Disease, The Concept

The Concept of Disease
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JOSEPH MARGOLIS* Austin Turk, surveying the literature of the criminal law, favored the view that "criminality is . . . the state of having been officially defined as punishable, whether or not one has been apprehended and punished" (Turk 1969, p. 18). He added that "efforts to determine causes of criminality have foundered on the fact that criminality is not a biological, psychological, or even behavioral phenomenon, but a social status defined by the way in which an individual is perceived, evaluated, and treated by legal authorities" (p. 25). It may seem surprising that such a viewrightly termed legal positivismis fairly matched within medical theory and theories governing other domains concerned with deviance and maladaption. For instance, Ian Gregory maintains that, "While professionals have a major voice in influencing the judgment of society, it is the collective judgment of the larger social group that determines whether its members are to be viewed as sick or criminal, eccentric or immoral" (Gregory 1968, p. 32).' The conjunction of these specimen views serves to fix our minds on the essential issues concerning the concept of health. For, even on the most casual canvassing of the relevant literature, it is obvious that medicine and the law are the two principal professional disciplines of advanced societies systematically concerned with rendering judgments that are at once informed by selected norms of human functioning and characterizable as findings of fact (ignoring, here, a more restricted usage in the law); that the extension of 'illness' (or 'deviance' or 'maladaptation') and the extension of 'criminality' are quite often confused with one another and even sometimes subsumed under one another (see Glueck [1954]; Menninger [1968]; Menninger, Mayman, and Pruyser [1963]; also the review of the issue in Flew [1973]: Kittrie [1971]; Szasz [1970]); and that we are * Professor of philosophy, Temple University, Philadelphia, Pennsylvania 19122. 1 The reference, I should like to mention, is cited in an unpublished paper by Christopher Boorse (1975a) which came into my hands just at the moment of composing my own account and from which, allowing for disagreements, I have much benefited.
The Journal of Medicine and Philosophy, 1976, vol. 1, no. 3. 1976 by The Society for Health and Human Values. All rights reserved.
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Joseph Margolis rather unwilling (though perhaps for different reasons) to regard illness and breaches of the law as matters merely of conventional classificationalterable without conceptual dislocation by whatever ingenious and imaginative historical turn given societies may have taken. The question of the nature of illness and disease (as well as that of crime) depends very substantially, as may be shown, on how we understand the nature of factual and value judgments, norms and normality, and the functioning of organs, organisms, and human persons. Obviously, the latter are vexed matters and may even seem to be quite remote from the concern of practicing physicians and of therapists in allied disciplines. Hence, in developing a theory of health and illness, a certain initial tolerance is required regarding certain ground-level distinctions which, if not provided, will be found to render debate practically useless. Furthermore, in attempting a fair account, we should consider the lack of uniformity in speaking of disease and illness and the possible difference in focus intended in speaking of health and disease. Thus, in a recent pronouncement, the World Health Organization (1958) held that "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (p. 459). Similarly, speaking of mental health, Marie Jahoda (1958) has stressed a comparable insufficiency when one thinks of health as the mere absence of mental disease. Also, a glance at the American Psychiatric Association's (1968; cf. International Classification of Diseases 1968) Diagnostic and Statistical Manual of Mental Disorders (DSM II), intended to adhere as closely as possible to the World Health Organization's International Classification of Diseases, confirms that the term 'disease' is hardly used in an explicitly systematic way. 1. VALUE JUDGMENTS Begin, then, with value judgments. For sentences of a predicative form, value judgments may be distinguished from nonvaluational judgments, by their predicates.2 That a predicate is a valuational predicate depends solely on the explication of its sense in terms of norms of some sort. The concept of a norm is the concept of a condition or parameter in terms of which a range of relevant phenomena may be (valuationally) graded or ranked as satisfying the condition given: valuational predicates, then, are used to grade or rank such phenomena relative to such norms. So seen, to admit a judgment to be a value judgment entails nothing at all about the defensibility or grounds for proposing particular norms; the distinction has to do only with the logical properties of different kinds of judgment. Construe illness
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The brief account given here is taken from Margolis (1971). 239
The Journal of Medicine and Philosophy as a lapse of some sort with respect to given norms of health: the judgment that Peter is ill (in whatever way may be specified) will count as a value judgment. Furthermore, seemingly nonpredicative sentences used in making value judgmentsfor instance, 'ought'judgments (whether moral or prudential or medical makes no difference)may always be fairly construed in a predicative way by simply replacing 'ought' by some such locution as 'oughtful' and making the required grammatical adjustments (see Margolis 1971). The account is convenient because, at one and the same time, it frees the characterization of value judgments from disputes about the defensibility of particular norms and permits us to see the sense in which value judgments and factual judgments are not distinct species of a common genus. In fact, we may say that a factual judgment, of any sort whatsoever, is simply a judgment to which we may assign truth values, usually, truth and falsity. So seen, there is no difficulty at all in admitting that a given judgment may be both a factual judgment and a value judgment. For example, the judgment that "Peter is tubercular" (which is not to say merely that the bacillus may be found in Peter's system) and that "Peter murdered Paul" (which is not to say merely that something that Peter did was causally responsible for the death of Paul) are, at one and the same time, value judgments and factual judgments: both may, in an obvious sense, be true or false, and 'tubercular' and 'murdered' are predicates by means of which we manage to grade conditions and behavior relative to certain medical and legal norms. Such judgments may be called "findings." An alternative way of putting the point is this: human institutions normally embody norms; hence, institutional facts (e.g., as