The Concept of Disease

Downloaded from http://jmp.oxfordjournals.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8, 2012

JOSEPH MARGOLIS* Austin Turk, surveying the literature of the criminal law, favored the view that "criminality is . . . the state of having been officially defined as punishable, whether or not one has been apprehended and punished" (Turk 1969, p. 18). He added that "efforts to determine causes of criminality have foundered on the fact that criminality is not a biological, psychological, or even behavioral phenomenon, but a social status defined by the way in which an individual is perceived, evaluated, and treated by legal authorities" (p. 25). It may seem surprising that such a view—rightly termed legal positivism—is fairly matched within medical theory and theories governing other domains concerned with deviance and maladaption. For instance, Ian Gregory maintains that, "While professionals have a major voice in influencing the judgment of society, it is the collective judgment of the larger social group that determines whether its members are to be viewed as sick or criminal, eccentric or immoral" (Gregory 1968, p. 32).' The conjunction of these specimen views serves to fix our minds on the essential issues concerning the concept of health. For, even on the most casual canvassing of the relevant literature, it is obvious that medicine and the law are the two principal professional disciplines of advanced societies systematically concerned with rendering judgments that are at once informed by selected norms of human functioning and characterizable as findings of fact (ignoring, here, a more restricted usage in the law); that the extension of 'illness' (or 'deviance' or 'maladaptation') and the extension of 'criminality' are quite often confused with one another and even sometimes subsumed under one another (see Glueck [1954]; Menninger [1968]; Menninger, Mayman, and Pruyser [1963]; also the review of the issue in Flew [1973]: Kittrie [1971]; Szasz [1970]); and that we are * Professor of philosophy, Temple University, Philadelphia, Pennsylvania 19122. 1 The reference, I should like to mention, is cited in an unpublished paper by Christopher Boorse (1975a) which came into my hands just at the moment of composing my own account and from which, allowing for disagreements, I have much benefited.
The Journal of Medicine and Philosophy, 1976, vol. 1, no. 3. © 1976 by The Society for Health and Human Values. All rights reserved.

238

VALUE JUDGMENTS Begin. confirms that the term 'disease' is hardly used in an explicitly systematic way. The concept of a norm is the concept of a condition or parameter in terms of which a range of relevant phenomena may be (valuationally) graded or ranked as satisfying the condition given: valuational predicates. on how we understand the nature of factual and value judgments. the distinction has to do only with the logical properties of different kinds of judgment. Similarly. Also. mental.oxfordjournals. as may be shown. are used to grade or rank such phenomena relative to such norms. So seen.2 That a predicate is a valuational predicate depends solely on the explication of its sense in terms of norms of some sort. 239 . then. For sentences of a predicative form. intended to adhere as closely as possible to the World Health Organization's International Classification of Diseases. cf. International Classification of Diseases 1968) Diagnostic and Statistical Manual of Mental Disorders (DSM II). by their predicates. The question of the nature of illness and disease (as well as that of crime) depends very substantially. speaking of mental health. a glance at the American Psychiatric Association's (1968.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. if not provided. the latter are vexed matters and may even seem to be quite remote from the concern of practicing physicians and of therapists in allied disciplines.Joseph Margolis rather unwilling (though perhaps for different reasons) to regard illness and breaches of the law as matters merely of conventional classification—alterable without conceptual dislocation by whatever ingenious and imaginative historical turn given societies may have taken. Obviously. Marie Jahoda (1958) has stressed a comparable insufficiency when one thinks of health as the mere absence of mental disease. Thus. 1. in a recent pronouncement. a certain initial tolerance is required regarding certain ground-level distinctions which. then. and human persons. will be found to render debate practically useless. the World Health Organization (1958) held that "health is a state of complete physical. and social well-being and not merely the absence of disease or infirmity" (p. in developing a theory of health and illness. 459). Hence. and the functioning of organs. Construe illness 2 Downloaded from http://jmp. value judgments may be distinguished from nonvaluational judgments. in attempting a fair account. with value judgments. Furthermore. norms and normality. we should consider the lack of uniformity in speaking of disease and illness and the possible difference in focus intended in speaking of health and disease. 2012 The brief account given here is taken from Margolis (1971). organisms. to admit a judgment to be a value judgment entails nothing at all about the defensibility or grounds for proposing particular norms.

