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Published in: Medicine, Health Care and Philosophy 1/2022

Open Access 01-03-2022 | Scientific Contribution

Wherein is the concept of disease normative? From weak normativity to value-conscious naturalism

Authors: M. Cristina Amoretti, Elisabetta Lalumera

Published in: Medicine, Health Care and Philosophy | Issue 1/2022

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Abstract

In this paper we focus on some new normativist positions and compare them with traditional ones. In so doing, we claim that if normative judgments are involved in determining whether a condition is a disease only in the sense identified by new normativisms, then disease is normative only in a weak sense, which must be distinguished from the strong sense advocated by traditional normativisms. Specifically, we argue that weak and strong normativity are different to the point that one ‘normativist’ label ceases to be appropriate for the whole range of positions. If values and norms are not explicit components of the concept of disease, but only intervene in other explanatory roles, then the concept of disease is no more value-laden than many other scientific concepts, or even any other scientific concept. We call the newly identified position “value-conscious naturalism” about disease, and point to some of its theoretical and practical advantages.
Footnotes
1
The two most common rival accounts of function are Boorse’s forward-looking or causal contribution account, and Wakefield’s backward-looking or etiological account of function (Boorse, 1975, 1976, 1977; Wakefield, 1992, 1995, 1999). The debate on the notion of function is now huge and its assessment is not among the aims of our present discussion.
 
2
Broadbent (2019) observes that, from the perspective of the contemporary meta-ethical and metaphysical literature, it is misleading to equate ‘natural’ with ‘value-free’, and ‘value-laden’ with ‘subjective’, and thus proposes a different taxonomy of positions about the concepts of health and disease, also involving the judgment-dependence dimension. We do not address it further.
 
3
We are well aware that other relevant normativist theories have been advocated but we believe that the positions we review here are sufficient to exemplify what traditional normativists mean when they claim that the concept of disease is intrinsically value-laden. It should also be noted that, in their analyses, some normativists do not consider the notion of disease, but rather those of ‘malady’ (Nordenfelt), ‘illness’ (Megone), or ‘disorder’ (Wakefield); however, as we have already clarified, for the aims of this paper all these concepts can be equated to that of disease, which is used as an umbrella term for all pathological conditions.
 
4
More precisely, Nordenfelt distinguishes between first-order and second-order ability, and identifies being healthy with having the second-order ability to achieve a minimal degree of happiness. First order abilities are, for example, the ability to speak a language, walk, or read, while a second-order ability is the ability to follow a training or learning path at the end of which one will be able to have a first-order ability.
 
5
See, e.g., (Hanna, 2016) for a counterfactual comparative account of harm.
 
6
There is consensus on the claim that naturalism is generally a revisionary position. See, e.g., (Murphy, 2020; Schwartz, 2017).
 
7
For further discussions, see also (Hausman, 2012, 2014; Schwartz, 2017).
 
8
Oncologists recently debated the classification of prostate cancer; see, e.g., (Epstein et al., 2016).
 
9
Boorse writes that “Local part dysfunctions need not have any gross effects on disability or deformity or distress. […] Liver cells, to be normal, must perform a host of metabolic functions because that is what liver cells collectively contribute to survival and reproduction. But a large number of liver cells can be pathological without clinically detectable effects or appreciable risk of such effects” (Boorse, 1987, pp. 371–372). His theory clearly distinguishes between disease as dysfunction, and conditions that calls for medical treatment (Boorse, 1997) See also (Kincaid, 2008) for a different approach to the problem of demarcating cancers.
 
10
In most of her works Cooper focuses on the concept of disorder as it is used in the debates between psychiatrists, psychologists, mental health workers, and patients or lobby groups—see, e.g., (Cooper, 2015a). It would be neither correct to locate her project on Kingma’s first level—that of ordinary use description—nor on the second level—that of “conceptually clean” accounts. What interests us, however, is value-intrusion normativity that both philosophers individuate, and which can be independently characterized without Kingma’s conceptual apparatus of levels.
 
11
As we said in the opening, we aim our discussion at the umbrella concept of disease, intended as a superordinate concept. It might be the case that Cooper would not accept her argument to be extended to the concept of disease, either, but we are not interested in an exegesis of her paper. We therefore make explicit that the interpretation of Cooper’s “belt-and-brace” strategy as being about the concept of disease is only ours.
 
12
We acknowledge that (typically) normativists’ arguments may have more grip in the case of psychiatry.
 
13
Arguably, this is a conceptual defect of the manual. In a recent paper Amoretti and Lalumera (2019) suggested that harm should be explicitly ‘unpacked’ for every DSM diagnostic category, to specify whether it is harm for the subject, his or her close acquaintances, or the society, and who can assess it.
 
14
Cooper individuates the relational model of disability as one of the forces that produced the conceptual shift of mental disorder towards naturalism.
 
15
If disease is strongly normative, then it is probably a thick concept in the traditional sense of having both a descriptive and an evaluative component—see, e.g., (Kirchin, 2013).
 
16
Of course, if the concept of disease has an evaluative component as an explicit part of its definition, as strong normativism claims, it clearly differs from most other scientific concepts, which lack such an evaluative component.
 
17
To be precise, the WHO’s definition of the underlying cause of death comprises another disjunct, that is “the circumstances of the accident or violent act that produced the fatal injury”; however, it is not relevant here.
 
18
See John 2021 for an updated review and discussion of “new-wave” objectivity.
 
19
Strong naturalism is a bold position that, for instance, can be ascribed to Boorse (1977) and Schwartz (2007b).
 
20
To repeat, we do not mention Cooper’s framework here as it would be less nuanced than Kingma’s and ours, as it only has two categories instead of three (section Weak/strong normativity vis à vis with other similar distinctions).
 
21
Jeremy Howick (2011) also makes a case for patient-relevant outcomes in medical research.
 
22
For a more thorough discussion of values in DALY see (Solberg et al., 2020).
 
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Metadata
Title
Wherein is the concept of disease normative? From weak normativity to value-conscious naturalism
Authors
M. Cristina Amoretti
Elisabetta Lalumera
Publication date
01-03-2022
Publisher
Springer Netherlands
Published in
Medicine, Health Care and Philosophy / Issue 1/2022
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI
https://doi.org/10.1007/s11019-021-10048-x

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