regarding murder) may entail reference to norms at the same time that they remain facts. Even this general distinction is helpful with respect to certain wellknown quarrels in the medical setting. For, it is very often maintained that one may have a disease without being ill, even if disease is still a normative concept, indicating "a state of affairs as undesirable and to be overcome" (cf. Engelhardt 1974; Feinstein 1967). It is also sometimes maintained that, while the concept of illness is a normative concept, that of disease is not. As Christopher Boorse puts it: "In our own culture and in others, the concept of illness is a compound of a theory of disease and a body of associated normative institutions"; "The physician as theoretician speaks of diseases, lesions, organs, functions, and the like: in his social capacity he speaks instead of illness, suffering, incapacitation, recovery, and the like. Statements made in this second vocabulary do typically have an evaluative component; but I believe statements made in the first do not" (Boorse 1975a).3 Boorse cites the following view of
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This manuscript (n. 1 above) has now appeared in somewhat revised form;
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Joseph Margolis Fredrick Redlich's as an instance of what he takes to be an error, the mistake of "normativism": "Most propositions about normal behavior refer implicitly or explicitly to ideal behavior. Deviations from the ideal obviously are fraught with value judgments; actually, all propositions on normality contain value statements in various degrees" (Redlich 1952). Boorse suggests that some idealizationslike that of ideal gasesare not normative, which is entirely fair; but the point of Redlich's remark remains entirely unaffected.4 A good deal hangs on this. The idealization involved in the gas laws concerns the provision of standard but nonexistent specimens to which actual gases may be compared in terms of resemblance onlyand for the sake of simplifying causal explanation: the ideal gases are not thought to be excellent in any respect whatsoever. A similar methodological strategy is involved in Max Weber's ideal types (see Girth and Mills 1946). But the idealization involved in medical and related settings essentially concerns the provision of theoretical states of health with respect to which the actual states of organisms are to be suitably graded and ranked as relatively defective (as ill or not ill, or as more diseased or less diseased than other specimens). From this viewpoint, it is quite possible to admit that an organism has a certain disease but is not ill, but it makes no sense to suppose that to ascribe a disease to an organism does not imply some reference to the very same normative states on which ascriptions of illness depend. The ''presence of a disease" (usually bearing on infection or deficiency or abnormality) rather than the presence of a "diseased state" normally signifies that causal factors that might well make an organism ill (produce a diseased state that a patient might complain about or that might make him ail) are benignly present in the body under circumstances that invite concern about imminent or potentially imminent illness (that is, the occurrence of an actual diseased state that is likely to produce complaint or ailing imminently, or eventually does so). There are several reasons for insisting on the connection. First of all, it explains why it is that medical diagnosis and prognosis are conceptually linked to the norms of health and illness even where particular judgments, for instance judgments merely describing (nonevaluatively) the condition of the body, probable causal developments, and the probable causal consequences of initiating chemical and other physical changes, may involve no explicit reference to the norms of health and disease; the intent in pursuing the latter sort of inquiry is normally to determine the presence of a disease, that is, the presence of causal see Boorse (19756). Boorse pursues the same theme in two forthcoming papers; see (in press) and (forthcoming). 4 The same charge is laid against my own book (1966).
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The Journal of Medicine and Philosophy factors that are likely to produce illness (disease states palpable to the patient in virtue of his symptoms). Second, it explains the sense in which medicine is primarily an art and, dependency, a science: it is primarily an institutionalized service concerned with the care and cure of the ill and the control of disease, in facilitating which certain purely descriptive and causal inquiries are pursued. Third, it suggests the potentially controversial nature of the norms of health and disease and the prerogatives and obligations of medicine: the objectivity with which the norms of health and the constraints of medicine may be specified are not in the least assured by merely acknowledging that medicine is a doubly normative discipline. Controversy about the inclusion, say, of homosexuality as a medically designated disorder (see "Should Homosexuality Be in the APA Nomenclature?" 1973; "Ideas and Trends" 1973)5 and about the revision of rights and obligations in the patient-doctor relationship (see Annas and Healey 1974; Sade 1971) makes this quite clear. But to collect the argument thus far advanced, we may say that value judgments are distinguished by their predicates, which entails that relevant ascriptions depend not merely on resemblances to standard but unexceptional specimens but, via grading and ranking, on approximations to, or deviations from, norms or standards of merit or worth (see Margolis 1971, chap. 5; cf. Hampshire 1959). Those norms, norms of health and illness, embody (in a way that needs to be specified) the relevant and legitimate concerns of human beings. The asymmetries between ascriptions of disease and illness reflect pragmatic distinctions relative to those concerns. And the proper constraints on the rights and obligations of patients and doctors, in the context of the practice of the medical arts, clearly must conform with those same concerns. There remains the problem, however, that, useful though they may be, these considerations are entirely formal. 2. NORMS Two sets of contrasting distinctions conveniently fix the problem of medical norms: disease and illness, pathologist and clinician. It is obvious that there is a fair sense in which a certain disease may be present in one's system and in which one may be in a distinctly diseased state (through any of a range of stages from the benign to the lethal) without actually ailing or complaining of any symptoms because of the disease. And it is equally obvious that one may complain about or ail because of putative symptoms that either are not linked to disease at all or are, for Dr. Robert L. Spitzer, who served as head of the APA task force on nomenclature and statistics, actually claims that 'normal' and 'abnormal' are "strictly speaking, not psychiatric terms" ("Ideas and Trends" 1973).
