Experimental Philosophy of Medicine and the Concepts of Health and Disease

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.

Full text

Vol.:(0123456789)
Theoretical Medicine and Bioethics (2021) 42:169–186
https://doi.org/10.1007/s11017-021-09550-3
1 3
Experimental philosophy ofmedicine andtheconcepts
ofhealth anddisease
WalterVeit1
Accepted: 30 October 2021 / Published online: 1 December 2021
© The Author(s) 2022, corrected publication 2022
Abstract
If one had to identify the biggest change within the philosophical tradition in the
twenty-first century, it would certainly be the rapid rise of experimental philosophy
to address differences in intuitions about concepts. It is, therefore, surprising that the
philosophy of medicine has so far not drawn on the tools of experimental philosophy
in the context of a particular conceptual debate that has overshadowed all others in
the field: the long-standing dispute between so-called naturalists and normativists
about the concepts of health and disease. In this paper, I 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]
Introduction
If one had to identify the biggest change within the philosophical tradition in the
twenty-first 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 intuitions of so-called armchair philosophers has led to a wealth of stud-
ies on the intuitions of the public concerning a diverse range of philosophical sub-
jects in epistemology, ethics, metaphysics, and even aesthetics. The field has quickly
* Walter Veit
wrwveit@gmail.com
1 Charles Perkins Centre, University ofSydney, Sydney, Australia
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grown into a lively community but faces criticisms from both inside and outside the
discipline of philosophy.
Owing to an array of defences by respected philosophers of science, experimental
methods have become increasingly common and accepted within the philosophy of
science (see [2–6]). While this has led to major changes in thinking and a more plu-
ralist 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 subdiscipline of philosophy of science in which experimental
philosophy is notably absent: the philosophy of medicine. I 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 given that 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 studies 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, one particular conceptual debate has overshadowed all others in the phi-
losophy of medicine: the long-standing dispute between so-called ‘naturalists’ and
‘normativists’ about the concepts of health and disease—specifically, whether these
terms refer to value-free scientific concepts or value-laden social ones. But as the
quotation from Daniel Dennett in the epigraph of this paper is meant to illustrate,
the very notion that a theory of health and disease could be developed by reference
to one person’s intuition alone strikes me as quite strange if not absurd, and yet this
seems to be the dominant view in the philosophy of medicine with mere intuitions
of different philosophers being traded. This is where experimental philosophy has a
useful role to play by gathering empirical data about the intuitions of a much broader
class of people. In this paper, I shall defend and advocate the use of empirical meth-
ods to inform and advance the conceptual discussion of health and disease 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: It begins in the next section by offering a brief
sketch of the philosophical literature on health and disease and articulates a prob-
lem for traditional conceptual analysis that I dub the intrinsic limitation problem,
following Maël Lemoine [15]. Then the methods of experimental philosophy are
introduced as a necessary solution to this problem and several of the objections
philosophers of medicine are likely to raise are addressed before concluding with a
discussion.
Conceptual analysis ofhealth anddisease
The central question within the philosophy of medicine is how to define and under-
stand 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). Tradition-
ally, the contenders within this debate have been grouped into two opposing camps:
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naturalists, who try to ground the concepts in objective biological facts, and norma-
tivists, who argue that these concepts cannot be grounded purely in objective facts
about science because they are ultimately value-laden (depending on the human
viewpoint) or culturally relative.1 While this characterisation offers only a simpli-
fied and coarse-grained picture of the multifaceted debate on these concepts, it will
be sufficient for my present purposes, since I simply aim to show that the traditional
philosophical method of trying to resolve this debate—conceptual analysis—is
likely to remain unsuccessful. I am not making any claims regarding the sensibility
of the dichotomy in terms of which the debate has been historically framed. Whether
one should be an eliminativist, pluralist, or unificationist 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 Lemoine’s recent critique of con-
ceptual analysis as a starting point.
