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Abstract

We situate the well-trodden debate about defining health and disease within the project of a metaphysics of science and its aim to work with and contribute to science. We make use of Guay and Pradeu’s ‘metaphysical box’ to reframe this debate, showing what is at stake in recent attempts to move beyond it, revealing unforeseen points of agreement and disagreement among new and old positions, and producing new questions that may lead to progress. We then discuss the implications of the two-way benefits between medicine and philosophy when the latter is driven and constrained by medical science.
teorema
Vol. XL/1, 2021, pp. 91-109
ISNN 0210-1602
[BIBLID 0210-1602 (2021) 40:1; pp. 91-109
91
Taking a Naturalistic Turn in the Health
and Disease Debate
Jonathan Sholl and Simon Okholm
RESUMEN
Situamos el debate, ya muy trillado, sobre la definición de salud y enfermedad den-
tro del proyecto de una metafísica de la ciencia y su objetivo de trabajar con y para la
ciencia. Hacemos uso de la caja metafísica de Guay y Pradeu para replantear este debate,
mostrando lo que está en juego en los recientes intentos de dar un paso más en el citado
debate, revelando puntos de acuerdo y desacuerdo imprevistos entre posiciones nuevas y
antiguas, y haciendo nuevas preguntas que pueden conducir a un progreso real. Poste-
riormente, discutimos las implicaciones de los beneficios bidireccionales entre la medici-
na y la filosofía cuando la ciencia médica impulsa y limita a esta última.
PALABRAS CLAVE: filosofía de la medicina, salud y enfermedad, el giro naturalista, metafísica de la
ciencia.
ABSTRACT
We situate the well-trodden debate about defining health and disease within the pro-
ject of a metaphysics of science and its aim to work with and contribute to science. We
make use of Guay and Pradeus metaphysical box to reframe this debate, showing what is
at stake in recent attempts to move beyond it, revealing unforeseen points of agreement and
disagreement among new and old positions, and producing new questions that may lead to
progress. We then discuss the implications of the two-way benefits between medicine and
philosophy when the latter is driven and constrained by medical science.
KEYWORDS: Philosophy of Medicine, Health and Disease, Naturalistic Turn, Metaphysics of Science.
I. INTRODUCTION
For half a century, philosophers of medicine have struggled with
how to define the concepts of health and disease, and this debate (hereafter
HDD) has been referred to as one of the fundamental and most long-
standing debates within philosophy of medicine [Reiss and Ankeny
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teorema XL/1, 2021, pp. 91-109
(2016)]. The most common approach has been to employ the method of
conceptual analysis to search for the necessary and sufficient criteria for
their application, which has resulted in several well-known positions,
amongst which naturalism (scientific facts drive definitions; [Boorse
(1997)]), normativism (cultural/personal values drive definitions; [Cooper
(2003)]), and hybridism (facts and values together drive definitions; [Wake-
field (1992)]) are typically considered the main contenders. This dissensus
has prompted various responses, from eliminating these concepts in fa-
vor of explicit fact-value considerations [Ereshefsky (2009)], to looking
for nuances and overlaps between the positions [Kingma (2014)], or
even rethinking the philosophical tools and methods used [e.g.[Lemoine
(2015), Fuller (2018)]. This has led to a converging view among many in-
terlocutors claiming that the HDD no longer shows signs of progress, all
too often resulting in a dull thud of conflicting intuitions [Schwartz
(2017), p. 487, Sholl (2015), Lemoine (2013), Fuller (2018)]. As there are
many causes for this lack of consensus, clarifying the problems and pro-
spects for the debates future remains an important albeit contestable is-
sue. We concur that too much of the HDD has been preoccupied with
the loop of analysis-counterexample-revision [Matthewson and Grif-
fiths (2017), p. 450], and that something has to change for this debate to
make progress [Lemoine (2013), (2015)]. Here, we suggest that recent
trends in the philosophy of science can highlight what this change might
look like, and how this could help to redirect philosophers of medicine
to investigate more basic questions before returning to health and dis-
ease definitions.