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Joseph Margolis reasons of technology or competence or the like, not detectably so linked; and even where symptoms are linked to disease, they may be associated with diseases other than the disease for which one's illness is classified. In this connection, Alvan Feinstein has usefully distinguished lanthanic diseases, that is, diseases that, though clinically evident, escape the patient's detectionas when there are no symptoms accessible to the patient or when, though there are, he is not a complainant. Feinstein here speaks of there being no iatrotropic stimulus. He adds the distinction of the co-morbidity of diseases associated with the disease for which one may be a complainant, with respect to which some symptoms that serve as iatrotropic stimuli may really be the symptoms of an associated illness (Feinstein 1967, chap. 9). Now, these distinctions presuppose a system of medical norms that Feinstein nowhere supplies. And yet, even with these formal distinctions in hand, it is clear why the concept of disease, though not entirely isomorphic with the concept of illness, makes no sens.e without reference to appropriate norms. A diseased state, on any plausible theory whatsoever, is a morbid or abnormal state of some sort, a state defective or deranged with respect to some condition of healthy functioning or suitably related to such a state, even if there is no complainant. A disease is either what is apt to cause a diseased state or that diseased state itself. Illness is simply a diseased state manifest to an agent through that agent's symptomssensations, introspective cognition, proprioceptive awareness, and the like; or, more informally and not narrowly the concern of medicine, a temporary condition of ailing (or complaint) not caused by a disease state at all. In that sense, plants may be diseased but never ill. But these distinctions still contribute very little to our understanding of the nature of disease itself. In fact, what needs to be emphasized is that it is conceptually not at all implausible to hold that an incipient disease or diseased state may well obtain without any malfunctioning whatsoevernot merely in the lanthanic sense but in the sense that, on whatever professional criteria may be admitted, the palpable onset on some disease, as among the cancers, need not be synchronic with any determinate malfunctioningprovided that what is so designated is causally linked in an appropriate way with the onset of malfunctioning and is not trivially taken as a form of malfunctioning itself. Here, one must bear in mind a common equivocation on 'abnormal' and cognate termsas designating determinate malfunctioning or what, under the circumstances, is likely to cause such malfunctioning. To return to our initial distinctions: Feinstein (1967) also contrasts the clinician and pathologist. After listing characteristic diagnostic categories (e.g., myocardial infarction, phlebothrombosis), he observes:
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The Journal of Medicine and Philosophy

Not a single one of these diagnostic terms represents an entity that is ever actually seen, heard, or touched in the ordinary bedside observations of a clinician. Every one of these entities is an abnormality of internal anatomic structure. The clinician at the bedside never observes these abnormal structures directly; he observes the symptoms and signs that are their clinical effects. With roentgenography, a clinician may see the silhouettes and shadows of these abnormal structures; with endoscopy, he may see those portions of an abnormality visible in the accessible lumen; with laboratory tests, he may note the associated disorders in physiologic and biochemical function; with surgical exploration in suitable situations, he may see a larger view of the abnormal structure and of its anatomic relations. But the only doctor who regularly witnesses the actual, complete appearance of all these anatomic entitiesthe only doctor who can regularly see them, feel them, and even cut themis a pathologist. [Pp. 73-74]
In effect, then, the clinician operates with the pathologist's categories. But Feinstein misleadingly concludes that the clinician is somehow confined to inferences from what he observes and that the pathologist actually witnesses the disease or diseased conditionwhich introduces an unexplained privilege. Thus he says: "To arrive at a diagnosis of morbid anatomysuch as myocardial infarction, epidermoid carcinoma of the lung, or hepatic cirrhosisa pathologist makes no deductions or inferences. He classifies what he sees" (p. 80). The question remains, What makes what the pathologist observes classifiable as disease? Whatever the grounds may be, they will also provide a basis for claiming that the clinician observes the symptoms and signs of disease. Alternatively put, clinician and pathologist make their usual observations and inferences informed by a common theory of medical norms of health and illness. There is another clue that the contrast between clinician and pathologist provides: the clinician normally attends to the complaints and therapy of his patient; the pathologist normally attends to the functioning of organs and other anatomical structures, systems of biochemical processes, and the behavior of cells. Psychiatry is at least a near exception. Clinician and pathologist, examining systematic behavior, tend to converge on the total condition of their human patients. But this is precisely what has raised the strenuous question of the medical status of psychiatric illness (see Szasz 1961; Margolis 1966). Nevertheless, two provisional conclusions may be drawn here. First of all, the conception of diseased cells, of microorganisms as disease entities (whether defensible or not) (see Virchow 1958), and of the diseases of organs must be dependent on the conception of the diseases and illnesses of human beings, animals, and plants as such. Second, the allegedly scientific and value-neutral status of medical pathology addressed to cells, organs,
