Pathocentric Health Care and a Minimal Internal Morality of Medicine

Christopher Boorse is very skeptical of there being a pathocentric internal morality of medicine. Boorse argues that doctors have always engaged in activities other than healing, and so no internal morality of medicine can provide objections to euthanasia, contraception, sterilization, and other practices not aimed at fighting pathologies. Objections to these activities have to come from outside of medicine. I first argue that Boorse fails to appreciate that such widespread practices are compatible with medicine being essentially pathocentric. Then I contend that the pathocentric essence, properly understood, does not prohibit physicians from engaging in actions that are not aimed at combating pathologies, but rather supports an internal morality of medicine that allows medical providers to refuse without penalty to engage in practices that promote pathologies.

Contemporary Accounts of Health

Contemporary philosophers of medicine have wrestled with the difficulty of defining health, and even over the basic question of whether this is a normative or descriptive concept. Both approaches seem to be prone to objections. The descriptive approach has difficulty defining health in a way that is not prey to counterexamples. Particular attention is given to the naturalistic accounts of Christopher Boorse and Jerome Wakefield. After the drawbacks of these accounts are discussed, it is suggested that normativism may be more promising but typically fails to meet two general conditions: isolating health from other normative states (the circumscription problem) and explaining how health relates to the value of a good life.

Internal morality of medicine and physician autonomy

Robert Veatch and others have questioned whether there are internal moral rules of medicine. This paper examines the legal regulatory model for governing professions as the autonomous exercise of professional skills and asks whether there is a theoretical basis for this model. Taking John Rawls’s distinction between the justification of a practice and justification of the rules internal to the practice, this paper argues that the autonomous exercise of professional skills is justified so long as it benefits society. In opposition to Christopher Boorse, it is argued that medicine is pathocentric and that physicians exercise skills in treating pathologies. The autonomous treatment of pathologies is justified because non-interference with physicians will lead to greater treatment of pathologies and so benefit society. Finally, the analysis of medicine as the autonomous exercise of skills in treating pathologies yields the rule that physicians not be forced to cause pathologies.

Normal e Patológico no naturalismo e no normativismo em saúde: a controvérsia entre Boorse e Nordenfelt

Resumo Partindo do pressuposto que a demarcação entre o normal e patológico é flutuante e que o debate se atualiza constantemente, o intuito deste artigo é ampliar o leque de discussão sobre esses conceitos como forma de oferecer subsídios para resistir à patologização da existência sem abrir mão dos mesmos, que são fundamentais para a prática médica. O objetivo do trabalho é apresentar as disputas entre as perspectivas normativistas e naturalistas contemporâneas que buscam clarificar os conceitos genéricos de saúde e doença. A análise do estatuto epistemológico dos conceitos de saúde e doença ou de normal e patológico foi extensamente realizada por Canguilhem na década de 1940 e, atualmente, a investigação da temática indica que o aparato conceitual canguilhemiano merece ser refinado. Em função disso, apresenta-se a controvérsia na literatura filosófica anglo-saxônica entre as perspectivas naturalista e normativista, com base nos trabalhos de Christopher Boorse e Lennart Nordenfelt. Enquanto Boorse contribui para a discussão ao trazer um conceito naturalista e funcionalista da saúde a partir da ideia de uma "norma não normativa", Nordenfelt pauta a saúde na ação pragmática do sujeito no mundo, considerando o terreno da manifestação afetiva do ser humano.

On the medical art: Health and disease between metaphysics, epistemology and medicine

The article treats one of the major issues of contemporary philosophy of medicine - the difficulty of giving a purely objective definition of health and disease - and examines its implications for the question of the epistemological status of medicine: is it possible to define medicine as a science, or should we be contented with a more modest, traditional view that medicine is simply the art of healing? In the first part of the article, this problem is shown to be present already in the debates of conflicting medical schools of ancient Greece. More generally, scepticism regarding the scientific status of medicine is explained in terms of the inner tension, which also shapes the Aristotelian concept of medical art, between the physician?s task of healing an individual patient and the universalistic aspect of medical knowledge. The second part of the text deals with the shift of perspective in our understanding of living organisms brought about by Darwin?s theory of evolution and with its consequences for the conception of health and disease. In this context, we examine the shortcomings of the leading contemporary theory of health proposed by Christopher Boorse and point out to some fundamental affinities between evolutionary developmental biology and personalized medicine.

Ορίζοντας την υγεία και την ασθένεια: Η αυτογνωσία ως κριτήριο υγείας

A central issue in the philosophy of medicine is to solve the problem of determining the nature of the concepts of health and disease. Some theorists claim that health and disease are purely value-free and descriptive concepts that are discoverable and grounded in the biological and medical sciences. Others claim that health and disease are essentially value-laden concepts, i.e. healthy states are those states we (individuals, groups, societies) desire or value and diseased states are those we want to avoid or disvalue.Considering the longtime disagreement among physicians, theorists of health and philosophers about the essential characteristics of health and disease, the aim in the first part of this paper is to briefly present four different philosophical approaches of health and disease in an attempt to introduce the readers to the debate. This article begins with the Biostatistical theory of Christopher Boorse. It turns to the Malady theory of Danner Clouser, Charles Culver and Bernard Gert, the holistic theory of Lennart Nordenfelt and finally the adaptation theory of József Kovács.In the second part of the paper, some objections will be stated to each theory. In the third and last part, a completely different account of health will be given, which holds that self-knowledge is a criterion of human health. Health, unlike disease, is not a state or a condition of the organism but an endless process. Its essence can be better captured in philosophical rather than medical terms and it should be applied only to human beings.

Saúde como ausência de doença: crítica à teoria funcionalista de Christopher Boorse

Este ensaio é uma introdução à obra de Cristopher Boorse, filósofo da medicina que criou, nos anos 70, a Teoria Bioestatística da Saúde (TBS). Em primeiro lugar, examinamos o argumento e a estrutura da TBS, destacando seus elementos epistemológicos fundamentais e principalmente as justificativas lógicas e teóricas de sua definição da saúde como ausência de doença. Em segundo lugar, discutimos as numerosas críticas recebidas por Boorse em duas décadas de circulação dos seus textos, buscando estabelecer a pertinência e atualidade dessas críticas. Em seguida, identificamos problemas e pontos fortes da teoria boorseana, retomando as principais críticas dirigidas ao autor, bem como suas tentativas de resposta. Por fim, levantamos algumas questões que podem propiciar uma continuidade e um enriquecimento do debate em torno do conceito de saúde a fim de explorar sua aplicabilidade para uma teoria geral da saúde-doença-cuidado, cada vez mais necessária neste momento em que se pretende uma maior articulação entre abordagens biológicas e ecossociais dos fenômenos da saúde e da doença.