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1
Experimental Philosophy of Medicine and the
Concepts of Health and Disease
Walter Veit
1
Abstract
If one had to identify the biggest change within the philosophical tradition in
the 21st century, it would certainly be the rapid rise of experimental philosophy to
address differences in intuitions about concepts. Yet, it is within the
philosophy of medicine that one particular conceptual debate has
overshadowed all others: the long-standing dispute between so-called
‘naturalists’ and ‘normativists’ about the concepts of health and disease. It is,
therefore, surprising that the philosophy of medicine has, so far, not drawn on
the tools of XPhi. I shall use this opportunity to defend and advocate the use
of empirical methods to inform and advance this and other debates within the
philosophy of medicine.
Keywords: philosophy of medicine; experimental philosophy; conceptual analysis;
health and disease; Boorse; naturalism
There is a widespread and unfortunate tradition in philosophy that the man in the
street has all the empirical knowledge required for philosophizing.
– Daniel C. Dennett ([1], p. 1)
1 Introduction
If one had to identify the biggest change within the philosophical tradition in the 21st
century, it would certainly be the rapid rise of experimental philosophy. What began as a
small initiative to promote empirical methods within philosophy and test the
1
University of Sydney, Charles Perkins Centre, Sydney, Australia; https://orcid.org/0000-0001-7701-
8995; wrwveit@gmail.com
Please cite as: Veit, W. forthcoming. Experimental Philosophy of Medicine and the Concepts of Health
and Disease.
Theoretical Medicine and Bioethics
.
Check https://walterveit.com/publications/ for citation details once published
2
intuitions of so-called ‘armchair philosophers’, has led to a wealth of studies on the
intuitions of the public concerning a diverse range of philosophical subjects in
epistemology, ethics, metaphysics, and even aesthetics. The field has quickly grown
into a lively community, but faces criticisms from both inside and outside the
philosophical community.
Owing to an array of defences by respected philosophers of science,
experimental methods have become increasingly common and accepted within the
philosophy of science.
2
While this has led to major changes in thinking and a more
pluralist attitude towards the use of scientific tools within philosophy of science itself,
it would be premature to call this a victory for experimental philosophy of science.
Indeed, there is one sub-discipline of philosophy of science in which experimental
philosophy is notably absent, i.e. the philosophy of medicine. We think this is unfortunate
and would like to use this opportunity to remedy this omission.
Indeed, the lack of empirical methods in the philosophy of medicine is all the
more surprising, since experimental philosophy has predominantly been used to
challenge many of the more intuition-grounded conceptual debates in philosophy.
Experimental work on scientific concepts includes early work on the gene concept
[7], innateness [8-10], the economists’ concept of choice [11] consciousness [12], and
conceptual differences between natural and social scientists more generally [13,14].
Yet, it is within the philosophy of medicine that one particular conceptual debate has
overshadowed all others: the long-standing dispute between so-called ‘naturalists’ and
‘normativists’ about the concepts of health and disease, i.e. whether (to put it into a
slogan) these terms refer to value-free scientific concepts or valueladen social ones.
But as the quote from Daniel Dennett at the epigraph of this paper was meant to
illustrate, the very notion that we could develop a theory of health and disease without
any reference to empirical data strikes me as quite weird if not absurd, and yet seems
to be the dominant view in the philosophy of medicine. Here, we shall use this
opportunity to defend and advocate the use of empirical methods to inform and
advance this and other debates within the philosophy of medicine, a discipline that
has so far resisted the empirical turn within philosophy.
The paper is structured as follows: Section 2 offers a brief sketch of the
philosophical literature on health and disease and articulates a problem for traditional
conceptual analysis that we shall, following Lemoine [15], dub the Intrinsic Limitation
Problem (ILP). Section 3 introduces the methods of experimental philosophy as a
necessary solution to this problem and addresses several of the objections
philosophers of medicine are likely to raise, before finally, Section 4 concludes the
discussion.
2
See [2-6].
3
2 Conceptual Analysis of Health and Disease
The central question within the philosophy of medicine is how to define and
understand concepts such as ‘health’, ‘disease’, and ‘pathology’. This philosophical
question has garnered much attention throughout recent decades and continues to
be one of the most heatedly debated issues in the field (see [16] for an overview).
Traditionally, the contenders within this debate have been grouped into two
opposing camps: ‘naturalists’, who try to ground the concepts in objective biological
facts and ‘normativists’, who argue that these concepts cannot be purely grounded in
objective facts about science, but are instead ultimately value-laden - depending on
the human viewpoint - or culturally relative.
