Download - Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology
![Page 1: Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology](https://reader036.vdocument.in/reader036/viewer/2022080200/5750a7581a28abcf0cc05b59/html5/thumbnails/1.jpg)
Mahesh Ananth: In Defense of an Evolutionary Conceptof Health: Nature, Norms and Human Biology
Ashgate, 2008
Mathew George
Received: 20 December 2012 / Accepted: 7 January 2014 / Published online: 21 March 2014
� Springer Science+Business Media Dordrecht 2014
The concept of health has always been a debatable
aspect when WHO defines it as ‘not merely an absence
of disease but a state of physical, mental and social
wellbeing’. The ambiguity implicit in the second part
of the concept is still debatable. Health also described
through capability approach situating within the
context of Justice as well as productivity-based
approach that uses DALY as a way to understand
health, highlights the importance attached to the
concept. In philosophy of medicine, the debate has
been slightly different as to whether the concept of
health is value free and objective as claimed by
naturalists or as that embedded in the context that has a
greater bearing of what one qualifies as healthy as
argued by normativists. Though this debate appears to
be more of clinical significance, as an offshoot from
the field of philosophy of medicine its insinuation has
lot to offer in the current studies in the field of
sociology of health and illness that examines the social
production of disease and health care and even in the
field of bioethics. The book by Ananth on an
evolutionary concept of health is an attempt to
examine the concept of health grounded within the
debates in philosophy of medicine. He is absolutely
right in choosing the definition by Christopher Boorse,
one of the strong proponents from Naturalists stream,
which is still the dominant definition in the field
despite having faced several criticisms from the
normativists camp. It is interesting to find that the
forward for the book is written by H. Tristam
Engelhardt Jr., one of the strong proponents of
normativist camp on the concept of health. Not only
does the concept of health remain as a strong influence
in medical practice, but also is an important determi-
nant in the current discourse on public health and
health policy. The attempt by Ananth to address the
complexity of the concept of health needs to be
appreciated as it brings a better clarity on a complex
concept and also about disease acknowledging its own
limitations. This leaves scope for applying it not only
in the fields of public health but also informs the
engagement of biomedicine with other systems of
medicine. This may appear as an over emphasis, but
part of the reason could be due to the fact that the
implications of a minor orientation in the core concept
of health and/or disease can influence all the above
fields tremendously.
The book starts with an introductory note on the
concept of health and the various dimensions it
generates and confines his inquiry only to physical
health which he himself considers is capable of
informing other dimensions of health too. The above
inquiry to the concept of health offers new orientation
to other disciplines due to the trans-disciplinary
characteristic of the concept per se. Though Boorse
M. George (&)
Centre for Public Health, School of Health Systems
Studies, Tata Institute of Social Sciences, Deonar,
Mumbai 400088, India
e-mail: [email protected]
URL: http://www.tiss.edu/faculty/dr.-mathew-george/
123
Medicine Studies (2014) 4:113–117
DOI 10.1007/s12376-014-0088-9
![Page 2: Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology](https://reader036.vdocument.in/reader036/viewer/2022080200/5750a7581a28abcf0cc05b59/html5/thumbnails/2.jpg)
himself is a strong naturalist, predominantly basing
disease definition on statistical normality, Ananth
cautiously eschews this position. This is because
statistical normality only gives a picture of what is
normally present as a feature of any given group and
not necessarily what is healthy or unhealthy. This
becomes obvious when one considers tooth decay,
which can be a statistical normality but unhealthy. On
the other hand, there can be certain functions like
eyesight which can be exceptionally better than the
normal, thus abnormal but can be healthier for the
person. Thus, instead of defining health based on
statistical normality, it is argued that health has to be
defined based on the function of the organism as a
whole. The function in turn is understood considering
the ultimate goal of human body as survival and
reproduction, owing to evolutionary theory. The book
further clarifies that the function of the organism
implies part functionalism, only to the part of the
organism, possibly a lead to explain the reductionism
in biomedicine. It is against the above understanding
of function that health is understood as the capacity for
adaptation to the environment. Adaptation here
implies that human body is capable to engage with
the environment and has potential to retain its basic
capacity to remain fit (survive) and reproduce. This
form of adaptation can be positive in terms of
transforming the environment itself making it condu-
cive for human habitation. On negative terms, it is
understood as the incapacity of human beings to
survive in difficult situations leading to ill health. The
author thus highlights the characteristic of health as
being in homoeostasis with the environment. This
characteristic of health very well goes with Engel’s
(1977) concept of health which calls for a biopsycho-
social concept.