To this end, we propose to situate the HDD within a broader discus-
sion in philosophy of science about the project of taking a naturalistic turn,
or advancing a metaphysics of science. In broad terms, this involves ad-
vancing philosophical inquiries that are in close alignment with current
scientific practice and knowledge, i.e. philosophy motivated by and in
the service of science [Ladyman and Ross (2013), p. 109]. By connecting
these two debates, we do not suggest that the traditional HDD has al-
ways been a metaphysical discussion. Rather, we claim that the ideas
about intertwining science and metaphysics, or philosophy, more
generally, that are explicitly addressed in this debate [Soto (2015) p. 24]
can help clarify the methodological and pragmatic dimensions (regarding
aims and justifications) of the HDD and highlight what is at stake in re-
cent attempts to move forward. To develop this, we first provide an out-
line of the metaphysics of science debate, and then make use of Guay
and Pradeus (2020) metaphysical box to reframe contenders in the
Taking a Naturalistic Turn in the Health and Disease Debate 93
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HDD in order to distinguish between different questions philosophers
need to make explicit when moving forward. We then suggest that taking
a naturalistic turn in the HDD will have implications for not only how
philosophy can contribute to science, but also shows unique benefits for
philosophy of medicine.
II. THE NATURALISTIC TURN: SITUATING THE METAPHYSICS OF
SCIENCE
Recently, philosophers of science have begun to recognize the im-
portance of how scientific knowledge from specific scientific disciplines,
such as immunology can help to shed new light on philosophical ques-
tions that have been fundamental since Aristotle, such as what constitutes
the identity of an individual through time [Pradeu (2019), p. 3]. Doing
metaphysics in this way involves developing an ontology, or worldview,
based on current science [Guay and Pradeu (2020), p. 1848] that can
work both on a local level, i.e. clarifying metaphysical questions that arise
from specific scientific issues like individuality or stemness in biology, im-
munology or oncology [Guay and Pradeu (2016), Laplane (2016)], or it can
entail the broader enterprise of critically elucidating consilience networks
across the sciences [Ladyman and Ross (2007), p. 28]. At all levels, the aim
is an intertwining of science and metaphysics, which, ideally, results in a
mutual contribution to both fields [Soto (2015), p. 26]. Moreover, this
project has dual aims. Positively, it aims to show that metaphysical hy-
potheses or problems could be evaluated or resolved by appealing to sci-
entific standards. Negatively, it suggests proceeds by avoiding appeals to
intuition or analyses based on thought experiments, armchair specula-
tions or a priori common sense [Ladyman and Ross (2007), pp. 10-16,
Kincaid (2013), p. 3]. With the positive aspect, a philosophy done within
science [Kincaid (2013), p. 15] is better able to address the conceptual
and metaphysical problems facing actual scientific practice. In turn, this
can prevent philosophers from imposing their own concepts developed
from refined common sense onto science [Kincaid (2013), p. 11], which
may hinder understanding and the advancement of empirical inquiry
[Ladyman and Ross (2013), p. 112]. While still rather general, the aims of
this project will be made more concrete when we look at how to apply
this to the HDD in the next section.
Within this context, Guay and Pradeu (2020) suggest situating the
project of metaphysics of science with respect to other metaphysical
94 Jonathan Sholl and Simon Okholm
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approaches within philosophy, resulting in a more inclusive understand-
ing of what this project entails and how it can be distinguished from the
narrower category they call scientific metaphysics. To clarify such a dis-
tinction, Guay and Pradeu (2020), pp. 1857-1859, suggest a categoriza-
tion along three axes (which will be helpful for categorizing the HDDs
contenders in the next section). One axis divides projects into descriptive
and revisionary based on their aim (or not) of revising our conceptual cat-
egories or frameworks. A second axis distinguishes a priori and a posteriori
methods, that is whether the method is mainly theoretical/philosophical
deduction or that of explicitly starting from the empirical methods of
science. The third axis distinguishes metaphysical projects in terms of the
authority appealed to for justification: traditional metaphysics largely ap-
peals to notions coming from history of philosophy and conceptual anal-
yses; common-sense metaphysics appeals to folk-intuitions and/or everyday
language; and metaphysics of science is any metaphysical project anchored in
current science [Guay and Pradeu (2020), p. 1859]. There are many inter-
esting implications of this categorization of metaphysical projects based on
differing aims, methods, and justification, e.g. that scientific metaphysics
is only one (particularly strong) form of metaphysics of science, with the
specific qualities of being a posteriori and revisionary. Also, contrary to the
negative aspects of a scientifically-informed metaphysics mentioned
above, Guay and Pradeus approach suggests that even a metaphysics of
science could be anchored in present science while still being a priori or
even descriptive. In short, there are many ways to balance the aims, au-
thorities, and methods of metaphysical inquiry.