hence. and 'tubercular' and 'murdered' are predicates by means of which we manage to grade conditions and behavior relative to certain medical and legal norms. lesions. For example. As Christopher Boorse puts it: "In our own culture and in others. 1 above) has now appeared in somewhat revised form. "The physician as theoretician speaks of diseases. recovery. of any sort whatsoever.3 Boorse cites the following view of 3 Downloaded from http://jmp. but I believe statements made in the first do not" (Boorse 1975a). value judgments and factual judgments: both may. truth and falsity. the judgment that "Peter is tubercular" (which is not to say merely that the bacillus may be found in Peter's system) and that "Peter murdered Paul" (which is not to say merely that something that Peter did was causally responsible for the death of Paul) are. be true or false. usually. Such judgments may be called "findings.The Journal of Medicine and Philosophy as a lapse of some sort with respect to given norms of health: the judgment that Peter is ill (in whatever way may be specified) will count as a value judgment. it is very often maintained that one may have a disease without being ill. and the like: in his social capacity he speaks instead of illness. Furthermore." An alternative way of putting the point is this: human institutions normally embody norms. the concept of illness is a compound of a theory of disease and a body of associated normative institutions". in an obvious sense. it frees the characterization of value judgments from disputes about the defensibility of particular norms and permits us to see the sense in which value judgments and factual judgments are not distinct species of a common genus. Engelhardt 1974.oxfordjournals.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. and the like. Even this general distinction is helpful with respect to certain wellknown quarrels in the medical setting. while the concept of illness is a normative concept. In fact. 240 . even if disease is still a normative concept. 2012 This manuscript (n. at one and the same time. incapacitation. institutional facts (e. For. functions. indicating "a state of affairs as undesirable and to be overcome" (cf. So seen. is simply a judgment to which we may assign truth values. organs. at one and the same time. The account is convenient because. there is no difficulty at all in admitting that a given judgment may be both a factual judgment and a value judgment. as regarding murder) may entail reference to norms at the same time that they remain facts.. Statements made in this second vocabulary do typically have an evaluative component. seemingly nonpredicative sentences used in making value judgments—for instance. suffering. It is also sometimes maintained that. Feinstein 1967). we may say that a factual judgment. that of disease is not.g. 'ought'—judgments (whether moral or prudential or medical makes no difference)—may always be fairly construed in a predicative way by simply replacing 'ought' by some such locution as 'oughtful' and making the required grammatical adjustments (see Margolis 1971).

4 A good deal hangs on this. actually. and the probable causal consequences of initiating chemical and other physical changes. may involve no explicit reference to the norms of health and disease. 2012 . The ''presence of a disease" (usually bearing on infection or deficiency or abnormality) rather than the presence of a "diseased state" normally signifies that causal factors that might well make an organism ill (produce a diseased state that a patient might complain about or that might make him ail) are benignly present in the body under circumstances that invite concern about imminent or potentially imminent illness (that is. Deviations from the ideal obviously are fraught with value judgments. or eventually does so). which is entirely fair. 4 The same charge is laid against my own book (1966).org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. it explains why it is that medical diagnosis and prognosis are conceptually linked to the norms of health and illness even where particular judgments. First of all. it is quite possible to admit that an organism has a certain disease but is not ill. the presence of causal see Boorse (19756). probable causal developments. but it makes no sense to suppose that to ascribe a disease to an organism does not imply some reference to the very same normative states on which ascriptions of illness depend. the intent in pursuing the latter sort of inquiry is normally to determine the presence of a disease. see (in press) and (forthcoming).oxfordjournals. From this viewpoint. Boorse suggests that some idealizations—like that of ideal gases—are not normative.Joseph Margolis Fredrick Redlich's as an instance of what he takes to be an error. for instance judgments merely describing (nonevaluatively) the condition of the body. The idealization involved in the gas laws concerns the provision of standard but nonexistent specimens to which actual gases may be compared in terms of resemblance only—and for the sake of simplifying causal explanation: the ideal gases are not thought to be excellent in any respect whatsoever. 241 Downloaded from http://jmp. But the idealization involved in medical and related settings essentially concerns the provision of theoretical states of health with respect to which the actual states of organisms are to be suitably graded and ranked as relatively defective (as ill or not ill. that is. There are several reasons for insisting on the connection. all propositions on normality contain value statements in various degrees" (Redlich 1952). or as more diseased or less diseased than other specimens). A similar methodological strategy is involved in Max Weber's ideal types (see Girth and Mills 1946). the mistake of "normativism": "Most propositions about normal behavior refer implicitly or explicitly to ideal behavior. Boorse pursues the same theme in two forthcoming papers. the occurrence of an actual diseased state that is likely to produce complaint or ailing imminently. but the point of Redlich's remark remains entirely unaffected.

2. it explains the sense in which medicine is primarily an art and. Third. these considerations are entirely formal.oxfordjournals. clearly must conform with those same concerns. 242 5 Downloaded from http://jmp. chap. it suggests the potentially controversial nature of the norms of health and disease and the prerogatives and obligations of medicine: the objectivity with which the norms of health and the constraints of medicine may be specified are not in the least assured by merely acknowledging that medicine is a doubly normative discipline. pathologist and clinician. useful though they may be. that. Controversy about the inclusion. actually claims that 'normal' and 'abnormal' are "strictly speaking. dependency. There remains the problem. And it is equally obvious that one may complain about or ail because of putative symptoms that either are not linked to disease at all or are. embody (in a way that needs to be specified) the relevant and legitimate concerns of human beings. norms of health and illness. And the proper constraints on the rights and obligations of patients and doctors. in facilitating which certain purely descriptive and causal inquiries are pursued. who served as head of the APA task force on nomenclature and statistics. of homosexuality as a medically designated disorder (see "Should Homosexuality Be in the APA Nomenclature?" 1973. Sade 1971) makes this quite clear.The Journal of Medicine and Philosophy factors that are likely to produce illness (disease states palpable to the patient in virtue of his symptoms). in the context of the practice of the medical arts. It is obvious that there is a fair sense in which a certain disease may be present in one's system and in which one may be in a distinctly diseased state (through any of a range of stages from the benign to the lethal) without actually ailing or complaining of any symptoms because of the disease. NORMS Two sets of contrasting distinctions conveniently fix the problem of medical norms: disease and illness. But to collect the argument thus far advanced. on approximations to. Spitzer. 5. Those norms. Hampshire 1959). Second. "Ideas and Trends" 1973)5 and about the revision of rights and obligations in the patient-doctor relationship (see Annas and Healey 1974. which entails that relevant ascriptions depend not merely on resemblances to standard but unexceptional specimens but. say. not psychiatric terms" ("Ideas and Trends" 1973). cf. 2012 . norms or standards of merit or worth (see Margolis 1971. for Dr. The asymmetries between ascriptions of disease and illness reflect pragmatic distinctions relative to those concerns. via grading and ranking. Robert L. however.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. a science: it is primarily an institutionalized service concerned with the care and cure of the ill and the control of disease. or deviations from. we may say that value judgments are distinguished by their predicates.

