PhD, Associate Professor E.L. Panova1
1I.M. Sechenov First Moscow State Medical University of Ministry of Health of Russia, Moscow
Keywords: health, disease, health service philosophy, method, human.
Background. Health as subject for research and management cannot be attributed to a specific theoretical or practical field for the reason that every discipline – medicine, physical education, sports, psychology, education science etc. – considers health within its specific domain and aspects. However, specific theoretical health models may be efficient enough when designed based on the fundamental theoretical grounds for its interpretation. It is very traditional for the modern medical philosophy to interpret health as some standard defined always with reference to a few notions including disease, pathology etc. – due to the specific practical objectives of the health service (much the same as those of modern physical education) that is driven by its specific logics that require a variety of favourable/ unfavourable, normal/ pathological, healthy/ unhealthy conditions and statuses being identified and differentiated in the attempts to control and manage an individual health condition.
The obvious deficiency of the modern national research process geared to find the theoretical and practical approaches to health service looks particularly disappointing as opposed to the determined, active and multisided studies of health and disease, normality and pathology in the Western science. This was the reason for us to apply mostly foreign study reports (dominated by publications in English) with concern to the modern health service philosophy. We have also analyzed the Soviet health theory and philosophy which addressed the notions of health and disease in different scientific domains (biology, cybernetics, philosophy etc.) from the viewpoints of different specialists including philosophers [7, 5], health theoreticians [9, 2, 3] and practitioners .
Objective of the study was to analyze the basic interpretations of health in nominalism and realism that are the key trends in the modern national and foreign health service philosophy.
Study results and discussion. Our analysis of the theoretical and practical trends in the ongoing studies of health in the global and national health service philosophy was largely based on the S. Holm’s classification driven by two conceptions of health and disease, namely the nominalistic/ normative and realistic/ functional ones [13, p. 79]. These two conceptions are different in the interpretations of health and disease by the researchers. The nominalistic conception that has been largely established by H. Tristam Engelhardt , Kenneth M. Boyd  and R.S. Downie  implies that the attempts to qualify one or another bodily status as pathologic or normal are never free of individual assessment aspect; and it is unlikely possible to find an accurate and objective way to distinguish health and disease for the reason that the assessment criteria applied to identify health and disease are never objective enough. References to biology as presumably the only science capable to clearly qualify health and disease are unlikely grounded enough since the notion of normality in modern biology is very wide in fact and refers to an extensive range of bodily conditions with the only exclusion for the terminal or pre-mortal ones. In terms of the modern theory of evolution, for instance, every living being may be qualified healthy as long as it lives. Modern biology applies a variety of the relevant notions including life, death, adaptation etc., with the notions of health and disease being applicable only in a few practical health service fields including sport medicine, adaptive physical education, psychology, educational science etc.; with each of the sciences holding to its own qualification criteria and definitions of health and disease.
K. Boyd in his analyses of the notions with concern to health and disease explores a variety of meanings and definitions offered in the modern English terminology to demonstrate how provisional they are [10, p. 10, 11]. The notion of disease, for instance, implies a pathological process on the whole and its expressed manifestations in particular including infections, oncology etc. associated with clearly visible deviations in the vital functions. The notion of illness is commonly interpreted as a physiological disorder detectable and reportable only by the suffering individual on his/her own. The Russian language offers its own equivalents for this notion that may be translated as ailment and indisposition. It is not unusual that the individual perception of illness and the pathological process it is triggered by are both obvious, but in many other cases the origin(s) of ailment cannot be easily attributed to some expressed pathology, particularly at the early stages of cancer, tuberculosis or diabetes. The notion of sickness largely implies the social measure of a disease as it refers to the individual social role/ status i.e. requires the individual status of a sick person being recognized by the society that offers its support and health service to the individual. This status depends on many factors other than the diagnosed pathology. It should be mentioned that the subjectively perceived illness may not be sufficient for the public recognition of the individual as a sick person in need of help. Moreover, even a diagnosed health disorder/ disease may not necessarily guarantee that the society fully recognizes the health disorder – since the people diagnosed with chronic diseases often look more healthy than those suffering from acute pathologies; while the social recognition of a variety of mental disorders is more often than not irrelevant to the health statuses and largely wayward and unpredictable.
