Naturalism in the Philosophy of Health, edited by Élodie Giroux, is an excellent example of the kind of work capable of being done in empirically informed philosophy. The book is a concise and dense collection of twelve essays, extending 229 pages, divided into three parts: The Biostatistical Theory of Disease: Criticism and Improvements; Health, Normativity and Naturalism; and Implications for Healthcare.

The book uses Christopher Boorse’s biostatistical theory as a starting point for thinking about naturalistic developments in the philosophy of health, making it a semitechnical read and requiring some background knowledge to appreciate the subtleties of the essays’ contributions. Although there is much to be gained from reading the essays without prior exposure to Boorse’s writings, the strengths and weaknesses of the individual essays are difficult to assess without knowing at least some initial details of Boorse’s view.

Without going into the fine-grained details, the biostatistical theory is concerned with how things typically are within a specific reference class. A healthy individual is taken to be a human who functions within the normal range and a diseased or ill human is one who is no longer functioning within that normal range. Health and disease on Boorse’s view are functional descriptions of an individual.

The narrow scope of the discussion is suitable for advanced students and scholars in history and philosophy of science (in which I include the philosophy of health). It is, however, too specialized for a general audience. In this review, I will provide a detailed overview of the essays of the first part and then a general summary of the second two parts.   

In the introduction, Giroux provides a nice explanation for the need to better understand how naturalism has the capacity to influence our understanding of health. In large part, he explains how the philosophy of medicine is influenced by the normative implications of our definitions of health and disease. In looking at the current state of the debate, Giroux cites Boorse’s writings on the subject as being central to our understanding of naturalist and normativist views of health (Boorse 1975, 1976a, 1976b, and 1977). Boorse’s views, in many ways, still serve as the main naturalist definition of health despite some objections put forward by Ereshefsky (2009) and Wachbroit (1994) that suggest that the naturalistic understanding of health may not be the kind of health that medical practitioners care about.

One of the main concerns has been to understand if diseases are intrinsically value-laden (as the normativist would have it) or not (as the naturalist suggests) (p. 2). In adopting some techniques from analytic philosophy, including conceptual analysis, Giroux states that the hope has been to establish a set of necessary and sufficient conditions for our understanding of concepts that are relevant to medicine. Boorse’s own analysis of the concept ‘health’ is to treat it as a theoretical concept, in which health is understood as being the absence of disease (defined as those internal states that depress a functional ability below species-typical levels) (Boorse 1977).

Giroux outlines three motivations for investigating naturalism’s impact on our understanding of health (pp. 6-8): there has been a renewed interest in naturalism and attempts to clarify the biostatistical theory; alternative naturalistic approaches may alter the tenability of the biostatistical theory; our understanding of the concepts of ‘health’ and ‘disease’ have significant implications for our medical practices that we should attempt to understand the viability of a naturalistic approach—even if it fails, we then have reasons to further explore other methodological approaches for our understanding of health and disease.

The first part, Biostatistical Theory of Disease: Criticisms and Improvements, consists of four essays aimed at understanding the form of naturalism that is relevant to our understanding of the biostatistical theory; exploring the extent to which function is required for the biostatistical theory; and determining if the comparativist approach to health is more beneficial than a non-comparativist approach.

In their essay, “Is Boorse’s Biostatistical Theory of Health Naturalistic?” Lemoine and Giroux argue that biostatistical theory is best understood in terms of a methodological, rather than ontological, naturalism. The former being “concerned with ways of investigating reality, and claims some kind of general authority for the scientific method,” while the latter “is concerned with the contents of reality, asserting that reality has no place for ‘supernatural’ or other ‘spooky’ kinds of entity” (Papineau 2015). This does not appear to be a contentious argument, given that much of medical progress is the result of its incorporation of scientific techniques (e.g., evidence-based medicine). In adopting methodological naturalism, two major implicit claims of the biostatistical theory are revealed: that priority is given to the theoretical, value-free, scientific concepts of health and disease, and that conceptual analysis is the right method for defining theoretical health and disease. There does not appear to be any immediate problem with the first claim, but the adoption of conceptual analysis poses some challenges. Conceptual analysis has yet to prove successful in providing the necessary and sufficient conditions for most concepts, if any. For example, the concept ‘bachelor’ understood as being an unmarried male has faced difficulties in considering cases such as adolescent males and members of the clergy. Something like ‘disease’ faces similar challenges within the biostatistical theory since it requires a specified reference class and requires some ontological commitments for understanding what is typical for a member of the species. Similar to ‘bachelor’ the term ‘disease’ requires additional stipulations to avoid vagueness and ambiguities in identifying the correct reference class when determining if something is either diseased or healthy. Lemoine and Giroux, however, still maintain that the first claim allows their understanding of biostatistical theory in terms of methodological naturalism, but that physiology is not sufficient for understanding medicine. Instead, they argue, that other biomedical sciences should be consulted in developing a definition of health and disease. This approach leads Lemoine and Giroux to be advocating for a naturalistic but non-reductionist account of health.

