Health, Science, and Ordinary Language (Value Inquiry) 9042013060, 9789042013063

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HEALTH, SCIENCE, AND ORDINARY LANGUAGE

VIBS Volume 110

Robert Ginsberg

Executive Editor Associate Editors

G. John M. Abbarno Mary-Rose Barral Gerhold K. Becker Kenneth A. Bryson C. Stephen Byrum H. G. Callaway Rem B. Edwards Robert N. Fisher William C. Gay Dane R. Gordon J. Everet Green Heta Aleksandra Gylling Matti Hayry

John R. Welch

Steven V. Hicks Richard T. Hull Laura Duhan Kaplan Joseph C. Kunkel Vincent L. Luizzi Alan Milchman George David Miller Jon Mills Peter A. Redpath Alan Rosenberg Arleen L. F. Salles John R. Shook Alan Soble

HEAL TH, SCIENCE, AND ORDINARY LANGUAGE

Lennart Nordenfelt

With contributions by George Khushf K.

w. M. Fulford

Amsterdam - New York, NY 2001

The paper on which this book is printed meets the requirements of "ISO 9706: 1994, Information and documentation - Paper for documents Requirements for permanence". ISBN: 90-420-1306-0 ©Editions Rodopi B.V., Amsterdam - New York, NY 2001 Printed in The Netherlands

CONTENTS

Foreword by Zbigniew Szawarski Author's Preface

ix xi

Part One. Disease and Illness Revisited: Where Should Medical Theory Go? One. Introduction 1. Background 2. The Purpose of This Study 3. The Purposes of a Philosophical Analysis of Medical Concepts 4. A Complication with Regard to the Notion of Having or Sharing a Concept 5. A Brief Outline of the Four Theories of Health, Illness, and Disease

3 3 4 4

Two. The Biostatistical Theory of Disease: Christopher Boorse 1. A Summary 2. An Investigation of Boorse's Project 3. Boorse on Dynamic Interaction: The Need for a Circumstance Clause 4. The Idea of a Pathological Disease 5. On Medical Classifications of Diseases and Related Conditions 6. Preliminary Conclusions Concerning Boorse's Project

11 11 12

7 8

14 18 21 24

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 1. Introduction 2. The Medical Paradigm 3. The Challenges of the Medical Paradigm and Some Mistaken Views About Disease 4. Reznek's Positive View Concerning Disease and Illness 5. Reznek's Definitions of Pathological Condition and Disease 6. An Examination of Reznek's Theory of Disease 7. Concluding Remarks on Reznek's Theory of Disease

32 35 37 39 50

Four. Toward Reverse Theories of Health and Illness: K. W. M. Fulford and Lennart Nordenfelt

53

29 29 30

vi

CONTENTS

1. Introduction 2. Fulford's Reverse Theory of Illness A. Fulford's Program B. The Concept of Illness as Basic; the Concept of Disease as Derived C. The Concept of Illness as Related to Failure of Action; the Concept of Dysfunction as Related to Failure of Doing D. Illness as Failure to Perform Ordinary Intentional Actions E. Diseases as a Subcategory of Illnesses F. The Place of Pain and Suffering in Illness G. On Illness, Disease, and Values H. The Notion of Mental Illness I. Fulford's Assessment of His Project J. The Methodology of Fulford's Project 3. Nordenfelt's Welfare Theory of Health A. The Sources and the Nature of the Project B. Health as the Primary Concept C. The Primacy of Ability and Disability D. Health as Ability to Reach Vital Goals E. Vital Goals as Preconditions for the Subject's Minimal Happiness F. Diseases, Injuries, and Defects as Causes of III Health G. A Preliminary Assessment of Nordenfelt's Project 4. A Comparison between the Theories of Fulford and Nordenfelt A. Similarities between the Two Theories B. Differences between the Two Theories

Five. Toward a Critical Assessment of the Reverse Theories of Health and Illness 1. The Notions of III Health, Illness, and Disease A. Introduction B. Fulford's Reflections on the Ordinary-Language Notions of Illness and Disease C. The Reconstruction by Fulford and Nordenfelt of the Concepts of Disease and Illness D. The Concept of Illness as Proposed by Medical Sociologists and Medical Anthropologists: The Place of Suffering in Illness E. Fulford and the Experience of Failure of Ordinary Doing F. Nordenfelt on Subjective Illness G. A Phenomenological Approach to Illness: The Proposal of Fredrik Svenaeus 2. On the Notion of Ability

53 54 54 56 57 57 58 58 59 59 61 62 63 63 65 66 67 67 69 69 72 72 73

75 75 75 76 77 80 83 84 85 88

Health, Science, and Ordinary Language

A. Fulford on Health and Ability B. What Abilities Are Relevant for the Characterization of Health? 3. On Medical Goodness and the Values Attached to Health and Illness-Ascription A. Fulford on Health and Values B. Health-Ascription as Overt Evaluation C. Nordenfelt, Health, and Evaluation 4. On the Relation between Health and Happiness 5. On the Clinical Use of the Reverse Theories of Health Six.

Summary and Conclusions Concerning the Four Theories of Health

VB

88 93 100 100 102 103 108 110 113

Part Two. Two Commentaries by George Khushf and K. W. M. Fulford 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 Introduction Ordinary versus Scientific Notions of Health and Disease: Situating the Problem of Natural Kinds in Medicine A. The Common Sense Notions of Health and Disease B. The Scientific Notions of Health and Disease C. The Relation Between Common Sense Notions and Scientific Notions of Health and Disease D. What Is Implied by the Claim that Disease Is a "Natural Kind"? Positivist Science and the Paradigm of Biomedicine A. Science and the Reforms of Abraham Flexner: Situating Modem Medicine Historically B. The Link Between Medical and Logical Positivism The Biostatistical Disease Concept as a Condition of Medical Positivism: Appreciating Boorse's Innovation in the Philosophy of Biology A. Theoretical Assumptions in Medicine: The Biostatistical Disease Concept as a Variant of Broussais's Principle B. Practical Assumptions in Medicine: Upholding Flexnerian Ideals in the Face of Social and Economic Transformations of Health Care

One.

1.

2.

3.

4.

123 123 127 128 131 132 133 135 135 138 143 145 146

Vlll

CONTENTS

5. Post-Positivist Philosophy of Science: Sustaining Practical Corollaries of the Positivist Project without the Assumption of Value-Neutrality A. The Breakdown of Logical Positivism B. Two Strategies for Sustaining a Strong Demarcation between Science and Nonscience 6. Post-Positivist Philosophy of Medicine: Establishing Debate among Normativists A. Lennart Nordenfelt's Distinction Between Normative and Descriptive Dimensions of Medicine B. K. W. M. Fulford's Distinction Between Medical and Nonmedical Values C: Preliminary Assessment of the Weak Normativist Project 7. On the Link Between Individual and Communal Flourishing: The Case for a Strong Normativism

149 151 154 157 158 160 163 167

Two. Philosophy into Practice: The Case for Ordinary-Language Philosophy. By K. W. M. Fulford 171 1. Introduction 171 2. Ordinary-Language Philosophy and Clinical Practice 172 A. The Models Project: A Brief Outline 172 B. Ordinary-Language Philosophy and the Models Project 174 3. Ordinary-Language Philosophy and the Role of Values 183 A. Values: From Theory to Practice 184 B. A Full-Field Model 187 4. Ordinary-Language Philosophy and Scientific Research 190 A. From Values to Action in Medical Theory 190 B. An Action Theory Analysis of the Experience of Illness 193 C. Action Theory, Psychosis, and Neuroscience '203 5. Philosophy into Practice: A Collaborative Approach 204 6. Conclusions: Psychiatry First 206 Afterword References About the Authors Index

209 215 227 231

FOREWORD The language of science is universal. Whatever your particular subject, be it physics, chemistry, or genetics, if you are a scientist you rely on the same basic textbooks and read the same international journals. Many of us believe that the same is the case in the medical sciences. Wherever they study, medical students are expected to acquire a similar body of knowledge and skills. When they do research, they are expected to publish in the same journals of international authority and reputation. On the other hand, when we carefully examine the theory and practice of medicine, we will notice some striking differences between medicine and most other sciences. For example, theorists of medicine cannot agree on the proper reconstruction of the conceptual framework of medicine. Should we begin with a definition of disease, or should we take as the starting point a definition of health and illness? Should we define health in the language of value-neutral functions, or should we define it in the value-laden language of actions or accomplishments of vital goals? The problem becomes even more complicated when we consider different linguistic traditions. There are countries where you can write a serious dissertation on the distinction between the concept of illness and disease, and countries where one word only is used to express both meanings. These differences are even more astonishing when we take into account other non-Western cultural traditions or even the way the same modem medicine is practiced in so-called Western culture. In Germany, low bloodpressure is a serious medical condition that is often treated, in the United Kingdom, it is usually a sign of good health. In America, the multiple personality disorder or attention deficit disorder has reached almost epidemic proportions. These two conditions are virtually unknown in Central Europe. And I have never come across a Polish doctor who has diagnosed chronic fatigue syndrome. You can say that this is a question of culture and cultural traditions transmitted through the academia. But more explanation is needed. The specific feature of modern medicine is that it has two absolutely different aspects, which cannot be boiled down to a common denominator. On the one hand, medical knowledge seems to be abstract, general, universal, value-free and applicable in all cases, which are similar in relevant respects. This is knowledge of the nature of health and disease. But another kind of medical knowledge exists, namely, knowledge of ill and suffering people. This knowledge originates at the bedside and is practiced in the art of diagnosis, prognosis, and treatment. Evidently, medicine is something more than

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pure theoretical knowledge about the healthy or malfunctioning human body. Medicine is also the practical knowledge of how to help ill people to regain their lost or severely damaged abilities. Although in both cases we are using the same words, we still cannot agree what is the exact meaning of health, disease, illness, injury, defect, disability, handicap, or even medical condition. Weare radically divided with regard to the questions if and how it is possible to offer a value-neutral defmition of health. This is precisely the main topic of this book. It is an extremely lucid, critical examination of four contemporary theories concerning the nature of health, disease, and illness. The fIrst of them (the biostatistical theory of health of Christopher Boorse) holds that it is possible to defme health in the value-neutral language of biological and psychological functions. The three others (the theories of Lawrie Reznek, K. W. M. Fulford, and Lennart Nordenfelt) contest Boorse's thesis and propose their own more or less normative defmitions of health and disease. How normative they can be and what are the possible social and political consequences of accepting these or alternative philosophies of health is a subject of an original and thoughtprovoking essay by George Khushf who brings in a new conceptual framework to discuss those complex issues. In a subsequent essay, Fulford explores in an interesting way the implications of a normative theory of health and illness for the science and practice of psychiatry. Many years ago, Edmund D. Pellegrino, a distinguished American physician and philosopher of medicine, had written that medicine is "the most humane of the sciences; the most scientifIc of the humanities" (1973, pp 1637). This new book by Lennart Nordenfelt, a leading world authority in the philosophy of health and illness, is an excellent confIrmation of that truth. Concentrating on one issue only, the possibility of defming health, disease, and illness, all of the authors contributing to the book beautifully exemplify this dramatic tension between the apparently value-free scientifIc, and the value-laden, humane aspect of medicine. The debate on the nature of health and disease is entering a new stage. Zbigniew Szawarski Professor of Philosophy Warsaw University

AUTHOR'S PREFACE The work with this book started during my sabbatical leave in Coventry, England, in 1998 and 1999. I then had the privilege to act as a Visiting Professor at the sparkling Department of Philosophy of Warwick University, England, which for me, with its mixture of analytical and continental approaches to philosophy, was a great source of inspiration. I was given the best facilities for academic work, and for this I wish to express my gratitude to the Head of the Department, Dr. Greg Hunt, and to the head of the section for Philosophy and Mental Health, Professor K. W. M. Fulford. My intention with this book was to reevaluate, and at the same time make a comparative analysis of, some current theories of health and illness (including my own proposal from 1987). It seemed to me that time was ripe to take a new stand. We have had two decades of debate between so-called descriptivist and normativist theorists of health. Progress has been made in this debate, and some positions have become clearer, but in a crucial respect no major steps forward have been taken. George Khushf expresses this quite clearly in his contribution to this volume: "The next stage in the development of philosophy of medicine will only take place when normativists move beyond the value-neutral disease concept and start to argue with each other." In the following pages it will become clear that the normativists, while agreeing on some basic matters, can present quite different theories of health with partly diverging implications for health care. The theories which are particularly under scrutiny here, those of Lawrie Reznek, K. W. M. Fulford, and Lennart Nordenfelt, have different foci (on disease in the case of Reznek, illness in the case of Fulford, and health in the case of Nordenfelt), and their input in terms of theories and examples differ. Nordenfelt and Fulford base much of their argument on modem philosophical action theory, whereas Reznek has his intellectual center in general analytic philosophy of science. Moreover, Fulford's theory is special in that it almost exclusively deals with mental illness. When my own manuscript approached a fmal stage, the Executive Editor of the Value Inquiry Book Series of Rodopi, Robert Ginsberg, inspired me to include in this volume some commentaries on my own contribution. I particularly appreciate this proposal after having read the two contributions by Khushf and Fulford. As I explain in my Afterword, these texts are much more than commentaries. They are quite independent essays contributing to the general topic of health theory from two quite different points of view,

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AUTHOR'S PREFACE

namely from philosophy of science in the case of Khushf, and the philosophy of ordinary language in the case of Fulford. I hereby thank them for their quite substantial input to this volume. A few of my local colleagues have read and commented on my initial manuscript. I wish to thank Per-Erik Liss, Per-Anders Tengland, and Fredrik Svenaeus for many helpful remarks. Thanks also to Robert Ginsberg for helping me to improve my language into publishable form. Finally, my gratitude is extended to Peter Berkesand at the Tema-department, who has spent many hours transforming the initial texts into a fmal camera-ready manuscript. Lennart Nordenfelt Linkoping December 2000.

PART ONE DISEASE AND ILLNESS REVISITED: WHERE SHOULD MEDICAL THEORY GO?

One INTRODUCTION 1. Background

The theory of the nature of health and disease, or of the concepts of health and disease, has been central in modem philosophy of medicine. I would venture to say that it has been a favorite topic and is becoming even more so, since this is the aspect of philosophy of medicine which - pace medical ethics - has attracted the greatest attention on the part of the medical professionals themselves. Two main streams of theories of health and disease have appeared in the arena. One main stream is sometimes called the medical one, or the biostatistical one. Typical of philosophers within this stream is that they claim the concepts of health and disease and their allies - there is a whole network of medical concepts including illness, injury, impairment, defect, disability, and handicap - are, or could be, treated like any biological, or in some cases psychological, concepts. "Health" and "disease" are biological concepts in the same sense as "heart" and "lung" and "blood-pressure" are biological concepts. In particular, nothing is evaluative or normative about the concepts of health and disease. Health and disease can be defmed in completely value-neutral terms. It may be true that health is as a matter of fact highly valued by human beings and that disease is disvalued, at least when these conditions strike the subject. But such is the case with many objects and properties in the world which in spite of this can be given valueneutral definitions. The other main stream in the philosophy of health takes a completely opposite position regarding these basic matters. According to these philosophers, who are often called normativists, health and disease are intrinsically value-laden concepts. They cannot be totally defmed in biological or psychological terms, if these terms are supposed to be value-neutral. To say that somebody is healthy partly means that this person is in a good state of body or mind. And to say that somebody has contracted a disease is to say that something bad has been contracted by that person. Some of the normativists have pointed to the fact that health is by defmition the primary goal of the praxis of medicine. The empirical content of health, on the other hand, seems

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to be open to argument. People can debate, and indeed they certainly do debate, exactly what configurations of bodily and mental states should be labeled as healthy. But they do not seem able to question that health, whatever it is, is a goal of medicine. This is given by defmition. Thus, they claim, the evaluative or normative nature of health seems more basic and clearer than its empirical nature.

2. The Purpose of This Study My aim in this text is to reconsider the basic ideas lying behind four contemporary theories concerning the nature of health, disease, and illness. The first of these is a representative of the medical mainstream. This is the biostatistical theory of Christopher Boorse. The other three theories are on the normative side. These, which explicitly contest Boorse's views, are the theories of Lawrie Reznek, K. W. M. Fulford, and Lennart Nordenfelt. The structure of my presentation will be the following. I will first present a theoretical background sketching plausible purposes of conceptual analysis in the field of medical practice and medical science. I preliminarily relate these purposes to the four theories to be scrutinized in this book. I then proceed to make detailed and critical analyses of each of the four theories mainly from the point of view of their purposes and their philosophical presuppositions. I will parallel the critical studies of Fulford's work and my own work since important similarities appear in our approaches. Finally, I try to assess the three theories at least from the point of view of their own programmatic declarations. The time is apt for a comparative analysis of this kind. Boorse has recently published a long-expected response to his critics in the lengthy paper, "A Rebuttal on Health" (1997). This paper contains several key clarifications of his position, which call for reactions from his adversaries. And Fulford is due to publish a new edition of his Moral Theory and Medical Practice (1989, the original version).

3. The Purposes of a Philosophical Analysis of Medical Concepts Conceptual analysis will never get off the ground unless it has a purpose. Sometimes disagreement between theorists can be found to be due to their diverging purposes. I will list here several possible alternative purposes. I. Investigating the essence of the notions of health and illness. 2. Investigating the use of the terms "health" and "illness" in medical research. Here we can find a few subdivisions. The most important one is between theoretical medical research and clinical research.

Introduction

5

3. Investigating how the terms "health" and "illness" are commonly used in medical practice. Here are subdivisions according to to what communities of medical practice we are referring (doctors, nurses, occupational therapists, etc.). 4. Creating a consistent theory of health and illness concepts which is as close as possible to one or more of the actual uses. 5. Creating a theory of health and illness concepts which without being extremely close to any of the current uses will serve the purpose of medical research or medical practice, or any of its subcategories, better than the current conceptual systems do. It is possible to have other purposes but this list is complicated enough. Let

me briefly comment on the alternatives. The first project is the real Aristotelian project. In the orthodox interpretation, it entails the idea that fundamental concepts of health and illness exist irrespective of any particular language use and which we may intuit through introspection. This project is today uncommon in its orthodox version. It does exist, and is flourishing, in a language-dependent version in roughly the following form. Our natural languages embed quite a defmite web of concepts. This web is not eternal, the languages continuously change, but at any time the web is definite. It is precise enough to admit the kind of exploration that linguistic philosophers, perhaps also phenomenologists, perform. Through such an analysis, we can arrive at truths about the logic of the conceptual web formed, for instance, by the current English language. We can then try to generalize and look at the substantial similarities within, for instance, the Indo-European family of languages, and say that observations made in one of these languages could hold good for some of the others as well. I will not here argue this point, although it is important, particularly for Fulford, who partly has in mind an Aristotelian purpose in the modern linguistic form. Alternatives 2 and 3 indicate investigations of an empirically linguistic kind. Sociolinguistics would be the discipline within which such explorations should be pursued. Such investigations are made with different methods, including interviews and questionnaires. This is hardly the job for philosophers, although some philosophers have thought that such studies are of great value to philosophy. And, admittedly, if we attempt to produce a theory as described under 4, then we need some backing of the kind that investigations of types 2 and 3 can provide. A key point to make here, made several times by linguistic philosophers, is that interviews, questionnaires, or even the close direct study of language-use is not clearly the best way to identify the conceptual web embedded in a natural language. The reason is that a lot of the actual language

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use is "poor" or blatantly "incorrect" use. People do not always talk carefully. Mostly they are quite aware of that and can correct themselves. But in such cases not the actual use but the "correct" use is of interest for the philosophical purpose. I do not want to deny that the "incorrect" use can be of interest for a lot of other purposes. Alternative 4, however, appears to be an important philosophical purpose. It is an explicit purpose of Christopher Boorse. He claims that he has formulated a theory which essentially captures the way doctors use the terms "health" and "disease." To capture this use is also a partial purpose of Reznek, Fulford, and Nordenfelt. Fulford and Nordenfelt, in particular, are equally interested in capturing the way lay persons use these terms. Moreover, they are interested in explaining the web of concepts which surrounds the ordinary concepts of health and disease. This brings them closer to the first Aristotelian purpose in its linguistic version. Perhaps my theory comes closer than the others to following purpose 5. I wish not only to construct a conceptual theory which is reasonably close to the general use of terms such as "health" and "illness," but also to contribute to the amendment of the prevalent medical conceptual network. My view is that the current conceptual network is deficient. For instance, notable ambiguities pertain to the use of "illness," where that term is sometimes used synonymously with "disease" and sometimes not. Such ambiguities, as well as other unclarities, do not contribute to the good cause of medicine. Ingmar Porn (1993) is an even more forceful proponent of this view. His aim is really to construct an exact theory of health. Philosophers who work with different purposes in mind when performing a conceptual analysis of the medical concepts will come up with partly different results. They have different objects of study. All these objects are worthy of study, and that different philosophers have chosen different courses is valuable. Boorse, Reznek, Fulford, and Nordenfelt have different purposes in mind. What they come up with are different theories. So far so good. Their theories, given the different purposes, may be quite compatible with each other. Such an observation does not in itself warrant the laying down of discursive arms. There are many important issues to be discussed. (1) We can discuss the value of the different purposes. Are they all equally valuable as philosophical enterprises? (2) We can discuss the realism of the different projects. To what extent, for instance, is it viable to study the language-use of people? Can we study more than idiosyncratic uses of small pockets of language users? (3) Most importantly, we can discuss whether the theorists are actually doing what they purport be doing. Does Boorse really study what doctors mean by "health" and "disease"? Does Reznek characterize the distinction between pathological and non-pathological which is made by

Introduction

7

"medical and laymen alike" (Reznek, 1987, p. 67)? Does Fulford make a linguistic analysis which can capture what medics as well as lay persons deep down mean by illness, dysfunction, and disease? Is Nordenfelt making an explication of medical concepts, reasonably well-founded in practice, which results in a viable logical reconstruction of the same concepts? (4) A question closely connected to this discussion, but which could be held apart, is the following: To what extent do the theorists succeed in their respective enterprises? Does Boorse come up with an adequate descriptive theory of the language use of the doctor? Does Reznek adequately characterize the distinction between a pathological and a non-pathological distinction made by doctors and lay persons? Does Fulford produce a deeply revealing linguistic analysis of the medical discourse? Does Nordenfelt succeed in making a fruitful reconstruction of the medical conceptual network? All these questions are enormous. I have no chance to answer all of them. Some of them are quite difficult, in principle, to answer. This holds particularly for the question about the value of the different projects. In the following, I will abstain from treating questions I and 2. I will assume that the different purposes are of equal value. I also assume that they are equally realistic. However, in practice I shall deal with purposes 2 and 3 only to a limited extent. 4. A Complication with Regard to the Notion of Having or Sharing a Concept For the correct understanding of, and for our ability to efficiently criticize, the different theories, we need to differentiate between at least two ways of having a concept. I have previously noticed this distinction (1993), and I fmd it important for the analysis of scientific concepts. In one sense, we can be said to have a concept when we have put forward or accepted an explicit defmition of the concept in question, for instance, the concept of disease. We may, for instance, accept Boorse's defmition of disease and say that this is the correct one, that this is what "disease" means. However, in spite of this explicit acceptance, we might not in practice work with this defmition. When we use the term "disease" or when we in other ways obviously refer to diseases, we show that we must mean something different from what the explicit definition says. This is a common situation. Few people can completely adhere to an explicit defmition. However, this situation becomes interesting when big differences occur between language-use and explicit definition. When Boorse, for instance, talks about the doctor's concept of disease, it is crucial to know whether he refers to the doctor's explicit definitions or to the doctor's language-use.

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The analysis of the idea of having a concept should be made even more sophisticated. "Actual language use" is ambiguous. In the simplest case, we may by "actual language use" mean the use of the specific term and nothing but this term. For instance, in the case of "disease," we may refer to the instances when a person explicitly mentions the term "disease." But it is possible, and for the purpose of conceptual analysis advisable, to mean something more sophisticated. What I have in mind is that we do not get a reasonable account of a person's concept of disease unless we study not only the explicit uses of the term "disease" but also the explicit uses of a number of other terms. I have in mind such terms as, according to a preliminary study of the language-use of the person and compatriots, are in various ways logically connected to the concept of disease. As a result of such a study, we can reconstruct a more complete and in a deeper sense truer map of the connections between concepts which have logical relations to each other. 5. A Brief Outline of the Four Theories of Health, Illness, and Disease Christopher Boorse has presented a comprehensive theory of health and disease. In his earlier writings, he also provided a theory of illness (a notion to be distingushed from disease). According to Boorse health is conformity to species design. Health is the case when all organs and tissues, as well as mental faculties, function in accordance with the design by which the organisms of the species in question maintain and renew their life. A disease, according to Boorse, is a type of internal state which is an impairment of normal functional ability (as statistically determined) or a limitation of functional ability caused by environmental agents. Given this definition of disease, health can also be characterized as the absence of disease. Boorse (1975) has defined a notion of illness whereby illnesses form a subclass of diseases: A disease is an illness only if it is serious enough to be incapacitating, and therefore is (i) undesirable for its bearer; (ii) a title to special treatment; (iii) a valid excuse for normally criticizable behavior. (p. 61) In later writings (1987, 1997) Boorse substitutes the terms "diagnostically abnormal" and "therapeutically abnormal" for "illness." Lawrie Reznek mainly provides a theory of disease. He also uses the term "illness" but it does not have a sense different from "disease". In his first work (I 987), Reznek also discusses a broader category called "pathological condition," which includes diseases, injuries, and defects. The common basic definition of "pathological condition" is the following:

Introduction

9

A has a pathological condition C if and only if C is an abnormal bodily/mental condition which requires medical intervention and for which medical intervention is appropriate, and which harms standard members of A's species in standard circumstances. (Reznek, 1987, p. 167) A disease is a pathological condition which is processual and involuntary. The abnormality involved in disease is not of a statistical kind, according to Reznek. A disease is a condition which is abnormal in a "constructed" sense (for a clarification, see Chapter Three, Section 5). Reznek does not discuss the positive notion of health. K. W. M. Fulford proposes a reverse theory of illness and disease. By this he means that illness is the primary concept, while disease is a derived concept. People are ill, according to Fulford, to the extent that they fail to do what they ordinarily do in the absence of obstruction or opposition. The patients who are ill are unable to do everyday things that people ordinarily just get on and do, moving their arms and legs, remembering ... things, finding their ways about familiar places and so on. (Fulford, 1989,p.149) The reasons for the failure, in the case of illness, should be internal to the person's body or mind. The concept of disease can be derived from illness, in the first instance as those illnesses which are more widely recognized as such. This process establishes the symptomatically defmed diseases. To this group of diseases causally defined categories are added. Thus, the whole set of established diseases is formed. Like Reznek, Fulford abstains from characterizing a notion of health. Lennart Nordenfelt has proposed what he calls a welfare theory of health. He considers health to be the primary concept in the web of medical concepts. His notion of health is characterized in the following actiontheoretic terms: A is completely healthy if, and only if, A is in a bodily and mental state which is such that A has a [second-order] ability to realize all his or her vital goals, given accepted circumstances. (Nordenfelt, 1995, p. 212)

If the person's (second-order) ability is reduced in accepted circumstances, then that person is to the same extent ill. Diseases, injuries, and defects form a common category of maladies (roughly equivalent to Reznek's "pathological conditions") which have similar definitions. For the case of diseases, Nordenfelt proposes the following characterization: "D is a diseasetype in environment E if, and only if, D is a type of physical or mental proc-

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ess which, when instanced in a person P in E, would with high probability cause illness in P." Observe how I assert that we should interpret this defmition. When a person has a disease, a process occurs in this person's body or mind. This process belongs to a type, the instances of which would most probably cause illness in all bearers of these instances. However, not all causes of illness are diseases or, in general, maladies. A configuration of factors may combine in a person to cause illness. Neither this configuration nor any of its elements need, however, be diseases (maladies) as defined above.

Two THE BIOSTATISTICAL THEORY OF DISEASE: CHRISTOPHER BOORSE 1. A Summary

In presenting Boorse's theory, I will adhere closely to the formulations in his latest work, "A Rebuttal on Health" (I997), where he answers many critical reviews of his earlier, highly influential, papers written during the 1970s. The goal of the biostatistical theory of disease (BS1) is to analyze the normal/pathological distinction. When the term "disease" replaces the term "pathological," it is intended to capture the whole range of pathological phenomena including defects, injuries, growth disorders, etc. In order to characterize the modem Western concept of disease, Boorse proposes a modem explication of the ancient idea that the normal is the natural when he says that health is conformity to species design. In modem terms, Boorse says "species design is the internal functional organization typical of species members, which (as regards somatic medicine) forms the subject matter of physiology: the interlocking hierarchy of functional processes, at every level from organelle to cell to tissue to organ to gross behavior, by-which organisms of a given species maintain and renew their life" (Boorse, 1997, p. 7). All conditions which are called pathological by ordinary medicine constitute disrupted part-function at some level of this hierarchy. With this general description as a background, Boorse presents the following defInitions: 1. The reference class is a natural class of organisms of uniform functional design; specifically, an age group of a sex of a species. 2. A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival and reproduction. 3. A disease is a type of internal state which is either an impairment of normal functional ability, i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents. 4. Health is the absence of disease. (Boorse, 1997, pp. 7-8)

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Noteworthy is that Boorse has slightly changed his characterization of disease in relation to his central paper "Health as a Theoretical Concept" (1977). There, on page 555, he says: "A disease is a type of internal state which impairs health, i.e. reduces one or more functional abilities." Boorse there construes disease as a state which reduces normal functioning, that is, causes subnormal functioning. He is obviously now inclined to identify the diseases with subnormal functioning. ''Normal functional ability" is to be defmed dispositionally, that is, as the readiness of an internal part to perform its normal functions on typical occasions with at least typical efficiency. ''Typical efficiency" in its tum is an efficiency above some arbitrarily chosen minimum in its species distribution. The notion of a biological function which is crucial to Boorse's analysis is analyzed in a valuefree way in the manner initially suggested by Sommerhoff(1950). An organism or its part is directed to goal G when disposed, throughout a range of environmental variation, to modify its behavior in the way required for G. And since "physiology was the subfield on which somatic medicine relies, medical functional normality was presumably relative to the goals physiologists seem to assume, viz. individual survival and reproduction" (Boorse, 1997, p. 9). This account defmes a theoretical concept of disease, not a practical concept. It aims at the pathologist's notion of disease, not the clinician's notion. When Boorse comes to the clinician's notion he has slightly changed his mind in relation to his earlier papers. There he defmed a category of illness as a subset of diseases which are incapacitating, undesirable for their bearers, and count as a valid excuse for normally criticizable behavior. The notion of illness, which was supposed to be value-laden, has now been replaced by a dimension of health on which appear the concepts of "diagnostic abnormality" and "therapeutic abnormality" meriting treatment. These concepts are clearly value-laden, according to Boorse, although he does not further analyze the nature of the values in question. Virtually the whole of this theory, Boorse still maintains, is applicable to mental health. This presupposes that human psychology is divisible into partprocesses with biological functions. Biology should then be understood as a general science of life embracing species-typical physiology and species-typical psychology (Boorse, 1997, pp. 13-14).

2. An Investigation of Boorse's Project In discussing Boorse again, let me concentrate on his latest contribution, where he is quite explicit about the purpose of his investigations. He also narrows his purpose in relation to his early papers. 1. A pathologist's concept of disease. Boorse says that his account "defmes a theoretical concept of health, not a practical one. It aims at a pathologist's concept of disease, not a clinician's, and still less at any social or

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legal category" (Boorse, 1997, p. 11). Hence, Boorse's purpose is much more limited than the purposes of Reznek, Fulford and Nordenfelt. Illness or ill health from the point of view of the clinician and that of the lay person is a central concept for those thinkers. 2. Disease as reconstructed from medical classifications. Boorse has the following characterization, made in connection with his "choice" of what those biological goals are, in relation to which bodily functions can be determined: "There is no choice here - that is simply what disease is, as the concept is best reconstructed from medical classifications" (Boorse, 1997, p. 25). This is a notable addition. It informs us of the criteria for judging whether we have correctly identified the pathologist's concept of disease. We can see that the medical classifications are considered by Boorse to represent "the actual use" of the concept of disease by doctors. Boorse could have limited himself to consulting pathological classifications. The fact that he does not will prove to be troublesome to him. 3. The doctors' notion of disease. Boorse does not, however, refer to medical classifications only. He sometimes talks more generally about "medicine" and "doctors." In connection with the case of unwanted pregnancy, he says that medicine refused to accept this as a disease although it is a state which may at times be covered by medical insurance. He says: "Medicine could easily have christened [unwanted pregnancy] with some bogus disease name like "dysgravidia" .. , . But medicine did not, and that is because doctors, in general, know what is disease and what isn't, even if they have trouble reducing their knowledge to a tight definition" (Boorse, 1997, p. 27). 4. The project as primarily descriptive with an element of explication. In the end, Boorse admits that his project is not exclusively descriptive. He may at times try to improve on the definitions. "My line on vagueness will be that the BST is never less precise than medical usage and fits all clear cases, except the two classes mentioned in HTe. Occasionally the BST may be more precise than medicine, in which case it is a precising defmition" (Boorse, 1997, p. 19). I will comment on these explicit formulations of purposes or descriptions of Boorse's procedure. First, I notice the Aristotelian ring about the quotation in 2. Boorse attempts to explicate what disease is. No question arises of the existence of different discourses given in different intellectual cultures, at least not as concerns pathology or medicine. One clear sense of disease exists, and that is the one to be discovered and explicated by Boorse. But Boorse also explicitly limits himself in the statement quoted in 1, that he aims at studying pathological disease and not clinical disease. To make these quotations fit, we must assume that disease is "ultimately" pathological disease. Clinical disease, whatever that is, is derivative, based on pathological disease. Boorse does not really aim to explicate the notion of pathological disease. In his

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earlier works, this does not come out clearly. Particularly in one of them, "On the Distinction between Disease and Illness" (1975), Boorse has a lot to say about clinical matters as well. What is the procedure by which we should find out the nature of pathological disease? One might have expected that Boorse would consult pathology textbooks. He occasionally does so. But this is not what he refers to when he describes his purpose. Instead, he refers to medical classifications. His idea, then, must be the following: In medical classifications of diseases many entities are classified which are normally called diseases. We should see what is distinctive about these entities, and we should try to produce a general theory that neatly covers these entities and nothing but these entities. We should not exclude the discovery of future diseases. Indeed, once we have a general theory, we could use this theory as a criterion for the inclusion of new categories in the set of diseases, and thereby in the classification of diseases. So, to sum up, Boorse, at least in his latest work, aims at constructing a viable theory of the concept of pathological disease. This theory is designed mainly to be descriptive. A stable concept of pathological disease is to be discovered, and the theory should defme it. As a result, some vagueness in ordinary pathological discourse can be remedied. Hence, Boorse cannot remain completely Aristotelian. He admits that his descriptive theory can have explicative elements in it. Thereby it is capable of improving the existing pathological discourse. . Does Boorse do what he claims? To what extent can we say that he succeeds? I will say a few things in reply to these questions. Before doing so I will analyze a fundamental criticism of Boorse's first version of his theory which has triggered a positive response from him. 3. Boorse on Dynamic Interaction: The Need for a Circumstance Clause In my criticism of the previous version of Boorse's theory of disease, On the Nature o/Health (1987/1995, pp. 29-33; in the following I refer to this book simply as 1995), I highlighted the lack of reference in his work to the circumstances surrounding the human being whose health is to be determined. When Boorse made his initial characterizations of normal and subnormal functioning, he offered no discussion of the "normal" variability of such functioning as a result of a variable environment. One gets the impression that the heart, the lungs, and the kidneys have only one normal way of functioning and that this remains the same, whatever the circumstances. A naive interpretation of this would be to believe that Boorse claims that the heart has a beating rate between 50 and 70 all the time, that our breathing rate is between 10 and 30 all the time, and that the liver at every instant makes the same purifying contribution to the body.

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In my analysis, I found important to spell out in detail how the Boorsian theory has to be developed in order to take care of the fact that varying circumstances can change the response of all parts of the organism. Hard work results in an increased functional activity in many parts of the body, not least with regard to vital functions such as the cardio-respiratory ones. The ''healthy'' response of the heart and the lungs to the running of a 100-meter race is a highly statistically abnormal cardio-respiratory activity. That is, it is statistically abnormal if we take all kinds of circumstances into account, and if we take a whole life-course into account. It need not, however, be statistically abnormal if we include the type of circumstance in which the cardio-respiratory activity occurs. The pulse rate always goes up considerably when one makes extreme bodily effort as one does in athletics. This is a standard change, and we consider it to be a healthy one. We can say, in line with Boorse's reasoning, that the heart and the lungs still make their species-normal contribution to the survival, but, I would also say, to the flourishing of the organism. In developing Boorse's theory along these reasonable lines, which he has accepted in his recent text (1997), we may detect difficulties which strike at the heart of his whole conception of disease. Many phenomena which we, and also medical classifications, normally accept as diseases can reasonably be viewed as the result of the defense mechanisms of the healthy organism. This means that many diseases are in fact the result of the statistically normal bodily reactions to a particularly harsh environment. This, in turn, means that, according to the BST, many diseases are statistically normal contributions to the survival of organisms. From this follows that many acknowledged diseases are not diseases according to the BST1 Thus, the BST leads to a serious paradox. I emphasized on this feature of the BST in (1995). A few other writers, including Norman Daniels (1985), have also done so. The general idea that one has to take the variability of circumstances into account in an adequate characterization of the concept of disease is now acknowledged by Boorse. Let me use his words on page 83 of (I997): "Every reaction of the organism on the occasion of whatever provokes it, and all disease manifestations will become normal - exploding the BST, which is left holding Sober's position that everything possible is equally natural." Here, Boorse is unnecessarily masochistic. Not all reactions to external circumstances are normal, given the circumstances. If the immune system bas broken down, or if the defense mechanisms in general are disturbed, then the reactions to stress or pathogens may be statistically subnormal, and we may be able to detect diseases also along Boorsian lines. The only thing that has been shown by the argument from circumstances is that some bodily processes which are intuitively identified as diseases do not come out as such given the BST. Boorse is now inclined to think that his theory needs revision to come to terms with this general line of criticism. We have to, he says, relate the idea of normal bodily functioning to a concept of statistically normal environment to

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capture the essence of health. This means that statistically normal functioning may occur in relation to extremely harsh circumstances, which no longer comes out as health in the revised EST. This is the only major revision that Boorse makes in his recent paper. Although Boorse makes this general concession, he dismisses my specific line of reasoning as impotent for the purpose (1997, pp. 84-86). I will briefly respond to this. My example intended to pinpoint the weakness of Boorse's theory was the disease category of infections. Infections form the classic paradigm of diseases. They still constitute a major category in the International Classification of Diseases and Related Health Problems (JCD, 1992). Roughly speaking, infections come about as the response of the immune system to external pathogens such as bacteria, viruses, and mycoplasma. They can therefore be said to be the result of the organism's healthy (statistically normal) response to an invasion of pathogens. In my presentation of this argument, I described in more detail what can happen at the initial stage when an infectious defense mechanism is triggered. I mentioned that often some immediate cell death occurs on the mucous membranes resulting from the toxins of the microbes. Boorse pinpoints this fact and says: here is the disease, the cells which die at this initial stage constitute the disease of infection. This cell death, Boorse claims, clearly fulfills his criteria of disease. All further reactions to this primary infection, however, such as inflammation and the rise of temperature, are natural responses. They have no part in the essence of the disease. My answer to this criticism is threefold. First, the death of some cells on the mucous membranes is not identical with the infectious disease as a totality. In fact, it constitutes at most a minor initial stage. I refer to my analysis in the coming section where I point out that many of our major diseases, as normally understood, are complex processes and not just identical with the subnormal functioning of a tiny part of the body. So, the dead cells on the mucous membranes do not constitute the disease of infection as it is characterized in a standard medical classification. Second, we must point out that the superficial dead cells as such are not the cause of the ensuing infectious process. The causal strength, or virulence, lies in the pathogens and the toxins. This observation is essential, given the state of the discussion in 1987 when I wrote my piece. Boorse in his previous works, including "Health as a Theoretical Concept" (1977), had defined disease as a "bodily state which interferes with the functioning of some part of theorganism." The dead cells could thus not be identified with the disease, as the concept was previously defmed. Third, questionable is whether a full-blown iiifection must start with some injury, or if the microbes through invasion could otherwise trigger the defense system. This has to do with our specification of an injury. Should we say that the invasion of a bacterium in a cell is in itself an injury? Or is it an injury only when the cell is obviously disturbed by the bacterium? I refer to the discus-

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sion of non-pathological infections in Reznek (1987, p. 83): "For example, the colonization of the human infant's gastrointestinal tract by lactobacilli is something that benefits the infant." We need not initiate a scholastic discussion about this, since Boorse has granted the general point that a characterization of disease must be related to a set of circumstances. To summarize: my point with the infection example was the following. Assume that a pathogen is so virulent as to trigger a strong but still statistically normal response, given those circumstances which include the pathogens. The strong response effected by the antibodies may lead to significant bodily change and a change in fimctional activity. The properties of this change, in terms ofinflammation, high temperature and, on the illness side, pain, fatigue, and disability, are quite well-known. We then have a typical disease (as recognized in medical classifications) which is constituted by a normal bodily response, in the sense of making a statistically normal contribution to survival, in relation to a harsh environment. QED. Before concluding this section, I will briefly comment on a feature of Boorse's revised version of the BST. In line with his general scientific spirit, he says that the environment included in his characterization should be a statistically normal one. He does not give us any further clues with regard to the basis for the statistical calculation. Presumably, again following his general spirit, he wishes to base his statistics on a consideration of the complete situation on earth, and all developments which, as far as we know, have as a matter of fact occurred on the earth, including the huge areas of the poles and the deserts. My question is: Is it really feasible and reasonable to use the global situation as a basis for such a calculation? It is plausible to believe, even now, before the occurrence of a more devastating pollution of the earth, that the majority of circumstances of the earth are unfavorable conditions with regard to health, as health is intuitively understood. I assume for the moment that we can agree on an instrument for identifying sets of circumstances. Large parts of Africa, for instance, are quite unhealthy. It has been claimed that 90 percent of the central· African popUlation carry the disease of Bilharzia. We can easily produce similar examples from the disadvantaged areas of Asia and South America. And what about cultural circumstances, such as the extreme poverty under which a majority of the world's population live? Such unfavorable circumstances are indeed statistically normal. The problem of founding a concept of disease on the idea of statistically nOlmal circumstances becomes even more troublesome with regard to mental disease and illness where a person's interpretation of the circumstances within which she or he lives, is crucial. A person's interpretation of a phenomenon as frightening or dangerous, and as something that motivates distress, may not have anything to do with this phenomenon's being unusual in a statistical sense. Such a

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person, like most of us in general, need not know anything about the statistical frequencies of circumstances. To conclude. Boorse's recognition of the need to incorporate the environment in his theory of disease is, I believe, a step in the right direction. However, the idea that we are to calculate the normal set of circumstances on the basis of global statistics is not promising. All this indicates again that Boorse's basic idea is not viable. But before drawing any conclusions, I will scrutinize my initial queries about the nature of Boorse's project. 4. The Idea of a Pathological Disease As I have said, Boorse has made a retreat in relation to his earlier writings, since he now emphasizes the pathologist's notion. On the other hand, he has not retreated from his old universal claims in that he still believes that this concept is basic to the "practical" ones such as diagnostic and therapeutic abnormality. He also still claims that his notion is valid for the theory of mental health, given that we take human psychology to be divisible into partprocesses with biological functions. Since pathology has become so prominent in Boorse's present explicit formulations, I will make a few comments on the discipline of pathology. Pathology, as it is normally understood and is identified as a subject within medical schools, is an exclusively somatic discipline. It concerns, for instance, the genetic basis of bodily processes, in particular abnormal ones, and it concems defensemechanisms against injury as well as consequences of such defense-mechanisms, nowadays primarily as described on a microscopic level. Inflammation, the immune response, and neoplasia are central areas covered by a textbook of pathology. But pathology textbooks do not normally contain any characterizations or even a classification of disease. A locution quite often repeated in such textbooks is that what is described is the pathological basis of disease. Consider the following quotations from Michael 1. Taussig, Processes in Pathology (1979). Diabetes mellitus results from a relative or absolute lack of the hormone insulin, produced by the B-cells of the islets of Langerhans in the pancreas. (pp. 414-415) We describe some of the ways in which an inherited mutation at a single genetic locus can lead to disease. (p. 384) Enzyme defects may also cause excessive storage of the substrates of defective enzymes, leading to conditions known as storage diseases. (p. 384) The impression we get is that the pathologist does not study or classify diseases as such, but investigates the microscopic mechanisms lying behind

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various diseases. A deep and interesting philosophical question is how these locutions, "leading to," "resulting in," "lying behind," should ultimately be analyzed. The pathologist is here not necessarily referring to causal relations. The mechanisms may instead partially constitute the diseases. But this analysis is not my concern. My concern is to remain, in a truly descriptive manner, on the level of the pathologist. My preliminary conclusion is that most pathologists do not defme a notion of disease. Even less do they identify or classify diseases. Instead they presuppose a notion of disease (as something self-evident), and they consider their main purpose to trace the mechanisms behind the diseases. Defmitions of disease are found in some pathology textbooks. I quote from a recent textbook, Essentials of Pathology, edited by Malcolm J. Mitchinson (1996). Its fIrst chapter has as heading the statement, "Any departure from the normal structure and jUnction ofan organism is a disease. " It goes on to say: Disease is a broad term and includes all sorts of abnormalities, even some that we do not usually refer to as diseases such as cuts and bruises. When we speak of a disease ... we mean a particular abnormality or group of abnormalities, recognised in some plants and animals. (Mitchinson, 1996, p. I) Observe that Mitchinson talks about normalities not only in function but also in structure. No clarification is given as to what kind of normality we are talking about. Weare not given a hint as to whether the normality in question is statistical or normative in any of the many possible senses of normative. Since Boorse claims his concept of disease is universal, covering the diseases of all living creatures, including plants, it should be of interest to see what plant pathologists have to say. I will consult the textbook, Plant Disease: An Advanced Treatise, Vol. 1, How Disease is Managed, edited by James G. Horsfall and Ellis B. Cowling (1977, p. 3): Any person can identify a diseased plant. In fact, we even have some empathy with diseased plants, because we ourselves sometimes become diseased. The standard question we ask a sick friend is: What is the matter with you? His reply normally is: my stomach is acting up, or my head aches or my vision is blurred. Something is functioning poorly, and hence we have come to the decision that disease is a malfunctioning process that is caused by continuous irritation. Of course this process must result in some suffering, and this produces symptoms. This conception of disease is accepted by the Committee on Terminology of the American Phytopathological Society and by the counterpart Committee of the British Mycological Society.

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Thus, "plant pathology is the study of the suffering plant. We think that the word "suffering" is not stretched too much when we use it for plants" (pp. 34). In the third volume of the same work (1978), the first chapter is called:

How Plants Suffer from Disease. Consider the following: Fundamentals ofPlant Pathology, edited by Daniel A. Roberts and Carl W. Boothroyd (1984), Chapter 1, The Essence of Disease in

Plants:

Disease is continuous malfunctioning. The two words, continuous malfunction, have far-reaching implications. First they state that disease is essentially physiological .... Second, the prefix mal-, inserted before function, tells us that disease is harmful - harmful to the physiological processes of plants. Harmfulness to the vital functions of crop plants invariably lowers their monetary worth: for this reason, some authors include the notion of economic loss in their defmition of plant disease .... Disease in a plant is a series of harmful physiological processes caused by the continuous irritation of the plant by a primary agent: it is exhibited by morbific cellular activity, and is expressed, in tissues and organs, by characteristic pathological responses called symptoms. (p. 7) My purpose in quoting these passages at length is not to take them in themselves as reliable guidelines to plant pathology as concerns defmitions of disease or the actual use of the term "disease" in plant pathology. To do such a thing, we would have to perform a much more thorough investigation and consider a variety of works. Some of the quoted attempts at defmitions are evidently deficient from a philosophical point of view. Note the blatant circularity in the last characterization. They seem, however, to show one thing. What a pathologist, be he or she a human pathologist or plant pathologist, means by "disease," is not altogether clear. Malfunction has a central place in all conceptions. But variation arises concerning the phenomenon that the prefix "mal" is related to. "Mal" need not necessarily be related only to survival. "Mal" may be related to flourishing, in the case both of human beings and of plants. And it may be related to other goals, as exemplified by monetary worth in the case of plants. To get hold of the pathologist's notion, we cannot rely on the pathologist's books. Perhaps Boorse's acquaintance with this fact forces him to refer us instead to what he calls medical classifications of diseases. Pathological disease is what is to be reconstructed from medical classifications, as he puts it.

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5. On Medical Classifications of Diseases and Related Conditions The medical classification par preference is The International Classification of Diseases and Related Health Problems, lCD, Tenth Revision (I992). This classification is used worldwide. It is published by the World Health Organization (WHO), and it is continually revised by the WHO. Almost all contemporary national classifications of diseases and related problems are based on the ICD. I will first make a preliminary comment on this classification. It does not purport to classify diseases only. The earlier versions of the classification were even more explicit on that matter. They mentioned in their titles injuries and other causes of death. In the ICD is a classification of typical external causes of injury and disease. This brings us to the topic of distinguishing between various species of malady. "Malady" is a technical term designed to cover all internal conditions of a human being which can reduce his or her health. See Culver and Gert (1982). Boorse has been accused of using too wide a concept of disease, obviously covering also injuries and defects. I need not repeat such criticism, and I am perfectly willing to use the term "disease" in this context in his wider sense. That sense may be a custom in pathology; see above the definition given by Mitchinson (1996). This would mean that all maladies - I disregard the external causes - classified in the ICD are to be considered as instances of disease. I will now strictly follow the logic of Boorse's procedure. To get the pathologist'S notion of disease, we will extract it from existing medical classifications. We now have the well established medical classification, that is ICD. Let us see, then, what we fmd in this classification. The ICD classifies the acknowledged diseases in the world into seventeen main categories. The ground for division is traditional, and it does not, as has been shown many times, fulflll elementary logical requirements. This need not concern us. We should look at the species and see whether they fit the Boorsian theory of disease. The next step is to consider how these species in their tum are characterized in comprehensive textbooks. I will use the well-known disease of asthma as my paradigm. In the lCD, asthma is a species of the genus Diseases of the Respiratory System. Strictly speaking, it is divided into two species, J 45 and J 46, the second having the label, Acute severe asthma. Ordinary asthma has in its tum four variants: allergic, nonallergic, mixed and asthma unspecified. For a comprehensive definition of asthma, I consult Harrison's Principles of Internal Medicine, Fourteenth Edition (1997). Under the heading "Definition" the paragraph in toto runs as follows: Asthma is a disease of airways that is characterized by increased responsiveness of the tracheobronchial tree to a multiplicity of stimuli.