as among the cancers. more informally and not narrowly the concern of medicine. 2012 .g. that is.oxfordjournals. though not entirely isomorphic with the concept of illness. is a morbid or abnormal state of some sort. makes no sens. Alvan Feinstein has usefully distinguished lanthanic diseases. need not be synchronic with any determinate malfunctioning—provided that what is so designated is causally linked in an appropriate way with the onset of malfunctioning and is not trivially taken as a form of malfunctioning itself. But these distinctions still contribute very little to our understanding of the nature of disease itself. on whatever professional criteria may be admitted. introspective cognition. plants may be diseased but never ill. a temporary condition of ailing (or complaint) not caused by a disease state at all.Joseph Margolis reasons of technology or competence or the like. phlebothrombosis). one must bear in mind a common equivocation on 'abnormal' and cognate terms—as designating determinate malfunctioning or what. a state defective or deranged with respect to some condition of healthy functioning or suitably related to such a state. even if there is no complainant. chap. even with these formal distinctions in hand. In that sense. it is clear why the concept of disease. myocardial infarction. To return to our initial distinctions: Feinstein (1967) also contrasts the clinician and pathologist. proprioceptive awareness.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. under the circumstances. with respect to which some symptoms that serve as iatrotropic stimuli may really be the symptoms of an associated illness (Feinstein 1967. he observes: 243 Downloaded from http://jmp. is likely to cause such malfunctioning. diseases that. In this connection. though there are. they may be associated with diseases other than the disease for which one's illness is classified. these distinctions presuppose a system of medical norms that Feinstein nowhere supplies. In fact. And yet. Illness is simply a diseased state manifest to an agent through that agent's symptoms—sensations. A diseased state.. 9). the palpable onset on some disease. and the like. and even where symptoms are linked to disease. not detectably so linked. Feinstein here speaks of there being no iatrotropic stimulus. Here. on any plausible theory whatsoever. what needs to be emphasized is that it is conceptually not at all implausible to hold that an incipient disease or diseased state may well obtain without any malfunctioning whatsoever—not merely in the lanthanic sense but in the sense that. or. Now.e without reference to appropriate norms. escape the patient's detection—as when there are no symptoms accessible to the patient or when. though clinically evident. A disease is either what is apt to cause a diseased state or that diseased state itself. After listing characteristic diagnostic categories (e. He adds the distinction of the co-morbidity of diseases associated with the disease for which one may be a complainant. he is not a complainant.

tend to converge on the total condition of their human patients. 73-74] Downloaded from http://jmp. they will also provide a basis for claiming that the clinician observes the symptoms and signs of disease. of microorganisms as disease entities (whether defensible or not) (see Virchow 1958). feel them. then. Every one of these entities is an abnormality of internal anatomic structure. Clinician and pathologist. [Pp. But this is precisely what has raised the strenuous question of the medical status of psychiatric illness (see Szasz 1961. With roentgenography. He classifies what he sees" (p. Thus he says: "To arrive at a diagnosis of morbid anatomy—such as myocardial infarction. with surgical exploration in suitable situations. heard. the pathologist normally attends to the functioning of organs and other anatomical structures. The clinician at the bedside never observes these abnormal structures directly. Margolis 1966). a clinician may see the silhouettes and shadows of these abnormal structures.oxfordjournals. 244 . and even cut them—is a pathologist. examining systematic behavior. the conception of diseased cells. epidermoid carcinoma of the lung. Psychiatry is at least a near exception. the clinician operates with the pathologist's categories. First of all. and of the diseases of organs must be dependent on the conception of the diseases and illnesses of human beings.The Journal of Medicine and Philosophy Not a single one of these diagnostic terms represents an entity that is ever actually seen. and the behavior of cells. organs. Nevertheless. But the only doctor who regularly witnesses the actual. he may see those portions of an abnormality visible in the accessible lumen. with laboratory tests. Alternatively put. and plants as such. clinician and pathologist make their usual observations and inferences informed by a common theory of medical norms of health and illness. systems of biochemical processes. 80). he may see a larger view of the abnormal structure and of its anatomic relations. or touched in the ordinary bedside observations of a clinician. But Feinstein misleadingly concludes that the clinician is somehow confined to inferences from what he observes and that the pathologist actually witnesses the disease or diseased condition—which introduces an unexplained privilege. The question remains. he observes the symptoms and signs that are their clinical effects. two provisional conclusions may be drawn here. Second. 2012 In effect. There is another clue that the contrast between clinician and pathologist provides: the clinician normally attends to the complaints and therapy of his patient. he may note the associated disorders in physiologic and biochemical function. What makes what the pathologist observes classifiable as disease? Whatever the grounds may be. animals. with endoscopy.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. complete appearance of all these anatomic entities—the only doctor who can regularly see them. the allegedly scientific and value-neutral status of medical pathology addressed to cells. or hepatic cirrhosis—a pathologist makes no deductions or inferences.