On examining the critique offered by Boorse
against the normative concepts of health, the author
examines the diverse versions of normativism, viz.
strong and weak, depending on the strength of
normativity attached to the concept of disease. In
both the cases, the value leadenness implicit in the
disease definition which considers disease as an
undesirable state by the normativists is highlighted.
For Boorse, irrespective of the fact that there is
undesirability attributed by the context/society, there
is physiological malfunction that is translated as
disease and according to him it is the illness that can
be undesirable. It is this understanding that can be
attributed to the conceptualisation of disease as
physiological and illness as sociological which in turn
propagates the nature/culture distinction more force-
fully. This conceptual distinction of illness, disease
and sickness has been critiqued by the constructivists
whose earlier proponent was young (1982) who argues
that disease too is contextually determined, as it is
always an outcome of the doctors’ subjective percep-
tion of patients’ symptoms. Additionally, in order to
distinguish the value leadenness in the concept of
disease, the author from the stand point of Boorse
argues that there are two versions of disease definition,
namely that follow the theory of biology and the latter
following the theory of clinicians. The former is
considered more scientific and free from any values,
whereas the latter could be based on the value of
clinicians and the patient’s context. This raises the
question of who is the right person to categorise a
person’s disease. As per Boorse, it should be the
biologist, which in the current context should be the
laboratory investigators or the physiologists and the
doctors role is secondary, which is value based. On the
other hand, isn’t it a feature that clinicians in the
process of becoming more scientific in defining
disease follows the theory of biology thereby greater
dependence to laboratory investigations and human
physiology than desired, a feature of ‘laboratory
medicine’, if one uses the category of Jewson
(1976)? The above question is left unanswered by
the author without taking a position on who should be
the right person, but the implications of this decision is
massive.
Thus, the concept of health in this book rules out
explanations based only on statistical normality and
those based on physiological dysfunction alone as
inadequate and considers those based on function
more acceptable. Though the chapter on function is
slightly tardy, but clarifies it by distinguishing it with
accidents in human life. The former distinction
between function and accident is based on the analysis
of the functioning of heart by the illustration that the
function of heart is pumping of blood during which
sound is also heard. The former becomes the real
function of the organ, and the latter is more of an effect
of the function which was not necessarily intended.
While understanding function of an organism or part
of human body, it is important to understand it based
on the design of the part and not just based on the
chronology of the events. Further functions per se are
114 M. George
123
![Page 3: Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology](https://reader036.vdocument.in/reader036/viewer/2022080200/5750a7581a28abcf0cc05b59/html5/thumbnails/3.jpg)
classified as conscious functions (artefact) and natural
functions (organism). This is based on the understand-
ing that there are certain functions of human beings
which were intended since its origin and there are
certain others which was developed in the due course
towards the goal of human body, which is survival and
reproduction. Another aspect of function that attains
relevance in this discussion is its nature, which Ananth
makes it explicit that it is part-functionalist that
Boorse refer to. Part-functionalist concept of health
implies that the function of the parts under consider-
ation is important irrespective of the function of the
human being as a whole. Here it is important to
understand the context in which the reductionist
approach of biomedicine is discussed within human-
ities, wherein the concept of health is understood as
being reductionist. Further, Ananth argues that Boorse
is more of an objectivist in two ways. First, Boorse
concept of health transcends beyond any cognitive
exercise and is treated as biological facts of nature.
