Conference on health and disease concepts. With the American philosopher of medicine Christopher Boorse

Program:

Friday, November 9:
 

• 9:45-10: Welcome
• 10-11:30: Christopher Boorse: Clinical Normality
• 11:30-12: Steeves Demazeux: Comments on clinical Normality
• 12-12:30: General discussion

Lunch

• 2-2:45: Mael Lemoine et Elodie Giroux : In what sense is Boorse's BST 'naturalistic'?
• 2:45-3:30: Denis Forest et Marion Le Bidan : Pathological mechanisms and biostatistical theory

Coffee break

• 3:45-4:30: Pierre-Olivier Méthot : The evolutionary roots of Christopher Boorse and Georges Canguilhem’s conception of health and disease
• 4:30-5:15 : Cristian Saborido, María González, Juan Carlos Hernández Clemente : Biological normativity beyond clinical normality
• 5:15-5:30: General discussion 

Saturday, November 10:
 

• 9:30-10:15 : Sarah Carvallo :
  Health’s norm and beauty’s canon versus arithmetical politics and empiricism in the seventeenth century’s medicine
  Norme de santé et Canon de beauté chez les médecins du dix-septième siècle
• 10:15-11: Arantza Etxeberria: Being healthy, yet imperfect. An examination of Boorse's views and a proposal

Coffee break

• 11:15-12 : Jean Gayon : Enhancement
• 12-12:30 : Closing discussion

Organisation : Elodie Giroux et l'Institut de Recherches Philosophiques de Lyon (IRPhiL)
Entrée libre

Abstracts

In what sense is Boorse's BST 'naturalistic'?

(Mael Lemoine et Elodie Giroux)

Boorse’s biostatistical theory of health and disease (BST) is so representative of a naturalistic definition of these concepts that ‘naturalism’ in the philosophy of medicine was defined in the very terms of his own theory, and has often been since. On the other hand, ‘naturalism’ is a broad philPsophical project and a very ambiguous term. At least a distinction is usually proposed between two main kinds of naturalism in philosophy that can be associated, but not necessarily: the view that all phenomena are natural, and/or the view that the methods of the natural sciences are applicable in every area of inquiry. What kind of naturalism exactly is Boorse’s BST?

This talk is an attempt to clarify in what sense Boorse defends a naturalistic definition. We identify different theses that can be termed naturalistic claims on health and disease and help analyze the core claims of Boorse’s naturalism. It appears that some of them have mainly to do with the central role physiology is bound to play in medicine. On the other hand, as no physiologist has hitherto proposed a satisfactory scientific definition of ‘disease’ and ‘health’, Boorse’s naturalism must at the same time i) propose one and ii) prove it is central to medicine. Our claim is that even if Boorse’s definition possibly succeeds in (i), it merely assumes (ii). Then, we shall examine the possibility that other naturalistic definitions of (or elements for defining) health and disease be extracted from other medical sciences.

The evolutionary roots of Christopher Boorse and Georges Canguilhem’s conception of health and disease

(Pierre-Olivier Méthot)

By way of a comparative analysis, this paper explores whether Christopher Boorse and Georges Canguilhem’s distinct views on evolutionary theory could explain some significant differences regarding their general conception of health, disease, and normality.

As is well known, Boorse’s point of departure is the axiom that health is the absence of disease. Although with time his naturalist account of health and disease, known as the biostatistical theory, has broadened to include references to the wider environment, Boorse’s definition of health is, by and large, conformity to the species design, a concept, I argue, that rests on a rather static view of evolution. In contrast, The Normal and the Pathological (1943) provides a more dynamic perspective of health and normality which includes, by definition, the very possibility for (healthy) individuals to fall ill and to recover. With the ecological concept of environment (or milieu), Canguilhem’s theory of health understood as the ability to adapt to changing environments likens medicine with evolutionary biology.

In Health as a Theoretical Concept (1977), however, Boorse had offered a powerful criticism of the view that health is relative to environment that threatens to undermine Canguilhem’s position: being well-adapted to environment E does not necessarily imply that E is a desirable environment for humans, plants, or animals to live in. I suggest that the crux of the matter in deciding whether health is environment-dependent rests partly on which notion of “adaptation” one adopts and how one uses it to define what the “normal” means. According to Boorse, the normal is the natural and the natural reflects what was adaptively selected by the process of selection in our ancestor’s distant past. The concept of species design intends to capture how selection has shaped the standard physiological functioning of organisms the deviation from which (with respect to age, sex, and species) implies a diseased state. For Canguilhem, however, the normal is a precarious state, constantly in flux and renegotiated between individual organisms and changing environments to which they strive to adapt and that they modify accordingly. Normality comes from what Canguilhem calls “biological normativity”, namely the capacity to transcend the habitual (statistical) norm and to create new norms of life in new situations.

Highlighting and discussing a number of strengths and problems associated with both accounts, this paper illustrates how our understanding of health and disease as biological phenomena often reflects, implicitly or explicitly, a particular view of what evolution means.  

Biological normativity beyond clinical normality

(Cristian Saborido, María González, Juan Carlos Hernández Clemente )

In this paper we develop a systemic-organizational account of the notion of biological normativity and present the implications of this theoretical model for the medical practice. Sharing with authors as Canguilhem the rejection of the bio-statistical notion of clinical normalcy, we try to ground the theoretical notion of biological normativity considering it as an inherent feature of biological systems. In the first part of this paper, we present a critical survey of the understanding of this specific normative dimension from the main approaches in the contemporary philosophical debate on natural norms. In the second part, we develop a different account, based on the adaptive mechanisms of organisms, that avoids the limitations of the other stances and allows us to explain the ways and the reasons a biological trait is malfunctional in terms of current organization. In our account, the organizational closure -i.e. the web of mutual constraining actions of the material structures on their boundary conditions that collectively self-maintain the whole organization of the system provides a naturalized grounding of the concept of normative functions from a systemic framework and constitutes the causal regime in which biological functions (or malfunctions) appear and can be identified. In the third part, we consider some significant medical examples showing how our approach is able to avoid the counterexamples and limitations of the bio-statistical approaches. We claim that our approach provides the theoretical resources for a naturalization of the notion of biological normativity with relevant implications for a different naturalist conception of notions of health and disease.