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LENNARTNORDENFELT Asthma is manifested physiologically by a widespread narrowing of the air passages which may be relieved spontaneously or as a result of therapy, and clinically by paroxysms of dyspnea, cough and wheezing. Asthma is an episodic disease, acute exacerbations being interspersed with symptom-free periods. Typically, most attacks are shortlived, lasting minutes to hours, and clinically the patient seems to recover completely after an attack. However, there can be a phase in which the patient experiences some degree of airways obstruction daily. This phase can be mild, with or without superimposed severe periods, or much more serious, with serious obstruction persisting for days or weeks, a condition known as status asthmaticus. In unusual circumstances acute episodes can cause death. (Harrison, 1997, p. 1419)

One thing striking in this characterization is that it covers a great deal of ground. A basic pathophysiological element is in it, but this is only a fragment of the characterization. It contains also a story of clinical evolution in terms of symptoms and signs, and it says something about prognosis. Thus, the description is quite comprehensive. The urgent question now is: What belongs to the ontology of the disease of asthma? What sort of entity is it? The most reasonable interpretation of the text would be to say something like the following: the disease of asthma is a complex process, initiated by a hypersensitivity to various stimuli, manifesting itself physiologically as a narrowing of air passages, and clinically by paroxysms of dyspnea, cough, and wheezing. The patient can experience these symptoms for short or long periods. Moreover, therapy is already mentioned under the heading "Definition." Such a description is rather far from the purified "pathological" story that Boorse presents. Consider now some species of disease found in the ICD which involve complications of another kind. The ICD contains several states or "disorders" which are really only deviant or abnormal, be it in a statistical or some other sense. Consider, for instance, E 30.0 ''Delayed sexual development"; E 66 "Obesity"; R 11 ''Nausea''; R 25.0 "Abnormal head movements," and in general everything which is covered by the title Symptoms, Signs and Abnormal Clinical and Laboratory Findings, such as: R 45.2 "Unhappiness"; R 46.0 "Very low level of personal hygiene"; R 51 "Headache"~ and indeed R 46.7 "Verbosity and circumstantial detail obscuring reason for contact." The mentioned conditions seem far from being instances of statistically subnormal functioning in relation to survival. They are just abnormal or undesirable, or else, as with the last condition, irrelevant. The topic of mental disease must be raised. Such diseases, or Mental disorders, which is the title under which they are classified, are represented in the

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medical classification of lCD. They are also, in contradistinction to the somatic maladies, given brief characterizations within the lCD itself. The standard mental diseases are mostly defined in terms of impaired mental functioning. Consider, for instance, some of the defining characteristics of schizophrenia: ''The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted.... The most important psychopathological phenomena include ... thought insertion or withdrawal ... delusional perceptions and delusions of control ... thought disorders and negative symptoms" (p. 325). The disease concept already partly connotes a set of disabilities, by characterizing the respects in which the subject has impaired functionings. Can we say anything about the goals presupposed in the traditional mental disease concepts? Should the mental disabilities be viewed as disabilities in relation to survival or in relation to other goals? The ordinary diagnostic descriptions give us little help on this point. The best answer we can get is probably given in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), which bravely formulates a general characterization of mental disorder: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability or an important loss of freedom" (p. xxi.). It is significant that avoidance of death is only one in a large set of goals mentioned in this central paragraph. What is the upshot of these observations? It seems as if mental disorders can constitute a mixed bag. On the one hand, they can be personality states which result in what society regards as undesirable behavior. On the other hand - and particularly in DSM IV, where the concept of mental illness has become more strictly defmed - they are conditions entailing suffering and disability for the subject. But "disability" is not necessarily connected with the lowering of the probability of the subject's survival. It seems as if Boorse's retreat to pathology closes the door on the possibility of saying anything whatsoever about mental illness, except perhaps for those rare cases where a clear somatic basis exists for such illness. This is notable since Boorse's earlier program had more universal ambitions. He believed that he could construct a more general theory of health. The question can then be asked: Does not such a thing as psychopathology exist? The term exists and a literature on the topic exists. Psychopathology, however, is not a part of pathology as ordinarily understood. Pathology as conceived in the medical curriculum is a completely somatic discipline. Mental illness comes in only as something for which some pathological (that is somatic) basis can exist. However, we need not be bound by institutional barriers in our theoretical discus-

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sion. Let me therefore consult a textbook on the topic: Psychopathology: Contributions from the Social, Behavioural, and Biological Sciences, edited by Muriel Hammer, Kurt Salzinger, and Samuel Sutton (1973). In their introductory presentation of the subject, the authors make the following comment: The meaning of deviance or social disruption in relation to pathology is not a semantic game to be played by others - it is a problem that the researcher encounters in the very matter he is studying. Even the question of whether the kinds of values incorporated in the concept pathology constitute the appropriate framework for scientific research must in some sense be coped with. The very conception that abnormal behaviour is to be viewed as illness, like cancer or tuberculosis or syphilis, is itself a product of the Zeitgeist of the last century and one that is already under attack. The patient is generally brought for treatment by his family or friends, and it is clear that the social mores defining normality are involved in the decision that abnormality is present. (Hammer et al., 1973, p. 2) A quotation drawn out of its context can show little. But from this short passage we can see that these doctors, known representatives of their subject, presuppose that values are incorporated in the general notion of pathology, presuppose that the idea that abnormal behavior is to be viewed as illness is a product of the Zeitgeist, and presuppose that it is abnormal behavior in general that is the criterion of illness and not subnormal behavior which would be closer to Boorse's notion of disease. The ideas contained in the quoted passage can be questioned and criticized. I could criticize them myself The existence of such ideas shows, however, that no simple and unanimous idea exists of what pathology is among doctors in general. 6. Preliminary Conclusions Concerning Boorse's Project

My analysis in the preceding paragraphs has scrutinized Boorse's version of conceptual analysis. Since Boorse purports to work quite close to the empirical field, that is, purports to characterize the concept of disease held by most doctors, at least implicitly, I have tried to support my analysis by using textbooks. This is relevant since Boorse has pointed out a clear criterion for identifying what doctors mean by the term "disease": Diseases are such entities as are classified in medical disease classifications. A natural procedure, then, is to take examples from such classifications and see to what extent they fit the abstract characterization. The first result of our investigation is that diseases as classified are not the kind of "pure pathological" entities that Boorse's theory asserts. They contain

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several elements apart from the pathological ones, including experiences and disabilities. This is to be noted when the distinction between disease and illness becomes my topic of analysis. To this a Boorsian answer may be made. I will now consider it. In 1997 (p. 64), Boorse says that he is not interested in nosology as such: [T]he BST is aimed at the demarcation problem, not at nosology. It seeks to say what is disease, not to individuate diseases. Individual disease entities should be defined and classified on whatever is the most scientifically convenient basis. I suppose I agree that etiologic classification is the best basis where available ... the BST per se has no implications for nosology except that any genuinely pathological state must include dysfunction. It does imply that an individual disease entity defined on a non-dysfunction basis must produce dysfunction in every case, or not (always) be a genuine disease. Good, the answer to my first observation, then, is that Boorse's theory does not aim at mirroring the richness of disease concepts, namely, that the defming characterizations of all major diseases contain a whole spectrum of features, including the patient's experiences. It aims instead at fmding some common denominator, a sine qua non of all diseases. This common denominator is dysfunction, understood as dysfunction in relation to individual survival or species survival. My answer to this is given in my second main observation. Examples exist of disease entities, as classified, which do not fulfill the sine qua non criterion. Most classified disease entities refer to or contain some kind of dysfunction, where dysfunction is taken in a wide sense. Mental diseases often entail disability pertaining to the individual. According to the Diagnostic Statistical Manual (DSM) they should always do so. Disability is a notion with clear connections to dysfunction, but it is not identical with dysfunction. Insofar as dysfunction is related to disability, it need not entail a dysfunction in relation to survival. The sociopath's inability to follow moral rules in our society is hardly bound up with any organic dysfunction relative to survival. To maintain Boorse's position we must make the following extremely strong claim: All human disabilities, whatever individual or societal goals they may be related to, are ultimately dysfunctional in relation to the goal of individual or species survival. Or put in other terms: All human disabilites lower, at least to some minute extent, the probability of the survival of the individual or of the species. I wonder how this strong contention can be supported. Most of all I wonder why it is necessary to make such a strong statement in order to construct a viable theory of health and disease. This could conclude my scrutiny of Boorse's latest position. The notion of pathological disease that Boorse is seeking to describe should come out in the

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medical classifications. I have shown that this is not the case. In my presentation I have also done something else. I have not exclusively relied on the medical classifications. I have consulted pathology textbooks and looked for their explicit and implicit characterizations of disease. I then made two observations. Pathology textbooks give little in terms of explicit characterizations. They do not treat diseases as classified; they treat what they often call the pathological basis of diseases. When they do contain explicit characterizations, these are often made in terms of dysfimction, malfimction, or abnormal fimction. I have not, however, found any explicit and exclusive reference to survival in the textbooks that I have consulted. The exception could be the use of the term ''vital fimction." According to the Gould Medical Dictionary (1979), "vital activity" means: ''the physiologic activity or fimctioning ... that is necessary for the maintenance of life." My conclusion is that Boorse has hardly succeeded in producing a descriptive theory of the pathological notion of disease, given the criteria he has suggested for grounding and testing such a theory. By this, I have not shown, however, that no other reasonable criteria exist by which Boorse might support his descriptive theory. He may claim that pathology textbooks are not adequate. Pathologists are not good at formulating their own concepts. Or he may say that my reading of medical classifications is partial and malevolent. We ought to dismiss the odd examples, he may contend, namely, those conditions which remain in the current classifications and which do not signify diseases proper. These conditions may be there for more or less administrative reasons, so that doctors can classify such people as seek health care without being diseased. Good, but it is then up to Boorse to present the criterion by which we can produce and test a descriptive theory of pathological disease. I think that Boorse is really doing something else than he purports. He succeeds much better in realizing another purpose than his explicit one. What he offers is a philosophical explication in the Hempelian sense, of the concept of disease. He proposes a definition of disease which is reasonably well-informed as to ordinary usage and stays close to this usage while at the same time containing stipulative precisations so that the resulting concept becomes as simple, clear, and fruitful as possible. Interpreted in this way, Boorse's theory constitutes an admirable achievement. I have elsewhere applauded it and noted many merits in it (1995, pp. 21-23). It is simple and clear; it provides a disease concept which can function universally for all living beings; it is a concept that in principle allows scientific measurement. Boorse's theory has a further merit which deserves mention, although it is of a more sociological kind. The theory tends to appeal to many of those scientifically-minded doctors who happen to pay attention to the issue of characterizing medical concepts. That it appeals to them is, however, not the same as saying that this is the concept they actually work with. We could say that Boorse's theory captures the Zeitgeist of late twentieth-century scientifically-

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minded medical doctors. In admitting this, I must, however, here exclude many psychiatrists and general practitioners. To say that Boorse's theory is simple and clear is not to say that it is ultimately fruitful. For a theory of health to be fruitful it should be able to perform many tasks, especially tasks which have to do with medical practice, with the interpretation of human illness, with the care and treatment of human illness, but also, secondarily, with the task of designing adequate medical and paramedical education and research. In Chapter Four, I will argue that we need a reverse theory of health, a theory which starts by identifying health and illness as primarily pertaining to the whole individual and as primarily having to do with negatively-valued phenomena such as distress and disability.

Three AN ALTERNATIVE MEDICAL PARADIGM OF DISEASE: LAWRIE REZNEK 1. Introduction

Lawrie Reznek is a philosopher and psychiatrist who has written extensively on the philosophy of health and disease. His most important works are The Nature of Disease (1987) and The Philosophical Defence of Psychiatry (1991). In these works, he defends a medical view of the basic notion of disease. However, this view is quite distinct from the medical view advocated by Christopher Boorse, which I have analyzed above. Reznek comes to the firm conclusion that the notion of disease is value-laden; therefore he rejects the so-called Identification thesis of the traditional medical paradigm. It is not true, he says, that scientific methodology is sufficient for the identification of diseases. They are identified on the ground that they are processes with harmful consequences. And the notion of harm is an evaluative notion. On the other hand, Reznek, as a practicing psychiatrist, vigorously defends the idea that, once we have fixed the values and decided on what we consider to be harmful to people, a proper scientific project involves the characterization of diseases and the search for an adequate treatment of these diseases. In his 1991 book, which primarily deals with mental illness, Reznek answers effectively many arguments which seek to throw doubt either on the reality of mental illnesses or on the appropriateness of scientific medicine's dealing with such illnesses. In one way, Reznek's theory is closer to Boorse's theory than to the theories of Fulford and Nordenfelt. He has the viewpoint of the physician in that he focuses on the notion of disease and says virtually nothing about health. His starting-point, as is especially obvious in Reznek, 1991, is also what he defmes to be the medical paradigm of disease. Reznek wishes to remain as close as he can to traditional presuppositions in scientific medicine. He illustrates his argument with several examples from medical research. His main intellectual sources are to be found in analytical philosophy of science. In spite of this focus, however, Reznek arrives at conclusions, as far as the characterization of

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disease and illness is concerned, which are far closer to the conclusions of Fulford and NordenfeIt than to those of Boorse. 2. The Medical Paradigm

As I have indicated, Reznek's starting-point (in his 1991 book) is a presentation of a medical paradigm of disease. This presentation is much more comprehensive than Boorse's version of the medical paradigm. An explanation of this is that Reznek does not make any distinction between disease and illness. He attempts to cover the whole area traditionally signified by these two terms. This fact, however, is not highlighted by Reznek himself. He uses both terms frequently, without any indication of a difference in meaning. Reznek's version of a medical paradigm thus encompasses the medical treatment of disease and illness. Reznek's theses constituting his medical paradigm are central to his argument. I will therefore reproduce them almost in extenso. The list is taken from his 1991 book, which mainly deals with mental illness. I therefore skip or appropriately change such theses as exclusively deal with mental illness. T1: The Conceptual Thesis: A disease is a process causing a biological malfunctioning. T2: The Demarcation Thesis: A mental illness is a process causing a malfunction predominantly of some higher mental function. All other diseases or illnesses are physical. T3: The Universality Thesis: Diseases are not culture- or time-bound. T4: The Identification Thesis: Scientific methodology enables us to identify diseases. T5: The Epistemological Thesis: Scientific methodology enables us to discover the causes and cures of these diseases. T6: The Teleological Thesis: Medicine's goal is the prevention and treatment of disease and illness. T7: The Entitlement Thesis: Having a disease entitles a patient to enter the sick role. T8: The Neutrality Thesis: Apart from the values implicit in the goal of preventing and treating disease, medicine is neutral with regard to any ethical or political position. T9: The Responsibility Thesis: Having one's behavior caused by an illness in a certain way excuses one from responsibility. (1991, p. 12) Reznek initiates his discussion (in 1991) with the following words:

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 31

As a branch of medicine, psychiatry is committed to the medical paradigm which assumes that there are such things as mental illnesses. In this chapter I will defme the medical paradigm, identify its virtues, and highlight the areas where it comes under fIre - it will be with these challenges and the defence of the medical paradigm that the rest of the book is concerned. Reznek claims that psychiatry, and implicitly all medicine, is committed to this medical paradigm. Reznek attaches high importance to the paradigm, although in the end, as we shall see, he fmds serious weaknesses in it. What, then, does the commitment amount to? Will traditional medicine and psychiatry collapse if one of the mentioned theses turns out to be false? A crucial concept in the medical paradigm is biological malfunction. According to the conceptual thesis, a disease is a process which causes a biological malfunction. This notion was thoroughly analyzed in Reznek, 1987, pp. 108119. Reznek there discusses alternative analyses of the notion but chooses in the end the following one: The function of X in Y is Z if and only if (1) X does Z, and (2) X doing Z makes a causal contribution to X's continued presence in Y via the mechanism of natural selection. According to the identifIcation thesis, scientifIc methodology enables us to identify such malfunctions. According to the conceptual thesis, biological functions are acquired by natural selection. For instance, the function of the heart is to pump blood and not make a noise, because only pumping blood was responsible for the natural selection of the heart (1991, p. 15). By investigating the evolution of organs, science can identify the functions of these organs. A disease, then, is identifIed by its tendency to prevent one or more organs from fulfIlling their proper functions. The answer that Reznek gives with regard to the notion of biological malfunction is similar to but not identical with the answer provided by Boorse in his explicit defmitions. In his later texts (1987 and 1997), however, Boorse relates himself to the theory of natural selection. In setting the stage for his analysis of theories of mental health, Reznek attaches great importance to this notion of biological malfunction. He says: There are many psychiatric conditions whose disease status is controversial - e.g. there is a question-mark over the disease status of homosexuality. This issue has been hotly debated in recent years, with no neutral means at hand of settling the issue. The medical paradigm is able in principle to settle such debates with TS - if there is a fact of the matter as to whether some condition is a disease, a scientifIc investigation to ascertain whether it is due to a biological malfunction can settle the issue. (1991, p. 19)

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In the end, Reznek will not uphold this characterization of disease. He argues convincingly that the conceptual thesis and the identification thesis in the medical paradigm are untenable. As a consequence, the medical paradigm is left without a resource to settle the issue of diseasehood in any clear and objective way. This also causes fundamental difficulties for Reznek which he may not have fully recognized. I shall return to this in my discussion. If diseasehood is not going to be connected with a notion of biological malfunction, then medicine will also face the problem of cultural relativism. Mental illness, in particular schizophrenia, is often identified through identifying delusions. These can hardly be identified independently of cultural norms, Reznek says: If a young man in our culture blames his abdominal pain on black magic inflicted by a former girlfriend, he is likely to be regarded as deluded. However, if the young man is living on a Caribbean island where the belief in black magic is commonplace, his belief would not be a delusion. Whether some belief or action is symptomatic of a mental illness depends not on norms that are universal, but on local and variable cultural norms. This leads to a disturbing relativity of our attributions of mental illness. (1991, p. 24) However, the medical paradigm could in principle solve this problem. If the mental condition under scrutiny does cause a biological malfunction, and not just cause a delusion, then it qualifies as a disease. But what are we left with when we get rid of the conceptual thesis? 3. The Challenges of the Medical Paradigm and Some Mistaken Views About Disease Reznek's 1991 book contains a valuable discussion of competing paradigms with regard to the nature of psychiatry, including Freud's psychoanalysis, Eysenck's theory of the normality of neurosis, Laing's rationalizing of madness, and Szasz's physicalization of disease. Reznek makes many sharp and, as far as I can see, correct points about these various theories. He finds on the whole that their- criticisms of the medical paradigm fail. My purpose here is not to make any detailed comments on this whole series of arguments. I confine myself to connnenting on a few major theses which Reznek advocates during this discussion and which have a bearing on his definition of disease. I will also illustrate with reasonings and examples from his 1987 book. (I) Reznek attributes to some of the theorists, including Freud, the socalled Essentialist Fallacy (Reznek, 1987, p. 63; and 1991, p. 299). "This is the fallacy of assuming that because a process is of a particular type - because it

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 33

has a particular nature or essence - it is a disease." Throughout the history of ideas, several theories on the nature of disease have held that all diseases have a particular internal essence. A major example of such a theory, says Reznek, is the Germ theory of disease holding that all diseases are infections. But such an idea is far from true, given our present lmowledge of diseases. Certainly not all diseases are infections: tumors, cardiovascular diseases, mental diseases, etc. can have entities other than microbes as their causes. Moreover, not all infections are diseases. Reznek takes an example from the plant world: leguminous plants (for example beans and peas) are infected by the bacterium Rhizobium. This bacterium penetrates the roots and enters into individual cells, causing them to enlarge to ultimately form the root nodules. However, these nodules are essential for the wellbeing of the plant, for they enable the plant to fix nitrogen and to synthesize its own proteins. This process almost identical [to an infection], far from being a disease ... is a beneficial symbiosis. (Reznek, 1987, p. 829) Conditions exist which could be called infections from the point of view of their causation but which are not pathological. Reznek says: "For instance, the colonization of the human infant's gastrointestinal tract by lactobacilli is something that benefits the infant - it protects him from the more pathogenic Escherichia coli. So it seems that being pathological does not consist in having a sort of explanatory nature" (Reznek, 1987, p. 83). Reznek's general point is that we cannot fmd any core property peculiar to all diseases or all pathological conditions. According to Reznek's conception: "Something is a disease not because of its nature or essence, but because of its undesirable consequences" (Reznek, 1991, p. 29; my italics). It might be said that after all all diseases must have a common nature. The notion of disease can be defmed in an Aristotelian way also according to Reznek's conception. We might say that the nature of diseases consists in their effects, namely, their undesirable consequences. Reznek has answered this objection (1987, p. 84): "But in looking for a particular type of explanatory nature that makes a condition pathological, we have to fmd a feature of the nature of the conditions that causally explains the relevant manifesting features. But to describe a nature as 'hannful' or 'productive of a malfunction' is to describe it in terms of its effects. But if we do this, then the nature can hardly be said to explain those effects." (2) No necessary connection exists between statistical abnormality and disease. Not only Reznek's theorizing but also the medical paradigm as explicated by him avoids the widely-held idea that diseases are statistically abnormal biological processes. A biological function - the notion on which the medical paradigm relies, according to Reznek - is a function that is naturally selected.

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This does not mean that the function is necessarily fulfilled in the majority of cases at any particular time. Thus, according to the medical paradigm a la Reznek, and according to Reznek's own position, a disease need not be be constituted by a statistically abnormal process. What is crucial for Reznek in the determination of diseasehood is that the process has undesirable consequences. Some statistically abnormal processes have desirable consequences, while some statistically normal processes have undesirable consequences. Thus, some statistically normal processes may come out as diseases. This, for instance, is the case with the worm-infection Bilharzia, which is extremely common in Central Africa. (3) Every disease is ultimately physical and has physical causes. Reznek has one strong metaphysical position which he probably shares with most physicians and perhaps most psychiatrists. It is a kind of physicalism. This fact is only indirectly indicated, through the reference to biological malfunction, in the medical paradigm. Reznek's assumption about physicalism is important in his discussion of mental illness. Some of the theorists of mental illness, such as Thomas Szasz, deny that so-called mental illness has anything to do with biological malfunction and thereby with bodily change. Thus, mental illness cannot properly be called illness. Reznek has two answers to such a claim. First, nothing in the concept of disease requires diseases to be physical. Second, physicalism is the only reasonable metaphysical position. If a mental disturbance occurs, a physical or bodily disturbance must also occur, according to Reznek. The idea ofa free-floating mental substance, such as dualism entails, is an absurdity. Reznek is at pains to quote all available evidence to the effect that mental disturbances are accompanied by neurological or immunological changes in the body. If one is a physicalist, it is tempting to draw the conclusion that all diseases are somatic and that no mental diseases exist. This is a conclusion that Reznek does not draw. A key distinction remains to be drawn between these two kinds of diseases, he says. One kind causes disturbances among the higher mental functions namely, the mental diseases or illnesses. The other kind of disease causes disturbances solely on the somatic level or among lower mental functions, presumably on the sensational level. These are the somatic diseases. The higher mental functions in their tum can ultimately be analyzed in terms of physical functions. However, Reznek maintains, it is still meaningful to identify functions on the mental level. We are interested in them as complex mental functions. Implicit in Reznek's analysis is an identity theory of the mind, though such a theory is not developed in he two books under scrutiny.

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 35

4. Reznek's Positive View Concerning Disease and Illness What is disease, then? And how does Reznek's view differ from the medical paradigm? I have already indicated that Reznek has to abandon the so-called conceptual thesis of the medical paradigm. According to this thesis, a disease is (or causes - Reznek wavers in his formulations) a biological malfunction. The notions of function and malfunction are defmed in terms of natural selection. The function of an organ is the one which has been selected during the evolution of the species. An organ is malfunctioning if it does not fulfill its naturally selected function. Reznek argues against the conceptual thesis in the following way: There are many healthy conditions that have underlying abnormalities. We saw that Einstein's brain contained an abnormal number of glial cells, which presumably was responsible for his genius. But we certainly would not regard this abnormality as a disease, and this because we value such consequences. Thus even if we discovered that political dissidents had an increased number of glial cells in their brains, this would not mean that they were suffering from some disease. And this is because the abnormality enables them to do something that we value to express their political view. (Reznek, 1991, p. 159) Reznek continues: We cannot argue that the factual mistake of holding that political dissidence is a disease is the mistake of assuming that political dissidence leads to reduced fertility and longevity (Kendell, 1975). This assumes that something is a disease if it leads to reduced fertility and longevity, and this is wrong. Imagine a condition that enables us to be highly creative - affected individuals lead intense, productive and fulfilling lives. However instead of having the average of 2.2 children, such individuals have on average 2.1. In addition, instead of living the usual three score and ten, they live three score and nine. Thus the condition reduces fertility and longevity. But because we value the other consequences more highly than we disvalue the marginal decrease in fertility and longevity, we would not classify the condition as a disease. (Reznek, 1991, p. 160) What Reznek is doing here may be fruitfully compared with the efforts of Boorse. Boorse says that he knows what a disease is. A pathological disease in Boorse's sense is exactly what Reznek denies a disease to be. Boorse solves the problem of value with regard to diseases by making distinctions between diseases and illnesses. Illnesses are the conditions that we wish to

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treat. In Boorse's most recent treatment (1997, p. 13) he also uses other terms such as "diagnostically abnormal" and ''therapeutically abnormal" for making the relevant distinctions. Diseases should not necessarily be treated. Reznek has not adopted this distinction. This may be a reason why he is forced to loosen the tie between disease and biological malfunction. Does Reznek provide a methodology for his conceptual analysis? What are the criteria for the correctness of such an analysis? Reznek is silent on this issue in The Philosophical Defence of Psychiatry (1991). The Nature of Disease (1987) is more informative. There Reznek notes that there is a class of negative human conditions which are recognized by medical and lay persons alike: In fact, the classes recognized by the layman and the physician are largely identical, with medical classification of conditions as diseases being more liberal than the lay classification. In a study of such classificatory habits, conditions that were the result of some infectious agent malaria, measles, tuberculosis, syphilis, and so on - were regarded as diseases by 95% of the laymen, and were regarded as diseases by 99% of medical men. (Reznek, 1987, p. 67) Reznek therefore concludes that a distinction is drawn by both experts and laypersons between pathological conditions and non-pathological conditions. In an investigation made in 1979, this distinction was by and large drawn in the same manner by all people who took part, although the medical concept of pathological condition is slightly more liberal than the lay concept. Both laypersons and medical persons, Reznek concludes, are operating with recognizably the same concept of disease. Reznek's explicit starting point is an empirical investigation indicating a conceptual behavior among both medical persons and laypersons. His purpose is to show the nature of this distinction. Reznek might seem the most empirically-minded of the theorists under scrutiny in this book. But this empiricism is only partial. In the subsequent discussion, Reznek is not using any empirical method. When he discusses crucial cases, potential counter-examples to a particular theory of disease, he is not using any informants, for instance, a group of laypersons or medical persons. Instead, in the standard philosophical fashion, he is relying on his own intuitions about the concept. Consider: It may be that a woman's capacity for orgasm is something that does not have a function [in the sense of biological function explicated above], but is the accidental result of the fact that men and women are made out of the same genetic blueprint. Suppose too that some process, say a viral infection, interferes with a woman's capacity for orgasm. Such a process would be very distressing, and I think we would be cor-

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 37

rect [my italics] to classify it as a disease. This would be so even though no function would have been disrupted, and so producing a malfunction is not necessary for being a disease. (Reznek, 1987, p. 131)

The crucial question is: what is the criterion of correctness? Is it simply Reznek's personal intuition? Or is it Reznek's belief that more than, say, 90 percent of the medical persons or the laypersons in Britain (or the world?) would classify a condition as a disease? Or, does he already have an explication of disease in mind (the one to be proposed in a subsequent chapter) which would have as a result that the mentioned kind of viral infection comes out as a disease? In spite of Reznek's high degree of methodological consciousness, he is unclear on this key point. This is not to say that Reznek could not fmd a good empirical defense of his position. One good argument would be to say that Reznek wishes to explain as much as possible of the current nosology of diseases and illnesses. He would surely fmd many instances of diseases (consider my discussion above) which are not at all identified on the basis of any biological malfunction. They are identified both theoretically and clinically on the grounds that they cause human distress and disability. The clinical goal, moreover, is to remove and prevent such distress and disability. 5. Reznek's Definitions of Pathological Condition and Disease In The Nature of Disease (1987), Reznek recognizes the highly generic concept of "pathological condition." This is a concept which has "disease" as a subconcept. It also encompasses injuries, defects, and handicaps. Reznek discusses possible distinctions among these subcategories but does not fmd any clear-cut boundaries between them. His conclusion is that they are concepts which have evolved for a long time and that they now have the character of family-concepts. In Reznek's 1991 treatise, only the notion of disease or illness is in focus. There Reznek accepts the idea that diseases are processes and that this distinguishes them from the other subcategories of pathological conditions. Consider Reznek's defmition of ''pathological condition" (Reznek, 1987, p. 167) and of "disease/illness" (Reznek, 1991, p. 163): A has a pathological condition C if and only if C is an abnormal bodily/mental condition which requires medical intervention and for which medical intervention is appropriate, and which harms standard members of A's species in standard circumstances. (1987) Something is an ... illness if and only if it is an abnormal and involun-

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The two definitions are similar, although the 1987 one is more detailed and more careful on some points. Reznek has taken care of the telling observation that not all diseases harm all their bearers. We can have instances of diseases which do not cause harm. What makes a condition a disease, or for that matter an injury or defect, is that standard bearers of it, under standard circumstances, will to some extent be harmed by it. The notion of harm is a crucial criterion of diseasehood for Reznek. Diseases normally do harm, that is, they diminish our well-being by causing such things as suffering and disability. "TIlls ensures that the concept of disease is value-laden - what counts as suffering and disability depends on our values" (Reznek, 1991, p. 164). Reznek says that blindness is a disability because being able to see is desirable, while the inability to curl one's tongue is not because such a trait is not desirable. The notion of harm itself is thoroughly analyzed in Reznek, 1987, pp. 134-153, but it is left completely unanalyzed in 1991. It will be discussed below. The notion of abnormality which is referred to is not statistical abnormality (cl above). It is a notion of "idealized" (Reznek, 1987, pp. 94-97) or "constructed" (Reznek, 1991, p. 163) abnormality. This notion will be discussed below. Reznek builds into his defmition of disease a relation to appropriate medical interventions. A reason for introducing this clause is given in the following example: It might be further objected that being extremely cold is both unpleasant and mildly disabling (one's limbs are stiff), but it is not a pathological condition. I suspect that this condition is not regarded as pathological because its correction does not require medical intervention. On the other hand, conditions like hypothermia are pathological because they do require such intervention. (Reznek, 1987, p. 163)

So something is a disease or a pathological condition in general only if it is best treated by medical means. The medical treatment should not only be efficient; it should also be appropriate. Drug addiction, for instance, is an abnormal condition that produces harm, and we might be able to do something about it by medical means. However, we might not wish to classify it as a mental illness because we feel that the problem ought to be handled by the law (Reznek, 1991, pp. 164-165). Consider also the following argument: While it might be the case that we could alter the neurological state [of criminals] by medical means - we could subject all criminals to frontal

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 39

lobotomy - it might not be considered appropriate to do so. We might not consider it appropriate because we feel that such behavior is ... freely chosen, and hence not due to some disease. Only if we feel it is appropriate to use medical means will the condition be considered pathological. It is because we do not consider it appropriate to alter criminal behavior by medical means that we will not consider the neurological state as pathological. (Reznek, 1987, p. 167) In the second defmition, Reznek highlights the feature of disease which distinguishes it from the other pathological conditions. A disease or illness is a process. He says that "static defects like Down's syndrome are not diseases because they do not evolve" (Reznek, 1991, p. 163). A component mentioned in the second defmition is that a disease must be an involuntary process. A disease cannot be immediately reversed by will. If something is under our direct control, it is instead, according to Reznek, a form of action. This is the main reason why things like political dissidence and sexual excess are normally not considered diseases.

6. An Examination of Reznek's Theory of Disease In turning to an examination of Reznek's doctrines, I concentrate on his ideas of normality and harm. I have little to say about the other criteria. I can easily ally myself with the thesis that diseases are bodily (or mental) processes. My own theory contains this idea, following the paradigm of Whitbeck (I 981) and Porn (1993), when I distinguish between injuries, diseases, and defects. I can also quite easily accept the idea that diseases should be non-actions, that is, involuntary processes. This does not preclude the possibility of identifying diseases through actions. Such is the typical procedure in the case of mental illness. I will say more about that below. The condition concerning medical treatability is, I think, highly doubtful as a sine qua non. Such a requirement would prevent us from classifying a condition as a disease as long as we are ignorant as to the adequate means for treating it. The clause on treatability will be briefly commented on in the discussion of abnormality and harm. (I) Reznek's idea of normality. A disease, says Reznek, is an abnormal condition, by which he presumably means an abnormal bodily or mental process. But the abnormality here has nothing to do with statistics. An unusual bodily or mental process is not necessarily pathological. Nor is a process which subnormally contributes to the survival of the individual (cf Boorse) necessarily a disease. So what kind of normality are we talking about? It is difficult to understand what Reznek means. This is partly because he has changed terminology from 1987 to 1991. A result of this change is that Reznek seems to contradict himself. Compare:

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40

Thus a process or condition must be of a type that is abnormal in the idealized [my italics] sense if it is to be pathological. This norm is selected because of its practical consequences. That is, it has a prescriptive content. (Reznek, 1987, p. 97) and: Something is an idealized [my italics] abnormality if it falls short of the ideal for that species. But we are not ill simply because we are not supermen .... The norm of health is in fact a construct [my italics). It is up to us where to draw it, and it is the consequences of any construct that influence this decision ... ; it is up to us to regard the menopause as an abnormality in view of its detrimental consequences - osteoporosis and heart disease. (Reznek, 1991, p. 163) Reznek has evidently changed the sense he attaches to the term "idealized abnormality." I shall assume that what he calls idealized abnormality in 1987 is identical with what he calls constructed abnormality in 1991. But what does that mean? To be abnormal in the constructed sense (I choose the latest term) is to fall short of a norm that has been selected by people, presumably in a culture (1987, p. 97). This norm has been selected because of its practical consequences. If the practical consequences of the norm are bad, then we would not select the norm. If they are good, then we might select the norm. Does Reznek say anything more? In the 1991 book, he focuses on the condition itself. He says that it is up to us to regard the menopause as an abnormality in view of its detrimental consequences. Reznek is not talking about the consequences of adopting the norm but about the consequences of the condition itself. But if abnormality is to be dependent solely on the consequences of the condition, then this criterion seems superfluous. Reznek already has a consequence criterion in harm. It takes care of the harmful consequences of diseases. Thus, abnormality cannot just be identical with hannfulness, if the idea is to be useful in this context. Reznek risks making the criterion of abnormality superfluous for yet another reason. This is when he says that what will influence whether we regard some process as normal is the ability we have to treat the condition medically. We are unlikely to regard ageing as a disease because we are at present unable to do anything about this process. But again, the treatability of a condition is already a separate part of Reznek's deftnition of disease. At other places Reznek seems to mean something peculiar. This is when he is looking into the general consequences of adopting a norm.

Three. An Alternative Medical Paradigm ofDisease: Lawrie Reznek 41

With the [constructed] norm, we would construct a norm in terms of which (appropriate) grief was a pathological condition. But this has undesirable consequences - we want to be the sort of people in whom it is healthy to respond to loss with grief, and so we do not want to adopt a norm with the consequence that grieving becomes a disease, and something we should cure with drugs. For this reason, then, we adopt one norm rather than another. (Reznek, 1987, p. 96) A similar idea appears in the 1991 book where Reznek is discussing homosexuality. Though he finds that heterosexuals are better off for various reasons than homosexuals, he says that we cannot conclude that homosexuality is a disease: But judging heterosexuals are better off does not mean that homosexuality is a disease. This is because in judging that a condition is a disease, we have to make a political judgment. We have to ask not only what sort of people it is worthwhile being, but also what sort of society we ought to create. A society where we stigmatize homosexuals is cruel and divisive. (Reznek, 1991, p. 169) What is going on here? It seems as if the norm of health is (and should be) the result of a political decision. Not all harmful bodily or mental processes should qualify as diseases. They must also pass a political test. For political reasons it would not be suitable to call every harmful bodily or mental process a disease. According to Reznek, it would be devastating to classify homosexuals as ill. And it would not be proper to say that a grieving person is ill, since we wish to be the sort of people who feel grief when good reasons occur for it. If this is what Reznek intends, as the quotations indicate, it has considerable consequences for his theory of disease. It undermines all the sharp theoretical analysis that Reznek performs at other places. What is the point in making a close theoretical characterization of the notion of disease, if the whole thing in the end is to be determined by a political decision? Or, does he mean that the political decision can only come in as an extreme exception? First, a condition must fulfill all other criteria for diseasehood (for instance, being an involuntary and harmful process), and then a question arises as to whether it passes the political test: would it be harmful to society to accept this condition as a disease? Before further analyzing this position, I will comment on Reznek's program for analysis. One interpretation of his reasoning is that he wishes to be as empirical as possible. He tries to describe a conceptual reality. In the end, political decisions are behind the official classifications of diseases and causes of

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death (cf. the JeD and the DSM). Authorities make decisions to include some conditions and exclude others from these classifications. An illustrative example of this is the 1973 conference of the American Psychiatric Association where a vote occurred concerning the status of homosexuality. As a result, homosexuality was excluded from the list of mental illnesses in the DSM (see Bayer (I 981). These authorities simply decided what should be counted as a disease. Reznek does not, however, recognize that medical authorities try to rely on some theoretical characterization of diseasehood in their classification. Such reliance was most evident in the case of homosexuality. Here the leading theoreticians, in particular R. M. Spitzer, presented a theoretical analysis of the notion of mental illness. The majority of the psychiatrists, who were present at the time of the crucial voting procedure, accepted this theoretical characterization, according to which homosexuality could not be a disease, and they voted for the exclusion of homosexuality from the classification. They considered the previous inclusion of the condition to have been a mistake. In their selfunderstanding they would parallel this mistake with the following. Assume that a group of mathematics teachers at a conference found that a frequently used textbook contained an arithmetic error. For several reasons this error had not been recognized by their predecessors. As a result of their discovery, the teachers decided to remove it. In a superficial sense, they would be making a decision, namely, to remove the error from the textbook. But in doing so, they would not construct a new norm for arithmetic, nor would they believe that they were doing so. Nor did the 1973 psychiatrists, presumably, believe that they had constructed a new norm for psychiatry. They had instead, as they believed, become much clearer about what are the criteria of diseasehood. Admittedly, the story behind the abolition of homosexuality as a mental illness is complex. For some people, and not just the members of the gay community but also psychiatrists, the issue was predominantly political. However, Spitzer, the leading theoretician at the time, saw himself as making a "scientific" analysis of the concept of mental illness and an unbiased scrutiny of whether homosexuality falls under the heading of illness. R. Bayer says: "From a review of the available literature he [Spitzer] concluded that a significant proportion of homosexuals were satisfied with their sexual orintation, showed no signs of psychopathology (other than homosexuality, if that were considered pathological, per se), and functioning in a socially effective fashion ... " (Bayer, 1983, p. 127). For a recent analysis of this story, emphasizing its political content, see Kutchins and Kirk (I 997). Back to Reznek's idea about the constructed norm as a political creation. We can wonder whether to talk about norms at all in this context is proper. According to Reznek's examples, it seems as if the decisions he is talking about, concerning grief, homosexuality, and criminality, are quite ad hoc.

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 43

Every single condition in Reznek's treatise is discussed on its own premises, and the question is asked: would it be detrimental to society if this condition were to be included among the diseases? The only norm that we are talking about is the generic norm: exclude any condition from the list of diseases (or pathological conditions in general) if the inclusion of it would be harmful to society. Reznek's reasoning about harmfulness to society presupposes some property of diseasehood, in the common understanding of it, which can have harmful effects. What is it about diseasehood that can be disturbing? And should this, then, not be discussed in the theoretical analysis of diseasehood? The idea, included in Reznek's theory, that diseases or illnesses, by definition, warrant medical treatment could be one such disturbing feature. A person may for various reasons not want to be medically treated for a condition. That person, for instance, may not fmd this condition as harmful as the social environment does. Or the person may be afraid of the treatment available. Assume now that a condition about which many people have this feeling exists. To insist that it it is a condition which ought to be treated might then cause general unrest. Thus, society may decide not to do so. Since the notion of disease/illness in Reznek's theory already contains a prescription about treatment, society might decide not to classify this condition as a disease/illness. So the argument may go. This strikes me as an argument to the effect that the prescriptive content should be removed from the defmition of disease. I think in many instances we have good reasons for abstaining from treating diseases in a medical way. I am now talking about conditions which without question are diseases. Mild diseases exist; cases occur where the treatment of a disease might cause more halm than good; in other cases people for religious or other external reasons do not wish to have treatment; and then telminal diseases occur. In such instances people have good reasons for abstaining from treatment. At the same time, according to ordinary language, we can have no question but that the underlying conditions are diseases/illnesses. Reznek's point may be deeper. It would not be enough, he might say, from an ethical or political point of view, to separate the idea of disease from the idea of medical treatment. If the criminal or the homosexual is classified as a person with the disease of "criminality" or the disease of "homosexuality," then a stigma is put on that person. Such individuals get the feeling that they have been deprived of a part of their humanity, of their free will to choose a life of their own. Thus, the humane political decision in a case like this, so the argument may go, is to abstain from classifying these conditions as diseases, although they may fulfill all other criteria of diseasehood. By including the possibility of a political decision in the very definition of disease, Reznek has made the concept much less useful for many of its princi-

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pal objectives. Medical or social authorities can no longer use diseasehood as an argument for a political decision. But that this should be a possibility is part of the common understanding of diseases. They can no longer say the following: modem medical science has shown that alcoholism is a disease; thus, alcoholics should have the right to medical treatment if they want it, and, as a consequence, we must establish clinics for alcoholics. This is impossible, because medical science can do nothing of the sort, according to Reznek. Ultimately, as he sees it, a condition C is a disease because we (the medical authorities) fmd it appropriate to so classify it. This conclusion does not deprive the authorities of the possibility of using the other parts of the defmition of disease in their argument. The medical scientists and practitioners can observe that a condition is an involuntary bodily or mental process which is harmful to its bearer, and this can be used as an argument for refonning a section of health care. We may then say that they can use a "reduced" conception of - or a theoretically purified conception of - disease for their purposes. The question is whether this theoretically purified conception is a better alternative as a reconstruction of the notion of disease than Reznek's proposal. By calling it a theoretically purified conception, I am not saying that it has been rid of all its evaluative content. I agree with Reznek that this is not possible. It need not, however, be evaluative or normative in all the dimensions that Reznek proposes. My solution to the dilemma is different from Reznek's. I would look much closer into the notion of harmful consequences, in particular, into the bearer of the harmful consequences. I would ask the question, Is the condition of, say, homosexuality harmful to most bearers, given the bearers' own longterm assessment of the condition? If the answer is yes, then this condition is a candidate for being a disease. The answer, however, as we know, is the opposite. (2) Reznek's idea of the involuntariness of diseases. The criterion concerning the involuntariness of diseases is at a fust glance easy to support. Diseases are not actions. The standard diseases, such as the cancers, the infections, and the cardio-respiratory diseases just happen to us and afflict us. They are not the sort of thing that can be directly created and reversed by an act of will. The most impOltant point is irreversibility. People may hurt themselves, for instance, by stopping their heart activity through an act of will. This could be quite a serious condition and a serious disease, unless such persons can immediately restore their state to normal again. Some diseases, although not actions in themselves, are close to actions in that they influence actions to a high degree. This is so with many mental diseases. A mental disease is often identified via so-called abnormal behavior; this is the case wit~ schizophrenia, mania, and also alcoholism. Reznek's claim, like the claim of most other theorists, is that the abnormal behavior as such does not

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 45

constitute the disease. The disease is the state of the person, ultimately a physical state according to Reznek's metaphysics, which issues in abnormal behavior. This already follows from his defInition of mental illness as a process that disrupts higher mental functions. It is not the abnormal behavior which disrupts higher mental functions. The abnormal behavior is a late effect of disrupted mental functions. This relationship means that intentional behavior, while not being identical with the mental illness itself, can be a sign of mental illness. In some cases people would not have acted in one way had they not been mentally ill. Thus, an intentional action sometimes has an illness-process as its partial cause. Reznek is committed to sharing this reasonable conclusion, given what he says about schizophrenia and alcoholism. However, in the area of mental illness and among the "modem" candidate-conditions for being classifIed as mental illnesses, the political arguments for or against diseasehood might operate. Consider Reznek's own discussion concerning drug addiction: Drug addictions are abnormal conditions that produce harm, but we might not wish to classify them as mental illnesses because we feel that the problem ought to be handled by the law. We might feel drug addicts are not victims of a disease, but slaves to be set free, and that the law is more likely to achieve this. (Reznek, 1991, pp. 164-165) Again, Reznek is inclined to put a pragmatic criterion into operation. If it turns out not to be appropriate to use medical treatment to get rid of an undesirable condition, then this condition should not be called a disease. (3) The nature of harm. Reznek provides a long and penetrating discussion of the notion of harm in his 1987 treatise (pp. 134-153). He proposes fIrst several naturalist explications of this notion (in terms of malfunction, biological needs, pleasure or desires) but rejects them all as insuffIcient for his purpose. He concludes by saying, tout court: "Being harmed does not consist in some complex fact - the concept of harm is a normative notion" (my italics): X does A some harm if and only if X makes A less able to lead a good

or worthwhile life. (Reznek, 1987, p. 153)

and: A has a disease P if and only if P is an abnormal bodily or mental process that does standard members of A's species some harm in standard circumstances. (Reznek, 1987, p. 161)

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Reznek's 1991 book presupposes this analysis and does not repeat it. The presentation in the later book would have been helped by some strict definitions. This need is deepened because in many contexts in this book another extremely generic term is used, namely, ''undesirable consequences." It is said to be a sine qua non that diseases have undesirable consequences (cf pp. 29, 33, 35, 37, 46, and 78). On other occasions in the book, references are made to the more specific and well-known consequences of "suffering and disability" (see, for example, pp. 57, 64), or even just "suffering." "Suffering and disability" could be said to have a favored position in 1991 since it occurs in Reznek's explication of his definition of illness. "Mental illnesses do harm - i.e. they diminish our wellbeing by causing suffering and disability" (Reznek, 1991, p. 164). The characterization of harm, and indirectly of disease, in terms of consequences of disability brings Reznek's theory close to the theories of Fulford and Nordenfelt (see the presentation in Part Three). Reznek's notion of disability, however, is broader than theirs, since it is not restricted to disability with regard to intentional action. And it is evident from diverse examples that Reznek's term "harm" could well refer to other undesirable consequences than the subject's suffering or disability. Disfigurement and premature death are examples of other possible consequences of diseases. We should bear in mind that Reznek's general defmition of "disease" or "pathological condition" is also intended to cover non-human cases. It should be applicable also to the world of non-human animals and plants. Consider: But although plants might not have interests (because they cannot have worthwhile desires and pleasures), we can also give an account of disease in plants or animals in terms of the notion of being worse off. All organisms have a good or well-being which can either be promoted or impaired. And because of this all organisms can be made worse off. In our case our good or well-being is understood in terms of the satisfaction of our (normative) interests, but this need not be the case for organisms that do not have interests. In their case their good must be understood differently. (Reznek, 1987, p. 165) This statement, as well as others, including the highly generic definition of harm in 1987, entails that Reznek must have a great variety of undesirable consequences in mind when he talks about the harm caused by diseases. In the human case, he normally exemplifies in terms of suffering and disability, but he has not ruled out other types of undesirable consequences. In the case of plants he must refer to other types of undesirable consequences. In making his defmition of harm so highly generic, Reznek runs into difficulties which he does not confront in his treatises. Is it reasonable to say that any kind of consequences which make a person less able to lead a good or

Three. An Alternative Medical Paradigm ofDisease: Lawrie Reznek 47

worthwhile life will do as criteria of diseasehood? Observe, fIrst, that no restriction has been made by Reznek concerning the dimensions of goodness. We could be talking about moral goodness, intellectual goodness or aesthetic goodness. Let me illustrate from the area of moral goodness. First, examples of bodily and mental conditions may restrict a person's ability to live a morally worthWhile life but which are far from being diseases or pathological conditions in the intuitive sense of these terms. A young woman with good looks, living in poor circumstances and in an area of high unemployment, which may be the standard circumstances in her country, may be much more predisposed to becoming a prostitute than a woman who is less attractive. Thus, given the circumstances, her good looks predispose her to a less worthwhile life from a moral point of view than if she had been less attractive. But "good looks" is as far from the intuitive sense of disease as any bodily condition can be. Conversely, an illness, in the intuitive sense, for instance a disfIgurement, can make a person much more morally conscious by making that person aware of the condition of being deviant and of being the object of negative attention on the part of other people. The illness may, as a matter of fact, considerably contribute to the person's ability to lead a morally good life. Consider now another dimension of goodness: A young man has for a long while been extremely interested in football and has planned a career as a footballer. He happens to break his legs severely in a match and has to give up his career as a professional player. Instead, he fmds that he has some other talents, namely, remarkable intellectual skills. He becomes a scientist who revolutionizes science. He thus eventually leads a more worthwhile life (from an intellectual and perhaps also from a personal-satisfaction point of view) than the one he was heading for before. This means that an obvious injury can trigger a person's ability to live a worthwhile life. If the notion of harm is left unspecifIed in the way Reznek leaves it, then we face diffIculty in fmding criteria whereby criminal and in general unethical conduct can be kept outside the pathological area. Recall one of the virtues that Reznek attaches to the Conceptual Thesis of the medical paradigm. According to this thesis, a condition is a disease or illness only if it is identical with or causes a biological malfunction. Hence, according to Reznek, some problematic cases have a quick solution. "Criminals are not mentally ill because their behavior is not due to a biological malfunction, while schizophrenics are because their brains are malfunctioning" (Reznek, 1991, p. 14). Since Reznek himself has dismissed the thesis as incorrect, this device for making a sharp distinction between pathological and non-pathological conditions has disappeared. If, moreover, no restriction occurs as to the nature of the harm caused by diseases, that is, the harm involved may be a moral harm, then the cause of a person's inability to comply with legal or ethical codes could certainly be classifIed as a disease.

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The problem which I have highlighted here is a consequence of the fact that Reznek has consciously avoided restricting his notion of harm to any specific kinds of harm. Reznek has not considered the multiplicity of normative dimensions. He has not restricted the health discourse to any particular normative dimension, for instance the welfare dimension, which is the one normally favored in the context of health. Consider now the difficult question concerning the relativity of the normative evaluations which are at issue in a claim concerning health and disease. To whom should the harm be harmful in order for an underlying condition to be qualified as a disease? It might seem self-evident that the harm concerned must be a harm to the subject. If a person suffers, the suffering is clearly a harm to the person. In the standard case, a disability is also a harm to the subject of the disability in question. I defme disability in such self-referential terms (see Chapter Four, Section 3). Moreover, in Reznek's formal defmition of disease, the locution is that the disease typically harms A, the bearer of the disease. Reznek consistently extends this idea to the world of plants. He says that human interests do not determine the disease-status of conditions in the world of plants (Reznek, 1991, p. 100). Contrast, however, the examples to be found in D. A. Roberts et al. (1984). "Desert grass and pestilent rabbits can have infectious diseases (even though we have no interest in their survival) because the infection does them harm." Normativity can be relative in yet another sense. Who is to judge that X does A harm? Should the evaluative judgment be made by the subject, or could it be made by anybody? Is only the diseased person to say that the disease causes the person harm? Or could anybody do that? A few things need to be disentangled here. We must not conflate the problem of epistemic access with the problem of evaluation. Subjects know more facts about themselves. They normally know more about what has happened to them, and they know better than anyone else whether they are in pain. In this sense, subjects can judge better. In one sense, subjects also know better than anyone else what degree of harm has been caused them. They know to what extent they dislike the situation which has occurred. They normally know better than someone else how unhappy they are with their condition. But the judgment of persons about their own happiness is not enough for ultimately assessing whether they are better off or not. A person may live a happy life without living a worthwhile life, according to Reznek. In his support, he cites several arguments, among others Derek Partit's (1984) Repugnant Conclusion: Suppose that I could either have a life of 50 years where my major desires are satisfied, or a life in which only my minor desires ~ satisfied, but which is long enough such that total desire satisfaction \bf this life

Three. An Alternative Medical Paradigm ofDisease: Lawrie Reznek 49

outweighs that in the fIrst life. My good would not be served by leading a life that was barely worth living, but which was long enough so that the amount of desire-satisfaction exceeded that in a short but satisfying life. (Reznek, 1987, p. 150) Reznek's idea, then, is that the total sum of pleasures or pains does not determine the goodness or harm of a person. This becomes even more evident if the good is also to include the morally good. The happiest person is not necessarily the morally most valuable person. The question could then be asked: Must not the ultimate judgment concerning whether harm, in Reznek's normative sense, has been done to A, be made by A? Assume that A understands Reznek's sense of harm. Can anyone else than A judge whether harm has been done to A? As far as I can see, Reznek's answer is that anybody can in principle make this judgment. The subject may have epistemic access in the ways described above, but the normative judgment can be made by anybody. We must make Reznek's position clear because it should be contrasted with yet another possible standpoint on the issue. First, to say that A has a condition which makes A less able to lead a good or worthwhile life is not to say that A judges that A is less able to lead a good or worthwhile life. If it were, then disease ascriptions would in the end be descriptive statements. They would be descriptions of the subjects' evaluations. But, second, to say that A is less able to lead a good or worthwhile life is not to say that most people, or the most influential people, in this country (or culture) judge that A has this disability. If this were so, a disease ascription would again be transformed into a descriptive statement, one describing a collective's evaluative judgments. For a discussion of this, see Reznek, 1991, pp. \02-\03. Reznek's position is clear: disease ascription is a purely normative judgment and not a description of other people's normative judgments. But pragmatic problems are associated with this position. In many contexts, especially in the medical world, the use of a descriptive language becomes a necessity. It is a fact that a great number of conditions are classifIed as diseases and are described in the utmost detail in medical textbooks. These conditions are consistently called diseases in the medical discourse, and the medical student is taught to call them diseases. When the medical person refers to these conditions as diseases she or he is clearly not making a normative judgment about the hann they cause their bearers. The medical person talks about them as the conditions which are described in the medical textbooks. These are the conditions which have been judged to be diseases by relevant authorities. The individual doctor can hardly deviate from these conventions. This situation can be compared with that of the lawyers who are applying their country's common law. When using the law and referring to the legal text,

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they are not evaluating anything. They are using the law as a fact. The evaluation behind the law was made long ago by the legislators and not by the lawyers. Thus, a common descriptive use of the term "disease" occurs, although basically related to some evaluation if Reznek's theory on this point is true. This ought to be acknowledged in a presentation of this kind of theory. The descriptive use of "disease" is even more obvious than the descriptive use of "health," since the diseases are so neatly classified and described in biological and psychological terms. 7. Concluding Remarks on Reznek's Theory of Disease Reznek is a psychiatrist who has made a philosophical analysis of the notion of disease. His platform is that of the medical person, the scientist, and the practitioner, who uses and appreciates the notion of disease. Reznek uses his expert knowledge in the attempt to show what kind of thing a disease is and to show that the concept of disease has a proper role in psychiatry and medicine in general. This purpose is made evident in his 1991 book, which starts with the introduction ofthe medical paradigm (see above). Reznek fmds that the medical paradigm has many virtues. If it were true, then the epistemology of medicine would be clear and questions about diseasehood could be easily solved by the science of medicine itself. During the course of his analysis, Reznek discovers, however, several flaws in the medical paradigm. Some of its cornerstones must be mistaken, he says. This holds for the Conceptual Thesis that a disease is a process causing biological malfunction, and for the Identification Thesis that scientific methodology enables us to identify diseases. But problems also arise with the Neutrality Thesis, which says that medicine is neutral with regard to any ethical and political position, and the Universality Thesis, which claims that diseases are not culture- or time-bound. Diseases do not in general cause biological malfunctions. They cause harm. Harm is not something that scientific methodology can discover. Harm is an evaluative notion, and a person's judgment as to what counts as harm may be quite dependent on that person's ethical platform. Thus, the medical paradigm, given Reznek's analysis, is far from true. In spite of this, Reznek claims that the concept of disease is a necessary concept for the practice and science of medicine. And he defends the concept of disease vigorously and effectively against several attacks which have come mainly from theorists of mental health and illness. These attacks have entailed either that no such thing as mental illness exists, or that many so-called mental illnesses do not fulfill reasonable criteria of illness. Most protagonists of these attacks have committed what Reznek calls the essentialist fallacy. They have for different reasons believed that a disease must have a special ontology, for

Three. An Alternative Medical Paradigm of Disease: Lawrie Reznek 51

instance, be caused by a microbe, be constituted by a bodily change, such as a tumor, or be a statistically abnormal process. No such essence is common to all diseases, says Reznek. The only thing that diseases have in common is that they are involuntary processes which cause harm. Reznek at one stage anticipates a reverse theory of disease and illness, the kind of theory to be discussed in the following chapter. He observes that the psychiatrist Ronald Laing in his critique of psychiatry takes an essentialist position. Doctors, according to Laing, correctly judge that something is a symptom of a disease because it is caused by the right sort of biological process. This, according to Reznek, is to take things the wrong way: But what comes fIrst in both physical and psychological medicine are symptoms - i.e. suffering and disability - and whatever causes this is a disease. We do not fIrst judge that some process (of the right biological type) is a disease, and then conclude that whatever it causes must be symptoms! (Reznek, 1991, p. 57) Reznek thus criticizes at least as much as he defends the cornerstones of conventional medicine and psychiatry. What is his purpose and what is his philosophical method? His purpose in many ways is similar to the purpose of Christopher Boorse. He wants to clarify what diseases are. After having studied an empirical investigation on the issue, Reznek is quite convinced that a stable notion of disease is shared by experts and laypersons and is amenable to serious analysis. He sets himself to analyze this concept. His method in doing so, however, is not empirically linguistic. Reznek does not interview any laypersons or experts, nor does he use a questionnaire. His method is traditionally philosophical. Reznek tests his own linguistic intuitions with the help of potential counter-arguments and with the help of the existing classifIcations of diseases. In appealing to these latter classifIcations and to their pathological descriptions, Reznek works in the tradition of analytical philosophy of science. Boorse and Reznek, who have both been taught within the Western medical tradition, arrive at quite divergent conclusions with regard to the notions of disease and illness. Boorse concludes that diseases are dysfunctional processes in relation to the bearer's survival or to the survival of the species to which the bearer belongs. Reznek concludes that diseases are involuntary processes which cause harm. They arrive at these diverging conclusions although they use examples from the same medical tradition. And they both consult works from roughly the same analytical philosophical tradition.