Secondly, the concept of heath is contextual with the
disciplines from which it is explained which make him
a disciplinary objectivist. Thus, the concept of health
is biostatistical, functional and theoretical. By statis-
tical, it means the reference class which is the norm
that ultimately fixes the species and the age. By
functional, it is the part functional that is referred
earlier which says that any part of the body fails to
function against the intended activity which restricts
the functioning of the parts. By theoretical, Boorse
means the concept of health as defined by the
discipline of physiology. This is an important rejoin-
der as he makes clear distinction between the concept
of health used in physiology and in medicine, and he
considers the latter may get biased based on physi-
cian’s value and patient’s context. Here the question of
which concept of health needs to be used in the field of
public health? Is it possible to follow different
concepts of health, one for public health discipline
and the other for the discipline of medicine? If so then
how it will be different? Which direction that differ-
ence can be in the current context? Within medicine,
can there be a similar concept of health when
interpreted by physiologist or by a clinician?
Having engaged with the concept of health, Ananth
moves on to examine Boorse concept of disease which
is rooted in statistical abnormality and pathological
conditions which is based on part-function. Here it is
important to note that pathology itself is based on
statistical abnormality and pathological condition of a
part or parts of the body may or may not disrupt the
overall functioning of the body. This further takes to
the core of his argument which says that Boorse is
concerned about part-dysfunction and thus is a value-
free concept but again treating the pathological state of
a part-function as disease or not is based on one’s
circumstances and interests. Thus, with reference to
health there is no disagreement that it is absence of
part-dysfunction whereas ‘disease’ may or may not
have part-dysfunction whose final attribute is the task
of the physician, the art component, hence value
based. The discomfort with Boorse concept of health
and disease based on diverse logic is expressed by the
author through its critics. The explanation of function
and its basis attributed to survival and reproduction
become ambiguous when one examine ways by which
functional normality becomes a determinant of sur-
vival and reproduction. There could also be situations
where statistical normality does not always lead to
functional normality even though Boorse assumes it.
On the other hand, whether all functional abnormal-
ities can lead to disease situations or what can be the
role of context in deciding it. Taking the case of
baldness, which as per Boorse, is a part-dysfunction,
becomes normal when it is among the old-age men,
but if it is premature, then it becomes a disease. Thus,
the part-functionalist argument reasserts the earlier
characteristics of age, sex and species-specific func-
tions and therefore has to be in tune with the existing
norm. Going further, another criticism stemming from
the earlier is that in terms of explaining function it is
the part-functionalist approach, which is concerned
only about the part of the body that is affected against
its expected performance irrespective of the human
being or the species as a whole. On the contrary, while
considering the reference class or normal functioning,
the species-related function like age, sex and other
characteristics is taken into account. This contradic-
tion becomes severe when one examines the pathol-
ogist view of disease as different from the physician’s
view of disease. In other words who should have the
right authority to define disease, a physician, a
philosopher or a pathologist? This led to the analysis
of the field of pathology and the claims within which
there are not really a consensus on the boundary of the
discipline. This is because of the fact that the
functional attribute for various parts of the organisms
by the pathologists is not always consistent, in which
Evolutionary Concept of Health 115
123
![Page 4: Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology](https://reader036.vdocument.in/reader036/viewer/2022080200/5750a7581a28abcf0cc05b59/html5/thumbnails/4.jpg)
case how are we to make a judgement against the right
function. The critique of Canguilhem (1991) towards
the discipline of pathology and the normality within
the discipline is a point that informs this debate. This
in the current context of laboratory medicine attain
greater significance as there is greater tendency to
define disease in the pathologists’ way, a kind of
technology induced medicalisation, possibly implicit
in the definition of disease itself as it is understood in
the dominant discourse.
Further the way Boorse has understood biology as a
discipline is questioned on two accounts, first, based
on evolutionary perspective in biology, all species are
evolving and so will be their functions. This Boorse
counters by arguing that his standard of function refers
to a specific spatio-temporal context, thereby justify-
ing the fact that disease categories and definitions can
change over time and need to be analysed in its
relevant contexts. Another criticism on the nature of
biology is the failure to acknowledge the environment
which is a strong influence in determining the
abnormality in disease definitions. This is because
any statistical abstractions of defining normality fails
to take into account the influence of environment
which can really decide the judgement of being normal
or abnormal. A departure from the earlier two
criticisms is that the concept of disease is more of a
theoretical one and is value free hence has little to do
with medical practice. Rather, medicine treats the
concept of disease within the context to make
decisions and in which case it is the context that
matters, namely the type of work, the age of the patient
and the family characteristics and so on. One can argue
that medicine is practised not necessarily like a
scientific activity similar to that of a laboratory but
is guided by the existing scientific categories like
disease, again a product of medical practice. This
adherence to scientific categories while practising
medicine may reduce uncertainties and abuse of
technical aspects within medicine. Despite these, it
has to be noted that the claim about the concept of
disease that is used in the current context and is
dominant at least in the field of biomedical practice
hovers around its scientificity and value neutrality,
which is a serious debate in the field of sociology of
health and illness.
