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Health and Science

"She Blinded Me With Science"

A Critical Analysis of the Scientific Model of Health

 

A senior thesis by Georgia Griffin submitted to the Bryn Mawr Philosophy Department

in partial fulfillment of the Bachelor of Arts Degree.

Thesis advisor Christine Koggel

 

April 18, 2005

 

 

Abstract

In this thesis I examine the predominant western theory of health, known as the scientific model, using the accounts of Christopher Boorse and Leon Kass. Together these two accounts provide a thorough representation of the salient points of the scientific model, which are in short: that health is a natural entity and is therefore objective, that it is opposed to disease, that health is not relative, that health is accordance with species design and that physical health is distinct from mental health. I argue contrary to Boorse and Kass that health is necessarily normative (value-laden), that it cannot be abstracted from the human experience of it, that perspective and power play an important role in the delineation of health standards, and that the scientific model of health leads to the discrimination of a large number of individuals. To support my arguments I examine the accounts of a number of theorists who take issue with the scientific model of health, including Martha Nussbaum, Amartya Sen, Michel Foucault, Ian Hacking and Shelley Tremain. I also use these accounts to outline what I believe to be a more appropriate theory of health. Such a theory begins from within human experience and therefore takes into consideration people's individual conceptions of the "good" in relation to health. This new theory of health also restores agency and "personhood" to the patient, thus circumventing many of the difficulties that arise within the scientific model regarding disability and mental health considerations.

 

 

Introduction

 

What is health?  The Merriam-Webster Medical Dictionary[1] defines health as:

The condition of an organism or one of its parts in which it performs its vital functions normally or properly : the state of being sound in body or mind <dental health> <mental health>; especially : freedom from physical disease and pain <nursed him back to health>

 

This definition coincides with the predominant conception of health in the west. We view ourselves in many ways as organic machines; as a series of interconnected parts and systems that each contribute to the overall being. Health, then, is for us the state in which everything is doing its job properly. The theory that is associated with this view of health is often referred to as the "medical" model, "ideal" model or naturalism. I call it the "scientific" model because of its claims to scientific fact and objectivity. Since the time of Hippocrates, the scientific model of health has dominated healthcare practice as well as the understanding of our bodies. More recently however, this model has come under intense scrutiny and reevaluation. The traditional theory of health, exemplified by the dictionary definition above, no longer seems adequate, or even appropriate in the face of arguments such as those from constructionist theorists, holistic medical practitioners, development ethicists, disability theorists, and Eastern medicine. Moreover, the validity of many of the presuppositions of this theory of health—that judgments about health are value-free, that it is possible to derive function from form, that disease and health oppose one another, and that science is objective—has also been brought into question. In other words, there are both serious practical and theoretical concerns about the theory of health that has dominated western cultures for centuries.  

            In this thesis I will examine the accounts of two proponents of the scientific model of health: Christopher Boorse and Leon Kass. These two theorists help elucidate the central aspects of the scientific model. Specifically I will look at Boorse's emphasis on species design in terms of function and his assertion that health is accordance with the norm. Ultimately I will question his claim that health is the absence of disease, and that both "health" and "disease" are objective matters of fact. My examination of Kass will focus on his suggestion that health is a positive entity that organisms can possess or lack. In addition I will look at his view of the doctor as the true "knower" of health, and at his concept of "well-working" as it fits into his theory of health.

            I argue, contrary to Boorse and Kass, that the scientific theory of health is not objective as it claims to be, but rather influences and is influenced by human values and practices. Health is, I believe, a normative concept, where judgments of value are always already there. Moreover I argue that it is not possible to derive function (telos if you will) from biological form. I aim to show not only that the scientific model of health is often inconsistent and incoherent, but also that it should be implicated in many cases of discrimination. That is to say, there is no room within the scientific model of health to take into account the specific health context of individuals. As a result, the notion of health is separated from those whom it supposedly refers to, and this can lead to the exclusion and devaluation of certain individuals, not to mention result in a less accurate picture of health. 

I will examine a number of accounts from constructionist theorists to help support my arguments against the scientific model of health. These theorists include Kim Sterelny and Paul Griffiths, Martha Nussbaum and Amartya Sen, Michel Foucault, Shelley Tremain, and Ian Hacking. Each of these thinkers points to some aspect or another of the scientific model that is illogical or problematic. I will therefore use them to show the importance of formulating a new theory of health. The theory that will emerge from my work is one that takes into consideration all of these arguments. That is, a theory of health that accepts rather than denies its inherent normativity, and that consequently gives more power to the patient as a result of taking seriously her own vision of health. I hope to use the aforementioned theorists to show that health conceived in this way is more coherent, and equally as important, it avoids the dehumanization and discrimination of all persons, especially those with physical and mental impairments.

 

The Scientific Model of Health

The goal of science, as it is commonly understood, is to establish or uncover facts about the world. More precisely, science concerns itself with those facts about the world that are independent of any human interpretation. In many ways then, science can be understood as the quest for objectivity. Therefore, it is no surprise that the scientific model of health is one in which health is considered to be an objective matter of fact. The scientific model regards the body as a mechanistic entity made up of individual parts, each of which has a distinguishable  "purpose".

The parts of an organism have specific functions that define their nature as parts: the bone marrow for making red blood cells; the lungs for exchange of oxygen and carbon dioxide; the heart for pumping the blood. Even at a biochemical level, every molecule can be characterized in terms of its function.[2]

 

Thus every organism's parts and processes are understood to have at least one function, the performance of which determines their nature. The discovery of the nature of any given body part or system simultaneously entails the establishment of a system of values. For example, to say that the function of a heart is to pump blood is to say that a heart is by nature a part of the body that pumps blood. Therefore it is possible to say that a heart that does not pump blood, or that pumps blood poorly, is a "bad" heart.