3
This is only a simplified and coarse-
grained picture of this many-faceted debate, yet it will be sufficient for my present
purposes, which is only to show that the traditional philosophical method of trying
to resolve this debate - i.e. conceptual analysis - is likely doomed to remain
unsuccessful. Here, I am not making any claims regarding the sensibility of the
dichotomy in which the debate has been historically framed. Whether we should be
eliminativists, pluralists, or unificationists about the conflict between normativism
and naturalism in this debate, is as I shall argue, to a non-negligible extent an empirical
matter. Here, it is useful to take Maël Lemoine’s recent critique of conceptual analysis
as a starting point.
2.1 The Intrinsic Limitation of Conceptual Analysis
Traditionally, conceptual analysis, i.e. the descriptive analysis of a concept, has been
assumed to play the central, if not only, role in settling the conflict between naturalism
and normativism. The two most influential ‘naturalist’ accounts in this debate - i.e. the
bio-statistical (BST) account of Christopher Boorse [19-22] and the harmful-
dysfunction account by Wakefield [23] have made explicit reference to conceptual
analysis in their methods. Boorse [21], for instance, explicitly states that “[t]wenty
years ago, in four papers, I offered a unified descriptive analysis of health, disease,
and function” (p. 4). This is no accident. Historically, most of the contributors to the
debate have paid little if any attention to the meta-philosophical questions of whether
this method is an appropriate one. As Lemoine [15] points out: “all participants
implicitly agree about the utility of conceptual analysis to settle the debate” (p. 316).
4
3
Despite the existence of these two camps, one should not think of either as particularly unified.
The positions of normativists in particular share only very little family resemblance aside from their
unified dismissal of naturalism about health and disease. These anti-naturalists reject Dennett’s dictum
of “Darwin’s universal acid” [17,18].
4
This assumption is not exclusive to the philosophy of medicine. It is very much conceived as the
modus operandi in many conceptual debates in philosophy - indeed the general practice of philosophy
itself - and has thus received an array of criticisms (see [24] for an overview).
4
There are a few notable exceptions, such as John Matthewson and Paul Griffiths on
the naturalist side and Quill Kukla on the normativist side, who don’t try to capture
the meaning of the terms as used among the public but explicitly try to revise the
concepts of health and disease for the purposes of science and justice respectively
[25-29]. Most of what has been published in this debate, however, squarely falls into
a conceptual analysis framework.
Since, I are interested in the intrinsic limitation problem (ILP) identified by
Lemoine [15], I will follow his formalization of this methodology in order to make
the problem visible.
5
When philosophers are interested in the conceptual analysis of
a term (be it the concept of ‘health’, ‘disease’, ‘pathology’, ‘disability’, or ‘illness’) they
start from something cognitive scientists have called exemplar theory.
Exemplar theory postulates that humans learn and apply concepts by
comparing new stimuli to stored paradigm cases, such that we classify the new stimuli
as a member of the class if there is enough of a family resemblance between the
entities in question [30]. While this intuitive categorization may be enough for the lay
folk, it is unsatisfying to most philosophers.
6
Instead of just comparing controversial
cases of diseases with uncontroversial paradigm cases (Lemoine calls this set the
extension of a term), philosophers aim to construct a definition from the latter. This
definition, Lemoine [15] argues, must provide us with necessary and sufficient
conditions for whether we classify something as health and/or disease, and may
include exceptions to these criteria in order to prevent easily-constructed counter-
examples. With such a definition in place, philosophers can then (if successful) place
controversial cases either within the extension of the term ‘disease’ or outside.
Progress, it is assumed, thus proceeds by exposing these accounts, or rather
definitions, to attacks that should then lead to a revision or replacement in the hopes
of finding the ‘correct’ account of health and disease. To do so Lemoine [15]
identifies three distinct kinds of “attack”:
They consist in presenting (1) cases falling within the commonly accepted
extension of the term but which do not satisfy the opponent’s definition, (2)
cases that do satisfy the opponent’s definition but which fall outside the
commonly accepted extension, and (3) cases that fall clearly inside or outside
the extension but which the opponent’s definition fails to classify at all.
5
His analysis of conceptual analysis is here based on Christopher Boorse [20-22], Lennart
Nordenfelt [31], and Jerome Wakefield [23, 32].
6
Also for policy-makers, funding agencies, and insurance companies who are faced with a line-
drawing problem of which conditions should be called pathological. Biologists, on the other hand,
should be much happier to embrace such vagueness since the biological world doesn’t lend itself to
sharp distinctions. A naturalist account of health and disease may thus permit a higher degree of
indeterminacy than normativist ones.
