Starting point – why do we want an account of the concept of disease

This is a pre-copy-editing version.
Papers, vol 36, no. 3, pp. 427-442.
Aristotelian Accounts of Disease – What are they good for?
Rachel Cooper
In this paper I will argue that Aristotelian accounts of disease cannot provide us with an adequate descriptive account of our concept of disease. In other words, they fail to classify conditions as either diseases, or non-diseases, in a way that is consistent with commonplace intuitions. This being said, Aristotelian accounts of disease are not worthless. Aristotelian approaches cannot offer a decent descriptive account of our concept of disease, but they do offer resources for improving on the ways in which we think about the harms that afflict human beings. While they cannot offer an account of ‘disease’ they can offer an account of ‘harm’ – and this it turns out, is ultimately of greater importance. At the outset, a terminological note is required. In this paper, as in most philosophical work on ‘disease’, ‘disease’ is used in a broad sense – to be roughly equivalent to ‘disorder’ or ‘pathological condition’. Some people find this odd, and would find it more natural to distinguish between diseases in a narrow sense, injuries, wounds, disabilities, and so on (categories that are all lumped together under ‘disease’ here). While I have some sympathy with those who find it strange to describe a broken arm as a disease, using ‘disease’ to encompass all pathological conditions has become so widespread in the philosophical, and indeed medical, discussions of the nature of the pathological, that it is too late to stem the tide at this point. ‘Disease’ will thus be used in a broad sense in this paper. Readers who find this problematic are invited to mentally translate each use of ‘disease’ into ‘disorder’ or ‘pathological condition’, and the argument will not be affected. The remainder of this paper is split into four sections: 1. The motivation behind accounts of disease. 2. Why the Aristotelian cannot provide a good descriptive account of disease. 3. A better descriptive account of disease. 1. The motivation behind accounts of disease
There is now a substantial literature that attempts to provide an account of our concept of ‘disease’.1 As with most philosophical projects, debates over disease have taken on a life of their own and it is easy to forget why formulating an account of disease seemed a worthwhile project to begin with. I suggest that the main reason for formulating accounts of disease is that disease functions as a category that we tend to think does moral work; we usually assume that those with a disease deserve special consideration. Thus, we think that the diseased deserve treatment, and we accept that suffering from a disorder can excuse certain actions and that those who suffer from a disease maybe excused from normal responsibilities (work, handing essays in on time, etc). Commonly, the idea that the diseased are more deserving than other categories of people suffering misfortune is written into legislation and benefit systems. So, in the U.K., those who are unemployed because of sickness receive a basic rate of £76 a week, while those who are unemployed for other reasons As those who suffer from a disease are treated differently from those without, it becomes important to decide which conditions are diseases and which are not. So, for example, when Viagra became available, it became important to decide whether male impotence is a disorder or merely a normal aspect of aging, as this would make a difference as to whether Viagra would be available on the NHS. Similarly, the disease-status of problematic conditions, such as alcoholism and ADHD is often debated, as it is thought that these conditions can only excuse problematic behaviour if they are diseases. Thus, it matters to us whether various conditions are diseases, and one major motivation for seeking a general account of disease is the hope that such an account might shed In recent years a great number of people have worked on developing accounts of disease. In this paper I will not consider the various accounts of disease they have produced, but will restrict myself 1 For a brief selection see Boorse 1975, 1977, 1997; Fulford 1989; Lilienfeld and Marino 1995; Reznek 1987; Wakefield 1992a, 1992b. to considering Aristotelian accounts of disease. I will argue that the Aristotelian fails to give an adequate descriptive account of our concept of disease. The Aristotelian cannot provide an account that distinguishes between diseases and non-diseases that fits with our intuitions – but ends up lumping different types of harm together. 2. Why the Aristotelian can not give a good account of disease
Aristotelian accounts of disease have been proposed by a number of authors, most notably by Philippa Foot, in Natural Goodness (2001), and by Chris Megone who has argued for an Aristotelian approach to disease in several influential papers (Megone 1998, 2000, this volume).2 The discussion here shall focus on Chris Megone’s work. The Aristotelian starts by considering what it means to say that a biological organism is a good specimen of its kind. In the case of animals, the Aristotelian account claims that for each species there is a characteristic life cycle. So, in the case of the frog, for example, it is characteristic that frog spawn hatches into tadpoles which develop into frogs that eventually produce more frog spawn. A good organism has all the biological equipment it needs to successfully live in the ways characteristic of its kind. So a good frog has a sticky tongue so that it can catch flies, and is attractive to frogs of the opposite sex. Having such attributes makes it more likely that the frog will lead a good froggy life. Of course, even the best frog may be unlucky and fail to lead a good life. Maybe, for example, it gets run over by a car. Having the attributes of a good frog is not an absolute guarantee that the frog will have a flourishing life; it just increases the frog’s chances of being successful. While a good frog has the body it needs to increase its chances of living a good life, a frog that doesn’t have the right biological equipment is diseased. In the case of humans, things become somewhat more complicated because the flourishing human life has more to it than just reproducing. Like other animals, humans need certain biological equipment if they are to survive and reproduce, but on Megone’s account the flourishing human life is also the rational life. In summarising his account Megone tells us that, ‘the human function is …the life of the fully rational animal. Illness is any incapacitating failure to realize (actualize) this human function.’ (2000 p. 56). 2 An Aristotelian account of disease can also be found in Von Wright 1963. It should be noted that Megone intends ‘rational’ in a very broad sense. For him, the rational human being isn’t merely one who is good at playing chess and doing sums, but the human that is fitted to lead a flourishing life – the rational human is not only intelligent, but has the right values, and can act in the right way. With this in mind, we can say that on Megone’s view, the healthy human has a body and mind that facilitates leading a flourishing life. I have some sympathy with the Aristotelian account and believe that with the addition of extra conditions it can be patched up. However, I shall argue that as it stands, Megone’s account is unacceptable. The fundamental problem is that his account is over-inclusive. It fails to distinguish conditions that are diseases from other states that reduce a human’s chances of flourishing. Megone has paid some attention to the problem of over-inclusivity, and his claim that illnesses are incapacitating failures to function enables him to distinguish diseases from some other bad states. So, staying in bed all day simply because one can’t be bothered to get up is a bad state but not a disease for Megone, because one is choosing to do nothing, as opposed to being incapacitated. However, although it can cope with cases like this, there are also various incapacitating bads that are not diseases, and these demonstrate that the Aristotelian account is inadequate. I will discuss these in three classes: 1) biological bads that are not diseases, 2) social and educational bads, and 3) i) Biological bads that are not diseases. There are various biological bads that we do not consider to be diseases. These include states such as being unintelligent, being short and being ugly. (Of course, we do consider intellectual disabilities, dwarfism and various deformities to be disorders, but I am thinking here of less severe cases). Biological bads, such as being ugly or unintelligent, disadvantage the individual. They result in an individual failing to live up to the ideal species design. They can result in an incapacitating In his work, Megone briefly considers cosmetic surgery and comments that ‘it might be questioned whether such treatment really combats illness on the basis of doubt as to the significance of the symptoms with regard to a good human life.’ (Megone 1998 p.198). Thus, in response to my worries Megone would probably suggest that ugliness, shortness, stupidity and the like are not disorders because the disadvantages that they bring about are not as great as those brought about by genuine disorders. However, a brief consideration shows that this suggestion cannot be upheld. Some diseases, such as athlete’s foot or eczema, frequently do little harm. In contrast, take the case of ugliness. Ugly children are more likely to be bullied at school (Sweeting & West 2001), and, if they grow up to be ugly adults, have their chances of getting desirable jobs or mates reduced (see, for example Harper 2000). Only those with an implausibly austere notion of the ‘good life’ would dismiss such effects as insignificant. That states such as ugliness and shortness are popularly considered to be capable of causing great disadvantage is shown by consumer demand for extreme treatments. Many people save for years to afford cosmetic surgery. In China, there is demand for surgeons who can add a few inches through the Ilizarov technique (a very painful procedure which involves cutting bones in the leg, and then daily increasing the distance between the severed ends as the bone begins to heal (Smith, 2002)). In the words of one patient, such procedures are worthwhile as post-treatment she can hope for ‘a better job, a better boyfriend and eventually a better husband’ (Smith 2002). I conclude that biological bads, which we do not consider to be diseases, can do more Thus, the first way in which the Aristotelian account is over-inclusive is that the Aristotelian has no means for distinguishing biological bads, such as ugliness, shortness and stupidity, from diseases. There are various social and educational bads that disadvantage the individual but that are not diseases. Examples include poverty, illiteracy and social alienation. Megone has the resources to distinguish some such bads from diseases. For Megone there is a disease when something goes wrong with a part of a human, leading to an incapacitating failure which diminishes a person’s chances of leading a flourishing life. Some social, educational and economic bads are located externally to the afflicted individual, and so can be distinguished from diseases on this basis. Thus, if I am too poor to buy a decent coat, the problem resides in my thread- bear clothes rather than in something internal to me. However, some social and educational bads can be located within the afflicted individual. Consider someone who has an incomprehensible accent, or someone who is illiterate, or a woman who has been brought up to believe that men are her natural superiors. These people’s problems reside within them (at least to the same extent as do recognised disorders such as dyslexia, or speech disorders). Thus, such