Abstract
Defining disease and delineating its boundaries is a contested area in contemporary philosophy of medicine. The leading naturalistic theory faces a new round of difficulties related to defining a normal environment alongside normal organismic functioning and to delineating a discrete boundary between risk factors and disease. Normative theories face ongoing and seemingly intractable difficulties related to value pluralism and the problematic relation between theory and practice. In this article, I argue for an integral—as opposed to a hybrid—philosophy of health based on Bernard Lonergan’s notion of generalized empirical method that provides a way to settle these difficulties dynamically and comprehensively, both in theory, by orienting functional and statistical investigation toward an explanatory ecological viewpoint, and in practice, by framing critiques in relation to the normativity intrinsic to all human inquiry.
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Notes
In contrast to David Hume, who anticipates a “mental geography” of the “operations of the mind” [8, §1], Lonergan invites human inquirers to experience, understand, and affirm themselves in their own acts of knowing and deciding as the key to self-understanding—the foundation of generalized empirical method. For an interesting comparison of Hume and Lonergan on the subject of self-understanding, see [9].
According to Lonergan, “Data of sense include colors, shapes, sounds, odors, tastes, the hard and soft, rough and smooth, hot and cold, wet and dry, and so forth…. On the other hand, the data of consciousness consist of acts of seeing, hearing, tasting, smelling, touching, perceiving, imagining, inquiring, understanding, formulating, reflecting, judging, and so forth. As data, such acts are experienced; but as experienced, they are not described, distinguished, compared, related, defined, for all such activities are the work of inquiry, insight, and formulation. Finally, such formulations are, of themselves, just hypotheses; they may be accurate or inaccurate, correct or mistaken; and to pronounce upon them is the work of reflection and judgment” [6, p. 299].
For a compact statement of the normative pattern of knowing and doing, see [17].
I discuss these definitions at greater length in [19].
Ludwig Fleck makes the same point with regard to the historical context of scientific advances [21, p. 50].
What Lonergan calls classical investigation in reference to mathematics and physics corresponds to what I call functional investigation in reference to biology.
Table 1 presents a more detailed comparison of these two modes of investigation.
Deciding reprises the operations of experiencing, understanding, and judging with respect to possible courses of action which have not yet occurred; it entails judgments of value as well as judgments of fact. I discuss this further in the section on actual boundaries of health and disease in concrete situations.
I discuss the implications of this ambiguity relative to functional and statistical investigation in [14].
I discuss Boorse’s notion of “reference class,” another source of ambiguity in the BST, below.
As I discuss in relation to Boorse below, this qualitative notion corresponds to a biological norm as opposed to a statistical norm.
Kingma’s lack of regard for biology in her example is apparent in her vague description of how the “poison” works. In [1, p. 251], she says that it “immobilizes the digestive system.” Does this mean that it impairs swallowing and gut motility or that it impairs the breakdown of complex foods to smaller, absorbable molecules? In [2, p. 400], she suggests another alternative: “Suppose it works—as it probably would—by binding a particular receptor that disables a transmembrane pump, such that the organism is unable to absorb water or certain electrolytes from the gut.” However, this would be at odds with her argument that exercise has the same effect on “digestion” as the supposed poison since people are able to hydrate orally during exercise.
Regarding oversight of the role of form in biological explanation, see Marjorie Grene [26, p. 93]: “Darwin distinguished two great principles in the living world: constancy of form or type and conditions of life…. Now to say that constancy of form is caused by conditions of life is not to do away with form and its constancy. On the contrary, b cannot be caused by a if b does not exist…. Many enthusiastic Darwinians … seem to deny the very existence of form. There is nothing but particular small variations … and that’s that.”
As Kosman remarks, “For the being of an animal consists in its life functions, in the characteristic activities and modes of living in which it engages. The specific form of an animal’s being is therefore, as we might say, its lifestyle; what it eats, how it gets its food, where it lives, the manner of its reproduction, sensation, movement, etc.: the entire complex of characteristic activities, in other words, that constitute the manner of its bios, and which it is the task of the biologist to describe and explain” [27, pp. 378–379].