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Joseph Margolis biochemical processes, and the like must be an abstraction (entirely defensible as such) from the value-freighted investigations of the world of disease and illness common to pathologist and clinician. The reason for both conclusions is the same, namely, reference to the medically relevant norms in terms of which alone diseases are construed as such. A first approximation to the theory of medical normslet it be stressed that it is only a first approximationhas it that the body is composed of certain structured systems each of which has an assignable range of normal functioning. Defect or disorder of such systems relative to such functioning constitutes a sufficient condition of disease; illness, then, is reflexively palpable disease. Psychiatry is once again problematic, since relative to mental illness, "functional" systems tend to be metaphorically identified and the norms that must be posited oblige us to assign functional characteristics to human nature as such (rather than to organs, limbs, or the like). In this regard, the norms of health and disease tend to correspondoften in a disputatious waywith putative norms of happiness and well-being (see Margolis 1966).6 To the extent that this occurs, it becomes difficult to treat the norms of medicine as altogether independent of ideologies prevailing in different societies (see Hollingshead and Redlich 1958). A closer review of the matter reveals, however, both that the functional norms of psychiatry are capable of a fair measure of objective support relative to the norms of physical medicine and that the norms of physical medicine are themselves dependent on a deeper commitment to a more-than-medical conception of human functioning. Furthermore, pursuing the implications of the disease/illness distinction, we must realize that there cannot possibly be a thorough and detailed form/function correlation for all diseases. Feinstein (1967; see, also Ryle 1961), noting that "abnormal structure and abnormal function [cannot] always be correlated, so that one constantly implie[s] the other and vice versa," offers the following counterinstances: Anginal pain may arise from pulmonary hypertension, not coronary disease; coronary disease may produce no angina. Skin may look yellow because of hypercarotenemia: a serum bilirubin value may be elevated without evident clinical jaundice. Cyanosis may be due to methemoglobinemia; a hypoxemic patient may be too anemic to look cyanotic. Lid-lag may sometimes occur in healthy people or in euthyroid patients with pulmonary disease; the exophthalmos associated with lid-lag and hyperthyroidism may persist long after treatment has made the patient euthyroid or even hypothyroid; hyperthyroidism may produce no lid-lag; and an elevation of protein-bound iodine, associated with neither lid-lag nor hyperthyroidism, may be Engelhardt (1974) cites the amusing "disease" drapetomania (the running away of slaves) (see Cartwright [1851, cited in Engelhardt]). 245
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The Journal of Medicine and Philosophy due to residual deposits of iodine dye used in a previous gall bladder X-ray examination. [Pp. 68-69]
Considerations of these sorts oblige us to admit that the functional conception in terms of which disease is to be specified cannot be read off directly by a scanning of observable form/function correlations, even if, for particular diseases, such correlations seem to present themselves (e.g., angina pectoris and coronary arteriosclerosis). Here, also, several additional qualifications may be proposed. First of all, whatever it may be made out to be, the notion of normal or healthy functioning cannot be straightforwardly assigned to the localized processes and structures of the body. Even the concept of homeostasis must be construed in a molar and functional way (i.e., with respect to the functioning of the healthy organism as such), by reference to which alone the distribution of relatively localized functions is itself justified. Not only may the homeostatic mechanism itself be diseasedwhich obliges us to construe bodily functions in terms of higher-order norms; the very "mechanism" of homeostasis presupposes "goal-directed activities" and "directively correlated processes"which cannot be identified except in terms of some antecedently governing function (see Sommerhoff 1974; Wiener 1953).7 Secondly, what is normal must be construed not as a fixed point but as a range of variations, tolerated in accord with some antecedent theory of the relationship between individual organisms and the populations of which they are members, a fortiori, between individual organisms and their environment. Species variation contributes to species survival in a changing world and individual variability may accommodate different careers and different kinds of tolerance (see Ryle 1961; Dobzhansky 1962). But to concede this much is to construe medicine as instrumental to ulterior values. What, then, is the nature of disease? 3. FUNCTIONS The notion that human beings have a natural function is essential to the eudaimonism of Plato and Aristotle and it is, in a way, presupposed by the claims of somatic and psychiatric medicine insofar as they suppose themselves to be value-neutral sciences.8 The difficulty of defending An essential consideration is that the application of (formal) homeostatic concepts to organisms must accommodate, within the margins or normality and health, the aging and death of individual organisms and favored forms of the viability of populations within their environments. Note the usual absence of discussion along these lines (see Engel 1953; van Bertalanffy 1950). But see the discussion of functions, below. 8 A particularly explicit specimen view is offered by Heinz Hartmann (1960). The theme obviously underlies the comparatively recent debate on the 246