Four TOW ARD REVERSE THEORIES OF HEALTH AND ILLNESS: K. W. M. FULFORD AND LENNART NORDENFELT 1. Introduction

K. W. M. Fulford and myself designed our respective theories later than Boorse and in explicit opposition to his theory and similar versions in the philosophy of somatic and mental health. In spite of the fact that Fulford and I have worked quite independently of each other, our theories have several common properties, on an abstract level of characterization. Weare both inspired by concepts and ideas in action-theory, and we stress the intimate relation between the pathological concepts and the functioning, to a great extent the activities, of the total human being. You could say that we both propose a Reverse Theory of health and illness, although only Fulford uses the expression "reverse view." Fulford stresses that illness is a concept logically prior to the concept of disease. The observation of illness comes before the diagnosis of disease. When we have observed that a person is not well, we look for an explanation of this state of affairs on the level of bodily, as well as basic mental, functioning. The processes found on that level, and which can reasonably be held responsible for the person's illness, constitute the dysfunction (Fulford) or the disease or injury (Nordenfelt) from which the person is suffering. For an account of Fulford's concept of disease, see below. Along with the evolution of the science of medicine, our knowledge has been generalized so that we can talk in more general terms about disease states as the states which are normally responsible for people's illness. As soon as this happens, the sciences of diseases start living their own life. It then becomes possible to consider the biological or psychological processes in themselves and temporarily disregard their relation to human illness. This is the reason, Fulford and I argue, why medical scientists can regard their enterprise as an exclusively "objective" scientific affair. However, on a fundamental level, the language of diseases can never become completely objective (in the sense of value-neutral) - on this point Fulford and I essentially

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agree - because what is to be identified as disease must ultimately be dependent on people's illnesses. What is to be counted as illness is dependent on the values of the ill person or sometimes the values of the nearest and dearest of the ill person. Differences arise when it comes to details between Fulford and myself, to which I shall return. Boorse, Reznek, and Fulford, on the one hand, have at least one thing in common. They focus on the negative side of people's health. Boorse talks mainly about diseases in a wide sense; Reznek concentrates completely on the notion of disease; Fulford focuses mainly on illness. My fundamental purpose, on the other hand, is to base a theory of medical concepts on a general theory of health. I focus on the positive side of health and attempt to give a positive theory of health. In this, I construct an even more radical Reverse Theory. The primary medical concepts are not the negative ones, but the positive ones. We cannot identify illness, even less disease, I say, unless we have a view about what positive health is. 2. Fulford's Reverse Theory of Illness A. Fulford's Program Fulford's starting-point is the debate about the status of mental illness which went on in the 1960s. This is the debate where several theorists, such as Thomas Szasz, threw doubt ,on the common assumption that such things as mental illnesses exist and where R. D. Laing had serious doubts about the common understanding of mental illness. Especially Szasz argued that what are commonly called mental diseases are fundamentally misconstrued as such. People who are labeled mentally ill may be deviant in some respects, they may be troublesome to their nearest and dearest and to society, but they do not have illnesses in any sense that resembles physical illness. These radical points of view initiated an intensive debate in which some representatives of the psychiatric establishment also took part. One of these was R. E. Kendell, who in his paper, "The Concept of Disease and its Implications for Psychiatry" (1975), attempted to lay down the fundamental criteria of diseasehood, which he claimed also were fulfilled by the conventionally assumed mental diseases. Fulford notes that both the "antipsychiatrists" and the established psychiatrists shared some observations. One such observation is that the prevalent paradigm of diseases is of somatic diseases. Another observation is that doctors in general [md the question of diseasehood in the physical case unproblematic. The criteria of disease seem to them in the case of physical disease to be crystal-clear. The problem, they say, lies exclusively in the field of mental illness. The problem is to substantiate the claim that so-called mental illnesses are suf-

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ficiently close to the paradigm of physical illness for these to be ''real'' illnesses. I am here using the terms "disease" and "illness" interchangeably. For an analysis and a distinction between them, see Chapter Five, Section 1. Fulford contested these fundamental assumptions in his Moral Theory and Medical Practice (1989) for a variety of reasons. First, he found that the reasoning, on this point, of both Kendell and Szasz was far from flawless. Some of the examples presented by them in favor of their cases could be shown not to be supportive. Some somatic diseases did not fulfill the presented "self-evident" criteria, while some purported mental illnesses did fulfill them. Second, and quite embarrassing to their whole project, they differed in their characterization of the "self-evident" concept of physical disease. Third, and most importantly, Fulford found that the most elaborate characterization of the concept of disease along the lines suggested by Kendell and Szasz which had been made so far in the literature was inadequate. This was the characterization made by Christopher Boorse in his early writings during the 1970s. Fulford was critical on many points, his main criticism being that Boorse's analysis failed to take account of the element of evaluation contained in disease-descriptions and illness-descriptions. Fulford's position, when he starts his positive analysis in the book, is much more open than the position of most of his forerunners in the debate. He sees a discourse going on in medicine and health care, and for that matter in ordinary life. In this discourse is a lot of talk of people being ill and having diseases. Also a lot of talk occurs about how their illnesses should be treated in order for the stricken ones to become well and healthy again. This discourse seems to function fairly well in many contexts, although it has hardly ever become fixed by means of any explicit definitions of the crucial terms involved. People seem to be able to communicate their problems; the health personnel seem to understand and take action. A lot of people get well. In short, the system functions. If this is so, then it should be possible, after a careful philosophical analysis, to formulate tentative general criteria of the central c.oncept involved. It should be possible to say when a person is healthy; it should be possible to say what is characteristic of such a bodily or mental state of affairs as could be called a disease or illness. As a result of this analysis, it should be possible to solve the initial problem concerning the contested mental illnesses. Fulford observes that the discourse in mental health care does not work as smoothly as the discourse in physical health care. To settle the diseasehood of schizophrenia, mania, and psychopathy, is not just a philosophical problem. It is sometimes also a practical problem. The practitioners themselves are at times uncertain whether a condition should be understood as an illness, or whether the person should be labeled as ill. Nor has the issue completely disappeared from the ideological arena. Some intellectuals contest the

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purpose of psychiatry. They worry about the problems of meaning in psychiatry. These facts provide a concrete rationale for Fulford's project. A demand exists, not just scientific but also practical, for the kind of investigation that he sets himself to perform. Medicine, especially psychiatry, can be helped by the kind of conceptual analysis of which Fulford provides an example. The science of psychiatry should try to improve its conceptual foundations. B. The Concept of Illness as Basic; the Concept of Disease as Derived

One phenomenon of which Boorse's theory fails to give an account plays a great role for Fulford's subsequent analysis. This is the phenomenon of human illness in such cases where no disease has been detected and perhaps could not even be detected. In Boorse's (1975) reconstruction of the notion of illness, illnesses form a subcategory of the category of diseases. An illness, according to Boorse, is such a disease as is noticed by its bearer and as creates suffering or disability in the bearer. Thus, according to this conception an illness can only exist in the presence of a disease, that is, a bodily (or perhaps mental) subnormal functioning. This means that, strictly speaking, we can never with certainty say that a person is ill, following the Boorsian characterization, until a proper disease has been diagnosed in this person. Such a conclusion is completely counter-intuitive, according to Fulford. A theory which starts by characterizing disease, and considers the other medical concepts to be derivable from disease, has reversed the logical order embedded in our ordinary discourse about health and illness. What is first detected is a case of illness. This means typically that a person experiences some pain or disability which has no immediate external cause or obstacle, such as a pin-prick. The subjects of illness typically consider themselves as ill, without knowing anything more about the situation: something is wrong with their body or mind. If the situation is not trivial, the person seeks help at a clinic and the problem is settled. A doctor would typically seek the cause or the background of the illness. In the normal somatic case, such a cause is sought in the body of the subject. It may be the case that a bodily malfunction is discovered. This malfunction may have a conventional name and be classified in a standard medical nomenclature. Thus, a disease diagnosis can be given. This, according to Fulford, is the standard order of discovery. But it is also a logical order. Illness must be characterizable first. If we are not able to say that a person is ill before a disease has been found, then we cannot get off the ground. We must have a coherent concept of illness first. Given that, we can look for diseases. This also means that "disease" is a concept derivable

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from the concept of illness. Thus, the logical order suggested by Boorse has been reversed. Fulford presents, as he says, a Reverse View of illness. C. The Concept of Illness as Related to Failure of Action; the

Concept of Dysfunction as Related to Failure of Doing

Fulford performs a long and sophisticated discussion concerning the logical relations between the notions of illness and dysfunction. He fmds important logical similarities. Both concepts rely on the notion of purpose. In the case of a machine, the purpose has been determined by the designer. So a car, for instance, has some dysfunction if, and only if, a part of it does not fulfill its designed-for function well. In a partially similar way, a person is ill if, and only if, some organ is not performing its function well. However, in the case of the person no designer has determined a purpose for the human being as a whole. The purposes of the human being must be derived from something else. Fulford's answer is that the person sets the purpose in his or her intentions. The purposes of a person are identical with or derived from the intentions that the person has. D. Illness as Failure to Perform "Ordinary" Intentional Actions A consequence of this line of thought is that the notion of intentional action is crucial for Fulford's concept of illness. The conception of illness can then be concisely formulated: a person is ill to the extent that he or she fails to do what the person ordinarily does in the absence of obstruction or opposition. Illness, then, is a special form of failure of intentional action. Central ideas here are the following: (1) Fulford consistently uses the term "ordinary" doing (within quotation marks to indicate its origin in the meaning given to the term by J. 1. Austin in "A Plea for Excuses" (1968). I will sometimes allow myself to drop the quotation marks). The failure which is significant for illness does not concern highly specialized or difficult actions. Such actions can fail for other reasons than illness. "The patients who are ill are unable to do everyday things that people ordinarily just get on and do, moving their arms and legs, remembering ... things, fmding their ways about familiar places and so on" (Fulford, 1989, p. 149). (2) The reasons for the failure should be internal to the person's body and mind. All kinds of ordinary doing can fail for various kinds of external reasons; for instance, something or somebody may be physically preventing the person from taking a daily walk. The idea that illness is a failure to perform ordinary intentional actions applies to both physical and mental illness. A person may fail to go to work both because he or she has broken a leg and because he or she is depressed,

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that is, both because of a bodily injury and because of mental disorder. In both cases, illness is present in the general sense. In order to differentiate between the two main species, we must look into the reasons for the failure of action. E. Diseases as a Subcategory of Illnesses Fulford directs his main attention to the category of illness. He notes that illness is the fundamental category in the area of mental health and psychiatry. He also acknowledges the category of disease and derives it as a subcategory of illness. Drawing on what he takes to be logical properties of value terms, he shows that the concept of disease can be derived from the concept of illness, in the first instance as the kind of illness that is more widely recognized as such. For instance, the cluster of symptoms which are referred to as schizophrenia are widely recognized as forming an illness. The cluster has acquired a name and is included in the acknowledged classifications of diseases. This process establishes the symptomatically defined diseases (migraine is an example in physical medicine). Once this group is established, causally defined categories are added on as scientific advances are made. In the case where a person has an illness which is more individual in the sense that it is not a widely recognized type of pathology, we tend not to speak of that person's condition as a disease. On this point, Fulford argues along different lines than Boorse and Nordenfelt. Boorse holds the diametrically opposite thesis, namely, that illnesses are a subcategory of diseases. F. The Place of Pain and Suffering in Illness Fulford's theory is based partly on value theory and partly on the idea of failure of action. In line with my procedure, he introduces an action-theoretic platform for the analysis of medical concepts. This brings up questions concerning features of illness which are not so obviously linked to action and ability. How does Fulford come to terms with the ordinary observation that pain and other kinds of suffering are so intimately linked with illness? Pain is not a doing, nor is it in itself a failure of doing. Fulford emphasizes the central position of pain and suffering and analyzes their relation to action in the following way. Pain as illness - as contrasted with many other forms of pain, for instance, self-inflicted pain - is a kind of pain from which the subject is unable to withdraw in the perceived absence of obstruction and/or opposition. I quote: One difference between the argument in respect of pain as a constituent of illness and that in respect of movement is in the kind of 'doing' in-

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volved. Withdrawal from pain is well towards the reflex end of the scale of kinds of 'doing'. However its connection with 'ordinary' doing is clear from the fact that, where obstructed or opposed, withdrawal from pain becomes very clearly something one does in the full sense of 'do' - that is with one's purpose before one's mind and so on. (Fulford, 1989,p.138) G. On Illness, Disease, and Values Thus, illness in particular, but derivatively also disease, is related to the notion of purpose, more precisely in the human case: intentions. A person is ill, if on his or her part a failure of action occurs in the absence of opposition and obstruction. The set of actions which fail are what Fulford calls "ordinary doing," the things which we ordinarily just get on and do. "Ordinary doing" is a species of intentional doing. Intentions, according to Fulford, entail positive evaluation on the part of the intending person. Thus, he contends that the language of intentions and wants is evaluative. I return to a discussion of this in Chapter Five, Section 2. This means that the ascription of illness entails a negative evaluation. Derivatively diseases must then also be negatively evaluated. The disease-language and illness-language is therefore not plainly descriptive in the sense envisaged by Boorse. The values which, according to Fulford, are attached to the notion of illness are not any old values. To be ill is not to be morally bad, nor is it to be ugly or unintelligent. In the language of illness, we are not referring to moral, intellectual, or aesthetic values. Instead, says Fulford, we are referring to specific medical values, that is, values indicating what is medically good. See von Wright (1963) for a similar idea. H. The Notion of Mental Illness Fulford's analysis provides a common ground for the notions of somatic and mental illness. This is done in a way which may be unexpected for the majority of debaters. The common core of somatic and mental illness is not to be found within the human body, that is, as organic malfunctioning. It is to be found "out" on the illness side. It is to be found in the failure of action. What is common to the physically and the mentally ill is that they are for internal reasons prevented from doing some of the things they intend to do. So they are ill in the basic undifferentiated sense of ill. They can be ill for various reasons. The faults in the subject's body or mind can vary a lot. The fault can be physical, as is the case when we break a leg, or can be found in the "mental machinery" of the person, as is the case where a person is unable to do anything constructive because of depression.

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This means that values come in as a common element in both somatic and mental illness ascription. Fulford notes a difference, however, between physical and mental health ascription when it comes to values. The value connotations in the case of mental illness are more obvious, he says, than in the case of physical illness. But this is, because the values entailed in physical illness are almost universally held. Therefore, they are not problematic and hence are often overlooked. Once the set of physical diseases has been constituted, partially with the help of values, then much study and research can be performed without recognition of the values lying behind them. Later I will scrutinize the idea of a difference between physical and mental illness as to values. Fulford proceeds with a long discussion about the contents of the mental "machinery" and the ways in which we can characterize the variety of pathologies in terms of different kinds of failure of action. The most penetrating part of the discussion concerns what he considers the kernel of mental illness, the psychoses, especially the phenomenon of delusion. Fulford challenges traditional textbook definitions of delusion, such as the defmition that makes delusion just false belief or unjustified belief. He proposes instead that delusion may be a defect in a different sense. Delusions, says Fulford, need not be of a factual kind at all. They need not concern matters of fact about which the subjects have formed beliefs. Delusions can have the form of value judgments. A delusion, for instance, can be a negative evaluation of something one has done or a depressive consequence of imagined guilt. But valuejudgments are not statements which can be true or false. They can be reasonable or umeasonable, or they can be umealistic. Delusions cannot, then, just be false factual beliefs. Fulford notes the similarities in this respect between delusions and reasons for actions. Reasons for actions can be both of a factual belief kind and of an evaluative kind, notably in the form of wants. A typical set of reasons for my doing something involves a want to realize a state of affairs, as well as my beliefs about facts. Assume that I want to buy a bottle of milk and that I believe that a grocery store is nearby. The want and the belief together constitute good reasons for subsequently setting myself to buy the bottle of milk in this grocery store. Reasons are the central elements in the rational deliberation of actions. According to Fulford, the reasons are "constitutive" of actions. The reasons defme the actions. The reasons are therefore quite different from other elements of the "machinery" of action which are causally needed for the execution of actions. This suggests to Fulford that delusions can be defects related to reasons for actions: "An interpretation of 'delusion' in terms of defective reasons for action is thus prima facie compatible with an interpretation of illness in tern1S of action failure" (Fulford, 1989, p. 218). This suggests in its tum a further parallel between delusions and rea-

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sons for actions. Delusion is the central species of psychopathology; reasons for action are central to the machinery of action. If illness is generally logically derived from failure of action, then delusion as a failure of the constitutive elements of actions will automatically emerge as a central species of illness. As Fulford puts it, "a defect in the structure of one's reasons for action ... is not an instmmental failure, not a difficulty in doing something, but a failure in the very defmition of what is done" (Fulford, 1989, p. 237). I. Fulford's Assessment of His Project

Fulford describes his project as both destructive and constructive. First, he undermines the grounds of the typical science-based view of illness. He claims to have shown "that even the biological-scientific concept of dysfunction could not be defmed (as required by all science-based theories) as valuefree: or to be more exact, that if dysfunction were so defmed, it could then not do the job which it actually does do, and which Boorse, despite himself, actually continued to make it do, in the logical structure of medicine" (Fulford, 1989, p. 262). Fulford then clarifies what he takes to be a reasonable logical derivation of a variety of concepts of disease. He starts from the conclusion that dysfunction and disease, if they are to do the job they do in ordinary language, logically must be defined in part, by negative value-judgments. But some value-judgments are more widely agreed upon than others. Hence, within the range of experiences and behaviors which may be negatively evaluated as illnesses, some will be more widely and consistently negatively evaluated than others. Those conditions widely and consistently evaluated as illnesses are co-extensive with the class of illnesses defmed by symptoms. However, once this first class is defined, other classes of conditions will be added by whatever connections can be found useful. The most useful connections are causal. Where causes of illness are established, causal disease categories come to predominate. A causally defined disease is a condition which is a cause of a symptomatically defmed disease. Hence, our causally defmed diseases are recognized and can be identified in the absence of symptoms. But the whole chain is driven by the original negative value-judgment marking out an experience as an illness. The further specification of illness, as what is required in addition to a negative value-judgment is made later in Fulford's book (chapter 7). The connection with value that Fuiford makes there is through the valuejudgment entailed in the concept of intention. Illness, as noted above, is for Fulford related to the kind of intentional action that he calls "ordinary" doing.

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Fulford considers his project to be fundamentally theoretical. His aim is to get the theory right. But the project also has repercussions for the question of clinical utility. The difficulties which prompted his project in the first place, about whether mental problems had anything to do with pathology, are difficulties which have profound practical consequences. Should a person with condition x be taken care of by the health care system? Should such a condition be treated in any traditional medical way? These difficulties, Fulford claims to have shown, do not arise from ignorance of empirical facts. They are difficulties which are non-empirical; that is, they are conceptual. By illuminating and analyzing these conceptual difficulties, Fulford indirectly serves clinical utility. A theory of health, he says, must be judged partly by theoretical criteria but partly also by the contribution it makes to resolving the difficulties from which it sprang. J. The Methodology of Fulford's Project

To specify the methodology in Fulford's project is more difficult than to specify the methodology in Boorse's project. I will start by saying what Fulford does not do. He does not have as his purpose to make an empirical investigation into the psychiatrist's uses, or any other doctor's uses, of the terms "illness" and "disease." Nor does he, as Boorse attempts to do, try to produce a descriptive theory of the doctors' concepts of illness and disease. Instead, Fulford says: The reverse-view analysis of the medical concepts developed so far in this book has been reached only by means of a series of more or less hard won steps away (my italics) from the way these concepts are conventionally understood in specialist contexts in hospital medicine. (Fulford, 1989, p. 139) His project, as I see it, lies on a deeper level of analysis. It is a more philosophical project than Boorse's. Fulford wishes to consider a whole web of concepts related to human health. He scrutinizes not only the "pathological" concepts but also concepts which could reasonably be seen as more basic, concepts which are presupposed by the "pathological" ones. As a result, Fulford observes a complex language surrounding the health of human beings. He tries to take into account the whole complexity of this "ordinary" language. I stress "ordinary," because Fulford deals with the ordinary person's language as much as the psychiatrist's language, and because he uses some of the tools of Oxford ordinary-language philosophy in the Austinian sense of "ordinary language" as non-philosophical language.

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Fulford's program can be formulated as follows. We must make as much sense as possible of the complex language of health and illness and its accompanying conceptual network. How must the conceptual network be organized for us to understand the way we ordinarily speak about illness and disease? He expresses the following belief: But it is worth adding in conclusion, that outside the context of medicine, at least the elements of a reverse view would not appear unfamiliar at all. It has already be noted that 'illness' and the evaluative connotations of the medical terms are more prominent in non-specialist than specialist contexts. (Fulford, 1989, p. 139) To what extent does Fulford succeed in what he is trying to do? This question is not as easily answered as in the case of Boorse, who declares that he is performing a descriptive project. I will not attempt a general diagnosis of Fulford's project. Instead, I will make several critical remarks in a joint evaluation of my lines of investigation and those of Fulford. I will highlight the following problematic issues: Fulford's characterization of the relation between illness and disease; the role of suffering in his theory; his description of failure of ordinary doing; his analysis of medical values and the relation between want-expressions and evaluations. 3. Nordenfelt's Welfare Theory of Health

A. The Sources and the Nature of the Project My basic treatment of health is to be found in On the Nature of Health (1987 and 1995, 2nd, revised, edition). Major additions to this treatment are in Quality of Life, Health, and Happiness (1993), concerning the notion of happiness and the notions of subjective health and illness. Some additional elements appear in Action, Ability, and Health (2000a). In (1995) I put forward a set of criteria which I then thought were reasonable criteria of a theory of health. Such a theory, I claimed, should be able to answer the following questions: 1. What are the logical relations between the health concepts? 2. What are the logical relations between the concept of health and some other central humanistic concepts? 3. What is the relation between human health and the health of other living beings? 4. What is the relation between mental and somatic health? 5. What is the relation between health and the environment? 6. What is the place of the health concepts in science?

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Some of these questions need an explication. By "health concepts," I refer to health itself, also vitality, illness, disease, impairment, injury, defect, disability, and handicap. By "some other humanistic concepts," I refer-to welfare concepts which have often been associated in the literature with health, such as ability, happiness, and autonomy. Question 5 is intended to cover both causal and constitutive relations between health and environment. I argue that the environment, in the form of a natural environment and of a society, does not only causally influence a person's health; it also enters into the very definition of health. These questions set the stage for the subsequent analysis. They also define the enterprise. The task is to come up with a theory of health which answers these requirements. This makes my investigation automatically different from the investigation of Fulford and probably also from those of Reznek and Boorse, although Boorse has given answers to some of my requirements; see (l997, p. 15). I am not asking what health "is" or what a disease "is" as the terms are used in pathology or by medical doctors, as Boorse does. And I am not attempting to delineate the distinction between pathological and non-pathological made by doctors and laypersons as Reznek does. Nor am I investigating in any detail how the ordinary "illness language" is logically construed, as Fulford does. I am perfectly willing to take part in some reconstruction of our ordinary medical language if it can serve a practical or scientific purpose. We need not only a concept of health which has coherence, clarity, and precision, but we also need a sharp characterization of the relation between this concept and its associates in the theory of medicine and welfare. This is not to deny that I value positively the investigations made by Boorse, Reznek, and Fulford, I consider that they make a good input into the kind of analysis which I have in mind. A theory of health to be workable at all must have a substantial connection to the existing medical and lay use of the central terms. In my procedure, I try to listen carefully to differences in uses. But I am not willing to follow these ordinary uses to whatever end. Ordinary uses of language can be confused or even incoherent. Some terms can be ambiguous. For instance, two rather different ordinary uses of the term "health" appear, one disease-related and one independent of the disease-concept. The boundaries between concepts in ordinary language can be so vague that the concepts are of little scientific use. Such considerations are elementary in the philosophy of science, and they lie behind the standard practice of explication of concepts in science. For a clarification, see Hempel (1952). When concepts are defmed in the exact sciences, they are normally explicitly defmed. These explicit defmitions are not identical with the full meaning of the basic colloquial terms used. When the concepts of mass and energy are defmed in physics, physicists do not intend that the defmitions should fully correspond to what ordi-

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nary people mean by "mass" and "energy." One of my purposes is to explicate a concept of health which can fulfill the elementary logical and other conditions, such as the ones mentioned above, for medical practice and science. To this, I wish immediately to add a proviso. The starting point for a discussion in this area should be the use of concepts in medical practice. My main focus will be on practice. Medical practice is both historically and logically prior to medical science. The task of studying medical practice lays a crucial constraint on the explication of the concept of health and related concepts. Medical practice essentially involves the communication between the carer and the user of health care. In this communication, the medical terms are frequently used. Since the layperson has no technical education in the medical language, some key terms must be used according to their colloquial use. This means that some of the basic concepts of medical practice should have strong foundation in ordinary language. I grant this, but I still see a place for innovations. This can be warranted, for instance, by the following. Some constant confusions might occur in medical communication. The doctor might use the term "healthy" in a way which is slightly different from how the patient typically uses it. The doctor may say: I have not found any disease in your body; thus, I declare you healthy. The patient, who suffers from great pain and is disabled in many ways, becomes confused. The patient would characterize the state as one of illness and cannot understand the doctor's judgment. Here is a case for the improvement of the language, as well as in many similar cases. This could be easily done without invoking complicated technical terminology. For an analysis of the reasons behind defective communication in the medical encounter, see Toombs (1992). My discussion in (1995) starts with a critical review of Boorse's theory of health and disease. The upshot of this discussion has been summarized in the previous part of this text. My main position is that health and illness are concepts which primarily pertain to the whole person and not to singular parts of the human body. They are concepts tied to the well-being and ability of the person. The ill person is distressed and disabled. The healthy person feels well and is an able person. The other medical concepts will have to be defined on these presuppositions. The details of this reconstruction will be presented below. B. Health as the Primary Concept

Most treatments of the medical concepts focus on the negative aspects of health, either disease or illness. This focus is understandable, given the attention that medical practice directs to those concepts. It is theoretically unsatisfactory to start a conceptual investigation with such concepts as deny that a

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positive state exists without having characterized this positive state in itself. In the case of traditional analyses in the health area, the theorists try to characterize ill health before having a notion of health. I have found reasonable to propose a reverse procedure. C. The Primacy of Ability and Disability

As I have said, two kinds of phenomena have a central place in traditional holistic accounts of health and illness. First, a kind of feeling, of ease or wellbeing in the case of health, and of pain or suffering in the case of illness; second, the phenomenon of ability, an indication of health, or disability, an indication of illness. These two kinds of phenomena are interconnected in many ways. First is an empirical, causal connection. A feeling of ease or well-being contributes causally to the ability of its bearer. A feeling of pain or suffering may directly cause some degree of disability. Conversely, a subject's perception of ability or disability greatly influences the subject's emotional state. Some theorists would argue that the relation between the two kinds of phenomena is even stronger, that conceptual links exist between a feeling of well-being and ability, and between suffering and disability. According to this idea, being in great pain partly means that the subject is disabled. Some degree of disability is a necessary criterion for the presence of pain, so that if a person's ability is not affected, the person can be said not to be in great pain. In my analysis, I make an assumption of a conceptual connection between suffering and disability, where suffering is taken to be a highly generic concept covering both physical pain and mental distress. A person cannot experience great suffering without evincing some disability. But a person may have a disability, and even be disabled in several respects, without suffering. In the following paradigm cases of illness suffering is absent. One obvious case is that of coma. Another is present in some mental disabilities and illnesses. In general, when patients cannot reflect properly on their own situation, their disabilities need not have suffering as a consequence. In short, wherever there is great suffering there is disability, but the converse is not true. These observations indicate that the concept of disability has a much more central place in the characterization of illness and ill health than the corresponding concept of suffering. If one of these notions is essential to illness it must be disability. This conclusion does not deny the extreme importance of pain and suffering - as experiences and not just as causes of disability - in most instances of illness. It is impossible to make a phenomenological analysis of the typical case of illness without paying attention to

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suffering. I have made a start in my study of what I call subjective health and illness (1993). More full fledged and penetrating analyses are those of Toombs (1992) and Cassell (1991). For a recent interesting attempt to amalgamate the notions of disability and suffering, see van Hooft (1999). Disability is a negative notion presupposing the semantic content of its positive contrary, ability. This gives the analysis of ability a primary place in my theory of health. D. Health as Ability to Reach Vital Goals The basic question, then, is: What should a healthy person be able to do? When is a disability such that we ascribe ill health or illness to a person? In approaching these questions, I adopt a special manner of speaking. Instead of talking about a set of actions that an agent must be able to perform, I assume that a set of goals which the healthy person must be able to achieve. This involves a simplification of the mode of speech. By concentrating on ultimate goals, I can avoid giving long enumerations of actions. My main project, which proves to be quite difficult, is to specify, on an abstract level, those goals - I coin the expression "vital goals" for them which are constitutive for the healthy person's ability. The general idea is the following. In order to qualify as a healthy person someone must have the ability, given standard or reasonable circumstances, to reach the person's set of vital goals. As main parts of this project, I scrutinize two plausible suggestions for the characterization of vital goals, but I must in the end dismiss both of them. The first suggestion entails that a person's vital goals should be equated with that person's needs. The second involves the idea that a person's vital goals should be equated with his or her wants. The idea of needs is not helpful, since it is either empty, meaning simply "being a necessary condition for a goal to be further specified," or, as in the traditional discussions of basic human needs (see for instance Maslow [1954]), it presupposes a concept of health. The idea of using the person's own wants as the criterion of vital goals fails for a variety of reasons, including the following. Highly destructive wants exist and people exist with an extremely low profile of wants. Should only these be fulfilled, the person might die of starvation. I find it odd to found a theory of health on a person's ability to commit suicide. E. Vital Goals as Preconditions for the Subject's Minimal Happiness My solution to the characterization problem rests on the notion of happiness. I propose that a person's vital goals are the states of affairs which are necessary and jointly sufficient for his or her minimal long-term happiness. This

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idea could be rephrased informally thus: A vital goal is a state of affairs which is either a component of or otherwise necessary for the person's living a minimally decent life. This includes more than mere survival. It includes life without disabling pain; it includes the realization of the most important projects of the person, such as having minimally decent accommodation, having a job, and successfully raising children. The concept of happiness that I have adopted is a want-related concept, so that happiness can be seen as an equilibrium between the subject's wants and the world as he or she finds it to be. This concept is defmed formally in (1993) and (1994). The introduction of the notion of want does not imply that we encounter again the problems with wants as criteria of vital goals. I am talking about happiness in the long run. Thus, the fulfillment of a momentary destructive want, that the agent later repents of, is not the fulfillment of a vital goal. The degree of happiness that we try to capture should define a minimal or acceptable level of happiness. The vital goals are the most important goals. They do not constitute a person's complete set of goals. Observe that health is not identical with minimal happiness, nor with the set of vital goals which are necessary and together sufficient for minimal happiness. A person's health is constituted by his or her ability to realize vital goals. Or to choose my fmal formulation: health is the bodily and mental state of a person which is such that he or she has an ability to realize vital goals, given standard or otherwise accepted circumstances. An intuitively plausible distinction exists between health and happiness. To have the ability to become minimally happy is not the same as being minimally happy. People can still fail to become minimally happy either because they are physically prevented from exercising their abilities or because they choose not to exercise their abilities. The point about prevention highlights the necessity to qualify the notion of ability as an ability related to a set of circumstances. This set of circumstances is not statistically defined. I have worked with two kinds of specifications which have a place in two different contexts. On the one hand, I assume a set of standard circumstances, a set commonly presupposed within a culture, as is done within a clinical context. On the other hand, I assume a set of reasonable circumstances. The term "reasonable" indicates that we are dealing with a more openly normative discourse. A paradigmatic context would be where a language-user openly disputes an illness ascription. "You call this person ill; no, he is perfectly healthy, he is only disabled by what for him are unreasonable circumstances." To capture both the sense of standard and of reasonable circumstances, I have recently coined the term "accepted" circumstances. In every health discourse, some set of circumstances must be accepted. In some discourses we accept a set of culturally defined standard

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circumstances. In other discourses, we propose a set of reasonable circumstances. F. Diseases, Injuries, and Defects as Causes of 111 Health Given the positive notion of health, the negative medical concepts, or the maladies, as Gert and Culver (1982) call them, disease, injury and defect, are given a place in the machinery. They are defmed as such states or processes of a person's body or mind as tend to cause ill health in their bearer. The formal defmition in (1995) follows. I will just present the disease case, for the other definitions are structurally similar. D is a disease-type in environment E if, and only if, D is a type of physical or mental process which, when instanced in a person P in E, would with high probability cause illness in P. Thus, we say that a person has a disease D, only if most instances of D tend to cause illness in those persons who contract D. A condition, or a configuration of conditions, in a person which happens to contribute to this person's illness, but which does not generally have such a consequence, is not a disease. The maladies do not always cause ill health. A disease, for instance, may be lanthanic and disappear without ever resulting in ill health or it may be so trivial that it never reaches the consciousness of its bearer and never compromises the person's ability. G. A Preliminary Assessment of Nordenfelt's Project In 1995 (pp. 145-149), I formulate a set of answers to the programmatic questions raised at the beginning of my project. I will briefly rehearse these. 1. What are the logical relations between the health concepts? This question

is answered in my series of defmitions. Health, illness, the maladyconcepts, as well as disability and handicap, are defmed and related to each other. 2. What are the logical relations between the concept of health and other humanistic concepts? This is dealt with in several ways. Health is distinguished from the excellence-concepts, such as intelligence and strength, as well as from the moral concepts. Health is closely related to the notions of ability and happiness. 3. What is the relation between human health and the health of other living beings? This question is answered in the book, but not related in this presentation since it has little bearing on the present project. I try there to indicate how the terms "health" and "disease" as applied to lower animals and plants can in principle be fitted into the same framework as human

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health. I make clear, however, that the human framework is primary. The other uses of the concept must be viewed as derivative. In this respect, a crucial difference arises between the way Boorse's theory is universally applicable to all living beings and the way my concept can be applied outside the case of human health. 4. What is the relation between mental and somatic health? The answer is that mental and somatic health are species of the same genus. My theory is a unified theory of health, focusing on people's abilities or disabilities and not on the compromisers of these abilities and disabilities. We can easily make the relevant distinctions between somatic and mental health in the following way. Persons are mentally ill if, and only if, their health has been compromised by states or processes in their mind. Somatic health can easily be given a parallel characterization. 5. What is the relation between health and the environment? The defming criteria in (1995) contain one salient environmental element, what I have been calling "standard circumstances" or "accepted circumstances." Two kinds of connections to the environment exist. First, any ability, in order to be understood at all, must always be related to an environment. When people act they always do so in a context. This is the first obvious connection. Second, what is to be counted as standard circumstances depends on what a particular natural and cultural environment is like. If something is standard, it is standard in relation to what is ordinarily the case in a particular part of the world. When I say "ordinarily," I am not referring to any statistical fact. The crucial issue is what people believe to be "ordinarily" the case. In the extreme case, the notion of a standard circumstance is decided upon by, for instance, a medical authority. So much for the defining or constitutive relations between health and the environment. To this should be added all causal relations. The environment is a continuous and obvious causal factor behind both health and ill health. The sound environment supports health; a great variety of external factors, both natural and cultural, contribute to compromising it. This obvious fact need not be elaborated in the philosophical enterprise of characterizing the nature of health. 6. What is the place of health concepts in science? My conclusions are the following. Health is a partly evaluative concept. This is to be analyzed further in Chapter Five, Section 3. Since the malady concepts are derived from the concept of health, they too are partly evaluative. This does not preclude their use in the medical sciences. As soon as the matters which are open to evaluation are decided upon, a standard is established which can be used for purely empirical investigation. That part of medicine which deals exclusively with the study of maladies does not normally even need such a standard. The major reason for this is that most mala-

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dies strike in such a basic and general way that health is normally affected by them, regardless of how we determine standard circumstances or the level of minimal happiness. Consider, in particular, all those maladies which cause pain and fatigue. Pain, even "local" pain, and fatigue strike the whole person. These sensations make all kinds of activities difficult for the person to perform. In that case the exact nature of the vital goals that the person should achieve will be of little importance. The existence of a standard is, however, essential for the science of rehabilitation and for the general enterprise of health care. So much for a recapitulation of my conclusions of 1995. But how sound are they? And how do they stand up to critical examination today? Some points need to be highlighted in the subsequent analysis.

I. The notions of illness and disease. I have adopted the terms "illness" and "disease" in my theory. They play an essential part, and I believe they are clearly defined. But good arguments exist for saying that my concepts are stereotypes and not sufficiently close to ordinary (medical or lay) language. 2. The role of suffering in illness. Suffering is in a way the paradigm of illness as ordinarily understood. Suffering is present in my theory. It is central in the further development of my notion of subjective illness in (1993). Still, it has been maintained that suffering ought to playa more central part in the basic defmition of illness. 3. The nature of the ability involved in health. What kind of ability constitutes health? I have argued for adopting the notion of a second-order ability. To be healthy is to have the second-order ability to realize a certain goal. But is this a convincing analysis? Is it not often just the first-order ability that is involved, when, for instance, a person is stricken by a disease and confined to bed? 4. The evaluative content of the medical concepts. In what sense are the medical concepts evaluative, and what are the consequences of their being so? I have elsewhere (1995, pp. 95-96 and 121-127) tried to answer this question. However, since this issue is so fundamental in Fulford's analysis of medical language, I wish to reconsider my views on it. 5. The relation between health and happiness. Is it reasonable to relate health and happiness to each other in such a strong way as I do? Does the healthy person have all the internal resources needed for his or her state of minimal happiness? 6. The applicability of my theory for medical practice and medical science. Both Fulford's theory and mine are far from an "ordinary" un-

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derstanding of medical concepts and medical language. Our concepts of health and illness may also seem to be open-ended and vague, in spite of my declaration of the opposite. To what extent do their concepts really help a user? What could a practitioner learn from these theories?

4. A Comparison between the Theories of Fulford and Nordenfelt I will briefly summarize and compare Fulford's position and my own position by pointing out similarities and differences. A. Similarities Between the Two Theories

The similarities between the two theories lie primarily in some common basic theses. This should not be understood in the sense that any of the theses below has been formulated by Fulford and myself in the way shown. The content has been extracted from our texts.

1. Fulford and Norden/elt share a basic conception of health and illness.

With a gross simplification, you can say that the two theories have a common basic conception of health and illness. Health is viewed as a kind of ability to act; illness as a kind of disability or failure of action. Action is understood in its full-blown sense of intentional action, including the derivative "ordinary doing."

2. The basic concepts of health and illness are common to physical and psychiatric medicine. The two theories accept the applicability of the

concepts of health and illness in the spheres of both physical and psychiatric medicine. The theories claim that basically the same notions of health and illness are operative in the two fields of medicine. 3. Health and illness are concepts on the level of the whole person. Both theories consider health and illness to be concepts which primarily belong to the level of the whole person. It is a human being as a whole who is healthy or ill. Only in a derivative sense do we say that kidneys, hearts, and lungs are healthy. 4. Action theory. The two theories are in general highly influenced by contemporary philosophical action-theory, not only in the way the basic concepts of health and illness are understood, but also in the way details of the theories are developed.

5. Health and illness are the primary concepts. Disease, injury, and defect are derivative concepts. As a corollary of 2 and 3, it follows that health

and illness are the primary concepts in medical language. Concepts which pertain to parts of the body and mind, such as local diseases, injuries, and

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defects, are secondary. Diseases, injuries, and defects are viewed as the typical causes of illness. 6. Both theories aim at practical applicability. Although the two theories do not attempt to produce tight descriptive theories of medical uses of "health" and "illness" (in the sense attempted by Boorse), they aim at providing a useful conceptual basis for the science and practice of medicine. B. Differences Between the Two Theories The differences between the two theories are to be found in the three spheres of (a) method and general aim, (b) focus, and (c) content. The most conspicuous differences concern their methods and general aims. 1. Fulford pursues ordinary language analysis; Nordenfelt pursues conceptual analysis for the explicit purpose of theory construction. Fulford's methods and general aims are, as I have said, to a high degree inspired by Oxford ordinary-language analysis. Fulford aims at arriving at conclusions which are close to conceptualizations embedded in ordinary language and therefore (normally) reasonable to the layperson. The expression "ordinary language," in Fulford's (and Austin's) use of it, is not, however, confined to the lay use. It also covers, for instance, ordinary medical language. In my analysis, I try to be sensitive to ordinary language but have no aspiration to achieve results which are quite close to ordinary conceptions. This is partly a result of the fact that I pursue my analyses in a foreign language. Yet I have the explicit purpose to suggest formal and precise definitions, and I attempt to tie together the network of medical concepts. This is not to deny that Fulford, in particular in his treatment of different concepts of disease, chapter 4, proposes a number of precise defmitions of these concepts. 2. Fulford focuses on illness; Nordenfelt on health. Fulford concentrates on the notions of illness and dysfunction and says little, explicitly, on the notion of positive health. What I have said in my interpretation of Fulford above is something that comes out implicitly. I have my focus on health but try also to connect health with the other major medical concepts. 3. Fulford focuses on mental illness; Nordenfelt on health (and illness) in general. Fulford's works are mainly intended as contributions to the philosophy of psychiatry, although he also makes considerable contributions to the general theory of health. I am primarily trying to characterize the general concept of health and its allies. 4. Fulford's and Nordenfelt 's concepts ofdisease are different. According to Fulford, diseases form a subcategory of illnesses: diseases are the generally recognized illnesses (together with conditions connected to illnesses

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by cause-effect links). According to my conception, diseases are such bodily and mental processes as tend to reduce health, that is, cause illness. Observe, however, that we both emphasize the conceptual relation between disease and illness. 5. Fulford emphasizes the value content of notions such as illness, disease, and dysfonction; Nordenfelt acknowledges their value content but has a different conception of it. Fulford distinguishes medical value from moral and aesthetic value. I have no specific notion of medical value. I recognize the relation between the notion of health and the notions of goal, reasonable circumstances, and happiness. I acknowledge the relation between the latter concepts and value judgments of various sorts. To unpack the exact nature of these value judgments is quite difficult. To this I will return in my discussion, Chapter Five, Section 3. 6. Fulford equates health with ability of "ordinary doing." Nordenfelt equates health with ability to achieve vital goals and indirectly personal happiness. This is perhaps the most conspicuous difference with regard to content between the two theories. Fulford relates health to a person's ability to do the things we "ordinarily" just get on and do, in the absence of obstruction or opposition, such as finding things and remembering things. A significant feature of the "ordinary" doings is that they are intentional but only preconsciously so. The "ordinary" doings are latent full intentional doings. I relate the notion of positive health to a person's second-order abilities to reach his or her vital goals. The vital goals envisaged need not be, although they can be, on an "ordinary" level. The goals can be distant from the subject's actual situation and require full-blown intentional actions. The vital goals are in their tum defined as conceptually related to the subject's long-term happiness.

Five TOWARD A CRITICAL ASSESSMENT OF THE REVERSE THEORIES OF HEALTH AND ILLNESS 1. The Notions of III Health, Illness, and Disease

A. Introduction It is extremely difficult to formulate something that approaches a comprehensive theory of health. Such a theory needs to be consistent and therefore also requires unambiguous terms. If we try to formulate a system of concepts that fulfills these requirements, we will, as we have seen, most likely come up with some suggestions that sound counter-intuitive to members of the community. One reason for this is that ordinary language is not unambiguous. This is easily illustrated by the term "health" itself. Some people have the strong intuition that the notions of health and disease are intimately connected in such a way that health is identical with the absence of all disease. Other people, and sometimes some of the same people in other linguistic contexts, use a concept of health which is not by defmition related to the absence of disease. Such a concept of health is explicated in the various holistic theories of health, including Fulford's theory and my theory. According to these, a person can be healthy despite having a disease. Moreover, he or she can be unhealthy even in the absence of disease. The situation is even more complicated. Differences arise between different languages. I am a native Swedish-speaker, and I am unaware of many nuances in the English language. For one thing, my own language, like most other European languages, lacks a specific terminology for the distinction roughly indicated by the English terms "disease" and "illness." In order to express this distinction in our own languages we have to use complex circumlocutions. Let me use these observations as a background for further reflection on the terminology and the conceptual web surrounding health. I start with illness and then tum to disease. With regard to both concepts I have modifications to make in relation to my previous proposals. But these are only modi-

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fications within my general framework, where the fundamental conception of health is the same. B. Fulford's Reflections on the Ordinary-Language Notions of Illness and Disease

Do any basic differences in ordinary English arise between the meanings of "illness" and "disease"? And can they be used for important theoretical purposes? Fulford pays more attention to this than anyone else in the present debate. Since he is a native English-speaker and an Oxford philosopher, we should have reason to listen to him on this matter. I will first quote from his summing up of the present discussion: In much of the debate about mental illness, 'disease' and 'illness' have been not merely identified with each other, but treated as synonyms. And the meaning of this combined concept 'illness/disease', has been analysed, essentially along the lines of the Shorter Oxford English Dictionary defmition of 'disease', in terms of disturbance of function of one kind or another. This approach is adopted, for example, by both Kendell and Szasz, ... [who] both ... use 'illness' and 'disease' as synonyms. (Fulford, 1989, p. 27) Yet the terms 'illness' and 'disease' and 'dysfunction', although closely related in meaning ... are none the less not always logically interchangeable. Sometimes, it is true, 'disease' may properly be used as a synonym for 'illness'; "He has some awful illness", for example, would normally mean the same as "He has some awful disease" .... But against instances such as these, there are clear cases in which 'disease' and 'illness', at least, are used not only with different but with contrasting meanings. Thus a diabetic whose condition is fully controlled by treatment would properly be said to have the disease diabetes, but not to be ill. (Fulford, 1989, p. 28) Fulford then notes that "disease" tends to be used more in technical contexts.

It is used by doctors rather than patients when the purpose is to express what

is wrong, "to describe, by way of a clearly defmed objective bodily changes ... the condition from which a patient is suffering" (Fulford, 1989, p. 30). But Fulford also says that clear uses of "illness" occur when the condition does not presuppose the existence of disease. This is contrary to the explication made by Boorse, when he classifies illnesses as a subcategory of diseases. A person with a hangover, says Fulford, is ill but does not have a disease, ac-

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cording to common understanding, as is also the case with a person who has taken an overdose of sleeping pills. Another interesting observation made by Fulford is that people fall ill and their bodies or parts thereof are not functioning properly. It is also in their bodies that we can often locate diseases; we can even talk about anatomically local diseases. "Illness" is often used as a global term, referring to the whole state of the human being. A conclusion to be drawn from this review is that ordinary-language indications exist for distinguishing between various concepts of illness and disease. In some contexts the two terms can be used synonymously. In other interesting contexts they are not interchangeable, for instance where "disease" refers to a clearly identifiable bodily state or dysfunction, and where "illness" refers to a general state of the whole person. The fact is that "illness" is a term dominant in the field of psychiatry, where more often the general state of the whole person is brought under consideration, while "disease" is a term dominant in somatic medicine, where it is more often a question of locating bodily dysfunctions. The lesson to be drawn from this whole discussion is that a constructive theory of disease and illness, if it is to be workable at all, cannot stick completely to all ordinary-language intuitions surrounding the use of the terms. In the end, Fulford does not do so with his theory. C. The Reconstruction by Fulford and Nordenfelt

of the Concepts of Disease and Illness

Fulford's basic ideas in his deep-level analysis of illness and disease can be summarized in a few statements. I. Illness is the logically primary concept. Illness is constituted by a

failure of action. 2. Some types of failure of action, that is, some illnesses, are widely recognized. These constitute the diseases which are identified in terms of symptoms. To this set of diseases is eventually added a set of conditions which are mainly causally linked to the symptombased diseases. This set of diseases nowadays dominates the medical classifications of diseases. The main point in Fulford's theory is that this set is also ultimately derived from illness understood as failure of action. Fulford's characterization of diseases is quite different from that involved in the popular anthropological distinction between disease and illness (see below). He does not at all restrict the use of the term "disease" to internal bod-

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ily dysfunction. For instance, he is quite willing to talk about psychiatric diseases. In this he follows the discourse of contemporary psychiatrists. He points out that well-known and reasonably well-defmed categories exist of mental diseases, such as dementia, mania, and schizophrenia. Diseases may thus refer to mental states and not just to bodily dysfunctions. The idea that diseases should be identified with bodily dysfunctions is common in the sociological/anthropological tradition to be presented below. For Fulford, disease is the derived concept mainly used in clinical practice and medical science. "Illness" is the term primarily used to denote the general state of failure of action. But it is also a term which can be used for referring to a particular failure of action, that is, a specific illness. In my analysis in (1995), I also have the double use of "illness." In one general use, illness is simply the contradictory of health. Thus, persons are to some extent ill if, and only if, their health is reduced to some extent, that is, they cannot realize all their vital goals, given accepted circumstances. According to the other use, we can talk of specific illnesses, constituted by specific disabilities or clusters of disabilities. Some of these illnesses are given names. such as "dysphagia" or "dyslexia." Other illnesses lack recognized names. For the sake of clarity, I wish to propose the expression "ill health" for the general state which is simply the contradictory of health. I suggest, then, that we say a person is in a state of ill health when this just means the contradictory of the person being healthy. The adjective to be used would however be "iII": the person is ill. Thus, the noun "illness" could be used exclusively to refer to the particular states, the clusters of disabilities, which have been given names or could be given names in medical classifications. In the case of disease, I have in (1995) a proposal which differs from Fulford's and is more in line with the main stream in the philosophy ofmedicine, and indeed anthropology and sociology of medicine. The idea is to identify diseases, as well as the other maladies, with particular bodily, but in my case also mental, processes or states. These processes or states are not necessarily to be seen as dysfunctions in relation to the person's survival. What they have in common is that they are dysfunctions in relation to the person's ability to realize vital goals. This entails that the characterization also covers most of those instances that are dysfunctions in relation to survival. It need not cover all dysfunctions in relation to survival. Some dysfunctions in relation to survival are easily and normally compensated for by the function of other parts of the body, so that no change occurs on the gross level of the organism. Fulford and I share the basic assumption of a conceptual connection between illness and disease. With Fulford, the conceptual relation is either one of identity, as in the case of symptomatic diseases, or a combination of

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causation and identity, as in the case of the conditions found to stand in a causal relation to designated symptoms. In my case, diseases are, by defmition, such bodily or mental processes as tend to cause ill health. A kind of criticism can legitimately be raised against my, and the mainstream, view of diseases. I have already raised it myself in my critical examination of Boorse's position. An extremely good source for this criticism is the dissertation by Per Sundstrom: Icons of Diseases (1987). He undertakes a thorough examination of some current somatic disease concepts, as they emerge in medical textbooks. What he says, with great emphasis and with a richness of exemplifications, is that diseases are complex structures containing pathophysiological changes of bodily and mental parts, but also containing a variety of symptoms on the level of experience, as well as consequences with regard to people's abilities to function in daily affairs. As Sundstrom observes, many explicit "defmitions"of diseases also contain prognoses of the processes in question and, surprisingly, recommendations with regard to treatment. The ontology of diseases becomes tremendously complex. Another way of putting this is to say that diseases become abstract objects. This seems to be the line Sundstrom is taking when he coins the expression "icons of diseases" for the entities described in the medical textbooks. I appreciate Sundstrom's analysis; it gives me reason to modify my theoretical characterization of diseases and other maladies. I do not think, however, that the explication we seek for a comprehensive theory of health can cope with all the things which happen to be included in "defmitions" of diseases in medical textbooks. These definitions have not been made from the point of view of a philosopher of science. They have been made by medical scientists and practitioners, in contexts where defmition is not a welldefined concept. The lesson to be learnt is that diseases, as clinically understood, can include illnesses. This brings me closer to Fulford. We may create, for useful theoretical purposes, a notion of "pathological disease," which isolates the pathophysiological processes. But we need also the notion of "clinical disease" which has some of the complex content pinpointed by Sundstrom. I primarily have in mind the person's experiences and other symptoms in terms of, for instance, disabilities. I disregard here prognosis and treatment. I doubt that the textbook author really intends that the treatment of a disease be seen as an integral part of the disease. Observe that the result is not, then, an identification of clinical diseases with illnesses. Clinical disease is the more inclusive category, including the pathological processes. Illness, that is, a state entailing a cluster of experiences and disabilities, is the less comprehensive category.