For Aristotle, natural objects were like seeds, waiting for the opportunity to express the nature inside, just as the acorn may wait through the winter to germinate and begin striving to grow into a mighty oak tree. In this picture, each natural object comes equipped with a "telos", a goal or a function, fulfilling which is the "good" for that thing.[3]

 

From this system of evaluation (good heart, bad colon, bum knee, weak stomach) follows a theory of health. That is, the body as a whole is broken down into its individual parts and systems, each of which is assigned a function or set of functions that act as standards for measuring the health of the organism in question.

For certain functions, the norms will be a mean between excess and deficiency—for example, blood pressure can be too high or too low, as can blood sugar or blood calcium; blood can clot too quickly or too slowly; body temperature can be too high or too low.[4]

 

All of this leads to the commonly held conception that "health" can essentially be defined as "the absence of disease". According to this account, it is possible to determine when a body is not functioning as it should (individual is unhealthy), and what should be done to return it to normal (i.e. return it to health). In other words, the scientific model establishes certain normative ideals for the functionality of parts and processes, and thus defines bodily health as the overall coherence with said ideals.

Boorse is one of a number of theorists who defends the scientific theory of health. Boorse's version of the scientific—or "naturalistic" to use his terminology—account of health, the biostatistical theory (BST), is one of the most widely discussed, and also controversial, theories in the field. The primary goal of the BST, according to Boorse, is to analyze and ultimately defend the "negative" theory of health. The negative theory defines health very simply as the absence of disease. Boorse argues that in order for such a thesis to be defensible the negative theory demands a characterization of disease that is quite broad. Broad enough, in fact, that the health/disease distinction is actually better understood as a normal/pathological distinction. This enables "injuries, poisonings, environmental traumas, growth disorders, functional impairments"[5] etc., what Boorse would call pathological conditions, to be included under the heading "disease". Conceived of in such a manner the negative definition of health can be considered comprehensive. The BST is defined as follows:

1.  The reference class is a natural class of organisms of uniform functional design; specifically, an age group of a sex of a species.

2.   A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival and reproduction.

3.   A disease is a type of internal state which is either an impairment of normal

functional ability, i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents.

4.    Health is the absence of disease.[6]

 

Health, therefore, is the state of having unimpaired normal functional ability, where "normal functional ability" is determined by the given reference class for the given organism. The concept of the reference class is essential to Boorse's account due to the natural variations in the morphology and physiology of organisms of different sexes at different times in their life cycles. Normal functioning, even within a single species, can change substantially according to sex and/or age. Individuals of the same sex and age however, should not exhibit differences in functionality. To use the entire species as a reference for determining the functionality of one individual would result in a highly inaccurate result. Uniformity of function is essential for comparisons to be made, which is why Boorse invokes the reference class.

By "function" Boorse means "a causal contribution to a goal",[7] where some examples of the kind of goals he has in mind are as follows: "individual survival, individual reproductive competence, survival of the species, survival of the genes, ecological equilibrium"[8] etc. That is, the goals of any organism, according to Boorse,[9] are more than simply survival and reproduction, but consist of an entire network of interrelated ends. Thus, the function of any part or process of an organism is to act so as to improve the organism's ability to achieve its goal or goals.

By statistically typical, I take Boorse to mean essentially statistic normality. As I understand it, "normality" for Boorse is not synonymous with the usual definition of normality. Rather, Boorse uses "normal" as it is used in statistics. In statistics, "normal" refers not to the average value, but to the range of values that the majority of points being measured fall within. In this case what is being evaluated is the level of functioning of organisms or their individual body parts/systems. Therefore organisms are considered normal if their level of functioning falls within the appropriate range, and any level of functioning outside that range would be considered pathological, or synonymously, diseased. One important thing to note about the normal curve is that the limits of the normal range are determined somewhat arbitrarily and will vary depending on what is being analyzed and who is doing the analyzing. In other words, whether the limits of the normal range will be a standard deviation of two, five, or ten units is basically a matter of interpretation.

Another important aspect of the BST is that it holds health to be a natural, objective, a priori entity. Boorse argues that "health and disease are value-free scientific concepts" whose definitions are evident in the "biological facts of nature".[10] This view is derived from his belief that "the normal is the natural—that health is conformity to a 'species design'."[11] Boorse argues that the BST is completely value-free due to its foundation in "scientific" concepts such as "biological function and statistical normality."[12] In the formulation of the BST, Boorse seeks to articulate a theory of health that is completely "scientific". Scientific theories purport to "tell us how things are and imply nothing about whether it is desirable that things be that way".[13] Thus they are considered to be descriptive theories. On the other hand, prescriptive or normative theories "tell us how things should be, are supposed to be, or ought to be; that is, how it is best for things to be. They identify certain states of affairs as having positive value, as being better than (at least some of) the alternatives."[14] Boorse believes that "theoretical health and disease" are entirely factual concepts, as opposed to evaluative ones, and therefore theories of health are themselves factual, i.e. descriptive. Much of this assertion rests on Gerd Sommerhoff's goal-directed theory of function that is adopted by Boorse. The theory explains how function can be asserted for a given part or process. In short, Boorse's theory of function is that living organisms and their processes are goal-directed (have functions) in that their activities result in their being better able to achieve said goal. As a result, "whenever one knows the goal of a process, one knows what is more or less function, and 'deficiency' simply means much less than average".[15]

The account of health that Kass outlines in "The End of Medicine and the Pursuit of Health" from his book Toward a More Natural Science differs from Boorse's account on a couple of key issues. Kass's definition of health relies heavily on the concept of "wholeness" in addition to that of "well-working," whereas wholeness is not a factor in Boorse's account. Kass defines health as the state in which an organism—as a whole—is working well such that said well-working is evident both internally and externally.

Health is a natural standard or norm—not a moral norm, not a "value" as opposed to "fact," not an obligation—a state of being that reveals itself in activity as a standard of bodily excellence or fitness, relative to each species and to some extent to individuals, recognizable if not definable, and to some extent attainable.[16]

 

Both Kass and Boorse include the idea of the parts of an organism working in accordance with their telos in their theories of health. For Boorse this is through his discussion of species design, and in Kass it is well-working. These concepts—species design and well-working—inherently imply a standard of functioning to which the structures and processes of an organism can be compared. This requires that such ideals can be known. In other words, Kass's theory and Boorse's theory both require that it be possible to derive function from form.

