Filosofía

CONCEPTS OF HEALTH AND DISEASE
Christopher Boorse

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SIGNIFICANCE

Basic to many clinical disciplines are the concepts of health and of its various defects — illness, disease, disorder, pathology, injury, disability, and so on. Philosophical analysis of these ideas can clarify many issues, both in the health professions and in their relations to society. Such internal or external issuesmay be either specific to a particular disorder or general, touching a class of them. As to specific internal issues, both ordinary medicine and psychiatry need a clear view of normality to decide whether some disputed diagnoses are disorders, or, for those that are, to fix their boundaries. Many such debates concern controversial treatments, such as giving children growth hormone for shortness[White, 1993; Tauer, 1995] or Ritalin for ADHD (cf. [Hawthorne, 2007]), or inducing pregnancy in postmenopausal women (cf. [Cutas, 2007]). Many people assume that if a child’s shortness is due to normal variation, not disease, then drug treatment is medically inappropriate. Similarly, if ADHD diagnosis is, as some say, often based on behavior normal for boys, its control by drugs is widely viewed asunethical. Moreover, even such well-established disorders as deafness are now sometimes denied to be such. Some disability advocates call deafness a normal variant on which a separate deaf culture is based, and so they oppose cochlear implants in children to cure it (cf. [Sparrow, 2005; Broesterhuizen, 2008; Shaw, 2008]). The most famous controversies over normality involve sexual psychopathology.The best-known recent example is the 1973 decision [Bayer, 1981] by the American Psychiatric Association (APA) to delete homosexuality from the third edition of its official Diagnostic and Statistical Manual of Mental Disorders (DSM). This decision, by vote of APA members, was influenced by explicit definitions of mental disorder (see section 5.5) offered by Robert Spitzer and his coworkers on the APAnomenclature committee. The change dramatically affected clinical practice, as well as society at large. Before it, some doctors used treatments as radical as electric shock to try to prod homosexual men into heterosexuality [Reznek, 1987, 8]. Now, professional organizations condemn even psychotherapy for homosexuals who wish to change [Cooper, 2005, 34]. In a transitional period, for such patients,DSM included the category ‘ego-dystonic homosexuality’, consisting not in homosexuality itself but in conflict over it. This category was later dropped — not, however, on the grounds that a patient’s or society’s attitudes to a condition should not determine its normality. Indeed, the rest of the classic perversion list
Handbook of the Philosophy of Science. Volume 16: Philosophy of Medicine.Volume editor: Fred Gifford. General editors: Dov M. Gabbay, Paul Thagard and John Woods. c 2010 Elsevier BV. All rights reserved.

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Christopher Boorse

remained in DSM, but only, as of DSM-IV [APA, 1994], for people whose sexual desires caused them problems. Critics claimed that, say, pedophilia is a perversion however a pedophile feels about it. The APA replied that moral judgments shouldnot be confused with psychiatric classification [Cooper, 2005, 28]. But can they be separated? In any event, DSM-IV-TR [APA, 2000] changed the rules: acting on one’s urges, with a child or other nonconsenting partner, now suffices for a diagnosis of pedophilia, voyeurism, exhibitionism, or frotteurism. An earlier parallel to contemporary sex debates was medical views about, and therapy for,masturbation. Much of mainstream 19th -century medicine viewed masturbation as not only a cause of many diseases, but also a disease in itself [Comfort, 1967; Engelhardt, 1974]. Some physicians took it to justify a long list of gruesome and painful treatments, including clitoridectomy for many women and castration for a few men. In the 20th century, the medical consensus reversed to count masturbation...