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Joseph Margolis functional norms is rather complex. For one thing, specimens of Homo sapiens are readily classified on the basis of resemblance to admitted specimens not otherwise distinguished in any way whatsoever regarding merit or excellence of any sorthence, neutrally to the competing eudaimonistic visions of Plato, Aristotle, and their progeny. For another, even for such an organ as the eyewhich one supposes to have a definite and assignable function, with respect to which, therefore, diseases may be objectively discernedit is quite possible to imagine a set of circumstances in which eyes would lose their "function" and yet not be diseased. For example, imagine that, because of terrestrial pollution, the human race adopts, and adapts to, a life maintained at a submarine level unpenetrated by sunlight. The unlikelihood of the example is not important, because the lesson to be drawn is not that the eye has no function but only what is entailed in saying that it does have a function. Or, again, imagine that sickle-cell anemia conveys immunity from malaria and that, among the black peoples of Africa, the first is significantly less lethal than the second and "functions" to insure the survival of given populationsadmittedly at the expense of selected individuals (see Dubos 1959). What is the clear sense in which both are diseases on functional grounds? Finally, it is perfectly clear that absolutely no theory of disease construes death itself or aging as dysfunctional or the result, merely as such, of disease. Man is essentially mortal and the trajectory of life from birth to death sets the boundaries within which particular diseases are so designated. There are diseases that are lethal but there are no diseases that are classified as such merely because they result in death. On the contrary, the most interesting general feature about disease is that it is a disorder or the cause of disorder of a certain sort within the functional range of ongoing life: that death may result from disease is a mere contingency but that disease may cause death or aging prematurely is not another contingency of the same sort. Imagine, for instance, that an extraordinary discovery conflrms that a certain drug could increase our life expectancy in general, at an "acceptable" level of activity, fourfold; that it would be inexpensive, accessible, and without unfavorable side effects; and that society would begin to adjust its expectations and social arrangements to the increased longevity of its members. Might not patterns of now-normal decline leading to eventual death "by natural causes" come to be viewed as disease syndromes, severely dysfunctional processes subject to medical correction? If not, why not? And if so, then what is the sense in which the functional norms of medicine may be objectively specified independently of social values and social expectations? medical status of homosexuality (see "Should Homosexuality Be in the APA Nomenclature?" 1973; Margolis 19756).
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The Journal of Medicine and Philosophy These questions set the essential puzzle,9 but we are far from understanding the sense in which we speak of the functions of human beings or other animals and the functions of the various organs and processes within their bodily systems or the systems of their behavior and life. One crucial distinction cannot be avoided. Whatever functions are assignable to organisms as suchhuman beings in particularare behavioral, in the generous sense of the term, such that no norms regarding the "appropriate," "proper," "normal" life of given organisms (extending even to plants and not confined in any way to merely medical concerns) can fail to include reference to the molar behavior (informed, where relevant, by mental states) or to what is the molar analogue of behavior where sentience is minimal or nonexistent (as among lower animals, plants, and machines). But the functions that are assignable to organs and processes within the bodily or life systems of particular kinds of organisms are dependently assigned in virtue of putative molar functions and are themselves (on what may be called the molecular level) never directly construed in behavioral terms. That is, the functions of living organisms are to be understood in terms of the goal-directed activities of those organisms, but the functions of their organs and processes are teleologically defined by reference to such activities though they cannot themselves be construed as goal directed or goal seeking (an anthropomorphism that is intelligible only in the context of the fable of the contract between the stomach and the other organs and limbs to cooperate for the sake of their various and independent interests). This is not to say that all goal-directed activity is functional or has a function or that all behavior that has a function is goal directed (see the extremely interesting account by Wright [1973]). It is simply to say that, wherever they are assigned, functions are assigned in accord with some deliberate plan or design (as with human work and machines), or with "natural" goals (as with living organisms), or with some more informal approximation to either of these models (see Sorabji 1964). The difficult cases, of course, are precisely those in which natural functions are assigned, and these are just the ones that concern medicine and are usually specified in terms of the subsystems (e.g., the organs) of living organisms themselves. Where natural functions are assigned to those very organisms as integers of some sortas, classically, by way of the eudaimonism of the Greeksthey are defined behaviorally and in It is interesting, in this connection, to consider the extremely convenient resume of the development of the concept of disease offered by Sir Henry Cohen (1961). Cohen recommends that disease interpreted as "deviation from the normal . . . should dominate our teaching and our approach to medicine." But he obviously takes it for granted that the normal or normal functioning is a straightforward matter both professionally and philosophically.
