2. A Naturalistic Theory of Health

Christopher Boorse's biological-statistical theory of health, formulated in the 1970s in some influential articles and defended extensively against the attacks of the normativists in the 1997 book: A Rebuttal on Health, will suit my purposes here, even though I will later bring Boorse closer to evolutionary arguments than perhaps he would go himself. According to Boorse, biological organisms are the entities that are healthy or non-healthy and they are so due to having or not having diseases. Non-diseased organisms are healthy organisms and diseased organisms are non-healthy organisms. Boorse, in his book, admits that what he calls ‘disease-plus concepts’ are important to clinical work, which obviously involves not only organisms but also persons.Footnote ¹¹ This, however, does not make Boorse change the fundamental structure of his health theory, which is indeed a naturalistic one, not only in referring to our bodily nature as essential to our health, (this claim many holists, and certainly phenomenologists, will affirm), but also in giving biology the sole role in determining if a body – a biological organism – is healthy or not. This, for Boorse, is the only way of saving medicine from the threat of normativism; only biology promises a health concept which is free of human interference.

Diseases are, according to Boorse, processes which influence the functionality of our body parts – organs, tissues, cells – making them perform in ways that are subnormal for the species in question. The normal figures of functions, in the bio-statistical theory, are determined by calculating the average of the functions from a large group of relevant individuals. Normal biological functions serve the aims of survival and reproduction of the organism, in Boorse's view. This does not mean that every disease will lead to death or incapacity to reproduce; it means that in determining what is to be counted as a disease one must take into account what is statistically normal in the case of the different functions of the body on a species level, allowing for differences of age and sex and maybe also race. When the organism is healthy it performs biologically in the way it was made to, the maker being not God, but evolutionary processes of variation and adaptation resulting in different species.

A tough question for the naturalist is what type of entities diseases really are. In a virus infection it seems crucial to separate the process of virus invasion from the biological states it will cause the body to take on. Increased temperature in a virus infection is not a pathological, but, indeed, a healthy response to the pathogen, attempting to fight the disease. In the case of diabetes (type II) it will be much harder to find a single disease process responsible for the statistically abnormal insulin non-sensitivity of the cells of the body. The disease, in this case, seems to be identical with the subnormal, functional state itself, which is clearly a kind of causal response to different things that have happened to the body (typically having to digest too much fat and sugar and having too little exercise), these things nevertheless not being diseases, but rather things that lead to diseases. Indeed, the whole question of what is a disease and what is the cause of disease today is made increasingly unclear by doctors labeling risk factors for diseases, such as obesity or high cholesterol, diseases in themselves.

The greatest challenge for the naturalist, however, will be a different one. Why are we to disregard, in the case of Homo sapiens, that the individuals who we find to be healthy or diseased are not only biological organisms but also persons, that is, conscious beings who think, feel and act in the world? If organisms are the entities we find to be diseased or not, persons, nevertheless, seem to be the entities we find healthy or not. Or, at least, so the holists claim when they urge us not to try to escape the normative nature of health, but rather give it a tenable form by developing a proper theory. To stay with biology only will either tell us too little about the nature of health, or even disguise the actual political norms at play in biology, covering up male, ethnic or social norms in a scientific dress, as the Science and Technology Studies scholar may argue.Footnote ¹²

3. A Holistic Theory of Health

Before we turn to phenomenology, I would like to present another type of holistic attempt to provide a theory of health, perhaps the most thoroughly developed and consistent theory developed up to this date, namely the action-theoretic approach to health developed by Lennart Nordenfelt. In On the Nature of Health, first published in 1987Footnote ¹³, Nordenfelt develops his theory as a criticism of Boorse's theory, stressing the fact that the welfare of persons does not only depend on their biology but also on the choices they make and how they realise these choices in a world of human projects and interactions. The healthy individual, according to Nordenfelt, has the ability to realise what Nordenfelt calls ‘vital goals given standard circumstances’.Footnote ¹⁴ This makes a clear distinction between happiness, which relies not only on what you are able to do, but on what you actually achieve in life, and health, which can be upheld in spite of harsh circumstances making important life goals hard to attain.