also Ryle 1961). In this regard. not coronary disease. then. pursuing the implications of the disease/illness distinction. or the like). it becomes difficult to treat the norms of medicine as altogether independent of ideologies prevailing in different societies (see Hollingshead and Redlich 1958). noting that "abnormal structure and abnormal function [cannot] always be correlated." offers the following counterinstances: Anginal pain may arise from pulmonary hypertension. Furthermore.6 To the extent that this occurs.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. coronary disease may produce no angina. a hypoxemic patient may be too anemic to look cyanotic. hyperthyroidism may produce no lid-lag. A closer review of the matter reveals. Feinstein (1967. limbs. however. the exophthalmos associated with lid-lag and hyperthyroidism may persist long after treatment has made the patient euthyroid or even hypothyroid. Psychiatry is once again problematic. and an elevation of protein-bound iodine. A first approximation to the theory of medical norms—let it be stressed that it is only a first approximation—has it that the body is composed of certain structured systems each of which has an assignable range of normal functioning. Cyanosis may be due to methemoglobinemia. The reason for both conclusions is the same. illness. Defect or disorder of such systems relative to such functioning constitutes a sufficient condition of disease. so that one constantly implie[s] the other and vice versa. Skin may look yellow because of hypercarotenemia: a serum bilirubin value may be elevated without evident clinical jaundice. we must realize that there cannot possibly be a thorough and detailed form/function correlation for all diseases. cited in Engelhardt]).Joseph Margolis biochemical processes.oxfordjournals. Lid-lag may sometimes occur in healthy people or in euthyroid patients with pulmonary disease. may be Engelhardt (1974) cites the amusing "disease" drapetomania (the running away of slaves) (see Cartwright [1851. see. namely. both that the functional norms of psychiatry are capable of a fair measure of objective support relative to the norms of physical medicine and that the norms of physical medicine are themselves dependent on a deeper commitment to a more-than-medical conception of human functioning. 245 6 Downloaded from http://jmp. associated with neither lid-lag nor hyperthyroidism. since relative to mental illness. "functional" systems tend to be metaphorically identified and the norms that must be posited oblige us to assign functional characteristics to human nature as such (rather than to organs. 2012 . the norms of health and disease tend to correspond—often in a disputatious way—with putative norms of happiness and well-being (see Margolis 1966). is reflexively palpable disease. reference to the medically relevant norms in terms of which alone diseases are construed as such. and the like must be an abstraction (entirely defensible as such) from the value-freighted investigations of the world of disease and illness common to pathologist and clinician.

Note the usual absence of discussion along these lines (see Engel 1953. What. 8 A particularly explicit specimen view is offered by Heinz Hartmann (1960).The Journal of Medicine and Philosophy due to residual deposits of iodine dye used in a previous gall bladder X-ray examination. several additional qualifications may be proposed.. Not only may the homeostatic mechanism itself be diseased—which obliges us to construe bodily functions in terms of higher-order norms. Here.g.7 Secondly. by reference to which alone the distribution of relatively localized functions is itself justified. what is normal must be construed not as a fixed point but as a range of variations. 68-69] Downloaded from http://jmp. Species variation contributes to species survival in a changing world and individual variability may accommodate different careers and different kinds of tolerance (see Ryle 1961. between individual organisms and their environment. below.. presupposed by the claims of somatic and psychiatric medicine insofar as they suppose themselves to be value-neutral sciences. for particular diseases. within the margins or normality and health. also. then. angina pectoris and coronary arteriosclerosis).8 The difficulty of defending An essential consideration is that the application of (formal) homeostatic concepts to organisms must accommodate. the notion of normal or healthy functioning cannot be straightforwardly assigned to the localized processes and structures of the body. First of all. But to concede this much is to construe medicine as instrumental to ulterior values. even if.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. But see the discussion of functions. van Bertalanffy 1950). tolerated in accord with some antecedent theory of the relationship between individual organisms and the populations of which they are members. with respect to the functioning of the healthy organism as such). the very "mechanism" of homeostasis presupposes "goal-directed activities" and "directively correlated processes"—which cannot be identified except in terms of some antecedently governing function (see Sommerhoff 1974. 2012 Considerations of these sorts oblige us to admit that the functional conception in terms of which disease is to be specified cannot be read off directly by a scanning of observable form/function correlations. Dobzhansky 1962). whatever it may be made out to be. Even the concept of homeostasis must be construed in a molar and functional way (i. [Pp.oxfordjournals. such correlations seem to present themselves (e. the aging and death of individual organisms and favored forms of the viability of populations within their environments. is the nature of disease? 3.e. The theme obviously underlies the comparatively recent debate on the 246 7 . Wiener 1953). in a way. a fortiori. FUNCTIONS The notion that human beings have a natural function is essential to the eudaimonism of Plato and Aristotle and it is.

