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Harm and the concept of medical disorder

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Abstract

According to Jerome Wakefield’s harmful dysfunction analysis (HDA) of medical disorder, the inability of some internal part or mechanism to perform its natural function is necessary, but not sufficient, for disorder. HDA also requires that the part dysfunction be harmful to the individual. I consider several problems for HDA’s harm criterion in this article. Other accounts on which harm is necessary for disorder will suffer from all or almost all of these problems. Comparative accounts of harm imply that one is harmed when one is made worse off, that is, worse off than one otherwise would have been. Non-comparative accounts imply that one is harmed when one is put into some kind of condition or state that is, in some way, bad in itself. I argue that whether harm is construed comparatively or non-comparatively, HDA’s harm criterion is problematic. I tentatively conclude that an analysis of medical disorder should not make use of the concept of harm.

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Notes

  1. See [1,2,3]. Many of the arguments will also threaten views that employ similar notions, for example, the malady account defended by Culver and Gert [4].

  2. The division of accounts of harm into comparative and non-comparative ones is common and useful. For some more discussion of the taxonomy, see Bradley [5] and Hanser [6].

  3. See especially [7, p. 384].

  4. For example, a doctor might administer drugs that will slow the rate of increase of a patient’s pain and suffering, so that the patient is worse off after the treatment than she was before it, but is much better off than she would have been without it. It is fairly clear that the doctor has benefited rather than harmed the patient, which indicates that we compare levels of well-being across worlds or outcomes, not times. For additional criticism of the temporal account, see [9, p. 368; 10, pp. 149–150].

  5. For more discussion, see Wakefield [8, pp. 674–676] and Spitzer [11].

  6. For an introduction to these issues and a nice review of the challenges to cultural relativism, see [12, ch. 2]. For some more critical discussion, see [13, ch. 11].

  7. I would like to thank an anonymous reviewer for suggesting this example.

  8. This terminology comes from Barnes [14].

  9. For discussion of the problem that preemption poses for the comparative account, see [5, 6, 10, 18, 19]. See also Parfit [20, ch. 3].

  10. See, for example, [15, p. 23; 21, p. 89].

  11. Cf. [6, p. 434].

  12. Reznek [3, pp. 161–162] holds that standard members of a species, not all members, need be harmed.

  13. A detailed account along these lines appears in [19]. See also [20, pp. 70–83; 22, pp. 127–135].

  14. There are cases in which a group of conditions or events can harm an individual even though there is no smallest group of the sort described in the text. I discuss and account for such cases in [19]. The complication is irrelevant here, however, and so I shall ignore it.

  15. For some discussion of the harm of events in a sequence, see [5, 6, 19].

  16. Wakefield [personal communication] has suggested, in the abstract case, that the disorder is the group, or complex, that results from X and Y taken together.

  17. The non-identity problem is most closely associated with the work of Derek Parfit. See [23; 20, ch. 16]. It has since been extremely widely discussed. For an excellent, recent, and thorough book length discussion, see [24].

  18. I find it plausible that if the sperm and egg whose fusion brought me about had never come together, then I would not have existed. This claim is widely accepted, but it is controversial. For a recent example see Lewens [25, ch. 6], who argues generally that interventions that affect one’s identity are quite likely rarer than they are widely believed to be. Again, however, the strong metaphysical claim is not needed.

  19. See [26] for a detailed discussion and defense of this perspective.

  20. One might claim that every dysfunction is harmful, so that the harm criterion is redundant and disorder can be analyzed merely in terms of dysfunction. This would allow one to accept Harman’s account and say that disorders are harmful dysfunctions. Of course, we might as well say they are dysfunctions since “harmful” has become redundant. De Block [28] defends a view like this, but his notion of dysfunction differs from that of Wakefield. See also Boorse [15, pp. 34–5] for some discussion.

  21. For a widely discussed non-comparative account, see [29]. See also [30, 31]. For critical discussion of non-comparative accounts generally, see [5, 6].

  22. For more discussion, see [5, pp. 400–401].

  23. For some recent discussion of this issue, see [33, 34]. In fact, Schwartz (see [34]), who argues that an account of disease is best understood as a proposal about how to define and use terms, thinks that Boorse’s naturalistic account (the BST) is to be preferred.

  24. I would like to thank audience members at the 2015 PANTC (Plato’s Academy North Tonawanda Campus) Conference on Bioethics and the Philosophy of Medicine for extremely helpful comments and suggestions. In particular, I am grateful to Christopher Boorse, Stephen Kershnar, Jerome Wakefield, and (especially) to David Hershenov.

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  1. Department of Philosophy, The State University of New York at Fredonia, Fredonia, NY, 14063, USA

    Neil Feit

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Feit, N. Harm and the concept of medical disorder. Theor Med Bioeth 38, 367–385 (2017). https://doi.org/10.1007/s11017-017-9418-8

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