Nordenfelt does not include the having or not having of diseases in his definition. He readily admits that diseases will often play the role of weakening our abilities, through making us ill, but he sees no necessary, conceptual connection between disease and health. Many things other than diseases influence our health status, such as diet, a safe environment, and, if Nordenfelt is right, the goals that we set up as vital to our life (consciously or unconsciously).Footnote ¹⁵ Lower ambitions in life might be good for one's health in the same way as increased abilities to fulfill them will be.

There are many things one could ask about Nordenfelt's theory and in his later work he has, indeed, just as Boorse has, tried to reply to the different criticisms of his view. However, Nordenfelt's theory rests on some basic assumptions that need to be accepted if one should accept his theory. An important point concerns vital goals. Do we really have such goals? Do people plan their life in this way (consciously or unconsciously), and if they do not, does not the idea of a goal profile for each person hang loose? The same doubt can be felt regarding happiness. Does happiness, even minimal happiness, really have much to do with attaining one's goals? Is not happiness, and maybe also health, rather a form of feeling, just as illness seems to consist in a set of painful experiences rather than failing abilities to do things? This criticism brings us to phenomenology as an alternative way to formulate a health theory of persons proceeding from the experience had by them and not only their ability to act. Ability to act includes intentionality, of course. That actions have goals aimed at by the persons executing them is what defines them as actions in contrast to events linked by a causal chain only. However, the concept of intentionality employed by the phenomenologist has a much wider reach than these kind of intentions to do things only. The phenomenological concept of intentionality includes every meaningful experience that a human being might find oneself in not only by acting, but also by perceiving, thinking and feeling different things.

4. A Phenomenological Theory of Health

The experience of illness is a promising starting point for a phenomenology of health, and most of the attempts made up to this point, by philosophers such as Richard ZanerFootnote ¹⁶, Kay ToombsFootnote ¹⁷, Drew LederFootnote ¹⁸, Havi CarelFootnote ¹⁹ and myselfFootnote ²⁰, have relied on the contrast between the disease world of the doctor and the illness world of the patient. As we have seen, both Boorse and Nordenfelt disregard this experience-based approach to health theory by focusing upon biological function or ability to act only. While the contrast with Boorse should be clear, the difference to Nordenfelt's theory is perhaps harder to discern. Yet, in turning illness into disability Nordenfelt surely gives up the necessary connection between embodied experience and ill health (we can be unable to realise our vital goals without feeling or thinking anything in particular because or about this), just as Boorse disregards the felt symptoms of the patient as anything but diagnostic clues. A person can be healthy despite feeling ill and ill (nonhealthy) despite feeling fine in both theories. Nordenfelt even coins a certain category as a kind of side track to real illness, meaning for him disability to realise one's vital goals, a category which he names ‘subjective illness’: that the person feels ill irrespectively of being disabled or not.Footnote ²¹ I think Boorse could go along with this category, if not for exactly the same reasons as Nordenfelt's; ‘subjective illness’ would suit Boorse in separating the patient's experience from the real business of health.

But a phenomenology of illness cannot rest satisfied with forming a kind of psychological complement to medical (or action based) health theories. This would be just as insufficient as the view that there is only a strategic use for phenomenology in medicine, which I touched upon above. Phenomenology is not a version of a dualistic psychology, only describing the subjective experience of how the world appears to different individuals. Phenomenology is an ontological theory, proceeding from the claim that the first-person perspective is primary in answering questions of what things – like health and illness – really are.Footnote ²²

It is very important to any attempt to understand health that we are embodied creatures. The knowledge of bodily processes is surely central to the medical project, even if, as many of the holists will point out, this is surely not the whole story about medicine and health. Nevertheless, it is a fact that everybody has a body – a body which can be of great joy, but also of great suffering and pain. The fundamental point that the phenomenologist would emphasise here is that not only does everybody have a body, everybody is a body.Footnote ²³ What is the difference?