and without unfavorable side effects. the human race adopts. for instance. with respect to which. and that society would begin to adjust its expectations and social arrangements to the increased longevity of its members. accessible. specimens of Homo sapiens are readily classified on the basis of resemblance to admitted specimens not otherwise distinguished in any way whatsoever regarding merit or excellence of any sort—hence. Imagine. neutrally to the competing eudaimonistic visions of Plato. The unlikelihood of the example is not important. On the contrary. and their progeny. Margolis 19756). again.Joseph Margolis functional norms is rather complex. then what is the sense in which the functional norms of medicine may be objectively specified independently of social values and social expectations? medical status of homosexuality (see "Should Homosexuality Be in the APA Nomenclature?" 1973. the most interesting general feature about disease is that it is a disorder or the cause of disorder of a certain sort within the functional range of ongoing life: that death may result from disease is a mere contingency but that disease may cause death or aging prematurely is not another contingency of the same sort. even for such an organ as the eye—which one supposes to have a definite and assignable function. the first is significantly less lethal than the second and "functions" to insure the survival of given populations—admittedly at the expense of selected individuals (see Dubos 1959). therefore.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. of disease. it is perfectly clear that absolutely no theory of disease construes death itself or aging as dysfunctional or the result. that it would be inexpensive. that an extraordinary discovery conflrms that a certain drug could increase our life expectancy in general. 247 Downloaded from http://jmp. Might not patterns of now-normal decline leading to eventual death "by natural causes" come to be viewed as disease syndromes. 2012 . For example. For one thing. at an "acceptable" level of activity. There are diseases that are lethal but there are no diseases that are classified as such merely because they result in death. Man is essentially mortal and the trajectory of life from birth to death sets the boundaries within which particular diseases are so designated. Or. among the black peoples of Africa. For another.oxfordjournals. fourfold. and adapts to. imagine that. What is the clear sense in which both are diseases on functional grounds? Finally. a life maintained at a submarine level unpenetrated by sunlight. Aristotle. severely dysfunctional processes subject to medical correction? If not. merely as such. imagine that sickle-cell anemia conveys immunity from malaria and that. because the lesson to be drawn is not that the eye has no function but only what is entailed in saying that it does have a function. diseases may be objectively discerned—it is quite possible to imagine a set of circumstances in which eyes would lose their "function" and yet not be diseased. why not? And if so. because of terrestrial pollution.

. the functions of living organisms are to be understood in terms of the goal-directed activities of those organisms. The difficult cases." But he obviously takes it for granted that the normal or normal functioning is a straightforward matter both professionally and philosophically. in this connection. This is not to say that all goal-directed activity is functional or has a function or that all behavior that has a function is goal directed (see the extremely interesting account by Wright [1973]). Cohen recommends that disease interpreted as "deviation from the normal . One crucial distinction cannot be avoided. such that no norms regarding the "appropriate. 2012 .g." "normal" life of given organisms (extending even to plants and not confined in any way to merely medical concerns) can fail to include reference to the molar behavior (informed. and machines). But the functions that are assignable to organs and processes within the bodily or life systems of particular kinds of organisms are dependently assigned in virtue of putative molar functions and are themselves (on what may be called the molecular level) never directly construed in behavioral terms. or with "natural" goals (as with living organisms)." "proper. by mental states) or to what is the molar analogue of behavior where sentience is minimal or nonexistent (as among lower animals. of course. the organs) of living organisms themselves. but the functions of their organs and processes are teleologically defined by reference to such activities though they cannot themselves be construed as goal directed or goal seeking (an anthropomorphism that is intelligible only in the context of the fable of the contract between the stomach and the other organs and limbs to cooperate for the sake of their various and independent interests).. wherever they are assigned. Whatever functions are assignable to organisms as such—human beings in particular—are behavioral. or with some more informal approximation to either of these models (see Sorabji 1964). . plants. functions are assigned in accord with some deliberate plan or design (as with human work and machines).The Journal of Medicine and Philosophy These questions set the essential puzzle.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. Where natural functions are assigned to those very organisms as integers of some sort—as. classically. should dominate our teaching and our approach to medicine. in the generous sense of the term. by way of the eudaimonism of the Greeks—they are defined behaviorally and in It is interesting. where relevant. and these are just the ones that concern medicine and are usually specified in terms of the subsystems (e. It is simply to say that.oxfordjournals. 248 9 Downloaded from http://jmp. are precisely those in which natural functions are assigned. to consider the extremely convenient resume of the development of the concept of disease offered by Sir Henry Cohen (1961). That is.9 but we are far from understanding the sense in which we speak of the functions of human beings or other animals and the functions of the various organs and processes within their bodily systems or the systems of their behavior and life.