bads cannot be distinguished from diseases of the basis of their location. Once again, neither can they be distinguished from diseases on the basis of the amount of harm that they cause. As we have already noted, some diseases do little harm, whereas educational and social problems can be life-destroying; in text-based societies few people are as disabled as the illiterate. Thus, such educational and social bads provide us with examples of another set of cases that the Aristotelian cannot distinguish from diseases. In the Aristotelian tradition, vices, like diseases on Megone’s account, are said to be states that reduce one’s chances of having a good life. Megone himself notes that moral vices will ‘constitute irrationality’ and ‘lead to functional failure’ (Megone 2000, p. 63). Megone suggests that vices and diseases can be distinguished on the following basis: The theoretical distinction between laziness, or any moral vice, and mental illness is that the former is within the agent’s power (hekon, in Aristotle’s terminology) while the later is an incapacitating failure (akon, in Aristotle’s terminology).’ (2000, p. 63). I will argue that Megone’s supposed distinction will not hold water – vices will give us another set of cases that the Aristotelian cannot distinguish from diseases. However, showing that this is the case will take some time, and my discussion of vices will thus necessarily be longer than my discussion of non-disease biological bads and of social and educational bads. Megone claims that vices and diseases can be distinguished in so far as one is responsible for one’s vices but not for one’s diseases, but as I shall show such a stance if difficult for an Aristotelian, such as himself, to maintain. It should be remembered that the Aristotelian stresses the role of habituation in the formation of character. Once one has a bad character it is not the case that one can suddenly decide to be good and expect this to make an immediate difference to one’s actions. To illustrate the problems that this poses lets take the case of Pete, who we will suppose, has a bad temper, gets irritated with me, and hits me. Now, given that Pete has a bad temper and that I’m deeply irritating, it may not be true that at the moment when he hit me Pete could have chosen not to hit me. Given his nature, he may have been bound to thump me in the circumstances. Still, the Aristotelian will say, Pete is responsible for his character. It is within his power to practice being even-tempered, to avoid aggression provoking situations and so on, until he becomes a better person. If Pete is bad tempered now, it is because of actions that he chose in the past. But, if the Aristotelian takes this route, a dilemma arises, and the Aristotelian will be caught on one horn or the other. On the one hand, we can question the degree to which Pete is responsible for his character. Our characters start to be formed in childhood. Suppose that Pete’s Dad told him that real men always hit back and reinforced his aggressive behaviour – then maybe Pete’s Dad rather than Pete is responsible for his current character. On the other hand, suppose it is true that our past-selves are responsible for our character. So, let’s suppose that Pete is violent because he chose to fight a lot when younger, and this means he is to blame when he hits me now. The problem here is that our past selves are also often responsible for our health in precisely the same kind of way. So, it might be the case that Pete is not only aggressive because he chose to fight when young, but that he also has lung cancer because he chose to smoke in the past. To the extent that he is to blame for being violent, he will be equally to blame for having lung cancer. Thus the Aristotelian cannot distinguish vices from disorders by saying that we are responsible for our vices but not our diseases. To the extent that we are responsible for our vices (i.e. when they result from bad choices we made in the past) we are also often responsible for Indeed, Aristotle himself seems to take this line. He compares the person who has become unjust by performing unjust acts with the one who is sick because he ignored his doctor’s advice and sees If someone does, not in ignorance, the things that will result in his being unjust, he will be unjust voluntarily – and yet he will not stop being unjust, and be just merely if he wishes it. For no more will the sick person be healthy merely for wishing it; and it may be that he is ill voluntarily, by living a life in weak-willed disobedience to his doctors. Previously, then, he had the option not to be ill, but once he has let himself go, he no longer has it, any more than it is possible for him to retrieve a stone after it has left his hand; but all the same it depended on him that it was thrown, for the origin of it was in him. So too at the beginning the unjust person and the self-indulgent one had the option not to become like that, and hence they are voluntarily unjust and self-indulgent; but once they have become like that, it is no longer possible for them not to be. Not only are bad states of the soul voluntary, but with some people those of the body are too, and these people too we blame… (Nicomachian Ethics, III.5 1114a13-24) Of course, as a neo-Aristotelian, Megone is not committed to following Aristotle on all points. Still, that Aristotle himself holds that we can be equally responsible for our vices and our diseases gives some support to my claim that this will follow from the adoption of any kind of Aristotelian account. Philippa Foot, too, in her book Natural Goodness, ends up with a view according to which vice is a ‘form of natural defect’ (p. 37), a position which she considers to flow naturally from her Aristotelianism. I conclude that, contrary to his claims, Megone’s account has no resources for At this point the Aristotelian might suggest the following: Fair enough they might say, on the Aristotelian view there is no clear-cut