The intrinsic limitation ofconceptual analysis
Traditionally, conceptual analysis, or the descriptive analysis of concepts, has been
assumed to play the central—if not the only—role in settling the conflict between
naturalism and normativism on the meaning of health and disease. The two most
influential naturalist accounts in this debate, Christopher Boorse’s bio-statistical the-
ory and Jerome Wakefield’s harmful dysfunction analysis, have made explicit refer-
ence to conceptual analysis in their methods [19–23]. Boorse, for instance, states in
his 1997 essay: ‘twenty years ago, in four papers, I offered a unified descriptive anal-
ysis of health, disease, and function’ [21, p. 4]. Historically, most of the contributors
to the discussion have paid little if any attention to the meta-philosophical question
of whether this method is an appropriate one. As Lemoine points out, ‘all partici-
pants implicitly agree about the utility of conceptual analysis to settle the debate’
on how disease should be defined [15, p. 316].2 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 do not try to capture the meaning of the terms as used
by the public but specifically try to revise the concepts of health and disease for the
purposes of science and justice, respectively [25–29]. Most of what has been pub-
lished in this debate, however, squarely falls under the rubric of conceptual analysis.
Since I am interested in the intrinsic limitation problem identified by Lemoine
[15], according to which conceptual analysis cannot rule out stipulations about a
term’s internal content, I will follow his formalisation of this methodology in order
1 Despite the existence of these two camps, one should not think of either as particularly unified. The
positions of normativists in particular share very little family resemblance aside from their unified dis-
missal of naturalistic approaches to health and disease. These anti-naturalists reject Dennett’s dictum of
‘Darwin’s universal acid’ that natural selection leaves none of our folk concepts unchanged [17, 18].
2 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).
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to make the problem visible.3 When philosophers are interested in the conceptual
analysis of a term—be it ‘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 collections of particular instances, such that a new stimulus
is classified as a member of a given category if it bears a strong enough context-
dependent similarity to the sum of the remembered instances, or exemplars, con-
tained within that category [30]. While this strategy of intuitive categorisation might
be enough in common practice to categorize pathologies such as an infection, it is
unsatisfying to most philosophers of medicine who want a theory of health and dis-
ase.4 Instead of simply comparing new cases against a set of uncontroversial cases
of health or disease, philosophers aim to construct a definition from the latter. This
definition must provide the necessary and sufficient conditions by which a case can
be classified as healthy or pathological and may include exceptions to these criteria
in order to provide against easily constructed counterexamples [15, p. 310]. With a
successful definition of health or disease in place, philosophers should be able to
place controversial cases either inside or outside the set of instances designated by
the term (called its extension). Progress, it is assumed, proceeds by subjecting these
definitions to attacks that would warrant their revision or replacement in hopes of
coming closer to the correct account of health and disease. Lemoine identifies three
distinct kinds of attack to that effect:
(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. [15, p. 310]
Boorse characterises this back-and-forth process of definition and attack as a
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’ [21,
p. 44]. And this game sure has had many contenders. Despite being doubtless the
most discussed work in the literature, Boorse’s decades-old bio-statistical theory—
first introduced in 1977 [20]—is far from well accepted. While there have been
slight amendments to Boorse’s original account, the continual assault against it in
the literature is hardly indicative of a process apt to culminate in the establishment
of a single prevailing definition: there are now more accounts rather than less. One
might thus question, then, whether the participants in this discussion are actually
following the supposed rules of conceptual analysis, according to which one wins
4 It may be similarly unsatisfying to policymakers, funding agencies, and insurance companies faced
with the 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 does not lend itself
to sharp distinctions. Naturalist accounts of health and disease may thus permit a higher degree of inde-
terminacy than normativist ones.
3 Lemoine’s analysis of conceptual analysis is based on the work of Christopher Boorse [20–22], Len-
nart Nordenfelt [31], and Jerome Wakefield [23, 32].
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the debate by ‘eliminating the other contenders’ definitions and not having one’s
definition eliminated’ [15, p. 311].
Nonetheless, as Lemoine shows, these rules seem to play a core role in the work
of Boorse, Nordenfelt, and Wakefield; all of them ‘(1) propose a definition of health,
disease, or both, (2) give examples of actual diseases, (3) examine apparent coun-
ter-examples, and (4) offer counter-examples to the contending proposals for defini-
tions’ [15, p. 311]. Definitions are often argued to be either too narrow, excluding
conditions considered to be diseases (such as septicaemia, asthma, or atheroscle-
rosis), or too broad, including conditions that would preferably not be labelled as
diseases (as in the pregnancy example above). Lemoine observes that for this kind
of analysis to eventually lead to success, or at least make progress, there needs to be
some manner of consensus among participants in the debate as to which conditions
count as healthy or pathological. But the need for such consensus extends only to
the clear cases a concept is intended to capture—since controversial cases can eas-
ily be dismissed as unclear out of hand, it is the inclusion of consensually healthy
conditions or exclusion of consensually diseased conditions that is damning for a
definition of disease. In that way, the argumentative process of conceptual analy-
sis will not lead to a definition that rules controversial cases in or out. As Lemoine
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]. Insofar as multiple different definitions of a concept are left standing in the
face of uncontroversial counterexamples, then, conceptual analysis alone will not be
able to settle the game and pronounce a winner. This is an ‘intrinsic limit of con-
ceptual analysis’: it cannot rule out specific claims about how a concept should be
defined [15, p. 316].