10 The trouble is that animals. the full-blooded planning of human beings (though not exclusively). But to say this is. "The first part. in particular. in clarifying his formulation. see Margolis (1971. which does not require that we think of them as fixed or determinate or essential or discovered.Joseph Margolis terms of the "appropriate" goals or objectives of the creatures in question. favoring. (a). Beckner (1959). as in the natural law tradition or the doctrine of eudaimonism)—cannot be straightforwardly made on the basis of some empirical inspection of the essential nature of such creatures. This is not to lose the notion of natural function but only to question in an important way the sense in which natural functions may be said to be discovered by an exercise of medical science or any other relevant science. with regard to the longevity example already supplied or with regard to familiar controversies over sexual deviance and other psychiatrically sensitive categories. 161). He usefully analyzes the weakness of a number of accounts that are primarily concerned with the nature of the functions of the organs and processes of biological organisms. including Homo sapiens. Canfield (1964). 11 A standard argument that the mere classification of human beings (or of anything else) entails reference to grading and ranking notions appears in Hampshire (1959. consider first the general analysis of functions advocated by Larry Wright: "The function of X is Z means (a) X is there because it does Z. p. natural functions to human beings or human persons (characteristically though not necessarily ethically freighted. displays the etiological form of func10 The point is effectively made in Wright (1973). . 154. in particular. 223). 249 Downloaded from http://jmp. to provide for quarrels about the provision of medical norms—as. the sense in which both artifacts and natural creatures have functions (and. the parts of artifactual systems and the organs and processes of organisms) is said to entail that the functions assigned be essential to their respective natures. (b) Z is a consequence (or result) of AT's being there" (1973. may be classified without regard to norms of functional excellence of any sort. p. Still. chap. precisely. To see this. are. for instance. "etiological. not merely accidental or accidentally useful or the like. 5). explanatory". concern the causal background of the phenomenon under consideration. of course. As it turns out. [that is.] concern how the thing with the function got there" (pp. by elaboration. Nevertheless. 2012 . But it is untenable and unnecessary. 156).org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. Wright implicitly betrays its own limitations. Wright correctly notes that "functional ascriptions are . Beckner (1969). For he says.oxfordjournals. solely in terms of resemblance to standard specimens that are not themselves supposed to be functionally superior or to provide functional paradigms of any sort. .11 And this signifies that the ascription of "natural" functions to organisms—most controversially. there is an extremely simple and straightforward sense in which natural functions may be assigned to human beings.

which we know to combine readily with hemoglobin. just the reverse is true. describes the convolution which distinguishes functional etiologies from the rest. on purely evolutionary-etiological grounds" (pp. It is the second part of course which distinguishes the combining with hemoglobin from the producing of energy in the oxygen-respiration example. Obviously. he says explicitly: "When we explain the presence or 250 Downloaded from http://jmp. we could properly say that the reason CO was in our bloodstreams was that it combines readily with hemoglobin. further. Notice that such cases are quite different from cases (mentioned by Wright) in which "organismic mutations. 2012 .The Journal of Medicine and Philosophy tional ascription-explanations. 159-60). its producing energy is a result of its being there" (p. Nevertheless.oxfordjournals. (b). The oxygenrespiration case concerns the fact that. Its combining with hemoglobin is emphatically not a consequence of oxygen's being in our blood. "if carbon monoxide. on the hypothesis. however. One has only to imagine the evolution of diseased populations to see that creatures and organs and processes may well be said to function in a certain characteristic way. the atmosphere were suddenly (!) to become filled with CO. We could not properly say. the survival of the species depended on ingesting CO and on its combining with hemoglobin and thereupon producing energy—circumstances in which (on Wright's own hypothesis) the process noted obtained "suddenly." This shows the difficulty. and the second part. however. on some relevant theory. Wright also maintains that. although it is etiologically true that oxygen is found in human bloodstreams because it combines with hemoglobin. cases in which the homeostatic mechanisms of an organism are themselves diseased. On the other hand." though accidental. 161). namely. 161). PRUDENCE AND DISEASE When Wright attempts to explain the way in which functional explanations operate. may yet confer in time functionhood on an organ or process. But there is another fatal consideration. of maintaining the asymmetry of the concept of "consequence" (that " 'A is a consequence of IT is in virtually every context incompatible with 'Z? is a consequence of A' ") (p.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. that Wright's formulation fails to exclude cases of disease—in particular. simply because one could well imagine sustained circumstances under which. although. were suddenly to become able to produce energy by appropriate (non-lethal) reactions in our cells and. in spite of what Wright says. This won't do. And that is precisely what we could say about oxygen. we should not wish to say that the function of what is in question would then be given by the formulation cited (see pp. that CO was there because it produces energy. something more is needed. 4. it is "colossally fatuous" to say that it is the function of oxygen to combine with hemoglobin—where it is the function of oxygen to produce energy. 141-43).

13 Obviously.oxfordjournals. be argued.12 It is impossible. capable of self-reference and cultural contribution). 164). constraints regarding normative matters. But it may. in a way that ignores the culturally prepared goals of human societies. that is. in such circumstances—relatively stable in fact for ages—the function of sickle-cell anemia is to confer immunity to malaria? This seems as "colossally fatuous" as what Wright had marked out in the oxygen-respiration case. natural norms are not simply straightforwardly discovered. that. viewed in a sense that is relatively neutral to their condition as animals or persons. the overriding consideration is that Z must be or create conditions conducive to the survival or maintenance of A"' (1973. But this means that the ascription of "natural functions" to human persons cannot possibly be provided. It is the subject of my as yet unpublished book. But it may be said that human beings. gratification of desires. among African populations. in a way that is conducive to survival in malarial environments (see the suggestive summary in Brothwell [1971]). A fair way of proceeding is to confine ourselves to what may be called rational minima. for instance. as has been suggested. therefore. which is hereditary. An essential part of the difficulty of all theories of these sorts applied to human beings depends on the important distinction between the human animal (the biological species Homo sapiens) and human persons (members of Homo sapiens who have been culturally trained in the mastery of language and who are.Joseph Margolis existence of X by appeal to a consequence Z. The evidence is empirical This very complicated matter I can only hint at here. prolongation of life. including the norms of health and disease. as earlier remarked. 13 The full account of the thesis presented here appears in Margolis (1975a). to speak of psychiatric disease and disorder exclusively in terms of the condition of the human animal: the disorders normally considered are formulable only in terms of the mental processes of culturally emergent persons. p. for the norms of medicine) from what has so far been sketched. functions. that are least controversial or objectionable to agents endowed with a minimal measure of rationality more or less presupposed by every significant human society. restriction of pain. that sickle-cell anemia. subscribe to a characteristic set of (what may be called) prudential values—avoidance of death. Is it the case. Persons and Minds. 2012 . then. And if the functioning of the human animal (what may roughly but only very roughly be thought to provide the concern of somatic medicine) may be fairly said to be inseparable from the functioning and functional objectives of human persons and if.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. then we need to provide a rather different rationale for the ascription of functions (a fortiori. and the like. 251 12 Downloaded from http://jmp. insuring security of person and body and property and associates. there will be quarrels here as well. in the context of psychiatry. for instance.