Another point of difference between Boorse and Kass is that Kass does not admit relativity in the same way that Boorse does in his discussion of the reference class. Boorse's discussion does not allow for comparisons between groups of different reference classes, that is, of different ages and sexes. Kass admits that health can appear to be relative to certain circumstances such as age and environmental factors, for example "[t]he hereditary deficiency of the enzyme glucose-6-phosphate-dehydrogenase results in serious illness for the individual who eats fava beans or takes certain drugs, but is otherwise without known consequence"[17]. However, Kass argues, this does not prove that health is itself relative.

To be sure, various absences of health can be ignored, and others overcome by change of circumstance, while still others, even if severe, can be rendered less incapacitating. But none of this affects the fact that they are absences of health, or undermines the possibility that health is something in its own right.[18]

 

Thus an individual who does not have an enzyme deficiency, or allergies, or astigmatism, etc. is still healthier than an individual who does have all of these, even in the absence of fava beans, ragweed, and with the use of corrective eyewear. In other words, for Kass health is something that one can possess. Therefore the individual who is free of all the above ailments possesses more health, i.e. is healthier than the individual who does suffer from enzyme deficiency, etc.

            The question of whether health is something that one can possess is another issue on which Boorse and Kass disagree. Kass is adamant that health is a positive entity, and not merely the absence of disease as Boorse argues. For Kass, the scientific Truth as to what constitutes health is a real entity that simply remains to be "discovered," or as he says, "health is something in its own right".[19] He argues that health is itself a good, which is not the same as the good of being free from disease. Moreover, the goodness of health is "real" for Kass, meaning that it does not exist simply "by convention or by human decree". [20] Therefore "[h]ealth, illness, and unhealth all may exist even if not discovered or attributed."[21] In other words, health is something that can be known in the scientific sense, meaning it is empirical and not constructed.

This idea of health as the subject of empirical knowledge is what leads Kass to declare that the doctor is the true "knower" in matters of health. A doctor, by nature of her education and training, is theoretically someone who has a certain level of expertise when it comes to the body and its functions.

If medicine is an art that aims at health, and if an art implies knowledge of ends and means, then the physician is a knower. As unnatural as it may seem that someone else should know better than I whether or not I am healthy—after all, it is my body and my pain and not the doctor's—still the doctor as a knower, should know what health and healthy functioning are, and how to restore and preserve them.[22]

 

Thus, to be a physician is to know what healthy functioning means for the body. This notion, of course, presupposes that there actually is a substantive entity to which we give the name "health". In other words, implicit within the idea that a doctor is a knower of health is the idea that health is a positive thing that can be known.

One last aspect of Kass's view of health that needs mentioning is his separation of mental health from physical health. Early on Kass restricts the domain of his investigation to bodily health only. While he does not seek to deny the existence of "a more minimal state of psychic health, namely, sanity or 'emotional equilibrium'," he separates this concern from that of physical health. Following his assertion that health is a positive entity, this would imply that any individual possesses two distinct health entities, the mental and the physical. This move is quite typical within the scientific model of health, and will be discussed later on in this thesis.

Together the theories of Boorse and Kass provide a more or less comprehensive account of the scientific model of health. The defining views of the model are thus:

(1)   Health and disease are natural entities.

(2)   Health and disease oppose one another such that health is (at least in part)

        characterized by the absence of disease.

(3)   Health is not relative; it is a natural norm, and is therefore recognizable

(4)   Physical health is distinct from mental health

(5)   Health is accordance with species design (form)

(6)   Knowledge about health follows from knowledge of the body, particularly

        from an understanding of the relationship between form and function

(7)   "Health" is more or less synonymous with "wholeness" and "well-working"

(8)   Health is coherence with the norm

            (9)   "Health" is an objective notion

 

The Critique

Many important objections to the scientific model focus on the claim that the scientific model is 'merely' descriptive. In order to show the validity of their arguments regarding health, Kass and Boorse both continually point to the ways in which their theories are "scientific". Specifically they point to objectivity, descriptiveness, freedom from value judgments, and a priori existence or "discoverability". For these theorists, only knowledge that fits these criteria can be considered scientific, and therefore truly knowledge. Not only is this a limited view of what counts as science, but it also wrongly discounts knowledge that truly is unscientific. I will argue contrary to the beliefs of Boorse, Kass and their like, that health is not objective, it is not value-free, and it does not simply arise out of an understanding of the relationship between biological form and function. However, this does not mean that "health" is an empty concept about which nothing can be said.

Contrary to the tenets of the scientific model, it is impossible to abstract all value from the notion of health. For one thing, as David Hume argues, matters of value (morality) are not observable, and it is a mistake to assume they can be derived from observable facts. To make this mistake is to fall victim to what Hume calls the naturalistic fallacy. A classic example is that of murder; although one can witness the act of murder, one cannot witness its wrongness. The question of the role of value is also an issue for theories of health. Essentially there are two kinds of theories: prescriptive and descriptive. Prescriptive theories assign positive and negative values to certain states, and assert that we ought to strive for those states that have positive values. On the other hand, descriptive theories claim to merely outline the observable facts of the matter.

Descriptive theories are meant to conform to the facts. If the theories do not fit the facts, we blame the theories. Normative [prescriptive] theories are such that the facts are supposed to fit them. If the facts do not fit the theories, we blame the facts.[23]

 

The scientific model of health claims to be purely descriptive, however the truth of the matter is that it is a prescriptive theory masquerading as a descriptive one. Advocates of the scientific model simultaneously assert that health is a "good" in that it is valuable to human beings, and also that health is a value-free, objective fact. Therefore the scientific theory of health falls victim to the naturalistic fallacy.