When we say that every experience is embodied, this means that the body is my point of view and way of experiencing and understanding the world. Not only can I experience my own body as an object of my experience – when I feel it or touch it or look at it in the mirror – but the body also harbours, on the subjective side of experience, the proprioceptive and kinaesthetic schemas which make a person's experiences possible in the first place.Footnote ²⁴ The body is my place in the world – the place where I am which moves with me – which is also the zero-point that makes space and the place of things that I encounter possible at all. The body, as a rule, does not show itself to us in our experiences and doings; it withdraws and so opens up a focus in which it is possible for things in the world to show up to us in different meaningful ways. The body performs its duties silently in the background, not only proprioceptively and kinaesthetically, but also as regards all the autonomic functions of our visceral life – breathing, our hearts beating, stomachs and bowels working, and so on.Footnote ²⁵ Sometimes, however, the body shows up in resisting and disturbing our efforts. It plagues us and demands our attention. A paradigm example is pain. If I have a headache it becomes hard to concentrate and think. Even before my attention is directed towards the headache itself, however, the whole world and all my projects in it become tinted by pain. When I read a book while having a headache, the letters become fuzzy, the text itself hurts in me trying to understand it. Illness, as the headache example (coming originally from Jean-Paul Sartre's Being and Nothingness Footnote ²⁶) displays a ‘mooded’ aspect tied to activities one is performing. Other examples of illness moods are nausea, unmotivated tiredness, or the way the body resists my attempts to do different things – like when I try to climb the stairs and my chest hurts unexpectedly. According to another influential phenomenologist, Martin Heidegger, writing in his main work Being and Time Footnote ²⁷, every experience we have is, as a matter of fact, attuned – ‘mooded’ – but this attunement of our activities, just like the embodied character of experience, stays in the background, not making itself known to us.Footnote ²⁸ In illness, however, the mood we are in comes forward, penetrating our entire experience, finally, when it becomes unbearable, bringing us back to our plagued embodiment. The lived body now resists our attempts to act and carry out projects instead of supporting them in the silent, enigmatic manner of healthy ‘being-in-the-world’ discussed by Hans-Georg Gadamer in his late work The Enigma of Health.Footnote ²⁹

The concept of being-in-the-world is introduced by Heidegger in his first major work, Being and Time, originally published in 1927Footnote ³⁰, and it was subsequently picked up by other phenomenologists, such as Gadamer, Sartre and Merleau-Ponty.Footnote ³¹ In analogy to the way I am a body rather than merely having a body, in the phenomenological understanding I am my world, rather than just being placed in it as a thing amongst things. I am immersed in the life world in a meaningful way, which connects its meaning patterns – and particularly the ones I rely on in my most vital life projects – to my identity. The world is not merely a physically extended geography in which I happen to have a place; being-in-the-world, in phenomenology, refers to the way human beings inhabit the world as a pattern of significance, a set of connecting relations between different ‘tools’, as Heidegger puts it.Footnote ³²

In the book The Hermeneutics of Medicine and the Phenomenology of Health I have tried to show in more depth and detail how healthy versus ill life can be explicated as homelike versus unhomelike being-in-the-world.Footnote ³³ This analysis is not something you find in Heidegger's philosophy; Heidegger's main interest was rather the question of human being, or perhaps, even more demandingly, Being – das Sein – itself. Homelikeness and unhomelikeness in my phenomenological analysis, inspired by, but not identical to, Heidegger's, refer to two opposed dimensions of the attuned being-in-the-world of human beings. To be ill means to be not at home in one's being-in-the-world, to find oneself in a pattern of disorientation, resistance, helplessness, and perhaps even despair, instead of in the homelike transparency of healthy life.Footnote ³⁴ Homelike being-in-the-world, however, does not mean that the person in question is necessarily happy. The phenomenology of homelikeness is supposed to capture the character of the normal, unapparent, things-as-usual ways of everyday life.