5
– Lemoine ([15], p. 310)
Boorse [21] characterizes this back-and-forth as a genuine game: “to call pregnancy
per se unhealthy would strike at the very heart of medical thought; it is the analytic
equivalent of the ‘Game Over’ sign in a video game” (p. 44). And boy have there
been a lot of contenders in this game. For instance, Boorse’s decades-old BST
account (first introduced in 1977; see [20]) despite surely being the most discussed
work in the literature, is far from a well-accepted account. While there have been
slight amendments to Boorse’s original account, the continuous assault on his
account in the literature is hardly indicative of an elimination process in which only
one definition will prevail. One may thus question whether the participants in this
debate are actually following the supposed rules of conceptual analysis, i.e. the
necessity to debunk and replace existing definitions with better ones in order to “win
such a debate” (Lemoine [15], p. 311).
But as Lemoine [15] shows, these rules seem to play a core role in the work of
Boorse, Wakefield, and Nordenfelt. All of them “1) propose a definition of health,
disease, or both, (2) give examples of actual diseases, (3) examine apparent counter-
examples, and (4) offer counter-examples to the contending proposals for
definitions” (p. 311). Definitions, it is claimed, are often argued to be either too
narrow, excluding conditions we consider to be diseases, or too broad, including
conditions we would prefer not to label as diseases, as Boorse’s pregnancy example
above illustrates. Lemoine argues that for such an analysis to eventually lead to
success, or at least make progress, it requires consensus among participants. But since
such consensus only requires consensus about the clear cases the concept is intended
to capture (controversial cases can easily be dismissed as unclear by the opposite side
and thus uncontroversial and damning cases are needed in order to be successful -
picture a sort of philosopher’s ‘mic drop’), Lemoine insists that it can never lead to a
definition that rules controversial cases out (or in). As he points out, “if several
definitions could match the same set of uncontroversial cases, it would not matter
whether they agreed or disagreed on controversial cases” ([15], p. 316). Conceptual
analysis (alone) would not be able to settle the game and pronounce a winner. This
is an “intrinsic limit of conceptual analysis: it cannot rule out a specific kind of
stipulation” (p. 316).
Whether the solution to the conceptual controversy about health and disease
finds itself in the naturalist or normativist ‘camp’ cannot be established if both sides
can offer accounts that cover the uncontroversial cases equally well. We see no a priori
reason to doubt that there is conceptual room on both sides for such definitions. It
is thus as Lemoine [15] argues “hopelessly unlikely [that we will be able] to decide
between two reasonably successful definitions of ‘disease” (p. 323). That is, if we limit
6
ourselves to conceptual analysis alone.
7
Lemoine concludes his paper with the
declaration that “[i]n order to prove naturalism or normativism right, another method
has to be embraced” (p. 324). I shall follow this call for action and thus introduce
another method in the philosophy of medicine in order to make empirically
supported judgements about the intuitions and use of concepts in the public and the
medical profession, i.e. experimental philosophy (sometimes abbreviated as X-phi).
8
3 Experimental Philosophy to the Rescue
That Lemoine’s call for an alternative method can be used to offer a defense of
experimental philosophy of medicine comes as no surprise. The criticisms Lemoine
brings forward against conceptual analysis have been echoed in similar form by many
naturalist philosophers, and especially those that advocate the use of empirical
methods. Experimental philosophers (among others) have long criticized the
philosopher’s tendency to rely on their own intutions to capture the meaning of a
term, rather than the intuitions of the general population they are supposedly
capturing [36]. Here, one may legitimately wonder whether intuitions (be they
philosophical, scientific, or lay) are at all helpful to understand the reality of a concept.
Why should we assume that mere intuitions can help us to settle these questions,
especially those of broader (non-specialist) populations?
9
Unfortunately, experimental philosophy is often narrowly understood
as the mere use of surveys to capture the intuitions of the public, rather than a more
general view of philosophy as a discipline continuous with the sciences and thus apt
to use empirical data to inform its debates. This naturalist understanding of the XPhi
critique of conceptual analysis turns the usual critique of XPhi on its head. Rather
than criticizing the use of empirical methods to address philosophical issues as
something that is “not philosophy”, a naturalist criticizes philosophical debates for a
lack of empirical tools. In promoting XPhi I aim to accomplish an empirical turn in
7
This is not to deny that conceptual analysis may have contributed positively to our
conceptualization of health and disease - progress that will surely be taken by some to argue for a
more optimistic stance on whether conceptual analysis can solve the debate. But this further step
should be avoided. For additional reasons regarding problems with conceptual analysis that I do not
have space to detail here, I am rejecting this position. [See [33] for various philosophical attacks on
conceptual analysis.] My primary goal is merely to convince philosophers of medicine to embrace a
wider toolkit of methods in order to settle the questions they are interested in.
8
While Lemoine intends to solve this debate by motivating a naturalist account of health and
disease that actually draws on the full breath of biomedical science, I offer an alternative solution here.
Nevertheless, in a conference report Lemoine et al. [34] tentatively suggested that experimental
philosophy could fruitfully be applied to the philosophy of medicine. In my PhD thesis, in turn, I
follow Lemoine’s call for an attempt to naturalize the concepts of health and disease [35].