The Naturalistic Fallacy mimics good reasoning by claiming to be "factually based," i.e. by appealing to well-established facts, but it is doing so in a context in which a choice of ideals is actually the issue. It does not so much recognize the interplay between fact and value as try to reduce questions of value to questions of fact.[24]

 

In contrast, normative models recognize the role that perspective and values play in defining health and health standards. I argue that any theory of health is necessarily normative, because when it comes to health, values are always already there. 

The BST is Boorse's attempt to articulate a theory of health that is completely scientific, meaning free from human interpretation or values. He believes that because we can have knowledge of the goals of biological processes, we can determine their level of function, where "'deficiency' simply means much less than average"[25] However, to say that something is deficient is to say that it should be otherwise. That is, using Boorse's definition of normal/pathological, if the normal level of blood glucose is 70-110 mg/dl (milligrams per 100 milliliters), then a blood glucose level of below 70 mg/dl (hypoglycemia) would be considered pathological. Saying that an individual is deficient in blood glucose, and calling such a state pathological, is the same as saying that an individual's blood glucose level should be above 70 mg/dl in order to be normal, and this is a value judgment. To even distinguish between states by using the terms "normal" and "pathological" implies a value distinction. This shows how within any theory of health, the normative is always already there. Obviously there are values attached to health. People desire to be healthy, and believe that they should look, should think, and should feel a certain way in order to be healthy. Health is something we strive for, that we desire; it is everywhere believed to be of worth to all living organisms. Therefore, questions of health are also necessarily questions of value.

A related problem with the scientific model of health is that it alleges that health exists a priori and is something that doctors "discovered". This claim arises out of the belief that knowledge of function (and therefore normal and deficient function) can be derived from observations of form. Health, according to the scientific or naturalistic model, is synonymous with proper functioning, and unhealthy with functional deficiency. The idea of function arises out of the morphology of the human body, or its form. However, to move from making observations about form to formulating theories of function is to make an assumption that is not necessarily warranted, and possibly even false. Therefore much rests on whether it is possible to justify the claim that we can know, and do know, what proper functioning is for an organism. The question of import is then, "Is it possible to determine function from form?" for if organic structures cannot be said to have functions, then evaluating how close they come to performing those functions would be a moot point. There are a couple of arguments that can be made contrary to the views of both Boorse and Kass however.

            Sterelny and Griffiths help provide an argument for why it is not possible to derive function from form in their book Sex and Death: An Introduction to Philosophy of Biology. In their discussion Sterelny and Griffiths distinguish between traits that are adaptations and traits that are adaptive. Adaptations are traits that exist because they have been favored by natural selection, or in other words because they increased the fitness of the trait bearing organism's ancestors. They use the example of the eye-blink reflex; this reflex exists for us today because it increased the fitness of our ancestors. This is distinct from adaptiveness however, which is a property possessed by traits that increase the relative fitness of their bearers.

[D]espite the close links between these two concepts, adaptiveness is neither necessary nor sufficient for a trait to be an adaptation. The human appendix, for example, is an adaptation that is not adaptiveƒa relic of previous selection. Conversely, the ability to read is adaptive without being an adaptation.[26]

 

If we apply this manner of thinking to the issue of form and function we see that structures can exist without having functions, and functions can evolve independent of any structure. Another example is that of feathers on birds. It is a commonly held belief that feathers evolved for the purpose of aiding birds in flight. However, evolutionarily, feathers evolved not for flight, but for thermoregulation—to keep birds warm. What does this tell us about the "true" function of feathers? That the purpose of feathers is both thermoregulation and flight perhaps? If the utility of feathers for flight is a mere accident, but we nevertheless assert that the function of feathers (among other things) is to assist in flight, where does this leave our understanding of what a true function is? Wouldn't it be equally acceptable to assert that the function of hair is to attract a mate? The argument seems to be that because the form of a feather is aerodynamic its function is to assist in flight. Hair is a sexually attractive trait for many people, but we do not claim that because the form of hair is appealing the function of hair is to attract a mate.

[A] blender can have the functions of mixing, blending, whipping, and liquefying. And it is easy to determine that these are its functions—we look at the instructions or telephone the manufacturer. Of course, we may use the blender for some purpose of our own. We might use it as a paperweight or a vase. But this does not change its function.[27]

 

Obviously there is no manufacturer to call, nor any instructions to read when it comes to biological organisms. Yet we treat the body as though it were designed, as though determining what the proper functions of bodily structures—and thus the body overall—is simply a matter of sufficient scientific analysis. To view organisms and their parts and processes as being "goal-directed" is to presume meaning where there is no evidence for it. The "goals" of biological systems and the organisms that contain them are human inventions based on a particular interpretation of the facts. The examples cited above betray the fact that there is an element of subjectivity that is inherent in determining what the function of anything is. A function toward what end? Whose ends? To claim, as Boorse does, that "individual survival, individual reproductive competence, survival of the species, survival of the genes, [and] ecological equilibrium"[28] are goals of organic life is to impose a sense of intentionality where it is not warranted. There is no observable evidence that organisms act in order to achieve "ecological equilibrium," or "survival of the genes," rather, these can only justly be called consequences of biological behavior, not goals. Therefore, the idea of "function" or "goal-directedness" is more a matter of opinion than of pure deductive science as Boorse and Kass claim it to be.

In addition, notions of health cannot be free from human interpretation because health is about human beings, and of human beings. That is, a theory of health that claims to be free from the realm of human experience cannot truly be a theory about health because "health" does not exist apart from living organisms. The very thought that something such as health, something so much a part of day to day human happenings, could be established from an Archimedean standpoint should be rejected. Nussbaum and Sen do just this in "Internal Criticism and Indian Rationalist Traditions". Nussbaum and Sen ask us to picture a group of "pure souls," situated on the rim of heaven, inquiring into the nature of medicine "without any knowledge of the feelings, the needs, the pleasures and pains of actual living creatures". It is easy to conclude that these "doctors" would be poorly equipped to handle their patients, even with objective knowledge of what constitutes a human being.

