726

Circulatory Diseases and Aging

Mukamal KJ, Kronmal RA, Tracy RP, Cushman M, and Siscovick DS

(2004) Traditional and novel risk factors in older adults:
Cardiovascular risk assessment late in life. American Journal of
Geriatric Cardiology 13(2): 6980.
Rosamond WD, Chambless LE, Folsom AR, et al. (1998) Trends in the
incidence of myocardial infarction and in mortality due to coronary
heart disease, 1987 to 1994. New England Journal of Medicine
339(13): 861867.
Stallard E (2002) Underlying and multiple cause mortality at advanced
ages: United States 19801998. North American Actuarial Journal
6(3): 6487.
Tunstall-Pedoe H (ed.) (2003) Monica: Monograph and Multimedia
Sourcebook. Geneva, Switzerland: World Health Organization.
Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H,
Ruokokoski E, and Amouyel P (1999) Contribution of trends in
survival and coronary-event rates to changes in coronary heart
disease mortality: 10-year results from 37 WHO MONICA project
populations. Monitoring trends and determinants in cardiovascular
disease. Lancet 353(9164): 15471557.
Ukraintseva SV and Yashin AI (2001) How individual aging may influence
human morbidity and mortality patterns. Mechanisms of Ageing
and Development 122: 14471460.

Vaupel JW, Carey JR, Christensen K, et al. (1998) Biodemographic

trajectories of longevity. Science 280(5365): 855860.
Yano K, Reed DM, and McGee DL (1984) Ten-year incidence of
coronary heart disease in the Honolulu Heart Program. Relationship
to biologic and lifestyle characteristics. American Journal of
Epdemiology 119(5): 653666.
Yashin AI and Manton KG (1997) Effects of unobserved and partially
observed covariate processes on system failure: A review of models
and estimation strategies. Statistical Science 12(1): 2034.
Yashin AI, Arbeev KG, Kulminski A, Akushevich I, Akushevich L, and
Ukraintseva SV (2007) Stochastic model for analysis of longitudinal
data on aging and mortality. Mathematical Bioscience 208: 538551.

Relevant Websites
http://www.nhlbi.nih.gov/resources/deca/directory.htm US National
Heart, Lung and Blood Institute.
http://www.ktl.ti/monica/ The WHO MONKA Project.

Classic Concepts of Disease

T Schramme, University of Wales Swansea, Swansea, UK
2008 Elsevier Inc. All rights reserved.

Glossary
Axiology A philosophical branch studying the
nature of value. This includes not only moral
value. For instance, the question, what is good for
human beings and prudential for them to pursue, that
is, so-called prudential values, is also a topic of
axiology.
Epistemology Concerned with the nature, sources,
and limits of knowledge. When can we justifiably
claim to know something? In medicine, we need, for
example, to know whether a certain condition is
abnormal and how it has been caused to establish
whether it is pathological.
Ontology The philosophical investigation into
existence or being. Ontological questions involve
which things (e.g., specific diseases) exist and what
it means for something to exist (e.g., whether
diseases exist as concrete entities or abstract
names).
Substance dualism A specific version
of mind-body dualism that holds that mind
and body exist separately in their own right.
Rene Descartes endorsed it by distinguishing
between res extensa and res cogitans, that is, an
extended substance in contrast to a thinking
substance.

The concepts of health and disease form the very foundation of public health and medicine. Therefore, the debate
concerning the proper definition of the terms, which is
mainly pursued in philosophy of medicine, is of utmost
importance and does not serve merely scholastic purposes. Disease is furthermore a notion with important
normative consequences. Social interests influence
which conditions are regarded as disease. It is no wonder,
then, that it is a highly contested concept.
In this article, I focus on systematic aspects of defining
disease. I do not offer a chronological history of different
attempts to come to grips with the concept of disease,
although the article is informed by the history of medicine
and uses historical illustrations. After introducing some
groundwork for the discussion to follow, I focus on three
aspects: the ontology, epistemology, and axiology of disease.

