives in an environment, and the more stable that environment is, the more pronounced the association between the environment and the individual’s bodily traits as adaptations advantageous for that environment.

If adaptation is the result of nature, which plays the role of the designer of bodily and mental processes, can a state in which the body or the mind does not perform a function designed by nature be considered a disease? And if both body and mind function according to nature’s design, can that be considered health? That is what the next section turns to.

A functional definition of health

Boorse holds that health (and disease) can be defined and assessed objectively, independently of subjective judgements. He believes that an objective definition of disease and health must be based on a combination of 1) the biological function of bodily and mental processes, which are the result of the organism’s evolutionary adaptation, 2) and the statistical typicality (normality) of their functioning.

Boorse draws on a vision of health that already appears in antiquity in the father of European medicine – Galen: what is normal is natural. Health is the normal state of a human being, and disease is something unnatural and abnormal. The essence and nature of the human being as a biological organism is health and the normal functioning of the body. From this point of view, everything that disrupts the normal functioning of the body is considered a disease.

The functions of cells, of the digestive system, of the heart, and even human behaviour are manifestations shaped by evolution for the purpose of survival and reproduction. Boorse and other proponents of the functional view of health and disease see the functions of the body as the fulfilment of the organism’s goals, and the highest of these goals are precisely reproduction and survival.

Bodily functioning, however, changes over the course of a person’s life. A person who is too young or too old, for example, is infertile. That a child or an old man is infertile at their age is not considered a disease, because this “non-function” is expected. That is also why we must understand the functioning of the body in relation to age. Further, the category of sex determines what bodily functions a given person can have. It is statistically typical for a biological male not to have a uterus and not to be able to give birth. This non-function is, again, expected of the male sex. Besides age, then, we must also assess the functioning of the body according to biological sex. Boorse mentions that to determine the statistically typical values of bodily functions precisely, people’s ethnic origin needs to be taken into account. But he does not develop the idea any further.

We never assess the normal functioning of bodily processes against an abstract image of the human being as a biological species; we refine it according to age, sex and possibly also the ethnicity mentioned above, which together form the so-called reference class.

The normal functioning of bodily processes is thus a state in which the parts of the body perform their biologically designed function, which contributes to survival and reproduction, at a level that is statistically typical or better for the given reference class.

A given bodily function need not be performed all day long. The digestive system does not work all the time; we sleep only a few hours a day, and so on. It is therefore good to add to the definition of normal functioning that a part of the body does not perform its function at a statistically typical level all the time, but is ready to perform this function in statistically typical situations.

What, then, are disease and health from the functional point of view?

Disease is a state in which some parts of the body do not perform their function contributing to survival and reproduction at a statistically typical level.

Health is then the absence of disease. Or rather, a state in which all parts of the body perform their function contributing to survival and reproduction normally – for the given reference class, at least at a statistically typical level or better.

Problems with Boorse’s definition

Boorse is aware that his theory does not always work. For instance, when a person is born with the heart positioned on the right (dextrocardia), current medicine considers it an anomaly and a congenital defect. From Boorse’s functional point of view, however, it seems to be neither a disease nor a disorder. A heart positioned on the right is still able, through its function, to contribute to survival and reproduction at a statistically typical level.

Far more controversial is the question of homosexuality. Boorse’s definition of disease seems to imply that the bodily processes of a homosexual person prevent parts of the body from performing their evolutionarily designed function for the purpose of reproduction at least at a statistically typical level. In practical terms, in homosexuals this level equals zero. But can we reconcile Boorse’s definition with the current attitude to homosexuality? Probably yes, if we recall that Boorse’s definition allows that bodily processes need not perform their function all the time; it is enough if bodily processes and parts are potentially able to fulfil their biological function designed for survival and reproduction. Homosexual people – unless they suffer from impotence or other problems – are theoretically capable of reproducing naturally, only their psychological software is programmed in such a way that they give up this capacity because they do not prefer it. Problematising Boorse’s functional view of health and disease in relation to homosexuality is a fascinating topic in the literature in its own right and beyond the scope of this article. So I will stop here, but I recommend reading up on the topic, because Boorse himself was unhappy that his work could be understood, and potentially abused, as an argument against homosexuality.

Defining positive health

Boorse’s theory also has consequences for the so-called conceptualisation of positive health. Apart, perhaps, from aesthetic medicine, contemporary medicine is not primarily concerned with positive health, in which it would try to go beyond restoring the original state and help improve the functioning of the body beyond what a person was born with. Boorse’s theory simply defines positive health as any intervention that improves the functioning of bodily (and mental) processes and parts in relation to survival and reproduction to a level that is statistically above average and better. That, again, is a topic that would deserve an article of its own and is beyond the scope of this text.

Summary

With his article Health as a theoretical concept, Boorse, as a philosopher of medicine, responded to the growing influence of the antipsychiatry movement in medicine and psychiatry. He disagreed with the movement, because he believed that health and mental disorders are not merely states of body and mind that depend on the subjective judgements of experts or of society. To defend an objective definition and the existence of health, and thereby of mental disorders, he focuses on a narrower project: a definition of health and disease (disease, disorder). If he succeeds, he can defend the existence not only of bodily but also of mental disorders and diseases.

He claims that what is normal is natural. To defend this claim, he borrows terminology from evolutionary biology and from the statistical view of health. Bodily and mental processes are the result of the evolutionary history of the human being as an organism: the functions of body and mind are adaptations whose main function, in the last instance, is to contribute to the goals of evolution and adaptation as such: survival and reproduction. If bodily and mental processes contribute through their function to survival and reproduction at least at the statistical level typical for a person of their age and sex, we can say that they perform their function the way nature “designed” them.

It follows that disease is a state in which bodily or mental processes do not contribute through their function to survival and reproduction as would be statistically typical for the given age and sex class. Health can then be defined as a state of body and mind in which disease is absent.

Although Boorse strives for an objective and conceptually rigorous definition, it is not without its problems. A traditional criticism of his position is the fact that homosexuality appears to be a disease: the bodily and mental processes of homosexual individuals do not perform the function that contributes to survival and reproduction at the statistically typical level for the given age and sex group. The theory could be rescued from the problem of homosexuality if we apply what Boorse himself claims: bodily and mental functions need not be “in operation” constantly; what matters is that the body and mind are ready and able to perform these functions. In other words, the bodily processes of homosexual individuals are theoretically capable of performing their function. For various reasons and causes that cannot be influenced by mere will, however, homosexuals have no interest in making use of these theoretical functions of their bodily processes.

Someone might object, though, that this inability, or absence of desire, to use the bodily processes and parts adapted for reproduction is a form of mental disorder, because this absence of desire is statistically atypical and does not contribute positively to reproduction.

Is that so? Boorse is aware that his theory can be abused to claim that homosexuality is a disease. It would be worth looking some time at how Boorse came to terms with this.

 

Sources

1. https://encyklopedie.soc.cas.cz/w/Antipsychiatrie ↑
2. https://encyklopedie.soc.cas.cz/w/Épistémé ↑
3. Derived from Greek: drapetēs = runaway slave, mania = madness ↑
4. https://www.jstor.org/stable/186939 ↑
5. https://www.wikiskripta.eu/w/Homeostáza ↑