Heavenly mathematics is one thing, but medicine seems paradigmatic of an art that is immersed, engaged, working in a pragmatic partnership with those whom it treats.[29]

 

Yet this kind of "perspective from nowhere" is exactly the kind of objectivity that the scientific model wishes for in its theory of health. When evaluating an individual's health status, the scientific model appeals to a standard of health that is "naturalistically defined"[30] and applies that standard universally to evaluate the health of each individual. In other words, an individual's level of health is determined by how closely it approximates the ideal. However, as Nussbaum and Sen point out, health is not mathematics; it is immersed in and emerges out of human experience.

[Medicine] must take very seriously [patients'] pains and pleasures, their own sense of where health and flourishing lie. Its aim is to help, and that aim can never be completely separated from a concern for the patient's own sense of the better and the worse.[31]

 

That is, it is senseless to look to ideals as a means of evaluating health. Leaving out the emotions, desires, pleasures, dreams, and pains of individuals in an assessment of health circumvents the issue entirely.

However, this does not imply that there are no available means with which to evaluate health. Rather than deny that human interpretation plays a part in science—and consequently in our knowledge about ourselves—Nussbaum endeavors to give a universal account of human life and flourishing that is embedded in human experience.

[I]f the only defensible conceptions of truth and knowledge hold truth and knowledge to be in certain ways dependent on human cognitive activity within history, the hope for a pure unmediated account of our human essence as it is in itself, apart from history and interpretation, is no hope at all but a deep confusion. To cling to it as a goal is to pretend that it is possible for us to be told from outside what to be and what to do, when in reality the only answers we can ever hope to have must come, in some manner, from ourselves.[32]

 

Nussbaum rejects metaphysical essentialism in favor of what she calls "internalist" essentialism, a "historically grounded" account of essential human properties that "takes its stand within human experience."[33] Nussbaum's internalist essentialism illustrates that knowledge can be "true" that emerges from within human history, and moreover that such knowledge can be useful.

[T]he failure to take an interest in studying our practices of analyzing and reasoning, human and historical as they are, the insistence that we would have good arguments only if they came from heaven—all this betrays a shame before the human.[34]

 

Instead, if we can learn to see the value that knowledge based in the context of human practice has, then we can alleviate many of the difficulties inherent to the concept of health understood under the scientific model. One example is the problem of the fact/value distinction that plagues the scientific model of health. As Nussbaum points out, we are no longer "pretending to discover some value-neutral facts about ourselves, independently of all evaluation,"[35] instead our analysis has more depth and meaning because it does not hold such things to be off-limits. Nussbaum's picture of health differs greatly from the scientific model. Nussbaum's account of human beings emerges out of a reflection on actual human lives, i.e. from a global and holistic view, whereas the scientific model begins with a particulate understanding, which is the result of the scientific evaluation.

            The "scientific evaluation" leads to another interesting argument that undermines the scientific model of health. A deeper reflection on the scientific model leads to the question of who is actually doing the evaluating. In other words, who or what is behind the decision to define health as the absence of disease, or as the statistical norm, or as wholeness or as whatever other characteristic becomes the focus. Even scientific analysis is colored by the perspective of the scientist doing the analyzing. In his discussion of the "clinical gaze" in The Birth of the Clinic, Foucault illuminates the oft ignored or forgotten presence of perspective and the role of power and authority in the "construction" of the scientific model of health. He argues that there is a peculiar power dynamic that arose out of the birth of modern medicine. Foucault's belief is that in the new form of medicine, where much emphasis was placed on the actual anatomy of the body, doctors and the diseases they "discovered" or named gave authority to one another.

The space of configuration of the disease and the space of localization of the illness in the body have been superimposed, in medical experience, for only a relatively short period of time—the period that coincides with nineteenth-century medicine and the privileges accorded to pathological anatomy. This is the period that marks the suzerainty of the gaze, since in the same perceptual field, following the same continuities of the same breaks, experience reads at a glance the visible lesions of the organism and the coherence of pathological forms; the illness is articulated exactly on the body, and its logical distribution is carried out at once in terms of anatomical masses. The 'glance' has simply to exercise its right of origin over truth.[36]

 

Thus, the "clinical gaze," meaning the perspective of the examiner, is both the cause and the product of the authoritization of a particular view of health and the body in general. Certain states are considered healthy because medical authorities determine them to be so. Furthermore, the doctor is given authority by virtue of being the discoverer of "truths" about health. Thus there is a mutual authoritization. This process places all the power firmly in the hands of the medical practitioner.  Therefore, the doctor is the knower and the patient the known. Here the patient's role is minimal; she is object, rather than subject of her own healthcare.

[D]efinitions and identifications that emerge from observations of the physical body and its movements and behaviour produce power. Such observations, which eventually form the basis for the medical categorization of illness, ignore the individual patient as a person.[37]

 

In fact, it is not only the patient who is stripped of her personhood within this framework, but the doctor as well. That is, there is a forgotten element of influence that the medical examiner has on what is ultimately examined. In turn, the general body of knowledge also influences the doctors doing the examining, the very same body of knowledge to which they originally gave authority. Therefore, although doctors are also persons, their personhood is ignored when it comes to the establishment of medical "truths". Colin Samson examines this situation through a discussion of the work of Foucault.

Foucault suggests not only that the way physicians "look" (gaze) upon the body is a representation of the subjectivities of the perception of the physician, but also that such gazes manufacture and perpetuate distinctive power relations. Medical knowledge that is the product of the clinical gaze establishes an authoritative "truth" about the body and the person.[38]

 

Medical knowledge of health and illness is based on the "discoveries" that result from anatomical dissections. This intensive "gazing" or examination leads to the arrangement of the "cells, tissues, organs and flesh" into a blueprint of the physical human body, as well as the revealing of certain clues as to normal and abnormal functioning.[39] Foucault wants to draw attention to the forgotten observer that is behind these observations, making them and also driving them. Inevitably the observer affects what is observed because she has a perspective; that is, as a result of the observer's own biases some patterns will be more distinct than others, or some things will warrant attention and others will not. Thus, both what is being observed and who is doing the observing will have an affect on the final picture that results. Therefore the issue of perspective has serious implications for Boorse and Kass in terms of their claim that health is objective.