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Joseph Margolis terms of the "appropriate" goals or objectives of the creatures in question, favoring, of course, the full-blooded planning of human beings (though not exclusively). Still, the sense in which both artifacts and natural creatures have functions (and, by elaboration, the parts of artifactual systems and the organs and processes of organisms) is said to entail that the functions assigned be essential to their respective natures, not merely accidental or accidentally useful or the like.10 The trouble is that animals, including Homo sapiens, may be classified without regard to norms of functional excellence of any sort, solely in terms of resemblance to standard specimens that are not themselves supposed to be functionally superior or to provide functional paradigms of any sort.11 And this signifies that the ascription of "natural" functions to organismsmost controversially, natural functions to human beings or human persons (characteristically though not necessarily ethically freighted, as in the natural law tradition or the doctrine of eudaimonism)cannot be straightforwardly made on the basis of some empirical inspection of the essential nature of such creatures. This is not to lose the notion of natural function but only to question in an important way the sense in which natural functions may be said to be discovered by an exercise of medical science or any other relevant science. As it turns out, there is an extremely simple and straightforward sense in which natural functions may be assigned to human beings, which does not require that we think of them as fixed or determinate or essential or discovered. But to say this is, precisely, to provide for quarrels about the provision of medical normsas, for instance, with regard to the longevity example already supplied or with regard to familiar controversies over sexual deviance and other psychiatrically sensitive categories. To see this, consider first the general analysis of functions advocated by Larry Wright: "The function of X is Z means (a) X is there because it does Z, (b) Z is a consequence (or result) of AT's being there" (1973, p. 161). Wright correctly notes that "functional ascriptions are . . . explanatory"; are, in particular, "etiological, concern the causal background of the phenomenon under consideration, [that is,] concern how the thing with the function got there" (pp. 154, 156). Nevertheless, in clarifying his formulation, Wright implicitly betrays its own limitations. For he says, "The first part, (a), displays the etiological form of func10 The point is effectively made in Wright (1973). He usefully analyzes the weakness of a number of accounts that are primarily concerned with the nature of the functions of the organs and processes of biological organisms; in particular, Beckner (1959); Canfield (1964); Beckner (1969). 11 A standard argument that the mere classification of human beings (or of anything else) entails reference to grading and ranking notions appears in Hampshire (1959, p. 223). But it is untenable and unnecessary; see Margolis (1971, chap. 5). 249
The Journal of Medicine and Philosophy tional ascription-explanations, and the second part, (b), describes the convolution which distinguishes functional etiologies from the rest. It is the second part of course which distinguishes the combining with hemoglobin from the producing of energy in the oxygen-respiration example. Its combining with hemoglobin is emphatically not a consequence of oxygen's being in our blood; just the reverse is true. On the other hand, its producing energy is a result of its being there" (p. 161). The oxygenrespiration case concerns the fact that, although it is etiologically true that oxygen is found in human bloodstreams because it combines with hemoglobin, it is "colossally fatuous" to say that it is the function of oxygen to combine with hemoglobinwhere it is the function of oxygen to produce energy. Nevertheless, Wright also maintains that, "if carbon monoxide, which we know to combine readily with hemoglobin, were suddenly to become able to produce energy by appropriate (non-lethal) reactions in our cells and, further, the atmosphere were suddenly (!) to become filled with CO, we could properly say that the reason CO was in our bloodstreams was that it combines readily with hemoglobin. We could not properly say, however, that CO was there because it produces energy. And that is precisely what we could say about oxygen, on purely evolutionary-etiological grounds" (pp. 159-60). This won't do, however, simply because one could well imagine sustained circumstances under which, on the hypothesis, the survival of the species depended on ingesting CO and on its combining with hemoglobin and thereupon producing energycircumstances in which (on Wright's own hypothesis) the process noted obtained "suddenly." This shows the difficulty, in spite of what Wright says, of maintaining the asymmetry of the concept of "consequence" (that " 'A is a consequence of IT is in virtually every context incompatible with 'Z? is a consequence of A' ") (p. 161). But there is another fatal consideration, namely, that Wright's formulation fails to exclude cases of diseasein particular, cases in which the homeostatic mechanisms of an organism are themselves diseased. One has only to imagine the evolution of diseased populations to see that creatures and organs and processes may well be said to function in a certain characteristic way, although, on some relevant theory, we should not wish to say that the function of what is in question would then be given by the formulation cited (see pp. 141-43). Notice that such cases are quite different from cases (mentioned by Wright) in which "organismic mutations," though accidental, may yet confer in time functionhood on an organ or process. Obviously, something more is needed. 4. PRUDENCE AND DISEASE When Wright attempts to explain the way in which functional explanations operate, he says explicitly: "When we explain the presence or