In order to illuminate this, let me give one example of a very common episode of illness: having a bad cold. We all know what it is like to be in this condition – dizzy, tired, shivering, listless, the throat is sore and the head is stuffed with cotton. When we try to do things we encounter severe resistance; it takes great effort to not simply stay in bed and sleep through the day. Illness is phenomenologically exactly such an obstruction to the transparency of health; everything that goes on without us paying explicit attention to it when we are healthy – acting, thinking, talking – now offers resistance. Our thoughts, actions, interactions with others, everything is now ‘out of tune’, ruled by feelings of pain, weakness and helplessness determining our whole unhomelike being-in-the-world of the cold. In such illness experiences the body reveals itself as having alien, unhomelike qualities that show up and resist our efforts and wishes.

Unhomelike being-in-the-world is a wider conception than illness, since external circumstances may render our being-in-the-world unhomelike in ways which we would not refer to as cases of illness in themselves, even though they could, of course, lead to illness. To be locked up in prison for years and be exposed to harsh conditions is such an example. To experience the suffering of war is another. An existential crisis suffered, for instance, after the loss of a loved one, a third. What I would like to stress here is that the unhomelike being-in-the-world of illness, in contrast to other forms of unhomelike being-in-the-world, is characterised by a fatal change in the meaning structures, not only of the world, but of the self (that is, the person). This unhomelike-making change in the openness of the self to the world is furthermore, in the case of illness, at least typically, a change in embodiment. The lived body forms the core of the self, and the ‘body-tools’ are most fundamental for our being-in.Footnote ³⁵ The self, however, is not identical with the lived body, but stretches out into dimensions of emotions, thoughts and language that go beyond bodily being in a narrow sense. In cases of mental illness, the deformation of the self, leading to difficulties in the person's being-in-the-world, is harder to track down to its embodied roots, even though promising attempts have been made by phenomenologists of psychiatry such as Thomas Fuchs.Footnote ³⁶

To sum up the foundations of my phenomenological theory of health: illness is an unhomelike being-in-the-world in which the embodied ways of being-in of the person have been thwarted. In illness the body shows up as an alien being (being me, yet not me) and this obstruction attunes the entire being-in-the-world of the ill person in an unhomelike way. Health, in contrast to this, consists in a homelike being-in-the-world. Homelikeness is supposed to catch the character of the normal, unapparent, transparency of everyday activities, not of feeling happy.

5. Connections and Differences between Naturalism and Phenomenology in Health Theory

Let us now compare the phenomenological and the naturalistic attempts for a theory of health, as promised in the title of this paper. The basic difference is, of course, that whereas the phenomenologist takes her starting point in illness as a first-person perspective of experience, the naturalist proceeds from a third-person perspective, focusing on the detection of various diseases. It is clear that the phenomenologist and the naturalist could disagree about whether a person is unhealthy or not, although in the majority of cases we will have illness as well as disease present. If this was not so, I think we would worry that the two health theories were really about different things altogether. The phenomenologist, however, could supplement his basic phenomenological ontology with a naturalist theory of diseases as a kind of specific, medical view on things developed on the basis of the lifeworld patterns of everyday practice. Maybe she could coin this secondary ontology ‘biological health’.

A parallel to this dual ontology is the debate about the necessity of ‘disease plus’ concepts in understanding different diagnoses. As we saw, even Boorse acknowledges that such supplements to the biological investigations are necessary for doctors to be able to do their job, and also, to understand what the entities we name by different diagnoses really are. But he, and most other naturalists, I think, will insist that at the bottom of all this cultural, extra filling of the cake there must be a functional abnormality of the body. If not so, we will not be dealing with a disease, and therefore not with an unhealthy individual, according to the naturalist. The phenomenologist will insist that no matter how important in the endeavour to understand and treat ill people scientific findings of dysfunctions of the body may come to be, these findings must ultimately be related to the suffering experienced by individual patients. Suffering is the reason biology matters to us in these cases, according to the phenomenologist. Processes of nature are important to our health since we are embodied creatures, but the materiality of the processes in question will primarily have to be approached through the experiences we have as embodied subjects, not by what the medical scientist finds in examining the body as a system of functions.