Whether the solution to the conceptual controversy about health and disease is
found in the naturalist or normativist camp cannot be established using conceptual
analysis if both sides can offer accounts that cover the uncontroversial cases equally
well. I see no a priori reason to doubt that there is conceptual room on both sides
for such definitions. The debate is thus, as Lemoine argues, ‘hopelessly unlikely to
decide between two reasonably successful definitions of “disease” or “health”’ [15,
p. 323]—that is, if its participants limit themselves to conceptual analysis alone.5
Lemoine concludes his paper with the declaration that ‘in order to prove naturalism
or normativism right, another method has to be embraced’ [15, p. 324]. I shall fol-
low this call for action and introduce another method in the philosophy of medicine
that can make empirically supported judgments regarding intuitions about and uses
5 This is not to deny that conceptual analysis may have contributed positively to the conceptualisation of
health and disease—progress that some will surely use 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
pertaining to 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 in this piece
is merely to encourage philosophers of medicine to embrace a wider toolkit of methods in order to settle
the questions they are interested in.
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of concepts in the public domain and medical profession—namely, experimental
philosophy (sometimes abbreviated as x-phi or XPhi).6
Experimental philosophy totherescue
That Lemoine’s call for an alternative method can be used to offer a defence of
experimental philosophy of medicine comes as no surprise. The criticisms Lem-
oine brings forward against conceptual analysis have been echoed in similar form by
many naturalist philosophers, and especially those that advocate the use of empiri-
cal methods. Experimental philosophers (among others) have long criticised the
tendency of philosophers to rely on their own intuitions to posit the meaning of a
term, rather than the intuitions of the general population whose usage they are sup-
posedly capturing [36]. Here one might legitimately wonder whether intuitions—be
they philosophical, scientific, or lay—are actually helpful to understand the target of
a concept. Why should it be assumed that mere intuitions can help settle these con-
ceptual questions, especially those of broader (non-specialist) populations?
Unfortunately, experimental philosophy is often narrowly understood as the use
of surveys to capture the intuitions of the public, rather than as a more general view
of philosophy as a discipline continuous with the sciences and thus apt to use empir-
ical data to inform its debates. A naturalist understanding of the x-phi critique of
conceptual analysis turns the usual critique of x-phi on its head. Rather than criticis-
ing the use of empirical methods to address philosophical issues as something that
is not philosophy, a naturalist criticises philosophical debates for a lack of empirical
tools. In promoting x-phi, I aim to spark an empirical turn in the philosophy of med-
icine similar to the one initiated by Dennett in the philosophy of mind. In his words:
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. [37]
What I am advancing here is not merely the uncontroversial claim that empiri-
cal methods can improve debates in the philosophy of medicine, but also the more
substantial one that empirical methods are necessary to make progress in the gen-
eral conception of health, disease, and pathology. Understanding x-phi as part of
the larger project of naturalist philosophy makes it naturally fit with two distinct
6 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. Neverthe-
less, in a conference report, Lemoine etal. tentatively suggest that experimental philosophy could fruit-
fully be applied to the philosophy of medicine [34]. In my dissertation, in turn, I follow Lemoine’s call
for an attempt to naturalise the concepts of health and disease [35].
