In Health Problems, Elizabeth Barnes presents a case for why theorizing about health is difficult, and there cannot be one single concept, theory, or measure of health. Talking primarily about health, and about health problems, is notable because much of the philosophical literature is framed around disease. This suggests a positive conception of health, as more than the absence of disease.

Barnes’s starting point is that health is valuable and changes in health are significant in four different ways: biologically insofar as health changes alter functioning; normatively because loss of health brings distinctive harms; politically because health is a public good; and phenomenologically insofar as health and loss of health are accompanied by distinctive ways of being in the world. Every good account of health must explain why health matters in these four ways. She concludes that “[t]here is no coherent, unified account of health…that can adequately explain all the ways in which health matters to us.… And there is no one thing in the world…that we’re tracking when we talk about health” (6). I think it is helpful to disentangle this into four main distinct claims:

1. 1. A semantic thesis: There are different health concepts in use;

2. 2. an epistemological thesis: There cannot be just one theory of health;

3. 3. a metaphysical thesis: There are different entities corresponding to the (possible) referents of “health”; and

4. 4. a normative thesis: We care about different health entities.

The basic argumentative structure assumes the normative thesis and uses it to justify multiple concepts, theories, and referents. The normative starting point, however, is stipulated rather than argued for. It is not clear that biological functioning (objective functional status, contributing to homeostasis and longevity) and phenomenology (what it feels like to be healthy or ill) are distinct sources of value; they both seem to be descriptive affairs. Only two of Barnes’s four sources of value survive as genuinely normative: the individual value that a subject S’s health has for S, and the collective value that S’s health has for her community (though perhaps the latter might be reduced to the former).Footnote ¹ Barnes’s basic point that health matters in many ways may be correct (there may be more fine-grained sources of value) but her stipulation of why this is so requires more argument.

Chapter 1 surveys the major theories of health, organized across three dimensions: positive versus negative, evaluative versus nonevaluative, and objective versus subjective. Each account apparently fails because it cannot accommodate one or more of the four stipulated values. Naturalistic function-based accounts are criticized not only for their familiar extensional inadequacy—miscounting some pathologies as healthy and some healthy variation as disease—but also for neglecting health’s normative, political, and phenomenological significance. Normativist, phenomenological, and social constructionist accounts miss the objective, biomedical dimension. Well-being–based accounts overmoralize health (healthism: treating “being healthy as a morally valuable end in itself”; 73), and hybrid approaches inherit problems from both naturalist and normativist camps. The overall point is that each theory may capture one health referent we care about, but none is fully adequate.

The following three chapters specify health’s relation to well-being, capability, and disability. Let us start with the “complex, non-linear ways in which health and wellbeing” (67) are related (chapter 2). Barnes argues against constitution views, which collapse the distinction between health and well-being, as inadequate (health and well-being can come apart) and committing healthism. She thereby seems to reject evaluative views of health, which explain what health is partly in normative terms. Yet this sits awkwardly with her continued insistence that health carries a distinctive normative significance.

Against contributions views—on which health is valuable only insofar as it contributes to well-being—she presents cases in which well-being and health come apart: resilient patients who adapt to chronic illness and maintain high well-being;Footnote ² and socially stigmatized conditions such as acne, which reduce well-being despite only little health loss. Tying the value of health to well-being would falsely imply that health is less valuable the more resilient one is. But these arguments compare absolute, interpersonal levels of well-being, rather than the relative difference an illness makes to a person’s well-being. It is compatible to say that the value of health is its contribution to well-being, while a resilient patient can have high absolute well-being yet low health, or an acne patient low absolute well-being yet good health. Barnes’s analysis of the acne case raises a further problem: It conflates what health is with why we value it; acne and some lung condition may induce similar drops in well-being; but this does not make them equally severe health reductions. To hold that it does would commit Barnes to a purely normativist theory of health, neglecting the biomedical dimension she emphasizes.

Chapter 3 makes analogous arguments for the relationship between health and capability. While health can reduce capability, there are highly functioning individuals with severe health conditions. Similar to the well-being cases, these puzzles dissolve once we distinguish absolute, interpersonal levels of capability from relative, intrapersonal capability. Barnes also argues that health is constituted by both objective biological functioning and subjective experience of the bodily state, which can in turn alter the objective state. How much pain caused by an objective dysfunction impairs capability is mediated by the subjective experience of pain. I am not sure this is distinctive to health: Inflation is an objective feature of an economy yet affected by attitudes such as fear. It seems right that both objective and subjective measures of health are needed.