The definition of health provided by the World Health Organization back in 1948 based on largely the same logics reads: “Health means the state of full physical, mental and social wellbeing that is not limited to the freedom from diseases or physical deficiencies”. R.S. Downie , an authoritative British philosopher, notes that despite the fact that this definition may be interpreted as too ambitious it is still relevant enough being reasonably metaphorical and provisional. The popular definition of health commonly accepted in the academic and medical communities till lately considered health as the disease-free status that may not be fully free from expressed physiological and/or anatomic disorders. It should be noted, however, that this definition fails to cover many marginal conditions on the way from health to disease including, for example, senile infirmity, post-traumatic ailments etc.
The nominalistic trend in the national science is represented by I.V. Davydovsky, a prominent Soviet pathologist, author of the “General human pathology” monograph, where he underlined the incompleteness and arbitrariness of many commonly applied terms including disease, pathology, pathological, sick cell, sick organ, sick body etc. – for the reason that they “provide an individual assessment of the subject rather than an objective idea of its physiological essence” [7, p. 17]. Health and disease shall be interpreted, as provided by Davydovsky, as the necessary and not always distinguishable components of a single biological normative response, with the specific expressed manifestations of pathological processes often falling within the normal adaptation process versions unique for every individual. A disease, in the Davydovsky’s opinion, is always individual since the evolutionary genetically programmed mechanisms of the pathological process are always unique being determined by the specific individual bodily traits. Within this interpretation, a disease may be viewed as beneficial in some aspects when, for instance, it is the “growth process sickness” natural for and inevitable in the individual transition to a new health status.
Within the more traditional realistic/ functional version of health and disease interpretations, both of the notions refer strictly to the opposite conditions of the human body and mind. Health is referred to as the combination of positive/ normal bodily functionality rates associated with the relevant mental and social behavioral standards; and a disease is viewed as the deviation from these norms and standards, with the notion always having a clear negative flavor. Christopher Boorse  may be mentioned as the most authoritative representative of the realistic trend in the Western research tradition. He defined health as the condition most facilitating for the integrated bodily systems to effectively attain their main objective that is to survive; with a disease interpreted as the functionality disorder making it impossible to attain the above or another life purpose.
The realistic interpretation of health and disease was dominant in the Soviet health service philosophy, with D.S. Sarkisov, М.А. Paltsev, N.K. Khitrov, A.D. Ado and V.P. Petlenko being the most authoritative proponents of the latter. It was very traditional for this school to consider a disease as “an essentially new bodily condition qualitatively different from the healthy one” [9, p. 479] associated with a “structural or functional disorder/ damage in one or another bodily organ, tissue or cell, with the relevant location (locus morbi) of the disease viewed as the key factor to distinguish a sick individual from a healthy one” [9, p. 479]. The negatively flavored interpretation of disease as “damage” is intended to emphasize the fact that the structural/ functional changes in the bodily systems are detrimental to the natural living process. The notion of health in this context is unexpectedly burdened with the socially sensitive aspects, with the “norm and health implying such living standards that make it possible for the individual to fully contribute to every domain of every social and labour process” [1, p. 202], with such healthy standards viewed as totally opposite to the above considered notions of sickness and social sickness.
Conclusion. Our analysis of the present theoretical and practical conceptions of health and disease in the modern health service philosophy shows the contradictions and differences in the most common interpretations of these notions however clear they may seem for the common (and even research) vision; and demonstrates that the modern meaning of health cannot be defined based on some isolated arrays of natural scientific or medical evidence and shall be addressed as a serious and challenging subject for studies and analyses using the versatile toolkits of modern humanities.