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naturalist critiques of conceptual analysis that are often brought forward against
x-phi: (i) concepts are not definitions and (ii) intuitions are a poor guide to under-
standing natural phenomena. First, x-phi may very well reveal that the way people
categorise the world cannot be captured in simple definitions made up of necessary
and sufficient conditions. But this finding would go to show only that conceptual
analysis has rested on mistaken assumptions, not that x-phi has somehow failed
because it cannot provide such conditions. Second, naturalists should be happy to
make a distinction between people’s psychological categorisations and the way the
world is. Conceptual analysis is sometimes ambiguously understood either as the
search for a concept’s essence or true meaning or as a mere set of ‘criteria of appli-
cation’ that actual humans use when employing certain concepts [38, p. 171], but
these goals are distinct. Naturalists can both engage in a scientific investigation of
how people end up with and employ concepts in communication with others and
their own thinking and engage in a scientific investigation of whether these concepts
map onto real phenomena in nature. Whereas Lemoine, along with others such as
John Matthewson and Paul Griffiths [25], abandons conceptual analysis in favour of
the latter approach—that is, grounding concepts in science [15, 39]—this paper will
advocate the former approach, using 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 where scientists’ intuitions diverge from their empirical findings,
as Griffiths and colleagues’ work on the idea of innateness and the gene concept ele-
gantly illustrates [7–10]. The once purely philosophical project of conceptual analy-
sis is thus replaced by two distinct investigations: one an empirical investigation of
the psychology and sociology behind our concepts, the other a scientific investiga-
tion of the phenomena these concepts supposedly map onto.7
Now, while it is surely justifiable to ask why one should be a naturalist 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 x-phi is notably absent.
Due to considerations of space, I give only a positive account, showing how experi-
mental philosophy could be used to improve the philosophy of medicine by discuss-
ing its most famous conflict. If this approach is meant to fail, its failure will likewise
have to be empirically demonstrated and not a priori asserted.
Conceptual analysis requires experimental philosophy
The primary argument for experimental—or, better yet, empirical—philosophy of
medicine is this: successful conceptual analysis in its nature requires empirical data.
Here a lexicographical approach is illustrative and shares a close connection to tradi-
tional conceptual analysis.
7 For more detail on the second of these options, see my article [40], parts of which are revised here.
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In the course of compiling a lexicon, lexicographers will select a list of exam-
ples representative of a word’s usage and then either organize these examples into
different senses or present a definition that covers all uses of the word. However, a
single definition is often not provided or may be stated in quite inclusive terms so as
to not exclude any examples. One reason for this is simply pragmatic: some lexical
items are applied in very different contexts in which they have different meanings
that cannot be unified under a single concept. The concepts of health and disease are
taken 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 as 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. Irrespective of
the tools philosophers use to get a grasp on these shared intuitions—whether they
rely on interviews, surveys, bibliographic data, or participation in or observation
of conversations about health and disease—even the very use of a lexicon to begin
one’s conceptual analysis is empirical (though one might prefer to call this ‘light
x-phi’ compared to more sophisticated and empirically demanding quantitative or
qualitative studies).
Experimental philosophy isnotphilosophy
With this in mind, I will turn to a frequent challenge brought against experimen-
tal philosophy—that while it may be useful, it does not qualify as philosophy. One
might then argue that philosophers should minimise their use of empirical methods
accordingly, insofar as engaging in them would take time away from doing ‘real’
philosophy. This challenge, however, is no obstacle to the necessity of the kind of
work advocated and carried out by those within the experimental philosophy com-
munity: if empirical methods such as surveys do not count as philosophy, then nei-
ther will opening a lexicon or reading medical papers. There is no line to draw here.
The semantic dispute about whether or not this work should be called philoso-
phy does not matter. It is work that needs to be done in order to make progress on
philosophical questions. Yet sociological, psychological, or scientometric studies
on the concepts of biomedical scientists or the public are relatively rare. After all,
non-philosophers are generally not interested in particularly philosophical questions
(with, perhaps, the exception of moral psychologists). So if good empirical evidence
is necessary for conceptual analysis to be successful, and such empirical evidence is
not otherwise collected, then philosophers occupied in conceptual debates may very
well be forced to utilise the toolkit of science—that is, if they are ultimately inter-
ested in answering their philosophical questions and not merely engaged in a form
of philosophical play.
But how can experimental philosophy be used to address the intrinsic limitation
problem of conceptual analysis identified by Lemoine? As mentioned above, at the
core of any conceptual analysis of disease is a set of uncontroversial paradigm cases
that any proposed definition needs to be able to cover and plausibly also a set of
cases that it ought to exclude such as pregnancy. The present state of the debate
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suggests that the current set is too small to allow for a determinate winner or even to
make substantial progress. Empirical methods like surveys can be used to widen the
set of phenomena that must be accounted for under a given definition, particularly
in talk of pathology within the biomedical sciences which may provide further para-
digmatic cases that should be included.