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D. The Concept of Illness as Proposed by Medical Sociologists and Medical Anthropologists: The Place of Suffering in Illness A rich literature now exists in medical anthropology and medical sociology within which a fairly well-defmed concept of illness is much used. The American sociologist Andrew Twaddle (1979 and 1993) has paid much attention to the distinction between disease and illness, as well as the sociologically defined concept of sickness. I quote from Twaddle: "A disease is a health problem that consists of physiological malfunction that results in an actual or potential reduction in physical capacities and/or reduced life expectancy" (1993, p. 8). "An illness is a subjectively interpreted undesirable state of health. It consists of subjective feeling states (e.g. pain, weakness), perceptions of the adequacy of ... bodily functioning, and/or feelings of competence" (1993, p. 10). According to this idea, an illness is completely subjective in that it consists of a set of mental states of the bearer. Moreover, an illness, according to Twaddle and most other people in this tradition, does not presuppose the existence of an objectively verifiable disease. The common anthropological defmition of illness is different from both Fulford's definition and my own. Neither of us defmes the general concept of illness in terms of a set of feeling states. We certainly both recognize the importance of sensations, in particular pain and suffering, in much illness, but we do not use the concept of sensation in our primary characterization of illness. Instead, the primary idea with us is the idea of disability or failure of action, as described at length above. Fulford acknowledges that many instances of illness are primarily constituted by sensations, the primary symptoms perhaps being fatigue and pain. This, he says, is still compatible with an analysis of illness in terms of failure of action. The failure of action in this kind of case is a failure to avoid the pain and fatigue. The essential point from which this arises is that although feelings and sensations are not things that we do, they are things that we do something about - withdrawing from pain, scratching an itch, steadying ourselves when we feel dizzy, changing position with paraesthesiae, catching our breath with breathlessness, going to sleep when tired and so on. (Fulford, 1989, p. 135) Fulford continues: There is thus in the present theory at least the possibility - there is the conceptual wherewithal - for illness constituted by feelings and sensations to be derived from the experience of failure of 'ordinary' doing in the absence of obstruction and/or opposition ... much as, according to

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the argument presented here, illness constituted by movement is so derived. (Fulford, 1989, p. 136) The failure of action to which Fulford here refers is the one where the person cannot do anything about his or her sensations when they are sensations of the sort that are embedded in illness. "Pain as illness then becomes pain from which one is unable to withdraw" (Fulford, 1989, p. 138). Experiences enter the picture of Fulford's theory in yet another way. This is in connection with his basic characterization of illness as failure of action. Fulford there talks about the subject's experience of failure of "ordinary doing" in the (perceived) absence of obstruction and/or opposition as "the logical origin of 'illness'" (p. 132). I will discuss this idea in the following section. The arguments for my position are quite different. I acknowledge the prominent position of pain and suffering in illness; the concept of suffering is to be preferred since it is more general and covers everything from physical pain, via itches, twitches, and pangs, to mental suffering of various kinds, including depression and anxiety. It is imperative that the phenomenology of illness should pay most of its attention to the suffering entailed in illness. Not so clear is that suffering has such a central place in the semantics of illness. When our purpose is to defme illness and we try to fmd as general a characterization of the concept as possible, then suffering cannot do on its own. That all illness entails suffering is not true. A person in coma is ill but yet does not suffer. A person in a manic episode is ill but yet not suffering. Other cases of illness typically express themselves directly as disability, not entailing suffering; this holds particularly for the ones which are the results of defect and injury, such as paralysis and deafness. That people may suffer when reflecting upon their state of illness is a completely different matter. This suffering is not a part of their illness. It is to be compared and equated with the grief that we may experience when reflecting upon other sad events in our lives. My purpose in proposing a defmition of health and illness was to fmd a minimally sufficient way of characterizing the two concepts. The notion of suffering was not adequate. The notion of disability was more promising. This was so for two major reasons. First, disability covers the cases that suffering does not. This is obvious with coma, deafness, and paralysis. But also mania entails some disability, namely, a disability in handling one's social life. Second - in this respect I make a move which is different from Fulford's - all suffering which is not trivial leads to some disability. Some theorists would say that suffering conceptually entails some disability. I think this is obvious. When a person is in great pain, as in an attack of migraine, that

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person cannot concentrate; the possibilities of doing any serious work have disappeared. I understand suffering and disability as notions which are much closer to each other than Fulford indicates in his preliminary analysis. To me, suffering of a degree above the trivial entails, or causally leads to, disability. The point about a semantic bond between suffering and behavior is central in modem linguistic philosophy. A locus classicus is Wittgenstein (1951, par. 580). To Fulford, the suffering of illness is something that the subject cannot do anything about. A reasonable theory of illness - and this demand must be imposed with equal strength on the anthropological theory of illness - must be able to differentiate between the pain and suffering which is a part of illness and that which is not. Pain and suffering, whatever its source, will lead to some disability, I would be forced to say. Many kinds of pain and suffering occur that a person cannot in practice do anything about and which are not obviously connected to illness. This fact has to be tackled by both Fulford and myself. When I suffer from the exchange currency relation between the Swedish crown and the British pound, this is nothing that I can do anything about; or to take a serious example, when people in the Third WorId suffer from their poverty this is indeed a suffering they can do nothing about. Both Fulford and I have answers to these kinds of arguments. I claim that the disability and pain of illness must be internally caused. This does not preclude some remote external cause which has in its tum caused an internal physiological or psychological state directly responsible for the disability or pain. In the case of many diseases, we believe that they are at least partially caused by external events, be it an invasion of microbes or a poison, or the occurrence of a stressful situation. In the case of the currency relation or the poverty, on the other hand, a continuous external sustaining cause of the disability occurs. As soon as the external state of affairs disappears, then, in the standard case, the subject is immediately relieved and regains his or her normal ability. In some cases when this does not occur, that is, when the sustaining external cause has caused enduring damage in the subject. But then we have a case of ill health. Fulford argues in a sirnilar way when he says that a failure of action or a sensation which is due to something that is done to or happens to a subject does not qualify as illness. He must then also presuppose that this something is done immediately to the subject, for instance, when a person touches something extremely hot, and the pain inflicted will disappear as soon as that person no longer touches the hot object. Many injuries are brought about by something done to a person or something that has happened to a person. An injury is completely on a par with a disease; it is a state which causes or entails an illness.

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E. Fulford and the Experience of Failure of Ordinary Doing My discussion concerning Fulford's views so far has concerned the passages where he focuses on feelings in terms of sensations such as pain, fatigue, itching, dizziness, and breathlessness. Fulford also highlights a person's experience of failure of ordinary doing (see, for instance, 1989, p. 124). He even says "the logical origins of the medical concepts are in the experience of failure of ordinary doing." See also: "Specifically, the logical origins [of disease] are to be found in the experience of failure of 'ordinary' doing in the perceived absence of obstruction and/or opposition ... " (p. 263). These paragraphs complicate the final definition of the notion of illness in Fulford's theory. They also complicate the analysis of Fulford's views on sensations as elements in illness. The experiences with which we are concerned are not ordinary sensations such as pains and itchings. They are on a par with cognitions. The subjects observe or understand that they have a failure of action in the absence of obstruction or opposition. Normally, the subjects then conclude that they are ill. Two ideas have to be distingushed here. One is evident and trivial. The other is controversial. First, we have no problem in acknowledging that the observation of the patients that they are disabled, for instance, after having tried to do something, is one way by which they get to know about their illness, where illness is defmed in terms of failure of action and not in terms of any experience. Fulford and I would agree on this. The second idea, which is indicated by the thought that the experience of failure of ordinary doing is the "logical origin" of the notion of illness, is that the experience of the failure is an essential ingredient in the concept of illness itself. By this I mean that the concept of illness should have a more complex definition than I have so far suggested and Fulford normally suggests. Yet the experience of failure cannot be a necessary condition of something's being an illness. A person in coma does not have any experience at all; some mentally ill patients do not have the experience of failure of action; and some physically ill persons have not yet discovered their illness, because they have not started trying to act, for instance, after a night's sleep. Still, they may be ill. Some alternative interpretations arise. One is that the "logical origin of a concept x," a notion which itself requires more elucidation, need not in the end be part of x. Thus, "experience of failure of ordinary doing" need not be an element of the notion of illness. While it is typical that a person who is ill also has an experience of illness in the cognitive sense of experience, it is not an essential element of the illness as such. The other interpretation is that Fulford's concept of illness is complex in the sense that it is disjunctive. Persons are ill, according to this suggestion, not only if they have a failure of

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"ordinary doing" but also if they experience a failure of "ordinary doing". In fact, the situation may be even more complex, since Fulford has alternative explications of the ceteris paribus clause: "in the absence of obstruction and/or opposition" or "in the perceived absence of obstruction and/or opposition." An important question is whether the experience and perception, respectively, can be mistaken. Should, for instance, a person who experiences a failure of ordinary doing, in the absence of "real" failure, be classified as ill under Fulford's interpretation of illness? F. Nordenfelt on Subjective Illness In spite of my defense in (1995) and in the present discus~' In, I acknowledge that my treatment of the experiential or sensational component of much ill health could be more comprehensive. In another book, Quality of Life, Health, and Happiness (1993), I have tried to remedy this deficiency somewhat. I there address this issue by identifying two notions of what I call subjective illness. The first of these notions refers to the cognitive state discussed above, where a subject believes that she or he is in ill health or is aware of being ill, where illness is understood in the sense explicated in (1995). The second notion of subjective illness refers to a set of mental states associated with illness in the objective sense. Here we come close to the mainstream anthropological notion. The typical mental states I have in mind are being in pain, feeling tired or feeling depressed, when these feelings do not have any immediate external cause. Subjective illness in one of these two senses does not presuppose subjective illness in the other, for they are quite compatible with each other. I will generalize this also for the case of positive health. A basic concept of "objective" health (ill health) is to be characterized in the actiontheoretic terms indicated earlier. Two concepts of "subjective" health (ill health) exist. Objective health (ill health) certainly is compatible with the two forms of subjective health (ill health) but is distinct from them. An empirical relation does exist between the second variant of subjective health (ill health) and objective health (ill health). This is most easily seen in the negative case. Strong feelings of suffering (subjective ill health) cause disability (objective ill health). Positive feelings, like a feeling of vitality or a feeling of happiness, can enhance ability and thereby improve objective health. These are in principle the ways by which I have attempted to incorporate the important element of sensations and experiences in general in health. I am not sure that this is the most natural or reasonable way. One critic, Briilde, (1998) and (2000), proposes that I together with other action-theoretic philosophers of health should abandon the one-dimensional way of characterizing objective health and accept that health is multidimensional in its

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basic form. I am prepared for developments in this direction. The critics must, however, propose a treatment of all the cases of ill health which do not presuppose any negative experiences. In the later text (2000), Briilde directs a more general criticism against my kind of health defmition. He claims that I follow a traditional, Aristotelian, pattern of defmition. This approach, according to Briilde, has two components: it is non-comparative, that is it focuses on levels rather than changes, and it tries to determine levels of health by looking for necessary and sufficient conditions. The alternative approach espoused by Briilde has the following features: (I) it is comparative in the sense that the concept to be characterized, A, is defmed in terms of another concept B so that, by defmition, A 's value is ceteris paribus determined by B's value, and (2) it does not aim at finding necessary and sufficient conditions for the presence or variation of A. It may suffice with something looser, for instance, that some or most changes in a variable are also, by defmition, changes in A. More concretely, Briilde maintains that there may be a partial conceptual covariation between a person's well-being and his or her level of health. For instance, such a covariation may exist on the positive part of the health scale but not on the negative part. According to Briilde's suggestion, in a particular instance of health and illness not all dimensions of health need be relevant. Briilde agrees with me that a person may be severely ill without feeling bad. The illness may be wholly constituted by a high degree of disability. However, from this need not follow that the feeling element is irrelevant to health. The feeling element may be necessary on the positive side of health. We may not be optimally healthy, for conceptual reasons, unless we feel well. This is an interesting suggestion, but it does not speak much for the exclusive choice of a comparative approach to defmition. If the conceptual situation is as Briilde suggests, then health and well-being do not covary in a simple way. A precondition for characterizing this covariation is that we define a crucial level of health, namely the state of minimally acceptable health, without which we cannot talk about positive health. Thus, Briilde's example speaks in favor of the necessity of partly using a non-comparative approach for definition. G. A Phenomenological Approach to Illness: The Proposal of Fredrik Svenaeus Some valuable contemporary texts characterize illness or ill health in terms central to phenomenological theory. The best-known theory is that of Medard Boss (1975), a pupil and late collaborator of Heidegger. For Boss, the work of Heidegger, and in particular his ontological analysis of human exis-

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tence (Daseinsanalytik), provides an important foundation for medical theory. Dasein, or the individual human existence, exists as a totality of inherently given possibilities to act. When the fulfillment of any of these possibilities is markedly impaired or when the individual is no longer free to act in the way he or she wants to and is accustomed to being able to, then, according to the view of Boss, illness or pathology occurs. In this way, "every form of being ill is a particular manner of impairment of the free fulfillment of an individual's inherently given human potentials or characteristics" (see Condrau [1998], p. 63). Such an impairment rarely occurs as an isolated symptom. According to Boss, following Heidegger, the basic human characteristics, the so-called existentials, are inseparable. Therefore, any impairment of a part or a· particular existential will reveal itself as an impairment of the whole. Although one aspect of the human being is primarily affected for example the mood in the melancholic individual, each of the other aspects will be affected too. In the case of melancholia there will also be restrictions on the subject's spatiality and ability to socialize. In identifying health with a person's ability to fulfill the person's potential in reality, Boss comes quite close to my interpretation of health as a person's ability to realize that person's vital goals. The main difference is that Boss assumes a defmite set of capabilities inherent in human beings. I dispute this, and I wish to point out that the assumption of an idea of inherent capabilities can yield counter-intuitive results. Certain individuals, those with obvious congenital defects, will not become healthy in any reasonable sense of the word just because they fulfill all their inherent, that is, congenital, potentialities. In order to avoid this difficulty, the concept of inherence must become an abstract and ideal notion, as for instance, what is inherent in the prototype of human beings. This opens the door to various interpretations. My proposal is one such interpretation. Some critics consider that Boss has misinterpreted Heidegger, in spite of the fact that Boss at one stage worked in close connection with him. They find that he has fallen into the existentialist trap of focusing on "freedom instead of understanding: authentic understanding is identified with freedom to choose our own way oflife" (Svenaeus, 1999, p. 154). Fredrik Svenaeus (1999) has recently proposed an alternative phenomenological interpretation of illness. His basic idea is that health should be identified with a person's "being at home in the world." The feeling of unhomelikeness was introduced by Heidegger in connection with his crucial notion of anxiety ("In der Angst ist einem 'unheimlich, '" Zollikoner Seminare [1994], p. 188). In anxiety the subject feels unhomelike. The subject does not then understand his or her situation in life and does not have control of it. In anxiety, this feeling is extreme as there is a sense of complete confu-

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sion and lack of control. But the so-called authentic anxiety only lasts for a short time, asserts Heidegger. Svenaeus proposes that unhomelikeness, initially introduced as a property of anxiety, can be used to characterize the human condition of illness. The unhomelikeness of illness can be quite partial and not so radical as that of anxiety. But elements of unhomelikeness, in particular lack of understanding and lack of control, are typical of illness. A person who is ill is partly transformed in a way that worries that person. The unhomelikeness of illness is also typically much more enduring than the corrsponding state which is involved in Heideggereian anxiety. The taken for grantedness, the transparency of her normal activities is changed into an effortful striving to keep up with what she used to perform easily; life now offers severe resistance. She feels transformed: Is this still me? Why do my body and mind not work as they used to do? Why are they getting out of my control. (Svenaeus, 1999, p. 162) One way for Svenaeus to explicate further the unhomelikeness of illness is to make use of the Heideggerian notion of a tool. Heidegger uses the example of a hammer. When carpenters are building a house they are most of the time not aware of the hammer they are using. Their attention is elsewhere, possibly on the construction to which they are contributing. But things change when all of a sudden the hammer breaks, for instance, loses its head, and cannot any longer be used. Then all the attention of the carpenter becomes focused on the broken hammer and the need for repair or replacement. This means fIrst that the carpenter becomes aware of the hammer as a tool and not just as any old thing. The hammer has in the breaking "revealed" its meaning as a link in a meaningful project. Second, it means that a breakdown also occurs in the carpenter's activity. The meaningful work of building can no longer, for some time, be performed. A situation of "senselessness" has arisen. Svenaeus extends the use of the meaningful tool to the various parts of the body. Many such parts, such as the limbs, the hands, and the legs, but also the oral language-producing organs, such as the mouth with all its constituents, can be likened to tools. When such an organ is impaired, and thereby a meaningful activity is disturbed or completely prevented, then the situation loses much of its meaning to the subject. The subject no longer understands what is happening or why it is happening. The subject enters a state of unhomelikeness, that is, a state of illness. Svenaeus's theory is limited to being a theory of illness and does not refer to a notion of physiological disease. A malady or disability of which the subject is not aware receives no phenomenological description. However, illness in the sense of unhomelikeness can occur even if the subject is not explicitly aware of a malady or disability. It may suffIce that the subject has a

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vague sense that something is wrong for the unhomelikeness to occur. The question then comes up whether the idea of unhomelikeness covers too much, or, in some cases, too little. Svenaeus's proposal, so far, does not distinguish between the case of unhomelikeness in relation to one's own body and mind, and unhomelikeness in relation to the external world. A person in jail and a person at war may certainly both have a sense of unhomelikeness, but not for (what we ordinarily call) illness reasons. At the opposite end, we have the trivial and light illnesses, such as the common cold. Is it reasonable to say that such an illness should be characterized as unhomelikeness and as a breakdown of understanding? Svenaeus has paid attention to this counterargument and seems to agree that his notion is one of serious illness, the illness that requires the attention of a doctor. 2. On the Notion of Ability A. Fulford on Health and Ability

To be ill is to be disabled in some sense; on this point Fulford and I completely agree. As a corollary,we ought to agree that to be healthy is to be able in some sense. In my work, I draw this conclusion explicitly and concentrate my analysis on it. Fulford gives almost all his concentration to the negative side of health. This difference of locus is in itself of philosophical interest. Fulford, like Boorse, notes that the medical profession has directed virtually all its attention to disease and illness, and he draws a philosophical conclusion from this. The negative concepts of health have priority over the positive concepts. This priority is not limited to a clinical motivation. It also has a key existential background. Gadamer has noted this fact in his Enigmas o/Health (1993). See also Austin (1968, p. 32): "For above all it will not do to assume that the 'positive' word must be around to wear the trousers; commonly enough the 'negative' (looking) word marks the (positive) abnormality." What he means here is that it is only when things go wrong, it is only when we run into difficulties, that we can "break through the blinding veil of ease and obviousness." Health matters are nothing that the bearer thinks about or notices until he or she becomes ill. Health becomes a matter of concern only when one lacks it. Health is the normal state of flow. Disease entails disruption and requires extraordinary measures. Thus, disease must become an object of attention. I appreciate this observation and agree with it. My reason for focusing on positive health is different; it is logical and epistemological. An analysis of disability logically requires a notion of ability. It is impossible to get a clear understanding of what it means to be disabled unless one knows what

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the doing with regard to which one is disabled is about. Fulford is aware of the logical point and has, as we have seen, a preliminary positive answer. He says, " the patients who are ill are unable to do everyday things that people ordinarily just get on and do, moving their arms and legs, remembering things, finding their ways about familiar places and so on" (Fulford, 1989, p. 149). Fulford is also aware of the necessity of adding a ceteris paribus clause: The inability entailed in health must be related to "the absence of obstruction and/or opposition" (p. 132). A person who is unable to move from one place to another because he or she is held back is not thereby automatically disabled or ill. Before I tum to scrutiny of my previous analysis of health-related ability in the light of a recent critical discussion, I will make some remarks on Fulford's implicit specification of positive health. 1. The problem of "ordinary" doing. Fulford says that our "ordinary" concepts of health and illness do not have a sharpness that allows us to specify positive health any further than by referring to the ability of "ordinary" doing, and by exemplifying in the way that Fulford has started to do. I think that we must interpret this locution further. The "ordinary doings" in Fulford's sense, and originally in Austin's sense, are such doings as we typically do not think about when we perform them. We perform them automatically or semi-automatically. Fulford sees the "ordinary doings" as somehow placed between functional doings and full-blown actions. They are preconscious and therefore not consciously intentional. Thus, Fulford, 1989, p. 117: "Ordinary doing is thus 'latent full' doing. And the reason for this is clear enough - namely, that in regard to the everyday things that people do, the elements of the full sense, by which their machinery of action is compromised, operate largely trouble-free." What are the consequences if health and illness are to be logically related to our preconscious doings? One thing to observe is that different people have slightly different sets of preconscious doings. A proficient driver can drive a car semi-automatically and preconsciously. A clever acrobat can perform the most complicated actions semi-automatically and preconsciously. The same holds for every person who has a set of actions that she or he has trained to perform, which may be quite peculiar to that person, and which may be complicated actions. This means that an ordinary doing in Fulford's sense need not be ordinary in any frequency sense of the word. Unclear to me is whether this was intended by Austin. He gives examples of doings which are not only typically preconscious but which are preconscious to almost all people. In any case, the relation to the subject's intentionality is the most important element in Fulford's notion of ordinary doing. The "ordinary doing", although typically preconscious, is still intentional doing. If the subjects

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cannot do what they ordinarily do, that is, what is of value to them, as Fulford puts it, then they are disabled in the specifically medical way. Observe the way Fulford focuses on the notion of expectation: "Thus it is only because of the expectation (in the absence of obstruction and/or opposition) one will just get on and raise one's arm, that failure to do so will lead one straight to the doctor" (Fulford, 1989, p. 125). This makes a more individualistic interpretation of "ordinary" quite natural: A person is ill if, and only if, the person cannot do what that person normally just gets on and does. Thus, an individualism arises in Fulford's theory of illness. The relation between a person's illness and that person's intentionality is partly parallel to the one I propose (see Chapter Four, Section 3); the difference is that Fulford limits himself to preconscious doing, and not, as I do, to the person's most important doing. People sometimes intend to do things which for themselves are unusual, and which may therefore require a conscious intention, but which still may be of great importance to them. According to Fulford's specification, these actions and the ability to perform them cannot be considered in the analysis of health. On this point, a big difference exists between Fulford and me. Questions remain to be answered by Fulford in his further development of the "ordinary doing" theory of illness. One group of questions has to do with the differences between people's sets of preconscious "ordinary doings." Some people have rich sets, while others have poor sets. Shall we say that the acrobat who fails to make a double somersault on one occasion, something that the acrobat ordinarily just gets on and does, is ill to the same extent as the ordinary person who fails to get out of bed in the morning? And what shall we say about those people who must concentrate and be conscious of almost everything they do, however trivial these doings might seem? They may be able to do everything that they ordinarily just get on and do, but this does not entail much, since they ordinarily just get on and do quite few things. Maybe they have lost an ability to do many things preconsciously, because of a disease. Maybe they earlier used to be able to do many things preconsciously, but that they can no longer do them as easily. Some failure results, although not really a failure of action since the persons can perform the action intentionally, but a failure of performing something as an "ordinary doing." If we make a specification in the theory along these lines, we can classify these persons as ill. But what if we are not talking about a case of obvious disease? Suppose that we are talking about persons with the characteristic of doing most of their things quite consciously; suppose that little is automatic in their doing. In such a case, these persons have all through their life a genuinely small set of "ordinary doings." If we are inclined to say that these persons must have some defect, the theory as it stands is not sufficient to handle this case.

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Consider how the idea of failure of "ordinary doing" fits with the traditional rule of thumb in much health care and public health, which says that persons who cannot go to their work and do their work properly, in the absence of obstruction or opposition, are to some extent ill. Many of the actions involved in many people's work are, or at least after a while become, of the "ordinary doing" type. This is especially so with the menial work in factories or certain offices. But most jobs, probably all jobs, also entail elements of which the subject must be quite conscious and where the subject's actions must be consciously planned. Some people have extremely difficult jobs about which they have to think carefully in almost every step that they take. I am not talking just about people who have high managerial or political positions but also about persons with jobs entailing complex and careful operations of an intellectual and of a manual kind. When we are talking about moderate illness, say, the illness of flu or a cold, it is typical that the subjects lose their ability to deal with the more demanding actions entailed in their work, but where they could perfectly well go on and do that part of it which is completely automatic. Thus, if we were to tie the notion of illness just to the failure of performing the automatic actions, we would not be able to identify some of the instances of moderate illness. I also wish to raise a question with regard to Fulford's "ordinary doing" theory which, if relevant, directly affects his central field of investigation, namely, the core of mental illness. My argument runs as follows. Many physical illnesses strike at ordinary doing. If you break your leg or arm, then in a striking way you cannot do many ordinary things, such as moving about or doing your housework. Likewise, if you have a cardiac failure or a stroke you are bound to your bed and prevented from doing many ordinary things. This is also true of some major mental illnesses. A depression or a severe condition of anguish may completely paralyze its subject on the ordinary doing level. But what about the psychoses in general? What about the manic and the schizophrenic, in particular? The manic can typically do most ordinary things quite well. The manic may even be better, temporarily, at doing some ordinary and some extraordinary things than before the onset of the illness. The problem with the manics is that they have difficulty in considering their life as a whole; they have difficulty in planning for the future and in considering the consequences of their actions, and they have difficulty in inhibiting themselves when this is appropriate for their long-term wellbeing. The problems of the manics are, as I see them, on a higher-order level than the ordinary-doing one. The manics are unable to reflect consciously on some key things in life. Similar considerations hold mutatis mutandis for some schizophrenics. I do not pretend to be able to talk generally about this extremely diversified category of illness. But a schizophrenic may be quite capable of doing the

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basic things in life, such as walking, talking, grasping things, and remembering things. The difficulty again comes in on a higher-order level. The schizophrenics may be unable to do more demanding things; they may be disabled from doing their work properly because they cannot cooperate well with their mates or they may be unable to concentrate on the more difficult aspects of their work. My conclusion must be the following: the "ordinary doing" analysis of illness needs, at the least, an elaboration to be able to cope with key instances of illness. The above arguments indicate that an adequate theory of illness must involve the failure of action on levels much above the ordinary "preconscious" level. So far I have tried to follow the conception of "ordinary doing" entailed in Fulford's analysis. Other ways exist of llIlderstanding a notion of ordinary doing. One possible interpretation is to say that the ordinary doings are doings which are simple in an action-theoretic sense, only involving simple bodily, or in some cases, mental, movements. According to this idea, ordinary doings could be identified with the so-called basic actions, explicated in modem action theory (see, for example, Goldman, \970). I will consider this idea below. 2. On the circumstance-clause. Not all kinds of action failure qualify as illness. Action failure due to something which happens to persons, or is done to them by some other human being, so that they are extemally prevented from pursuing a course of action, is obviously not illness. Thus, we must always presuppose that illness is action failure in the absence of obstruction or opposition, as Fulford puts it in his characterization. This is evident, and I have a similar qualifying clause in my definition of health (see Chapter Four, Section 3). But if Fulford's clause is to work properly, then the circumstances to be excluded must not be confmed to preventive events or actions. We have to include far-ranging harsh circumstances. Persons who live in an environment which is poor or otherwise demanding is not evidently opposed or obstructed in their actions. No simple preventive happening is involved and no particular opposing action is performed. The subjects may anyway fail to do what they wish to do, and we are not inclined to regard this failure as a sign of reduced health. I have attempted to include all sorts of extemal circumstances which may prevent the execution of a person's ability. In recent writings, I have proposed two ways of doing it. These two ways mirror two uses of the health concept, one of a more descriptive use and one which is more clearly normative. I distinguish therefore between standard (culture-related) circumstances and reasonable circumstances. See the presentation of these ideas above, Chapter Four, Section 3.

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3. Reflections on purpose and methodology. The place of "ordinary doing" in Fulford's theory of health highlights the methodological differences between Fulford and myself. Fulford makes every effort to trace the origins of our common concepts of "ordinary doing" and of illness. He consults one of the most advanced philosophers of ordinary language that ever existed, J. L. Austin, and employs his notion of "ordinary doing" and the locutions Austin uses for the characterization of "ordinary doing." Fulford does not, however, try to describe the set of actions included among "ordinary doings" in any way that goes beyond their semi-conscious nature. The first possible interpretation of Fulford's analysis is that the analysis of the notion of "ordinary doing" should not exceed the point that Austin suggests. Lay people are not philosophically sophisticated people; their notions are rough and vague. Fulford therefore sees no point in analyzing the idea of "what people just get on and do" any further. The ordinary notion of "ordinary doing" and, derivatively, the ordinary notion of illness are not more specific than this. If our purpose is just to analyze the ordinary notion of illness, we should not go on to do anything else. We could legitimately stop our analysis at this point. A second interpretation, and the most plausible one in the light of Fulford's whole project, is the following. His ultimate purpose is not just to analyze ordinary language notions. He wishes to contribute to medical theory. He considers that such a contribution can be sound only if we start with the ordinary notion of illness which is attached to the idea of "ordinary doing." Fulford might wish to go on to say, that in order to make this intuition helpful in medical practice, we must say a lot more. Austin himself looked upon ordinary language as a starting point for a philosophical analysis. The presentation given in Fulford's writings so far, then, is just preliminary. His present theory-construction must be supplemented in a considerable way on this point. B. What Abilities Are Relevant for the Characterization of Health? In the following, I will critically focus on my analysis of the actions required of a healthy agent. I focus on the question: What should one be able to do in order to be considered healthy? To me, not all abilities can qualify if we intend to stick to ordinary intuitions. My primary reason for refusing to include all abilities is that if we did include them we would not be able to differentiate between health and general strength and excellence of various kinds. A man who does weight-lifting and increases his muscle strength tremendously has not thereby improved his health, according to ordinary intuitions. He may have improved his health as a side-effect. He may have strengthened his immune system by his training, but that is different from the

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pure muscle strength. Likewise, a woman who practices languages a lot and becomes an extremely proficient speaker of several languages has not improved her health, according to ordinary intuitions. Thus, a set of excellence concepts should, at least in the first instance, be kept distinct from the concept of health. On this point, see Briilde (1998), who proposes counterintuitively, that any improvement of a person's ability is an improvement of health. What alternatives do we have, then, in our search for the peculiar medical abilities? Let me again list several alternatives, some of which have already been mentioned and can be easily dismissed. The abilities of health are I. the ability to satisfy our basic needs 2. the ability to satisfy our wants 3. the ability to do "ordinary things" 4. the ability to run our daily affairs 5. the ability to make ourselves minimally happy, i.e. the ability to reach our vital goals (1) is too narrow if "basic needs" only refer to survival. If we side with

Maslow's definition of basic needs, the characterization becomes circular, as I have indicated above in Chapter Three, section 3. (2) is both too narrow and too wide. We may have unrealistic and "mad" wants, or we may have too Iowa level of wants. (3) is, as I have just indicated, unclear. "Ordinary" has to be unpacked. (4) probably provides a good rule of thumb but has much of the unclarity of (3) in it. The question also remains whether health only has to do with our ability to do the ordinary and daily things. Do not some unusual, but yet important, things exist which healthy people should still be able to do? Should they not be able to get married, or be able to make a long journey, or, in general, to deal with the demanding and unusual complexities that life may contain? (5) is my attempt to cover a good deal of that ground which I think the health concept should cover. This proposal has to be interpreted and operationalized, however, to be directly clinically useful. For the moment, I have no other proposal which has the merit of covering enough ground and also of being immediately operational. Another aspect of ability has to be scrutinized in the health context. Abilities occur in layers, where one layer presupposes another, but not the other way around. At least three different dimensions of such layers exist which require to be analyzed in this context. Consider them in tum:

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1. The distinction between first-order and second-order abilities 2. The distinction between basic competence and power to execute basic competence 3. The distinction between basic abilities (abilities to perform basic actions) and generated abilities 1. In (1995), I made use of the idea of second-order abilities. I claim that the ability involved in health is of the second-order kind. What does this mean, and why do I claim this? A second-order ability is a "quasi-ability." If you have a second-order ability to drive a car, then it does not follow that you can actually drive a car, that you have the first-order ability. What the expression says is that you have the basic physical and mental resources to learn to drive a car, if you are given the proper instructions. Why, then, do I opt for this quasi-ability in characterizing health? The reason is obvious. I do not wish to say that it is only those people who have been given the adequate training in different respects who have health. I wish to say that the person who has not gone to school and who has not become cultivated in other respects, can be as healthy as the highly cultivated person. This is so because the untrained person may have as good basic biological and psychological resources as the cultivated person. By emphasizing the second-order level as the more appropriate level for this defining purpose, I have pushed the concept of health more toward a person's basic biology and psychology. However, in doing this I may also be doing something which is counterintuitive from another point of view. To see this, consider the typical case of illness due to a well-known disease. Assume that you are stricken with influenza. You get a high temperature, you feel pain, become quite tired and are confined to bed for several days. What happens there? Is it your first-order or second-order ability which has been affected? The immediate and natural response is that the first-order ability has been affected. From a state where you have been able to go to work, for instance, you are now, from internal causes, unable to go to work. I dealt with this counter-argurr•.;nt in (1995), pp. 51-52, making use of the distinction between basic competence and power to execute basic competence. I agreed that the first-order ability most obviously vanishes in the typical state of illness, but I claimed that the second-order ability goes as well. When we are in great pain and are tired, our second-order ability to perform our work has also been reduced; we do not then have the ability to put ourselves into a training program which would result in an ability to do our work. The typical kinds of illnesses affect our general ability on a basic level.

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An argument against this runs as follows: The persons who are ill for a couple of days still retain their second-order ability to work. They have already received all the training or education needed; it is the fInal end of their ability (the fIrst-order end), not its fundamentals (the second-order basis), which the illness has affected. I believe that in this argument a conflation of concepts has occurred. The notion of second-order ability may have been conflated with the notion of basic competence, which brings me to the second distinction to be dealt with. 2. The influenza-stricken persons in bed keep their basic competence to perform a job. They need not at all have lost their professional skill, although this may happen in grave illness. What has happened is normally something more superfIcial, that the sick persons have lost their executive power. While in bed, in pain and tired, they cannot any longer execute this basic competence. But basic competence is a concept different from second-order ability. They belong to different dimensions. You can have a basic competence but lack both second-order and fIrst-order ability. This is the case illustrated above. A trained doctor, who has the competence to do medical practice, may, due to illness, lose the executive power to do her or his work, but typically also loses temporarily the ability to regain this executive power, the second-order ability. Executive power in itself is identical with fIrst-order ability. The relationship between basic competence and second-order ability can be explicated in the following way. To say that A has a basic competence for F is to say that A has some normally mental resources necessary for performing F. These resources need not at all be suffIcient for performing F. To say that A has a second-order ability for performing F is to say that A can initiate a process whereby A receives the fIrst-order ability or the executive power to perform F (see Nordenfelt, 1997). Bengt BIiilde (1998) has criticized my view that illness has to be located at the second-order level for the reason that some second-order abilities have nothing to do with health. The ability to learn a language, he says, may be necessary for the realization of vital goals. But the lack of such an ability is not a criterion of ill health. The lack may concern a kind of excellence, say, intelligence. Here BIiilde pinpoints a basic problem which must be faced by every theorist of health who has an action-theoretic approach. The excellence concepts, for instance strength, intelligence, and endurance, have their negative counterparts, say, weakness, idiocy, and lack of endurance, which, given standard intuitions, need not be identical with, or due to, ill health. Still, a person's weakness, low intelligence, and lack of endurance can cause or constitute an inability to realize vital goals. We face a dilemma: We must either try to fInd criteria by which we can sort out such lack of excellence as

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is not due to or identical with ill-health (obviously, lack of excellence can be due to ill health), or we must face the fact that we operate with a stipulative definition of health which covers more ground than ordinary language permits. Before addressing this dilemma I will comment on Briilde's specific criticism. The case of lack of excellence, he says, shows that the retreat to second-order abilities is unhelpful. It is much more intuitively plausible, he claims, to locate health at the first-order level, the level which is so obviously afflicted in ordinary illness. Since Briilde has such confidence in this idea, I believe that he has certain disease-paradigms in mind. He is primarily envisaging the ordinary able adult who suddenly catches flu and thereby loses executive power. But other key paradigms exist. We have the congenital defects, which can be the cause of many reduced excellences, and we have the whole range of chronic illnesses. These forms of ill health affect markedly the basis of ability, the second-order level. The essence of these forms of ill health lies in the fact that basic abilities have been compromised. I return to the question of the wide definition of health. Do ways exist to differentiate grave lack of excellence from ill health, and must we make such differentiations? I will take up the second question first. We have ordinary intuitions that persons can be weak, even extremely weak, or can have a low degree of intelligence, without their being unhealthy. Thus an ordinary-language argument exists for distinguishing between the two categories. Perhaps as a corollary of this, an institutional differentiation exists as well. A distinction is made in many cultures between health care, which treats the ill, and the care of the disabled. This is a basic cultural distinction with great social and economic implications, and it warrants a good conceptual backing supported by a viable philosophy of health. A theory of health which just relies on the notion of internal second-order disability does not give this support. What, then, distinguishes ill health from grave lack of excellence in our intuitive understanding? The answer must be that ill health, at least typically, is due to the occurrence of disease or some other malady, like a congenital defect. So, when a disability is due to a malady we have ill health, according to this intuition. The question now is, can theories like Fulford's and my own, sticking to a reverse view of health and illness, handle this intuition? The first impression might be that we would end up in the following circle. According to us, illness or ill health is primary. First, we must identify illness; derivatively we can identify diseases, either as a subcategory of illnesses (Fulford) or as typical causes of ill health (Nordenfelt). But does not the solution to our present problem presuppose that diseases can be identified independently of illness?

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My answer is that no problem need arise. I will develop the defense for my own case. Diseases can ultimately only be identified via the observation of ill health and illness. When we have observed that a person has a disability, in my qualified sense, we can start looking for the internal cause of this disability, either a somatic or a mental cause. If this kind of cause proves to hold for similar instances of illness in other persons, we have found a disease which can be registered in the medical classifications. Once we have found the disease-type, this disease can, as I have said, live a life of its own. We can describe the disease in physiological or psychological terms, without reference in this description to its disposition to cause illness. We can, for instance, identify this disease-type in other individuals who have not, at least not yet, acquired a full-blown illness. In principle, therefore, we can easily distinguish between cases of disability with and without a triggering disease. Already in (1995, p. 149), I suggest a conceptual apparatus for such distinctions. I distinguish between three versions of health. One of these is called the disease-concept of health: A is healthy, in this sense, if and only if A's ability to realize her or his vital goals is not compromised by having a disease. This state of health is then compatible with the subject's ability being compromised for other reasons. A deeper question lurks. Can we conceive of a disability which does not have a cause, be it physiological or psychological? If we cannot conceive of such a disability, must not its cause be some kind of malady, for instance, a congenital defect? Would not, then, the putative distinctions between disability SimpliCiter and disability due to malady vanish? (see Edwards, 1998, and my response, Nordenfelt, 1999). My answer to this is twofold. First, an understandable and proper distinction exists between such disabilities for which we have clearly identified internal causes, and such disabilities for which no such causes are to be found. This distinction is sufficient to warrant the institutional distinction between health care and disability care. Second, that all things, including disabilities, must have a causal background, does not entail that they must have a background in terms of clearly identifiable typical causes. Diseases, in my sense, are typical and previously categorized causes of disabilities. Disabilities exist which have no such typical backgrounds. 3. A few words about "ordinary" doing in terms of simple, basic doing. I noted that there is a possible interpretation of the notion of "ordinary doing," although this is clearly not Fulford's own interpretation, to the effect that the disability of illness is a disability related to simple bodily movements and to simple operations of mind. As I mentioned, in modem analytical action-theory a much used distinction is between basic actions and generated actions. Briefly, the notion of basic action refers to such simple actions as are performed without performing any other actions. Examples are moving your

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hand, moving your leg, and thinking that today is a sunny day. The generated actions are such as are performed by the performance of some other action, ultimately by a basic action. Examples: You drive a car by moving both your hands and your feet. A judge pronounces a sentence by uttering certain sentences. He or she does so in tum by moving tongue and lips. The questions can now be made precise. Is the disability involved in ill health restricted to basic actions? And should we leave the generated actions aside? This is not to deny that the disability in respect of basic actions must have repercussions on the generated actions as well, since the generated actions depend on the basic ones. The questions come to the following: Can we completely concentrate on basic disabilities in fully characterizing the disability of ill health? I do not think that we can offer a full account of ill health by paying attention solely to basic actions. My main reason for saying so is that what is primarily needed in the generation of complex actions is a set of mental factors, mainly knowledge and attention. In order to drive a car, for instance, the drivers must not only have their hands and feet in good shape, they must also know how to use the hands and feet for various purposes. Moreover, the drivers must be attentive to apply this knowledge at the right moments. Knowledge and attention are not in themselves action categories. Knowing that such and such is the case is not an action of any kind, let alone a basic one. Nor is being attentive an action. They belong to the conditions for the performance of actions rather than being actions in themselves. A person's inability to drive a car can indicate ill health. This can be so even if the basic actions involved are not primarily affected. Aspects of people's know-how or aspects of their attention may be primarily affected. This would be the case in mental illness, for instance. My reasons here are similar to the ones given for doubting that Fulford's notion of ordinary doing can do the work required in the case of psychoses. Thus, I must dismiss the proposal that the disability of ill health is just a disability in respect to performing basic actions. A twist of the proposal about basic actions might meet my argument above. It runs as follows: The disability involved in ill health is either a disability to peform basic actions or a disability in respect of such complex generated actions as are the result of such basic, mainly mental, features of the person as enable the person to generate complex actions. This may be a reasonable proposal. But the question is whether it makes my theory more pregnant. I have come quite close to this idea already in my original defmition which refers to a person's second-order ability. The second-order ability refers to a person's ability to learn to be able to act in various ways. The learning concerns the knowledge to be used in generating complex actions.

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3. On Medical Goodness and the Values Attached to Health and Illness-Ascription A. Fulford on Health and Values

According to Fulford, a value is embedded in the notions of health and illness. The value is of a peculiar type; it is not moral or aesthetic. Fulford chooses to talk about it in terms of medical goodness. This term can be found also in von Wright's Varieties of Goodness (1963). I will try to analyze the idea of medical goodness, both as it appears in Fulford's theory and as it crops up in my theory. A fact supporting Fulford's claim that health and illness are value-laden concepts is that they are intimately linked to the subject's intentions and wants. Fulford claims that all concepts, even non-biological ones, which are defined in terms of purposes are value-laden. Fulford claims in a later paper (1999a) that intentions are among the most clearly evaluative of teleological terms. We can see this by the test of self-contradiction: it is self-contradictory to claim that I intend x and, at the same time, to deny that I evaluate x positively, other things being equal. For support of this view, see also Anscombe (1968). In Fulford (1989), this idea is clarified in the following way: "For what is found is that the expressions by which successive purposes are defined become increasingly likely actually to be evaluative expressions: why signal a taxi? - to be helpful to someone; why make a bid? - to get something of value to me" (p.130). Fulford considers expressions of wants in themselves to be or to entail evaluations. He says: Reasons for actions, like delusions, may come either as statements of fact or as expressions of value. For example, if, while driving my car, I am asked why I turned a particular way, I may reply either in factual terms - for example, "this is the way to so-and-so" - or in evaluative terms - for example, "I want (or need or ought) to go to so-and-so". (Fulford, 1989, pp. 215-216) Things need to be disentangled here. I will not question the basic idea concerning the relation between illness and intentional action. I support the idea that illness entails a failure in performing a set of intentional actions. The pertinent question is whether this eo ipso entails that a statement ascribing illness to a person is an evaluative statement. 1. The relation between intentions, wants, and values. Fulford connects intentions, wants, and value ascriptions so closely that expressions of intention as well as expressions of wants become subcategories of evaluative statements. I question this idea. Here I wish to use the well-known distinction

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between expressing an intention or want and ascribing an intention or want to a person. This distinction is used by Fulford in his book, but in a context different from the one I am using here. First, pace Fulford and Anscombe, I may intend to realize a state of affairs, say to destroy a bridge to prevent the enemy from advancing, without valuing this state of affairs at all. I may feel that I must do something, since I have been ordered to do it, but I do not value it. I may evaluate the idea of following an order, but I need not evaluate the action under the description of "destroying the bridge." The resulting action of destroying the bridge is still an intentional action. Something similar holds, although here the situation is somewhat different, for wants. An alcoholic may say: "I want liquor, but I don't value liquor." The alcoholic craves liquor; this is all she or he needs in order to perform the intentional action of getting hold of liquor. But the alcoholic need not basically value it. For the sake of argument I will grant that the fIrst-person expression of a want must on some level involve an evaluation of a state of affairs. I grant that when I say that I want to have a glass of vodka I evaluate this state as a desire-gratifying state. But from this does not follow that an ascription of a want to a person is an evaluative statement. Let me elaborate on this. 2. On ascribing intentions and wants to a person. An important distinction needs to be made between fIrst-person expressions of wants and thirdperson ascriptions of wants to a person. Derivatively, we can also have fIrstperson ascriptions of wants. A similar distinction is to be made, and it has frequently been made, between evaluations and ascriptions of evaluations. Ascriptions of values are descriptive statements. Consider now the situation in the health case. . Our task is to characterize the statement S: "John is completely healthy now." Let us simplify the provisional analysis of S to: John is able to do what he wants to do now, or what he ordinarily wants to do. What kind of statement is this on the descriptive/evaluative scale? The statement relates John's abilities to what he evaluates, in the want-sense of evaluation. Clearly, S is not in itself an evaluative statement; it relates one fact to another fact, albeit the second fact is in itself an evaluation. The person who issues this statement need not evaluate anything. Thus, to make a third-person ascription of health to somebody is to describe and not to evaluate. What, then, about the situation where I say (S1): "I am healthy now"? We proceed with the same analysis: I am now able to do what I want to do. It seems we can come up with a conclusion identical to the above conclusion. I am relating two facts about myself to each other; I am relating my abilities to my wants. I am describing a situation, not evaluating it. An interesting rival analysis of S1 is available. It may speak in favor of Fulford's analysis. According to this analysis, S1 is a complex, consisting of

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one descriptive part, the ascription of ability to myself, and one expressive/evaluative part, my expression of my want. As a result of this analysis, SJ is seen as a hybrid, something quite different from a descriptive scientific statement. I do not wish to deny that some of our first-person health-statements have this character. If this is so, it has repercussions on our view of the firstperson health-language. But I do not see that this makes many if any of the statements which occur in medicine or psychiatry evaluative statements. Virtually all of these statements report facts which pertain to a person other than the one who issues the statement, or to a category of people not including the person involved. My conclusion from this scrutiny, therefore, is that health-ascriptions, as conceived by Fulford in his basic action-theoretic analysis, are in general descriptive statements, although they are valuerelated descriptive statements. B. Health-Ascription as Overt Evaluation

A rather different common thesis in the literature on health pertains to evaluation. This is the simple idea that health ascription is overtly evaluative. The idea is that the concept of health entails an evaluative element which surpasses the analysis of details of the concept. To say that John is healthy now, according to this idea, is simply to say that John is in a good state now. This is compatible with Fulford's analysis, so that the full analysis of S (above) might be: John is able to do what he wants now, and this is good. The basic idea about overt evaluation is compatible with several other descriptive analyses of health. This may be a reasonable analysis of many health statements. Health is generally highly valued. This evaluation of health can be connoted by the speaker who issues a health statement. The question, however, is to what extent this fact marks off "health" from many other concepts used in the social sciences (and in the natural sciences) and what consequences it has for the scientific treatment of these concepts. Several concepts in sociology and economics are associated with values in a similar way. "Welfare" is the best example. Many of the components of welfare, either in themselves or derivatively, have the same features. "Full employment," for instance, although easy to specify descriptively, is a value-laden concept in much the same way as is health. The concept of "evolution," which occurs in the social and natural sciences, is positively value-laden in both branches of science. Insofar as the mentioned value-laden concepts are given a descriptive, although in some contexts stipulatively decriptive, defmition for the purpose of scientific investigation, the extra "goodness" need not disturb the scientific treatment of the phenomena covered by the concepts. What is important is

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that the scientist or scholar is aware of the sometimes stipulative nature of his or her concept. This has repercussions on scientific communication in the first place. C. Nordenfelt, Health, and Evaluation I wish now to scrutinize the ways in which evaluation enters into my theory of health. If I am right in my observations, then I think they have a bearing on Fulford's and other action-theoretic approaches to the analysis of health. The starting-point in my analysis was that health could well be a purely descriptive concept. In issuing a health statement like S, we relate, according to my analysis, a person's abilities to her or his vital goals and to a standard environment. Whatever the nature of the goals and the environment, this seemed a descriptive statement. Let me refer to my previous observation that a statement may be descriptive although some of the facts referred to are in themselves evaluations. According to my theoretical analysis, the fact that S refers to a complex relation between an agent, vital goals, and a standard environment makes the concept special and for some purposes difficult to treat both in practice and in science. From this, however, does not follow that health is an evaluative concept or that S is an evaluative statement. But facts on the fringe of my analysis of health throw a different light on this issue. Consider my notions of "vital goal," "standard circumstances," and "accepted circumstances." A vital goal of A is a state of affairs which is necessary for the attainment of A's minimal happiness in the long run. But how is happiness in its tum defmed? And can happiness be ascribed to a person without some evaluation? The theory of happiness to which I adhere is a want-based theory. The concise definition is the following: A is completely happy (in the basic dispositional sense of happiness) at

time t if, and only if,

(1) A at t wants xl ...xn to be the case at t, and A has at t no further wants

concerning t,

(2) A is at t convinced that xl .. .xn are the case at t.