Forest and Le Bidan explore the problem of understanding physiology in terms of functions in their essay “In search of Normal Functions: BST, Cummins Functions, and Hempel’s Problem.” They argue that we should not define ‘health’ in terms of survival and reproduction, but, instead, that we should recognize that normal and abnormal functioning on their own contribute to an organism’s capacity to survive and reproduce. Functions, then, are defined as contributors to capacities that are distinctive in each reference class; physiologically or psychologically determined; and basic to our usual interactions with our environment. By incorporating the way an organism interacts with its respective environment as one of the indicators for normal functioning, Forest and Le Bidan provide a point at which evolutionary theory and medicine converge.

Hausman develops and defends a comparativist approach to the biostatistical theory in his essay “Comparative and Non-Comparative Concepts of Health.” He responds to objections put forward by Schoeder (2013) who argues that non-comparativist approaches result in a stalemate regarding our understanding of health and disease. Hausman argues that a comparative approach is both consistent with and requires a noncomparative approach since judgements about health cannot be made by only making comparisons.

The second part, Health, Normativity, and Naturalism, consists of three essays that explore natural or biological normativity and some possible accounts of health that could be based on natural normativity. The central concern with this part is determining what is normal for an organism in its respective environments. Like the first section, the second section provides a technical discussion, but relies more so on the connection between biology and medicine. For example, Sholl’s essay “Contextualizing Medical Norms: Georges Canguilhem’s Surnaturalism” analyzes Canguilhem’s account of health, which argues that each organism’s environment must also be considered to better understand the organism’s health. While this view may result in relativistic accounts of health, Sholl argues that such an approach has the strengths of integrating the dynamic features of organismic development and the variability that may arise over time in biological norms. Such an approach allows for a naturalistic account to more appropriately model how organisms develop over time in different environmental situations.

While the first two sections appear to be more theoretical with regards to how we should best understand health within a naturalistic framework and appropriately model normal and abnormal behaviors for living organisms, the third section, Implications for Healthcare, is centrally concerned with the implications of these considerations for medical practice. This section consists of four essays that aim to identify and assess some of the implications that naturalism has for healthcare and closely examine Boorse’s own attempts to develop a positivistic / non-valuative account of health. In particular, Boorse’s own contribution “Goals of Medicine” is his first formal attempt to analyze the implications of the biostatistical theory of health on the practices of medicine, the difficult issues of the goals of medicine, and the boundaries between treating a patient who is ill and enhancing a patient who is already healthy.

This last section brings the conversation full-circle. While it was Boorse’s own attempts in the 1970’s to understand how a concept of health can be understood in non-naturalistic terms, the strength of his account is tested against contemporary concerns. This approach is certainly helpful to understanding how philosophy bears on real world matters and can be empirically informed. As the essays currently stand they certainly get at many of the nuances of the relationship between naturalism and the normativity of ‘health’, but they would benefit from a closer analysis of the relationship between naturalism and normativity more broadly construed. The implications of that discussion would have immediate implications for our thinking of ‘health’ if it is indeed a normative concept. While the normativity of ‘health’ is assessed statistically, there may be other ways to identify its normative features by looking at its usage as action-guiding—we claim we should do things that contribute to our health and avoid those things that are detriments to our health. Understanding the normativity of health in terms of actions would have implications for our naturalistic endeavors since we would be more inclined to seek out causal relationships rather than statistical regularities.

Overall, the text is a technical and challenging book. The technicalities, however, are important enough for any scholar working in philosophy of science, medicine, or health who is concerned with the appropriate methods for examining key medical concepts that have deep and significant implications for the healthcare fields.

Additional Works Cited

Boorse, C. (1975). On the distinction between disease and illness. Philosophy and Public Affairs, 5, 49-68.

Boorse, C. (1976a). What a theory of mental health should be. Journal for the Theory of Social Behaviour, 6, 61-84.

Boorse, C. (1976b). Wright on functions. The Philosophical Review, 85, 70-86.

Boorse, C. (1977). Health as a theoretical concept. Philosophy of Science, 44, 542-573.

Ereshefsky, M. (2009). Defining ‘Health’ and ‘Disease’. Studies in the History and Philosophy of Biology and Biomedical Sciences, 40, 221-227.

Papineau, David, “Naturalism”, The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2016/entries/naturalism/>.

Wachbroit, R. (1994). Normality as a biological concept. Philosophy of Science, 61, 579-591.

 

© 2017 Andrew M. Winters

 

Andrew M. Winters, Department of Philosophy, Slippery Rock University of Pennsylvania