9
I thank an anonymous reviewer for their suggestion to include a discussion of these points.
7
the philosophy of medicine similar to the one initiated by Dan Dennett in the
philosophy of mind:
[...] as a graduate student at Oxford (1963-65), I developed a deep distrust of
the methods I saw other philosophers employing. That was the heyday of
ordinary language philosophy, and “theories of mind” were debated on the
basis of a lean diet of conceptual analysis–as if one could develop a theory of
horses on the basis of nothing other than a careful investigation of the meaning
of the ordinary word “horse”. I decided that I had to supplement (and maybe
even adjust!) the fruits of ordinary language analysis with an attempt to figure
out how the brain could possibly accomplish the mind’s work.
– Daniel C. Dennett ([37], p. 12) [italics in original]
I am here not merely making the uncontroversial claim that empirical methods can
improve the debates in the philosophy of medicine, but the more substantive one
that empirical methods are necessary to make progress on our understanding of
health, disease, and pathology. This understanding of XPhi as part of a larger project
of naturalist philosophy makes it compatible with naturalist critiques of conceptual
analysis of two distinct sorts that are often brought forward against XPhi: i) concepts
are not definitions, and ii) intuitions are a poor guide to understand natural
phenomena. But these issues are importantly not incompatible with naturalism.
Firstly, XPhi may very well reveal that the way we categorize the world cannot be
captured in simple definitions of necessary and sufficient conditions. But this only
goes to show that conceptual analysis has rested on mistaken assumptions, not that
XPhi fails because it cannot provide such conditions. Secondly, naturalists should be
happy to make a distinction between our psychological categorizations and the way
the world is. Conceptual analysis is sometimes ambiguously understood as both the
search for essence or true meaning of a concept, or merely a set of “criteria of
application” that actual humans use when employing these concepts (Neander [38],
p. 171), but these goals are distinct. Naturalists can engage both in a scientific
investigation of how we end up with and employ concepts in our own thinking and
in communication with others and a scientific investigation of whether there these
concepts map onto real phenomena in nature.
Whereas Lemoine [15,39], alongside others such as Matthewson and Griffiths
[25], abandon conceptual analysis in favour of the latter approach - i.e. to ground
these concepts within science - I use this opportunity to advocate the use of XPhi in
the form of surveys of the public, medical practitioners, and scientists to advance the
debate between so-called ‘naturalists’ and ‘normativists’. Importantly, however, these
approaches are not incompatible and can inform each other, especially when the
intuitions of scientists and their empirical work comes apart, as Griffiths’ work on
the idea of innateness and the gene concept elegantly illustrates [7-10]. The once
purely philosophical project of conceptual analysis is thus replaced by two distinctive
8
investigations: one is a investigation of the psychology and sociology behind our
concepts, the other a scientific investigation into the phenomena these concepts
supposedly map onto.
10
Now, while it is surely justifiable to ask why we should be
naturalists and rely on empirical data at all, this is not the place to answer these
concerns. This is a paper about the philosophy of medicine, a field where scientific
approaches such as those of Lemoine, Griffiths, and Matthewson are rare and XPhi
notably absent. Due to considerations of space, I merely want to give a positive account
and show how experimental philosophy could be used to improve the philosophy of
medicine by discussing its most famous conflict. If this approach is meant to fail, this
will likewise have to be empirically demonstrated and not a priori asserted.
3.1 Conceptual Analysis requires Experimental Philosophy
The primary argument for experimental or better empirical philosophy of medicine
is thus this: successful conceptual analysis in its nature requires empirical data. Here, the
lexicographical approach is indicative and shares a close connection to traditional
conceptual analysis.
What lexicographers seek is usually a list of examples of a term’s usage
(including paradigm examples), a list of different sub-types these examples fall into,
or a definition that covers the usage of the term. The latter is often not provided, or
instead is stated in quite inclusive terms so as to not exclude any cases. One reason
for this is simply pragmatic: some terms are applied in very different contexts in
which they have a radically different meaning, and cannot be unified by a single
concept. Most take the concepts of health and disease to be radically different in that
regard, assuming that there is a single ‘correct’ unifying concept. If the goal is
conceptual analysis of a term used by a linguistic community, one cannot take one’s
own intuitions as a starting point, unless there is evidence that these intuitions are
widely shared. Indeed, it is doubtful that one could even engage in such conceptual
analysis without empirical methods. Whatever tools a philosopher uses to get a grasp
on these shared intuitions, whether they rely on interviews, surveys, bibliographic
data, or participating in or observing conversations about health and disease, even
the very use of a lexicon to begin one’s conceptual analysis is empirical – though we
may prefer to call this ‘light X-phi’ compared to more sophisticated and empirically
demanding studies (whether quantitative or qualitative).
