The Problem With Social-Justice Based Definitions of Health

A couple of days ago, I published an academic research article titled “Health and Disease Concepts Cannot Be Grounded in Social Justice Alone” in the Croatian Journal of Philosophy.

The title is self-explanatory and highlights a central problem in the philosophy of medicine: how do we define terms like health, disease, mental illness, and pathology?

There are broadly three approaches in the field.

Naturalists argue that we should define health and disease as biological concepts. They relate to statistical normality, biological functioning, and our species-typical design.

Social Constructivists, on the other hand, argue that we should treat these terms as reflections of particular social judgements at a certain point in time. What are the social norms and practices that led to some differences between humans being labelled as pathological? Different communities at different points in time might make very different judgements here, e.g. schizophrenia and homosexuality.

Finally, normativists try to define health and disease in terms of the values that make these states desirable or undesirable.

The philosopher Quill Kukla argued that naturalists and social constructivists have failed to capture the inherent normativity of these terms, and that we should instead define them purely in terms of social justice, by asking whether it would benefit our collective wellbeing to medicalize a certain state with our medical tools. Unfortunately, Kukla doesn’t define collective wellbeing so it is up to us to interpret it as ways in which society may benefit.

This approach may seem intuitively appealing because it could allow us to sidestep difficult questions about human biology to decide whether someone should receive medical resources or not.

However, as I argue in this article, any attempt to define health purely in terms of social justice (or any other purely normative account) must end up self-defeating, for the following two reasons.

Problem 1: Making the concepts of health and disease a political battleground

Firstly, terms like social justice, collective wellbeing, or the social good are notoriously controversial. Even when people agree that we should aim at achieving social justice, different groups have very different views of what that entails. Take conservatives and liberals in the USA as an example. While political polarization is incredibly high now, I suspect there would be wide agreement on whether certain conditions are pathological or not.

If we were to make the question of what we call a disease a political issue, however, one could easily imagine that very religious conservative forces would label homosexuality or atheism as pathologies. After all, all they would have to do is assert that it is in the interest of collective wellbeing to do so. People with widely different political values often do not agree on even basic empirical questions. Trying to achieve socially just aims by building social justice into accounts of health and disease could ultimately undermine the very goal of such accounts, if very different groups of people get to be in power.

Indeed, people from any political viewpoint should see this as a worry that is best avoided.

Problem 2: Circularity and Progress

The second problem concerns the tools of medicine. If there are no biological constraints on what can count as a health condition, then the natural conclusion will be that medicine will extend its scope to encompass all things seen as promoting social justice/collective wellbeing. Medicine would become the equivalent of social justice promotion. You might think that this doesn’t follow because many medical interventions won’t address issues like poverty, but the tools of medicine are not fixed. They are developed with a certain goal in mind, i.e., to treat certain conditions. Under a purely normativist account, there is nothing that would stop medicine from gradually expanding its tools to encompass all means to promote social justice. This process may be very slow, but it would be inevitable.

Conclusion

If a purely normativist approach leads to new political battlegrounds over what should count as a disease and fails to distinguish health conditions from other conditions of injustice, it is hard to avoid the conclusion that this approach is entirely self-defeating. Indeed, I hold an entirely opposite view of Kukla. Instead of thinking that a biological view of health and disease fails to build intrinsic goodness or badness into them, we can simply accept that it is a matter of empirical fact that most pathologies will reduce human autonomy, wellbeing, and life-satisfaction. No magical ingredient is needed. No need to try to define health purely in terms of values. But even if we wanted to say that pathologies, such as anxiety disorder, are inherently bad – we should add biological constraints to what counts as a pathology.