One suggestion made by Guay and Pradeu (2020), p. 1855, is that
projects within the area of metaphysics of science will be most fruitful if
they start from one local science and then explore generalizations across
sciences. So, there is still a general aim towards unification of the hypothe-
ses and theories within scientific images, but before we arrive at a full-
blown elaboration of consilience networks across sciences, we might
first elaborate local images within a given science, e.g. investigating im-
munology or biogerontology instead of biology and physics, which have
been the main focus of such projects. Their approach thus leaves the
door open for attempts to clarify the scientific images, and their related
concepts, arising from the local fields of the medical sciences. As we will
show, doing so reveals some issues that are perhaps unique to these
fields while also suggesting their broader philosophical import.
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III. REFRAMING THE HDD IN PHILOSOPHY OF MEDICINE
We suggest that reframing the HDD based on Guay and Pradeus
distinctions may help to explain what is at stake in both older and cur-
rent positions, and how we might make more progress. There are three
caveats to mention. First, while this in a sense imposes a foreign
framework onto the philosophy of medicine, there is still much that we
can learn from doing so; for instance, finding interesting similarities be-
tween otherwise rival positions, or unexpected differences between
seemingly related ones. Second and relatedly, the point of this classifica-
tion is not to suggest that participants have actually been engaging in met-
aphysics. Instead, the classification can help uncover some background
assumptions, both metaphysical and methodological, and bringing these
assumptions to light can help to formulate new questions that capture
the crux of what going beyond the traditional HDD entails. Finally, it
can help to show that one dividing line between older and newer contri-
butions may actually concern the convergence (or lack thereof) with ide-
as coming from this naturalistic turn in metaphysics of science. In short,
this framework could specify what is promising about some newer ap-
proaches to advance the HDD.
The following Table 1 is our categorization of several key positions
in the HDD based on Guay and Pradeus framework. Rather than aim-
ing for being exhaustive, we chose to focus on some key authors who
can arguably be seen as representatives of a general position. So, while
there clearly are variations on the basic positions e.g. Broadbents
general Boorsean framework (2019) or Stegengas particular take on hy-
bridism (2018) the point is merely to capture the general features of
these positions. Second, and more importantly, while we believe the
three axes genuinely reflect distinct metaphysical (and correspondingly
methodological) positions, it is less important for us whether a given au-
thor is definitively categorized. The categories are not arbitrary, e.g.
Boorse is not carrying out scientific metaphysics and Lemoine is not an a
priori common-sense metaphysician, but nor are our classifications dog-
matic. Hence, we make use of a mixed category to reflect some uncertain-
ty, and we accept that authors may move between categories.
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Name and
reference
Descriptive/
Revisionary
A priori/
A posteriori
Traditional/
Common-sense/
Metaphysics of Science
Boorse (1997)
Descriptive
A priori
Traditional
Cooper (2003)
Descriptive
A priori
Common-sense
Wakefield
(1992)
Descriptive
Mixed
Common-sense
Svenaeus (2011)
Descriptive
A priori
Common-sense
Schwartz (2007)
Revisionary
A posteriori
Traditional
Lemoine (2015,
2020)
Revisionary
A posteriori
Metaphysics of Science
Fuller (2018)
Revisionary
A posteriori
Metaphysics of Science
Matthewson &
Griffiths (2017,
2018)
Mixed
A posteriori
Metaphysics of Science
Table 1. Reframing the HDD in terms of metaphysical/methodological
assumptions.
In these classifications the first consideration was whether the au-
thors aim in general is to revise our concepts of health and disease, that
is prescribing a specific meaning for how they should be used, or instead
to provide a description of how they currently are used in a particular con-
text. In large part, this consideration follows many classical descrip-
tions of central positions in the debate, e.g. Boorse and Wakefields aims
to analyze the pathologists or the psychiatrists concept of disease or
disorder, respectively. Interestingly, along this axis there seem to be
overlaps between approaches that otherwise have been portrayed as an-
tagonistic to one another, e.g. Svenaeus anti-naturalistic (2013) phe-
nomenology and Boorses naturalism, neither of which seems to aim for
substantial conceptual revision, but rather to produce a coherent defini-
tion that is consistent with a specific subfield of medicine or common
experience.
