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

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

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

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

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

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

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

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

© 2002 Patricia Ross

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

Categories: Philosophical