Medicine, Health Care and Philosophy (2007) 10:510 Springer 2006

DOI 10.1007/s11019-006-9017-3

The concepts of health and illness revisited

Lennart Nordenfelt
Department of Health and Society, Linkoping University, 58183, Linkoping, Sweden (E-mail: lenno@ihs.liu.se)

Abstract. Contemporary philosophy of health has been quite focused on the problem of determining the
nature of the concepts of health, illness and disease from a scientic point of view. Some theorists claim
and argue that these concepts are value-free and descriptive in the same sense as the concepts of atom,
metal and rain are value-free and descriptive. To say that a person has a certain disease or that he or she is
unhealthy is thus to objectively describe this person. On the other hand it certainly does not preclude an
additional evaluation of the state of aairs as undesirable or bad. The basic scientic description and the
evaluation are, however, two independent matters, according to this kind of theory. Other philosophers
claim that the concept of health, together with the other medical concepts, is essentially value-laden. To
establish that a person is healthy does not just entail some objective inspection and measurement. It
presupposes also an evaluation of the general state of the person. A statement that he or she is healthy does
not merely imply certain scientic facts regarding the persons body or mind but implies also a (positive)
evaluation of the persons bodily and mental state. My task in this paper will be, rst, to present the two
principal rival types of theories and present what I take to be the main kind of reasoning by which we
could assess these theories, and second, to present a deeper characterization of the principal rival theories
of health and illness.

Key words: biostatistical theory of health, disease, health, holistic theory of health, illness, medicine, values