While revisionism is what sets several authors apart, further clarifi-
cation comes from asking what exactly is being revised, a question not di-
Taking a Naturalistic Turn in the Health and Disease Debate 97
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rectly raised by Guay and Pradeu. Here we find an interesting difference
concerning the aims of otherwise similar authors such as Schwartz and
Lemoine. Lemoines naturalization proposal involves reframing the
HDD by focusing on gathering pathophysiological details from particu-
lar scientific models/theories of diseases in an attempt to generalize and
unify them into a general theory of disease. Schwartzs project of philo-
sophical explication, on the other hand, aims for variability and free
choice [Schwartz (2007), p. 61] in order to diversify and construct differ-
ent concepts for distinct clinical roles. Whereas the latter project sup-
ports the normative ambition to revise disease to settle practical issues
(i.e. drawing lines between normal and abnormal), the former aspires to
work out a theorical concept of disease in the medical sciences. Further-
more, such revisionism need not be a straightforward either-or matter:
Matthewson and Griffiths seem to offer a mix, since they at times call
for revisionism that advances our understanding of what it is … to be in
a normal or pathological state [Griffiths and Matthewson (2018), p.
302], while elsewhere claiming that even a revisionary account must
keep relatively close to the intuitive meaning [Matthewson and Griffiths
(2017), p. 450].
The second consideration concerns the degree to which authors fa-
vor theoretical deduction or a more inductive, empirical methodology,
which is similar to Fullers distinction between top-down and bottom-up
methods (2018): either we analyze disease into its most general features
or necessary and sufficient criteria (e.g. dysfunction, harm, etc.), and then
deduce whether a condition fits this definition, or else we inductively analyze
specific descriptions of diseases in medical science and search for unifying
properties. Importantly, as Fuller also notes, these imply entirely different
questions: the former asks Is X a disease?, the aim being to answer practi-
cal line-drawing problems, whereas the latter asks, What kind of thing is
disease X?, by looking for general properties the clarification of which
may be of use to science. Those asking the former tend to have little to
say about the latter [Fuller (2018), p. 3201]. With this in mind, what
unites otherwise rival accounts like Boorse and Cooper is their shared
commitment to top-down deductivism. For Boorse, while his frequent
references to medical sciences suggest a bottom-up approach, his general
aim seems to be that of clarifying the standard usage of a term like disease
through conceptual analysis, not that of clarifying medical descriptions
and explanations of what this term refers to on a pathophysiological level
[Lemoine & Giroux (2016)]. By contrast, the bottom-up approach is ex-
plicitly favored by authors like Lemoine and Fuller in their search for
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unifying disease properties within the scientific literature. For instance,
Fuller concludes that the relevant medical literature reveals chronic dis-
eases to be bodily states or properties that are typically dispositional but
sometimes categorical [Fuller (2018), p. 3217]. Wakefield apparently hits
a gray area as he explicitly acknowledges that both deduction and intui-
tion are at work [e.g. Wakefield (2000)], but he nevertheless clearly in-
corporates evolutionary considerations into his dysfunction account.
These differences highlight that what is at stake in several recent contri-
butions to the HDD is to start from current medical or evolutionary de-
scriptions and then use philosophical methodology to answer questions
such as what kind of thing a given condition is, rather than proposing a
delineation of health and disease based on supposed a priori usage. Do-
ing so suggests new insights about how philosophy can contribute to
medical science, which we will discuss in the next section.
The third consideration dealt with the diverging appeals to authori-
ty and here too interesting results emerge. First, while all classical con-
tributors, e.g. Boorse, Cooper and Wakefield, rely on the method of
conceptual analysis, we feel that Boorse does so in a more traditional
manner than the others in that even while binding his account to the
considered usage of pathologists (1997, p. 53), he relies on logic and
traditional methods to settle the philosophical debate, viz. analyzing how
pathologists use terms.1 While scientific authority does play a role, his
concern is primarily linguistic, not scientific. Conversely, Cooper, Wake-
field and Svenaeus rely more on conceptual frameworks used in ordinary
life and the manifest image (such as luck, harm, or feelings of home-
likeness). More significant differences come out in authors like Lemoine,
Fuller and Matthewson and Griffiths who are generally in line with the
metaphysics of science in their aim to let their views be driven by current
science, from which they then draw philosophical implications regarding
disease definitions.