Chapter 4 examines health and disability. Barnes diagnoses an ambiguity in reports of people with disabilities: They affirm to flourish with their condition and not to be better off without it; yet they wish to minimize it and advocate for prevention funding. Analogously to David Lewis’s contextualist analysis of the statue/clay problem, Barnes proposes the same bodily state should (a) qua disability, be embraced and destigmatized; (b) qua biomedical pathology, be treated and prevented. There is no perspective-free answer to what we should do about disabilities, or whether they are harmful. Narrowing down the context yields a definite answer—within that perspective. Conflicts concern which perspective is more helpful. Barnes situates her view between the spectrum view—that disability is simply severe ill health (as it cannot account for the healthily disabled, e.g. a lower-limb amputee marathon runner; 134)—and a purely social model.

Chapters 5 and 6 present Barnes’s own view, which she calls ameliorative skepticism: We are tracking a range of real and interdependent things when we talk about health, and general questions about who is healthy or healthier lack a determinate answer (the skeptical bit); yet health is real and worth theorizing about and we should accept the messiness (the ameliorative part). The target of any theory of health, following Philippa Foot, is the “wellbeing of the organism”—broader than basic biological functioning, yet narrower than well-being of the person. This is “fundamentally unstable” (199) ground: “[N]othing can play all the roles that we ask health to play” (203). Ameliorative skepticism is situated between error theory, eliminativism, and fictionalism on one side and versions of realistic pluralism on the other. Against the former, health is real; it has many rather than no referent(s). Against the latter, separating health’s distinct roles cannot explain their interrelatedness; even in specific contexts we cannot single out a verdict as “we’re still pulled in multiple, conflicting directions” (215). Barnes claims that “the pluralist account misses…the thorough-going confusion we encounter in trying to understand health” (215). I am not convinced. Force, mass, and acceleration in F = ma are interrelated yet usefully separated analytically. The mess Barnes diagnoses could plausibly be resolved the pluralist route, distinguishing H₁, H₂, and so on. In fact, Barnes concedes that “the best way forward is to be pluralistic about our approaches to measuring and assessing health” (246), while denying that this amounts to endorsing “pluralism about health, or about health measures” (ibid.). Her objection is therefore not methodological but ontological; she takes her view to be “significantly stronger—and more metaphysically robust—than pluralism” (216). It is not clear to me what the stronger commitment amounts to, or why it is preferable to pluralism. Her further argument against pluralism is that we cannot “shrug and say ‘pragmatism’ and assume values will tell us which ranking to employ in which context—since our values, aims, and goals are themselves caught up in this confusion” (246). Yet such an aim-relative contextualism is widely endorsed by scientific pluralists, who treat the selection of aims as a substantial normative question, rather than as a further symptom of a conceptual mess. Barnes owes us a reason why health should be different.

On the semantic side, Barnes borrows Delia Graff Fara’s work on interest-relative shifting standards—not to argue for health’s semantic vagueness, a fact she calls “probably not very interesting” (233), but to show that a vague concept such as health is useful given that the corresponding reality is unsettled, and our aims when talking about health and the corresponding standards are often usefully imprecise and adaptable. Questions whether someone is healthy or who is healthier lack definitive answers tout court. Yet for precise-enough aims and narrow-enough contexts answers are possible (which she rejects earlier). It is left unclear whose context is operative and whether it is subjectively or objectively determined.Footnote ³

The label ameliorative skepticism is doubly problematic. (1) The skeptical component moves quickly from vagueness, a semantic and/or metaphysical issue, to skepticism, an epistemic attitude of judgment suspension. While “health” is vague and has in general no determinate referent, it is not clear why this should warrant suspension of judgment—Barnes’s arguments show that there is no answer to general health questions, not that we cannot know it with enough confidence. (2) An ameliorative approach, following Sally Haslanger, would reduce “what is health?” to “what should health be?”—a potentially pluralistic conceptual engineering project. Barnes’s account instead claims to be “therapeutic” (263) on a meta-level by calling out the “mess,” where it seems some more tidying up would be possible. Her account of “health” as vague and the ensuing contextualism make good progress on the semantic level. For the epistemic, metaphysical, and normative dimensions, more work needs to be done. Crucially, keeping the normative, semantic, epistemic, and metaphysical dimensions analytically separate is itself part of the clean-up work. Barnes’s conclusion that “health has special significance because all of the things we’re tracking when we talk about health have special significance” (247) shifts across these dimensions, generating some of the very confusion she diagnoses.

Health Problems is a rich source of interesting puzzles and examples, and provides an excellent overview of debates on health, well-being, and disability. On these grounds, I recommend the book. Barnes’s proposal of ameliorative skepticism and its delineation from rival views seem unsuccessful. Health may be a mess, but more of it could have been cleared up.