One way of widening the set would be to confront the public with controversial
cases of diseases at the forefront of the conflict between normativists and natural-
ists. Another would be to expand the set of paradigm cases by considering the intui-
tions of the scientific community regarding the nature of medical conditions such as
diabetes, autism, and viral infections that do not cause any felt harm but are never-
theless harmful to the organism (e.g., mosaic virus 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 natu-
ralistic methods could appear to unfairly shift the debate in favour of naturalism,
especially when directly investigating the intuitions of scientists rather than the pub-
lic at large. Expanding the set of paradigm cases to encompass any sense of pathol-
ogy in science might offer the impression that the game has become rigged, in that
many normativists believe that the definitions of health and disease should be based
not on scientific practice but on the common understanding of these notions. This
potential for rigging the game by giving preferential treatment to the folk under-
standing of health and pathology might be called the dice-loading problem of
naturalist experimental philosophy. Yet I contend that the dice-loading problem is
immaterial insofar as experimental methods need favour neither a naturalist nor a
normativist account of health and disease: the ‘winner’ of the conceptual game is
determined—as with anything else in experimental philosophy—empirically.8
There are two possible results for a study in experimental philosophy of medicine
on the concepts of health and disease: either there is found to be substantial agree-
ment about the extension of these terms among the public, medical practitioners,
bioethicists, and biomedical scientists or there is found to be substantial—perhaps
insurmountable—disagreement. Finding consensus that increases the number of
uncontroversial paradigm cases of disease (and uncontroversial paradigm cases of
non-disease states) should at least be able to foster more harmony within the con-
ceptual literature on health and disease. Since any successful analysis would be
required to cover these cases, the intrinsic limitation problem could be minimised.
8 An anonymous reviewer objected that the use of scientific methods might favour, 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. First, the worry is that naturalist methods
favour naturalist conclusions. If the opposite were true—that naturalist methods favour normativist con-
clusions—there would not be much of a problem: naturalists should then happily endorse normativism
for it follows from naturalist reasoning. Second, it is not true that a failure of science to provide neces-
sary and sufficient conditions for disease implies a failure for naturalism. The biological world simply
does not lend itself tobasic definitions in terms of necessary and sufficient conditions, so the concept of
disease may very well have to be amended if it fails to map onto its counterpart in the natural world.
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The use of experimental methods would create a dice-loading problem only if there
were a priori reasons to think that the empirical data would inherently support one
view over another. But this is not so: experimental philosophy of medicine might
just as well find that there is barely any consensus on the concepts of health and
disease. Finding such a lack of consensus would make the case against naturalism
much stronger, favouring those normativist accounts that relativise the concept to
human interests and cultural dynamics. Let me turn now to examine both possibili-
ties—finding disagreement and finding agreement, respectively.
Pluralism andelimination
Brian Robinson etal. and James Beebe and Finnur Dellsén have shown that sci-
entists in different fields not only hold different methodological standards, but also
interpret philosophical concepts such as objectivity and realism in very differ-
ent ways [13, 14].9 An anecdote is useful here: the behavioural economist George
Loewensteinobserves that economists seem to have a much more thorough and
empirically supported take on what constitutes a ‘theory’, for instance, as compared
to how psychologists understand the term.10 Suchobservations are relevant to the
project of experimental philosophy of medicine insofar as the use of terms that have
different meanings in medical practice, paleopathology, immunological research,
bioethics, evolutionary biology, and wider public use could impact on the nature
of results pertaining to the concepts of health and disease. In using experimental
methods to investigate whether those in different fields fall more into the normativ-
ist or naturalist camp, then, it is important to consider the nature of the questions
asked. For example, if a study were to employ a simple survey-based methodology
asking ‘Is health an objective measure?’ and find that the vast majority of partici-
pants across fields respond ‘yes’, this concurrence still might not reveal much about
the concept of health held by the respondents, given that the concepts of objectivity
and measurement are likely to vary among disciplines. The same goes for diverging
results that may arise between fields: what initially appears as a difference in how,
for instance, paleopathologists and medical practitioners understand the concept of
health might really be an artefact of differences in how they conceive of ‘objective
measures’. These difficulties are not insurmountable, but it is important to recognise
them when designing appropriate questionnaires.