When all the power for evaluating health is assigned to the doctor, the patient is essentially denied any voice in her own healthcare. One of the greatest deficiencies of the scientific model of health is that when it is applied practically, it is not possible to take into account the specific details of each individual's health. Proponents of the scientific model of health assert that health is objective, ahistorical, and should therefore be universally applicable. However, the standards that are established through the scientific evaluation cannot actually apply to all human beings because of the great number of individuals who do not fit those standards. Moreover, such a method denies patients any agency in determining what their physical and mental goals should be. As a method of evaluating the actual health of individual persons, the scientific model is thus inaccurate because of the inattention paid to particular contexts.

This is the groundwork for the arguments made by disability theorists against the scientific model. Disability theorists assert that the scientific model of health leaves out and even causes the devaluation of impaired persons. Under the tenets of the scientific model, people with physical and mental impairments will always be considered unhealthy, sub-par, or defective. There is no room within such a theory to value anything or anyone that deviates from the standard, which is especially peculiar given a species of such tremendous diversity. The standard represents the ultimate good that is to be desired, and everything else is thus undesirable. There is clearly a value hierarchy being constructed here, one which leaves a vast number of individuals without the hope or the possibility of ever achieving "good health". A theory based on the mean can never hope to be comprehensive, and a particularly exclusive one poses the question of bias. That is, if we find that the majority of individuals are left out of a vision of health, we should wonder how accurate such a vision could possibly be, and whose needs are being fulfilled. That is, as Susan Wendell points out, "[m]uch of the world is also structured as though everyone is physically strongƒas though everyone can walk, hear and see well".[40] This leaves a lot of people handicapped, not by their physical impairments, but by a society that refuses to acknowledge their needs.

In her article On the Government of Disability, Tremain examines the relationship between "impairment" and "disability". Tremain argues that although "impairment" is traditionally associated with the objective, physical fact of the matter, and "disability" with socially constructed classifications, the two concepts are equally historical. Tremain calls herself a nominalist, which is someone who's beliefs are characterized by "the view that there are no phenomena or states of affairs whose identities are independent of the concepts we use to understand them and the language with which we represent them".[41] Much like Foucault, Tremain specifically emphasizes the objectification of the body that emerged as the result of "eighteenth-century clinical discourse."[42] That is the tendency to treat the body as a thing, which is a defining feature of the scientific model as well as a consequence of it. As objects, persons (or more correctly bodies) are subject to manipulation and therefore segregation into categories. This kind of categorization naturally leads to evaluation, and eventually to discrimination. "Through these practices, subjects become objectivized as (for instance) mad or sane, sick or healthy, criminal or good."[43] If, however, we let go of the belief that there is such a thing as a description of the body that is free from any form of evaluation, the supposed "natural" hierarchy of function can be dropped out. Clearly this does a lot to improve the status of "impaired" persons, as Tremain understands them. Tremain, along with Foucault and myself, argues that rather than continue to subscribe to a "theory, doctrine, or permanent body of knowledge," we should conduct a "critical ontology of ourselves". Which is to say, an ethos wherein the critique of ourselves is always also a critique of our contextual—including social, political, historical and environmental—constraints.

Much of Hacking's work focuses on the important role that social and historical context plays in shaping how we view ourselves. One of the most influential factors in the formation of our views about our bodies is "scientific knowledge," Hacking argues.

I am especially impressed by the way that scientific knowledge about ourselves—the mere belief system—changes how we think of ourselves, the possibilities that are open to us, the kinds of people that we take ourselves and our fellows to be. Knowledge interacts with us and with a larger body of practice and ordinary life. This generates socially permissible combinations of symptoms and disease entities. [44]

 

So much of the way that we view our bodies and ourselves is the result of "scientific knowledge" about human bodies in general. This is similar to the concerns expressed by Foucault regarding the scientific model and the production of a particular understanding of health. However, Hacking also implicates belief systems as wielding power over our knowledge of ourselves.  If this is true, it would seriously undermine the alleged universality of the scientific model. In that case, health would not only be in some ways relative to different cultures, but also to different time periods in any one culture. Historically speaking, this appears to be the case; there are stark differences in what we consider to be healthy now versus what we believed was healthy even twenty years ago. Although these differences can in part be explained by advancements in technology or improved knowledge, I argue, along with Hacking, that the predominant factor in changing health paradigms is changing social paradigms. This calls into question whether or not the scientific model is justified when it claims to represent the biological "truth" of health and illness.

In his book Mad Travelers: Reflections on the Reality of Transient Mental Illness, Hacking examines mental illness through a historical analysis of a specific kind of disorder, transient mental illness. By transient mental illness Hacking does not mean that the disorder is fleeting within a particular patient, but that it "appears at a time, in a place, and later fades away."[45] Such illnesses also tend to target individuals of a particular gender or social class. Therefore, transient mental illnesses provide an interesting case for the question of whether mental illness, or even illness in general, is "real". Examples of such illnesses include melancholy, hysteria, schizophrenia, dissociative identity disorder (multiple personality), and fugue, which is the focus of Hacking's Mad Travelers. Our perception of each of these illnesses has changed so dramatically over time that our understanding of them is undeniably fashioned by social influence. To use Hacking's example, in the early stages of its documentation fugue was thought to be a species of hysteria by some, and latent epilepsy by others. In late 19th century France, the setting for the birth of fugue, epilepsy and hysteria were  "the two great but mysterious mental pathologies of the day".[46] Therefore, every attempt was made to show that fugue was a subclass of one or the other disorder. It was only when all efforts at consensus had been exhausted that fugue emerged as a new, distinct kind of mental illness.[47] This status seems short lived however, as cases of fugue have all but died out, leading to a new debate over whether or not fugue is a "real" disorder. In fact, there is much debate about whether any transient mental illnesses qualify as psychological disorders, due to their apparent temporality and contextuality.