Moreover, as these latter positions reflect revisionary, a posteriori
metaphysics of science, they overlap with Guay and Pradeus (2020) sub-
division of scientific metaphysics and hereby diverge quite strongly
from more classical approaches to the HDD. However, there does ap-
pear to be an interesting difference to consider. For instance, while
Fuller is starting from science, his question is generally that of assessing
whether medical descriptions of chronic diseases fit with traditional met-
aphysical concepts (is chronic disease a process, disposition, etc.?). In a
recent paper on aging, Lemoine (2020) starts from what biogerontology,
physiology and evolutionary theories tell us about aging before extracting
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one possible overarching definition of it. This is of course a different
context, but the methodological import remains. The key difference is
that Fuller is trying to apply well-established metaphysical categories to
science, whereas Lemoine is trying to develop a philosophical position
within science (an approach shared by Pradeu (2019) in immunology). The
latter, we claim, is a more radical version of scientific metaphysics than the
former in that the intertwining of philosophical and scientific questions
become harder if not impossible to separate.
We can draw several conclusions from this classification of the
HDD. First, it suggests some interesting convergences between other-
wise rival positions (e.g. naturalism and normativism, or naturalism and
phenomenology), as well as unexpected differences between seemingly
related approaches (e.g. Schwartz and Lemoine or Fuller and Lemoine).
More importantly, this also suggests a movement towards addressing
new questions to get beyond the HDDs stalemate of conflicting intui-
tions. To take aging as one example, this movement can be summarized
as follows:
1. Traditionally, the approach has been to stipulate a definition of
disease/health and then ask, is aging a disease? [see De Winter
(2015), Schramme (2013)].
2. Similar to Fullers metaphysical approach, a different question
would be: What kind of things are aging diseases? or asking
what, if anything, age-related diseases have in common by drawing
on the scientific literature and pre-existing metaphysical concepts.
3. Finally, instead of assuming any explicit metaphysical concepts or
disease judgement, a more basic question in line with Lemoine
(2020) is: What is aging as described by the science(s) of aging?
A similar shift in terms of questions pursued can also be seen in the no-
tion of homeostasis. Instead of asking whether homeostasis in general is
healthy [Boorse (1977), p. 54], another approach is to investigate what
various sciences say homeostasis is and then ask whether what homeostastic
regulation refers to can be unified enough to explain something specific to
physiology [Sholl and Rattan (2020)]. In short, this is a shift from con-
ceptual analysis to referent analysis. Notably, in both cases it seems that
the more we commit to being scientifically informed the more we move
away from demarcation issues in the HDD. Importantly, however, ask-
ing question 3 does not necessarily negate the others. Instead, these
100 Jonathan Sholl and Simon Okholm
teorema XL/1, 2021, pp. 91-109
questions can be complementary when asked in reverse: first striving to
provide a clearly delineated object within and based on the relevant sci-
ences before debating the health or disease status of that object.
A related conclusion, which converges with the critiques mentioned
in the introduction, is that one reason the HDD has not been able to es-
tablish consensus and thereby make much progress is that it has not fully
reckoned with the aims and methods used: concept analysis is not a
method for understanding the metaphysics of diseases, but for under-
standing the definition of disease’’ [Fuller (2018), p. 3199]. It helps to
ask what disease means, but not what it is ontologically speaking. Subse-
quent contributions would benefit from being clearer about what exactly
they aim to do, how they will do so, and what is their justification or au-
thority. Third, it is also interesting to see that when looking at the medical
sciences, the aim for revisionism can be driven by practical/normative or
theoretical/empirical considerations. This difference was not mentioned
by Guay and Pradeu but is perfectly in line with their insight to move
from local to general. While such considerations get at the heart of the
medical sciences, further insights could be gleaned from analyses of spe-
cific or local medical sciences, such as oncology or biogerontology, and
can surely be generalized to philosophical analyses of other practical or
applied sciences. Finally, placing the HDD within the discussion about
metaphysics of science also suggests that one possible benefit of devel-
oping a scientifically informed philosophy is that it could more easily
contribute to clarifying empirical questions or even advancing scientific
debates. While this is surely one possible and valuable benefit to consid-
er, what often goes overlooked are the benefits to philosophy for engaging
more closely with science, thereby resulting in a mutual contribution. We
turn now to an elaboration of what this mutual contribution could entail
and what it means for the HDD.