line between vices and disorders, but this is not a problem with the account, rather it is merely a consequence of it! The Aristotelian is chiefly interested in investigating how humans might achieve a flourishing life. Various different states can prevent this, including what we currently call diseases, and what we currently call vices. But on the Aristotelian view the differences between them are relatively unimportant, and this is why no sharp dividing line between them can be found on the Aristotelian account. I have some sympathy with such a response, but on balance it must be rejected. In so far as the aim is to give an account of our current concept of disease it is not open to the Aristotelian to propose an account that lumps vices and diseases together. Our current concept of disease does distinguish between diseases and vices (obviously there are problematic cases, such as personality disorders, but in the main we are quite clear that there is a distinction to be drawn). Indeed one of the main functions of disease-talk, for us, is in deciding whose behaviour should be excused. Thus, for us, the distinction between vices and diseases is of crucial importance. An Aristotelian account that elides this distinction is thus not offering us an account of our concept of disease at all. Rather, though it purports to tell us about ‘disease’, it actually tells us about some completely different notion. Such Aristotelian accounts of ‘disease’ are thus not accounts of disease at all, but rather a suggestion that Of course, there is not necessarily anything wrong with introducing new concepts. Some new concepts are theoretically fruitful, and enable us to think things we could not previously have thought. However, I see no advantage in those who seek to introduce new concepts reusing the names of old concepts. This leads only to confusion. In so far as Megone’s new and, arguably, improved concept of ‘disease’ is unlike our existing concept of ‘disease’, he should pick a new I conclude that vices offer another example where Megone’s account is over-inclusive. He lacks the resources for distinguishing diseases and vices. 3. A better descriptive account of disease.
To sum up, the Aristotelian account is over-inclusive. It cannot distinguish diseases from various other bad states. To get a good descriptive account of disease more clauses will need to be added. In an account of disease that I have previously proposed, I suggest three conditions that are jointly necessary and sufficient for a condition to be a disease (Cooper 2002). Here I will not so much argue for my account, but present it as an example of the kind of account that will be needed to deal with the problems of over-inclusivity. Like the Aristotelian I hold that for a condition to be a disease it must be a bad thing, but to this I add that a condition is only a disease if the sufferer is unlucky, and if the condition is potentially appropriately medically treatable. When I say that the sufferer of a disease must be unlucky I mean that the sufferer could reasonably have expected to be better off. In nearby possible worlds most people like them are in a preferable state. In saying that a condition must be potentially appropriately medically treatable to count as a disease I don’t mean that a treatment must currently be available. Rather the condition must just be the sort of thing where it’s reasonable to assume that a treatment will be forthcoming at some point – the condition is at least the kind of thing where it seems worth doing medical research. As my account places greater restrictions on what counts as a disease it can deal with the cases that tripped up the Aristotelian. Unlike the Aristotelian, my account can distinguish social and educational problems from diseases. Such states are not potentially appropriately medically treatable. Rather than are better ameliorated by economic, social, or educational means. Vices can be distinguished from diseases similarly. When someone is vicious the appropriate response is to reason with them, or punish them, rather than treat them. On my account, biological bads that are not diseases can also be distinguished from diseases because the sufferer is not unlucky in the right kind of way. If I have athlete’s foot this counts as a disease because I could reasonably have expected not to have athlete’s foot – in nearby possible worlds most people who are relevantly similar to me are not so afflicted. Now let’s consider the case of short stature. Suppose I am 3’ tall. This is plausibly a disorder. The vast majority of people in nearby possible worlds are taller. On the other hand, if I’m 5’2’ tall, though I’m certainly on the short side, there are far fewer possible worlds in which I am taller. I’m unlucky to be 5’2’, but not unlucky enough for my condition to count as a disorder. Thus, in contrast to the Aristotelian, my account of disease offers an adequate descriptive account of our concept of disease. The necessary trick is to add more conditions for a state to count as a disease. Of course, here my account has only been briefly presented, and some will not find it fully convincing, but that will not affect the key point I want to make here. What I want to argue for here isn’t so much the correctness of my particular extra conditions, but rather that some such extra conditions will needed. Only by adding more conditions to the Aristotelian account is it possible to At this point in the paper, it is worth summarising where we have got to so far. I have argued that Aristotelians cannot give a good descriptive account of disease – their account is over-inclusive. I have also suggested what I think is a better descriptive account. But now let’s remind ourselves what the whole project of getting an account of disease was about. We wanted to give an account of our concept of disease because this concept seems to do moral work. We wanted to get clearer about disease as a way of deciding who deserves