Fidgety children have been with us forever; then came hyperactivity; next, attention deficit; at present attention deficit hyperactivity disorder, for which the steroid Ritalin is prescribed. Is that a real mental disorder? Or is it an artifact of psychiatry demanded by a culture that wants to medicalize every annoyance that troubles parents, teachers, bus drivers and all the other powers that be?[48]

 

Where we draw the line between so called "normal" yet irritating behavior and behavior that is so inappropriate as to be "abnormal," is determined by our social and cultural standards, and those are constantly being redefined. Therefore when it comes to fugue, multiple personality, hysteria, or attention deficit, whether these conditions count as "real" mental illnesses is in many ways dependent on the era.

This carries over into the physical side of health as well. For example, when we look back on the evolution of body image ideals, what counts as a healthy body changes dramatically depending on the time period. This can be illustrated by a recent study where a team of researchers examined changing body ideals by looking at popular toys. In the study the researchers measured the chest, biceps and waist of two G.I. Joe dolls, one from 1973 and the other from 1998, and scaled their measurements to approximate the dimensions of a 70 in. tall male.

The chest increased in size from 44.4 in. to 54.8 in. and the biceps increased from 12.2 in. to 26.8 inƒ Although the waist increased in size also (31.7 in. to 36.5 in., the authors noted that the latter figure has "the sharply rippled abdominals of an advanced bodybuilder" (p. 67) whereas the early models have far less definition.[49]

 

The increased muscularity of the toy demonstrates the change in physical ideals from the early 1970s to the late 1990s. This change in ideals implies a change in what was considered healthy, since as was discussed earlier, "healthy" is more or less synonymous with "ideal". Therefore, just as in the case of mental illness, what we consider to be healthy or unhealthy is in many ways the product of social influence. Hacking maintains that he is not a skeptic about transient mental illnesses, or for that matter illness in general. However, he is quick to point out the importance that psychiatrists, the surrounding environment, and other factors have when it comes to the identification and classification of such disorders.

[O]ne fruitful idea for understanding transient mental illness is the ecological niche, not just social, not just medical, not just coming from the patient, not just from the doctors, but from the concatenation of an extraordinarily large number of diverse types of elements which for a moment provide a stable home for certain types of manifestation of illness.[50]

 

This points the way to a very different understanding of health from that of the scientific model. For Hacking, health does not exist in a vacuum, but just like the organisms that embody it, it exists in and through an intricate web of relationships between individuals and their environments.

In addition to the reasons outlined by Hacking, part of the need for a more holistic account of health has to do with the fragmentation that is the result of the scientific model. A system of medicine where health is viewed as the absence of disease leads to difficulties when it comes to patient care; the focus is on the problem—locating and fixing it—rather than on the patient.

In order to know the truth of the pathological fact, the doctor must abstract the patientƒParadoxically, in relation to that which he is suffering from, the patient is only an external fact; the medical reading must take him into account only to place him in parentheses.[51]

 

This prevents the doctor from viewing the patient as a person, and treating them accordingly. Thus the now familiar complaint that doctors "treat the problem and not the patient". The scientific model of health results in the separation of the person from the body, and deeper still, of the whole body from the sum of its parts. This is what is happening when Boorse and Kass argue that it is possible to understand the human body as a conglomeration of many parts, each of which has its own individual function.

[T]he medical understanding of illness was bound up with the identification of body parts and functions through a form of 'mapping' on the anatomical atlasƒAnatomical drawingsƒwere a means of rendering the cells, tissues, organs and flesh into patterns.[52]

 

Not only is this dehumanizing, it is akin to looking at a painting through a microscope—you simply are not getting the whole picture. It is impossible to effectively treat illness in this manner; the body is not a compartmentalized entity, rather it functions only as the result of the coordination of many parts and processes. The visual system is a perfect example of this. The human eye is an incredibly complex structure capable of experiencing a wide range of visual stimuli from color to motion to depth, and this is only the beginning of a long process of signal transduction, coordination, translation and reception that results in our ability to "see".[53] A problem with vision could be the result of damage to any one of a number of structures in the eye or in the brain, or it could be the result of a breakdown in communication between structures, or both. The point is that like many other mental or physical capabilities, vision is made possible not by the well-working of one structure or perhaps two, but of many structures independently and in conjunction with all the others.

The example of vision also shows how the relationship between the mental and the physical is so close that it is not possible to abstract one from the other. To try and conceive of vision as a purely physical phenomenon is an impossibility. Similarly, it is impossible to think of physical health as separate from mental and vice versa. One example of this is psychosomatic illness. A person suffering from psychosomatic illness is without a doubt experiencing physical pain, despite the inability of doctors to locate a physical cause for it. This is because psychosomatic illness is a physical manifestation of a mental problem. The fragmentation that results from the scientific model of health also contributes to an inadequate understanding of mental health. The general public is becoming increasingly aware of the importance of a holistic view of medicine because of the more accurate definition of health that is made possible.

[H]ealth is a potential, a process, a set of complex relationships that an individual or population has with their surrounding social, cultural and natural environments. It is not a thing apart, but a pattern that connects.[54]

 

That is, there is an increased awareness that the body is made up of many interconnected systems, including the mind, and treating an illness requires an examination of all the systems, as well as their connections to one another.

 

Conclusion

In this thesis I have attempted to show the necessity for a reevaluation of the scientific model of health. Despite arguments against it, of which the ones I have outlined are only a few, the scientific model of health is still the prevailing theory of health for the west and beyond. This is evidenced by the way "health" is defined in the dictionary, as well as how it is used in everyday language. In addition, the continuing predominance of the scientific model of health has serious consequences for healthcare practice, and for society in general. As long as people continue to subscribe to this model, our picture of health can never be complete. Human beings will continue to be viewed as the conglomeration of a number of more or less independent structures rather than as unified wholes, and more importantly, the mental will remain separate from the physical. In addition, patients will remain deprived of agency as doctors will continue to have all the power when it comes to defining what health is and should be. Finally, the traditional dichotomy of "normality" and "abnormality" as they pertain to health will be preserved. As a consequence, the value hierarchy that naturally results from this dualism will also be preserved, and a large number of individuals will continue to be labeled "defective". Therefore I hope also to have shown that it is possible to leave the scientific model of health behind and yet still have a notion of health of which to speak. Abandoning the prospect that health is objective does not imply that health cannot be known, or that there is nothing to learn from such knowledge. Rather, this opens up the possibility for a new kind of knowledge about health, one that arises out of an understanding of the individual.

