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: matsajo@gmail.com

URL: http://www.tiss.edu/faculty/dr.-mathew-george/

123

Medicine Studies (2014) 4:113–117

DOI 10.1007/s12376-014-0088-9

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

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

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

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