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Joseph Margolis existence of X by appeal to a consequence Z, the overriding consideration is that Z must be or create conditions conducive to the survival or maintenance of A"' (1973, p. 164). But it may, for instance, be argued, as earlier remarked, that sickle-cell anemia, which is hereditary, functions, among African populations, in a way that is conducive to survival in malarial environments (see the suggestive summary in Brothwell [1971]). Is it the case, then, that, in such circumstancesrelatively stable in fact for agesthe function of sickle-cell anemia is to confer immunity to malaria? This seems as "colossally fatuous" as what Wright had marked out in the oxygen-respiration case. An essential part of the difficulty of all theories of these sorts applied to human beings depends on the important distinction between the human animal (the biological species Homo sapiens) and human persons (members of Homo sapiens who have been culturally trained in the mastery of language and who are, therefore, capable of self-reference and cultural contribution).12 It is impossible, for instance, to speak of psychiatric disease and disorder exclusively in terms of the condition of the human animal: the disorders normally considered are formulable only in terms of the mental processes of culturally emergent persons. But this means that the ascription of "natural functions" to human persons cannot possibly be provided, in the context of psychiatry, in a way that ignores the culturally prepared goals of human societies. And if the functioning of the human animal (what may roughly but only very roughly be thought to provide the concern of somatic medicine) may be fairly said to be inseparable from the functioning and functional objectives of human persons and if, as has been suggested, natural norms are not simply straightforwardly discovered, then we need to provide a rather different rationale for the ascription of functions (a fortiori, for the norms of medicine) from what has so far been sketched. A fair way of proceeding is to confine ourselves to what may be called rational minima, that is, constraints regarding normative matters, including the norms of health and disease, that are least controversial or objectionable to agents endowed with a minimal measure of rationality more or less presupposed by every significant human society.13 Obviously, there will be quarrels here as well. But it may be said that human beings, viewed in a sense that is relatively neutral to their condition as animals or persons, subscribe to a characteristic set of (what may be called) prudential valuesavoidance of death, prolongation of life, restriction of pain, gratification of desires, insuring security of person and body and property and associates, and the like. The evidence is empirical This very complicated matter I can only hint at here. It is the subject of my as yet unpublished book, Persons and Minds. 13 The full account of the thesis presented here appears in Margolis (1975a). 251
12
The Journal of Medicine and Philosophy and statistically overwhelming and the argument does not in the least assume the discovery of what is essential or normatively natural to human existence. Now then, the set of prudential values that may be ascribed to human beingsand, by extension, adjusted for lower animals and, by analogy, adjusted for plantsis relatively open-ended, putative, and merely determinable. Any determinate recommendation regarding the management of prudential values for an entire society constitutes an ideology or part of an ideologyassuming that there are no discoverable natural norms of human existence, or at any rate in the absence of any compelling discovery of that sort. Medicine and the law are the two principal professionalized disciplines of every complex society that have provided an institutionally determinate rule for managing a portion of our prudential interests: the lawin terms of restricting harm or the threat of harm to those interests, caused by another (criminal law), or of protecting the exercise of those interests, as in the use of rights and property, in the arena of social exchange (civil law); medicinein terms of insuring the functional integrity of the body (or mind or person), as by care and cure, sufficient for the exercise of our prudential interests. Prudential interests, then, are merely enabling interests, that is, the general (determinable) condition on which any ethical, political, economic program viable for a complex society must depend; in that sense, the pursuit of prudential interests is prima facie rationalwhich of course is not to deny that, as in suicide and self-sacrifice, there may well be grounds on which prudential interests may be waived without being irrational (hence, without breaking the law or without being diseased or disordered) (see Margolis 1975a). Since the human body (unlike social institutions) has changed relatively little over millenia, the functional norms of somatic medicine are relatively conservative (unlike the norms of law). But since, understandably enough, medicine has expanded its purview to include the concerns of mental health and mental illness (see Margolis 1969, also 1966), and since medicine in general must subserve, however conservatively, the determinate ideology and ulterior goals of given societies, the actual conception of diseases cannot but reflect the state of the technology, the social expectations, the division of labor, and the environmental condition of those populations. This is no more than a sketch of the nature of medical norms. Still, it is the conception rather than the details that is so elusive. The apparent obviousness of the natural functions of the organs and bodily processes can only be understood in terms of the conservativism of our prudential interests, such that the shifting of ideologies leaves relatively intactbut only relativelythe detailed schedules of bodily disease and illness. What we see is that it is entirely fair to insist on the natural functions of the various parts of our system. What has been changed (or challenged) is 252