IV. CLARIFYING THE TWO-WAY EXCHANGE BETWEEN PHILOSOPHY
AND MEDICINE
Much in line with the trends among philosophers of science to ap-
proach findings from current science to better address metaphysical
questions, the inverse call for philosophys relevance to science has re-
cently also been voiced by philosophers. Notably, publishing in the pres-
tigious PNAS journal, several philosophers teamed up with scientists to
make a strong case for why science needs philosophy [Laplane et al.
Taking a Naturalistic Turn in the Health and Disease Debate 101
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(2019)]. Philosophers, they argued, can contribute to science by clarifying
existing scientific concepts, formulating new theories or concepts, critically
assessing assumptions and methods, or fostering dialogue across the sci-
ences and to society. When successful, this results in a reinvigoration of
science at all levels, one that returns to us the benefits of close ties with
philosophy [Laplane et al. (2019), p. 3951]. Recently, and more specifically
to medicine, similar claims for philosophys relevance have been suggested
for improving medical education [Clarke, Ghiara and Russo (2019), Boon
and Van Baalen (2019), Boniolo and Campaner (2020)] and scientific and
clinical reasoning [Andreoletti and Maugeri (2019), Anjum, Copeland and
Rocca (2020)]. Importantly, these approaches seem in line with developing
a scientific metaphysics that is not only beneficial to philosophical discus-
sions, but also aims to advance medicine. Such concerns raise the question
as to whether and how this also could be achieved within the HDD.
At least part of what is at stake in overcoming the HDDs stalemate
is not only to advance a philosophical debate, but also the aim to influ-
ence science, that is contributing to science, by formulating as tentative
theories whatever generalization the science of diseases produces [Lem-
oine (2015), p. 30]. However, besides Wakefields contributions and
recognition outside philosophical circles, most other issues debated in
the HDD have not had much impact on medicine. Put differently, the
HDD has largely been an insular one, confined to philosophical circles,
without much so-called radical interdisciplinarity [Clarke, Ghiara and
Russo (2019)]. Now, this is not to say that the philosophical debates as
they now stand have no way of contributing to medicine. For instance,
the usefulness of conceptual analysis is to help draw clearer lines for clin-
ical reasoning, e.g. by clarifying the disease-status of grief [e.g. Horwitz
and Wakefield (2007)]. However, while this is indeed a helpful contribu-
tion to medicine, such attempts are unfortunately rare and perhaps hin-
dered by other aspects of how the HDD typically proceeds, like focusing
on counterexamples, a priori reasoning and pre-scientific concepts.
Other contributions in line with scientific metaphysics build on the
bottom-up approach by proposing ways of unifying knowledge claims
within the medical sciences to develop theories of health or disease, much
like the humoral or germ theories of past medical history. For instance,
Darrason (2013) argues that scientific research into the genetic changes
associated with various infectious diseases challenges our current disease
classifications and could provide a theory to unify many, if not all, diseases.
A similar idea could be at work in recent philosophical interest in whether
aging research [e.g. Lemoine (2020)] can provide a theory to account for
102 Jonathan Sholl and Simon Okholm
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the occurrence of many diseases by either being age-dependent or at least
related to old age. In the case of health, Sholl and Rattan (2020) compiled
a variety of explanations from distinct sciences such as immunology,
neurophysiology, biogerontology, odontology, evolutionary biology, and
public health in an attempt to look for general patterns that were specific
to healthy physiological properties, e.g. homeostasis, homeodynamics,
robustness or adaptation. While such a full-fledged theory of health re-
mains to be developed [Sholl (2020)], and there is some doubt that medi-
cal research needs any theory of health or disease [Kincaid (2008)], this
kind of skepticism could be assuaged by assessing what unites these vari-
ous notions in terms of their underlying mechanisms and the biomarkers
that are used to track these mechanisms.
Now, what is less discussed in these debates on the relationship be-
tween philosophy and science is the other side of the exchange. As sug-
gested above, many aim to show philosophys relevance for science and
medicine but some interestingly argue that philosophy has neglected
medicine and that the future of their relationship depends on the devel-
opment of a positive two-way trade between them [Fulford (1991), p.