Such a vision of health is not empty of meaning. It is not a "free for all," relativistic vision of health. There is still a "fact of the matter" that can be known. However, this fact of the matter is not independent of, but rather is highly dependent upon the context of the patient. That is, because human beings are defined by their culture, their goals, their desires, their relationships, and their personal conception of the "good," so too health—as something that is in and of human beings—must depend on all these things as well. Although this notion of health is subjective (in that it accounts for individual input or accounts), it is not limited to purely subjective knowledge. Historically grounded knowledge can still be true knowledge, as Nussbaum's account of "internalist essentialism" shows. However, with this new concept of health, both the doctor and the patient have a voice in defining the appropriate standard of health.



[1] Merriam-Webster Medical Desk Dictionary, Revised Edition © 2002 Merriam-Webster, Inc.

[2] Kass, Leon. The End of Medicine and the Pursuit of Health. Toward a More Natural Science. The Free Press. New York, NY. 1985 (p171)

[3] Richman, Kenneth A. Ethics and the Metaphysics of Medicine: Reflections on Health and Beneficence. The MIT Press. Cambridge, MA. 2004 (p13)

[4] Kass, Leon. 1985 (p172)

[5] Boorse, Christopher. Defining Disease. What is Disease? Humana Press. Totowa, NJ. 1997 (p6)

[6] Ibid. (p7)

[7] Boorse, Christopher. 1997 (p8)

[8] Ibid (p9)

[9] Boorse attributes his definition of goals mostly, if not entirely, to Gerd Sommerhoff.

[10] Boorse, Christopher. 1997 (p4)

[11] Ibid (p7)

[12] Boorse, Christopher. 1997 (p4)

[13] Richman, Kenneth A. 2004 (p6)

[14] Ibid

[15] Boorse, Christopher. 1997 (p21)

[16] Kass, Leon. 1985 (p173)

[17] Kass, Leon. 1985  (p169)

[18] Ibid

[19] Ibid (p168)

[20] Ibid

[21] Ibid

[22] Kass, Leon. 1985  (p166)

[23] Richman, Kenneth. 2004 (p6)

[24] http://www.cuyamaca.net/bruce.thompson/Fallacies/naturalistic.asp

[25] Boorse, Christopher. 1997 (p21)

[26] Sterelny, Kim and Griffiths, Paul E. Sex and Death: An Introduction to Philosophy of Biology. The University of Chicago Press. Chicago, IL. 1990 (p217)

[27] Richman, Kenneth A. 2004 (p13) (italics added)

[28] Boorse, Christopher. 1997 (p9)

[29] Nussbaum, Martha and Sen, Amartya. Internal Criticism and Indian Rationalist Traditions. In Relativism: Interpretation and Confrontation. Michael Krausz (ed). University of Notre Dame Press. Notre Dame, IN. 1989 (p310)

[30] Brock, Dan. Quality of Life Measures in Health Care and Medical Ethics. The Quality of Life. Nussbaum and Sen (ed). Clarendon Press. Oxford. 1993 (p100)

[31] Nussbaum, Martha and Sen, Amartya. 1989 (p310)

[32] Nussbaum, Martha. Human Functioning and Social Justice: In Defense of Aristotelian Essentialism. In Moral Issues in Global Perspective. Christine Koggel (ed). Broadview Press. Peterborough, Ontario, Canada. 1999 (p127)

[33] Ibid

[34] Nussbaum, Martha. 1999 (p130)

[35] Ibid

[36] Foucault, Michel. Spaces and Classes. In Health Studies: A Critical and Cross-Cultural Reader. Edited by Colin Samson. Blackwell Publishers. Oxford, UK. 1999 (p22)

[37] Samson, Colin. Health Studies: A Critical and Cross-Cultural Reader. Blackwell Publishers. Oxford, UK. 1999 (p9)

[38] Samson, Colin. 1999. (p9)

[39] See Colin Samson "The Anatomy Lesson" in Chapter 1 of Health Studies: A Critical and Cross Cultural Reader. Blackwell Publishers. Oxford, UK. 1999 (p5-10)

[40] Wendell, Susan quoted in David Wasserman Disability, Discrimination, and Fairness. Appearing in Moral Issues in Global Perspective Christine Koggel (ed). Broadview Press. Ontario, Canada. 1999 (p390)

[41] Tremain, Shelley. "On the Government of Disability". ©2001 by Social Theory and Practice, Vol. 27, No. 4 (October 2001) (p618)

[42] Ibid.

[43] Ibid. (p619)

[44] Hacking, Ian. Mad Travelers: Reflections on the Reality of Transient Mental Illness. University Press of Virginia. Charlottesville, VA. 1998 (p10)

[45] Hacking, Ian. 1998 (p1)

[46] Ibid (p32)

[47] Ibid (p38)

[48] Hacking, Ian. 1998 (p8)

[49] Thompson, Kevin J. Ph.D., "Body Image, Bodybuilding, and Cultural Ideals of Muscularity" Copyright © 2004 Think Muscle LLC. http://www.thinkmuscle.com/articles/thompson/body-image-and-bodybuilding.htm

[50] Hacking, Ian. 1998 (p13)

[51] Foucault, Michel. 1999 (p25)

[52] Samson, Colin. 1999 (p9)

[53] A good, thorough examination of the visual system is Matthew Schmolesky's "The Primary Visual Cortex". 2000. http://webvision.med.utah.edu/VisualCortex.html

[54] www.livingknowledgeconsulting.com/definitions.html




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