Joseph Margolis "only" the theory of such functions: they are now seen to subtend the putative prudential interests of the race, which are themselves determinable values subserving in ideologically determinate ways the ulterior functional norms ascribed by different doctrines to the life of man (as in eudaimonismeven in the inverted form advanced by Freudor the natural law doctrine or the like). In a sense, therefore, medicine is ideology restricted by our sense of the minimal requirements of the functional integrity of the body and mind (health) enabling (prudentially) the characteristic activities and interests of the race to be pursued. And disease is whatever is judged to disorder or to cause to disorder, in the relevant way, the minimal integrity of body and mind relative to prudential functions. REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3d ed. Washington, D.C.: American Psychiatric Association, 1968. Annas, George J., and Healey, Joseph M., Jr. "The Patient Rights Advocate: Redefining the Doctor-Patient Relationship in the Hospital Context." Vanderbilt Law Review 27 (1974): 243-69. Beckner, Morton. The Biological Way of Thought. New York: Columbia University Press, 1959. Beckner, Morton. "Function and Teleology." Journal of the History of Biology 2 (1969): 151-64. Boorse, Christopher. "The Descriptive Core of Mental Health Judgments." Unpublished manuscript. 1975. (a) Boorse, Christopher. "On the Distinction between Disease and Illness." Philosophy and Public Affairs 5 (1975): 49-68. (b) Boorse, Christopher. "What a Theory of Mental Health Should Be." Journal for the Theory of Social Behaviour, in press. Boorse, Christopher. "Health as a Theoretical Concept," forthcoming. Brothwell, Don. "Disease, Micro-Evolution and Earlier Populations: An Important Bridge between Medical History and Human Biology." In Modern Methods in the History of Medicine, edited by Edwin Clarke. London: Athlone Press, 1971. Canfield, John. "Teleological Explanations in Biology." British Journal for the Philosophy of Science, vol. 14 (1964). Cartwright, Samuel A. "Report on the Diseases and Physical Peculiarities of the Negro Race." New Orleans Medical and Surgical Journal 7 (1851): 707-9. Cohen, Sir Henry. "The Evolution of the Concept of Disease." In Concepts of Medicine, edited by Brandon Lush. London: Pergamon Press, 1961. Dobzhansky, Theodosius. Mankind Evolving. New Haven, Conn.: Yale University Press, 1962. Dubos, Rene. Mirage of Health. New York: Harper & Row, 1959. 253
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Engel, George L. "Homeostasis, Behavioral Adjustment and the Concept of Health and Disease." In Mid-Century Psychiatry, edited by Roy R. Grinker. Springfield, 111.: Charles C. Thomas, 1953. Engelhardt, H. Tristram, Jr. "The Concepts of Health and Disease." In Philosophy and Medicine, edited by H. Tristram Engelhardt, Jr., and Stuart F. Spicker. Vol. 1. Dordrecht: D. Reidel, 1974. Feinstein, Alvan. Clinical Judgment. Baltimore: Williams & Wilkins, 1967. Flew, Anthony. Crime or Disease? London: Macmillan Co., 1973. Girth, H. H., and Mills, C. Wright. Introduction to From Max Weber: Essays in Sociology. New York: Oxford University Press, 1946. Glueck, Bernard. "Changing Concepts in Forensic Psychiatry." Journal of Criminal Law, Criminology and Police Science 45 (1954): 123-32. Gregory, Ian. Fundamentals of Psychiatry. Philadelphia: W. B. Saunders Co., 1968. Hampshire, Stuart. Thought and Action. London: Chatto & Windus, 1959. Hartmann, Heinz. Psychoanalysis and Moral Values. New York: International Universities Press, 1960. Hollingshead, A. B., and Redlich, F. C. Social Class and Mental Illness. New York: John Wiley & Sons, 1958. "Ideas and Trends." New York Times, December 23, 1973. International Classification of Diseases Adapted for Use in the United States. 8th revision. Public Health Service Publication no. 1693. Washington, D.C.: Government Printing Office, 1968. Jahoda, Marie. Current Concepts of Positive Mental Health. New York: Basic Books, 1958. Kittrie, Nicholas, N. The Right to Be Different. Baltimore: Johns Hopkins University Press, 1971. Margolis, Joseph. Psychotherapy and Morality. New York: Random House, Inc., 1966. Margolis, Joseph. "Illness and Medical Values." Philosophy Forum 8 (1969): 55-76. Margolis, Joseph. Values and Conduct. New York: Oxford University Press, 1971. Margolis, Joseph. Negativities: The Limits of Life. Columbus, Ohio: Charles E. Merrill Publishing Co., 1975. (a) Margolis, Joseph. "The Question of Homosexuality." In Sex: From the Philosophical Point of View, edited by Robert Baker and Fred Elliston. New York: Prometheus Books, 1975. Q>) Menninger Karl. The Crime of Punishment. New York: Viking Press, 1968. Menninger Karl; Mayman, Martin; and Pruyser, Paul. The Vital Balance. New York: Viking Press, 1963. Redlich, Fredrick. "The Concept of Normality." American Journal of Psychotherapy 6 (1952): 551-69. Ryle, J. "The Meaning of Normal." In Concepts of Medicine, edited by Brandon Lush. London: Pergamon Press, 1961. Sade, Robert M. "Medical Care as a Right: A Refutation." New England Journal of Medicine (1971), pp. 1288-92. 254
Joseph Margolis "Should Homosexuality Be in the APA Nomenclature?" American Journal of Psychiatry 130 (1973): 1207-16. Sorabji, Richard. "Function." Philosophical Quarterly 14 (1964): 289-302. Sommerhoff, Gerd. Logic of the Living Brain. London: John Wiley, 1974. Szasz, Thomas S. The Myth of Mental Illness. New York: Harper-Hoeber, 1961. Szasz, Thomas S. The Manufacture of Madness. New York: Harper & Row, 1970. Turk, Austin. Criminality and Legal Order. Chicago: Rand McNally & Co., 1969. van Bertalanffy, Ludwig. "The Theory of Open Systems in Physics and Biology," Science 111 (1950): 23-29. Virchow, Rudolf. Disease, Life, and Man: Selected Essays by Rudolf Virchow. Translated by Lelland J. Rather. Stanford, Calif: Stanford University Press, 1958. Weiner, Norbert. "The Concept of Homeostasis in Medicine." Transactions and Studies of the College of Physicians of Philadelphia 20 (1953): 87-93. World Health Organization. The First Ten Years of the World Health Organization. Geneva: World Health Organization, 1958. Wright, Larry. "Functions." Philosophical Review 82 (1973): 139-68.
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Disease, The Concept

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The Concept of Disease

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