81]. So, if either or both are to progress, we need to acknowledge this
mutual dependence: Philosophy thus needs medicine as much as medi-
cine needs philosophy [Fulford (1991), p. 84]. But what does this entail?
This brings us back to the project of scientific metaphysics and its
positive and negative aims. One thread running through this debate is
that by appealing to science as the primary authority, philosophers are
then forced to take certain epistemic and ontological constraints into ac-
count [Soto (2015), p. 53]. Put differently, science holds the relevant de-
siderata for providing the standards for what counts as relevant
information/knowledge, which methods are most successful, and what is
(or is not) real, which then should guide our philosophical theorizing.
Surely this, by extension, holds for scientifically inclined philosophers of
medicine, and this negative constraint can be spelled out in two points.
First, it puts limits on what a relevant, naturalistic definition of health or
disease should look like, which we will return to shortly, and second it
constrains what kinds of criticisms can be legitimately leveled against it.
In terms of these latter constraints, claiming that naturalism falls short by
unjustly prioritiz[ing] the epistemic perspective of natural, behavioral or
social sciences over the first-persons authentic experience of illness
[Svenaeus (2019), p. 466] does not undermine any scientific theory of
disease. This only reveals different aims and methods and suggests that
ones justifications for appealing to one or another set of desiderata are
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different. To use Guay and Pradeus distinctions, such phenomenological
accounts represent common-sense metaphysics aimed at understanding ra-
ther than explanation, and the latter explanatory aim involves some form
of commitment to a project of metaphysics of science.
Returning to the first constraint, how could science put limits on
what our health or disease definitions should look like? One strong ar-
gument could be that only those who are in line with the aims of scientific
metaphysics will have a say in our future disease definitions. A weaker,
perhaps more plausible, claim could be that a blend of empirical meth-
ods and common-sense concerns may still provide helpful insights into
our understanding of health and disease. We do not want to rule out ei-
ther possibility. Rather our point is to highlight that with newer ap-
proaches like those of Lemoine, Darrason and Fuller which are more in
line with metaphysics of science, there is a push towards developing new
forms of naturalism in the HDD that do not seem to share much in
common with any traditional Boorsian framework. To us, this suggests
that part of the problem with the HDD has been that naturalism, as we
know it, actually has not been naturalistic enough, which indeed seems to
be the thrust of the argument that many naturalist or hybridist accounts
currently on offer impose no strong ontological restrictions on diseases
[Fuller (2018), p. 3201, emphasis added] or that naturalism has only lin-
gered on a pre-theoretical notion of disease [Lemoine (2015)].
To be perfectly clear, we can only speak in generalities of what such a
naturalistic definition constrained by science could look like, since the actu-
al demonstration of a scientific approach to health or disease is still only a
promise sketched by a few authors. Nevertheless, what seems to be at stake
in carrying out these inductive approaches is to find the ontological re-
strictions on our definitions. So, whether Fullers account succeeds over
others, e.g. Langes (2007) or Smarts (2014), will depend on an evaluation
of their proximity to the most robust scientific methods and descriptions of
pathological (chronic disease) reality. We can thereby ask, for instance,
whether Fullers medical-physiological description of the ontology of
chronic diseases is consilient with what evolutionary biology has to say
about disease more generally [Gluckman et al. (2011)]. Likewise, whether
Matthewson and Griffithss approach holds rests on its consistency with
evolutionary biology, not its consistency with common or dictionary usage,
with the implication that counterexamples or thought experiments alone
are not enough to discredit it [for a recent defense, see Veit (2021)]. Here,
we could ask whether the biological criteria provided by their evolutionary
account are consilient with physiological aspects, such as homeostasis, bio-
104 Jonathan Sholl and Simon Okholm
teorema XL/1, 2021, pp. 91-109
chemical regulations, immunological and metabolic dynamics, etc. The
question would turn on whether they do in fact agree, and whether the lat-
ter aspects provide further constraints to complement the evolutionary
ones. Thus, what medical science can provide to philosophers of medicine
is a way to better evaluate rival accounts beyond appeals to intuitions or
counterexamples. At first, filtering out what does not work would already be
significant progress in these debates.