3.2 Experimental Philosophy is not Philosophy
With this in mind, we can turn to a frequently uttered challenge against experimental
philosophy: that while it may be useful, it doesn’t constitute philosophy. One may
10
For more detail on the second of these options, see [40], though parts of it are revised here.
9
thus argue that philosophers should minimize their use of empirical methods, for
engaging in them would take time away from doing ‘real philosophy’. This, however,
is no obstacle to the necessity of the kind of work advocated and practiced within
the experimental philosophy community: if empirical methods such as surveys do
not count as philosophy, then neither will opening a lexicon, or reading medical
papers for that matter. There is no line to draw here.
The semantic dispute on whether we call this work philosophy or not doesn’t
matter. It is work that needs to be done in order to make progress on the
philosophical questions. But sociological, psychological, or scientometric studies on
the concepts of biomedical scientists or the public are comparatively rare. That is
because non-philosophers are often not interested in particularly philosophical
questions (with perhaps the exception of moral psychology). But if good empirical
evidence is necessary for conceptual analysis to be successful philosophers
themselves may very well be forced to utilize the toolkit of science - that is, if they
are ultimately interested in answering their philosophical questions, rather than just
engaging in ‘philosophical play’.
But how can we use experimental philosophy to address Lemoine’s [15] ILP
of conceptual analysis? At the core of any conceptual analysis of disease is a set of
uncontroversial paradigm cases that the concept needs to cover. The present state of
the debate suggests that the current set is too small as to allow for a determinate
‘winner’, nor even substantial progress, in the debate. Here, we can rely on empirical
methods such as surveys to widen the set of phenomena we aim to include,
particularly in talk of pathology within the biomedical sciences.
One way of doing this would be to confront the public with controversial cases
of diseases at the edge of the conflict between normativists and naturalists. Another,
would be to expand the list of paradigm cases by considering the intuitions of the
scientific community regarding the nature of medical conditions such as diabetes,
autism, or viral infections that do not cause any felt harm, but are nevertheless
harmful to the organism (e.g. pathology in trees). Sophisticated surveys might even
attempt to discover the more abstract reasoning behind the classification process of
participants. Are they drawing on scientific facts or the values of society?
Normativists may be reluctant to adopt this procedure since the reliance on
naturalistic methods may appear to unfairly shift the debate in favour of naturalism,
especially when we directly investigate the intuitions of scientists rather than the
public at large. By extending the set of paradigm cases to include any mention of
pathology in science, one may come under the impression that the game becomes
rigged, since many normativists hold the view that our definitions of health and
disease should not be based on scientific practice but our common understanding of
these notions. What may be called the dice-loading problem of naturalist experimental
philosophy, however, need neither favour a naturalist nor normativist account of
10
these notions: the ‘winner’ of this game is likewise determined - as with anything else
in experimental philosophy - empirically.
11
There are two possible results for a study in experimental philosophy of
medicine on the concepts of health and disease: either we find substantive agreement
among the public, medical practitioners, bioethicists and biomedical scientists, or we
find that there is substantive - perhaps insurmountable - disagreement. If we can
widen the number of uncontroversial paradigm cases of disease (and uncontroversial
paradigm cases of non-disease states) we should at least be able to foster more
agreement within the conceptual literature on health and disease. Since any successful
analysis would require covering these cases, we could at least minimize the ILP. It
would only constitute a dice-loading problem if we have any a priori reasons to think
that the empirical data supports naturalism. But this is not so since experimental
philosophy of medicine might just as well reveal that there is barely any consensus
on the concepts of health and disease. This would make the case against naturalism
much stronger, favouring those normativist accounts that relativise the concept to
human interests and cultural dynamics. Let me therefore turn now to examine both
possibilities.
3.3 Pluralism and Elimination
Robinson et al. [13] and Beebe and Dellsén [14] have shown that scientists in different
fields not only hold different methodological standards, but also interpret
philosophical concepts such as objectivity and realism in widely different ways.13 This
is relevant for the concepts of health, disease, and pathology insofar as they could
hold different meanings in medical practice, paleopathology, immunological research,
bioethics, evolutionary biology, and wider public use. If we were to use experimental
methods to investigate whether scientists and medical practitioners fall more into the
normativist or naturalist camp, it is important to consider the nature of the questions
we ask. If we were to employ a simple survey-based methodology asking participants:
11
An anonymous reviewer objected that the usage of scientific methods might favor, rather than
negatively affect the normativist position. For example, if one can empirically show that there are no
necessary and sufficient conditions for a given state to be classified as a disease, then the normativist,
rather that the naturalist, claim is validated. There are two replies to this. Firstly, the worry is that
naturalist methods favour naturalist conclusions. If the opposite was true there wouldn’t be much of
a problem since naturalists should then happily endorse normativism - for it follows from naturalist
reasoning. Secondly, it is not true that a failure of science to provide necessary and sufficient
conditions for disease implies a failure for naturalism. The biological world simply doesn’t lend itself
to simple definitions in terms of necessary and sufficient conditions, so we may very well have to
amend our concept of disease if it fails to map unto its counterpart in the natural world.