This, of course, is nothing but the classic contrast between the first-person perspective (maybe including the second-person perspective) of phenomenology and the third-person perspective (or, rather, the non-person perspective) of naturalism. What makes the contrast no less sharp, but more urgent to bridge in the case of health, is the central position of the body. Health and illness may include many questions beyond the reach of biology, but a theory of health cannot disregard embodiment as its central topic. The phenomenological health theorist acknowledges this by focusing upon embodied experience.

So far I have discussed only differences between the theories, what about connections? Paul Ricoeur talked about the necessity of facilitating phenomenological understanding by way of scientific explanation as well as enveloping such explanations in phenomenological patterns of understanding.Footnote ³⁷ His examples are taken from the humanities and the explanations in question are of a semiotic type, but I think the pattern of facilitation and envelopment could be used to understand what is going on in medical practice, as well.Footnote ³⁸ The phenomenological understanding of illness could be facilitated by way of medical examinations and tests, but these procedures ultimately receive their meaning and significance from the lifeworld context of the suffering patient. In addition to the possibility of linking the phenomenological and the naturalistic theory by giving the opponent theory (or perhaps rather opponent perspective) a kind of strategic, supplementary role within each theory, I would like to highlight some points that emerge in comparing my phenomenological theory to the naturalistic theory of Boorse.

It is central to the idea that illness is a certain form of unhomelike being-in-the-world that the body in such cases displays a kind of life of its own which I do not control and which plagues me. This phenomenological focus upon the body as an alien creature in illness relates to the medical objectification of the body performed by the naturalist. My own body as I find it in the X-ray picture, or in the lab test, is also a kind of alien, as many have pointed out.Footnote ³⁹ The two forms of bodily alienation are far from identical, but they both point towards the nature in me, or perhaps rather of me, that cannot be controlled. I am at the will of my own body, and although this will of the body is not a real will in the sense of being a meaningful address from someone, it certainly feels like this, since my body forces me to experience and do many things that I do not desire when I am an ill.Footnote ⁴⁰

A second similarity between phenomenological and naturalistic theories can be found by focusing upon the concept of homelikeness as characterising the relationship between the individual and the world that we find in health. To be at home in the world means to inhabit the meaning patterns of the lifeworld in a transparent way, which depends on bodily as well as mental characteristics of the person. The self is never a self, a person, separately from the world. She is what she is as a being-in-the-world. At the bottom of the naturalist theory we find a somewhat similar necessity to relate the normal functions of the organism to the environment its species has adapted to. To make oneself at home will surely mean very different things in the case of the being-in-the-world of the person and the development and survival of a species in a certain ecological niche. But in both cases it becomes necessary to include the relationship between an entity and its environment to understand what health is, and to do so in a way that stresses the adaptation of the person or organism to this environment. Even if the processes of evolutionary change are not purposeful, or, indeed, meaningful in any phenomenological sense, they produce on their blind way a series of homelike equilibria between organisms and the environments that they are fit to live in. The naturalistic health theory is anchored in these equilibria when it determines what are the normal functions of a body belonging to a certain species, such as Homo sapiens. Finally, evolutionary biology might display another similarity with the phenomenological attempts to understand health in so far as it stresses that the fitness to survive and reproduce will not only count in relation to one environment; the fitness will be even greater if it allows for stressful changes, the organism being able to make itself at home under changed circumstances, including fighting off diseases or adapting to a new environment. This is the key element of the concept of health found in CanguilhemFootnote ⁴¹, and it is also similar to what Friedrich Nietzsche called ‘the great health’, something he claimed to embody despite the many diseases he suffered from.Footnote ⁴²