Introduction health? To what more precise goal shall we direct

It is often maintained that health is one of the
major goals of medicine or even the goal of
medicine. This idea has been eloquently formulated
by the American philosophers of medicine
Edmund Pellegrino and David Thomasma in their
A Philosophical Basis of Medical Practice (1981,
p. 26):
Medicine, then, is an activity whose essence ap-
pears to lie in the clinical event, which demands
that scientific and other knowledge be particular-
ized in the lived reality, of a particular human,
for the purpose of attaining health or curing ill-
ness, through the direct manipulation of the
body, and in a value-laden decision matrix.
Although some other goals of medicine exist, such
as the basic goal of saving lives and the recently
developed goal of quality of life, health is still
taken to be the central goal in the medical
disciplines or in public health. However, the
formidable task of interpreting the nature of health
remains to be pursued. What, more specically, is
our efforts in medicine and health care?
These questions are not simply academic. They
are of great practical and thereby ethical concern.
The consequences for health care diverge consid-
erably, not least in economic but also in social and
educational terms, depending on whether health is
understood as peoples happiness, or their tness
and ability to work, or instead just the absence of
obvious pathology in their bodies and minds.
There are adherents of all these ideas in the
modern theoretical discussion on health.
Contemporary philosophy of health has been
largely focused on the problem of determining the
nature of the concepts of health, illness and
disease from a scientic point of view. Some
theorists claim and argue that these concepts are
value-free and descriptive in the same sense as the
concepts of atom, metal and rain are value-free
and descriptive. Moreover, a disease in a human
being can be discovered, according to this line of
thought, through ordinary inspection and through
the use of scientically validated procedures,
without invoking any normative evaluation of
the persons body or mind. To say that a person
6 LENNART NORDENFELT
has a certain disease or that he or she is unhealthy
is thus to objectively describe this person. On the
other hand it certainly does not preclude an
additional evaluation of the state of affairs as
undesirable or bad. The basic scientic description
and the evaluation are, however, two independent
matters, according to this kind of theory. Impor-
tant protagonists of such a theory are Boorse
(1977, 1997) and Schramme (2000 and in this
issue), among philosophers, and Scadding (1967),
among physicians.
Other philosophers claim that the concept of
health, together with the other medical concepts, is
essentially value-laden. To establish that a person
is healthy does not just entail some objective
inspection and measurement. It presupposes also
an evaluation of the general state of the person. A
statement that he or she is healthy does not merely
imply certain scientic facts regarding the persons
body or mind but implies also an evaluation (a
positive one) of the persons bodily and mental
state.
Yet other people, for instance Wakeeld (1992),
maintain that health has both an objective element,
one of natural function, and an evaluative element,
a component of well-being. This means that in
order to qualify as a disease or disorder a condition
must be both unnatural and harmful (for instance
involve disability and pain).
My task in this paper will be, rst, to present the
two principal rival types of theories and present
what I take to be the main kind of reasoning by
which we could assess these theories, and second,
to present a deeper characterization of the princi-
pal rival theories of health and illness.
A presentation of two rival theories of health
The starting-point for my analysis will be the
biostatistical theory of health and disease devel-
oped by Christopher Boorse during the 70s and
revised in his famous paper from 1997: A
Rebuttal on Health. There are two central
denitions that form the basis of Boorses char-
acterization of health. There is rst the denition
of disease: A disease is a type of internal state
which is either an impairment of normal func-
tional ability, i.e. a reduction of one or more
functional abilities below typical eciency, or a
limitation on functional ability caused by envi-
ronmental agents (p. 7). Second, there is the
denition of health based on this characterization
that says laconically: health is identical with the
absence of disease.
The crucial concept here is functional ability.
This has been explained at other places in Boorses
writings. An organ exercises its function, for
instance the heart is pumping in the appropriate
way, when it makes its species-typical contribution
to the individuals survival and reproduction. For
Boorse, survival and reproduction are the crucial
biological goals. The notion of biological function
is tied to these goals.
Boorses elegant theory seems to have several
advantages. The notions of survival of the individual
and survival of the species fall well within evolu-
tionary theory, which is much celebrated in both
biological and sociological contexts these days. It is
true that Boorse does not explicitly found his ideas
on evolutionary theory, but roughly the same ideas
have been taken up by Wakeeld (1992), who very
clearly puts them into the evolutionary framework
in his explications.
Another advantage of Boorses biostatistical
theory, as I have indicated, is that it can be quite
easily generalized and applied to other living
beings than humans. Survival of the individual
and survival of the species are notions applicable
to all living beings. Not only apes, but also worms
and amoebas can fail to reproduce or die. And
the same holds for all plants, from orchids to
mosses.
It is signicant that the holistic theories, on the
other hand, refer not only to the survival but also
to the quality of life (mainly the welfare) of the
individual. According to these theories, a person
can be ill, not only if the probability of the persons
survival has been lowered but also if he or she does
not feel well or has become disabled in relation to
some goal other than survival. In his classical
analysis of health Galen, from the second century
AD, says that health is a state in which we neither
suer pain nor are hindered in the functions of
daily life (translated by Temkin, 1963, p. 637).
Fulford (1989, p. 149) says that people who are ill
are unable to do the things that people ordinarily
just get on and do; moving their arms and legs,
remembering things, nding their way about
(familiar) places and so on.
Let me now attempt to formulate the two main
rivals in such terms as to make them easily
comparable. I will formulate them both in positive
terms. Thus, a characterization of health according
to Boorses Biostatistical Theory of Health (BST)
is the following:
 THE CONCEPTS OF HEALTH AND ILLNESS REVISITED
I. A is completely healthy if, and only if, all
organs of A function normally, i.e. if they, given
a statistically normal environment, make at least