Further, Robinson etal. note that questions probing scientists’ intuitions may be
ambiguous to the extent that it is unclear whether participants are being asked to
make judgments about a concept like the gene across the sciences or within their
specific field [13]. Such challenges should be taken seriously prior to experimen-
tal design, for they could seriously hinder the descriptive analysis experimental
philosophers are trying to achieve. One answer to this problem is that the results
would still be meaningful since it would be both the natural scientists and the social
9 They show this difference to be especially pronounced between the social and natural sciences, thus
making scientific integration difficult.
10 From a class of his at Carnegie Mellon University.
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scientists who interpret the question as one about either science in general or their
specific discipline. But this is only an assumption. A medical practitioner might
have a conception of disease that she takes to hold generally across all disciplines,
whereas a paleopathologist might have a much more restricted understanding and
see talk about health and disease as discipline relative. A veterinarian working in
the agricultural industry might understand animal health in a distinctive way, nar-
rowly relating to factors that reduce livestock production.11 Here the usual criteria
for informative scientific surveys such as sufficiently large sample sizes apply.12
One possible way of avoiding some of these problems is to engage in a particu-
lar form of experimental philosophy that, as Michiru Nagatsu points out [45], has
become the standard within experimental philosophy of science—namely, factorial
surveys, as introduced into sociology by Peter Rossi [46, 47]. These quasi-experi-
mental survey methods employ vignettes, (i.e., concrete hypothetical descriptions)
that are intended to capture participants’ implicit norms and concepts, while allow-
ing for a sort of experimental manipulation of variables.13 Popularised within social
psychology research, this method has been applied fruitfully to capture the diversity
of conceptualisations in the biomedical sciences.
Confronting participants with descriptions of conditions in animals could present
a straightforward prospective means of testing their intuitions about health and dis-
ease. The intuitions of laypeople may support either normativism or naturalism in
these cases. Of course, 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, then at least three options
will appear on the table: (1) animals cannot be diseased and animal disease is just a
social construction, (2) biological differences exist between human and animal dis-
ease and to analogize them is merely to engage in some sort of ‘sympathetic regres-
sion’ from human experience to other living things [48, p. 223],14 or (3) there is
no relevant distinction between human and non-human disease and human diabe-
tes should be understood precisely the same as canine diabetes. One pathway for
navigating these options might be to confront participants with the discovery of
virophages (i.e., viruses that infect other viruses) and evaluate whether the exist-
ence of virophages changes their intuitions as to whether viruses can have diseases,
especially in response to statements about viruses by microbiologists such as Jean-
Michel Claverie, who argues that ‘there’s no doubt this is a living organism. … The
11 Animal welfare has historically been understood in this narrow way as physiological health or well-
functioning [41–43].
12 Nonetheless, what might 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].
13 See Nagatsu [45] for a longer description and analysis.
14 Note that Georges 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
[49]. 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 [50–52].
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fact that it can get sick makes it more alive’ (quoted in [53, p. 677]). Examples such
as these are likely to be counterintuitive 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—
for instance, broken leg in humans versus broken leg in dogs versus broken wing in
birds—one should be able to test whether we are just anthropomorphising animals
with high degrees of similarity to us or whether disease judgments persist even in
cases considered controversial in the literature (e.g., plants).
What if the analysis ultimately shows that there is no consensus? In that event, the
idea of a conceptual ecology will be helpfulin mapping out the different functional
roles of varieties of concepts [2]. One result that may be encountered is a diversity
of conceptualisations of disease, even within the biomedical sciences. Veterinarians,
for instance, might demonstrate a different concept of animal pathology than evolu-
tionary biologists. When experimental philosophy is used to reveal such differences
in how groups of people or scientists think, the experiments can be fine-tuned to
figure out the epistemic purposes a concept serves within a given group—that is,
its epistemic niche. If there is a unified concept among livestock veterinarians, one
can conceive of two extreme possibilities: either the concept is merely constructed
for human purposes such as animal farming and slaughter, in which case classifying
animals as pathological would be akin to diagnosing people with drapetomania (a
disease hypothesised to explain why African slaves fled from captivity); or despite
the involvement of various special interest groups and funding for research into min-
imising pathologies that cause a loss of yield, it is found that there is no difference in
how veterinarians and biologists treat the concept of disease—both approaching it in
a way that is purely objective. The possibilities are manifold.