As Lonergan remarks, “Because within the range of human vision the earth is approximately flat, it does not follow that the integration of all such views will be a flat surface” [6, p. 322].
As Bates remarks, “The attempt to separate ecology and physiology, to separate what I like to call ‘skin-out biology’ from ‘skin-in biology,’ creates serious difficulties—but so does any attempt to categorize approaches to knowledge. We have to remember that events inside the individual and outside form connected systems and that our separation is purely a matter of convenience. The study of digestion requires rather different methods from the study of food-getting behavior: and thus it is at times profitable to pursue them separately. But at other times we have to relate external and internal events, and we need to be careful that our system of organizing knowledge does not interfere with this” [28, p. 549].
Lonergan writes, “[T]he structure of classical empirical method … operates as a pair of scissors. Its upper blade consists in a heuristic structure … [that is] a set of generalities demanding specific determination, and such determination comes from the lower blade of working hypotheses, precise measurements, empirical correlations, deductions of their implications, experiments to test the deduced conclusions, revisions of the hypothesis, and so da capo” [6, p. 600].
As Lonergan notes, “It has been argued that there exists a complementarity between classical and statistical investigations; perhaps it now is evident that the whole of science, with logic thrown in, is a development of intelligence that is complementary to the development named common sense” [6, pp. 202–203].
Aesthetic values relate to experiencing, moral values to deliberating and acting. I am concerned here with the way that judgments of value enter into deciding what to do.
According to Lonergan, “The advance of technology, the formation of capital, the development of the economy, the evolution of the state are not only intelligible but also intelligent. Because they are intelligible, they can be understood as are [schemes of recurrence] in the fields of physics, chemistry, and biology. But because they also are increasingly intelligent, increasingly the fruit of insight and decision, the analogy of merely natural process becomes less and less relevant. What possesses a high probability in one country or period or civilization may possess no probability in another; and the ground of the difference may lie only slightly in outward and palpable material factors and almost entirely in the set of insights that are accessible, persuasive, and potentially operative in the community. Just as in the individual the stream of consciousness normally selects its own course out of the range of neurally determined alternatives, so too in the group commonly accessible insights, disseminated by communication and persuasion, modify and adjust mentalities to determine the course of history” [6, pp. 235–236].
Put in the affirmative, the norms appropriate to the conscious operations of experiencing, understanding, judging, and deciding are to be attentive, intelligent, reasonable, and responsible [7, p. 53]. These are all pertinent to the emergence and survival of human organisms and human social schemes.
The bidirectional interaction of theory and common sense has affinities with Kingma’s description of the “looping” of naturalistic and normative approaches in understanding health and disease [33]. Besides differences regarding their understanding of theoretical inquiry, there are differences regarding what Kingma calls “social constructivism” and Lonergan calls “sociology of knowledge” [7]. A more detailed comparison would be worthwhile, but is outside the scope of this article.
Patients in the intensive treatment group took an average of three antihypertensive medications to achieve target blood pressure compared to two medications on average for those in the standard treatment group. In addition to raising medication costs, this also adds to the costs of clinical and laboratory monitoring for patients treated with the lower blood pressure target. This is an example of the inflationary pressure exerted by expanding the range of theoretical determinants of disease to which I referred in the opening paragraph. Fuller cost analysis is outside the scope of this article, but definitely pertinent to developing the integral model of health presented here.
In this respect, the GEM model is consonant with Daniel Sulmasy’s “biopsychosocial-spiritual” model of healthcare [44], to which it adds a methodical basis linking natural and human science. In this article, I have focused on the organic/biological and social dimensions. I plan to address the psychological and spiritual dimensions at greater length in subsequent articles.
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Acknowledgements
The author wishes to thank Wendy Rogers and Mary Walker for their detailed and helpful comments on earlier versions of this article. He is also grateful for improvements suggested by Daniel Kim, as well as an editor and an anonymous reviewer of this journal.
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Daly, P. An integral approach to health science and healthcare. Theor Med Bioeth 38, 15–40 (2017). https://doi.org/10.1007/s11017-017-9396-x
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DOI: https://doi.org/10.1007/s11017-017-9396-x