At other places, I have commented extensively on this schema and made clarifications (see for instance (2000a, pp. 85-94). This is unnecessary for my present purpose, since I will concentrate on the relation between health and happiness and on the problem posed by the idea of minimal happiness. The definition above makes it in principle clear what complete happiness is. But, as I have argued, it is umeasonable to say that health is the ability to reach

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anything approaching complete happiness, a notion which I have in the end problematized for other reasons (2000a). The relation between health and happiness must concern a minimal level of happiness. When you are healthy, you should be able to live a decent life, if the circumstances are reasonable, not necessarily a life of great fulfillment. But in what, more exactly, does this minimality consist? How is it to be determined, and who determines it? I have dealt with this problem in a preliminary way in (1995), pp. 90-92. My conclusion there is that the level of minimal happiness, which corresponds to achievement of the set of vital goals, must be determined in a primary evaluation. It is not a level to be discovered, but a level to be evaluated and decided upon. I will expand on this discussion. The evaluation of what should count as minimal happiness is not a completely fortuitous affair. Some important limitations are given in the health concept itself. According to my conception, the vital goals are the goals which are most important to the subject. These vital goals belong to the subject's whole range of goals which are organized, though not consciously organized, in a loose semiordered hierarchy. Some goals are more basic or more important to the subject than other goals. The ones which are most important to the subject, and the realization of which contributes most to the subject's happiness, must belong to the set of goals ultimately evaluated as vital. Assume for the sake of simplicity that A has a set of 100 goals which are ranked in the order from I to 100. Here can be no choice of vital goals such that the one ranked ftrst or second can be left out, and no choice such that goal 100 is included in the set of vital goals. The choice does not concern the ranking; it concerns where exactly in the hierarchy the line should be drawn between vital goals and non-vital goals. Should it be drawn between goals 15 and 16, or between goals 50 and 51 ? Since the hierarchy of goals is embedded in the personality of the subject, a good case exists for saying that ultimately the subject should decide about the content of the set of vital goals. This is my basic view, but it has to be supplemented with several clarifying provisos. I wish ftrst to pay attention to the distinction between evaluation and decision which I have so far glossed over. The basic concept in the theory is evaluation. Evaluation is sometimes looked upon as a type of action, but in my interpretation it need not be. When a subject becomes unhappy because of an unfortunate event, an evaluation has been made on the subject's part, but rarely has an intentional action of evaluation been perfomed. A decision, on the other hand, is eo ipso an intentional action. The non-agentive evaluation of states of affairs in the world and the ranking of goals is primarily done by the subject. But so is the evaluation of what is the dividing line between vital goals and non-vital goals. This

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evaluation becomes most apparent in the emotional response of the subjects to the course of events affecting them. When the life-situation of people is at a level where they hesitate as to whether they are on the whole happy or unhappy, then they are, I would say, on the minimal level of happiness. The minimal level is such that below it the person is unhappy, while above it the person is happy, not necessarily completely happy, except for the limiting case. This person's set of vital goals is constituted by all the states of affairs which have to be realized in order to reach this level of minimal happiness. This is the basic theoretical platform. Epistemic complications surround this platform. I will try to disentangle these. People do not have a complete epistemic access to their emotional life. For people to have an allencompassing understanding of their level of happiness is sometimes difficult. The "surface" of someone's emotional life, which is often filled with trivial irritation and aggression, can block a sensible understanding of how well organized this person's life is on a deeper level and how well she or he feels on this deeper level. It is an even more difficult affair for people to look into the future and understand what has to be fulfilled in order for their happiness to come about. To do this they may need to have comprehensive knowledge. Such knowledge, however, is what is needed in order to see what the set of vital goals is. Thus, even if the true evaluation of what constitutes welfare always exists in every human being, almost no human being can wholly understand the nature of this welfare, because of a defective epistemic access to her or his emotional life and, more evidently, because of a lack of knowledge concerning empirical matters. A consequence of this is that the conscious judgment of the subjects concerning their set of vital goals need not capture the set of their true vital goals. Thus, when persons are asked to make a verbal declaration about this set, for instance, for purposes of rehabilitation, their answer is probably not an ultimately perfect answer that exactly mirrors their true evaluation. So much for the theoretical basis and the subject's epistemic access. Let us now turn to pragmatics. Who should in practice decide on what is to be considered as a person's level of minimal happiness and thereby this person's set of vital goals? Or, to put it in other words, Who should in practice judge whether a person is in good health or not? Again, the obvious answer to me is: The subjects themselves are in most circumstances the experts. The normal adults have a better epistemic access to their emotional life than anybody else. The normal adults know more about their surroundings and the impact of these surroundings on them than anybody else. Thus, in spite of the epistemic shortcomings of the normal subjects from the point of view of an ideal, they know far more about their health than anybody else. This, then, is the epistemic reason for saying that

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the normal adults should determine the set of their vital goals, when this is needed. To this we can add an ethical reason. The views of the subjects about the limits of their health should be respected and normally acted upon by the nearest and dearest, as well as by health-care personnel, even if they should have good reason to believe that the judgment of the subjects is defective. What holds for the normal adult does not hold for babies, the mentally retarded, and the senile. We could rehearse the well-known arguments used in many ethical contexts. My main concern here is still the epistemic one. Babies, the mentally retarded, and the senile cannot make judgments about their levels of happiness and their vital goals. They have little epistemic access to the limits of their health. This is not to deny that they may often show when they are unhealthy, in particular when they are in great pain. Our concern here, however, is not with identification of obvious cases of ill health but with having in general a reliable judgment of the subject's health. So in these non-standard cases I would certainly say that the judgment of the nearest and dearest would be the most reliable way of characterizing the subject's set of vital goals and general level of happiness. Another pragmatic decision needs to be made. This is the level where health-care personnel should come in and decide to take care of a patient's health. Mrs. Brown is convinced that she is unhealthy and approaches a health-care institution. A member of the health-care personnel, say a nurse, sees Mrs. Brown. She makes the decision what action the state of Mrs. Brown warrants on her part. This is a pragmatic decision of great importance, which calls for philosophical reflection. 1 will not, however, address this issue more than in one respect. It is, if I am right, 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, for sound epistemic reasons. The patient is the only one who has sufficient knowledge. The decision to be made by the doctor or nurse is what they can do to help the patient in enhancing the patient's health. I say what they can do and not whether they can do anything, because health care can always do something valuable for a patient. When the nature of health is understood in the relational way that I have indicated above we should not, as we often are in somatic health care, be bound to the idea that health care consists in the manipulation of a person's body or mind. Health can be improved and supported by many other means, for instance, by considering the person's total life-situation as well as by considering her or his goals in life. I will sum up my discussion of vital goals in relation to the question of evaluation. The result is again a difference between first-person and thirdperson health statements. A man who says, "I am healthy" may be making a complex statement with regard to values. The man asserts that he has the ability to reach minimal happiness, which he evaluates to be at such-and-such

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a level. The person who says "A is healthy," however, makes a descriptive statement. This person asserts that A has the ability to reach a level of happiness that A evaluates as minimally adequate. The statement refers to an evaluation but it does not itself evaluate. I tum to the second area where evaluations may enter into Iily characterization of health. This is the area concerning the circumstances surrounding a person's abilities. I have said that every action occurs in a set of circumstances. Every ability has to be evaluated in relation to a set of circumstances. What is this set in the case of health? My answer has been twofold. The set is either a set of standard circumstances, what is normally taken for granted in a culture, or a set considered reasonable by the person who makes a health statement at the moment she or he makes it. In both cases, values are involved. The standard circumstances taken for granted in ordinary speech are not the statistically most frequent circumstances, however these should be detern1ined. They are instead the result of cultural convention, but since they are not determined by conscious action, the process of determination is probably quite complex. An ordinary speaker who relates her or himself to these circumstances does not necessarily make a primary evaluation of them. Instead, the speaker takes the set for granted and makes a descriptive statement. The other case is different. Here the whole purpose of the statement is normative. We can imagine that the health status of a person, say John, is questioned. A speaker wishes to assert that John really is healthy. This whole argument also holds for the egocentric case, where a speaker asserts that she or he is healthy. The speaker may address the evaluation of circumstances and say something like, "It is true that John was not able to go to work yesterday. But he was under unreasonable pressure. He was not in a standard situation. At least, this is not what I call a standard situation. John is healthy. You will see that, when his life has become better organized." Here is a primary evaluation on the part of the speaker concerning what is to be included in the set of reasonable circumstances. But, it may be argued, once the speaker has defined her or his set of reasonable circumstances, the rest of the statement becomes completely descriptive. What is the upshot of my analysis? Evaluations enter the picture in many ways in expressions of health and ascriptions of health. The result of the analysis. however, is complex. Many third-person ascriptions of health to persons are descriptive statements, although these descriptive statements partly refer to evaluations made by the subject. First-person health statements can be hybrids between descriptive and evaluative, when they contain the evaluation of a level of minimal happiness. Once the evaluation has been done, they may become descriptive. Some both first-person and third-person

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health statements are partly evaluative when they make a primary evaluation of what are considered reasonable circumstances. What repercussions does this conclusion have on my view of the nature of statements in medical science? The consequences are hardly revolutionary. We have seen how third-person ascriptions of health either are already descriptive statements or have a descriptive content which can easily be extracted. This is what we need if we are to make generalized statements of the form, The majority of people in X-country are healthy. Such statements are not evaluative. However, even such statements are rare in the medical literature. The typical statements concern criteria for diseasehood and conditions for the occurrence of diseases. But what about diseases and evaluations? The answer to this question came out in the previous analysis of disease. Diseases are value-related since they are, by defmition, related to ill health. However, according to my analysis, the notion of disease is not related to any particular person's health but to that of the majority of people. A disease is a process, internal to people's bodies and minds, that tends to compromise or be negatively involved in the health of the majority of people. So diseases are internal processes that, as a matter of fact, tend to prevent the majority of people from achieving their vital goals. A statement about the occurrence of a disease is then a descriptive statement. In practice, the picture becomes even simpler since the disease categories are conventionally codified and listed in the standard classifications. A user of the term "disease" can after that only refer to the classification and say, "by disease D I mean that physiological or psychological state of affairs which has been described and classified in register R." It is not up to the user to justify the existence of the register R. That is the business of the constructor of the register. 4. On the Relation Between Health and Happiness In my basic characterization of the concept of health an indirect reference occurs to the notion of happiness. Health is the subject's ability to reach her or his vital goals. The vital goals are each necessary and together sufficient for the subject's minimal happiness. Earlier in this text, I went through details in this characterization, for instance: (I) the fact that health still is quite distinct from happiness and compatible with great unhappiness, given, for instance, a harsh environment; as well as (2) the intricate problem of drawing the line between unhappiness and happiness and thus of characterizing the level of minimal happiness. I will now face a further intriguing problem problem which I have never addressed. I will assume that every person has a set of at least unconsciously held vital goals. That each of them is necessary for the person's minimal happiness also holds according to my definitions. But are we reasonable to hold

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that the realization of the set of vital goals is sufficient for minimal happiness? Is not our minimal happiness highly dependent on external factors? Can we guarantee, that the ability of a healthy person, given standard circumstances, is sufficient for realizing the vital goals, and that the realization of the vital goals is sufficient for the subject's minimal happiness? I will treat the last question first. The relation between vital goals and minimal happiness is not an empirical one. We cannot test my theory by making an experiment, for instance, by creating a state of affairs and then observing whether a person becomes happy or not as a result of this. The vital goals of A, by defmition, are those states of affairs which, as perceived by A, constitute A's state of minimal happiness. Observe that my notion of happiness is a cognitive/dispositional one and not a sensational one (see Chapter Four, Section 3). The first question deserves a tight analysis. What can we sensibly require of a healthy person, even given standard circumstances, or, say, those recognized in Western countries such as the USA, England, and Sweden? Are not many persons quite healthy, by any reasonable standard, who end up unhappy in these countries? The first discussion that this question calls for concerns "standard circumstances." Observe that my alternative conception in terms of accepted circumstances makes my case easier. Given that conception, every user of the term "health" can fill in whatever she or he finds reasonable. We may be talking about different layers of circumstances. The question above, which was put in terms of the standard circumstances of a society, presupposes a discourse about a basic set of circumstances, uniform to all members of that society. This set includes the physical topography of the country, cultural institutions, basic assets, and its economic conditions. This is a crucial set of circumstances, and is included in the standard set of circumstances of every member of the society in question, but it cannot exhaust what my theory of health needs. A reasonable theory of health must come much closer to the person. On top of the basic set, we must also presuppose what might be called the standard flow of events. This flow includes the fact that the person's work-place is functioning, for instance, that it has not gone bankrupt. It includes that the weather is reasonable, that no natural catastrophe is occurring. The standard flow also presupposes that no major accident afflicts the subject in question. An accident may entail a loss of one of the subject's nearest and dearest, or it may entail that she or he is physically prevented from carrying out what she or he intends to carry out. If the accident strikes and hurts the person's body or mind, we automatically have a case of impairment and thus of ill health. Thus qualified by including a clause about the presence of a standard flow of events, the notion of a standard circumstance can fulfill the role

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which is intuitively required if a healthy person is regarded as able to attain minimal happiness in my sense. 5. On the Clinical Use of the Reverse Theories of Health How can the reverse theories of health be put to use in a clinical context? Do these theories give us any new knowledge for the identification of ill health and illness, let alone diseases? Can medical personnel learn anything from these theories? Can laypersons learn anything? Or at best can only the philosophical anthropologist benefit from our discussions in his or her pursuit of clarifying the character of human nature? The analyses performed in the action-theoretic philosophy of health, and which have here been sketchily summarized, are analyses of the basic concepts, in particular, illness in the case of Fulford, and health in my case. The ordinary concepts of health and illness are not well-defined from the beginning. The attempts made by Fulford and myself, and also by Boorse and Reznek, already make ordinary concepts more precise. They are not, however, so precise that they can be immediately put to use for the purpose of the identification of a new disease or illness. Boorse may dispute this and claim that his concept of disease is immediately operational. Great empirical difficulties arise when it comes to ascertaining whether a function is subnormal in relation to survival. We have seen that Fulford's and my characterizations of health and illness are far from being traditional medical accounts, and that these characterizations open the door to questions concerning specifications and precisations which have to be made in a clinical context. I do not think that either of these facts entails a defect in the theories. Health, illness, and disease are concepts which have a place in ordinary, non-clinical, human affairs. I have in earlier texts preferred to call these concepts "anthropological" concepts rather than "medical" ones (1995, pp. 1-2). When we call them medical concepts we have already turned them into technical concepts. No wonder that an attempt at characterizing an ordinary abstract concept such as health, even if it has explicative purposes, ends up with a concept which has considerable openness. For the explication to retain some of the openness of the explicandum is a virtue. The analysis necessary to make the concepts operative can come in a later technical discussion. I will return to make some suggestions concerning such measures. Here I will just pinpont one feature of my concept of health which distinguishes it from the three other suggestions and which has important clinical implications. I say that healthy persons are those who can realize their vital goals. I thereby indicate that different people may have slightly different vital goals. This may sound like a problem to the universal science of medi-

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cine. Should we acknowledge individual variations? Do as many health concepts exist as there are people? Is this not automatically a reductio ad absurdum? No, I do not propose many different health concepts. In fact, I have captured a definition in one formulation. But I have pinpointed the relational nature of the health concept. Health to persons is a relation in which they stand with regard to their abilities, goals, and circumstances. As a consequence, we cannot just identify health with abilities tout court. We must also look into the vital goals of subjects and what are reasonable circumstances in the environment in which they find themselves. Is this not alien to the science and practice of medicine? Does medicine not just identify injuries and diseases and then try to treat and cure them and eventually send the patients back home? No, contemporary clinical medicine does much more, even if clinical medicine can be improved in several ways. Crucial to my present argument is that clinical medicine pays a lot of attention to rehabilitation. After the treatment of disease, patients are as a rule put into a program of rehabilitation with the aim of restoring their positive health. Rehabilitation has a lot to do with enabling people. In concrete practice, it deals with enabling people with regard to their work. Being able to work for most people is a vital goal. Yet working conditions of people are quite divergent. We need only consider such different crafts and professions as being a sailor, builder, army officer, nurse, professor, and photo model. In order to enable these people to perform their work properly, after having been severely injured or diseased, the rehabilitator has to focus on different things in the different cases. The rehabilitator must act with regard to different parts of people's bodies and minds. The sailor and builder must have their hands, arms, and legs well in order. This is not equally important for the professor. On the other hand, the professor must be able to read and write. The army officer needs his or her voice and the photo model needs his or her looks, for their respective professional purposes. But does a danger arise in relativizing health to the individual's own vital goals? Can health care really be individualistic in the sense that the doctor or nurse should consider their patient's wants and wishes in life? Is this not completely umealistic and umeasonable? Some people might as a result get much more out of health care than others who are in roughly the same state of health. Several points here should be separated. First, I must reemphasize that "vital goal" is a technical concept. A vital goal is not one that the agents simply wish to attain. Instead, it is a state of affairs which has a much deeper relation to the personality of the subjects and has to do with what is good for them in the long run. The individualistic care that my theory suggests is therefore not directly related to the patient's expressed wishes. That commu-

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nication with persons is an indispensable method in identifying their vital goals in my sense is another matter. Second, we cannot truly say that a pianist who has broken her or his fingers and a singer who has broken the same fmgers in a similar way, are in the same state of health. Health is a three-place relation between person, vital goals, and circumstances. The pianist's situation, that is health, is much worse than the singer's situation. Thus, health care can justifiably pay more attention to the pianist's condition. Third, all measures taken by the health-care institution must correspond to the resources of this institution. First things must come first. Some institutions do not have resources for more than the saving of life and the treatment of the most dangerous diseases. No talk should then arise of making differentiations on the positive part of the health ladder. But, health care in the Western countries still has resources for such differentiations, and all health care has the ambition to reach maximal positive health (cf the slogans of the WHO). For these purposes, we must have clear conceptual foundations. We must have conceptual foundations for making priorities between people in the light of scarce resources. And we must have conceptual foundations for talking about maximal health in order to steer the development of health care in the right direction. Fourth, we must distinguish between the individualistic health care which is entailed by the theory of health that I have suggested, and individualistic health care as recommended by an ethical theory. Ethical reasons exist, over and above the reasons suggested by the concept of health itself, for taking people's personal wants into account in the care of them. People may have reasonable wants concerning ways of treatment and care; they may, for instance, belong to a religious community which prefers one way of treatment to another. People may in the extreme case want to abstain from treatment altogether, even against what the observer believes is in their ultimate interest. Such wants are, in the normal case, to be respected by health care personnel. This is what most official ethical codes say, and this is in accordance with my ethical attitude. But this whole story lies outside the scope of the present discussion.

Six

SUMMARY AND CONCLUSIONS CONCERNING THE FOUR THEORIES OF HEALTH I will sum up this comparative analysis of the four theories of health. My intention was first to identify the explicit or implicit purposes of these theories and then go on to analyze and criticize the theories, mainly from the point of view of these purposes. This model was easy to pursue in the case of Boorse. He has made several explicit declarations, in particular in his most recent work (1997), with regard to his analytical enterprise. Among these are: (I) he intends to make a decriptive study; (2) he wants to describe what doctors mean by health and disease; (3) he characterizes a pathological notion of disease; (4) he fmds this notion codified in medical classifications. In my critical analysis, I was able to refute all these statements. Boorse claims that his notion of disease is applicable to the whole living universe By referring to standard textbooks of pathology, both human pathology and plant pathology, I was able to show that no simple consensus exists about the sense of pathological abnormality. By exemplifying from the most universally spread medical classifications [CD and DSM, I was able to show that many conditions mentioned and classified there do not fulflll Boorse's criteria of diseasehood. In the case of DSM, they explicitly propose a set of criteria of diseasehood, for mental diseases, which is distinct from Boorse's criteria and more in line with the holistic theories of Fulford and myself. When it comes to interpreting Boorse's phrase "what doctors mean by disease," my answer is twofold. First, some doctors interested in theory believe that Boorse's theory of disease is more descriptively adequate than Fulford's and mine. They would then be prepared to side with Boorse's definition. But being prepared to side with a definition of X is distinct from embracing a concept X. See my point about this in the Introduction, Section 4. Embracing a concept means that the subject consistently uses the term "X" in accordance with the meaning of the concept X We can side with a defmition without thereafter paying any attention to this definition in our actual language use. Doctors who side with Boorse's definition of disease must face the fact that they on other occasions

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use textbooks and classifications which are not in complete accordance with this definition. Second, some doctors, particularly in general practice and in psychiatry, explicitly reject a theory of the Boorsian type. I therefore conclude that Boorse's theory is not a descriptive theory of health and disease. On the other hand, I claim that it is an attractive theory viewed as an explication, a stipulative improvement, of a notion of "pathological" disease. It is attractive mainly because of its potential universality. Since the only biological goals referred to in the definition are individual and species survival, these can easily be referred to with regard to the whole of the animal and plant kingdom. They can be used in the characterization also of the diseases of bacteria and amoebas. A holistic theory referring to intentional actions is limited to human beings and possibly to the other higher mammals. This does not preclude the possibility, or the need, of constructing middle-range theories of health also for lower animals and plants. See my examples from textbooks of plant pathology in Chapter Two, Section 4. The question remains whether Boorse's explication of the notion of pathological disease is reasonable and fruitful for human medicine. If we consider, as Fulford and I do, medical practice to be at the heart of medicine and to be that part which should guide all other branches of medicine, such as medical science and public health, then the concepts of health and disease which pertain to, or are most adequate for, medical practice ought to be the ones to consider first. The notions of ill health and illness are central to medical practice; this is conceded by Boorse. These notions are explicitly excluded from Boorse's present formulation of his theory. I therefore conclude that Boorse has quite consciously limited the scope and importance of his theory. Reznek has a purpose similar to Boorse's. In many ways, he has the viewpoint of the physician. He is attracted by the clarity and efficiency of the medical paradigm. Reznek is also a physicalist, which means that he believes that a physical foundation exists of every mental state. He has the firm belief, grounded in an empirical investigation, that a reasonably clear distinction, drawn in the same way by experts and laypersons, exists between pathological and non-pathological conditions. Reznek sets out to clarify this existing distinction. Like Boorse, he attempts to tell his readers what a disease is. Reznek's conclusions, interestingly enough, are not identical with Boorse's. He pays a lot of attention to the thesis, essentially adopted by Boorse, that a disease causes, or is identical to, a biological malfunction, where the malfunction is understood in terms of biological evolution. Reznek rejects this idea as incapable of capturing the existing notion of disease. Abnormal processes occur in the malfunction sense which we value and would thus never classify as diseases, and normal processes occur which

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could be classified as diseases. Reznek in a similar way rejects the idea, which is distinct from, but sometimes conflated with, the idea of biological malfunction, that diseases are always statistically abnormal processes. The reason why the two ideas are often conflated is that the determination of what is a proper biological function is often made with the help of statistics. Boorse combines them in his biostatistical theory: a disease exists if an organ fails to make its statistically normal contribution to the survival of the individual or the species. Instead, the distinctive feature of diseases, according to Reznek, is that they are bodily processes which cause harm for those who bear them. Informally, the idea of harm in Reznek's texts is most often interpreted in terms of suffering and disability. Diseases cause suffering and disability. Formally, the notion of harm is defined in terms of the person's not being able to lead a good or worthwhile life. The notion of goodness is not made more precise by Reznek. I have noted above (Chapter Three, Section 5) that the formal explication thus opens the door to the inclusion of too many bodily and mental states within the class of diseases. In spite of a lot of differences in detail, Reznek basically approaches the reverse theories of health and illness. He claims that "disease" is a normative notion. Essential is that a risk of harm occurs to the bearer. No scientific procedure exists by which we can identify a disease, unless we have tacitly assumed the harm-criterion of diseasehood. What distinguishes Reznek from the subsequent two theorists is that the others attempt to develop the medical conceptual network a little more and that they study some consequences of the normative nature of diseases. Fulford and Nordenfelt do not claim that they just "mirror" the distinction made by experts and laypersons in the field of health and disease. Nordenfelt, in particular, claims that he is involved in a reconstruction of the medical conceptual network. The primary focus of Fulford's investigation is the "ordinary" use of the notion of illness. In order to characterize this notion, Fulford pays considerable attention to ordinary language and the ordinary uses of such terms as "illness," "dysfunction," and "disease." To a great extent, he uses the techniques and insights of Oxford ordinary-language phi1osophy. Fulford's purpose is more complex than the purposes of Boorse and Reznek. He is a psychiatrist, and he wishes to contribute to the theory of psychiatry. This means that he must also pay attention, highly critical attention, to the use of the central medical concepts in the psychiatric discourse. The two purposes are connected. Fulford's contention is that the prevalent view of many doctors, including some psychiatrists, with regard to the notions of disease and illness is distorted. Because of the technicalization of medicine, especially medical research, the doctors tend to look upon diseases as a class of biological phenomena "conceptually" living a life of their own. The obvious logical link

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between diseases and human illness, entailing suffering and disability, has often been forgotten. Fulford wishes to emphasize that the starting point of medical theory is, and must be, human illness. The notion of human illness is a lay concept. For many valuable reasons, it ought to remain a lay concept. If this were not the case, the mission of medical practice would be compromised. Medical treatment and care is a service offered to the general public to help solve certain of their problems, ones well-known to them as problems of illness. How odd to help them by redefming this basic notion so that they no longer know what problems the medical establishment exists to solve! An intrinsic bond should exist between medical language and lay language as concerns notions such as health, illness, and disease. Not all medical language can be technical and specified only with a scientific purpose in mind. This is one of Fulford's valuable messages. From this it does not follow, however, that no parts of medical language or medical theory can be technical. On the contrary, the whole success of modem Western medicine is dependent on the fact that much disease-language is technically advanced. When we enter into the field of trying to causally explain why human beings suffer, we are much helped by the kind of microscopic and technical analysis of the human body that modem medical science gives us. In spite of this, a critic may say, also the practical medical language needs to be made much more precise for several purposes. The lay notion of illness needs refinement, at least when in communication between professionals, as when professionals compare the states of illness of their patients. Although the core of illness is well-known to the layperson, parts of the notion are unclear, and lay intuitions vary about them. For instance, no clear lay intuition exists about whether a pedophile is ill or whether an alcoholic is ill. On points such as these, we often enter into the paradoxical situation that the layperson asks the medic whether these people are ill! The distortion has gone so far that the layperson believes that the notion of illness is basically a technical medical notion. Because of such facts, we need an improvement of the lay language of health and illness, which indeed must also become a part of the professional and scientific language of health. On this point, my theory of health and illness can come in. I am aware of the primacy of the lay language of health, although I have not shown this in such a profound way as has Fulford. I have emphasized the reverse logical order, in relation to a Boorsian view, of the concepts of health, illness, and disease. An important point of mine, however, is that to show this is not enough. Not only medical science but also medical practice needs a clear theoretical structure and clear definitions of concepts. This may entail that also the basic lay concepts of health and illness should be made clearer, at least for the purpose of theory and of internal professional communication. Certainly, laypersons, however familiar they are with the paradigmatic cases

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of illness, do not have a precise view of the scope of their notion of illness. It is commonplace in philosophy that perfect practical grasp of a concept need not entail that we are able to give a good explicit definition of this concept. Thus, a case exists for clarifying conceptual analysis. One critical comment that I have with regard to Fulford's theory, then, is that his purpose of contributing to medical theory requires more than an ordinary-language analysis of the concepts of health and illness. This is especially visible in the specification of the notion of "ordinary doing" which, according to Fulford, is entailed in the notion of illness. In my discussion, I have tried to show that this concept is not sufficient to account for some important types of illness which typically affect more demanding and complex actions than the ordinary preconscious ones. Another critical comment is that his reverse theory of health and illness is not radical enough. I argue, that the concept of disease does not only presuppose the concept of illness, but that the concept of illness presupposes the concept of health. This is quite noticeable when we propose an action-theoretic theory of illness, as Fulford and I do. Because, if illness is a kind of failure of doing, then to defme the failure we must be able to defme the doing. In formulating such a defmition, I should say, one automatically characterizes health. In a way, Fulford does this. However, he does not explicitly inform us that he is, or even intends to be, characterizing a notion of health. Another major question-mark that I have discussed at length Chapter Five, Section 3, has to do with an element in Fulford's meta-analysis of his theory. He says that illness-language is a thoroughly evaluative language. According to my analysis, health-language and illness-language need not be plainly evaluative. Most statements ascribing health and illness can be interpreted in a descriptive way, although they are all value-related. The basis for my analysis is the observation that a statement of the form, "A values X highly" is in itself not an evaluative statement. It is a descriptive statement which is value-related. My theory has several explicit purposes. It is not a descriptive theory, either in Boorse's sense of describing the language of doctors, in Reznek's sense of making precise the distinction made by experts and laypersons, or in Fulford's sense of describing ordinary language. It is intended to provide explications, stipulative improvements, of the medical concepts which should fulfill a set of specified requirements. An adequate theory of health, I propose, should be able to answer satisfactorily the following questions: What are the logical relations between health-concepts? What are the logical relations between health-concepts and some other humanistic concepts? What is the relation between human health and the health of other living beings? What is the relation between mental and somatic health? What is the relation between health and the environment? And what is the place of health-

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concepts in science? I am not claiming that my theory answers these questions satisfactorily, but it gives some answers to them (Chapter Four, Section 3). In the critical discussion of my theory in the whole of Chapter Five, I have found several things which should be improved given my purpose. I will here only rehearse them by making a list. (1) The two senses of "illness" in my previous formulations can be terminologically separated by the use of the term "ill health" for the opposite of health and the term "illness" for each of the specific illnesses. (2) I ought to reconsider the place of feelings with regard to health and illness. Although I have arguments for keeping feelings outside the semantic defmition of health and illness, a case may exist for reconsideration. The feeling element, pains and suffering in general, is so conspicuous and plays such a role in the identification of most paradigmatic illnesses that it should perhaps have a more prominent place also in the defining characterization of illness. Compare in this respect, Svenaeus's (1999) phenomenological description of illness as "unhomelikeness." Perhaps we should not attempt to give strict Aristotelian defmitions of health and illness. They might be given in disjunctive terms. An important, perhaps typical, set of illnesses is characterized by human suffering and disability, but a significant, although smaller, set of illnesses lacks the element of suffering but entails disability. (3) I must improve my definition of disease. When I have regarded diseases as the bodily or mental causes of illness I have adopted a sociological mainstream view (cf Twaddle (1993) and suggestions made by Whitbeck (1981) and Porn (1984).) Sundstrom's (1987) analyses show that diseases as identified in medicine, and indeed also by laypersons, are more inclusive entities, sometimes entaling the whole of the corresponding illnesses. Such a rectification could be made without disturbing the basic structure of my health concept. A new proposal for a defmition of disease, as well as the other maladies, could then be: D is a disease-type in environment E, if, and only if, D is a type of physical or mental process which,-when instanced in a person P, would with high probability cause illness in P, or D is a complex consisting of a type of physical and mental process, as described above, and the kind of suffering and disability which is caused or constituted by these processes. The last clause in the disjunction means that a disease sometimes entails its corresponding illness. Apart from this, deep philosophical questions need much further elaboration. More is to be said about the nature of the ability embedded in the notion of health. Should it be solely characterized in terms of a second-order ability, or should we again consider a disjunctive definition to the effect that health is sometimes identical with first-order ability? More is to be said about the relation between health and happiness. Is happiness the only reasonable ultimate anchor for the concept of health? What of the case for a notion of human flourishing closer to the Aristotelian eudaimonia than to my want-

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satisfaction notion of happiness? I leave these questions for the next revision of my characterization of health and illness.

Part Two TWO COMMENTARIES by George Khushf and K. W. M. Fulford

One 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 1. Introduction

Interest in the concepts of health and disease is interdisciplinary, extending well beyond the philosophy of medicine. Talcott Parsons's (1951) account of the "sick role" helped defme the sociology of medicine (Bosk, 1995, provides a good review of the sociological literature). Medical anthropologists pay close attention to the influence of culture on the conceptualizations of illness (Young, 1995), and those in English and Comparative Literature have an extensive discourse on the narratives of health and disease (Frank, 1995). Some overlap exists with the literature in medical anthropology and the phe~ nomenological literature in philosophy (see Kleinman, 1988; Good, 1994). When taken as a whole, however, this interdisciplinary literature is fragmented, and limited cross fertilization between disciplines takes place. We should probably speak of many debates about health and disease, rather than just one. At the same time, a profound link unites the debates in a way that is yet to be specified. The deep but unthematized issue gives order and coherence to the many disconnected forms of discourse on the topic. This is the issue I seek to disclose. Even if we restrict our literature review to the philosophy of medicine, the core problems and issues are still nebulous. Despite several attempts at sketching the various alternatives (Temkin, 1977; Boorse, 1977; Sade, 1995), no fully adequate geography of the debate exists. Most accounts frame the debate as a controversy between naturalists, who advocate a value-neutral disease concept, and normativists, who argue that disease concepts are evaluative (Boorse, 1975, pp. 546-547). However, something more is at stake.

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The problem remains fuzzy, and a review of the extensive literature on the topic gives us the same impression that we get when looking at the interdisciplinary context: people often do not really engage one another or refine their conceptual reflections by means of previous contributions. The debate appears to start all over again each time someone writes on the topic. A good example of this can be found in Paul Thagard's recent book, How Scientists Explain Disease (1999), where an otherwise insightful analysis is provided without any reference to the preceding literature. Just as the disciplinary discussions do not intersect with one another, so the reflections of individual philosophers do not really intersect. As a result, no actual debate takes place at all. Perhaps we can better view the discourse as a series of monologues, with occasional flurries of discussion. After each flurry, the process starts afresh. One notable exception stands out. Within the last twenty five years, critics have again and again taken up Christopher Boorse's biostatistical disease concept. A good list of his critics can be found in the bibliography of Boorse's recent rebuttal (1997). According to Boorse, disease concepts are value-neutral, and the biological sciences alone trace the line between the normal and pathological. Hardly anyone agrees with him, but everyone develops their ideas by criticizing his. Why, despite the almost universal rejection of his health concept, does everyone feel the need to return to it once again? Why not just refer to the previous criticisms and move on in the discussion? Further, why don't the many opponents of Boorse carefully refme their positions with respect to each other, and why haven't other conceptualizations of health and disease come to attract the same careful criticism that Boorse has inspired? By answering these questions, I show why the debate on health and disease is so important, what is at issue, and how the disconnected aspects of the interdisciplinary discussion are intertwined with one another. Weare now on the threshold of a new stage in the discussion, one that moves beyond the period of monologues and its Boorse-fixation. This new stage does not just depend on the emergence of substantive, constructive alternatives to Boorse, although such alternatives have indeed emerged. It also depends on the altered material conditions of health care. By placing the debate on health and disease in the context of these radical changes in health care, I bring into view the full range of concerns that lie behind that debate. My argument proceeds in six steps. First, I consider the relation between common sense notions of health and disease and those notions found in the biomedical sciences. Are these two domains of description independent? How do researchers specify the notions in each domain, and how do these domains relate to one another? Through these questions, I provide a preliminary formulation of the problematic of health concepts and show how

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this problematic concerns the relation between science and the practical activities of individuals and society. In the second section, I show how modem biomedicine is intertwined with a positivistic notion of science. This notion of science involves the assumption that theoretical and practical problems can be neatly separated and that scientific theories should arise out of inductive generalizations from observational data and experiment. Under these assumptions, the conceptual problems associated with the philosophy of medicine (including concepts of health and disease; see Hesslow, 1993) have no relevance for science, and philosophy of medicine's task is restricted to identifying and critically assessing those factors that might distort good science (an approach that parallels the way philosophy has been related to other sciences; see Rosenberg, 1985). The commitments of modem medicine help us understand the significance of Boorse's writings. Under the assumptions of medical positivism, the line between the normal and pathological should be specifiable by the biological sciences alone. In the third section, I argue that Boorse provides an innovative construction of the disease concept implied by biomedicine, and he does it by drawing on core concepts in the philosophy of biology, namely, evolutionary theory and the concept of part function. He correctly claims to articulate the concept implied by modem medicine, although he falsely gives the impression that his conceptualization arises inductively from an assessment of current nosologies. The type of project advanced by Boorse is closely linked to the core commitments of modem medicine. This explains why so many philosophers feel the need to engage Boorse on this issue. He stands as a cipher for the broader project and brings to language the kinds of concerns that are found in medicine's implicit disease concept. Boorse and medical positivism stand or fall together. Unfortunately, when assessing the merit of Boorse's claims, most critics have not separated the two key questions, whether disease concepts are value-neutral and whether biomedicine generally presupposes a value-neutral disease concept. Philosophers of medicine usually address these two questions together and assume that identification of the evaluative component of disease suffices to disprove Boorse's claim to articulate the biomedical disease concept. However, we could also argue that medicine presupposes a value-neutral disease concept and that disease concepts are not value-neutral (Khushf, 1997). In other words, Boorse can be correct about the assumptions of biomedicine and yet wrong about the nature of health and disease. Under such conditions, the criticism of Boorse can be extended into a broader criticism of biomedicine. In the fourth section, I situate the debate on medical positivism within a broader debate in the philosophy of science. Although philosophers generally

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no longer regard logical positivism as viable, important heirs of that position survive, namely, the advocates of what Hempel (1979) called "analytical empiricism." Today, within philosophy of science, there is a dispute between radical "socio-historical critics" of science and those who defend a more traditional notion. Both sides concede that values playa role in science, but they differ on whether a strong demarcation between science and nonscience can be sustained. As defenders of the traditional notions of science, analytical empiricists advance two important arguments for sustaining the integrity of the scientific domain. First, they distinguish between epistemic and nonepistemic values, and argue that only the former play a constitutive role in the construction and evaluation of scientific theories. Second, while they concede that values playa role in determination of the ends that guide scientific activity, they believe that the identification of such values opens the door to a form of descriptive activity that differs from normative evaluation. Radical critics, by contrast, argue for a more intimate link between epistemic and nonepistemic values and between domains of description and evaluation. In the fifth section, I argue that medical positivism has no more validity than scientific positivism. However, this does not imply a radical criticism of biomedicine. Just as current critics of scientific positivism need to be divided into two camps, so also do the normativist critics of the positivist disease concept. In fact, important defenders of the traditional medical paradigm use arguments quite similar to those advanced by the analytical empiricists. A radical critic can no longer assume that a criticism of Boorse amounts to a sufficient criticism of biomedicine. It is time to move beyond the Boorse fixation and engage the weak normative defenders of medicine, as well. I show how K. W. M. Fulford and Lennart Nordenfelt should be regarded as such defenders of biomedicine. They bring the debate to its next stage, and we should regard Nordenfelt's critical assessment of the debate among weak normativists as a marker in the philosophical discussion of health and disease. Finally, I advance an argument on behalf of the more radical critic of medicine. I suggest that an inescapable hermeneutical circle exists between epistemic and non-epistemic values, medical and non-medical values, and between domains of description and evaluation. We cannot escape the intrusion of value pluralism into medicine. I argue that the current material transformations in health care involve a radical paradigm shift, and I show how alternative notions of human flourishing entail alternative disease concepts. By linking these diverse modes of description and evaluation, I show how the interdisciplinary debates on health and disease reflect a deeper debate about the relation between science, human agency, and politics, a debate that, in essence, concerns how we understand ourselves and our age. No less than this is at issue.

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2. Ordinary Versus Scientific Notions of HeaIth and Disease: Situating the Problem of Natural Kinds in Medicine The concepts of health and disease are subject to two domains of description. First, they are found within the "ordinary" or "everyday" domain, readily apparent to all people. We might refer to this as the common sense notion of health and disease. (In a more detailed exposition, it would be valuable to elaborate further on the confluence of traditions that are concerned with such everyday notions, for example, the confluence of ordinary-language philosophy (J. L. Austin), phenomenological accounts of "every-dayness" or Alltliglichkeit (Heidegger), and the hermeneutical tie to the sensus communis (Gadamer). Each of these traditions has been the point of departure for a discussion of health concepts.) For the purposes of this essay it is sufficient to note that everyone knows what it is like to feel sick and to see someone who is ill or dying. We know how illness disrupts our lives and how it involves an alteration of our capacities to realize goals and enjoy life. Health, by contrast, involves a feeling of energy and vitality, and a readiness to engage in those tasks that we consider worthwhile. We do not need to be scientists or even live in a scientific age to have an understanding of health and disease. Such an understanding goes with the human condition. Because we value health and disvalue disease, we consider disease (or the lack of health) to be a problem, one that needs to be overcome or at least mitigated. As modem people, being scientifically-minded as we are, we tum to the method and knowledge base of science for the tools required to address the problem. However, within the domain of science, a subtle but profound reconfiguration of the problem takes place (Foucault, 1975; Engelhardt, 1996, Ch. 5). Disease is no longer understood in terms of a disruption of our life projects and loss of energy and vitality, but it is configured in terms of the descriptive language of biology. It moves from being an experienced, qualitative disruption of life to becoming a quantitative diminishment of some typical level of function or functional ability. In the practical activity of health care, the ordinary and scientific domains intersect (Toombs, 1990). Guided by a common sense notion of disease as a disvalued state and problem, a patient comes to a physician for help, and, more generally, communities seek to advance the common good by establishing systems for the provision of health care. The physician then configures the patient's disvalued state in terms of a biologically specifiable condition and draws on the tools of science to overcome the problem. At this site of intersection between scientific and common sense domains, the philosophical problem of specifying the nature of health and disease arises in its current form.

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In order to properly address this philosophical problem, we must recognize that there are three distinguishable subproblems. We must ask, ftrst, how health and disease are conftgured in the ordinary domain; second, how they are conftgured within the domain of science; and third, how these two domains of description are related to each other in the theory and practice of health care. Each component of the problem will have its own distinct set of concerns. A. The Common Sense Notions of Health and Disease People experience disease as a disruption of life (Merleau-Ponty, 1962; Zaner, 1981; Leder, 1992a, 1992b; Toombs, 1990). It is a disvalued state. Every community and culture has some way of conceptualizing health and disease, showing that these are marks of the human condition generally. But this does not mean that all people experience health and disease in the same way (Good, 1994). A person's experience of health or disease is at least partly constituted by the person's framework of meaning. This meaning framework is socioculturally situated and relates to the particular biographical narrative and goals of the individual. This complex linkage between sociocultural interpretive framework and individual constitution characterizes the problem of delineating the common sense notions of health and disease. Since such ordinary level conceptualizations are intimately intertwined with individual and communal notions of human flourishing, they clearly have an evaluative component. An exploration of the common sense notions of health and disease can take different forms, depending on whether we focus on the universal or particular characteristics of the phenomenon. Anthropologists consider how culture conditions health and illness. Sociologists focus on the way social institutions, expectations, and norms conftgure the phenomena. Those working in the domains of Comparative Literature and "narrative ethics" tum to the biographies of patients. In each of these approaches, researchers highlight the particular and contingent and investigate the role semiotic systems play in the formation of the health and disease phenomena they study. Philosophers explicating the common sense notions can be divided into two groups, one critical, the other constructive. Critical philosophers seek to make explicit how culture forms our experience, so that the implicit constructions can be reappraised. Such critical reflection often takes the form of a sociohistorical exploration, and it is informed by anthropological and sociological modes of analysis. Research discloses that which is common (the sensus communis) so that its subtle power may be broken. Bringing to light the implicit configurations that form our lives makes these forms of life subject to revision. Good examples of such critical work can be found in the

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writings of Michel Foucault (1975) and H. Tristram Engelhardt (1974; 1996, Ch.5). Constructive philosophical endeavors can take many forms, but they share an interest in articulating universal aspects of common sense notions of health and disease. They are thus part of a philosophical anthropology. They abstract from the particular and contingent in order to disclose the general marks of the human condition. For the purposes of this essay, I identify two strands of philosophical reflection in this area, a prominent one in the Angloanalytic tradition and in the Continental tradition. In the analytic tradition, action theory has been used to understand the common sense meaning of health and disease. Approaches differ according to whether the thinker gives priority to concepts of illness or to those of health. K. W. M. Fulford (1989) gives priority to illness, which he regards as a failure of ordinary doing. People are ill when they cannot engage in the kinds of tasks that they usually take for granted in life, and when an involuntary, internal condition causes that failure. By contrast, Lennart Nordenfelt (1987 and in this volume) gives priority to the health concept, arguing that illness logically presupposes health, which is thus more basic. According to Nordenfelt, goals direct action, and vital goals are those which are necessary for minimal happiness. When a person is in a physical or mental state in which vital goals can be attained, that person is healthy. Illness (or lack of health) is present when, given a set of accepted external environmental conditions, a person is not in such a state. In other words, a person is ill when vital goals cannot be attained. While Fulford's notion depends on the philosophical analysis of "ordinary doing," Nordenfelt's depends on the analysis of the goal, namely, his wants-based notion of minimal happiness and the internal conditions for its attainment. Both are linked to action theory and thus closely tie the common sense notions of health and illness to the language of intention at the heart of such theory. In the Continental philosophical tradition, philosophers explicate common sense notions of health and illness through a phenomenology of the "lived body" (Merleau-Ponty, 1962; Leder, 1992a, 1992b). They understand health as an experienced harmony of self, others, and the meaning system that guides life. The self is transparent to itself in the activities of life. As Leriche notes, health is "life lived in the silence of the organs" (cited in Canguilhem, 1991, p. 91). The object of intention is usually not self-evidently the self project; rather, the selfs task entails a focus upon that which is external and to which the self relates. Thus, for example, when I reach for a cup of water, I focus on the cup and am unaware of my body as separate from my self. "I," as self-identical, grasp the cup. However, when ill, an experienced alienation from self is experienced. The person with multiple sclerosis reaches for the cup, but the hand does not cooperate. It hits the table instead,

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emerging as "other." "I" must now focus on "the hand," redirecting my gaze from the primary task. The new task of relating properly to my hand emerges; when I have achieved this relation, my hand may grasp the cup. A division thus exists between me and my hand. Similarly, in illness, a rupture emerges in a person's relation to others. People experience the suffering of illness as private, creating a barrier to the discourse that normally characterizes the world of the healthy and alienating people who are ill from the norms and systems of meaning in the dominant culture. Phenomenologists draw a distinction between the logical priority of the experienced wholeness of health and the epistemological priority of the experienced disruption associated with illness (Mordacci, 1995). They explicate the notions of health and disease in the context of a hermeneutical circle that encompasses the positive and negative experiences, as well as the senses of self, community, and reality. In both analytic and Continental accounts of common sense notions of health and disease, the language of intention is crucial. As Drew Leder says of the phenomenological account, "if one notion can be said to lie at the heart of this paradigm, it is that the lived body is an 'intending' entity." By this, Leder means that "it is bound up with, and directed toward, an experienced world. It is a being in relationship to that which is other: other people, other things, and environment" (1992b, p. 25). Key terms include "experience," "action," "sociocultural meaning system," and "individual goal." Common sense notions of health and disease are thus clearly evaluative, and their explication requires a more general philosophical anthropology. A noteworthy but subtle difference exists between the two philosophical traditions. The analytic tradition isolates the account of action theory that informs the analysis of health concepts from broader discussions regarding the appropriate form of community or the nature of human flourishing. Analytic philosophers assume that the task of understanding science can be separated from that of understanding human agency, and both, in turn, can be separated from debate about the nature and appropriate form of community. Continental philosophers, by contrast, hold to a more organic view, where all of the dimensions of life are intimately intertwined. We can only make sense of an action in the context of a broader account of meaning, which, in turn, is linked to the specific notions of individual and communal flourishing (Taylor, 1971). This was readily apparent in the health concept itself, since Continental philosophers see health as a lived harmony of self, community, and the systems of meaning that guide life. In illness a rupture occurs between these domains, and their separation is an indication of pathology. Later in this essay, we shall see that this difference between philosophical traditions leads to two significantly different forms of normativism to which I will refer as weak and strong normativism. They have quite different views on the role

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of evaluation in biomedicine. Boorse, who originally coined this distinction (1975, pp. 546-547), stipulates that strong normativists see health concepts as purely evaluative, while weak normativists also acknowledge a descriptive dimension. In contrast, I stipulate that both forms of normativism have both dimensions. I cannot think of a single health concept that does not include a descriptive consideration. For me, the strong normativist sees descriptive and evaluative considerations as inextricably intertwined, while the weak normativist thinks they can be disentangled. B. The Scientific Notions of Health and Disease Any analysis must distinguish between the human and natural sciences. In a human science, the object of study coincides with the subject that studies. This object can be understood as a self-constituting subject, one that is brought to knowledge in a "scientific" activity that is at least partly selfinterpretive (Taylor, 1971). Such a science will focus on the identification of the way social and individual artifacts and activities have been constituted, the way these condition knowledge, and their openness to re-construction and further development. Knowledge will be nested within a circle of selfconstituting activity. For most people, the natural sciences have a different character. Nature is distinct from culture and does not depend on human institutions or values for its constitution. In the natural sciences, researchers seek to provide a description that mirrors the world, an "objective" description not linked to social and individual bias. Thus, in physics, chemistry, and biology, scientists seek to understand a world that is independent of us and our knowing, constituting activity. Human health and disease are not simply objects of natural science. The way we understand them plays a constitutive role in how we experience them. To the degree that we seek to understand them as experienced, we cannot escape the hermeneutic circle found in the human sciences. The "scientific" knowledge of them is simply the activity of explicating the ordinary or common sense notion. However, we can also understand health and disease as an object of the natural sciences. As such, they would have a determinate content independent from human institutions and values. People often tacitly assume this natural scientific view of health and disease, and, as I will make clear later in this essay, modem medicine presupposes it. Thus, for example, diseases like tuberculosis, cancer, and AIDS, all are seen as having a determinate content independent of our interpretive activity and experience (as in Sontag, 1990; for accounts of these diseases that call into question this assumption, see King, 1982, Ch. 2; Gardell-Cutter, 1992; Epstein, 1996). Diseases are "in the body," and the language of modem

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biology can describe them. Their nature, it is assumed, has nothing to do with how we understand and respond to them. According to this view, we can neatly separate the scientific description of disease (a function of biology) from the way they are experienced by the person who has them. A disease is then viewed as a natural kind, not a cultural artifact. This is the view advanced by Christopher Boorse (1975, 1977, 1997) and criticized by Lawrie Reznek (1987, 1995). C. The Relation Between Common Sense Notions and

Scientific Notions of Health and Disease

According to the common sense notion of disease in the West, the nature of disease has no relation to our values and assumptions. We have come to experience health and disease in this way. When we become ill, we look for some anomaly in the body. For this reason, an explication of our common sense notion moves naturally to a description of the way modem medicine and the basic natural sciences that inform it understand health and disease. This has made us blind to the full problem of understanding health and disease. The common sense and natural scientific domains of description collapse, and we address both simultaneously by providing an account of the notions implicit within the basic sciences of medicine. A more careful analysis reveals important differences between the ordinary and scientific domains of description and between the theory and practice of medicine. Even in our modem context, an ongoing tension exists between the intentional, goal-directed language of common sense (for example, Fulford's "failure of action" and Nordenfelt's "conditions for minimal happiness") and the nonteleologicallanguage of function associated with the natural sciences (for example, pathoanatomy and pathophysiology; see Boorse [1976, 1997] on function). Every analyst of health and disease concepts recognizes that these concepts have an evaluative dimension in ordinary usage and when they guide medical practice (Boorse included; see 1997, pp. 12-13). Therefore, we need not ask whether there is an evaluative component in ordinary usage, since that is conceded. Instead, we must ask whether we can specify a value-neutral, natural scientific, theoretical core which remains independent of the evaluative component. Boorse addresses this question, and his many critics respond to it, as well. Unfortunately, this question by itself provides a truncated formulation of the actual problematic of understanding health and disease concepts. Even if Boorse correctly identifies a value-neutral core specifiable by the natural sciences alone, this resolution leaves open the complex problematic regarding the relation between the value-neutral, theoretical concept and valueladen ordinary level conceptualization that guides medical practice. In fact,

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we may link these domains in many ways, one of which would even allow for the compatibility of Boorse's theoretical concept and common sense notions like those of Nordenfelt and Fulford. Further, some of the most interesting questions in philosophy concern the linkage between the nonteleological language of function in biology and the intentional language that is at the heart of human experience and action. This is a variant of Immanuel Kant's general problem of integrating pure and practical reason, and in the philosophy of science the problem is found in the issues of scientific unity and reduction (see Fodor, 1974). The debate in the philosophy of medicine needs, therefore, to move beyond the naturalist!normativist dichotomy and address the full scope of the problem. D. What Is Implied by the Claim that Disease Is a "Natural Kind"? Boorse's theoretical disease concept still allows for diverse resolutions of the ordinary level concept of disease. It leaves open the way the ordinary level conceptualization relates to the natural scientific conceptualization. For example, the two domains could be independent, or the scientific could provide a foundational core for the ordinary level concept, which was Boorse's view. However, Boorse's theoretical disease concept also involves constraints on how the broader problematic is resolved, since he excludes some resolutions. If he is correct, disease must be a natural kind, although he does not use this phrase and would object to any implied "essentialism" (1997, p. 38). The theoretical meaning of disease is independent of the semiotic systems that culturally configure how a particular people (as opposed to all people) experience disease. The problem of natural kinds in science is complex, and I need not get into its full details for the purposes of this essay. It will suffice to consider an object of science that is regarded as a natural kind and then ask if disease sufficiently resembles this object. Following Hilary Putnam (1975, especially Chs. 8, 11, and 12), I consider the chemical element gold. (Although I draw from his work, my analysis departs from Putnam's. He sought to develop a post-positivist account of meaning and framed his discussion of natural kinds for that end. While he briefly considers the distinction between diseases that "have turned out to have no hidden structure" and those like tuberculosis that do (1975, p. 241), he only uses this as an example serving his broader analysis of meaning. Since my concern is with disease, rather than meaning, I significantly reframe the problem.) At the phenomenal (or "operational") level, gold has multiple properties such as being a yellow metal, being malleable, melting at a relatively low temperature, conducting electricity, costing $265/ounce, and serving a symbolic function as a marker for royalty or even for the transcendent realm. When we see this list of properties, we quickly

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distinguish between "natural" properties such as being a yellow metal (although pure gold is white), being malleable, and having a low melting point, on one side, and the "cultural" properties such as its value and symbolic function, on the other. The diverse natural properties are correlated with an underlying structure or "essence," one associated with the atomic number of gold and its place on the periodic table of elements. An important link thus exists between some of the phenomenal properties and the domain of theoretical description. The fact that these elements do not depend on our systems of knowledge or value makes these properties "natural." They are independent of us and discovered as such. However, this is not the case for the "artificial" cultural properties. The value of gold or its function as a marker of transcendence depends on our economic and cultural systems. The logic of physics and chemistry does not sufficiently explain value and symbolic function while it does explain conductivity and malleability. The additional cultural properties are linked to what human beings do with gold, and thus we can only explain them in the context of a science of the human, a science that involves the complex hermeneutic circle outlined earlier. Modem societies link cultural properties to the theoretical scientific frameworks that explain many of the natural properties, establishing science in a foundational role for culture. For example, in the distant past, being a yellow metal may have been enough for something to have a high market value and serve as a marker of transcendence. The cultural properties of "gold" might thus have included things that today would not be identified as gold. However, two developments took place that significantly constrained the cultural meaning of "gold." First, people specified other natural properties more carefully and associated them with one another. Being a yellow metal did not suffice, since other things also have this natural property. The substance also had to melt at relatively low temperatures, be malleable, and so on. Only then would it have a high market value. Thus some natural properties could be used to pick out "gold" from other things that are yellow metals. This already can be viewed as an important "scientific" development, leading to clusters of properties. (The clustering of properties was emphasized by 1. S. Mill when he first used the phrase "natural kind," and it has been recently used by D'Amico [1995] in his analysis of disease as a natural kind. Reznek [1995] provides a critical response to D'Amico.) But an additional development takes place, establishing a more foundational science. The natural properties that are clustered (and constitute what Putnam has called the "stereotype") come to be associated with a deep-level structure or "essence" which explains and causally accounts for (many of) the natural properties in question. In fact, a theoretical linkage exists between the clustering phenomenon of certain "natural" properties and the deep level structure or essence, two factors that have been put forward independently as

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sufficient for demarcating a natural kind. The phenomenon of clustering leads to a confidence in the existence of a deep level essence, even if that essence has not yet been discovered (perhaps because the theoretical framework for specifying it has not yet been developed). In the case of disease we must ask whether it sufficiently resembles gold. Can we draw a sharp line between the domain of "facts" associated with scientific disease concepts and the evaluative considerations in common sense health concepts? At the phenomenal level, can we distinguish between natural and culturaVartificial properties of disease, where the natural properties are independent of the culturally relative semiotic systems that contingently configure the experience of illness? Do the natural properties cluster in important ways? And can we associate the clusters with deep level descriptions situated solely within a natural scientific theoretical framework? In all cases, Boorse answers "yes." His many critics say "no." 3. Positivist Science and the Paradigm of Biomedicine The debate about health and disease is simultaneously a debate about science, the nature of modem (as opposed to premodern) medicine, and the appropriate role of normative evaluation in medical theory and practice. We should thus situate the debate historically and link it to broader debates about the intt(grity of medicine as a science; for example, the debate about the biopsychosocial model of medicine and the notion of science inherent in the older biomedical model (Engel, 1988). Putting this same point negatively, we cannot just look at nosologies and through induction develop a theoretical disease concept as a form of generalization. Boorse claims he does just that (1977, p. 551; 1997, pp. 62-63), and critics like Nordenfelt refute his valueneutral disease-concept by highlighting the evaluative components and the ambiguity in current systems of disease classification or in texts of pathology (this volume, pp. 18-24). However, such localized forms of analysis do not sufficiently address how the nosologies function within the broader framework of medical theory and practice. When we situate the debate on disease within the history and current theory of medicine, then Boorse obtains greater support for his position than he could from an analysis of the nosologies alone. A. Science and the Reforms of Abraham Flexner: Situating Modem Medicine Historically A brief overview of the Flexner Report (1910), one of the most influential documents on medical theory and education, can help us elucidate the basic tenets of biomedicine. In this report, Abraham Flexner outlines how modem

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scientific medicine emerged from its prescientific predecessors, and his philosophy of medicine provided the blueprint for twentieth-century physicians' understanding of their profession. Flexner divides medical history into three stages, referred to as dogmatic, empiric, and scientific. He associates the frrst stage with humoral theories, where health was understood as a kind of equilibrium and disease as a form of imbalance in which one humor becomes overly dominant. Such "dogmatic" medicine was rooted in tradition and authority, and "facts had no chance if pitted against the word of the master" (Flexner, 1910, p. 52). In this period, speculative and philosophical systems rather than science governed the field of medicine. Flexner regards the second stage as an important advancement, since it emerges with the frrst flowering of science. The "empiric" turned to experience, instead of authority. Although Flexner does not elaborate, he clearly had the medical nosographists in mind. For Thomas Sydenham and those who followed him, diseases were like plants, to be classified according to their natural history. The medical researcher carefully observed signs and symptoms, and diseases were simply the constellation of properties obtained by observation. Nosographists like Sydenham and John Locke were skeptical regarding true causes, often conceding much to the humoral framework but seeking to bracket the speculative concerns so that an effective practice might be advanced (Sanchez-Gonzalez, 1990; Romanell, 1987). Flexner is critical of them because "medicine was still under the sway of preconceived preternatural principles of explanation," which, in subtle ways, would influence how signs and symptoms were grouped. The empiric lacked a technique with which to distinguish between apparently similar phenomena, to organize facts, and to check up observation; the art of differentiation through controlled experimentation was as yet in its infancy .... Ignorant of causes, the shrewdest empiric thus continued to confound totally unlike conditions on the basis of superficial symptomatic resemblance. (Flexner, 1910, p. 52) The empiric resembles a person who confuses gold and pyrite because both exhibit some of the same phenomenal properties. They did not yet have an awareness of the underlying structure that enabled one natural type to be differentiated from the other. Flexner clearly associates the third stage with the clinic-laboratory dialectic of the Paris school (p. 9) and, more recently, with the formation of the Johns Hopkins School of Medicine in the United States (p. 12). At this point, medicine emerges as a full science. This means two things for Flexner. First, medicine must be rooted in the basic sciences: "The human body belongs to

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the animal world. It is put together of tissues and organs, in their structure, origin, and development not essentially unlike what the biologist is otherwise familiar with." The causes of disease are now rooted in the body understood as a machine, and these causes can be known as a matter of "fact." He writes, "The empiric set up some unverifiable existence back of and independent of facts (a vital essence, for example); the scientific theory is in the facts, summing them up economically and suggesting practical measures by whose outcome it stands or falls" (p. 53). The empiric associated the cluster of properties with some immaterial or transrational principle or cause. Now, the scientist correlates the phenomenal cluster of properties (signs and symptoms) with a material cause (the underlying pathology) which is itself a fact, known to the laboratory sciences. We fmd here a parallel to our earlier discussion of gold, with its correlation of natural property clusters and a deep level essence. Medicine qualifies as a science not just because it places clinical phenomena in the context of the basic sciences (physics, chemistry, and biology). Its method also makes it scientific. Flexner strongly criticizes any attempt to divide the method of research from the way of practice (p. 22). Medicine is a science, according to him, because it practices by the same scientific method it uses in research (pp. 65--(6). From the signs and symptoms (the phenomenal properties seen in the clinic), physicians formulate a hypothesis, that is, a preliminary diagnosis. They then test it in three ways. Ideally, they have access to a laboratory test. Otherwise, physicians must manage the patient's condition according to the disease hypothesis, and the effectiveness of an intervention serves to confmn the diagnosis. When the physician cannot effectively intervene, however, the third and most conclusive means of testing becomes available, the autopsy. "Too often, all is dark until the autopsy reveals the truth" (p. 66). Through the autopsy the pathologist can "convey to the student an objective conception of the nature and effects of disease as a process" (p. 67). The scientific method that directs medical practice is thus intimately linked to a particular notion of disease. From the phenomenal cluster of properties (the signs and symptoms), a physician formulates a disease hypothesis, which relates to matters of fact hidden within the body and understood in terms of pathoanatomy and pathophysiology. Sometimes laboratory tests or autopsy enable physicians to directly identify that underlying pathology. In other cases, they must be satisfied with a probablistic confmnation. But in either case, the natural sciences can sufficiently understand disease. On the basis of his ideals regarding medicine as a science, and, by implication, on the basis of his implicit disease concept, Flexner proposes a series of influential educational and socio-economic reforms. For the purposes of this essay, three of these reforms are worth mentioning.