What such an analysis would reveal, however, is that there might not be a single
unified concept of health or disease. Insurance companies, politicians, medical prac-
titioners, evolutionary biologists, veterinarians, and the public might all have differ-
ent conceptions of what it means to be diseased—thereby revealing that the notion
serves a variety of purposes that perhaps cannot be accomplished using a single con-
cept. On the one hand, normativists such as Kukla are primarily interested in the
roles the concepts of health and disease play for the purposes of justice [28], with
some arguing that the purely naturalist conceptions of health and disease should be
eliminated as mere misapplications or anthropomorphisms of these concepts. On the
other hand, naturalists such as Boorse argue that it would do better to eliminate the
idea that the concept of disease has any necessary connection to concerns about who
deserves treatment or not [21, 22]. Some bioethicists, myself included, have even
argued that the concept of disease plays no special role in deciding who deserves
treatment or medical resources more generally, focusing instead on the notion of
‘enhancement’ [54–59]; that way, a normativist account of health and disease might
even be abandoned.
However, as Ingo Brigandt argues in the case of the species concept, pluralism
need not imply eliminativism [60]. Scientists may very well embrace pluralism and
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Experimental philosophy ofmedicine andtheconcepts ofhealth…
learn to live with different concepts or models of health.15 Elsewhere, I have argued
for a functional distinction between two kinds of conceptual engineering: moral
conceptual engineering and naturalist conceptual engineering—the former aimed at
moral, social, or political ends and the latter undertaken for scientific purposes [70].
Whereas moral and scientific goals dovetail nicely for concepts such as well-being
or welfare, it is possible that concepts such as health and disease are simply used
toward disparate ends, thus warranting a conceptual division. Boorse, for instance,
has argued for a distinction between the concepts of disease and illness along those
lines [19]. Alternatively, one could posit a biological disease concept called pathol-
ogy, while reserving the terms disease and disability for a concept geared towards
resource allocation (e.g., dysfunction plus welfare loss), in a combination of natural-
ism and normativism à la Wakefield [23].16 In maintaining such distinctions, it is not
clear whether normativists and naturalists should be considered winners or losers.
Nonetheless, if x-phi can help to resolve the needlessly hostile dichotomy between
normativists and naturalists by challenging the very idea that there is in fact a single
concept to be discovered through conceptual analysis, then my case for an empirical
approach to these issues would be all the better. I will now address the possibility
that empirical investigation should instead reveal consensus across scientists, medi-
cal practitioners, and the public.
Unification
Perhaps a more optimistic result of experimental philosophy of medicine would be
the straightforward 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 that experimental philosophy of med-
icine may indeed support naturalist conceptions. If experimental methods such as
surveys show broad agreement across different domains (including the biomedical
ones), the extension of the concept of disease will likely expand to include animal
pathologies. But as Matthewson and Griffiths argue in their defence of naturalism,
some versions of normativism would entail accepting ‘conceptual divorce between
human disease and pathology as a biological phenomenon’ [25, p. 451]. If natural-
ism can account for all these cases of animal pathologies in addition to the narrower
prior paradigm set and normativism cannot, a strong case is made for naturalism.
Broadening the conditions that are considered diseased within a linguistic commu-
nity in this way would then imply a failure of at least some normativist accounts that
15 I have argued for this with respect to models of empirical phenomena more generally [61–66]. It
might not be possible to capture notions such as ‘autism’ [67, 68] and ‘welfare’ [66, 69] within a single
concept or model, since the underlying phenomena are too disunified, attempting to map onto both nor-
mative and natural features of the world. The same may hold for health and disease.
16 I have reservations against Wakefield’s view because his account makes it hard to discuss trade-offs of
health and well-being that are clearly important in all kinds of bioethical debates, from those as straight-
forward as the potential injuries caused in mixed martial arts [71] to those as controversial as de-extinc-
tion [72]. Many debates in animal ethics are likewise centred around the question of whether it matters
that we injure and kill other animals if they cannot feel pain [73]. Health and well-being can come apart.
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have neglected to consider pathology in the nonhuman realm. An account could no
longer claim to offer the superior conceptual analysis if it fails to capture paradigm
cases of health and disease in animals.