- Ado A.D. Voprosy obschey nozologii. (Istoriko-metodologicheskie etyudy) [Questions of general nosology. (Historical and methodological studies)]. Moscow: Meditsina publ., 1985, 239 p.
- Davydovsky I.V. Obschaya patologiya cheloveka [General human pathology]. Moscow: Meditsina publ., 1969, 612 p.
- Davydovsky I.V. Problema prichinnosti v meditsine (etiologiya) [Problem of causality in medicine (etiology)]. Moscow: State publ. med. lit., 1962, 130 p.
- Zhirnov V.D. Meditsina – pervaya nauka o cheloveke: Predposylki nauchno-gumanisticheskoy revolyutsii v meditsine [Medicine - the first human science: Preconditions of scientific and humanistic revolution in medicine]. Moscow: URSS publ., 2016, 256 p.
- Zhirnov V.D. Problema predmeta meditsiny [Problem of subject of medicine]. Moscow: Meditsina publ., 1978, 239 p.
- Panova E.L. Teoretiko-poznavatelnye tendentsii evolyutsii ponyatiy zdorovya i bolezni v sisteme znaniya o cheloveke. Dis. kand. filos. nauk [Theoretical and cognitive tendencies in evolution of health and disease concepts in human knowledge system. PhD. diss. abstract]. Moscow, 2013, 128 p.
- Petlenko V.P., Serzhantov V.F. Problema cheloveka v teorii meditsiny [Human problem in theory of medicine]. Kiev: Zdorovye publ., 1984, 200 p.
- Rybin V.A. Evtanaziya. Meditsina. Kultura: Filosofskie osnovaniya sovremennogo sotsiokulturnogo krizisa v mediko-antropologicheskom aspekte [Euthanasia. Medicine. Culture: Philosophical foundations of modern socio-cultural crisis in medical-anthropological aspect]. Moscow: URSS publ., 2009, 328 p.
- Sarkisov D.S., Paltsev M.A., Khitrov N.K. Obschaya patologiya cheloveka [General human pathology]. Moscow: Meditsina publ., 1997, 608 p.
- Boorse C. On the distinction between health and illness. Philosophy and public affairs. 1975. 5. P. 411.
- Downie R.S., Fyfe C., Tannahill A. Health promotion: models and values. Journal of moral education. 2000, 20 (1), pp. 101-103.
- Engelhardt H.T. The foundation of bioethics [second edition]. Oxford. Oxford university press, 1996. P. 446.
- Holm S. Does chaos theory have major implications for philosophy of medicine? Medical ethic. Medical Humanities. 2002. 28, pp. 78-81.
- Kenneth M. Boyd. Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts. Medical ethic. Medical Humanities. 2000, 26, pp. 9-17.
Corresponding author: firstname.lastname@example.org
The study considers the theoretical and practical approaches to modern health conceptions. Objective of the study was to analyze the basic interpretations of health in nominalism and realism that are the key trends in the modern national and foreign health service philosophy. The nominalistic trend assumes the notions of health and pathology being provisional enough as descriptions of some health statuses. This research interpretation has been supported by some British and American experts in the health service philosophy and bio-ethics including S. Holm, Tristam Engelhardt, Kenneth M. Boyd, R.S. Downie; plus I.V. Davydovsky, a prominent national pathologist. Proponents of this research approach argue that the modern biology forming a practical foundation for medicine tends to rate “normal” quite a wide range of provisionally healthy and pathological bodily conditions and functions. This means that the healthy and pathological conditions are rated rather by one or another individual values system than some objective biological criteria. The realistic/ functional trend assumes that health and disease mean the objective physical and/or mental conditions and refer to the qualitatively different human health statuses defined by the specific bodily or mental functionality disorders plus locations (locus morbi) of the disease as the key distinguishing criteria for both notions. This research approach is supported by Christopher Boorse and some Soviet researchers including D.S. Sarkisov, М.А. Paltsev, N.K. Khitrov, A.D. Ado, V.P. Petlenko et. al.