in the arena of social exchange (civil law). the determinate ideology and ulterior goals of given societies. that is. however conservatively. Still. Any determinate recommendation regarding the management of prudential values for an entire society constitutes an ideology or part of an ideology—assuming that there are no discoverable natural norms of human existence.oxfordjournals. in that sense. the actual conception of diseases cannot but reflect the state of the technology. such that the shifting of ideologies leaves relatively intact—but only relatively—the detailed schedules of bodily disease and illness. This is no more than a sketch of the nature of medical norms. and merely determinable. medicine has expanded its purview to include the concerns of mental health and mental illness (see Margolis 1969.The Journal of Medicine and Philosophy and statistically overwhelming and the argument does not in the least assume the discovery of what is essential or normatively natural to human existence. Prudential interests. as in suicide and self-sacrifice. medicine—in terms of insuring the functional integrity of the body (or mind or person). the functional norms of somatic medicine are relatively conservative (unlike the norms of law). and the environmental condition of those populations. understandably enough. What we see is that it is entirely fair to insist on the natural functions of the various parts of our system. Since the human body (unlike social institutions) has changed relatively little over millenia. What has been changed (or challenged) is 252 Downloaded from http://jmp. without breaking the law or without being diseased or disordered) (see Margolis 1975a). or at any rate in the absence of any compelling discovery of that sort. The apparent obviousness of the natural functions of the organs and bodily processes can only be understood in terms of the conservativism of our prudential interests. the pursuit of prudential interests is prima facie rational—which of course is not to deny that. and since medicine in general must subserve. the set of prudential values that may be ascribed to human beings—and. putative. as by care and cure. Medicine and the law are the two principal professionalized disciplines of every complex society that have provided an institutionally determinate rule for managing a portion of our prudential interests: the law—in terms of restricting harm or the threat of harm to those interests. caused by another (criminal law). as in the use of rights and property. it is the conception rather than the details that is so elusive. adjusted for lower animals and. sufficient for the exercise of our prudential interests. then. adjusted for plants—is relatively open-ended.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. by extension. But since. the general (determinable) condition on which any ethical. Now then. or of protecting the exercise of those interests. also 1966). the social expectations. are merely enabling interests. political. economic program viable for a complex society must depend. there may well be grounds on which prudential interests may be waived without being irrational (hence. the division of labor. 2012 . by analogy.

"The Evolution of the Concept of Disease. "The Patient Rights Advocate: Redefining the Doctor-Patient Relationship in the Hospital Context. 1975. Mirage of Health." Unpublished manuscript.. "On the Distinction between Disease and Illness." Journal for the Theory of Social Behaviour. Theodosius.Joseph Margolis "only" the theory of such functions: they are now seen to subtend the putative prudential interests of the race. New York: Harper & Row. Mankind Evolving. "Health as a Theoretical Concept. which are themselves determinable values subserving in ideologically determinate ways the ulterior functional norms ascribed by different doctrines to the life of man (as in eudaimonism—even in the inverted form advanced by Freud—or the natural law doctrine or the like)." forthcoming. Joseph M.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. Micro-Evolution and Earlier Populations: An Important Bridge between Medical History and Human Biology. Christopher. 1959." Philosophy and Public Affairs 5 (1975): 49-68. edited by Brandon Lush. Canfield. 14 (1964). Washington. (b) Boorse." British Journal for the Philosophy of Science. in press.: American Psychiatric Association. 3d ed. 1971. Morton. In a sense. and Healey. Cohen. Conn.: Yale University Press. vol. Christopher. therefore.C. Don. medicine is ideology restricted by our sense of the minimal requirements of the functional integrity of the body and mind (health) enabling (prudentially) the characteristic activities and interests of the race to be pursued. Boorse. Jr. Annas. Dobzhansky. John." Journal of the History of Biology 2 (1969): 151-64. 1968. "What a Theory of Mental Health Should Be. Christopher. 253 Downloaded from http://jmp. Boorse. 2012 . in the relevant way. Diagnostic and Statistical Manual of Mental Disorders. the minimal integrity of body and mind relative to prudential functions. edited by Edwin Clarke. REFERENCES American Psychiatric Association. "Function and Teleology. The Biological Way of Thought. Cartwright.. Rene. "Disease. 1959.oxfordjournals. New York: Columbia University Press. Beckner. D. And disease is whatever is judged to disorder or to cause to disorder. 1962." In Modern Methods in the History of Medicine. Dubos. "The Descriptive Core of Mental Health Judgments. Morton. George J. London: Pergamon Press. New Haven. "Teleological Explanations in Biology. 1961. Christopher." In Concepts of Medicine. Beckner. Sir Henry. (a) Boorse. Samuel A." New Orleans Medical and Surgical Journal 7 (1851): 707-9. London: Athlone Press. Brothwell." Vanderbilt Law Review 27 (1974): 243-69. "Report on the Diseases and Physical Peculiarities of the Negro Race.