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(I) The teaching of students should proceed in three stages. First, undergraduate premedical training should involve a grounding in physics, chemistry, and biology (p. 25). Second, in the fIrst two years of medical school, the basic sciences of anatomy, physiology, pathology, bactefiology, and so on, should be taught (Chs. 4-5). Clinical experience has little value before students complete the second stage, since the they do not yet have the knowledge needed to properly understand what they would see in the clinic (p. 91, n. 1). Only after the solid grounding in the sciences should students be placed in a clinical setting. This exposure in the fmal two years of medical school should emphasize the subtle coordination of the clinical phenomena (the cluster of signs and symptoms) with the knowledge of disease provided by the laboratory sciences (the underlying disease) (Chs. 6-7). (2) Social and economic systems should be established to assure that medicine is taught and practiced as a science (Ch. 8). That means medicine should be insulated from the economic pressures and influences that prevailed in the nineteenth century. The intrusion of stewardship or economic considerations into the understanding or practice of medicine would compromise its scientifIc character. Much ofFlexner's report involved an attempt to identify and exclude these outside social and economic influences. (3) As a science, medicine is rooted in facts, not philosophical speculation. This means that only one kind of medicine exists. Medicine is either scientifIc or it does not exist at all. Medical sectarianism is inappropriate and, thus, so are different schools such as allopaths, homeopaths, and osteopaths (Ch. 10). Pluralism and philosophical dispute are expunged as medicine establishes itself as a science. Each of these reforms presupposes a positivist notion of science, with the attending assumptions that only natural science can sufficiently know disease and that medicine should be practiced according to the scientifIc method. Individual, religiocultural, or socioeconomic values should play no role in determining the core concepts or methods of medicine. B. The Link Between Medical and Logical Positivism

I have spoken of Flexner's view of science and medicine as ''positivist.'' I need to further qualify this designation. In a late twentieth or twenty-fIrst century discussion of the philosophy of science, "positivist" obviously refers to the logical positivist tradition. We could also speak of positivism more generally or of legal positivism. At approximately the time Flexner was writing his famous report (1910), some prominent mathematicians, economists, and physicists formed an informal discussion group referred to as the Vienna Circle. These philosophers were radical empiricists, and they initiated a philosophical movement which later came to be known as "logical positiv-

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ism." A central goal of this tradition was to provide an account of science that freed it of all metaphysical speculation. A good review of this tradition can be found in Passmore (1967), and Ayer (1952) gives a classic exposition. The concerns of this movement resonate with those of Flexner. Further, Christopher Boorse speaks from within an analytic philosophical tradition that is clearly under the sway of logical positivist ideals. However, Boorse would reject being called a "medical positivist," since he uses the phrase to characterize those who say a disease is whatever medicine treats (Boorse, 1977, p. 545). I follow Berliner's (1975) use of the phrase, which links "medical positivism" and the ideals of the Flexnerian paradigm. We can take Flexner, in tum, as representative of the modem biomedical paradigm, and his view of basic science fits well with Boorse's general project. We will briefly discuss, then, the relation between the medical positivist tradition associated with Flexner and the logical positivism that frames many of the issues in the philosophy of science and that provides the backdrop for Boorse's theoretical disease concept. We cannot directly link the ideas of the Vienna Circle and Flexner. To understand the resonance between them, we must look for those intellectual currents that influenced both lines of thought. We need look no farther than the Paris School of Medicine itself in order to fmd this common influence. In the period of post-revolutionary France, when modem medicine first emerged in the form celebrated by Flexner, the interests of speculative philosophy were set against those of science. This was in part a reaction against an earlier school of medicine, associated with the rival city of Montpellier (with precedent dating backto the Hippocratic school), in which physiology and morality were intimately linked (for an outstanding review of the Montpellier tradition, see Williams, 1994). Against this "anthropological medicine," some of the most prominent representatives of the Paris school advanced their ideal of science. Perhaps the most noted expression of this scientific ideal was found in Franyois Broussais. His best known arguments pertain to the nature of disease. I will closely follow Canguilhem's (1991) discussion of Broussais's influence on later traditions. In virtually all previous medical systems, the pathological state was viewed as qualitatively different from the normal (Canguilhem, 1991, p. 41). This assumption mapped well on to human experience, but it prevented scientists from understanding disease in terms of the natural processes on which the other biological sciences focussed. A rift separated the logic of the pathological and that of the normal. Broussais saw the pathological as no more than a quantitative variation on the normal. For him, the line between the normal and the pathological consisted in "the excess or lack of excitation in the various tissues above or below the degree established as the norm" (cited in Canguilhem, 1991, p. 47-48). In this way, disease could be measured

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and specified in the language of science, namely, the language of number and form. Or, to put it in a more modem idiom (that of Boorse), for Broussais the line between the normal and pathological became a function of an atypical diminishment of some typical level of excitation, a deviation from the "established norm." A short step brought the next milestone: viewing the natural processes of life as basically of the same kind as the nonliving, distinguished only by its goal-directed, self-organizing activity, and not by any nonmaterial, "metaphysical" element. In his commentary on Sommerhoffs (1960, p. 6) account of life, Boorse (1997, p. 9) elaborates the new view. Foucault (1975) sees the emergence of modem medicine as a reinterpretation of the nature of life and death. In this way, biology is put in continuity with physics and chemistry, a development usually associated with the artificial synthesis of urea, and it is subject to the same kinds of analyses. Broussais's assumption regarding the quantitative character of the difference between the normal and pathological allowed him to assert the identity of pathology with anatomical and physiological states that could be localized within the body. Thus, in a way echoed in Flexner (1910, pp. 52-53), Broussais criticizes earlier nosographists: [they] have filled the nosographical framework with groupings of arbitrarily formed symptoms ... which in no way represent the affections of the different organs, which is to say, the actual diseases. These groupings of symptoms are derived from abstract entities or beings, entirely factitious, ontoi; these entities are unreal, and the treatment one gives them is ontology. (Cited in Bole, 1995, p. 543) This quotation is the original locus for referring to nosographists as "medical ontologists." Sydenham and Locke would have rejected this name, since they never claimed to be identifying the "real" entities but only providing a grouping that had utility for medical practice (Sanchez-Gonzalez, 1990). The effect of Broussais's condemnation was to associate alternative medical traditions with philosophical speculations (ontology); those of the Paris School, by contrast, were engaged in science. In the medical tradition of the earlier Montpellier school, science, philosophy, and ethics were complementary (Williams, 1994). Now they were set in opposition to one another. Science was thus regarded as independent of philosophical disputes, a view that has remained influential to the present (King, 1982; Rosenberg, 1985). Broussais 's notion of disease and science had an extensive influence. The line from his thought to that of Flexner is obvious. However, Broussais's influence goes beyond medicine, extending directly to the logical positivists. This linkage is mediated by the most noted representative of the nineteenthcentury positivist tradition, Auguste Comte.

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Comte directly appropriated Broussais's idea regarding the continuity between pathological and normal phenomena (that they involve a difference in quantity, not quality) and extended it to a broad methodological principle. Medicine was not alone in its empiricism, eschewal of philosophical speculation, and prioritization of matters of fact. Comte did not need to look to Broussais for these, since they were found in the blossoming physical and chemical sciences. However, for many at that time, life, and human life in particular, required a different form of science. The qualitative distinction between pathological and normal phenomena pointed to vital principles which were not empirically accessible and which were disrupted in illness. Broussais's principle enabled Comte and others to place all sciences on the same epistemological footing, and the laws of one could be used to understand the other. Thus Comte summarizes: Until Broussais, the pathological state obeyed laws completely different from those governing the normal state, so that the exploration of one could have no effect on the other. Broussais established that the phenomena of disease coincided essentially with those of health from which they differed only in terms of intensity. This brilliant principle has become the basis of pathology, thus subordinated to the whole of biology Further, Comte argues that the same principle enables us to go beyond pathology and understand more complex levels of organization like society. The collective organism, because of its greater degree of complexity, has problems more serious, varied, and frequent than those of the individual organism. I do not hesitate to state that Broussais's principle must be extended to this point and I have often applied it to conflrm or perfect sociological laws. (Cited in Canguilhem, pp. 49-50) In this way, the ideals of the natural sciences, originally kept distinct from broader ideals for understanding a person, society, and the cosmos more generally, were now extended from a local to a universal context, grounding a comprehensive program in which all knowledge would be unifled and provided with a scientiflc foundation. Earlier we discussed the tension between the common sense and natural scientiflc notions of disease. Broussais's Principle allowed for a continuity between them. Sciences dealing with greater complexity would require a method responsive to the logic of that complexity (thus one cannot have a single method, as Descartes presupposed). And they would also presuppose and be built upon the previous forms (for example, physiology presupposes physics and chemistry). But all

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science has a common form, distinguished from nonscience (metaphysics or theology) by its grounding in fact. This harmonizing of the natural and human sciences made possible by Broussais's principle allows for the notion of progress found in Comte's famous tripartite notion of history. Comte argued that society, each individual, and each science went through three stages, characterized as theological, metaphysical, and positive. In the fIrst stage, they see natural phenomena as the product of supernatural agents. In the second, metaphysical stage, the supernatural agents are transformed into abstract principles, but those principles are not empirically accessible. Finally, in the third positive stage, the search for ultimate causes and principles is abandoned, and the proximate laws of observable phenomena suffice. Only with this last stage does science emerge. Comte saw a progress from the fIrst to the third stage, and the goal of humanity was to have an extensive, integrated science of all things. Social and economic structures were to be so established that they build upon and further this broad positivist program. The nature of the threefold development was clearly seen in the movement from humoral to empiric to scientific medicine, the very development outlined in Flexner's history. Although the line from Comte to both Flexner and the logical positivists involves many intermediate steps, I have already clarified the trajectory and accounted for the resonance between the two movements. Flexner's reforms of education and society (the three mentioned in the previous section) characterize the positivist program more generally. All knowledge is built up, fIrst, from physics, chemistry, and biology, then, second, from the basic sciences organized round the normal and pathological states of the human organism. Finally, the complex kinds of personal and social phenomena found in the clinic and public health yield knowledge in their tum. Social and economic reforms are directed toward establishing the conditions of scientific knowledge and practice. We expunge the pluralism associated with multiple philosophical speculative traditions as we move to positive knowledge, that is, to science. Similarly, the basic tenets of logical positivism (a program in science and philosophy that is still readily apparent in Anglo-American analytic philosophical traditions) are well elucidated in the context of Comte's account of history. The word "positivism" in the designation that came to characterize the movement initiated by the Vienna Circle and its sympathizers was directly taken from Comte's program. Logical positivists reject the speculative concerns traditionally associated with philosophy (coming under the rubric of "metaphysics"), and they seek to develop an epistemology that grounds knowledge in the basic units of experience. Knowledge of human phenomena is no different than knowledge of other natural phenomena, being similarly constructed from logical and observational units of analysis. A

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foundationalism for knowledge thus exists, with more complex notions in biology being built upon more basic accounts in physics and chemistry. Most importantly, science is sharply distinguished from the disputes in nonscientific domains. We must thus separate the culturally contingent modes of evaluation from the descriptive project of science; in other words, science is concerned with matters of "fact." Dispute about values stands outside the scientific enterprise. The general tenets of a value-free science, unencumbered by speculative philosophical disputes and working toward a broad unity of science, still lies behind an important strand of the Anglo-American analytic tradition in philosophy. This positivist program forms the backdrop for Christopher Boorse's philosophy of biology and his disease concept, in particular. At issue is thus much more than a particular disease concept. Broussais's Principle, which Boorse defends, is no less than the condition of the possibility of the positivist project of scientific unification. It is also the condition of the social-medical ideal advanced by Flexner, an ideal apparent still in the health systems of all modem societies. 4. The Biostatistical Disease Concept as a Condition of Medical Positivism: Appreciating Boorse's Innovation in the Philosophy of Biology In a series of seminal articles published in the latter part of the 1970s, Christopher Boorse drew on prominent themes in the philosophy of biology to define a theoretical disease concept. Following Lennart Nordenfelt (1987) and, more recently, Boorse himself (1997), I will refer to his theoretical notion as the biostatistical disease concept. Boorse distinguished the theoretical concept from those practical concepts that guide clinical practice in medicine. He conceded that clinical practice and its health and disease concepts involve evaluative considerations, but he argued that the theoretical concept was value-neutral and dependent on science alone for its meaning (1997, pp. 12-13). He provided the following, oft-cited defmition: I. The reference class is a natural class of organisms of uniform

functional design; specifically, an age group of a sex of a species. 2. A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival and reproduction. 3. A disease is a type of internal state which is either an impairment of normal functional ability; i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents. 4. Health is the absence of disease. (1997, pp. 8-9)

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Prominent in this defmition are the core concepts in current philosophy of biology, concepts such as part function, species design, environment, and individual survival and reproduction. Boorse claims that his disease concept provides a generalization that captures the criterion of inclusion in current medical nosologies. He gives the impression that his concept was developed descriptively, through a careful analysis of the "considered use" of those in medicine, especially pathologists (1977, p. 551; 1997, p. 53). Further, as his analysis shows, he thinks medical practitioners are basically correct, that is, as scientists they properly understand disease (Nordenfelt, in this volume, p. 13). Boorse thus advances two related claims. First, his concept provides a generalization of the notion in medicine (it is descriptively true of medical nosologies); second, this concept is true; disease is a natural kind, properly known as such by the biomedical sciences (especially pathology). Usually the two claims are dealt with together. People criticize Boorse by showing that disease is not, in fact, value-neutral. However, it is possible that Boorse is correct when he claims to articulate biomedicine's disease concept but wrong about the status of disease as a natural kind. In this case, biomedicine would also be wrong about its disease concept, and the criticism of Boorse would be extended into a broader criticism of biomedicine. At least two people have attempted to address these claims independently, although not necessarily in the context of an evaluation of Boorse's philosophy. Lawrie Reznek (1991) argues that the medical paradigm involves a series of theses, among which are a "conceptual thesis" which claims disease is a biological process of malfunctioning, a "universality thesis" which claims that disease is not culture-bound, and an "identification thesis" which claims disease is sufficiently specified by scientific methods alone. Reznek thus accepts the claim that medicine presupposes a value-neutral disease concept of the sort advanced by Boorse, but he goes on to argue that all of these claims are false. Reznek then provides an alternative norrnativist disease concept which allows for social values to play a role in configuring medical theory and practice. Lennart Nordenfelt (1993 and in this volume) seeks to avoid such a radical critique of medicine by making a distinction between "two ways of having a concept." He argues that many "scientifically-minded" physicians and medical researchers explicitly side with Boorse's defmition (they hold to a value-neutral disease concept), but their actual language-use shows that they work with a different implicit disease concept. Through a careful consideration of current medical nosologies and pathology texts, Nordenfelt argues that Boorse is mistaken on both counts. Disease concepts are not value-neutral, and medicine does not presuppose such a value-neutral account.

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Nordenfelt works with a valuable distinction. Through the division between explicit and implicit notions, a dialectic of analysis can be introduced that enables us to critically engage and refine current systems of knowledge. However, his use of the distinction needs to be further specified (Khushf, 1997). Contexts of analysis vary, and some language uses might involve an accord between implicit and explicit notions, while others involve a divergence. Nordenfelt is a defender of biomedicine and thus wishes to free it of any dependence on a disease concept that he considers false. In doing this, he does not sufficiently appreciate the many ways that the current medical paradigm is wed to a value-neutral concept in both theory and practice. A. Theoretical Assumptions in Medicine: The Biostatistical

Disease Concept as a Variant of Broussais's Principle

Remember what Comte called Broussais's primary accomplishment: he "established that the phenomena of disease coincided essentially with those of health from which they differed only in terms of intensity. This brilliant principle has become the basis of pathology, thus subordinated to the whole of biology" (my emphasis). At the heart of Broussais's theory was a reconfiguration of disease. No longer was it merely the grouped signs and symptoms identified by the nosographists. The cluster of phenomenal properties was now correlated with the true cause, which was located in the body and, in principle, empirically accessible and subject to the science of biology. This reconfiguration of disease, according to Flexner, was the condition for medicine to emerge as a science. Christopher Boorse's disease concept can be viewed as a variant of the same notion, and to this extent, represents a broad theoretical commitment of modem medicine. For him, "behind [the] conceptual framework of medical practice stands an autonomous framework of medical theory. . . . This theoretical corpus looks in every way continuous with theory in biology and the other natural sciences" (1975, p. 550). However, this does not mean that Boorse simply parroted an earlier conceptualization. He makes an innovative revision, one that is required by the logic of Broussais' s Principle. If the core concept of medicine, that of disease, is to be properly "subordinated to the whole of biology," as Broussais suggests, then it must draw on those core concepts found within modem biology, namely, the concepts of evolutionary theory. As Philip Kitcher notes, "Darwin is the Newton of biology. Evolutionary theory . . . has unified biology" (1982, p. 54). In the words of Dobzhansky, "nothing in biology makes sense except in the light of evolution" (cited in Kitcher, 1982). If we are to understand pathology as a subject of biological science, it too must be configured in terms appropriate for its unifying theory.

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The problem is that few thinkers seem interested in situating biomedical theory, especially pathology, in the context of evolutionary biology. At fIrst this might seem to be an argument against Boorse's conceptualization (and that of Broussais), and, in fact, it does show that some of his assumptions about the nature of medical science are misguided. But we could also argue that the lack of interest in situating medicine within evolutionary theory simply shows a defIciency in medicine, a defIciency that we must overcome. Nesse and Williams advance this argument in their book, Why We Get Sick: The New Science of Darwinian Medicine (1995). On this reading, Boorse's disease concept can be viewed as an important contribution in theoretical biology. He solves the following puzzle posed by the theoretical commitments of modern medicine: Broussais's Principle, which is central to the emergence of medicine as a science, requires a linkage between the phenomenal property clusters found in the clinic and the underlying, internal physiological state, which is the "actual disease." However, the core concepts of evolutionary theory never suffIciently specifIed the biological phenomenon called "disease." A defender of positivist medicine must, therefore, use the concepts in theoretical biology to specify the key medical domain (that of pathology), and must do this in a way that generally captures the actual nosologies found in current medical practice. Boorse's disease concept thus represents both a conservative and progressive concern. His general project is framed by core theoretical commitments at the heart of modern medicine, commitments that trace back to its emergence as a science in the early part of the nineteenth century. But his use of concepts in the philosophy of biology to specify the normal/pathological distinction involves an innovation pointing medicine in the direction of an unrealized ideal, namely, its theoretical unifIcation with the rest of the biological sciences. B. Practical Assumptions in Medicine: Upholding Flexnerian Ideals in the Face of Social and Economic Transformations of Health Care Not just at the theoretical level do we fmd support for Boorse's claim to articulate the disease concept implicit in medicine. The theoretical disease concept is linked to the way medicine is conceptualized as a science, which, in turn, is linked to ancillary commitments regarding the way clinical medicine should be practiced and the way society should confIgure its health care systems (Khushf, 1998 and 2000). We saw this linkage in Flexner's recommendations for reform and also in the general positivist program on scientifIc unifIcation. These practical corollaries are still readily apparent in medicine,

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as can be seen in the way physicians respond to the social and economic transformations that are currently taking place. In the United States, the structural changes in health care are especially conspicuous in managed care, where mechanisms of payment are explicitly integrated with the mechanisms for providing care (these developments are nicely reviewed in Morreim, 1995; Rodwin, 1993). As a result of new administrative policies and economic incentives that are operative within such health plans, physicians often have obligations to organizations (for example, to control costs or advance the health of a population). These obligations can be in tension with the interests of individual patients and can alter the standard of care (Khushf and Gifford, 1999). Physicians, patients, and the public more generally have reacted strongly against managed care systems. The arguments against the socioeconomic transformations are telling. Physicians argue that the intrusion of economic considerations into care distorts medicine as a science and disrupts the core ethical obligation that a physician has to individual patients. I cannot explore here the merit of the various arguments against managed care (see Khushf, 1998, 1999a, 2000). For the purposes of this essay, I want to highlight some of the assumptions behind the criticisms. Critics often assume that they have provided a sufficient argument against managed care when they show that under such arrangements outside values play a role in configuring how physicians practice. If economic considerations influence what a physician calls "medically necessary" or they determine whether a test is indicated, the critics presume the scientific and ethical character of medicine is compromised (Angell, 1987; Pellegrino and Thomasma, 1981). A similar kind of assumption is found in other areas of medicine were social or economic values influence the standard of care or the status of evidence. Thus, for example, Marcia Angell (1996), an editor of the New England Journal of Medicine, strongly objects to the influence of women's groups on the guidelines that determine whether breast cancer screening mammography is indicated for women of a certain age group, because she thinks that such guidelines should be a function of science alone, not of political forces. She is also concerned about the use of legal criteria for evidence that do not rest on standard "scientific" criteria. These critics are not completely naive regarding the need for economic constraints on health care or regarding the role social values play in determining whether care is provided. However, they believe that the value considerations should remain separate from the science. They are thus foundationalist with respect to the science. In practice, physicians first take a history and do a physical. From these they formulate a preliminary disease hypothesis and confIrm or refine it by laboratory tests and effective clinical management of the patient. The "medically indicated" course of treatment is a func-

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tion of science, not economics or political ideology. If what is medically indicated costs too much or violates the interests of a particular patient or patient population, then this may be a good reason not to provide it. But the value considerations come in as a second step, addressing the use and abuse of the independently formulated, scientifically grounded recommendations. Many of the prominent ethical ideals in medicine work with this assumption regarding the mutually exclusive relation between the science of medicine, on one side, and the ethics or economics of health care, on the other. Here we have the positivist split between facts and values. Consider, for example, the ideals associated with informed consent and advance directives. They often assume that physicians first investigate what is wrong, and then, when they are in a position to make a recommendation regarding treatment or some invasive test, they bring it to the patient, who assesses the benefits and burdens in the light of the patient's own values. Physicians independently determine what best promotes health and alleviates disease. "What best promotes health and life is naturally thought to be an objective factual matter, an empirical question, one not dependent on a particular patients' preferences and values," says Brock (1997, p. 367). But it is recognized that the promotion of health and life (the physician's end) may not be what the patient seeks. "Values" are something that a physician elicits to determine whether a medically indicated treatment is also morally indicated. They put a check on a medical paternalism that advances somatic health as the appropriate human end. However, the challenge to paternalism in medicine does not extend to the way medical reality is itself constructed. Veatch (1995) has recently criticized informed consent doctrines in this more radical manner. The challenge to paternalism posed by informed consent doctrine only addresses the patient's ability to critically assess whether a "medically indicated" course of action (or one among other medically indicated courses of action) is the best for the individual patient. When taken as a whole, literature on medical ethics, economics, and education provides considerable support for Boorse's claim to articulate the biomedical disease concept. The literature assumes that the process of diagnosis and recommendations for treatment are rooted in science alone. The writers also assume that values come in as a separate strand (the "plus" in Boorse's "disease plus" categories) for the purpose of directing the use of the knowledge obtained by science. Those criticizing Boorse should appreciate how their criticisms have implications that extend beyond his theoretical disease concept. Should not the normativist position on disease concepts have implications for how values are integrated with the science, implications that are not apparent when we observe health care research and practice? If values playa role in even the basic sciences (for example, pathology), as the normativist would contend, the construction of medical reality should

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not just be up to basic scientists or physicians. Why should their values alone determine when and what kinds of treatment are indicated? These are decisions that have important social implications, and it would seem appropriate for the value component in such decisions to be addressed in a more explicit way. Is breast cancer screening or even the staging of cancer (Gardell-Cutter, 1992) not a decision about how to weigh risk, cost, and benefit, and should this not be a decision that is socially configured (against Angell)? A normativist position on disease requires a more dialectical relation between matters of science and those of ethics; it would thus challenge the scientific foundationalism presupposed in much of the literature (Khushf, 1997). Boorse and his allies could thus argue that the absence of such a dialectic in the construction of medical reality shows that people generally do not work with a normativist disease concept. Using Nordenfelt's distinction between two ways of having a concept, Boorse could argue that society and the medical community has a language use fully consistent with the value-neutral disease concept that is explicitly espoused. Values may be added to form "disease plus" concepts that direct individual care, but one could always distinguish between the natural properties and those associated with culture/values. Flexner's positivism still holds great sway. A criticism of Boorse would thus seem to require a more radical criticism of the whole paradigm of modem medicine, rather than just a criticism of some ancillary commitment of the paradigm to a value-neutral theoretical disease concept. The debate about health and disease becomes a variant of the broader debate about the "biomedical model" and its alternatives (for representative contributions to this broader debate, see Engel, 1988, 1980, 1978, 1960; Leder, 1992b). 5. Post-Positivist Philosophy of Science: Sustaining Practical Corollaries of the Positivist Project without the Assumption of Value-Neutrality We have seen an intimate linkage between medical positivism, logical positivist philosophy of science, and the value-neutral disease concept. Each part of this broad paradigm reinforces the other. The value-neutral disease concept reinforces the project of reduction and scientific unification found in positivist philosophy of science (Broussais's Principle). It also supports the medical positivist assumption that we can separate theory from practice, facts from values, and science from the ethics. At the same time, the understanding of science in logical and medical positivism provides the condition for developing the value-neutral disease concept in the first place, giving it a plausibility it might otherwise lack. Because of the way these strands are so tightly linked, a criticism of one part has broad implications for the others.

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Boorse's arguments exemplify these diverse strands, and this is why so many theorists have felt compelled to engage his disease concept. This debate involves much more than a parochial problem in philosophy of medicine. The debate on health and disease concerns the very nature of science, medicine, ethics, and their relation to one another within the theory and practice of modern health care. Up to this stage in the essay, I have attempted to bring the full scope of this problem into view. Now we will take stock of the positivist paradigm itself. A good place to begin our assessment of Boorse's disease concept (and of Broussais's Principle generally) is with a discussion of the positivist approach to science, and, more specifically, its claim that science is value-free. Boorse is especially impatient with any claim that scientific knowledge is evaluative. When George Agich claims that the biostatistical disease concept involves "an unacceptably simplistic view of science as value-free," Boorse cannot withhold his disdain. If health and disease are only as value-laden as astrophysics and inorganic chemistry, I am content. I admit having no sympathy for the view that scientific concepts or knowledge is evaluative. Obviously, we do science, as we do everything, for evaluative reasons. But I do not see why our motives for information-gathering must infect the information gathered, injecting values into science, mathematics, and the Bell telephone directory. However, I leave defending the value-freedom of physics to physicists and philosophers thereof. (1997, p. 56) But this response is disappointing. Normally Boorse quite effectively addresses his critics, carefully considering their arguments and providing slight revisions and clarifications that buttress his own views. However, in this case, he dismisses without consideration an argument that has weight. Obviously, if values playa significant role in science generally (including biology), then, even if biological science alone specifies disease concepts (a highly contested claim), the concepts may still have an evaluative component. It is incumbent upon him to take his critics more seriously on this point. Boorse says he will leave defending the value-freedom of physics (and presumably the other natural sciences) to the practitioners and philosophers of those fields. But when we turn to the noted philosophers of these sciences, many of the arguments do not favor Boorse. Philosophers generally concur that the approach to science found among the logical positivists cannot be brought to completion, and that science does involve an evaluative dimension. Some, such as Ernan McMullin (1983), even argue that "the watershed between 'classic' philosophy of science ... and the 'new' philosophy of science can best be understood by analyzing the change in our perception of

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the role played by values in science" (p. 3). A careful consideration of how philosophers of science see values playing a role would thus seem to be even more imperative. We have an even more important reason to review the state of the debate in the philosophy of science. Normativists can effectively argue against the biostatistical disease concept without the foray into philosophy of science (Engelhardt, 1996, Ch. 5; Nordenfelt, 1987). While the foray is helpful because of the close linkage between the value-neutral disease concept and the positivist program generally, it is not necessary. The philosophy of science debate holds another lesson, one that can provide considerable guidance for the development of the next stage of the debate on concepts of health and disease: some of the practical correlates of the positivist project can still be sustained without the assumption of value-neutrality. For example, one can still argue for a strong demarcation between science and nonscience and, with this, attempt to insulate science from outside, distorting influences. By considering how post-positivist philosophers of science sustain a strong demarcation criterion, we can see how normativist philosophers of medicine can simultaneously be defenders of a fairly traditional biomedicine. The current dispute between the more radical, socio-historical schools of science studies and the more conservative analytical empiricists exemplifies the kind of rich discourse that should now take place among normativists themselves. It is time for the discussion in philosophy of medicine to move beyond the naturalist versus normativist dichotomy, and the philosophers of science show how this can take place. A. The Breakdown of Logical Positivism For the logical positivist, scientific knowledge was built up from the basic units of experience (for a good review of logical positivism and subsequent criticisms of that tradition, see Suppe, 1977). A meaningful claim had to be testable, and that meant there must be observational implications that can be publicly assessed. Further, it was assumed that knowledge comes in bits and pieces, with each part independently testable. Laws provide generalizations from observations or lower level laws, while broader theories linked prominent laws and developed yet higher level generalizations. Knowledge in science arises through this piecemeal concatenation of a more local kind of knowledge, coupled with the development of fundamental principles linking diverse kinds of knowledge into a systematic unity. According to this view, since scientific knowledge is built up from observations and lower level generalizations that are not themselves dependent on the higher level principles or systematic structure, knowledge is not distorted by outside philosophical or cultural commitments (whether moral, religious, or metaphysi-

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cal). As Alexander Rosenberg notes (1985), philosophy of science on this account plays no constructive role within science itself. It is reduced to the role of "the study of implicit and explicit defmitions of the terms ubiquitous in science," terms such as "mass" and "force" or, in our case, "disease." Knowledge, for the positivist, arises from the ground upward. Assumptions regarding the value-neutrality of scientific knowledge are thus wed to the whole positivist program. Although he does not elaborate on the way knowledge in science is developed, Christopher Boorse aligns himself with many positivist assumptions. He gives the impression that his own disease concept merely clarifies what pathologists assume or, in his earlier writings, that he makes an inductive generalization from a study of the extant medical nosologies. He sees the medical theory as separate from practice. Analysis of the core disease concept involves specifying the more basic units of analysis, derived from biological theory, and then defming disease in terms of those basic units. Boorse thus puts forward his claims as a result of the kind of "from the ground upward" observation and generalization associated with the positivist program. The breakdown in logical positivist philosophy of science (often referred to as "the Received View") is directly associated with its inability to sustain a "bottom up" approach to knowledge, the approach reflected in Broussais's Principle, with its straightforward movement from simple to more complex systems. The problems with the positivist program can be well illustrated by considering the deficiencies in Boorse's claims about his own method. In a previous section, we saw that Boorse does much more than induce from extant nosologies. He brings to medicine a theoretical framework and concepts initially formed in the context of theoretical biology. The framework and concepts have had limited influence in medicine, especially in the field of pathology (with the possible exception of bacteriQlogy and infectious disease). Boorse also brings a broader philosophical system, informed by philosophy of science, debates over naturalism and reduction, and a progressive, positivist ideal of medicine. Directed by these initial commitments, he picks out terms that play an important role in pathology, terms such as "function," and he links them to the explanatory principles of evolutionary biology, so that the explanatory principles now account for the logic of inclusion of current nosologies. When faced with historical data on the actual logic of inclusion, or when faced with the current nosologies and their logic of organization, Boorse is not moved, even though such data do not support his position. Instead, he refines his arguments, reframing ancillary claims so that the data now is in accord with his core disease defmition. Boorse's recent response to his many critics (1997) shows how adept he is at nuancing his core thesis. I also have littl~doubt that when he reads Nordenfelt's most recent criticisms (this volume, pp. 18-20), which indicate how a

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careful review of pathology texts and current nosologies do not support his claims, Boorse will show himself equally adept at reinterpreting the data. For the logical positivist, such a loose link between data and theoretical commitments would indicate a deficiency in the knowledge. However, postpositivist philosophers of science have shown that a more complex interaction between broader commitments and observational data characterizes all of science. N. R. Hanson is best noted for making this clear (and Suppe [1977, pp. 151-166] provides a good review of Hanson's arguments). Knowledge is not developed from the bottom upward. Even the most basic kinds of observational data are already "infected" with theory . . . and with values. Further, knowledge does not arise from the simple concatenation of more basic kinds of knowledge. Instead, it involves a web of commitments and is always tested in bundles (Quine, 1951; Duhem, 1962; for a good review of these arguments, see Curd and Cover, 1998, Ch. 3). Core principles can be saved against countervailing data by reinterpreting ancillary commitments necessary for the interpretation of the principle so it is observationally relevant. All of the unifying principles in science are underdetermined with respect to observational data. Science may thus produce plural viewpoints, all of which are supported by evidence. The kind of plural viewpoints we see in the philosophy of medicine on the nature of disease thus accords with the view of core concepts in science generally. On the basis of these criticisms of the positivist project, many prominent philosophers of science have challenged the notion of a strong demarcation between science and nonscience. Following the thought of Fleck (1979), Kuhn (1996), and Feyerabend (1975), such socio-historical critics argue that there are "thought collectives" or "paradigms," which involve a rich constellation of theory and practices that can only be understood by a complex process of initiation. Among competing paradigms, incommensurability exists between units of analysis. Thus, for example, "force" within a Newtonian framework means something quite different than it does within an AristotelianlPtolemaic framework, with the meaning determined by other core concepts such as matter, movement, and cause. The parts cannot be empirically tested or otherwise assessed independently. They must instead be assessed in bundles. Because of the way science is linked to a broad worldview into which a person must be fully initiated, science can function like an ideology. Many views can be considered legitimate, if legitimacy consists of being justified within a broad paradigm. Scientific beliefs are also linked to cultural and social beliefs, as well as to the individual interests of particular scientists. An evaluative dimension thus permeates all of science. For the logical positivist, such a radical view would follow directly from the concession that values play a role in science. Either science is rooted in fact and able to justify its knowledge or it is intertwined with meta-

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physical and values disputes and indistinguishable from nonscience. In earlier years of the debate over positivism, the alternatives were presented in this stark manner. Either you have a value-free science with all of the practical correlates or you do not really have science at all; science becoming the latest form of religious dogmatism (Feyerabend, 1975, Ch. 18). Gradually, however, a middle ground became apparent. Many philosophers of science, whom I will call "analytical empiricists," were sympathetic to the positivist program, especially the practical correlates. These analytical empiricists came to recognize that core positivist distinctions such as the one between theory and observation could not perform the pivotal role they were supposed to in justifying knowledge. As these distinctions were reassessed, philosophers of science were forced to discard simple verification or falsification standards of demarcation between science and nonscience. This did not mean they rejected the problem of demarcation. In fact, the watershed to which McMullin refers takes place when philosophers of science concede an evaluative dimension while simultaneously sustaining many of the practical correlates of the positivist program, especially the strong demarcation between science and nonscience. B. Two Strategies for Sustaining a Strong Demarcation Between Science and Nonscience A discussion of the post-positivist approaches to the problem of demarcation would take us too far afield. Instead, I will briefly outline strategies used by analytical empiricists to protect science from an inappropriate intrusion of outside beliefs or values. For the conservative post-positivist philosophers of science, the key to protecting a more traditional view of science was to carefully identify what kind of values play a role in science and to outline how they play their role. Once this is done, the difference between appropriate and inappropriate roles for values can be more carefully specified. Two strategies of demarcating the legitimate from illegitimate roles for evaluation stand out. McMullin (1983) illustrates the first in his examination of the problems of theory justification. Scientists use several criteria to assess a theory, including predictive accuracy, internal coherence, unifying power, fertility (ability to make novel predictions and have imaginative resources for extending theory), and simplicity. However, these criteria can sometimes conflict with one another. The problem is that no fixed rules can adjudicate among competing concerns. Theory choice always includes a decisional element which involves a subtle kind of balancing and judgment. This decisional element (implied by the absence of a rule governed strategy for resolution) makes the introduction of values into science inevitable. In fact, McMullin argues that "theory-appraisal is a sophisticated form of value-

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judgment." But this does not imply that all values are relevant. McMullin goes on to argue that empirical adequacy is central as a goal of science, and only those values that further this goal are legitimate: When no sufficient case can be made for saying that the imposition of a particular value on the process of theory choice is likely to improve the epistemic status of the theory, that is, the conformity between theory and world, this value is held to be nonepistemic in the context in question. (p. 531; see also Hempel, 1960) For McMullin, many kinds of values can be taken as epistemic, including those located within broader metaphysical and religious worldviews. However, if the value is not taken as one that advances the empirical adequacy of the theory (understood as its accord with the world), then it is nonepistemic and illegitimately plays a role in theory assessment. The second strategy for delineating the appropriate role for values is linked to the more general problem of distinguishing normative evaluation from description. Science is concerned with providing an adequate description of the world, thus yielding information about the phenomena being described. The interest in description is directly linked to the goal of empirical adequacy that grounded McMullin's distinction between epistemic and nonepistemic values. However, some "applied sciences" use knowledge to advance some other end. For example, science is used to build bridges (civil engineering), make people happier and better adjusted to their circumstances (psychiatry), or eliminate disease (medicine). In these arenas, outside values direct the organization and utilization of knowledge; even Flexner conceded this point with respect to the basic sciences of medicine. We can thus make a distinction between those categorical kinds of evaluation that involve the specification of an end and the instrumental judgments of value that are linked to the activity of science. McMullin makes a similar distinction between epistemic values which give the goals of pure science and other epistemic values, which are instrumental for realizing those goals (1998). In an applied science, some normative values are tied to extra-scientific ends. Once those ends are specified, however, instrumental values can be determined. Science provides description, and this is value-free. Instrumental values are not values that are alien to science but a form that the descriptive activity takes once the extra-scientific ends have been specified. This account of applied and pure science, with its distinction between categorical and instrumental values (reflecting the distinctions between evaluation and description and between ends and means), agrees completely with broader positivist premises. But in post-positivist philosophy of science, it is now recognized that even "pure" science involves some of the normative

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considerations previously thought to be found only in the applied sciences. Consider, for example, Bas van Fraassen's (1980) account of scientific explanation. He notes how, in the past, scientific explanation was seen to be a species of description; the "explanatory power" of a theory was understood as "those features and resources of a theory that make it informative (that is, allow it to give better descriptions)" (p. 154). For several reasons, this account of explanation could not be sustained, and philosophers of science came to understand explanation as irreducible. Van Fraassen regards explanation as an answer to a question. While description is concerned with the relation between fact and theory, explanation deals with the relation between theory, fact, and context. It responds to a question that itself involves a desire for something, namely, information that addresses some end that is linked to the values of the questioner. In this way, explanation, which is an activity of even the purest science, is linked to outside values. "So scientific explanation is not (pure) science but an application of science," says van Fraassen; "It is a use of science to satisfy certain of our desires; and these desires are quite specific in a specific context, but they are always desires for descriptive information" (p. 156). Since science gives information, which is dependent on description, it presupposes the distinction between description and categorical evaluation, and works with instrumentalities that further a specified end. Outside ends can direct the way the information is provided, but they cannot determine what the information is once the ends have been specified. These two distinctions (the one between episternic and nonepisternic values, and the one between description and normative evaluation) enable post-positivist philosophers of science to sustain a strong demarcation between science and nonscience, while conceding an important role for values in key scientific activities such as those of explanation and theory assessment. At the same time, more radical critics of science argue that the distinctions cannot be sustained. They also point to more intimate links between episternic and nonepisternic concerns, and between normative and descriptive components of science. An active debate is occurring within science studies on whether the strong demarcation (with many of its practical correlates) can be upheld. These debates, in tum, have many implications for how science is and should be practiced, and the role that these outside interests and values play and should play in the construction of scientific reality. This is a debate that can provide considerable guidance for those discussing the nature of health and disease.

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6. Post-Positivist Philosophy of Medicine: Establishing Debate among Normativists The next stage in the development of philosophy of medicine as a field will only take place when normativists move beyond the value-neutral disease concept and start to argue with each other. The debate should no longer be about whether values playa role, but rather how and what role. Norrnativists now need to carefully nuance distinctions among themselves. Lennart Nordenfelt's (this volume) critical review of Reznek's, Fulford's, and his own health concept is exactly the kind of work that we need, and it can be regarded as a marker in the debate. In addition to the new theoretical work being done in the philosophy of medicine, altered forms of medical practice indicate that we are entering a new stage in the debate. Structural changes in the fmancing and practice of health care challenge medical positivist assumptions, making normativist positions practically relevant in ways they have not been in the past (Khushf, 1998, 1999a). When the structure of health care followed a Flexnerian ideal (as it did in the United States during the twentieth century), the normativist consensus among philosophers of medicine had little impact on the theory or practice of medicine. Medical practitioners largely ignored the debate on health and disease, with the notable exceptions of the debates on the legitimacy of the category of mental illness and the consideration of specific conditions such as homosexuality as a mental illness (see Szasz, 1968; Bayer, 1981). The general absence of regard for such debate actually buttressed the claims of Boorse, since it implied that the conceptual philosophical disputes were extemal to the science of medicine and that medical theory was insulated from the kinds ofvaiues dispute found in society (Khushf, 1997). Now, however, social and economic transformations have provoked a new debate over how medicine should be conceptualized and practiced (Khushf, 2000). Within this context, a greater resonance has emerged between the normativist position and the realities of practice. We need to ask the key question: what kind of guidance can normativists provide? In a way that closely parallels the options in philosophy of science, normativists can take two approaches to current transformations in medicine and to the antecedent positivist tradition. First, they can advance a radical criticism of both the theory and practical correlates of medical positivism. They can explicitly incorporate normative reflection as a constitutive moment into the construction of medical reality. Ethicists, economists, and other "outsiders" such as hospital administrators, insurers, and health plan organizers would playa direct role in forming the standard of medical care. Such a development is indeed taking place in many areas of health care, especially at institutions that integrate mechanisms of payment and provision (managed

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care) and that use outcome information (for example, on quality of life) to assess the care provided. The radical critic thus celebrates exactly those current socioeconomic developments that the medical positivist decries, seeing the development as a practical correlate of the recognition that values playa role in even the basic concepts of medicine. I argue for this position in the frnal section of this essay, and it parallels the position of the more radical sociohistorical critics and constructivists in the philosophy of science. I will call this "strong normativism," deviating from Boorse's (1975, p. 546) use of the phrase. Normativists can also take another approach. As in the philosophy of science generally, a normativist can sustain some of the practical corollaries of the medical positivist program without holding to the affirmation of valueneutrality. I will call these "weak normativists," and they are defenders of a more traditional biomedicine. Weak normativists resist the constructivism of the radical critics and want to see medical knowledge and practice insulated from the broader, extra-medical values disputes in society. However, unlike the positivists, they do not think that knowledge arises from the natural sciences upward. Rejection of the value-neutral disease concept involves a rejection of Broussais's Principle, that is, a rejection of the bottom up approach to science, which allows for the ordinary level meanings of disease to be constructed by a simple addition of values to the scientific concept. Instead, they see a more intimate link between the practical interests and theory. Weak normativists begin with ordinary level health and disease concepts, which specify the end of medicine, and thus involve normative considerations that guide the construction of medical reality. As with the more traditional post-positivist philosophers of science, however, they also want to mark off the appropriate from inappropriate range where values direct medicrne. The strategies used by weak normativists resemble those used by postpositivist defenders of science. They distinguish between descriptive scientific concerns and evaluative considerations or mark off medical from nonmedical values (the analogue to the distinction between epistemic and nonepistemic values). The first strategy is seen in the work of Nordenfelt, the second in the work of Fulford. A. Lennart Nordenfelt's Distinction Between Normative and Descriptive Dimensions of Medicine Lennart Nordenfelt defends many of the practical corollaries of medical positivism but provides a nuanced, post-positivist account of the relation between descriptive and evaluative dimensions. He holds to a strong demarcation between science and nonscience and seeks to resist constructivist use

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of broader social and political values in determining whether something is a disease. When Lawrie Reznek makes the disease status of homosexuality dependent upon a political judgment regarding the type of people we want to be, Nordenfelt asks: "what is the point in making a very close theoretical characterization of the notion of disease, if the whole thing in the end is to be determined by a political decision?" (this volume, p. 41; for his more detailed discussion of homosexuality, see 1987, pp. 131-139). Nordenfelt recognizes that socio-political factors have previously influenced the way medical reality has been constructed, but he thinks that increased clarity regarding the nature of disease enables medical authorities to make decisions in a more appropriate manner. For example, psychiatrists came to see that the previous inclusion of homosexuality in psychiatric nosologies was a mistake (Bayer, 1981). Good theoretical analysis (the type Nordenfelt wants to provide) enables us to take these kinds of decisions out of the political arena. As with the positivists generally, Nordenfelt believes that social policy should be grounded on a science which is independent of socio-political values, and which provides the basis for the development of sound policy. This concern is especially apparent in the following quote: By including the possibility of a political decision in the very defmition of disease Reznek has in fact made the concept much less useful for many of its principal objectives. Medical or social authorities can no longer use diseasehood as an argument for a political decision. But that this should be a possibility is clearly part of the common understanding of disease. They can no longer say the following: modem medical science has shown that alcoholism is a disease; thus, alcoholics should have the right to medical treatment if they want it, and, as a consequence, we must establish clinics for alcoholics. This is impossible, because medical science can do nothing of the sort, according to Reznek. (This volume, p. 44) Nordenfelt seeks "to explicate a concept of health which can fulfill the elementary logical and other conditions . . . for medical practice and science" (this volume, p. 65), and one of these conditions is the capacity of medical science to determine the diseasehood of a condition. Through his analysis, Nordenfelt defends a notion of disease that allows medical theory to provide a foundation for the development of social policy. In order to protect medicine against the inappropriate intrusion of outside values, Nordenfelt uses the normative/descriptive distinction. He argues that the primary health concept is health, not illness. Health is present when there is functional ability of the whole person in a standard environment to realize vital goals, which, in turn, are those necessary for minimal happiness.

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By advocating a wants-based notion of happiness, Nordenfelt makes the key evaluative consideration individually relative. Once the individually relative health meaning is specified, medicine can address everything else descriptively. We thus have the key marks of an applied science. Science cannot specify the end, but once specified, science can consider the conditions for its realization. What is the place of the health concepts in science? My conclusions are the following. Health is a partly evaluative concept. ... Since the malady-concepts are derived from the concept of health, they too are partly evaluative. This does not preclude their use in the medical sciences. As soon as the matters which are open to evaluation are decided upon a standard is established which can be used for purely empirical investigation. (This volume, p. 70; 1993, p. 147; and 1987, p. 147) B. K. W. M. Fulford's Distinction between Medical and Nonmedical Values The defense of the modern biomedical paradigm can take several forms. However, central to all of the forms is an attempt to sustain three things: (I) its scientifically foundational character; (2) an individual patient orientation; and (3) the secondary character of the macro-level socioeconomic structures. Social and economic systems of financing and provision should be formed so that they provide the conditions for the individually oriented, scientifically grounded practice. This means that medicine has an integrity of theory and practice which is independent of broader social and economic norms and policies and which provides the basis for the formation of those norms and policies. Allowing social values regarding deviance, justice, or the common good to directly influence how we understand illness or disease would imply a radical critique of the current biomedical paradigm. This led to Nordenfelt's concern about Reznek's contention that the disease status of homosexuality depends upon what society considers cruel. At the heart of the classical paradigm of medicine is thus a presumed ability to mark off medical theory and practice from the socioeconomic forms of life that sustain our ability to provide health care. In our scientific age, we want the policy to be built upon the medicine, not vice versa. This division between the microlevels and macro-levels of analysis, and the capability of the micro-level theory and practice to ground macro-level policy constitutes the demarcation problem in the philosophy of medicine. K. W. M. Fulford provides a theory of health concepts that he thinks sustains the core demarcation. As with Nordenfelt, he uses the distinction between evaluative and descriptive dimensions to defend an individually

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oriented, scientific medicine. Thus, "fact and value, 'is' and 'ought,' remain sharply distinct" (Fulford, 1989, p. 208). However, the two approaches differ in important ways. Nordenfelt gives priority to health concepts, and through his theory of health, he seeks to explicitly identify the end that directs medicine. This positive evaluation enables Nordenfelt to move directly from the end to the descriptive activity of science, which develops the means for sustaining that end. By contrast, Fulford gives priority to the concept of illness rather than health; priority is given to a negative evaluation rather than a positive one. From this negative evaluation, the end is developed indirectly by being linked to the intention that is thwarted in the failure of action associated with illness. This analysis leads to a more complex dialectic between evaluative and descriptive considerations, a dialectic that pervades all of medicine. In order to sustain the needed demarcation, Fulford thus requires an additional strategy, closely analogous to the post-positivist use of the distinction between episternic and nonepisternic values. Through a detailed discussion of the meaning of dysfunction, disease, and illness, Fulford (1989) argues for a theory that reverses the conventional scientific foundationalism found in Boorse and medical positivism. Thus he calls it a "reverse theory." He gives priority to evaluative illness concept and calls disease and dysfunction derivative. Illness is present when a person cannot do the things that are normally done, and when the reason for such action failure can be found neither in external circumstances nor in the person's own will. Since human action is intentional, with both facts and values providing reasons for action, a failure of such action, as a thwarting of intention, entails a negative evaluation. Disease is simply a condition that is widely construed as illness (a condition over which there is relatively little controversy). It too has a factual and evaluative component. As a descriptive term, disease may determine the symptoms, causal explanatory factor, or statistical range associated with an illness. Dysfunction often concerns the failure of means needed to sustain action and thus is also linked to the purpose implicit in those things that we ordinarily do without thinking much about them. For Fulford, mental and physical illness are each species of the more general form of action failure. He uses his theoretical analysis to address problems in clinical medicine which demonstrate the practical import of philosophical debates on disease, for example, the debate on mental illness and involuntary psychiatric commitment. Antipsychiatrists such as Thomas Szasz (1968) are concerned about the way a medical model of mental illness is used as a basis for taking away the liberty of patients. Szasz argues that mental illness is an evaluative term, expressing social disapproval of certain forms of rationality and behavior. It is thus one of society's tools to prevent deviancy. Because of the role that

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such evaluation plays in mental illness, it is dis analogous to somatic disease, and thus a myth. It does not provide an independent scientific basis for society to make decisions about mental health but, instead, expresses social decisions about the appropriate kinds of reasoning and behavior. Szasz thus assumes the biomedical demarcation between micro-levels and macro-levels and uses the absence of such a demarcation in the case of mental illness as a basis for rejecting the concept. Fulford concedes that mental illness embodies values. However, he makes a strong distinction between medical and nonmedical values (the philosophy of medicine analogue to the distinction between epistemic and nonepistemic values in science). Through a discussion of the meaning of delusion, he shows how the demarcation between micro-levels and macro-levels of analysis can be sustained. Fulford argues that the kind of action failure associated with illness can take place in two ways. All other failures [besides those involving delusions] are, as it were, instrumental failures, failures in which the required action is defmed but cannot (or cannot wholly) be performed - failures involving ... the "machinery of action" at the motor or sensory levels in the case of physical illnesses, and at the cognitive, emotional or appetitive levels in the case of mental illnesses. But the failure of "ordinary" doing at the heart of . . . delusions is more radical than these. As a defect in the structure of our reasons for action, it is not an instrumental failure, not a difficulty in doing something, but a failure in the very defmition of what is done. (1989, p. 238) By linking mental illness to a particular kind of failure of action (not a moral, criminal, or aesthetic negative evaluation, but a medical one), Fulford attempts to disentangle the concept of mental illness from the kinds of outside social and moral evaluations that Szasz considered inappropriate. "The failure of 'ordinary' doing implied by a reverse-view analysis is a failure in the very specification of what is done. The psychotic ... lacks intent in that his intentions are defective" (p. 242). Fulford thus sustains psychiatry's validity as a basis for determining when illegal behavior should not be regarded criminal (as a result of mental illness). Further, since we also associate rights (such as the right to liberty) with capacity for responsibility, mental illness can be used as a basis for involuntary psychiatric commitment.