Norme de santé et Canon de beauté chez les médecins du dix-septième siècle. William Harvey, Jean Riolan et Claude Perrault

(Sarah Carvallo)

La médecine moderne nourrit le projet d’une anthropographie, qui accomplirait enfin l’injonction du temple de Delphes en alliant à la connaissance de l’âme celle du corps promue par l’anatomie. Or cette philosophie naturelle du corps requiert d’établir une norme de la santé. Si la différence et la variété règnent dans les corps disséqués ou soignés, ils se réfèrent tous néanmoins à un seul et même corps naturel et parfait, dont ils ne seraient que des variations. A travers la dissection de multiples corps variables, l’anatomie part ainsi en quête du corps naturel parfait, qui ne représente pas le plus petit dénominateur commun, mais l’achèvement idéal de l’essence du corps humain. Son projet s’avère en cela symétrique de la question esthétique qui interroge la beauté corporelle, en peinture, en sculpture ou en architecture. Le beau corps ou le corps sain ne constituent en effet que deux dénominations du même corps parfait naturel.

En reprenant l’héritage antique de Vitruve et Galien, Harvey, Riolan fils ou Perrault opèrent une synthèse entre la référence esthétique, la doctrine médicale et la connaissance de soi. En particulier, ils établissent un parallélisme entre la norme de la santé et le canon de la beauté, qui déterminent la connaissance vraie de l’homme.

Pourtant à la fin du dix-septième siècle, se dessine une autre voie pour connaître le corps naturel. Cette nouvelle approche conteste l’équivalence entre nature et perfection, et part du principe qu’il n’y a pas d’autre réalité à connaître que les corps concrets. L’arithmétique politique met alors en place les conditions épistémologiques d’une approche alternative de la santé en termes statistiques. 

Health’s norm and beauty’s canon versus arithmetical politics and empiricism in the seventeenth century’s medicine

(Sarah Carvallo)

In line with galenism and aristotelism, the modern physicians (for example, Riolan, Harvey or Perrault) identify nature, health and perfection. Accordingly medicine presents itself as the knowledge of the perfect body. Even though difference and variety are predominant through anatomized corpses, they all refer to the one and only original, natural and perfect body, which they realized through their own pecularities. By dissecting numerous corpses, anatomy looks for the natural perfect body, which does not represent a statistical norm, but achieves the human body’s essence conceived as health. In so far the medical project turns out to be symetrical with aesthetics, which aims at presenting the human beauty. The healthy body and the beautiful body portray two figures of the one and only perfect natural body. In line with fine arts, medicine must therefore establish the human body’s norm or canon.

Yet at the end of the seventeenth century appears a new method for medicine. It questions the equivalence between nature, health and perfection. It supposes that there is no other reality as the empirical bodies, which are all distinct and sometimes ill. Accordingly physicians as Petty, Sydenham or Locke deal no more with health, but with diseases induced by environmental factors. Therefore their task consists in describing symptoms, their evolution and proposing a prognosis. Taking into account the medical empiricism’s lessons, the political arithmetics (Graunt or Leibniz, for example) establishes new epistemological conditions for determining health and disease in statistical terms.

Being healthy, yet imperfect. An examination of Boorse's views and a proposal

(Arantza Etxeberria)

Boorse's account of health and disease aims to provide a "substantive analysis" of these concepts. It is based on a notion of normality according to which for a condition to be considered as disease it has to be statistically rare. The statistical clustering of the normal cases is based on an evolutionary account of biological function derived from understanding fitness as dispositions, and not selected effects. Thus "diseases are internal states that depress a functional ability below species-typical levels" (Boorse 1977).

Boorse's work has triggered an enormous literature of comments and debates. From the biological sciences perspective the approach has been charged, among other things, of being typologist, that is to say, of grounding medical judgement in an essentialist view of biological entities. On the other hand, his view of normality, for which both disease and "positive health" are rare, is at grips with the optimality account of the definition of the WHO. Thus, according to Boorse's evolutionary account, a state could be considered to be healthy but yet "imperfect".

This presentation will first examine the two mentioned aspects of Boorse's work. One is how to conceive the objectivity and the normativity that stems from medical knowledge in relation to biological accounts of health. Here different approaches to naturalism and normativity in medicine will be taken into account, and a pluralist framework will be defended. The other is how to reconcile normality with a view that does not conceive health as perfection; that is to say, how to biologically conceive health taking into account that a healthy state may need to obtain goods from others, including medical aid. Boorse offers a statistical answer to this, but a different one based on the radical interactivity of biological organization will be explored at this point. Examples will proposed for the two topics.

Subsequently, a proposal is offered to elaborate a notion of health which does not only take into account the constitutive aspects of biological organization, but includes interactive ones. This notion is built taking into account the radical interactivity of biological organization, as it is being called attention to from many different approaches in biology today (with special attention to those in evo-devo). Thus a sketch of a notion of health based on interactivity will be proposed, connected with an argument maintaining that health can be understood as a biologically incomplete or needful state, open to satisfy its needs by means of interaction.