Now, the same holds for any position in the HDD, be it phenome-
nological, a refinement of Boorses naturalism, or strong proponents of
normativism. Taking the naturalistic turn seriously implies that there are
scientific facts of the matter about what health and disease are, even if
we do not have a complete account or theory of them (yet). These facts
collectively impose constraints on ones position, meaning that some
minimal form of scientific realism about health and disease could be the
starting point of the HDDs future. In partial agreement with Simon
(2011), the debate would then turn around how far this realism can take
us in pursuing a more scientific approach to defining health and disease,
which could very well be beneficial to medicine as well.
V. CONCLUSIONS: GIVING MEDICAL SCIENCE THE
PHILOSOPHY IT DESERVES
It seems, then, that philosophers of medicine have quite a bit to gain
from embracing the naturalistic turn as advanced in the broader philoso-
phy of science debates over the metaphysics of science. One overarching
conclusion coming from our analysis is that if philosophers of medicine,
whatever their position, contend to contribute to medical science or prac-
tice (i.e. not just to philosophy), they will have to be scientifically well-
informed and even engage with medical scientists. Nearly every contribu-
tion to the debate is claiming to say something about what health and dis-
ease ultimately are, which is one justification for incorporating some
metaphysical or ontological constraints. This would even apply to strong
normativist stances rejecting that there is anything that medicine or biology
can provide by means of such constraints [e.g. Cooper (2002), p. 271]. This
would have to be proven, rather than supposed. However, as soon as we
accept that the medical sciences provide at least some input, e.g. that genetics
challenges our basic categories or that notions like homeostasis, robustness
or adaptability point to real physiological properties or mechanisms, then
we are forced to take on the minimalist constraints of consistency or con-
silience with scientific theories. This, in turn, leaves each account open to
Taking a Naturalistic Turn in the Health and Disease Debate 105
teorema XL/1, 2021, pp. 91-109
evaluation based on this very consistency. By accepting constraints, phi-
losophers of medicine too may benefit by engaging more intimately with
medical scientists and in that way perhaps even helping to foster concep-
tual and theorical developments in science. Furthermore, what medicine
provides to philosophers of medicine is a way to better evaluate rival ac-
counts and filtering out what does not work, and this, we claim, could be a
significant step towards advancing the HDD.
A second conclusion is that this two-way exchange need not be
isolated to metaphysical or ontological questions about health/disease,
but can also apply to other debates in philosophy of medicine. It could,
for instance, be relevant to those developing the epistemological turn
towards medical evidence [Stegenga et al. (2017)] who seem to share
some commitments to scientific authority, even if they are critical of
that very authority. Similarly, those promoting a philosophy of science
in practice [Ankeny et al. (2011)] also seek to engage with science as it
is actually performed, but wish to bring out the values and ideals bound
up with this practice so as to have a more productive interaction with
science. This might call for a different notion of consistency between
philosophical and scientific theorizing, but the shared aim to be an-
chored in current science remains.2 So, a closer engagement with sci-
ence can have multiple payoffs throughout philosophy of medicine.
A final and somewhat controversial conclusion is that philosophy
of medicine, or of any science for that matter, is not relevant for its given
science a priori, i.e. simply because it is asking questions or making cri-
tiques of that science. This relevance needs to be demonstrated and we
suggest that philosophy of medicine is most relevant when most empiri-
cally informed. The basic aim to hold different positions accountable,
thereby filtering out disproven speculations or at least setting ontological
constraints on them, could be the main benefit of bringing the frame-
work of metaphysics of science into the HDD. In Le matérialisme rationnel,
Gaston Bachelard lamented that science does not have the philosophy it
deserves [Bachelard (1953), p. 20; our translation]. Philosophers of med-
icine can provide the medical sciences with such a philosophy, but only if
they are willing to engage with and be corrected by actual science.
University of Bordeaux, CNRS
ImmunoConcEpT, UMR 5164
3300 Bordeaux, France
E-mails: jonathan.sholl@u-bordeaux.fr, sokholm@immuconcept.org
106 Jonathan Sholl and Simon Okholm
teorema XL/1, 2021, pp. 91-109
NOTES
1 For instance, Boorse (1977) situates himself in relation to Aristotle and
the history of philosophy, and aims to develop a lexical definition (2014).
2 Another philosophical approach that may benefit from these insights,
but which we could not explore, is experimental philosophy involving the use
of quantitative methods. For differing views, see Hofmann (2017) and Veit
(forthcoming).
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