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C. Preliminary Assessment of the Weak Normativist Project The next stage in the debate on health and disease concepts must involve a detailed assessment of the weak normativist strategies for defending biomedicine, for example, an assessment of the use of the normative/descriptive distinction or the division between medical and nonmedical values. One of my primary tasks in this essay has been to show why such assessment now moves to the center .of the philosophy of medicine. I cannot provide the needed detailed analysis here, but, by way of preliminary assessment, I would like to make two observations regarding the weak normativist position. First, positively, if one wants to defend the biomedical paradigm in its classic form; that is, sustain the strong demarcation, with its scientific foundationalism, individual patient orientation, and secondary character of macro-level considerations, then one must turn to weak normativists like Nordenfelt and Fulford or to others with similar kinds of arguments (such as Pellegrino and Thomasma, 1981; see the assessments of Pellegrino and Thomasma's arguments for a weak normativism in Khushf, 2000). We can no longer look to a value-neutral theoretica.1 foundation. Medical positivism is no more viable than logical positivism. If Boorse were correct about health and disease, he still could not provide the support that we need to address the medical demarcation problem, with its practical correlates. Boorse recognizes that core concepts in clinical medicine have a significant evaluative component (1997, pp. 12-13). He defends the claim that "medicine has a distinctive theoretical foundation in a value-free science of health and disease" (p. 23). To sustain the details of his value-neutral account of science, he shifts his focus from clinical nosologies (the emphasis in his earlier work) to the pathology of the bench scientist (his most recent emphasis), driving a thicker wedge between the practical and theoretical domains. At the clinical level, values come in as a second strain, added to the theoretical concepts to provide "disease plus" concepts. In the end, Boorse claims there are several disease concepts: "theoretical, clinical, and even social" (p. 51; see also p. 28 on the "medical disease concept"). He attempts to provide an explication of just one of those concepts, the theoretical. Unfortunately, Boorse says little about how values might be added at the clinical and social levels and how the lines are drawn between diagnostic normality and abnormality or between therapeutic normality and abnormality (p. 13). As his writing on the topic matures, he is forced to distance his theoretical disease concept more and more from the diagnostic and therapeutic categories that are central for clinical medicine. By defending his concept against criticism, he makes it increasingly irrelevant for addressing the practical problems that we currently face. He argues that we cannot expect too

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much from disease concepts and accepts many of Hesslow's (1993) claims about the uselessness of health concepts for addressing a host of issues in science and clinical practice (Boorse, 1997, pp. 53-55). Boorse only wants to maintain the value of providing an analysis of the concept, so that confusion and abuse of the concept can be avoided: this goal for analysis reflects positivist assumptions regarding the role of the philosophy of science (Rosenberg, 1985; for a detailed discussion of the linkage between Hesslow's thesis and Boorse's disease concept, see Khushf, 1997). Even if Boorse were correct about the value-neutral core, his theoretical concept would no longer provide the basis needed to support the practical corollaries Of medical positivism. His concept is now too distant from the debates on how medicine is conceptualized and practiced. This does not mean his theoretical work on disease is no longer valuable; in fact, when appropriately nuanced, I believe Boorse's concept becomes one of the significant options among other normativist contenders. We could refer to the variant as a "weak normative functionalism." Boorse prepares the way for such an alteration of his position by recognizing that his general defmition could be linked to a notion of function that is not value-neutral (1997, p. 10). If we wish to support the practical corollaries of medical positivism, we must thus look to some variant of weak normativism. I want to make a second, more critical point about weak normativism. Much still needs to be done to clarify the relation between individually relative ends and values (for example, regarding action failure or vital goals), science, and the socio-economic conditions of health care. Foucault (1975) correctly disclosed the liberal underpinnings of modem medicine. Weak normativists presuppose this liberal framework, with its assumptions that social conditions can be established for sustaining and fostering individual experiments in living, with their plural ends. The conditions for establishing equality of opportunity are thus regarded as independent of substantive commitments regarding individual ends. Science then comes in to provide the instrumentalities for upholding the individually relative ends. Many people believe that social values embodied in the social systems of health care do not infect or distort the capacity to elicit and advance the individually relative health ends. Whether this assumption can be sustained, however, is another matter. Consider, for example, Fulford's claim that delusion involves a failure in the structure of our reasons for action. In order to distinguish medical from nonmedical ends, Fulford had to link delusion to the failure of ordinary doing. However, will not a further explication of the "ordinary" in this case disclose exactly the kinds of nonmedical social norms and expectations that Fulford sought to exclude from medical decision-making? Can the nature of delusion really be specified independent of broader social values regarding

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the appropriate range of ends and forms of rationality? I am struck here by a case reported in the Journal of Clinical Ethics where a psychiatrist ruled that a Pentecostal woman was incompetent to make treatment decisions because of a "religious delusion that she would be saved without medical treatment" (Powell, 1995, p. 74). In this case, an ethics committee overruled the psychiatrist's initial conclusion because of the broad range of respect provided for religious liberty in the United States. However, I cannot see anything in Fulford's analysis that insulates the specification of delusion from these nonmedical values disputes. In order to sustain his line between medical and nonmedical values, he must more carefully specify the positive ends (individual and social) and thus move beyond the negative evaluation associated with illness. Nordenfelt provides the needed positive evaluation with his health concept, and perhaps the weak normativist position could be further strengthened by linking his account with that of Fulford. However, similar questions can be raised about Nordenfelt's analysis. Can he really sustain the individually relative account of health? His health concept involves an individually relative evaluation, which he associated with a modem, wants-based or "subjective" notion of happiness (1987, pp. 81-90). He sets the individually relative evaluation against the background of a social evaluation embodied in the notion of a standard environment and an appropriate range of variability for vital goals, distinguishing between ''unusual'' vital goals, which are legitimate, and "unrealistic" or "mad" ones, which are not (1987, pp. 90-97 and 100-104). Consonant with liberal attempts at marking off individual experiments in living from the social conditions that give the condition for their possibility, Nordenfelt carefully disentangles the individual and social elements of evaluation. Medical researchers and practitioners should only play their role in forming medical reality after this set of evaluations is specified. Nordenfelt explicitly argues that healtll care workers should not incorporate their own evaluations into the determination of clinical reality. The physician could and should remain a technician. The formulation of vital goals should be in the hands of individuals themselves, and - concerning certain basic vital goals - they should be in the hands of politicians and policy-forming health authorities. The clinician and medical scientist should instead work in the light of such a well-defmed concept of health. Given a well-defmed set of vital goals the clinician can use his expertise in theoretical judgment: what bodily and mental states are risk-factors for a subject's ability to realize his given set of vital goals? (1987,p.129)

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But can this intricate balance between individual evaluation, social evaluation, and scientific description be sustained? A slight modification in any of the elements of Nordenfelt's account would disrupt the balance, for example, if we move from his individually-relative, wants-based notion of happiness to a more Aristotelian notion. With respect to the range of variability for vital goals (distinguishing between unusual and "mad" forms), we can always ask whether the pathology of a mad vital goal depends on something inherent in the individual or external in society, since a conflict between the social and individual evaluations is part of what specifies the goal as "mad." Calling an over-reaching vital goal "mad" implies that the "ill health" depends on an internal condition of the individual rather than an inappropriate social formation or evaluation; in other words, that the problem is with the individual and not with society. A more careful probing of Nordenfelt's analysis of health may show that the kinds of "social evaluations" he found objectionable in Reznek's analysis may also playa role in his own account. Finally, we can ask whether Nordenfelt could sustain his strong distinction between the evaluative dimensions which specify the ends (both individual and social) and the instrumental reasoning of medicine which advances the realization of those ends. Should medical researchers and practitioners just be technocrats? Can they be? Or will their own evaluation unavoidably playa role in configuring health care reality, influencing the administrators and politicians who are supposed to provide the health evaluations? The formation of both theory and practice in health care may be a function of a more dialectical relation between descriptive and normative considerations, making it impossible to disentangle matters of fact from those of value. Through further analysis, I believe it can be shown that the arguments of Fulford and Nordenfelt are not independent: the positive ends associated with happiness (or, more appropriately, human flourishing) are specified together with the experienced failure of realizing them. Similarly, the negative evaluation associated with action failure presupposes positive ends, not just of the constrained, "ordinary" sort (such as the proximate ends found in ordinary intention), but the broader ends associated with a life project. A hermeneutic circle thus exists between health and illness concepts, and most significantly, this hermeneutic circle presupposes a broader circle between individual and communal well-being. This circle, in tum, calls into question the capacity to isolate micro-levels and macro-levels of analysis. The broader hermeneutic circle between individual and communal well-being becomes even more apparent when we consider the way individually relative evaluations (whether Fulford's negative ones or Nordenfelt's positive ones) are linked to the basic science that undergirds medical notions of disease. Both Nordenfelt and Fulford need a much richer account of the nature of that basic science, perhaps an account that is informed by philosophers of biology like

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Boorse or Kenneth Schaffner (1993). I am thus confident that the further development and elaboration of weak normativist positions will involve a more radical critique of their basic assumptions, a critique that leads to the next step, namely, a strong normativism. 7. On The Link Between Individual and Communal Flourishing: The Case for a Strong Normativism In Philosophical Arguments, Charles Taylor (1995) addresses a cluster of problems that continually haunt our age, although he argues that the full scope of the problem never quite comes to full expression. Taylor's first chapter attempts "a direct attack on the Hydra whose serpentine heads wreak havoc throughout the intellectual culture of modernity" (p. vii). That Hydra is called "epistemology," but what Taylor actually has in mind is the root doctrine that links modem science, action theory, and politics. He addresses exactly those notions that I have addressed in this essay. He considers the subtle linkage between the radical empiricist approach to knowledge, its view of science, anthropological beliefs associated with individual liberty, the "punctual self, ideally ready as free and rational," and the social consequence of these positions, namely, "an atomistic construal of society as constituted by, or ultimately to be explained in terms of, individual purposes" (p. 7). Taylor seeks to "overcome" this modem project, aiming his sword past the individual heads of the Hydra (the diverse projects of logical empiricism, action theory, and liberal politics) in order to strike at the base from which these many heads diverged. My analysis in this essay can be taken as a case example of Taylor'S broader thesis. To this extent, the problems associated with health and disease concepts can be seen as instantiating a deep crisis in modernity. I have shown how a positivist view of medical science, with its value-neutral disease concept, is linked to practical correlates, among which are the individual patient orientation, scientific foundationalism, and the separability of microethical and macro-ethical domains. These are the concerns that constitute the medical problem of demarcation, and the debate between weak and strong normativists can be regarded as a debate about whether such a demarcation can be sustained. Weak normativists seek to uphold a more traditional view of medicine, with its liberal ideal. I side with Taylor, believing that this project must be overcome, so that we may move to a richer notion of human flourishing. The debate surely cannot be resolved in the closing lines of this essay. But it may be helpful to briefly anticipate future arguments and suggest why I think the strong normativist position is preferable.

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For a start, health care is in the midst of qualitative transformation, and the result will no longer resemble classic biomedicine. No longer is medicine practiced just by individuals. Instead, health care is increasingly practiced by teams, and, even further, by organizational agents. Professionals will no longer practice medicine individually. Instead, they will increasingly practice in teams, and, even further, with organizational agents. Nor is health care aimed at individuals. Health care now has dual orientation, to individuals and communities, with the attendant task of integrating the two orientations. With these shifts, we can no longer sustain the distinction between micro-ethical and macro-ethical domains. We must move beyond the traditional accounts, and develop an inter-ethic for those middle-level institutions that increasingly act as the agents of health care (Khushf, 1998, 1999a, 2000). These developments are most conspicuous in managed care, but they are present everywhere. Within the context of these changes, we cannot skirt the values associated with communal well-being. Individual flourishing and communal flourishing are intimately intertwined. As we come to terms with these new health care realities, we are forced to reassess some of the liberal ideals of science and individual agency that were associated with the classical paradigm. The debate between weak and strong normativists will play itself out as a dispute over the appropriateness of these shifts in health care. I believe that the inner logic of the evolution of medicine will favor the strong normativists. This does not imply that a simple priority should be given to an account of well-being that is socially specified. Fulford and Szasz correctly worry about how social values come to be embodied in institutions such as involuntary psychiatric commitment. I have that worry, too. Similarly, Nordenfelt is right to be concerned when Reznek sees the disease status of homosexuality as dependent upon social judgment regarding what is cruel. We are thus faced with a dilemma. Either we must separate communal/social values from medicine (something I argue is impossible) or we allow medicine to legislate those values on individuals that do not share them (something that I, along with liberals generally, would regard as morally inappropriate). Here the liberal versus communitarian debate plays itself out within medicine, and siding with Taylor (as a prominent communitarian) has its dark side. A third alternative escapes the liberal/communitarian impasse (Khushf, 1999b). It does not presuppose the centralized health systems taken for granted by Nordenfelt, Fulford, and Reznek, but instead allows alternative communal visions of flourishing to be linked to alternative standards and forms of health care. Plural visions of human well-being translate into plural types of health care, reflecting multiple communal options within a single society. Elsewhere, I have elaborated further on this alternative (Khushf,

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1999a, 2000). Here it suffices to note how much is at issue in the debate on health concepts. At the beginning of this essay, I pointed to an unthematized issue lurking behind the seemingly disconnected interdisciplinary disputes on health and disease, giving order to the disparate literature on health and disease. That same subtle something coincides with that which Taylor says he never quite rightly expresses. It is none other than the core problem of modernity itself, with its deep linkage between the problems of scientific knowledge, human agency, and social polity. Little wonder that it has been so difficult to bring this problem to language. As long we allow the positivist project to frame the issue, we could not appreciate its full scope. Now we can see how this "boundary defming problem" (Caplan, 1992) in the philosophy of medicine provides a segue way to some of the richest debates of our day. The debate on health and disease is no less than a debate on the whole enterprise of modem health care, its nature, and how it should be configured, and that is no less than a debate on the nature of modernity itself. Acknowledgements

Thanks to Charles Bryan, Edmund Erde, Lennart Nordenfelt, Alfred Nordmann, and Christopher Tollefsen for helpful comments on an earlier version of this manuscript.

Two

PHILOSOPHY INTO PRACTICE: THE CASE FOR ORDINARY-LANGUAGE PHILOSOPHY By K. W. M. Fulford 1. Introduction

I am delighted and honored to contribute a chapter alongside George Khushf to Lennart Nordenfelt's Health, Science, and Ordinary Language. Nordenfelt has asked me to concentrate on my work in this area. As he so ably describes, we have much in common work. I will concentrate, though, on some of the differences between us. At the heart of both our theories is an analysis of the medical concepts, health, illness, disease, and so on, as they are used in broadly agentic, as distinct from the standard functionalist, terms. One difference between us, is that whereas Nordenfelt has focused on these concepts primarily in general bodily medicine, I have focused on their uses primarily in psychiatry. I will therefore respond to Nordenfelt's observations especially by reference to the analysis of the concept of mental disorder set out in my Moral Theory and Medical Practice (\989) and subsequent publications. However, most of my comments will concern where, as Nordenfelt puts it in the title of his contribution to this book, medical theory should go. My conclusion will be that if by "medical theory" we mean medical philosophical theory, then it should become an integral part of everyday clinical work and scientific medical research. The last ten years has seen a positive explosion of philosophical theory in psychiatry. The philosophy of psychiatry, however, has already taken its first small but highly significant steps from theory into the practical arena. In this chapter, I will deal with these first steps, particularly as taken by ordinary-language philosophy. I will describe them in relation to clinical practice (Section 2), to the role of values (Section 3), and to scientific research (Section 4). Taken together, these first philosophical steps will suggest the need for a collaborative approach to work in this area (described in Section 5). The significance of these first steps is not limited to psychiatry. Indeed, in stark

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contrast to psychiatry's second-class status in both biomedicine and bioethics, in what we might call biophilosophy, psychiatry is leading the way. The take-home message of my comments will thus be "psychiatry fIrst!" 2. Ordinary-Language Philosophy and Clinical Practice This fIrst part of this chapter, then, deals with the role of philosophy in clinical practice. Rather than discussing this role in general, I will illustrate it with a project on which Nordenfelt and I have been working together with Tony Colombo (as principal researcher) at Warwick University. What I will call here the Models Project is in effect a case study in the role of analytic philosophy in clinical practice. It is a case study, moreover, in the role of a particular kind of analytic philosophy, associated especially with a former Professor of Moral Philosophy at Oxford University, J. L. Austin (19561957). This is called ordinary-language philosophy (or sometimes, more grandly, linguistic analysis). Following a brief description of the Models Project, I will outline some of the ways in which it illustrates the importance of ordinary-language philosophy for everyday clinical work in psychiatry. I will also indicate some of the connections between the Models Project and the more theoretical results set out in my Moral Theory and Medical Practice. A. The Models Project: A Brief Outline

The Models Project, as its name implies, is concerned with the implicit models (or concepts) of disorder which structure mental health practice. Recent failures of community mental health care form the practical background to the Project. At their worst, these failures have resulted in high profIle cases like the tragic murder in the United Kingdom of Jonathan Zeto by a man suffering from schizophrenia. Such cases, however, make up only the tip of an iceberg of patients failing to receive the care and treatment they need. A number of offIcial inquiries (for example, the Report of the Clinical Standards Advisory Group, 1995) and research reports (Rogers, Pilgrim, and Lacey, 1993) have investigated the failings of community care. They have all highlighted the need for better communication between different agencies (psychiatrists, social workers, and others) as the basis of a collaborative or team approach to the clinical management of mental disorders in the community. These studies, however, have failed to explain precisely why communication breaks down. The hypothesis guiding the Models Project is that communication between agencies may break down because those involved fail to recognize

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their different ways of understanding mental disorder. Textbooks give the impression that everyone shares a balanced biopsychosocial concept of mental disorder. Theoretical work in analytic philosophy (Fulford, 1989) and the social sciences (Colombo, 1997), on the other hand, in addition to much anecdotal evidence, suggests that people with different backgrounds and experiences may bring very different implicit models of mental disorder to bear in practice. This would explain the failures of communication we see in community care, since the different agencies involved do have very different backgrounds. Rendering the various implicit models explicit, therefore, could help to improve both inter-agency communication and standards of collaboration in clinical care. In the Models Project, we are combining empirical social science techniques with philosophical analytic methods to identify and characterize the implicit models involved in the community care of people with long-term schizophrenia. The study design involves using a semi-structured interview to assess the responses of five key agencies (psychiatrists, social workers, nurses, patients, and informal caregivers) to a detailed case vignette. The vignette describes a man, Tom, whose behavior suggests that he may have schizophrenia. The vignette, however, does not mention any particular diagnosis. Exactly how an individual responds to Tom's story, therefore, their diagnosis, proposed treatment, and so forth, reflects their implicit model of disorder. We have developed a reliable scoring system that allows us to summarize the detailed information derived from the interviews in the form of twoway tables, or "models-grids." The models-grid in Figure 1 shows the disparities between the responses of 20 psychiatrists and 20 social workers to Tom's story. I will describe these results in more detail below. The key point, though, is that the yawning gap between these two key groups' models of mental disorder indicates the potential for conflict rather than communication between them. The individual comments of respondents bears out this potential for conflict. For example, one psychiatrist said, "they (social workers) are not willing to acknowledge the importance of early medication." By contrast, a social worker said, "they (doctors) place their desire to treat patients before safeguarding their basic civil rights." We have found similar wide differences between community psychiatric nurses, patients and caregivers. We have also been able to link differences in implicit models directly with problems in practice using a modified form of critical incident technique. In a future study, we will be developing a short self-score questionnaire based on the results of the interview study. We will use this questionnaire to test the extent to which our results are reproducible across a wider range of clinical contexts. Some exciting developments are emerging here, including a

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project already underway in partnership with Nordenfelt's department in Sweden. The Models Project is a first for philosophy and mental health. It is also a first for collaboration between researchers and the users of mental health services, the patients and informal caregivers who will eventually benefit from the results of the research. Instead of contacting patients and caregivers in the conventional way through hierarchical clinical teams, we recruit them directly from local user groups. This creates a level playing field in which all those involved, including professionals, patients and caregivers, can feel confident that their voice will be heard on an equal basis. This will be particularly important when we come to turning the results of the Project into training programs. We plan to use our results and methods (the quick-score questionnaire, the models-grids, and others) as the basis for a unique approach to joint user-provider training workshops. With this fmal stage of the Project, collaborative research will thus be converted through joint training into shared clinical care. B. Ordinary-Language Philosophy and the Models Project The Models Project illustrates a number of the ways in which ordinarylanguage philosophy can be used to inject philosophical theory directly into the lifeblood of clinical practice in modem mental health care. Conceptual problems are the point of contact here between philosophy and practice. Insofar as it is distinct from science, philosophy is concerned with conceptual problems (Fulford, forthcoming, a). The problem of disparate implicit models among mental health practitioners is, in part, a conceptual problem. Ordinary-language philosophy brings to this conceptual problem, a shared understanding of its origins, an appropriate methodology for dealing with it, and practically relevant results. I will consider each of these in tum. i. A Shared Understanding of the Origins of Conceptual Problems

According to ordinary-language philosophy, conceptual problems arise in part from our limited ability to reflect directly upon, and hence to defme, the concepts through which we make sense of the world around us. Outside of philosophy, though, we do make sense of the world. The idea, then, which is generally ascribed to Wittgenstein, is that people are better at using concepts than at defining them. Time is a standard example of a concept that we use

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effortlessly, for the most part, but cannot defme. Thus, a gap may exist between explicit defmitions (whether produced by philosophers or nonphilosophers) and the concepts we actually use. This way of understanding conceptual problems coincides directly with the problem of conflicting models of mental disorder in the multi-agency teams of modem mental health care. If, as most health-care professionals imagine, and as the text books suggest, everyone ascribed to a balanced biopsychosocial model, there would be little room for conflict and disagreement. Based, however, on the official inquiries and research reports noted earlier, we can make a strong case that the various agencies employ very different models. More significantly, and in accord with the insights of ordinarylanguage philosophy, those concerned are not fully aware of the differences between them. They employ implicit models which in shaping their approach to diagnosis, treatment, and so forth, operate at the level of intuitive or craft knowledge rather than by way of a fully conscious reflective process. Such a situation leaves much room for conflict, disagreement, and failure of collaboration in clinical care. Ordinary-language philosophy, it is important to add, does not prioritize the use of concepts by "experts." It does not assume, as does Boorse (1975) for example, that the use of disease concepts in medical textbooks trumps their use by doctors in the clinic, or by other health-care professionals (nurses, social workers, and so on), or indeed by patients, informal caregivers, and lay or non-professional people in general. Ordinary-language philosophy deals with concept use as we fmd it. As another Oxford philosopher, Gilbert Ryle, put it, ordinary-language philosophy sets out to describe the "logical geography" of the concepts in a given area of discourse (Ryle, 1980). I will be returning later to Ryle's metaphor of logical geography. But ordinary-language philosophy, like science, starts from the facts (facts of linguistic usage in this case). Ordinary-language philosophy, then, consistently with the methodology of the Models Project, offers a "level playing field" without privileging rank or title. All agencies are represented on an equal basis. This level playing field, as noted above, was directly reflected in the Models Project by the involvement of the five key groups on an equal basis at all stages: in the planning of the study, the design of the test instruments, and, most importantly, in the method of accessing research participants. Health researchers typically work through the hierarchical arrangements of health-care clinical teams. In the Models Project, by contrast, we approached participants for each group directly through their own representative organizations. Thus we approached patients through patient self-help groups, psychiatrists through the Local Health Authority, and so forth. In the later stages of the project, we will invite all five groups similarly to contribute to the validation and assessment of the results and to help both in the planning of

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ongoing studies and the development of clinical training materials (see below). Ordinary-language philosophy and modem mental health care both deal, then, not with explicit defInitions but with concept use as implicit in everyday discourse. I give many examples in my Moral Theory and Medical Practice of the contrast between use and defmition relevant to the philosophy of psychiatry. In one perhaps surprising example, although it accords with the insights of ordinary-language philosophy, textbook defmitions of delusion directly contradict the concept's use in practice as illustrated, in part, by the examples in those very same textbooks. I return to this in more detail later. But the point is that, while delusions are defIned in the textbooks as false or unfounded factual beliefs (Harre and Lamb, 1987), in practice they include value judgments (for example some delusions of guilt in depression, see Fulford, 1989, Ch. 10; also, 1991). As in the Models Project, then, philosophers should not limit themselves to textbook defmitions of delusion, they should also study the concept as it is actually used in practice. Limiting their attention to textbook defmitions of delusions has indeed led a number of philosophers (for example, Glover, 1970; Flew, 1973; and Quinton, 1985) to build theories of the meaning of the clinical concept of delusion on the mistaken assumption that delusions are limited to false factual beliefs. An ordinary-language investigation of delusion (which includes ordinary medical language) shows that the concept includes much more than false factual beliefs. As a former Professor of Psychiatry at the Institute of Psychiatry in London, Sir Denis Hill, put it, the effect of ordinary-language philosophy in this respect is rather like that of psychoanalysis: both are "consciousness-raising exercises" (personal communication). How, then, should we go about this consciousness-raising exercise? ii. An Appropriate Methodology Wittgenstein had a negative spin on the fact that conceptual problems, arising as they do from our limited powers of reflective defmition, are selfcreated. He thought that this made philosophical problems an artefact of philosophy and that recognition of this fact would lead philosophy to selfdestruct. Austin, by contrast, had a positive spin. He believed that our welldeveloped powers of concept use gave us a probe or microscope (not his metaphors) for meanings. In other words, if we are better at using concepts than at defIning them, we should do some fIeld work. Rather than tackling conceptual problems passively, by sitting alone and reflecting on them philosophically in a study in Oxford or Link6ping, we should actively investigate how people actually use the relevant concepts in a given area of discourse.

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We have done exactly this in the Models Project. In Moral Theory and Medical Practice, I adopted a half-way house approach, looking at the uses

of the medical concepts mainly in secondary sources, such as medical textbooks (as with delusion, above) and lay accounts of illness. In this I was following the master: the nearest that Austin came to looking at primary sources of concept use was his study of the transcripts of legal cases (Austin, 1956-1957). In Moral Theory and Medical Practice, I extended the method a little to what might be called tertiary sources: I carried out linguistic metaanalyzes of the debate between Thomas Szasz (1960) and R. E. Kendell (1975) about the validity of the concept of mental illness (in my fIrst chapter), and of Boorse's (1975) influential work on illness and disease (in my third chapter). Both meta-analyses exploited contradictions between the defmitions put forward by these authors and the way they themselves actually used the relevant concepts in their papers. Boorse, for example, put a value-free defInition of disease at the center of his analysis, but his own use of the concept remained value laden. That even Boorse, an experienced analytic philosopher with a vested interest in disease being value free, cannot avoid using the concept with evaluative connotations offers strong evidence for an essential evaluative element in the meaning of the term. Using secondary and tertiary sources can be highly productive, therefore. Even so, only with the Models Project, in partnership with Tony Colombo as a social scientist, have I fmally been able to apply ordinary-language philosophy's method to genuinely primary sources of linguistic usage in the way that Austin proposed. As a method of inquiry, ordinary-language philosophy has been criticized for amateurism. The analysis of language use, professional linguists in particular have argued, belongs to professional linguists (Fann, 1969). Amateur, it is perhaps worth noting, is a term of commendation rather than of criticism in England! But the criticism is anyway misplaced. The insights of linguistics would indeed have been relevant in Austin's early sketches of the method of ordinary-language philosophy. But this is not an argument against ordinary-language philosophy. It is rather an argument for collaboration between ordinary-language philosophy and linguistics. As we will see later (in Section 5), an important strength of ordinary-language philosophy as a method of inquiry is that it is readily combined with, rather than being exclusive of, other methods. In the Models Project, we have combined philosophy not with linguistics but with social science. Philosophy has provided the analytic skills, social science the empirical methods. On models of disorder, the two disciplines already overlap. In Chapter 5 of Moral Theory and Medical Practice, I cite social science studies of lay models of illness which describe, though sometimes in different terms, many of the same implicit elements of meaning that I had identifIed analytically. In the Models Project, we have taken the

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synergy between philosophy and social science considerably further by combining empirical and analytic methods. The Project employs two main empirical methods: fIrst, a case vignette with a semi-structured interview to assess respondents' implicit models; second, a modifIed form of critical incident technique to look for correlations between conflicting models and failures of collaborative clinical care. Analytic philosophy, on the other hand, has shaped the content of the study: the elements of the case vignette and the questions asked in the semi-structured interview are a direct product of philosophical analytic work on concepts of disorder. Philosophical analysis will also play an important role in the interpretation of the results. Ordinary-language philosophy is thus a natural partner of other methods, whether linguistic or scientifIc. As I have described in detail elsewhere (Fulford, 1990; also Fulford, Adshead, and Davies, forthcoming), ordinarylanguage philosophy has a number of other methodological virtues: it tackles small scale, manageable problems rather than grand metaphysical theories; it has modest theoretical ambitions, seeking clarifIcation rather than wholesale revision (though in revealing inconsistencies between defmition and use it may lead to revisions, as, for example, in the case of the use of the term "psychosis," in the work of Jackson and Fulford, 1997). Also, since it works at the level of everyday usage, its results tend to be directly relevant to the conceptual problems arising in clinical work and research. How, then, do things turn out in practice? iii. Practically Relevant Results The results of the Models Project have yet to prove their practical value. The Project is underway, and the ultimate test of the practical value of its results will be improvements in practice. This is an ambitious test for philosophy. It corresponds, however, with one of two general constraints on philosophical theory I introduced in Chapter 1 of Moral Theory and Medical Practice (the other constraint being the more familiar theoretical constraint of logical consistency and comprehensiveness). As I argued in Moral Theory and Medical Practice, philosophical theory, in dealing with the concepts of health, illness and disease, starts from problems in practice. Therefore, it must also end with practice. A philosophical theory of the concepts of health, illness, and disease, that fails to make a difference of some kind to practice, is at best incomplete, at worst plain mistaken. ClarifIcation may be all the difference it makes, but the philosophical theory must make a difference of some kind. Consequently, in this area the difference between theory and practice, between pure and applied philosophy, is more apparent than real (Fulford, 1995).

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The results of the Models Project to date, although not yet measured directly against the ultimate test of practical utility, certainly look promising and in precisely the way one would expect of a project in ordinary-language philosophy. That is, they give us a more complete picture of the operative concepts. In Sir Denis Hill's terms, noted above, the Project is raising our level of consciousness of the concepts we actually use in practice. The Models Grid shown in Figure 1 illustrates some of our preliminary results. It sununarizes the pooled results for two of our target groups, psychiatrists and social workers. The columns represent the six key models which, on philosophical, clinical and sociological grounds, we anticipated would be implicit to a greater or lesser extent in practice. The rows represent the key elements of these models, as defmed originally by Tony Colombo (1997). The letters in the cells (P for psychiatrists, S for social workers) represent respondents' comments on Tom as recorded in the semi-structured questionnaires. Behind each letter, then, stands a rich set of qualitative data (coded with an inter-observer reliability of over 81 percent). On diagnosis, for example, psychiatrists' comments reflected elements of the medical model: "I think that he (Tom) is clearly suffering from some type of mental illness and that it looks quite serious judging by the psychotic symptoms," said one; another said, "On this information I would say he (Tom) has a serious mental illness, no question about that." Social workers' comments, by contrast, reflected a social construct model. One said, "there are a lot of stressful events in Tom's life right now and in the past which are eating away at his mental health," while another said, "I would say that there are a number of things wrong, mostly to do with life-events during the course of growing up which are now causing both Tom and his family a great deal of distress." The Figure thus shows the extent of the disparity between these two key groups. Psychiatrists' comments reflected a strong and consistent commitment to a medical model of Tom's problems. They saw him as suffering from some type of "serious mental illness." Social workers, by contrast, understood Tom's problems more in terms of a social model: he was "mentally distressed" due to stressful events in his life. The gap between the two groups was not complete. Social workers shared with psychiatrists a "medical" model in that they recognized that "the use of medication is okay in principle, at least for some people." Psychiatrists, conversely, shared with social workers the importance of recognizing that "psychological and social factors are important (in defming the etiology of Tom's mental health problems) .... There must be in some way a genetic predisposition and I suppose stresses of various kinds can precipitate mental illness." Overall, however, there was a considerable gap between the way these two key clinical groups understood Tom's problems.

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We have found similar though not quite as dramatic disparities between our other groups. Thus, community psychiatric nurses shared a medical model of diagnosis with psychiatrists but expressed a mixed medical and social model of treatment. Patients, as one of our two user groups, were divided into those with a broadly medical and those with a broadly social response to Tom (possibly correlating with the severity of their own disorders). Informal caregivers, our other user group, showed no regular adherence to a single model. As I noted earlier, these disparities in models of disorder leave much room for conflict rather than co-operation in the practical management of problems like Tom's on the part of multi-agency teams. If the key "agencies," including the patient, have very different models of the problem, their objectives, their priorities, their choice of treatments, and so on, will all be potentially at odds. We have preliminary evidence from the second part of the study, the critical incident interviews, that problems in practice do indeed follow the observed disparities between models. That the models reflected in the responses to Tom's story are implicit rather than explicit in the minds of those concerned, as anticipated by Austin's ordinary-language philosophical theory, greatly increases the room for clinical conflict. Had we simply asked our respondents their views on the diagnosis, etiology, treatment, and, so forth, of schizophrenia, they would all have come up with a balanced "biopsychosocial" account reflecting the textbook approach. This is the counterpart of "definition" in ordinary-language philosophy: explicit understanding expressed in reflective mode. The responses to Tom, on the other hand, are the counterpart of "use" in ordinarylanguage philosophy: implicit models reflected in what we actually do, in the way we respond, feel and behave, in practice. The overall effect, then, of this study should indeed be, as Sir Denis Hill anticipated, to raise awareness of the implicit conceptual frameworks we bring to bear in our everyday clinical work and of the considerable extent to which these differ from the models we think we use. Tony Colombo and I have reported our results in this preliminary form to a number of relevant groups, both at conferences and in teaching sessions. Our listeners are at first surprised by and then come to identify with our findings. I had a dramatic example of this recently with a group of trainee psychiatrists in a session on "Models of Mental Disorder." The session immediately preceding had dealt with the etiology of schizophrenia, covering biological, social and psychological factors. The group were thus primed to respond to Tom's story with a balanced biopsychosocial view. In the event, the responses they gave showed an even stronger bias toward an exclusively medical model than the responses given by the psychiatrists in our main study.

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The extent of the bias shown by this group of trainee psychiatrists was the more remarkable because I did not run through the full research interview with them. I simply gave them the case vignette and asked them to write down what aspects of diagnosis, etiology, and treatment they felt would be important clinically if they were faced with Tom. I summarized their responses on a blank models-grid on an overhead and showed them, by overlaying their responses with a series of models-grids derived from our main study, how their responses coincided with or differed from those of the five groups in the Models Project. Initially, they were astonished by the extent of their focus on the medical model and the dramatic differences between their responses and those of our other groups (social workers, community psychiatric nurses, and, crucially, patients and caregivers). As we worked through the results, though, the trainees themselves came up with examples of their own of disparities, mysterious at the time, between their own clinical priorities and those of other agencies. This in tum led into a more detailed discussion of the different models, of the debates in the literature, and so forth. By the end of the session, then, the trainees were aware of (1) the extent to which their own intuitive approach in practice was biased toward biological aspects of schizophrenia; (2) the radically different models of other groups; and (3) the details of the different models they were likely to encounter in their clinical work. The reaction of these trainee psychiatrists is encouraging. The first step in improving practice is to become aware of the problem. More than this, though, once we make the disparities in models explicit, we have taken the first step to changing the disparities from a problem to an asset. A number of important intermediate steps, in moving from conceptual problem to practical asset, remain: our results must be replicated; we must develop short forms of the semi-structured interview for use in training programs; and we must set up collaborative training sessions involving all agencies, including patients and caregivers. The aim of these training sessions, as with my group of trainees described above, will be to improve mutual understanding and hence communication between agencies. We will achieve this aim, however, not by homogenizing practice but through a balanced heterogeneity of models. Such a balance is a positive asset for practice not least because it respects the legitimately different perspectives on mental disorder represented by different agencies, including patients and caregivers. These perspectives bring us to the role of values in clinical practice.

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3. Ordinary-Language Philosophy and the Role of Values

The practical outcomes of The Models Project are consistent with the kind of results we should expect from ordinary-language philosophy as we move from theory into practice. This approach, as I have described, maintains that conceptual difficulties arise in part from gaps between use and defmition. Attempts to defme concepts directly, such as dictionary defmitions, the accounts in textbooks, and even the analytic· work of philosophers, yield only limited or partial understanding. Looking directly at the uses of the relevant concepts, on the other hand, gives us a more complete picture of their meanings. The Models Project has begun to sketch out a more complete picture of the conceptual models implicit in the approaches of different agencies to the management of schizophrenia. The specific aim of a balanced heterogeneity of models, rather than conceptual homogenization, follows in a general way from the descriptive rather than prescriptive nature of ordinary-language philosophy. Ordinarylanguage philosophy aims, in the first instance at least, to set out the logical geography (Ryle's term introduced above) as fully as possible. If inconsistencies and gaps exist, then ordinary-language philosophy may lead in its own right to revisions. Mike Jackson and I proposed a revision in the use of the term "psychosis" in the work I noted earlier. Psychosis has come to be equated with pathology. The JacksonlFulford proposal, which directly reflects the ordinary use of the concept of psychosis, is that a distinction should be made between "pathological psychotic experiences" and "nonpathological psychotic experiences" (Jackson and Fulford, 1997). Nonetheless, ordinary-language philosophy, in contrast to Boorse's philosophy and in some respects Nordenfelt's, does not set out in the first instance with the aim of redefining terms. Ordinary-language philosophy sets the agenda for revision but only by making us fully aware of the items on the agenda (the features of the logical geography) for which any proposed redefmition must account. Accounting for these features, I should add, does not necessarily mean endorsing them. As I describe in the first chapter of Moral Theory and Medical Practice, accounting (philosophically) for the features of a given logical geography means offering an explanation, either of why the logical geography in question really does have the features it has, or of why its features are illusory. The aim of a balanced heterogeneity of models, rather than homogeneity, also follows specifically from the role of values in the medical concepts. I do not have space here to give a full theoretical account of this point. I set it out in detail in Moral Theory and Medical Practice (especially Chapters 3-6; also, Fulford, 1999b and 2000a), drawing directly on the work of a number of Oxford philosophers in the "ordinary-language" tradition, notably R. M.

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Hare (1952 and 1963), G. J. Warnock (1971), and J. O. Urmson (1950). The main point, however, deserves mention because it goes directly to an important difference in emphasis between Nordenfelt and myself arising from our respective focuses on general concepts of health (Nordenfelt) and mental disorder (Fulford). In the next subsection, I will fIrst state the point, then illustrate it, and then indicate its importance for the ways in which Nordenfelt and I treat values in our respective theories. A. Values: From Theory to Practice The point, then, is that there is a difference in the degree of homogeneity of human values between mental health and bodily health. Of course, "mental" and "bodily," in this context, sit at either end of a spectrum rather than of a polar opposition. Across this spectrum, however, people largely share values in the areas of experience and behavior covered by general bodily medicine, especially the high-tech areas which have been so successfully developed within the "medical" model, whereas their values differ greatly in the areas of experience and behavior covered by psychiatry. Thus, severe chest pain and collapse (illness-experiences involved in a "heart attack") qualify, in themselves, as bad experiences in anyone's system of values. Here our values are shared. But in mental health we are concerned with areas in which our values are characteristically not shared: belief, desire, volition, emotion, and so forth. In the areas with which psychiatry is concerned, what one person, group, or culture considers good may be considered bad from the perspective of another person, group, or culture. The varying reactions to Tom's story in the Models Project directly reflects the heterogeneity of the human values operative in mental health. This heterogeneity flows through into the practical arena in mental health in many ways. In the first place, it extends the agenda of bioethics. Thus, in bodily medicine we have become accustomed to the idea that people's values may differ widely when it comes to treatment. This forms the basis of the move, rightly promoted by bioethics, from the dictatorship of medical benevolence to the democracy of patient autonomy (though "patient choice" threatens to become so dominant a value in some countries as to constitute a new dictatorship). In mental health, by contrast, as one of my colleagues, Dr. V. Y. Allison-Bolger, has put it, the diversity of human values has the consequence that patients must "have a say" not just in how their problems are treated but in how they are understood in the first place. A "scientifIc" counterpart of this is to say that we must take individual values seriously in psychiatry because they are variable, while we can ignore them in physical medicine because they are more or less constant. This has implications for psychopathology (Jackson and Fulford, 1997), for classifIcation (Fulford, 1994 and forth-

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coming, a}, and for the diagnostic process (Fulford and Jackson, forthcoming), consequences which, if ignored, can and do lead to grossly abusive practices (Fulford, Srnirnoff, and Snow, 1993). The difference in degree of homogeneity of values between physical medicine and psychiatry, is reflected in two differences of emphasis - one in theoretical orientation, the other in practical aims - between Nordenfelt's (general-health focussed) and my (psychiatry focussed) theories. The difference of emphasis between us in theoretical orientation can be understood in the terms of a long-running debate in ethical theory about the logical relationship, or relationship of meaning, between description and evaluation. This debate is also known as the is-ought debate. In its modem form, the is-ought debate has been primarily between descriptivists (like G. J. Warnock, 1971) who believe that in some circumstances value judgements can be reduced to descriptions, and nondescriptivists (like R. M. Hare, 1952, 1963, and 1981) who believe that they cannot. The complex moves in this debate are an under-utilized resource for medical philosophical theory. I draw on some of these moves in Chapters 3 and 6 of Moral Theory and Medical Practice and have developed them further in two more recent articles (Fulford, 1999, and 2000a). Like Nordenfelt, I argue that all health concepts, including disease and dysfunction, are essentially evaluative in nature. Also like Nordenfelt, I argue that some of the medical concepts (like all value concepts) may carry primarily descriptive meaning. The importance of the diversity of values in the area of mental health, means that issues that are side issues in Nordenfelt's work are of central concern in mine: one example is the issue Nordenfelt raises (notably in this volume pp. 105-106) about whose values should be relevant to specific health care decisions. This is a side issue if people's values are by and large similar; it is a central issue if people's values are different. Similarly, in physical medicine one can conclude, with Nordenfelt (for example, this volume, p. 106), that "babies, the mentally retarded, and the senile" are "nonstandard cases" and that "for the normal adult," the patient's values should prevail. But in psychiatry the non-standard is, as it were, the norm. The difference of emphasis in theoretical orientations between Nordenfelt and myself - that differences of values are peripheral in Nordenfelt's theory while lying at the center of mine - leads directly to the second difference in emphasis between us, the difference in practical aims. Thus, Nordenfelt, working primarily with general medical health concepts in mind, seeks "a reliable judgment of the subject's health" (this volume, p. 106). But if Nordenfelt means by "reliability" a high degree of inter-observer agreement, then, in psychiatry, we must be prepared in some circumstances to sacrifice reliability for validity. For if health, illness, and disease are value concepts, and if the relevant values in psychiatry are diverse, then inter-observer

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agreement on health judgements in psychiatry can only be achieved by imposing one person's (or group's) values on another. By sacrificing reliability for validity, some may fear that we risk falling into an extreme value relativism leading to chaos. But human values, even if diverse, are not chaotic. And historically, the greater danger for psychiatry has been, not value relativism but absolutism (see Fulford, forthcoming, a). Once this is recognized, the emphasis of the practical aims of theory shifts away from consensus (reliability) to what I have called elsewhere "dissensus" (Fulford, 1998a), from the desire for certainty to tolerance of uncertainty (Fulford, 1996), from criteria to process in ethical reasoning (Fulford, forthcoming, b), and from a merely contingent to an essential link between ethical reasoning and communication skills in medicine (Fulford and Bloch, forthcoming). These practical consequences, except in the case of medical student training (see below, the Oxford Practice Skills Project), are merely foreshadowed in my philosophical work in this area. But as described above, they are consequences that are consistent with and in some respects have directly influenced, the practical objectives of the Models Project. I must add one further practical corollary of recognizing the heterogeneity of values in mental health. In arguing for the importance of values in defining the health concepts, neither Nordenfelt nor I argue against the importance of facts. Value theory, at least in the analytic philosophical tradition in which we both work, adds values to rather than subtracting facts from the conceptual structure of medicine. Whether we emphasize value consensus (as in Nordenfelt's work on the general health concepts) or value dissensus (as in my work on these concepts as used in psychiatry), the importance of science (insofar as science itself is value-free) remains unchanged. Nordenfelt and I share the theoretical objective of using analytic philosophical methods to identify and characterize the ways in which values (as well as facts) come into the definitions of the medical concepts (health, disease, illness, dysfunction, disability, and so forth). As Nordenfelt carefully notes (see especially the whole of his Section 3 in Chapter Five), the logical relationships between description and evaluation may be highly complex. Notably, while a given value term may indeed directly express a value judgement, this is the exception rather than the rule. Everyday language (which includes, as I emphasized above, both lay and medical language) weaves together evaluative and descriptive elements of meaning (along with altogether different logical elements) in a rich and subtle tapestry. The richness of this tapestry underpins the rationale of ordinarylanguage philosophy as a philosophical method. But ordinary-language philosophy aims primarily to identify and characterize the elements in the tapestry, not to reduce one to another, and still less to remove or exclude one or another element (the descriptive or evaluative element) altogether.

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B. A Full-Field Model

We return, then, to the characteristic output of ordinary-language philosophy as raising our consciousness of the full meanings of the concepts we employ in everyday usage. In Moral Theory and Medical Practice, as Nordenfelt correctly reports, I called my theory a "reverse" model of the medical concepts. I called it this to emphasize that value theory reverses the logical (though not the causal) relationship between illness and disease that is assumed by the standard medical model. Instead of illness being defmed by disease (as Boorse, 1975, for example, suggested in his version of the medical model), in a "reverse model" illness defmes disease. Perhaps, though, "full field" would be a better description of my model. The analysis developed in Moral Theory and Medical Practice replaces both the half-field (fact only) medical model of mental disorder and the half-field (value only) antipsychiatry model with a full-field model which combines these two halffield models. I show this diagrammatically in Figure 2. The full-field model brings together factual with evaluative logical elements, the patient's experience of illness with medical knowledge of disease, and, crucially for psychopathology, the (medical model) analysis of disease in terms of disturbed function with the (NordenfeltlFulford model) analysis of illness in terms of disturbed agency or action. Again, the model is inclusive not exclusive. In a full-field model of the medical concepts, we give each of the elements shown in Figure 2 equal importance in the conceptual structure of medicine. Similarly, then, each of the components of the full-field model, as Nordenfelt and I have both shown, has practical as well as theoretical significance. The value element has all the practical implications noted earlier in this part of my article. The whole of the right half-field, on the other hand, together with the factual (or descriptive) element of meaning, is broadly the area of science. Disease and dysfunction, as I have described, are nonetheless, in both Nordenfelt and my theories, value terms in the sense that, although carrying predominantly descriptive meaning, an inherent if hidden evaluative element of meaning determines their logical properties (see, in Moral Theory and Medical Practice, Chapters 3 and 4 on disease, and Chapters 3 and 6 on dysfunction; also Fulford, 2000a). Values, although present throughout the diagram, are more overtly evident in the left half-field of Figure 2; but this can be shown to be only because, for reasons similar to those discussed above in connection with mental illness, values in this area are more heterogeneous (see Moral Theory and Medical Practice, Chapter 5). The more overt value element in the left half-field in Figure 2 explains in part why illness and agency have traditionally been associated (as in Boorse's, 1975, model, for example) with ethical and practical aspects of medicine. The patients' experience of illness (the upper-left quad-

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The "Medical" Model /'

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/ Disease

FACT Failure of

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A Value-Based Model

V FACT L Failure Failure U of of E

Figure 2. Diagramatic Representation of the Relationship between the "Medical" Model and a Value-Based Analysis of the Medical Concepts. An ordinary-language analysis of the medical concepts gives us an enlarged or more complete view of the conceptual framework of medicine. The "medical" model, emphasizing the factual element in medicine, is a half-field view. The medical model is thus not so much mistaken as blind to the importance of the evaluative element in the meanings of the medical concepts. With the evaluative element, as described in the text, go two further logical elements: (1) the patient's experience of illness (alongside medical knowledge of disease): and (2) failure of action (alongside disturbances of functioning of particular bodily and mental systems).