Preliminaries Concerning the Logic

of Medical Terminology
Concepts and Conceptions
It has become customary in philosophy to distinguish
between concepts and conceptions. A particular concept,
such as disease, implies certain elements as criteria, which
identify individual phenomena as falling under a particular

Classic Concepts of Disease

idea. This is often achieved by means of theorizing about the

phenomenon in question, with the purpose of extracting its
essentials. Such a theory usually culminates in a definition,
which captures the meaning of a term. For instance, someone might define the concept of disease as an undesired
process or condition of an organism which can be altered by
intervention. A definition need not be explicitly stated. In
fact, an important task of the philosophy and history of
medicine is to identify implicit definitions of disease in
different times and belief systems.
A concept might, however, lead to different conceptions, because the core elements of an idea can be interpreted in several ways. In the example mentioned, it is
possible to give different accounts of a condition of an
organism by referring, for example, to organs, cells, or the
whole organism. A conception determines, as it were, a
particular shape of a structure that is set by a concept. It
is an interpretation of the meaning of a notion. A conception of human disease is an interpretation that is based
on specific experiences and ideas concerning the body
and the human organism, life and death, and other
aspects of what it means to be human. A conception of
disease is therefore determined by a mix of anthropological, biological, and evaluative aspects.
But there seems to be a limit to what can plausibly be
regarded as different conceptions of the same concept.
For instance, one might wonder whether someone who
defines disease as a punishment for sins is still talking
about the same concept, since this idea of disease is fairly
remote from the definition mentioned earlier. We might,
therefore, assume that different times and people actually
had different concepts of disease, and it is possible to find
various conceptions at one particular time or in one belief
system, even for the same concept. This point of view still
allows for a debate on whether there might be some
conceptions of disease that are plainly false, because
they are not in line with the allegedly true core elements
of the concept of disease. I shall not take sides in this
debate but assume that there is no single true meaning of
the term, and hence that there is a reasonable plurality of
concepts (not just conceptions) of disease.
Different Perspectives
There is another aspect of the distinction between concept and conception, which stems from the fact that
medicine cannot be reduced to a scientific discipline but
is first and foremost concerned with the patient. This has
important repercussions on the conceptualization of medical terminology, because the concepts of health and disease need to be seen in relation to aspects of the human
condition that are difficult to pin down in an objective
manner; for example, suffering or individual ideals of how
to live. From this perspective medical terminology seems
to be subjective and relative. On the other hand, medicine

727

relies on scientific observations and generalizations when

it comes to diagnosis, treatment, and prognosis. From this
perspective, the language of medicine is, on the contrary,
objective and universal. And yet ill health is not merely a
medical problem but typically has social consequences
that culminate in particular liberties and responsibilities
of patients; for example, the right to absence from work.
Here we have another perspective on medical terms that
relies on certain public interests. Obviously, these three
different perspectives on the phenomenon of ill health
need not be the end of the story, for example religious
beliefs might add to the picture.
Some theorists have suggested using various terms in
order to distinguish between these different perspectives.
The concepts of disease, illness, and sickness may be
feasible in order to capture the respective aspects. Disease
would then be rendered a feature of the biological organism, illness a mode of being and feeling of an individual
person, and sickness a particular social role. There is
ample discussion about the logical relation between
these terms, especially whether there can be illness without disease and the other way around. Be that as it may,
this differentiation is clearly an analytical device, not
common to all languages and also not found explicitly in
the history of medicine. It is nonetheless important to
keep these different perspectives on the phenomenon of
ill health in mind, because it will then become obvious
that some accounts of disease might not be in conflict,
because after all they focus on dissimilar aspects for
instance the biological organism, personal well-being, or
social role. Some theories of ill health might even discuss
different concepts, which could be distinguished by using
dissimilar terms.
The General Concept and Specific Concepts
of Disease
There is yet another way to conceive of concepts of
disease. We use concepts such as syphilis or tuberculosis
in order to single out specific conditions or processes;
these specific disease concepts are studied in nosology
and eventually form the content of classification systems.
However, when these notions are used, it is not the general concept of disease that is addressed. There is a difference between disease as a generic term and specific
concepts of disease.