special consideration. However, now we can at least begin to see the outlines of an adequate descriptive account of disease, we can see that our concept of disease cannot do the kinds of moral work we might have hoped that it would do. On investigation, working out whether a condition is a disease is of little use in determining whether a person deserves help, to be excused, and so on. Why should whether a condition is potentially medically treatable, or the number of possible worlds in which I am better off be relevant to these kinds of questions? Of course, some will think that the conditions I add to the Aristotelian account are not the right ones. Instead of my conditions, they may prefer to add others, such as that diseases must have a biological basis, or be an evolutionary dysfunction, or be statistically infrequent, or whatever. Still, the main point I want to make will remain - it appears unlikely that any proposed extra conditions will be of moral significance. Thus, we started out thinking that those who are diseased deserve special consideration. This is why we set out to provide an account of disease. But, having analysed our concept of disease, we can see that there is nothing especially deserving about being disordered, as opposed to being socially disadvantaged, for example. Working out whether a person suffers from a pathological condition will not help us decide who deserves special consideration. If we want to decide who to help, who to excuse etc we need different concepts. The ways in which we classify people at present into deserving disordered and undeserving others is unjustifiable. We need new concepts to determine who deserves special consideration – and, I will suggest, it turns out that an Aristotelian account can plausibly give us the kinds of concepts that we need. The Aristotelian cannot offer us a good account of disease, but can offer us new categories for thinking about the varieties of harms that afflict people. So, in outline, following the Aristotelian, we can distinguish between states that impede flourishing and those that don’t. Only those states that impede flourishing are going to be candidates for amelioration, and assistance should aim at increasing the individual’s ability to lead a good life. When made explicit this seems obvious, but it is a point that much medical treatment has over- looked. As Amundson (2000) discusses, much medical treatment has aimed at normalisation rather than at promoting human flourishing. As a result, great effort has been put into making untypical bodies and minds more typical, even though better functioning would be achieved by untypical means. So, Deaf people have been forced to learn to speak and lip-read rather than being permitted to sign; and thalidomide children have been strapped onto ‘leg-like’ platforms and made to ‘walk’ rather than being allowed to use wheelchairs. An Aristotelian approach can help us to see what is wrong with such practices. From an Aristotelian perspective it becomes obvious that flourishing rather than being normal should be what matters. When it comes to states that impede flourishing we might usefully distinguish between those for which an individual is responsible and those for which they are not. Thus, there are some harms for which an individual has no responsibility (for example, being born with no arms, being born into a deprived area, and going to a bad school). There are some harms for which an individual’s past-self is responsible (for example, lung cancer caused by smoking, debt caused by previous extravagant living, having a really ugly facial tattoo). And, there are some harms for which an individual is responsible right now (for example, taking heroin because one likes it and doesn’t want to stop, living in a very messy house). Rather than granting special consideration to those who suffer from diseases (as compared with those who suffer social problems, say) we might better seek to alleviate all those conditions that restrict flourishing whatever their cause (plausibly, giving priority to states that cause most suffering and for which the individual is least responsible). To sum up, the quest for an account of disease began because ‘disease’ is a concept that prima facia appears to be of moral significance. At the end of this paper, however, we can see that the task of distinguishing diseases from non-diseases, and the task of determining which people deserve special moral consideration are two distinct tasks. If we want to distinguish diseases from non-diseases we should reject Aristotelian accounts. Aristotelian accounts have no resources for distinguishing diseases from various other types of bad state and so cannot provide an adequate descriptive account of our concept of disease. Plausibly, however, once we have developed an adequate descriptive account of ‘disease’, it will turn out that the distinction between diseases and non-diseases should be taken to be of little moral significance – whether a condition is a disease or not will almost certainly depend on factors that can be seen to On the other hand, if we want to determine who needs and deserves help, then an Aristotelian approach that aims to identify states that impede human flourishing may well be useful. The Aristotelian cannot tell us who is diseased, but they may be able to tell us who is in a bad way and to guide us in determining appropriate ways of responding to human suffering. Acknowledgements
This paper has been presented at Lancaster University, and at the 2005 Conference on Disease, held at Leeds University and sponsored by the British Society for the Philosophy of Science and the Society for Applied Philosophy. I am very grateful for comments from those present. In addition, I owe special thanks to my colleagues David Archard, Alan Holland, John O’Neill, Floris Tomasini, and Garrath Williams – who read drafts and suggested improvements. References
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