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rant in Figure 2) forms a key theoretical element in an approach to medical student education which Tony Hope and I developed at Oxford, the Oxford Practice Skills Course. An important feature of this Course is that it treats ethical reasoning as a key ''practice skill" (see Hope, Fulford, and Yates, 1996). Nordenfelt, in his On the Nature of Health: An Action-Theoretic Approach (1987), and I emphasize equally the practical importance of agency or action (lower-left quadrant in Figure 2). This quadrant represents aspects of medicine which in the past were considered relevant mainly in the fields of medical law and ethics. "Loss of agency", however, is a key feature of the experience of illness. I prefer the term "loss of agency" to Nordenfelt's "disability" (p. 66 of this volume) because "disability" tends to be used of long-term more or less fixed conditions, a feature which distinguishes disability conceptually from illness (see Moral Theory and Medical Practice, Chapter 7). Loss of agency, moreover, distinguishes illness (insofar as the terms are not used synonymously) from disease. This is relevant for example to the loss of full agency implied by the ethical and legal concept of an excuse. Thus, illness, as the sociological literature in particular has emphasized (for example, classically, Talcott Parsons, 1951), is an excuse. People who are ill are, to a greater or lesser extent, not responsible for their actions. They are in this sense not full agents. People with a disease, on the other hand, if not actually ill, remain fully responsible. The difference is perhaps clearest in law in which disease (if serious) may mitigate while illness (if serious) excuses. The person who steals from a shop and turns out to have a serious but still asymptomatic cancer, may receive a lesser sentence on grounds of compassion, but they would still be considered legally responsible. Disease in this case mitigates. A person, by contrast, who steals from a shop in a state of confusion induced by low blood sugar due to diabetes would not be held responsible. In this case illness excuses because of the disturbance of agency it entails. The conceptual connections between agency, action, responsibility, excuses, and so forth, were a particular focus of Austin's work. Indeed, his seminal paper on ordinary-language philosophy takes the form of a study of excuses (Austin, 1956-1957). Austin used legal cases as his "database" of ordinary-language excuses. At the end of the article, though, he pointed to abnormal psychology as an even richer linguistic resource for philosophers interested in agency and actions. A number of philosophers besides Nordenfelt (1992) and myself (Fulford, 1993) have started to access this resource. The quadrant of the full-field model representing the agency component of the conceptual structure of medicine, if important in the past for medical law and ethics, could well turn out in the future to be no less important for medical science. This is counter-intuitive from the perspective of the traditional medical model, in which, as in Boorse's (1975) model noted earlier, the

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right half-field, the field of disease and dysfunction, is the proper conceptual reserve of medical science. So far as the traditional medical sciences (such as gastroenterology and cardiology) are concerned, limiting our science to the right half-field may well be sufficient. When it comes to the "new" neurosciences, though, which are the sciences relevant to work in psychiatry on the higher mental processes such as belief, desire and volition, the left half-field could well prove decisive (Fulford, 2000b). In the fourth part of this chapter, I will tum to the contribution of ordinary-language philosophy to research in the new neurosciences. 4. Ordinary-Language Philosophy and Scientific Research

Besides the misplaced charge of amateurism, noted in the second section of this chapter, ordinary-language philosophy fell out of favor with philosophers because it was considered empty. True but trivial, critics charged. That criticism is also misplaced. Ordinary-language philosophy is empty only to the extent that any methodology is empty until it is applied to something. As I have illustrated in Sections 2 and 3 of this chapter, ordinary-language philosophy is indeed fruitful when applied to practical problems in the area of mental health. In this section of the chapter I will show that ordinary-language philosophy is equally fruitful when applied to the research agenda of psychiatry. As just noted, I will be focussing here particularly on the agency quadrant of the full-field view shown diagrammatically in Figure 2. I will start by tracing the conceptual links between values and action in medical theory. I will then outline the key elements of my "action-theoretic" approach and the ways in which this is similar to and different from Nordenfelt's. Finally, I will illustrate a key difference between us by looking in detail at an action-theory analysis of the key psychopathological concept of psychosis. A. From Values to Action in Medical Theory According to yet other critics of ordinary-language philosophy, even when it is applied in a practical arena, it can only describe, not resolve, the conceptual problems with which philosophy is concerned. This charge, that ordinary-language philosophy begs the question, might seem pertinent when we move from values, as a generic element in the diagram in Figure 2, to action. The concept of action, after all, with its related stable of concepts (agency, responsibility, rationality and so forth), connects directly or indirectly with many of the deepest problems in philosophy: free will, personal identity, and the mind-body problem, to name but three. Here, then, it may seem, a mere

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description of ordinary-language use can do no more than repeat and restate these philosophical conundra. In a sense, this criticism is right. Ordinary-language philosophy, as I have emphasized above, does indeed have a primarily descriptive rather than directly explanatory motivation. Closer inspection, however, shows this to be a strength rather than a weakness of the method. As a working method, ordinary-language philosophy constitutes a ftrst step, no more and no less, in tackling conceptual issues. In Austin's model, ordinary-language philosophy is one way of getting started with some kinds of philosophical problem (see generally, Warnock, 1989, Chapter I). It is a powerful way of getting started, however, particularly in an area like mental health, precisely because it helps to make clear the features of the concepts with which we are concerned. Austin called this a ground-clearing exercise. We might think of it rather, in Ryle's metaphor of "logical geography," as an exercise in preparing the ground. Ordinary-language philosophy aims to describe the logical geography by setting out as fully as possible the features of the relevant concepts. With the ground prepared in this way, then, substantive philosophical analysis can get underway with a full view of the features of the logical geography for which it must account. Even as a ftrst step, ordinary-language philosophy can produce useful results. In Moral Theory and Medical Practice, it was a key step at several points in the argument. It showed that both sides in the psychiatry versus anti-psychiatry debate (represented respectively by Szasz, 1960, and Kendell, 1975), despite their surface opposition shared an unrecognized set of guiding assumptions (Fulford, 1989, Chapter I). This formed the basis for a deeper analysis of the concept of disease in which, as noted above, I showed that advocates of a value-free deftnition of the concept, such as Christopher Boorse, continue to use it with clear evaluative force (Fulford, 1989, Chapter 3; see also my analysis of Jerome Wakefteld's recent application to the medical concepts of a defmition of dysfunction based on evolutionary theory, Fulford, 1999b, and 2000a). This in tum led to analyses of disease (Chapter 4) and illness (Chapter 5) which, building only on the assumption that both are value terms (that is, terms whose meanings include an essential evaluative element), drew together a wide variety of their diverse properties in ordinary usage (set out and deftned originally in Chapter 2). Among other results, this reconciled the pro- and anti-psychiatry positions from which, in Chapter I, the arguments of this part of my book sprang. In ordinary-language philosophy, then, ftrst steps are not theoretically insigniftcant. All the same, as Austin put it, ordinary-language philosophy, if sometimes the ftrst word, is never the last (cited in Warnock, 1989, p. 5). With the Models Project, we have, as I described in Section 2 above, taken a second step by carrying parts of the theoretical structure developed in Moral

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Theory and Medical Practice fully into the practical arena. In raising our consciousness (in Sir Denis Hill's terminology) of the different models of disorder guiding practice, we aim to replace clinical conflict and misunderstanding (the practical counterpart of the psychiatry versus anti-psychiatry debate) with improved communication and collaborative decision making. This in tum connects with the wider, if less fully developed, practical implications of value theory for mental health practice outlined in Section 3 of this chapter. Ordinary-language philosophy, then, is successful, in the terms of this book, in carrying philosophical value theory into practice. However, as both Nordenfelt and I have emphasized, there is a deeper level of conceptual difficulty in medicine. This deeper level is connected, broadly, not with the role of values as such, but with the particular kind of value expressed by the medical concepts. As Nordenfelt describes, I adopt von Wright's term "medical value" to differentiate the negatively evaluated conditions of disease and illness from other categories of negatively evaluated condition, such as ugliness, wickedness, foolishness, and so on. For those authors, like Boorse (1975) and more recently Wakefield (1995 and 2000), who believe that medicine is dermed by a value-free core of biological theory, demarcating medical value presents no difficulty: medical value, according to these authors, is simply the negative value judgments attaching to states of disease dermed value-free by scientific criteria of disturbed functioning. This way of demarcating medical value, although consistent with the traditional medical model, requires a naturalized, that is value free, way of defining biological dysfunction. Nordenfelt and I are among those who believe that biological "dysfunction," contrary to the project of philosophical naturalization, includes an essential evaluative element of meaning. I have gone further, arguing that function itself contains an essential (albeit deeply hidden) evaluative element of meaning (see Moral Theory and Medical Practice, Chapter 6; also Fulford, 2000a). This position, which I have called "radical evaluationism" (Fulford, 2000a) is, I have argued, more self-consistent than any form of naturalism, including the sophisticated non-reductive naturalism proposed recently by the Warwick philosopher Tim Thornton (2000). But radical evaluationism carries with it a requirement for an alternative (that is, nonnaturalistic) explanation for the particular kind of value expressed by the medical concepts. The need for an alternative account of medical value leads, in my work, from value theory into the philosophy of action. I agree with Nordenfelt's focus on action theory. In terms of ordinary-language philosophy, we both recognize the importance of the prima facie conceptual connections between loss of agency (incapacity) and the experience of illness. I noted one such connection, in the ethical and legal concept of excuse, at the end of Section 3

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of this chapter. We also agree on another such connection, the part-whole parallel between function and disease on the one hand, and action and illness on the other. This parallel is to the effect that parts of bodies - livers, limbs, etc - function, while people as a whole carry out actions; correspondingly, parts of bodies get diseased, but people as a whole fall ill. To this point, then, Nordenfelt and I are in close agreement on the importance of action (as well as function) in the conceptual structure of medicine. In focusing on the analysis of general concepts of health, however, I believe that Nordenfelt underestimates the extent to which action theory offers resources for explaining psychopathology. In his account of my work in this area, he focuses on the use I make of Austin's concept of "ordinary doing." He is right to say that there is more work to do here (pp. 89-91, for example). Austin would have said the same. Even as a ground clearing exercise, his work on agency and action was left at an early stage when he died (before his 50th birthday). As I have emphasized several times, Austin's ordinary-language philosophy is at most only the first step in philosophical research. All the same, if my work on psychopathology is taken into account, it is fair to say that I have taken the ordinary-language analysis of illness as action failure further than Nordenfelt's account of my use of "ordinary doing" suggests. I will not go into the details of my analysis of illness as action failure (a kind of loss of agency); the analysis occupies most of the last two-thirds of Moral Theory and Medical Practice. But I would like to fill out Nordenfelt's account of my work briefly in the area of psychopathology. This will indicate how ordinary-language philosophy can be a useful first step, not only in taking medical theory into clinical work (as with the Models Project and philosophical value theory) but also into research. This in tum will pave the way for the "psychiatry first" concluding message that I signalled at the start of this chapter. B. An Action Theory Analysis of the Experience of Illness In this section, I will first outline the role of "ordinary doing" in my account of the primary experience of illness as a kind of incapacity. I will then broaden this account to indicate how it leads to analyses both of illness in general and of the many and diverse kinds of particular physical and mental illnesses. Finally, I will indicate how psychotic illness (which Nordenfelt implies, this volume pp. 90-91, I neglect) falls naturally out of this account, including, crucially, the core psychotic symptom of delusion.

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i. Ordinary Doing and the Primary Experience of Illness.

"Ordinary doing" (which is another concept I derive from Austin) means, as Nordenfelt indicates (this book, p. 57), the actions that people perform without, on the whole, having to think about them: reaching for a pen, standing up, saying "good morning," remembering where one's chair was when sitting down again, and so forth. Reflex or fully automatic "doings" (like blinking) are not included. Ordinary doing thus stands somewhere between a fully intentional action (that we think about and plan) and a fully automatic action (which, under normal circumstances, is not intentional at all). In this sense, as Nordenfelt puts it, ordinary doings are "pre-conscious" actions (this book, p. 74). Ordinary doings, however, may become consciously intentional when they are obstructed or made difficult in some way. In Moral Theory and Medical Practice, I give a number of examples of this (p. 188). Thus, walking is an "ordinary doing." It is normally not fully intentional but may become so when it is made difficult (as by a strong wind). Nordenfelt, although accurately characterizing my use of the Austinian concept of ordinary doing, goes on to imply (for example, in Section 2 of Chapter Five) that I have sought to analyze the experience of illness tout court as a failure of ordinary doing. A reader could understand some of my more synoptic statements in this way. But the role of ordinary doing in my theory is in fact considerably narrower. Its role is to identify the particular kind of failure of action which would mirror (and to this extent explain) the phenomenological features of the primary experience of illness (see, for example, pp. 120-125 of Moral Theory and Medical Practice). These features, as identified for example by medical sociologists, include, besides negative evaluation, a certain level of intensity and duration (we do not experience a mild, brief pain, for example, as illness). Intensity and duration, in tum, are defmed against what both Nordenfelt and I have written of, in different terms, as a given set of background norms specific to the experience of the individual. These norms, as I show, help to distinguish which, among our actions, are experienced as ordinary doings and hence potentially as failures of ordinary doing. This in tum leads to two further important distinctions by which the primary experience of illness is characterized. Thus, it explains, first, why the experience of being ill is distinct from the experience of things happening or being done to one. I do not, of course, limit the latter to direct manipulation. Second, and even more importantly, it explains why the experience of being ill is also distinguished from the experience of doing things, that is of agency. This is the "loss of agency" feature of illness, which, as noted above, has been emphasized by sociologists and forms the basis, among other things, of illness being a legal excuse. Loss of agency, moreover, in the form of failure

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of ordinary doing, can be shown to distinguish illness conceptually from dysfunction. A long philosophical story lies behind this last point (see Moral Theory and Medical Practice, Chapter 6). Briefly put, dysfunctionings, like functionings, are distinct from things that are done or happen to the functional object in question. In this respect, dysfunction and illness coincide. But dysfunctioning is also something that a functional object, natural or artificial, does (a machine or bodily part which is not functioning properly is doing something or failing to do something). In this respect, illness and dysfunction diverge conceptually. This divergence is a key and otherwise unexplained feature of the (Rylean) logical geography. The fact, therefore, that this divergence can be shown to be consistent with failure of ordinary doing, amounts to a strong linguistic-analytic signal that failure of ordinary doing forms an important conceptual element in the meaning of illness. ii. Ordinary Doing and Illness as Action Failure Up to this point in the analysis, the linguistic features of illness fit well with the features of failure of ordinary doing. I had to do considerable analytic work to reach this point. In Moral Theory and Medical Practice, this part of my analysis occupies all of Chapter 6 and the first part of Chapter 7. Even so, failure of ordinary doing forms at most a conceptual starting point for the analysis of illness. Failure of ordinary doing is only an origin, a conceptual germ cell, from which, combined with other elements, the diverse range of illness concepts (physical and mental), and indeed of other medical concepts altogether (disease, disability, trauma, and so on), must all be constructed. iii. Physical Illness and Mental Illness as Failures of Different Kinds in the Machinery of Action Ordinary doing, then, is heuristically fruitful in medical philosophical theory. However, in Moral Theory and Medical Practice, having taken the analysis of the primary experience of illness this far, I openly set my hand against further analysis of the concept of "ordinary doing." Austin, as is well known, provided a good deal of careful analytic ground work in the philosophy of action (Austin, 1956-1957; also, 1966), and the subject has recently made something of a come-back, though now more among philosophers of mind than moral philosophers (for example, Luntley, 1999). In Moral Theory and Medical Practice, however, I spell out that I will not be diving off into the metaphysical deeps of the philosophy of action. Instead, my strategy is to explore the extent to which, as a conceptual germ cell, failure of ordinary

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doing can help to explain, and must form an essential part of any explanation of, the features of the whole range of medical and related concepts. I do this by adopting, in Chapter 7 of Moral Theory and Medical Practice, another Austin image, the "machinery of action." Austin called attention to the complexity of actions. Moral philosophers have concentrated on intention, voluntariness, and so forth, as key elements of actions. But the machinery of action also involves judgment, foresight, memory, affect, control, and a wide variety of other elements. Given this range of elements, different kinds of illness experiences can be derived as failures of different kinds and in different parts of the machinery of action. In my Chapter 7, I consider bodily illness, specifically movement disorders and various kinds of sensory and perceptual defect, as well as the related concepts of disability and trauma. This builds on my analyses of the concepts of disease and dysfunction in earlier chapters (especially Chapters 2, 3, and 4 on disease, and Chapters 2, 3, and 6 on dysfunction). In Chapter 8, I extend the "machinery of action" approach from bodily illness to the extraordinarily diverse range of mental disorders (including obsession and alcoholism). In Chapter 9, I show how we can identify the elements of Austin's machinery of action in scientific classifications of mental disorder such as the ICD and DSM, once we know what to look for (see also Fulford, 1994). And in Chapter 10, I extend the analysis to the central species of psychopathology, the psychotic disorders (see below, sub-section iv). The concept of mental disorder, given the above analyses, now emerges as being more significant logically than that of bodily disorder. This is an early signal of my "psychiatry first" message. The signal has to do with the philosophical treatment of the diversity of mental disorders. I illustrate this diversity in Figure 3 which represents diagrammatically a Rylean logical geography. Physical illnesses, as I discuss in my Chapter 7, are primarily concerned with movement, sensation and perception. But mental disorders, as Figure 3 illustrates, cover a far more diverse range of experiences and behaviors. Mental disorders offer, therefore, both an explanatory challenge and an ordinary-language resource for philosophical analysis. A further explanatory challenge, also illustrated by Figure 3, is that mental disorders form a conceptual bridge between physical disorders, traditionally the preserve of science, and moral problems. In the medical model, the restricted varieties of bodily illness and their ready reduction (scientifically, on this model) to disease receive more attention. The medical model takes bodily illness (because conceptually uncomplicated) to be the paradigm according to which mental illness is measured. This was one of the assumptions common to pro- and anti-psychiatry in the debate about mental illness that, as I noted earlier, I identified in Chapter 1 of Moral Theory and Medical Practice. On the model of a Rylean logical geo-

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graphy, rather than molding mental illness to the conceptually simpler physical illness, our objective should be to account for the (conceptual) features of illness as a whole. On this model, the diversity of mental disorder, as the richer conceptual "database," is more significant conceptually than the relatively simple concept of physical illness. Within this model, as Nordenfelt also implies (this volume, for instance p. 60), psychosis poses a particular challenge for philosophical analysis. iv. Ordinary Doing, the Machinery of Action, and Psychosis Nordenfelt calls for elaboration of my theory of illness as being derived from failure of ordinary doing. I believe that I do elaborate. Up to this point in my analysis, much of the explanatory work could be done in terms of failures of function as readily as failures of action (though not all of it, see, for example, my analysis of addictive behavior, Chapter 8). Psychopathology, however, offers a crucial test of philosophical medical theory in the concept of delusion. Surprisingly, one of the areas that Nordenfelt accuses me of neglecting is the psychoses (this volume, pp. 90-91). But in the whole of the long Chapter 10 in Moral Theory and Medical Practice, I deal, not indeed with the broad categories of mania and schizophrenia to which Nordenfelt refers, but with the specific and central psychotic symptoms of thought insertion, hallucination, and delusion. Either an action-based or function-based account of the medical concepts can accommodate the less specific features of the psychotic disorders which Nordenfelt considers. In schizophrenia, for example, thoughts may become disconnected, and distractibility is characteristic of mania. We can readily conceptualize both of these features either as failures of particular cognitive functions or as failures of particular parts of the machinery of action. Nordenfe1t characterizes mania, by the way, as a failure to properly evaluate one's life as a whole: this is a philosophical interpretation, not a psychopathological description of the condition, and it is a contentious interpretation at that (see Moore, Hope, and Fulford, 1994). When it comes to the specific psychotic symptoms, though, ordinary-language philosophy takes us well beyond previous philosophical work in this area. For it shows that these symptoms, central as they are in the "map of psychopathology," cannot be (sufficiently) explained in terms of failures of function, while, on the contrary, they can be explained in terms of failures of action (see Chapter 10 of Moral Theory and Medical Practice). These symptoms therefore provide a crucial test of theory in this area, distinguishing between conventional function-based accounts (as in the medical model) and agency-based accounts (as proposed by Nordenfelt and myself).

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Figure 4 illustrates one respect in which an action-theoretic account of the psychotic symptoms takes us beyond function-based accounts. The traditional medical model has failed to explain why, and has largely ignored the fact that, psychotic symptoms involve what is called "loss of insight." So difficult has it been in the traditional model to defme the kind of loss of insight involved in psychotic symptoms, that psychiatry, following one of its scientific founders, Sir Aubrey Lewis (Lewis, 1934), regards loss of insight, and with it the concept of psychosis, as scientifically empty. It is significant, therefore, from the perspective of ordinary-language philosophy, that the concept has persisted undiminished in psychiatric usage, not least in psychiatric classifications (Fulford, 1994). Ordinary-language philosophy considers the persistence of the concept of insight to be significant because, as noted above, use (in this case, psychiatric usage) is often a surer guide to meaning than defmition (in this case, Aubrey Lewis's failed attempts at defmition). Furthermore, in contrast to the difficulties of defmition of insight in the medical model, the distinction between psychotic (insight-lacking) and non-psychotic (insight-preserving) forms of experience drops readily, indeed inevitably, out of an action-based analysis. As Figure 4 illustrates, the concept of psychotic loss of insight maps directly on to the double distinction (noted in section i above) between illness and things that are both done by and done (or happen) to us. Similar tables can be drawn up for other psychotic symptoms, such as hallucination (see Moral Theory and Medical Practice, Chapter 10, pp. 230-231). v. Reasons for Action and Delusions The psychotic symptoms and the kind of loss of insight by which they are defined psychopathologically, thus map readily on to the features of the primary experience of illness. The ease with which they do this strongly endorses the need for action-based (as well as function-based) logical elements in an account of the conceptual structure of medicine. Further endorsement of the need for both kinds of element comes from the constraints on analysis of the key psychotic symptom of delusion. The relevant starting point, again, is the logical geography of delusion. Just as psychotic symptoms are at the center of the conceptual map of psychopathology, so the symptom of delusion forms the central feature of the logical geography of psychosis. Karl Jaspers, the philosopher-psychiatrist and founder of modem psychopathology, pointed this out in his General Psychopathology (Jaspers, 1913). Its central place in psychopathology, stands in stark contrast to the difficulty of defming the concept of delusion within the conceptual resources of the medical model. At first glance, delusion might seem to yield to a medical model, a function-based, analysis: the Ox-

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ford Textbook of Psychiatry, for example, defmes delusion as an "unfounded belief," implying some specific disturbance of cognitive functioning (Gelder, Gath, and Mayou, 1983). Remarkably, though, researchers have yet to fmd such a disturbance, despite much recent effort (Garety and Freeman, 1999). This has not affected medical practice, at least to the extent that we can still reliably identify delusions. The practical problems here arise in medical law and ethics (Fulford, 1993). Ethical problems include major abuses of psychiatry, like the notorious "delusions of reconstruction" which led in Soviet Russia to political dissidents being diagnosed as suffering from schizophrenia (Fulford, Smirnoff, and Snow, 1993). But the real challenge here is the scientific challenge of how delusion itself, as a key psychopathological symptom, should be characterized. This was one of the issues that sparked off the remarkable renewal of philosophy of psychiatry that we witnessed over the last decade of the twentieth century (see, for example, the prescient work of Glover, 1970; Flew, 1973; and Quinton, 1985). This early work, however, as I noted earlier, relied on defmitions of delusion, derived from textbooks, as false factual beliefs. In my Chapter 10, by contrast, I showed that an examination of the ordinary usage of the concept of delusion (that is, its use in clinical practice rather than merely as it is defmed in the textbooks) shows a concept of delusion with a conceptual richness unsuspected by most philosophers and indeed practitioners. Besides the "false factual beliefs" of the textbooks, the clinical use of delusion includes true beliefs (as in the Othello syndrome), value judgments (negative, as in depression, and positive, as in hypomania), and, most intriguing of all, the paradoxical hypochondriacal delusion of mental illness. In Moral Theory and Medical Practice (Chapter 10; also, Fulford, 1991), I give examples of all these different logical species of delusion. I show that, taken together, they call for an account of delusion as a disturbance of reasons for action rather than of cognitive functioning. I base this conclusion on two main ordinary-language grounds. First, reasons for action map conceptually onto the different logical forms of delusion: reasons for action, like delusions, may take the form of statements of fact, true or false, and of judgments of value, positive or negative (see Moral Theory and Medical Practice, p. 206, for example). This account can also be shown to be consistent with and to explain the (otherwise) paradoxical delusion of mental illness (see Moral Theory and Medical Practice, pp. 204-205). Second, the idea that disturbed reasons for action form the basis for delusion explains, within a general theory of illness as action failure, the central place of delusions in the map of psychopathology. As noted above, in earlier chapters of Moral Theory and Medical Practice I developed an account of the variety of different kinds of illness, bodily as well as mental, as distur-

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bances of different kinds in the machinery of action. These failures, though, were all executive; in other words, they concerned failures to perform an action. Paralysis counts as one such failure, but loss of memory, failure of control (as in compulsive disorders), and so on, are all executive failures in this sense. Reasons, by contrast, do not execute but constitute actions. If I wave my arm, this may be the action of, say, hailing a taxi or making a bid. Which action it is, is determined by my reasons for waving my arm. Thus, if delusion is, as its logical psychopathology suggests, a failure of reasons for action, it will be a constitutive rather than merely executive failure of action. And a constitutive failure of action, consistently with the central place of delusion in the map of psychopathology, is a deep failure. With any of the variety of executive failures of action, the failure concerns the carrying out of an action. With a constitutive failure there is, literally, no action at all. With this result, moreover, we get an explanatory bonus in the area of ethics and jurisprudence. Delusion's central position in the "map" of psychopathology corresponds with its status as the paradigm case of mental illness as an excuse in law. The standard medical model fails to explain this. Accident, inadvertence, mistake, and so forth, the traditional list of excuses, are all in one way or another species of failed intention. Since the standard medical model considers delusion a disturbance of functioning, delusion might mitigate responsibility but should not serve as an excuse. Yet it is the central case of mental illness as an excuse. Reasons for action, though, are often logically equivalent to intentions; my reason for waving my arm is equivalent in many contexts to my intention in waving my arm. Hence, an account of the psychopathology of delusion in terms of failure of reasons for action amounts to an account of delusion in terms of failed intention. Furthermore, an account of delusion as a constitutive failure of action amounts, as we have just seen, to a case of "no action" (since actions are constituted by reasons). The account is thus equivalent to an account of delusion in terms of "no intention." In this action-failure account, then, delusion is naturally and inevitably assimilated to the traditional list of legal excuses (all of which involve "no intention"). An equivalent account can be given of the central place of delusion as a ground for involuntary psychiatric treatment. Studies show that involuntary treatment is used far more for psychotic illnesses than for other kinds of mental disorder (Fulford, 1993). Disturbance of rational choice serves as the ground for involuntary psychiatric treatment. The "full-field" account of delusion, as a constitutive failure of action, explains why psychotic disorders involve the most profound disturbance of rational choice.

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C. Action Theory, Psychosis, and Neuroscience

In an action-based account, then, delusion involves a disturbance of reasons for action. This completes (in Moral Theory and Medical Practice) my account of the variety of bodily as well as mental illnesses being derived from a particular kind of disturbance of action. Such an account, I have indicated, accords with a key feature of the logical geography of the medical concepts shown by the map in Figure 3, namely placing delusion at the conceptual center of psychopathology. Action-based accounts of psychopathology, therefore, go beyond and thus complement function-based accounts. Function-based accounts suffice in many areas of psychopathology (in respect of dementia, for example, Fulford and Hope, 1993). But in other areas, notably the central area of psychotic symptoms such as delusion, the traditional exclusively function-based account does not suffice. Here the traditional medical model has to be supplemented by adding the conceptual resources of the left-half field of the full-field model (of Figure 2, above) to the traditional right-half field. Even so, as Austin warned us, and Nordenfelt in effect says, this is only the first step. We must take many more steps before we can claim anything like a full account even of the clinical concept of delusion. As I emphasize in Moral Theory and Medical Practice, the constitutive failure of action to which the logical geography of delusion points, remains entirely unanalyzed in my work. A demonstration of the need for such an account already shows progress. But I have really no idea how to identify or characterize the required constitutive failure of action. My account shifts the focus of attention from the part-functions of the traditional medical model to the actions of whole persons. This is a worthwhile "raising of consciousness" (in Sir Denis Hill's term, noted above). But it begs the further move from whole persons as individual agents to persons as members of a society. Nordenfelt's account comes closer than mine to accomplishing this move. As I have emphasized above (see also Fulford, 1989, and 1998b), delusion involves a profound "loss of insight" in which the patient's construction of reality differs from everyone else's. But loss of insight, at first glance at least, is defmed in interpersonal rather than intrapersonal conceptual space. As a way of getting started, then, action-based accounts are consistent with the linguistic data. As such, therefore, and as Austin anticipated, they open up psychopathology to the rich resources of modem philosophical work on the nature of agency: in Anglo-American analytic philosophy, for example, Michael Luntley's work building on neo-Fregean philosophy of mind (Luntley, 1999), or, in the Continental philosophical tradition, drawing on phenomenology (Bracken, 1999). Such work remains promissory concerning delusion. But the American philosophers George Graham and Lynn Stephens

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have developed a detailed agentic account of the central schizophrenic symptom of thought insertion (1994; also Stephens and Graham, 2000). This line of research, in action theory, was always open to us in principle, of course. But the recent development of dynamic brain imaging techniques has given it a new urgency (Fulford, 2000b). The interpretation of dynamic brain images requires the development of whole-agent rather than part-function models. Some of the points of connection between dynamic brain imaging and work in the philosophy of mind on consciousness were explored in a recent series of seminars organized jointly by the Philosophy and Ethics of Mental Health Programme and the Humanities Research Board Programme for Consciousness and Self-Consciousness, at Warwick and Oxford Universities, and at the Institute of Psychiatry in London, under the auspices of the McDonnell-Pew Centre for Cognitive Neuroscience, Oxford. Papers in these seminars will be published in a special issue of Philosophy, Psychiatry, and Psychology under the editorship of Christoph Hoed. New work in neuroscience and the philosophy of mind, therefore, is not limited to the "cognitive functioning" paradigm, important and productive as this paradigm has been. In taking seriously the full logical psychopathology of delusions and related psychotic experiences, this new work starts from and explores the resources of the full-field picture of the clinical concept of delusion to which we are led by an ordinary-language analysis of the medical concepts. 5. Philosophy into Practice: A Collaborative Approach I have noted a number of criticisms of ordinary-language philosophy in this article. Yet another criticism is that in practice ordinary-language philosophy amounts to ordinary English language philosophy. This may have been the case. But it does not have to be the case. On the contrary, the basic idea behind ordinary-language philosophy, as I have described, is that language use (what people actually say) provides a better guide to meaning (the concepts people hold) than explicit definitions (reflecting people's limited powers of direct introspection). And this basic idea translates directly and irresistibly into a cross-linguistic frame. Thus, if one language acts as a rich resource for philosophical enquiry, other languages will multiply those resources. Nordenfelt gives us an example of this in reverse. Swedish, he points out (this book, p. 75), does not have distinct words corresponding with the difference marked in English by "illness" and "disease." The Swedish "sjukdom" covers both. Many other European languages (French and Romanian, for example) lack the words to mark this distinction. The difference, though, broadly between the patient's experience of illness and medical knowledge of disease (specific patterns of

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symptoms, causal processes, and so on), is nonetheless present in the conceptual framework of medicine in all these countries. The distinction, therefore, could in principle be made by a Swedish, French, or Romanian philosopher as readily as by an English philosopher. But it would be easier to spot in the fIrst place for a philosopher, whether English, Swedish, French, or Romanian, who starts by examining the use of the medical concepts in English. English people, myself included, are not noted for their foreign language skills. But as a way of getting started with philosophical problems, ordinary-language philosophy, far from being confmed to the English language, positively invites a multi-lingual approach. We need to be careful here, since ordinary-language philosophy requires a sharp eye for meaning, which is difflcult to achieve in a language other than one's own. Genuinely bilingual speakers do exist. But few can claim full competence in more than two languages. Inter-language cooperation in ordinary-language philosophy thus requires a model of collaboration between native language speakers rather than a given philosopher attempting to work in several languages at once. This model of collaboration in philosophical research differs greatly from the "sole trader" model traditionally associated with philosophy. Scientists commonly work in research teams, breaking large problems down into smaller and more manageable parts and distributing them across whole communities of researchers. Philosophers have traditionally worked alone and often more in conflict than collaboration with their colleagues. Austin, although apparently a merciless opponent in debate, believed that philosophers, for some kinds of philosophical research at least, should work more in the model of scientists (Warnock, 1989, Ch. 1). He came to this view through his experience as an Intelligence Offlcer in the Second World War. He was impressed with the way in which large problems could be solved by an extended team of operatives each contributing small items of intelligence. Since Austin died before his fIftieth birthday, he never tried out his ideas about the collaborative organization of philosophy in practice. Philosophers, not least in the Oxford tradition, still work largely in sole trader mode. The system of independent Oxford Colleges, powerful as it is in bringing together scholars from different disciplines, works against the intradisciplinary contact which a faculty system encourages. I have been fortunate at Warwick University in fmding myself in a faculty which combines, uniquely I believe in the United Kingdom, experts in Continental as well as Anglo-American philosophy. The Warwick faculty, moreover, has strong traditions also of both cross-disciplinary and international collaboration. In the research initiatives on neuroscience noted above, a collaborative approach between Warwick, Oxford, and London has already been established.

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Warwick philosophy, I should add, cannot compete in degree of interdisciplinary integration with Nordenfelt's TEMA Department in Linkoping. Hence we were fortunate to have Nordenfelt in the Department at Warwick as a visiting professor for two terms in 1998-1999. As a result of this visit, we have already taken the Models Project beyond the English language into Swedish. This is a very exciting next step for the philosophy of psychiatry. It presages future inter-language collaborative research in this area. Europe has a rich tradition of different approaches to both theory and practice in psychiatry and an equally rich tradition of different languages. It could prove to be uniquely well suited, therefore, to the development of an ordinarylanguage philosophy of mental health which is both theoretically sophisticated and fully engaged in practice. 6. Conclusions: Psychiatry First I have indicated in this chapter some of the ways in which the philosophy of psychiatry, having gone through an explosive growth of theory in the last decade of the twentieth century, is beginning to take its fIrst steps into the practical arena of clinical work and neuroscientifIc research. I have concentrated on my own work in this area, particularly as it connects with Nordenfelt's: the Model's Project (with Tony Colombo), which is now well advanced in taking theoretical work on the concepts of disorder into the practical arena of the community care of people with long term schizophrenia; the variety of ways in which value theory is fmding applications in all aspects of clinical psychiatry; and the action-based accounts of psychopathology which are starting to connect with problems in the "new" neurosciences, notably in dynamic brain imaging. I have emphasized the importance of collaboration, interdisciplinary and international, in this area. I have presented these developments in the philosophy of psychiatry as "advances." They would have a very different, and less favorable, construction in the traditional medical model (Fulford, 2000b). By the lights of this model, indeed, the explosive rise of philosophy of psychiatry in the last decade of the twentieth century was something of an historical paradox. After all, biological psychiatry, through dramatic advances in the neurosciences, also came into its own during this period. According to the medical model, then, this should have been the decade over which philosophy, as the antithesis of science in many medical minds, far from expanding into medicine, should fInally have been expelled from it. On closer inspection, however, the rise of philosophy of psychiatry and advances in the neurosciences, are two sides of the same coin (Fulford, 2000b). The coin is scientifIc psychiatry, and its two sides are empirical (the data gathering techniques of the neurosciences) and conceptual (the philo-

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sophical analytic methods required to make sense of the data). We need both sides of the coin of science, its empirical and conceptual sides, in psychiatry. We need both sides of the coin of science in research. We need both sides in our clinical work. Psychiatry, then, in the full-field model presented here, far from being scientifically primitive (as the traditional medical model would have it) is scientifically complex. In the twenty-first century, though, we are likely to see other areas of medicine following psychiatry in becoming more, not less, conceptually difficult. This is because technological advance is already taking these other areas of medicine into areas of human experience and behavior in which, as in psychiatry, conceptual as well as empirical problems are practically as well as theoretically important. Assisted reproduction and organ transplantation, for example, already raise questions of personal identity which, although essentially conceptual rather than empirical questions, have a crucial impact practically. Psychiatry, then, in tackling conceptual as well as empirical problems in a philosophically-enriched model of medicine, could well be beating a path which other areas of medicine will soon have no choice but to follow. This reversal of psychiatry's position in medicine, from running behind to running ahead, would not have surprised Austin, the inspiration for ordinary-language philosophy. He pointed out that we are just so good at using high-level concepts (like health, illness, and disease) that we fail to see the difficulties of meaning inherent in them. Only when things go wrong, when these concepts cause difficulties, do we break "through the blinding veil of ease and obviousness" (Austin 1956-1957, p. 23). Psychiatry, I believe, in leading theoretical philosophy back into the heartland of clinical practice and research, is breaking through medicine's blinding veil of conceptual ease and obviousness. In the twentieth century, psychiatry had second place in medicine. In the twenty-first century, it will be psychiatry first. Acknowledgements The Models Project is principally funded by The Nuffield Foundation. It has also received support from the Vice Chancellor's Infrastructure Fund, Warwick University, and the Laces Fund. Dr. Tony Colombo and I are grateful to these organizations for their fmancial support. We are also grateful to the many academics, practitioners, and users, who, as members of the research team or as participants, have made the study possible. The Oxford-Warwick seminars in philosophy of mind, neuroscience, and schizophrenia were funded by the Novartis Foundation, London, and by the McDonnell-Pew Centre for Cognitive Neuroscience, Department of Physiology, University of Oxford. I am grateful to Tony Colombo for permission to publish Figure 1. I

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am grateful to Lennart Nordenfelt and to Tony Colombo for their helpful comments on earlier drafts of this chapter.

AFTERWORD I did not initially intend to include in this volume a reply to my invited commentators. Nor do I fmd it quite proper to take advantage of being the editor to get the fmal word in a discussion. After having read the two interesting and provocative essays by George Khushf and K. W. M. Fulford, however, I came up with a compromise. Instead of writing a new essay commenting on their contributions, I have decided to make a few notes in response to passages where Khushf and Fulford deal with my theory of health or with statements that I make in this volume. I am grateful to Khushf for his elegant overview of modern philosophy of science and for his clear and penetrating analysis of some contemporary theories of health from the point of view of philosophy of science. I have learnt a lot from his essay, and I think that it has substantially moved the discussion forward. His innovative distinction between strong and weak normativism in the philosophy of health serves him well, although he needs to clarify it further. A weak normativist, according to Khushf, "sustains some of the practical corollaries of the medical positivist program without holding to the affIrmation of value neutrality" (p. 158). Strong normativists do not (if this is possible) retain any of the traditional presuppositions of current medical practice. In particular, they do not presuppose the predominantly individual orientation of traditional medicine, with its emphasis on individual values. According to this paradigm, the very notion of health must rely on some social factors in addition to individual factors. Khushf claims that Fulford's theory and my theory belong to the category of weak normativism, whereas Khushf attributes the position of strong normativism to himself. I will comment on this basic and highly interesting issue, but fIrst, I offer a short note on a detail in Khushfs criticism of my version of a weak norrnativist theory. Khushf makes substantial use of a passage in my discussion about vital goals in On the Nature of Health (1995) in order to show that social evaluations must play a role also in my account. I know and have acknowledged that some social evaluations must playa role, for instance, in the case of establishing the defmitions of a standard circumstance and a level of minimal happiness. Thus, I do not qualify as a pure weak normativist after all. Nor am I as faithful a defender of conventional medicine as Khushf suggests. I also do not recognize the validity of Khushf's specifIc argument against me. He attributes to me a distinction between "legitimate" and "il-

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legitimate" vital goals, as if there were some social authority legitimized goals. I do not subscribe to this idea at all but remain consistently with a highly general defInition of a vital goal. P is a vital goal of A's if, and only if, the realization of P is a necessary condition of A's long-term minimal happiness. In the passage quoted by Khushf, I discuss some cases which, at fIrst glance, might render my analysis of the concept of health implausible. I discuss cases of unusual, unrealistic, and "mad" vital goals, in order to gage their relevance. Khushf picks up the concept of a "mad" goal and claims that this label must presuppose a social evaluation. Thus, he argues, my theory is in effect even more saturated with social evaluations. However, I use the term "mad" provisionally. Having a "mad" goal, in my sense of the word "mad," does not entail that one has reduced health. If a goal fulfllls the basic criterion of being necessary for the subject's long-term happiness, then it is a vital goal, and if the subject is able to fulfIll it in standard circumstances, then he or she is, as far as this goal is concerned, a healthy person. In his chapter, Khushf criticizes two weak normative theories, and in the end, he prefers the strong normativist position. According to his main argument, health care is in the midst of qualitative transformation, and "the result will no longer resemble traditional medicine" (p. 168). Health care will be practiced by teams and organizations and will also be both individually and community-oriented. As one of the results, we will no longer be able to sustain the distinction between micro-ethical and macro-ethical domains. Together with Khushf, I have been observing with fascination this development, which will change the appearance of medical practice and also, perhaps, the essence of medical practice. I do not rule out the possibility of a resulting conceptual change, even with a concept as basic as health. Medical philo'sophers of the coming decades must study this conceptual change. I doubt, however, the radicality of the change on the level of the concepts of health and illness. In the future, too, health care will have to treat people individual people as well as groups of people - with problems which are mainly due to defects in their bodies and minds. We will continue to call these people unhealthy. People's vital goals, however, will inevitably change, maybe even drastically. As society changes, the goals that are dependent on the construction of society have to change. Consequently, some diseases disappear from the landscape, new diseases appear, and this occurs for conceptual, not just empirical reasons. But this change need not alter my theory's conceptual point of departure. My theory provides a general framework which can encompass changes in vital goals as well as changes in accepted or standard circumstances. I cannot quite tell whether Khushf considers the analyses by Fulford and me fundamentally defIcient as analyses of the present-day concept of health or illness, given today's health discourse on the lay and the expert

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level. Or does he mean, more modestly, that our analyses will not suffice for tomorrow's practice of medicine? His most explicit argument (in the last section of his text) concerns the future, but this argument is only a sketch and cannot really be tested. Khushf gives some indication that he means something more. Dissatisfied with our theories even as theories of a contemporary concept of health, he hints at the ultimate impossibility of distinguishing between medical and nonmedical (for instance, ethical) values. For him, such a distinction is not sustained in practice today, in spite of the prevalent beliefs about this issue on the part of the health personnel. Khushf may be right in this, but I detect a difference in attitude between Khushf and myself with regard to the theoretical work to be done here. I question the impossibility of distinguishing between the two kinds of values. And if the distinction turns out to be practically impossible in some cases, should we not try to minimize the frequency of these cases? And should we not try to reconstruct concepts of health and illness, where the two kinds of evaluations are held distinct? This may help physicians to realize what they are doing and what their motivations are. In most cases, for instance, the question whether a subject has a low position on a welfare-scale differs markedly from the question whether the person is a problem to society. The two questions are related but can normally be separated in practice. A reconstruction of a concept necessarily contains some simplifications and other provisional compromises. They may be needed for clarity or for the sake of improved communication in the area of health care. On the issue of improved medical communication, Fulford has said all that needs to be said in his contribution to this volume. I do not aim to completely mirror ordinary practice and ordinary language. (Fulford and I differ slightly here, although Fulford does not claim that the end result of a philosophical analysis should be a detailed description of ordinary language.) Instead, I aim to take part in a scientific project and to contribute to a systematization of practice which may and should entail some change to science and practice itself. Such a systematization has in my case required the recognition of different kinds of values in the practice of health care. As Khushf remarks, and as Fulford has demonstrated in a number of texts (for instance, Fulford and Smirnoff, 1993), the application of just any social values in the practice of medicine, in particular in the practice of psychiatry, can lead to disasters. We need to distinguish between different kinds of values, and some values (in particular, the values of welfare) will necessarily have a place in the reconstruction of the notion of health. Other values, at least some of the moral and political values, will not and should not have a place there. Khushf, as a defender of strong normativism, is perhaps suspicious of such systematic attempts. These reconstructions may have petrifying conse-

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quences, in particular if they become parts of textbooks. They may make us less open to the inevitable changes of science and practice. But what is the alternative? Must we not have some provisional platforms on which to stand? I am equally grateful to Fulford for his impressive contribution to this volume. His text complements Khushfs in an interesting way. Whereas Khushf has taken his starting point in contemporary philosophy of science, Fulford starts from the practice of medicine and ordinary lay discourse on matters of illness. While I had predicted that my commentators would come up with rich and fruitful texts, I had not predicted nor foreseen this perfect complementarity. Fulford demonstrates how philosophy can enter the practical arena by presenting in detail his Models Project, which monitors representatives of the various professions in mental-health care with respect to their understanding of a case of mental illness. The observation of the discrepancies between the models embraced by the different categories of people is an interesting fact itself. More importantly, as Fulford notes, this observation paves the way for the necessary harmonization of these models. Consequently, it could lead to a much closer and more accurate communication between the members of the different categories of mental-health caregivers. Fulford's Models Project underlines the importance of the distinction previously mentioned in this volume between two ways of embracing a concept: siding with a defmition of a concept and actually making use of the concept (for elaboration and use of this distinction, see pp. 7 and 174-176 in this volume). As Fulford says, most mental-health care professionals imagine that they subscribe to a balanced biopsychosocial model of health and illness. However, when it comes to practice, the psychiatrists observed in Britain demonstrate that they have a predominantly biological understanding, while the social workers show that they have an almost entirely socially oriented understanding of the same phenomenon. The two kinds of personnel may have sided with the same defmition, but their practice and language-use are different. Fulford's models of mental illness embrace much more than the concept of mental illness. The models include such things as assumptions concerning the causes and the proper treatment of mental illness. This fact indicates that Fulford has not just put philosophy into practice, but he has also put some parts of the science of psychiatry into practice in an unorthodox way. As both Fulford and I have testified in this volume, we share much in our outlook on the philosophy of health. We share the idea concerning the genesis of medical concepts. First come the general concepts of health (or illness), and then, as a part of the explanation of illness, come the particular concepts of disease. We agree that the logical order is the reverse of the causal order. We also share the hypothesis, which we hope is quite well cor-

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roborated by now, that the notion of disability (or loss of agency) is central in the notion of illness. I differ from Fulford in my attempt to reconstruct a concept of health in which the positive notion of ability is central. Perhaps the most interesting difference between us concerns the demarcation of the sets of abilities, disabilities, or incapacities that are relevant for the characterization of health and illness. I am more preoccupied with this matter than Fulford. Drawing the line between the healthy and the unhealthy is, for me, one of the crucial questions in medical practice. It has, for one thing, profound legal implications. In order to solve the problem of characterizing health, I propose the introduction and defInition of the notion of a vital goal. Neither Khushf nor Fulford take issue with this attempt in their commentaries. When it comes to demarcating health from illness, Fulford proposes that we use the concept of failure of ordinary doing and, to some extent, the experience of such failure. This is an interesting idea and an excellent starting point for the analysis of the concept of illness. I also understand that its primary role is to "identify the particular kind of failure of action which would mirror. .. the phenomenological features of the primary experience of illness" (p. 194). However, in this volume, I mean to ask to what extent the notion of failure of ordinary doing helps us to mark out the border between the healthy and the ill. I ask this question since many ill people (as defmed by our pretheoretical understanding of illness) do not experience their illness. As I address in the passage that Fulford discusses in his commentary, some clearly ill people manage their ordinary doing quite well but fail in performing more complicated tasks as are required from them. A mild infection need not prevent us from grasping for things or remembering things, but it frequently prevents us from concentrating on some of the more demanding tasks that our jobs require and thus prevents the realization of some of our vital goals. The mild infection is clearly a case of illness, but I wonder how this case would be handled in Fulford's theory, and I still wonder after reading his answer in this volume. In my text, I also say that the argument from "extraordinary doing" may pertain to some but certainly not all or even the majority of cases of mental illness. This is the issue which I raise. I regret if Fulford thinks I accuse him of neglecting the psychoses or, in general, neglecting to apply his theory to the psychoses. I cannot fmd a passage where I say anything close to this. Fulford has written more than anybody else on the relation between action-theory and mental illness, and he has applied the notion of failure of action to wonderfully differentiate between various categories of mental disorder (see his presentation on p. 197). I certainly also agree with him that both schizophrenia and mania can be analyzed as "failures in different parts of the machinery of action" (p. 196). If I did not think so, my theory of health and illness

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would fail. I do not question whether these illnesses are instances of failures of action. They certainly are. I do wonder, however, whether they are always failures of ordinary (preconscious) action. For instance, are not some maniacs quite good at performing ordinary actions, even better than healthy people? Their failures mainly concern actions of a more complex and overarching character (for example, planning and organizing their lives) and the appropriateness of certain actions, such as their ways of interacting with other people. In this volume, I aimed to initiate a discussion with Fulford on the scope of the concept of ordinary doing for the purpose of demarcating health from illness. Having achieved this, we can take up the discussion in another forum.

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ABOUT THE AUTHORS Lennart Nordenfelt

Lennart Nordenfelt is Professor of Philosophy of Medicine and Health Care at the Department of Health and Society, University of Linkoping, Sweden. He studied philosophy, history of ideas, history of religion, and Russian at Uppsala University. As a graduate student, he spent a year, 1969, at Oxford, under the supervision of John Mackie, where he started preparing his doctoral dissertation on Explanation of Human Actions, which he defended at Uppsala in 1974. After a year as a secretary at the Office of the Chancellor of the Swedish Universities, he was in 1975 appointed a lecturer in Theoretical Philosophy at the University of Stockholm. From 1978 and onwards Nordenfelt has devoted himself to studies and research in the philosophy of medicine and health care. The new research interest prompted him to apply for a position as Associate Professor at the then newly founded transdisciplinary faculty of themes at Linkoping University in 1982. He initiated there a research program under the title Theory, Ethics and Ideology of Health Care which is still running. Twelve persons have so far taken their PhDs within this program. He became a full professor in 1987. He and his wife Kerstin have two children. Nordenfelt's monographs include Explanation of Human Actions (1974), Events, Actions, and Ordinary Language (1977), Causes of Death (1983), On the Nature of Health (1987; 2nd, revised, ed. 1995), On Crime, Punishment, and Psychiatric Care (I992), Quality of Life, Health, and Happiness (I993), Talking about Health: a Philosophical Dialogue (I997), and Action, Ability, and Health (2000). Together with B. Ingemar B. Lindahl, he edited Health, Disease, and Causal Explanations in Medicine {I 984). This book was the academic result of the First Nordic Symposium on the Philosophy of Medicine, held in Stockholm 1982. He is the editor of Concepts and Measurements of Quality of Life in Health Care (1994). Nordenfelt is also the author of a number of monographs and textbooks in Swedish. He has contributed to several journals, including Theoria; Theoretical Medicine; The Journal of Medicine and Philosophy; Health Care Analysis; Philosophy, Psychiatry, & Psychology; International Journal of Technology Assessment in Health Care; and Scandinavian Journal of Social Medicine. He was a research fellow at the University of Western Ontario, London, Canada, in 1976, and at the Institute for Advanced Studies in the Humanities

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at Edinburgh University, Scotland, in 1989. He was Visiting Professor at the University of Warwick, England, in 1998-1999. He has made presentations to philosophical as well as medical gatherings in all the Scandinavian countries, several European countries, as well as the United States and Canada. Since 1999, he is President Elect of the European Society for the Philosophy of Medicine and Health Care. Since 1994, he has been a member of the board of Linkoping University. Nordenfelt has made contributions mainly to action theory, theory of medicine, and the theory of health and welfare, in particular. His theory of health draws upon concepts central to action theory. The concept of health itself is in his theory defined in terms of the subject's ability to realize her or his vital goals. This book contains elaborations and defenses of this theory of health. George Khushf

George Khushf is the Humanities Director of the Center for Bioethics and Medical Humanities, and a faculty member in the Department of Philosophy at the University of South Carolina, Columbia, South Carolina. After completing an undergraduate degree in civil engineering at Texas A&M University (B.S., 1983, summa cum laude), he studied religion and philosophy at Rice University. In 1988-1989 he received a Fulbright award for research in the philosophy department at the University of Tuebingen, Germany. His M.A. thesis (1990) was on the work of S0ren Kierkegaard and G.W.F. Hegel, and his Ph.D. dissertation (1993) addressed current disputes in continental philosophy and theology (hermeneutics and deconstruction). Upon completion of his graduate study, Khushf accepted a position as Managing Editor of The Journal ofMedicine and Philosophy, and served in a research capacity at Baylor College of Medicine in Houston, Texas. In spring, 1995, he was the Rockwell Visiting Scholar at the University of Houston, and, following that, moved to his current position in South Carolina. Khushfs research in bioethics and the philosophy of medicine focuses on scientific, economic, and structural changes in health care theory and practice. His publications address issues such as the nature of clinical judgment, concepts of health and disease, developments in molecular biology and genetics, economic influences on medicine, and administrative and organizational ethics. They have appeared in journals such as The Journal of Medicine and Philosophy; Theoretical Medicine; Medicine, Health Care, and Philosophy; Current Opinion in Critical Care; The Journal of the South Carolina Medical Association; and Medical Humanities Review. In addition to his theoretical research, Khushf serves as a clinical ethicist. He is a member of two hospital ethics committees, and serves as an

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ongoing consultant to the Ethics Committee of the South Carolina Medical Association. He also consults for hospitals in areas of administrative and organizational ethics, and has served as a contractor for the Department of Health and Environmental Control of the state of South Carolina, developing a health concepts grid for public health strategic planning. Khushf has worked to advance research in the areas of administrative and organizational ethics, and serves as Section Editor on the topic for HEC Forum, an interprofessional journal for health care ethics committees. He is Assistant Editor of The Journal of Medicine and Philosophy, and on the editorial boards of several other journals. In 1998, he was co-chair of the program committee for the American Society for Bioethics and Humanities, and currently serves as the South Carolina state liaison for the Health Care Compliance Association. K. W. M. Fulford

K. W. M. (Bill) Fulford is a medical doctor with a research degree in philosophy (DPhil, Oxon). He is Professor of Philosophy and Mental Health in the Department of Philosophy, University of Warwick, where he runs a Masters, PhD, and research program in Philosophy, Ethics and Mental Health Practice. This is the fIrst center of excellence for inter-disciplinary work between philosophy and mental health. He is also an Honorary Consultant Psychiatrist in the Department of Psychiatry, University of Oxford; Visiting Professor in Psychology, The Institute of Psychiatry and King's College, London University; Visiting Professor in Philosophy and Professional Practice Skills in the Centre for Professional Ethics, University of Central Lancashire; and Visiting Professor, Kent Institute of Medicine and Health Sciences. He is the Founder Chair of the Philosophy Special Interest Group in The Royal College of Psychiatrists (over 1,200 members). He is a Fellow of both the Royal College of Psychiatrists and The Royal College of Physicians (London). He was Director of the Oxford Practice Skills Programme which established the Oxford Practice Skills Course. This course brings together ethics, law, and communication skills in an integrated problem-solving approach to medical student education (see T. Hope, K.W.M. Fulford, and A. Yates, 1996, Manual of the Oxford Practice Skills Project. Oxford: Oxford University Press.) He is the Founder Editor of the fIrst international journal for philosophy and mental health, PPP - Philosophy, Psychiatry, & Psychology. In his capacity as Chair of the Royal College of Psychiatrists Philosophy Group, he has organized a number of national and international conferences. The latest of these, Madness, Science, and Society: Florence, Renaissance 2000, organized jointly with The Societa Italiana di

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Psichiatria, launched a new International Network for Philosophy and Psychiatry. Fulford has published widely on philosophical and ethical aspects of mental health. The analysis of the health concepts described in this chapter is set out in his Moral Theory and Medical Practice (1989, paperback 1995, reprinted 1999, second edition forthcoming from Cambridge University Press). He has developed aspects of philosophical value theory in a number of articles and chapters - see bibliography. His most recent work in this area includes (1999) "Nine Variations and a Coda on the Theme of an Evolutionary Definition of Dysfunction" Journal of Abnormal Psychology, 108, pp. 412-420; and (2000), "Teleology without Tears: Naturalism, Neo-Naturalism, and Evaluationism in the Analysis of Function Statements in Biology (and a Bet on the Twenty-First Century)," Philosophy, Psychiatry, & Psychology, 7: 1, pp. 77-94. He has written on other aspects of the philosophy of psychiatry. Besides articles listed in the bibliography, note Chapter 1 in Philosophy, Psychology, and Psychiatry, ed. A. Phillips Griffiths, Cambridge, England: Cambridge University Press, for the Royal Institute of Philosophy (1995). His work on medical and psychiatric ethics includes (1993) "Bioethical Blind Spots: Four Flaws in the Field of View of Traditional Bioethics," Health Care Analysis, 1, 155-162; and (forthcoming) "The Paradoxes of Confidentiality," in C. Cordess, Confidentiality: Philosophy and Practice, London: Jessica Kingsley Publishers. He has a jointly authored book on psychiatric ethics forthcoming from Oxford University Press: D. Dickenson and K. W. M. Fulford, In Two Minds: A Casebook of Psychiatric Ethics, Oxford: Oxford University Press. Besides further philosophical work on the value structure of psychopathology (as above), Fulford's recent research has focussed on bringing together philosophical with empirical disciplines. The Models Project, with Dr. Tony Colombo, as described in the chapter in this volume, is the most fully develope