their statistically normal contribution to the sur-
vival of A or to the survival of the species to
which A belongs.
The concept of disease in BST is given in the
following: A has a disease if, and only if, there is at
least one organ of As which functions subnor-
mally, given a statistically normal environment.
The disease is identical with the subnormal func-
tioning of the organ.
The characterization of health given in my own
version of the Holistic Theory of Health (HTH) is
the following:
II. A is completely healthy if, and only if, A has
the ability, given standard circumstances, to reach
all his or her vital goals.
The notion of a vital goal is crucial here and I
have spent a lot of time and space on it in my
writings. However, for the present purposes it is
sufcient to say that a persons vital goals are
his or her most essential goals in life. What they
could be will become clearer in the following.
Note also the notion of a standard circum-
stance. Standard circumstances are something
different from statistically normal circumstances.
Standard circumstances are related to a cultural
norm. My version of the HTH does not allow
talk of an organs being healthy, except in a
derivative sense. Health is a concept which
basically pertains to the whole person. The
concept of disease in the HTH comes out in
the following way:
A has a disease if, and only if, A has at least one
organ which is involved in such a state or process
as tends to reduce the health of A. The disease is
identical with the state or process itself. (Observe
here that health means something else than in the
BST case.)
The phrase tends to reduce the health of A
is selected because not all diseases actually
compromise health in the holistic sense of being
able to realize vital goals. Some maladies are
aborted, i.e. disappear before they have inu-
enced the person as a whole; others are latent;
yet others are so trivial that they are never
recognized by their bearer.
How can we attempt to assess these ideas? Are
they both equally plausible or implausible? I will
here present two stories.
7
The Reverse Theory of Disease and Illness:
The Historical Argument
I wish here to use an argument pertaining to the
genesis of the notion of health and I will do so via
the opposite of health, viz. illness. I will also make
a crucial distinction between illness and disease.
My basic idea is that the notion of illness when it
comes to humans has its basis in the existence of a
perceived problem. Let me introduce this idea with
the help of the following, hopefully plausible, story
with regard to the emergence of the concepts of
illness and disease.
1. In the beginning there were people who experi-
enced problems in and with themselves. They felt
pain and fatigue and they found themselves un-
able to do what they could normally do. They
experienced what we now call illnesses, which they
located somewhere in their bodies and minds.
Many people came to experience similar illnesses.
This led to the giving of names to the illnesses,
and hereby the presence of the illnesses could be
eciently communicated. This was the phase of
illness recognition and illness communication.
2. The people who were ill approached experts,
sometimes called doctors, in order to get help.
They communicated their experiences to their
doctors or other carers, via the illness language.
The carers tried to help them and cure them. In
the search for curative remedies, the carers did
not just rely on the stories told by the people who
were ill. They also looked for the causes of the ill-
nesses within the bodies and minds of the ill. This
meant in the end that they initiated systematic
studies of the biology of their patients. This was
the phase of search for the causes of illnesses.
3. As a result of these studies the carers found cer-
tain regular connections between certain bodily
states and the symptoms of their patients. They
formed hypotheses about causal connections
between the internal states and processes and the
illness-syndromes. They designated these causes
of illnesses diseases. And they invented a vocabu-
lary and a conceptual apparatus for the diseases.
This was the phase of disease recognition.
This is a quasi-historical sketch of the development
of the notion of disease. According to this story the
concept of illness is primary to the concept of
disease. At the heart of the story lies a problem that
has to be solved, through an investigation into the
causes of this problem. These causes are assumed
to exist within the subjects body or mind.
8 LENNART NORDENFELT
This explication is more plausible than the rival
one that says that diseases are bodily states that
make a statistically subnormal contribution to the
survival and reproduction of their bearers. A
problem constituting illness need not entail a
threat to or a reduced support of the persons life
or reproduction. The problem quite often concerns
pain, other kinds of suffering, or disability. And
the subject normally correctly believes that this
problem has some kind of internal (biological or
psychological) cause. I therefore conclude that the
concept of human disease is related primarily to
suffering and disability and not to the increased
probability of death.
The medical encounter
Second, I will consider the standard medical
encounter today, the encounter between a potential
patient and a medical carer (a doctor, a nurse or a
paramedic).
1. A person approaches the health service with a
problem. John approaches his family doctor with a
problem. He says that he has been ill for some
time. He has had considerable pain in his stomach
and this has prevented him from going to work for
a week. He says that he must have some disease.
He cannot explain his ill-health otherwise. Here we
see that John asserts that he is ill. He has not made
any inspection of his body in order to establish this
fact. He has noted his pain (a pain which has no
immediate external cause) and he observes that he
is prevented from going to work. He assumes that
there is a disease that is responsible for this
problem.
2. The doctor diagnoses the problem and treats
the patient. The doctor makes an examination of
John. He tries to assess the nature of the problem
and when he is convinced about its nature, he seeks
the cause of it. Given his medical training he will in
the rst instance try to nd the cause of the
problem in the organic functioning of Johns body.
In short, he seeks some malady. It is important,
however, to see here that he is not seeking a malady
for its own sake. He is not seeking any old malady.
He wants to nd the cause of the patients problem,
primarily in terms of the disease language to be
found in medical classications and textbooks.
Having found the malady that he believes to be the
cause of the problem he starts treating it lege artis,
i.e. according to the recommendations of the
contemporary art of medicine.
3. The patient is healthy again when he or she has
got rid of the problem. The medical encounter is
considered successful, and John considers himself
healthy, when he no longer feels the pain in the
stomach and can go to work as usual.
This simple exposition of the typical successful