13A difference that they show to be especially pronounced between the social and natural sciences,
thus making scientific integration difficult.
11
Is health an objective measure? and the large majority of participants across these fields
were to respond with ‘yes’, we may still not have learned much about the concept of
health held by the participants. This is because the concepts of ‘objectivity’ and
‘measurement’ are likely to differ between different disciplines. The behavioral
economist George Loewenstein, for instance, noted that economists seem to have a
much more thorough and empirically supported take on what they consider a ‘theory’
as compared to what psychologists seem to understand when they use the term.
12
Similarly for diverging results that may arise for different fields: what may be seen as
a difference in how, for instance, paleopathologists and medical practitioners
understand the concept of disease might be an artefact of differences in what they
consider to be ‘objective measures’. These difficulties are not insurmountable, but it
is important to recognize them when designing appropriate questionnaires.
Further, Robinson et al. [13] note that such questions may be ambiguous in
that it is not clear whether scientists are asked to make judgements about a concept
such as the gene across the sciences or in their specific field. Such challenges should
be taken seriously prior to experimental design, for they could seriously hinder the
descriptive analysis experimental philosophers are trying to achieve. Their answer to
this problem is that the results would still be meaningful since it would be both the
natural scientists and the social scientists who interpret the question as either one
about science in general or their specific discipline. But this is only an assumption. A
medical practitioner might have a conception of disease that they take to hold
generally across all disciplines. A paleopathologist on the other hand, might have a
much more narrow understanding and see talk about disease and health as discipline-
relative. A veterinarian working in the agricultural industry might understand animal
health as something distinctive, relating narrowly to something that reduces farming
yield.
13
Here, the usual criteria for informative scientific surveys such as sufficiently
large sample sizes apply.
14
One possible way of avoiding some of these problems, is to engage in
a particular form of experimental philosophy that, as Nagatsu [45] has pointed out,
has become the standard within experimental philosophy of science, i.e. factorial surveys
as introduced into sociology by Peter Rossi [46]. These quasi-experimental survey
methods employ vignettes, (i.e. concrete hypothetical descriptions) that are intended
to capture the participants’ implicit norms and concepts, while allowing for a sort of
12
From personal conversation.
13
Animal welfare has historically been understood in this narrow way of physiological health or well-
functioning [41-43].
14
Though what may be assumed to be a necessary requirement of experimental design has not
stopped publication of various experimental philosophy papers with astonishingly small sample sizes
[44].
12
experimental manipulation of variables.
15
Popularized within social psychology
research, this method can usefully be applied to capture the diversity of
conceptualizations in the biomedical sciences. Yet, it would take too much space to
go into detail here, requiring a paper of its own.
One straightforward prospective way of testing the intuitions of participants is
to confront them with descriptions of potential diseases in animals. The intuitions of
the public may support either normativism or naturalism in these cases. Naturally,
the views of the public may differ when compared to the views of medical
practitioners, veterinarians, or evolutionary biologists. If there is no conceptual
divorce between animal and human health, there will appear at least three options on
the table: Either animals cannot be diseased and this is just a social construction or
purely biological difference, where humans are different and we merely engage in
some sort of “sympathetic digression” from man to animal (Canguilhem [47]),
16
or
people will think human diabetes should be understood precisely the same as canine
diabetes. One pathway for testing these issues, may be to confront participants with
the discovery that there are virophages (i.e. viruses that infect other viruses) and test
whether this changes their intuitions as to whether viruses can be sick, especially
when we expose them to quotes by microbiologists such as Jean-Michel Claverie who
argues that “[t]here’s no doubt this is a living organism. The fact that it can get sick
makes it more alive.” ([52], p. 677) [italics added for emphasis]. Examples such as
these are likely to be counter-intuitive to most people, even scientists not working in
microbiology, undermining the idea that experimental philosophy would lead to a
dice-loading problem. By adjusting and comparing examples in different samples, e.g.
broken leg in humans vs dogs vs broken wings in birds, we should be able to test
whether we are just anthropomorphizing animals with high degrees of similarity to
us, or whether disease judgements prevail even in cases considered controversial in
the literature (e.g. plants).
