Mary Ann Cutter’s "Reframing Disease
Contextually" draws together a number of themes in philosophy of medicine
in order to make the case that disease should be understood contextually and
locally.  By "contextual" Cutter means that our understanding of
disease depends on a context created by a set of ontological, epistemological
and axiological commitments; by "localized" she means that the
specific commitments we make, and thus our understanding of disease, depend on
historical, socio-political and cultural influences.  The book is strongly
influenced by a clinical perspective that emphasizes that what we know about
disease depends, in large part, on what we can do — or what we prefer to do —
about it.

After an introductory chapter that sketches the
motivation and the plan for the book, Chapter 2 uses the case of AIDS to show
how our understanding of a disease forms and changes.  Cutter points out that
the way in which medicine has characterized AIDS has changed in response to new
clinical and physiological knowledge, as well as to various social changes. 
She describes this chapter as a "summary" of the project she
undertakes in the book (p. 13).

This summary is fleshed out in Chapters 3
through 8, where Cutter considers four debates that she sees as central to
explaining disease.  Her strategy for the first three debates is to outline
arguments on either side and then use these positions to situate her own
approach (which combines aspects of both sides of the original debate). 
Chapter 3 looks at the metaphysics of disease, sketching the "realist"
view that disease is an entity in itself, and the "anti-realist" view
that disease reflects a departure from the normal functioning of an organism,
rather than a distinct entity.  The various authorial positions she discusses
are, for the most part, not contemporary thinkers, though Cutter links Lawrie
Resnik’s views on the natural kind status of disease (that it isn’t a natural
kind) to historical anti-realist accounts.  Chapter 4 contrasts the "rationalist"
and the "empiricist" views of disease, where the former stresses the
importance of knowing the causes of disease, and of the need for certain
knowledge (which cannot be obtained through observation).  The latter, by
contrast, relies on clinical observations and emphasizes statistical
regularities rather than causal relations.  The distinction Cutter draws
between rationalist, causal thinking and empiricist thinking is not clearly
defended.  The medical systems described to illustrate this distinction do not
clearly show why those systems are rationalist or empiricist in nature.  A
closer connection between Cutter’s discussion of rationalism and empiricism in
philosophy (in general) and her discussion of the distinction in philosophy of
medicine (in particular) may have been helpful here.  Moreover, the causal
reasoning that is supposed to characterize rationalist thinking is described in
terms of the deductive-nomological account of laws, which explicitly avoids
making reference to causal relations and describes laws of nature solely in
terms of empirically-observable regularities.

Chapter 5 raises a very interesting and
important issue in medical epistemology, which is the relationship between
knowing disease and the ability to intervene in its course.  Cutter describes
the intimate relationship between medical theory and medical practice, showing
how our knowledge of disease is both informed by, and directed to, prevention
or treatment.

Chapters 6 and 7 examine the role of values in
our understanding of disease.  Chapter 6 reviews the debate between those who
(like Boorse) argue that disease can be defined without reference to values and
those who (with Wulff and Engelhardt) believe that the concept of disease is
always value-laden.  Whereas Cutter’s strategy with regard to the metaphysical
and the epistemological debates is to propose a middle ground that combines the
insights of each side, her conclusion in this chapter is a version of the
normative account of disease.  She does, however, caution that the values that
frame disease are not completely subjective, as we can find shared values based
on universal human needs.  This point reflects her conclusion regarding the
fourth debate: that between those who believe that contextualism implies
relativism and those who believe that it does not, contexualism is not a
form of relativism.  Having established that values do play a role in our
understanding of disease, Cutter turns in Chapter 7 to a discussion of the
kinds of values that are involved.  She identifies four classes of values:
functional values tell us what "ideals of activity" we should aim to
meet; aesthetic values express norms relative to our ideals of form and
function; instrumental values guide treatment (Cutter’s example here is of the
staging of cervical dysplasia and carcinoma, which guide treatment decisions on
the basis of prognosis, rather than of strict morphological criteria).  The
fourth class of values Cutter identifies are ethical values; she suggests that
the first three classes of value are non-moral.  This claim seems debatable.  Instrumental
values may have moral overtones, or implications and aesthetic values, which
can contribute to eating disorders or even to some plastic surgeries; these can
also be considered as morally objectionable.  Despite this, the "geography
of values" Cutter provides in Chapter 7 does show the variety of value
judgments that may come into play in shaping our ideas about disease.

Cutter describes Chapter 8 as summarizing her
argument in the preceding chapters and showing how the combination of
ontological, epistemological and axiological commitments shape our
understanding of disease.  Her argument for this "contextualism"
shades into her argument that the understanding of disease is localized.  Since
the specific commitments that contribute to our understanding of disease are
determined by historical, social and political factors, this interrelationship
is not surprising.  Perhaps a good way of distinguishing between the two
concepts that Cutter describes is to say that "contextualism"
emphasizes the type of values that shape our understanding of disease,
whereas the claim that our understanding of disease is localized emphasizes the
source of our values.  This analysis of disease is important and Cutter’s
case studies in Chapters 9 (genetic disease) and 10 (several examples of gender
bias in medicine), like her previous discussion of AIDS, provide strong support
for her views.

Overall, this book makes an
important case for viewing disease as "contextual" and, as noted
above, the examples of contextualism analyzed by Cutter are a useful and
powerful way of making this point.  The debates that she describes regarding
the metaphysics of disease, the epistemology of disease and the issue of
whether values are relevant to disease concepts provide a good overview of
issues in philosophy of medicine, and, more to the point, serve to distinguish
the various types of value commitments that inform our concepts of disease. 
That said, I felt that Cutter’s argument strategy, to sketch the two sides of
the debate and then construct a resolution that draws on both sides, sometimes
directed her presentation of the issues, rather than showing how the issues led
to her conclusion.  For example, in resolving the issue of whether values play
a role in defining disease, she suggests "one’s answer to the first debate
concerning whether values play a role in how disease is framed depends on one’s
answer to the second debate concerning the nature of the values [subjective or
objective] that frame disease" (p. 88).  Surely, this ordering is backwards,
and it appears to have been made in the service of salvaging something from the
"neutralist" view.  Similarly, the equation of rationalist (a
priori) knowledge of disease with knowledge of causes seems to be made in
order to justify Cutter’s conclusion that "rationalism and empiricism
offer limited yet complementary approaches to knowing disease" (p. 60).

All in all, this book is well worth
reading.  Cutter has pulled together a number of strains of philosophy of
medicine (a field that is, as she notes early in the book, both complex and
diverse) to construct an account of disease that is at the same time unified
enough to be philosophically satisfying and flexible enough to cover vastly
different types of disease.  One final quibble: the book should, at some stage,
have been proofread more carefully.  The typographical errors are frequent
enough to be distracting and in one case the labeling of a figure is at odds
with the description of the figure in the text.

© 2006 Robyn Bluhm

Robyn Bluhm, Ph.D. (Postdoctoral
Fellow in Neuropsychiatry, The University of Western Ontario)

Categories: Ethics, Philosophical