medical encounter indicates to me that the health
concept used is a variant of the holistic concept of
health. The establishment of the fact that John is ill
does not presuppose any internal inspection on the
organ level. John can himself (at least equally as
well as the doctor) determine that he is in a state of
ill-health. Ill-health for John is when he is in pain
and unable to do something urgent for him, e.g. go
to work, given that the circumstances are standard.
Second, it is clear that health as assumed by the
patient, as well as by the health-care personnel, is a
state of affairs over and above the absence of
disease. Health has not been restored just because a
malady has been eliminated, i.e. the disease has
been cured. Normally, the patient cannot go to
work until after a time of recovery and rehabilita-
tion. This also speaks in favour of a version of the
HTH.
I therefore endorse an idea that has been
labelled the Reverse Theory of Disease and Illness.
It was indeed rst suggested by Canguilhem as
early as 1943 (rst published in English in 1978),
and developed by Fulford in 1989.
The primary focus of attention is thus the illness
the problem as perceived normally by the subject.
From the concept of illness we can derive the
concept of disease, i.e. the internal state which
causes (or tends to cause) the illness. But observe
here how the diseases are identied. They are
identied on the basis of an illness-recognition. A
discovery of the disease presupposes the occurrence
of an illness. (To avoid misunderstanding: the
illness need not have occurred in the individual
case, but the disease-type would not have been
discovered, and labelled as a disease, in the rst
place if there were not someone who had experi-
enced the corresponding illness.)
Given this interpretation, we also arrive at a
denition of disease which differs from the Boor-
sian biostatistical one. A preliminary denition of
disease would thus be: Disease = df a bodily or
mental process which is such that it tends to cause
an illness (understood as a state of suffering or
disability experienced by the subject). Certainly,
many of the conditions picked out by the Boorsian
criteria will be identical with the ones picked out by
the holistic criteria. A cancer is a disease for Boorse
as well as for myself. But the reasons differ. For
 THE CONCEPTS OF HEALTH AND ILLNESS REVISITED
Boorse a cancer is a disease because it makes a
statistically subnormal contribution to the subjects
survival. For me, however, a cancer is a disease
because it tends to cause its bearer disability and
suffering. But, and this is important, some diseases
picked out by the holistic criteria will not be
counted as diseases by the Boorsian ones. A person
may be in pain and disabled by internal bodily
causes without this condition lowering the proba-
bility of the persons survival. But the converse
may also hold, there may be diseases picked out by
the biostatistical criteria which are not picked out
by the holistic ones.
There are alternative ways of using the crucial
concepts of suffering and disability in the con-
struction of theories. Either one uses both kinds
of concepts, as Galen does and as Reznek (1987)
does, and says that illness is constituted by both
suering and disability, or by either suering or
disability, or one focuses on one of them for the
purpose of denition. A number of contemporary
theorists, myself included, have focused on the
pair of concepts ability and disability since we
nd it to be more universally useful than the pair
well-being and suering. (See Nordenfelt, 1995,
2001.)
A comparison between the two theories of health
and illness
After this preliminary way of positioning myself I
can compare the two kinds of theories in a more
stringent way. The presented versions of the BST
and the HTH are clearly quite dierent theories of
health. The dierences can be summarized thus:
1. In the BST health is exclusively a function of
internal processes in the human body or mind.
In the HTH health is a function of a persons
abilities to perform intentional actions and
achieve goals.
2. In the BST health is a concept to be dened
solely in biological and statistical terms. In the
HTH the concept of health presupposes extrabi-
ological concepts such as person, intentional
action and cultural standard.
3. In the BST health is identical with the absence
of disease. In the HTH health is compatible with
the presence of disease. The concept of disease,
however, is logically related to the concept of ill-
health (or illness) also according to the HTH. A
malady is dened as a state or process which
tends to reduce its bearers health.
9
However, there are also important structural
similarities between the BST and the HTH. These
similarities have come out in my presentation.
Health in both models has to do with whether a
person as a whole or some of his or her bodily or
mental parts are able to achieve certain goals.
Generalizing the theories of health
Let me nally deepen this comparison between the
two types of theories by observing how the theories
could be generalized. In principle the bio-statistical
foundation of the BST could be extended to cover
the domain of human abilities in the following
way:
An expanded version of the BST (BSTe). A is
completely healthy if, and only if, all organs of A
function normally and A has the ability to perform
all actions which are statistically normal, given a
statistically normal environment. (The addition
with regard to a statistically normal environment is
given in Boorse, 1997. For a commentary see
Nordenfelt, 2001.)
Conversely, the HTH can be extended to cover
the biological domain: An expanded version of the
HTH (HTHe). A is completely healthy if, and
only if, the organic structure of A is such that it
enables A to achieve all his or her vital goals, given
standard circumstances. (In fact my own version of
HTH (1995) was initially formulated as an
expanded version.)
Through this expansion we can observe not
only the common features but also the two features
which fundamentally distinguish the BSTe from
the HTHe. The rst important dierentiating
criterion concerns the goals of the organism and
the person. According to the BSTe the only goals
that are relevant in the analysis of the health
concept are the survival of the individual and the
survival of the species. According to the HTHe
there are further goals. The agent has other
possible vital goals than the one of pure survival.
But survival must also be included. This is so
because survival is a necessary condition for the
accomplishment of all other goals. Thus, according
to the HTHe there are things required in order to
be completely healthy other than in the BSTe.
According to the HTHe it is not sucient that you
are normal in relation to survival. You must also
have resources which are adequate for other vital
goals.
The second important differentiating criterion
concerns the nature of the circumstances
10 LENNART NORDENFELT
presupposed in the concept of health. The BSTe
refers to statistical normality. The HTHe refers to
circumstances that are considered to be standard in
a particular cultural context.
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