What should we do if our analysis shows that there is no consensus? Here, the
idea of a conceptual ecology will be helpful [2]. One result we may encounter is a diversity
of different conceptualizations of disease even within the different biomedical
sciences. Veterinarians, for instance, may reveal a different concept of animal
pathology than do evolutionary biologists. When experimental philosophy is used to
reveal such differences in how different groups of people or scientists think, we can
finetune the experiments to figure out what the epistemic purposes of a concept are
in a particular group of scientists, i.e. the epistemic niche. If there is a unified concept
15
See Nagatsu [45] for a longer description and analysis.
16
Note that Canguilhem did not hold that animal diseases are a mere social construction and I have
highlighted the importance of a phenomenological view of animal health and suffering elsewhere [48].
To tie the concept of health to the notion of subjectivity, however, might lead us to restrict these
concepts to all and only those animals deemed conscious, thus transforming the debate into an even
more perplexing one about the boundaries of animal sentience [49-51].
13
among veterinarians we can conceive of two extreme cases: either the concept is
merely constructed for human purposes such as animal farming and slaughter, thus
classifying animals as pathological would be akin to the way in which drapetomania was
hypothesized as a disease that explained why African slaves fled from captivity; or
despite the involvement of human interests and funding for research into minimizing
pathologies that cause a loss of yield, we find that there is no differences in how
biologists treat the concept, i.e. in a purely objective way. The possibilities are
manifold.
What such an analysis would reveal, however, is that there might not be a single
unified concept for health and disease. Insurance companies, politicians, medical
practitioners, evolutionary biologists, veterinarians, and the public might all have
different conceptions of what it means to be diseased - thus revealing that the concept
serves a variety of purposes that can perhaps not be accomplished by a single
concept. Normativists, such as Kukla [28], are predominantly interested in the roles
the concepts of health and disease play for the purposes of justice, with some thus
arguing that the purely naturalist conceptions of health and disease need to be
eliminated since it is a mere misapplication/anthropomorphism of the concept.
Boorse, on the other hand, has argued that we’d be better off eliminating the idea
that the concept of disease has any necessary connection to concerns about who
deserves treatment or not (Boorse [21,22]). Some bioethicists, myself included, have
even argued that the concept of disease plays no special role regarding who deserves
treatment or medical resources more generally, focusing on the notion of
‘enhancement’ instead [53-58], thus suggesting that a ‘normativist’ account of health
and disease may even be abandoned.
But as Brigandt [59] argued in the case of the species concept, pluralism need
not imply eliminativism. We may very well become pluralists and live with different
concepts or models of health.
17
Elsewhere, I have argued for a distinction between
two kinds of conceptual engineering: moral conceptual engineering and naturalist
conceptual engineering [69]. Whereas these goals go nicely together in the case of a
concept such as wellbeing or welfare, the concepts of health and disease may simply
be used for two different purposes - thus requiring a division. Boorse [19], for
instance, has initially argued that we may have different concepts of ‘disease’ and
‘illness’ respectively. One possibility would thus be to have a biological disease
concept called pathology, while a disease concept used for purposes of resource
allocation may continue to use the term disease or disability, in a sort of Wakefield-
style [23] combination of naturalism and normativism, i.e. dysfunction + welfare
17
As I have argued in the case of models for empirical phenomena more generally [60-65]. Notions
such as ‘autism’ [66,67] and ‘welfare’ [65,68] may not be able to be captured within a single concept
or model since the underlying phenomena are too disunified, trying to map onto both normative and
natural features of the world, and the same may hold in the case of health and disease.
14
loss.
18
Here, it is not clear whether both normativists and naturalists should be
considered winners or losers, but a divorce of the two disease concepts may not be
as problematic as initially thought. If XPhi helps us to resolve the needlessly hostile
dichtonomy between ‘normativists’ and ‘naturalists’ by undermining the very idea
that there is a single concept out there that conceptual analysis could help us to
discover, then all the better for my case for an empirical approach to these issues. Let
us now turn to the possibility that our empirical investigations reveal consensus
across scientists, medical practitioners, and the public.
3.4 Unification
Perhaps a more optimistic result of experimental philosophy of medicine would be
the straight-forward expansion of uncontroversial cases of diseases. If not resolving
the controversy between naturalists and normativists, such a result should bring both
groups closer together. There is a sense here in which experimental philosophy of
medicine would indeed support naturalist conceptions. If experimental methods such
as surveys show broad agreement across different domains (including the biomedical
ones), the extension of the concepts health and disease will likely become expanded
to include animal pathologies. But as Matthewson and Griffiths [25] argue in their
defense of naturalism, some versions of normativism would force us to accept
“conceptual divorce between human disease and pathology as a biological
phenomenon” (p. 451). If the naturalist account can account for all these cases in
addition to the more narrow prior paradigm set, while normativism cannot, a strong
case is made for naturalism. A broadening of the cases our linguistic community
considers to be diseased would then imply a failure of at least some versions of
normativism that have neglected talk of the pathological in the non-human realm.