Some normativists might worry that the inclusion of animal cases could under-
mine the idea that the concept needs to be relativised to the interests of particular
communities or perhaps needs to be split to have one concept for humans and one
for non-human animals. Yet I am doubtful that encompassing animals in the exten-
sion of health or disease would serve to rule out all versions of naturalism or nor-
mativism. What remains in such a scenario will most likely be some kind of hybrid
account of disease, requiring biological dysfunction but with some room for social
considerations—for example, many people would not consider conditions such as
post-vasectomy sterility to count as a disease. If there is a large degree of unity
among the public, such an approach may 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’ [46, p. 266]. Indeed, I view this inves-
tigation 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, I will now situate them in their broader con-
text and conclude the discussion.
Discussion
A core motivation of experimental philosophy is to shift the philosophical commu-
nity’s perception of philosophy itself—moving 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 con-
ceptual questions. In this paper, I have argued that participants in what is perhaps the
oldest debate within the field—namely, the question of how to understand health,
pathology, and disease—are mistaken in thinking that a solution can be reached
using conceptual analysis alone. Indeed, it is doubtful that many philosophers are
actually interested in mere intuition play (despite statements to the contrary). When
in the course of conducting a descriptive analysis of concepts, philosophers proceed
to engage in what Lemoine calls extensional stipulation—namely, the inclusion
of ‘cases of consensually healthy conditions’ (e.g., pregnancy) or the exclusion of
‘cases of consensual diseases’ (e.g., cancer) from the set of diseases [15, p. 318]—
they are not purely using conceptual analysis; they are doing something else.
Fields such as bioethics and medical ethics, with strong historical ties to the phi-
losophy of medicine, have become increasingly empirical over the years, embracing
the use of surveys, interviews, and other scientific tools to improve their investiga-
tions. Philosophers of medicine would do well to follow suit. While I have limited
my discussion to surveys here—given that this method is most directly associated
with experimental philosophy and has straightforward application to the concepts of
health and disease in the philosophy of medicine—surveys are by no means the only
possible empirical tool philosophers of medicine could import. Edouard Machery
proposes that experimental philosophers might also avail themselves of a diverse
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Experimental philosophy ofmedicine andtheconcepts ofhealth…
range of cliometric and bibliometric techniques (e.g., machine learning and topic
modelling) [6]. A more thorough overview of how different empirical tools could
be applied within the philosophy of medicine is offered in the introduction to this
special issue [74]. Much of recent philosophy of medicine is closer to the ‘philoso-
phy of science in practice’ and ‘philosophy in science’ movements, which seek to
be more naturalist, more pragmatic, and fundamentally closer to science than tradi-
tional armchair investigations [75, 76]. Questions such as how medical practitioners
see, use, and evaluate concepts like health, pathology, and disease are important to
the philosophy of medicine. Yet these questions cannot be answered through intro-
spection alone. They require investigative empirical methods. Even something as
scientifically contested as anecdotes would offer better evidence than the mere intui-
tions of a single philosopher [77].
It is nevertheless important not to demand too much from experimental philoso-
phy[78]. Conceptual analysis must proceed from shared paradigm cases in order to
bring forth resolution. The more shared paradigm cases there are (to which x-phi
may add), the further the discussion can proceed with conceptual analysis. There
is plenty of space for improvement short of complete resolution of a philosophical
debate. The latter is rare, so it would be overdemanding to expect x-phi to resolve
major disputes entirely—and overblown to criticise it for failing to do so. An
absence of resolution is not the same as a lack of progress.
One should therefore not expect empirical methods to produce a definitive and
unique answer to the question of whether normativism or naturalism is right about
the concepts of health and disease. Experimental philosophy may very well call into
question the foundation of the debate itself by empirically investigating the intui-
tions that have given rise to it. The conflict might be settled in favour of one side,
pluralism, or unification. I do not commit myself to any one of these pathways pre-
cisely because the correct course is not just a conceptual matter, but an empirical
one too. That philosophers already possess all the empirical knowledge required for
engaging in conceptual debates like the one about health and disease is a fantasy
that needs to be abandoned. I can only hope that others will take up this baton in
furtherance of an empirical turn in the philosophy of medicine.
Acknowledgements I would like to thank Heather Browning, Katelyn MacDougald, two anonymous
reviewers, and the Theory and Method in Biosciences group at the University of Sydney for their com-
ments on my various versions of this paper.
Funding This research was supported under Australian Research Council’s Discovery Projects funding
scheme (project number FL170100160).
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit https:// creat iveco mmons. org/ licen
ses/ by/4. 0/.
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