" Philosophy Forum 8 (1969): 55-76. Saunders Co. "The Concepts of Health and Disease.The Journal of Medicine and Philosophy Engel. Washington. 1967. New York: Viking Press. Nicholas. George L. "Illness and Medical Values. "Ideas and Trends. Springfield. 111. C." Journal of Criminal Law. 254 Downloaded from http://jmp. 1966.org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8. 1975. Marie. Hollingshead. Q>) Menninger Karl.: Charles C. London: Pergamon Press. Wright. Sade. Girth. 1968. Jr. The Crime of Punishment. New York: International Universities Press. Tristram Engelhardt. 1963.. Feinstein.." New England Journal of Medicine (1971). Gregory. Bernard. Redlich. C. Criminology and Police Science 45 (1954): 123-32. New York: John Wiley & Sons. The Right to Be Different. International Classification of Diseases Adapted for Use in the United States. Mayman. 1953. and Pruyser. Martin.. Heinz. Robert M. 1959. New York: Oxford University Press. 1960." In Concepts of Medicine. "Homeostasis. Columbus. Alvan. Social Class and Mental Illness. Negativities: The Limits of Life. (a) Margolis. 1961. H. J.. pp. Joseph. Merrill Publishing Co. 2012 . Crime or Disease? London: Macmillan Co. H. and Mills. Thomas. N. Tristram. 1693. New York: Prometheus Books. Spicker. 1968. Reidel. New York: Oxford University Press. Hampshire. Current Concepts of Positive Mental Health. 1974. Kittrie.C.. Joseph. 1. 1971. 1975. Stuart." New York Times. "The Concept of Normality. Philadelphia: W." American Journal of Psychotherapy 6 (1952): 551-69. "The Question of Homosexuality. Menninger Karl. New York: Random House. Joseph.: Government Printing Office. Ian.. Psychotherapy and Morality. edited by Roy R. edited by H. Thought and Action. Margolis. D. 1958. New York: Viking Press. Introduction to From Max Weber: Essays in Sociology. Paul. B. Margolis. "The Meaning of Normal. Fredrick. 1971. Baltimore: Johns Hopkins University Press. Ryle. Margolis. Baltimore: Williams & Wilkins. Fundamentals of Psychiatry. Engelhardt. Clinical Judgment. The Vital Balance. 1946. Inc. Anthony. Dordrecht: D. Values and Conduct. Joseph. Glueck. 8th revision." In Philosophy and Medicine. Margolis. Jahoda. edited by Robert Baker and Fred Elliston. "Changing Concepts in Forensic Psychiatry. edited by Brandon Lush. London: Chatto & Windus." In Sex: From the Philosophical Point of View. A. December 23." In Mid-Century Psychiatry. F. 1958. Joseph.oxfordjournals. "Medical Care as a Right: A Refutation. Public Health Service Publication no. 1288-92. Jr. Hartmann. and Redlich. B.. Ohio: Charles E. Flew. New York: Basic Books. 1973. 1973. and Stuart F. H. Behavioral Adjustment and the Concept of Health and Disease. Grinker. 1968. Psychoanalysis and Moral Values. Vol.

org/ at Fundação Coordenação de Aperfeiçoamento de Pessoal de NÃ-vel Superior on June 8.." Science 111 (1950): 23-29. 1958. 2012 255 . Disease. Rudolf. Sommerhoff." Philosophical Review 82 (1973): 139-68. 1970. London: John Wiley. Turk. and Man: Selected Essays by Rudolf Virchow. "The Theory of Open Systems in Physics and Biology. Szasz. 1958. The Myth of Mental Illness. van Bertalanffy. Thomas S. Gerd. Norbert." Philosophical Quarterly 14 (1964): 289-302. Weiner.Joseph Margolis "Should Homosexuality Be in the APA Nomenclature?" American Journal of Psychiatry 130 (1973): 1207-16. Rather. World Health Organization. The First Ten Years of the World Health Organization. Thomas S. 1969. Calif: Stanford University Press. Sorabji." Transactions and Studies of the College of Physicians of Philadelphia 20 (1953): 87-93. New York: Harper & Row. The Manufacture of Madness. Ludwig. Larry. Austin. Downloaded from http://jmp. Szasz. Richard.oxfordjournals. 1974. Chicago: Rand McNally & Co. New York: Harper-Hoeber. "Function. Stanford. Wright. Virchow. Logic of the Living Brain. Life. Criminality and Legal Order. 1961. "The Concept of Homeostasis in Medicine. Geneva: World Health Organization. Translated by Lelland J. "Functions.