Abstract
This paper seeks to develop a theory of health that aligns with the shift in contemporary medical practice and research toward a temporally extended epidemiological view of health. The paper describes how such a theory is at the core of life course based approaches to health, and finds theoretical grounding in recent work in the philosophy of biology promulgating a process theory of life.
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Notes
This paper does not analyze the terms of health and disease (as Boorse’s BST attempts), rather, as Lemoine (2015) suggests, it offers a theoretical understanding of what health is, as it emerges from a particular scientific research program, and refines it based on a view in theoretical biology (for further discussion of this “naturalistic turn” see Sholl & Okholm, 2021). A prime example of this “bottom up” approach, taking research in aging as its starting point, was recently offered by Sholl (2021) in this journal. The present paper, though developed too early to fully benefit from his insights, comes to conclusions that are in many ways parallel, and hopefully it can be read in dialogue with his general approach and call to “let a thousand theories bloom” (p.44).
Giroux (2015) notes that Schwartz mistakenly conflates a physiological marker or indicator with the function/dysfunction itself.
Other examples of disease precursor risk factors not discussed by Schwartz might include certain precancerous lesions or polyps. As with stage 1 hypertension and high cholesterol, the preventative treatment for these may be similar or identical to treatments for the actual disease states such as excising potentially cancerous growths.
Schwartz’s neglect of Boorse’s own attempt to explain preventative treatment is perplexing.
To be clear, at a theoretical level the BST will make use of longitudinal measures in order to determine what counts as a significant loss of functional efficiency. A cross sectional survey of a population will only reveal the distribution of a given measure of functional efficiency; it will not tell you what level of loss of efficiency actually results in a loss of biological fitness in terms of survival or reproductive success (Boorse takes these to be the primary goals that organisms have evolved to accomplish); for this, longitudinal data is needed.
LCE and LCHD can be viewed as parallel research clusters (the former centered in the UK, the latter in the USA) but a full discussion of how they intersect and differ is beyond the scope of this article. A textbook framing the LCE approach to chronic disease was published in 1997 (Kuh & Ben-Shlomo, 1997) and a highly-cited article describing the emerging research program was published in 2002 (Ben-Shlomo & Kuh, 2002). That same year the LCHD cluster published its own programmatic outline (Halfon & Hochstein, 2002) and about fifteen years later each group sought to consolidate the state of the field and vision for the future of the research program; for LCE, a special issue of the International Journal of Epidemiology (Volume 45, Issue 4, 2016) and for LCHD an edited volume (Halfon et al. 2018). I focus more on LCHD due to the degree of conceptual framing it offers.
This image of an emerging state of constant health surveillance and risk assessment is, to say the least, problematic, but the subject for a different discussion.
Morgan argues that one can arrive at a similar view proceeding from substance ontology, in which living systems are likewise “temporally extended, dynamic, ecologically dependent, and have vague boundaries” (Morgan, 2021, p. 13). Although he convincingly shows that advocates of process ontology overstate the inflexibility of various explications of substance ontology and the intractability of attendant metaphysical puzzles, none of this undermines what I understand to be their central claim, that ‘process’ is a better fit for characterizing the essential nature of living organisms. Indeed, to a large extent, what contemporary process ontology attempts to counter is not a sophisticated version of substance ontology, but a ‘folk’ substance ontology that carried over into the life sciences from other scientific domains. Such ontological presuppositions can profoundly change how one characterizes, for example, ‘development’ (Fabris, 2018). For present purposes the more salient consideration is what ontological claims are reflected in the relevant biomedical theories and frameworks. Here, the life course frameworks are marked by a shift toward an underlying processual understanding of the organism and health. Still I am sympathetic to modesty when it comes to claims about what really exists, and for those so inclined, Pradeu argues that the processual view ought to be understood as an epistemological viewpoint while remaining agnostic on ontology (Pradeu, 2018).
Morar and Skorburg (2018), while not proceeding from a processual view, offer a similar rejection of strict individuation (in part based on the integral importance of the microbiome) and explore the implications of their theory of “extended health”. The implications of the microbiome for our understanding of health has also been addressed by Inkpen (2019).
Schwartz struggles with some of the counterintuitive implications of the definition of a disease changing based on changes to the reference class over time. Compared to traditional hunter‐gatherer societies everyone today is at higher risk of cardiovascular disease, but we would not want to say that nearly everyone harbors a dysfunction and therefore is diseased (2008, p. 328). This problem is easily avoided once we conceptualize health beyond the mere absence of disease and can talk about relative states of healthy and less healthy. This, along with other considerations motivates Schroeder’s (2013) argument that health is a comparative concept, which is fully compatible with the theory of health I describe here.
As a reviewer noted, the definition offered by Fabris as maintenance of a “single, fixed steady state” does not reflect how homeostasis is described in the literature, particularly given that many biological systems can function well within a certain range of values (Kotas & Medzhitov, 2015). However, the intent, per Fabris’s understanding of Waddington, is to capture how an organism maintains stability through a developmental course that exhibits a great deal of plasticity.
Both Ananth and Dussault and Gagne´-Julien, without emphasizing a shift in the locus of analysis, similarly turn from an analysis of disease to one focused on health. Both theories, it should be noted, see in Boorse’s own analysis an overlooked underlying theory of homeostasis.
This convergence emerges both from the ‘bottom-up’, as research on aging over the past two decades has been influenced by life course approaches to health and wellbeing (Ben-Shlomo et al., 2016; Hanson et al., 2016; Kuh & the NDA Preparatory Network, 2007), as well as at the theoretical level, where one finds parallels with Waddington’s process-based developmental theory of phenotypes as “temporally extended epigenetic trajectories” (Fabris, 2018, p. 246).
Dussault and Gagne´-Julien (2015), in a parallel manner, incorporate a forward-looking aspect of health by characterizing it in dispositional terms, as does Werkhoven (2019). I favor the term capacity as better capturing a property like health which manifests in different ways under different conditions and at different levels of analysis (e.g. individuals and populations). On the relationship between a process view of life and a dispositional account of causation see Anjum and Mumford (2018).
Morar and Skorburg’s (2018) extended concept of health similarly begins to efface the boundary between the individual, population, and environment. Their suggestion for how to delimit the proper bearer of health relies, in part, on where efficacious biomedical interventions are targeted.
However, as mentioned above, the incorporation of a broader, normative understanding of human goals is also compatible with the LCPT, allowing one to integrate changing reproductive goals and an expanded timeframe of healthy fertility.
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Acknowledgements
My thanks to all those who have read and commented on this paper, in particular, the guest editors of this issue, Nitzan Rimon-Zarfaty and Mark Schweda, who organized the conference that this special issue grew out of. Jeremy R. Simon offered valuable feedback on an earlier version of this paper, and two anonymous reviewers provided extensive comments, suggestions, and references that improved this paper in many ways. I would also like to acknowledge Fred Gifford for teaching a graduate seminar on the philosophy of medicine in which a section of this paper was first developed.
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Schick, A. Health as temporally extended: theoretical foundations and implications. HPLS 44, 32 (2022). https://doi.org/10.1007/s40656-022-00513-y
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DOI: https://doi.org/10.1007/s40656-022-00513-y