They could no longer claim to offer the superior conceptual analysis if they fail to
capture the paradigm cases of health and disease in the non-human realm. What some
normativists might thus be worried about is the possibility that disease
categorizations show large conformity, undermining the idea that the concept needs
to be relativized to the interests of particular communities. Yet, I am doubtful that
such an analysis would rule out all versions of naturalism or normativism. What
remains in such a scenario will most likely be some kind of hybrid account that
requires a biological failure with some room for social considerations, because many
people would not consider conditions such as vasectomy for example, to be a disease.
18
I have reservations against Wakefield’s view because it makes it hard to discuss tradeoffs of health
and wellbeing that are clearly important in all kinds of bioethical debates, from something as straight-
forward as the potential injuries caused in mixed martial arts [70] to something as controversial as de-
extinction [71]. Many debates in animal ethics are likewise centered around the question whether it
matters whether we injure and kill other animals if they cannot feel pain [72]. Health and wellbeing
can come apart.
15
If there is a large degree of unity, such an approach may thus also allow for a bridging
of naturalism and normativism by investigating “(i) which dimension(s) weigh more
and (ii) whether and how different dimensions are interacting” (Nagatsu [45], p. 266).
Indeed, we view this investigation of conflicting intuitions as the most interesting
avenue for future empirical work in the philosophy of medicine. Having discussed
the potential outcomes of experimental philosophy of medicine, let us now place
them in their broader context and conclude the discussion.
4 Discussion
A core motivation of experimental philosophy is to shift the philosophical
community’s perception of philosophy itself away from the methodological idea that
philosophy is about a specific set of tools and towards a more content-based
conception of philosophy as a discipline that is interested in more abstract and
conceptual questions. In this paper, I have argued that it was a mistake to think of
what is perhaps the oldest debate within the field - i.e. the question of how to
understand health, pathology, and disease - as a debate that could be solved with
conceptual analysis alone. Indeed, it is doubtful that pure intuition-play is what many
philosophers are really interested in (despite statements to the contrary). When
philosophers claim to use conceptual analysis, but proceed to engage in what
Lemoine [15] calls extensional stipulation, i.e. the inclusion of “cases of consensually
healthy conditions” [e.g. pregnancy] or an exclusion “consensual diseases from the
set of diseases” [e.g. cancer] (p. 318), they cannot be engaged purely in conceptual
analysis – they are doing something else.
Fields such as bioethics and medical ethics originally had a very strong
connection to the philosophy of medicine, yet have become much more empirical
over the years, drawing on surveys, interviews, and other scientific tools to improve
their investigations. Philosophers of medicine are well-advised to follow suit. While
I have only discussed surveys here, partially because they are the method most
directly associated with experimental philosophy and have a straightforward use in
the philosophy of medicine concerning the concepts of health and disease, we should
be wary not to narrow the possible empirical tools philosophers of medicine could
import. Machery [6], for instance, highlights that experimental philosophers can also
rely on a diverse range of cliometric and bibliometric techniques (e.g. machine
learning and topic modeling). A more thorough overview to how different empirical
tools could be applied in the philosophy of medicine is offered in the editorial to this
special issue. Much of recent philosophy of medicine is closer to the philosophy of science
in practice and philosophy IN science movements that seek to be more naturalist,
pragmatic, and fundamentally close to science, than hitherto purely armchair
investigations. Questions such as how medical practitioners see, use, and evaluate
concepts such as health, pathology, and disease, are important to the philosophy of
16
medicine. Yet, these questions cannot be answered by mere armchair speculation.
They require investigative empirical methods. Even something as scientifically
contested as anecdotes would constitute better evidence than the mere intuitions of
a single philosopher [73].
Here, it is nevertheless important not to demand too much from experimental
philosophy. Conceptual analysis must proceed from shared paradigm cases for it to
bring forth resolution. The more shared paradigm cases there are (to which XPhi
may add), the farther we can get with conceptual analysis. There is plenty of space
between no influence and a complete resolution of a philosophical debate. The latter
rarely occurs for most, so it would be overdemanding to criticize XPhi for failing to
resolve major debates entirely. A failure of resolution is not the same as the absence
of progress.
One should therefore not expect a definite and unique answer on whether
normativism or naturalism is right. Experimental philosophy may very well call into
question the very foundation of the debate by empirically investigating the intuitions
that have given rise to it. The conflict might be settled in the favour of one side,
pluralism, or unification. I don’t want to commit myself here to one of these pathways
precisely because this is also an empirical matter, not a purely conceptual one. That
we already have all the empirical knowledge required for engaging in the philosophy
of medicine is a hope that needs to be abandoned. I can only hope that others will
take up this baton and move the debate further.
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