Taking cues from Boorse concept and acknowl-
edging the criticisms to it, Ananth offers an evolu-
tionary concept of health which is a combination of
evolutionary concept of function and an evolutionary
homoeostasis concept of health. The concept of
function becomes meaningful and appropriate in the
context of health only when function implies a
historical basis (natural selection) or modification
and should contribute to the organism’s goal of
survival and reproduction. The second important
characteristic of the evolutionary concept of function
is that there should be clear distinction between the
genuine functions and side effects. This is because all
effects of an event may not be functions of that
organism unless it contributes to the survival of the
organism and is not happened by chance but intended
by natural selection of the organism. The second
important characteristic that the author considers
relevant in defining the concept of disease is the
concept of homoeostasis. The intercellular homoeo-
stasis, a nature of human body considered as a
necessary criterion for explaining stability of the body
within the biological sciences is adapted here. Further
the author adds the concept of organism homoeostasis
which is determined by the interaction of the body
with the environment and thus any interaction of the
human body with the environment can alter the
intercellular homoeostasis. Thus, the two aspects that
the author uses for his evolutionary concept of health
are a combination of evolutionary concept of function
and an evolutionary concept of homoeostasis. This
attains relevance in the context of eco epidemiology
approach proposed by Susser and Susser (1996) as a
way to understand population health.
Thus, an evolutionary homoeostatic concept of
health (EHCH) as per Ananth is:
An organism—within a certain species, gender,
age group and environment –is in a state of
health if and only if its relevant parts and overall
behavioural activities have and retain evolved
functional propensities to secure dual-homoeo-
stasis, which in turn confers as survival enhanc-
ing functional propensity on the organism as a
whole.
In order to demonstrate the prospects and challenges
of the evolutionary homoeostatic concept of health,
five diseases of diverse kinds were examined. The
analysis reveals the function aspect, evolutionary
aspect, the degree of illness and most importantly
the species-specific attributes like gender, age (oste-
oporosis) and the environment (sickle cell). Finally,
116 M. George
123
![Page 5: Mahesh Ananth: In Defense of an Evolutionary Concept of Health: Nature, Norms and Human Biology](https://reader036.vdocument.in/reader036/viewer/2022080200/5750a7581a28abcf0cc05b59/html5/thumbnails/5.jpg)
the unit of selection was determined to be the
individual as opposed to the gene or the group, even
though this may raise several questions on its appli-
cability in public health. This can be a starting point to
examine whether the new evolutionary concept of
health opens up opportunities for defining health
across social groups and also strengthens the homo-
eostasis characteristic that takes into account the
environment. The characteristic of human–environ-
ment interaction if taken seriously can offer opportu-
nities for addressing the health status of individuals
from the point of view of public health as well as
defining health and disease more holistically, a feature
of alternative systems of medicine where there is
greater acknowledgement of the capacity of human
body to interact with environment. The book offers a
more humane naturalistic account of health and
disease which if acknowledged can possibly help
practise of medicine more humane and as well inform
the current discourse about health and disease within
the field of sociology of health and illness.
References
Canguilhem, G. 1991. The normal and the pathological. New
York: Zone Books.
Engel, G.L. 1977. The need for a new medical model: A chal-
lenge for biomedicine. Science 196(4286): 129–136.
Jewson, N.D. 1976. The disappearance of the sick man from
medical cosmology 1770–1870. Sociology 10: 225–244.
Susser, M., and E. Susser. 1996. Choosing a future for epide-
miology II. From black box to Chinese boxes and eco
epidemiology. American Journal of Public Health 86(5):
674–677.
Evolutionary Concept of Health 117
123