The Ontology of Disease

Ontology is concerned with existence or being. With
regard to disease it focuses on issues such as (1) the
location of disease and (2) the ontological status of specific diseases. Other topics concerning ontological problems in medicine are (3) the role of dispositions and the

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Classic Concepts of Disease

environment in the constitution of disease, (4) the distinction between disease and illness, and (5) the relation
between somatic and mental disease.
The Location of Disease
In antiquity, the whole person was regarded as the site of
disease. Health was equilibrium, whereas disease was
imbalance. According to some theories, for example,
Egyptian, the imbalance was not merely an internal one
but seen in relation to the environment, in particular gods
or spirits. However, the most influential, Hippocratic,
school did not believe in religious influences on the
disease process. Their conception was mainly drawn
from an analogy derived from a certain account of harmonies in nature. The human organism, or microcosm,
was seen in parallel to the macrocosm of nature, a belief
that can also be found in other traditions, for example,
Ayurvedic and Chinese medicine. Disease for the ancient
Greeks, and for many subsequent generations, was an
imbalance of the humors: blood, phlegm, yellow bile,
and, added later, black bile.
With the advancement of knowledge about the human
body the location of disease became more specific. Although
anatomical studies had already been conducted, albeit on
animals, by Galen (ca. 130ca. 201 C.E.) in the Roman era,
Giovanni Battista Morgagni (16821771) was the first to
locate disease in organs. His theory was in line with the
progress of pathological anatomy, especially attributable
to anatomical and physiological findings of medical scientists such as Andreas Vesalius (15141564) and William
Harvey (15781657). Marie Francois Xavier Bichat
(17711802) later situated disease in tissues, and Rudolf
Virchow (18211902) famously founded cell pathology. In
recent times, medicine has become accustomed to identify
DNA as a site of possible pathology. So it is tempting to posit
a reductionist trajectory in medical history. However, this
would be too simplistic, as different levels of disease location
have almost always been present in medical theory.
The Ontological Status of Specific Diseases
Another pervasive subject matter of medical theory is the
ontological status of disease entities. Does a specific disease such as arthritis exist in its own right or is it an
abstraction derived from individual cases? This problem
is obviously related to the previously mentioned topic of
the localization of disease, because if the whole body is the
site of disease, it is difficult to attach to it an ontological
status in its own right. For theorists such as Hippocrates
(ca. 460ca. 375 B.C.E.), disease cannot be distinguished
from the affected person; it is as individual as the patient.
Diseases therefore have no common, let alone independent, existence, but are singular and heterogeneous occurrences in individuals. This is called the physiological

theory. However, once disease is localized in areas that

are shared by organisms, it is but a small step to see
diseases as separate entities, a creed that is known as the
ontological theory. According to this view particular pathological alterations follow the same pattern and can therefore be identified as occurrences of one single type. These
types can then be collated in a classification system.
Historically it may be speculated that the frequency and
similarity of particular disease events such as the bubonic
plague and syphilis fuelled the belief in homogeneous
disease entities.
Strictly speaking, there are two different claims of
the ontologists that need to be distinguished. First, the
assumption that disease comes in types that can be coherently differentiated. Individual occurrences of a disease
are, according to this view, tokens of a particular type, that
is, a specific disease such as gout or lumbago that has a
certain unity or identity. These specific diseases can be
discovered. Second, ontologists believe that disease itself
exists independently of a patient who has the disease. It is
an entity in its own right that can befall a person. Again, in
the history of medicine the discovery of germs and their
relevance for the onset of disease was especially congenial
to this belief. The foreign entity invading the organism,
according to this view, is the disease.
The second of the ontologists claims has now become
hard to believe, since more recent discoveries in medical
science have shown that germs or other bodies are rarely the
sole causes of disease. The interaction with the host builds
the sufficient condition of the onset of disease. Nevertheless, the first of the ontologists beliefs, that is, that diseases
come in types, is still widely shared by medical theorists.
But to be sure, there is a huge difference between the
ontological view that we can discover these specific disease
entities by reading them, as it were, off from nature and the
alternative, physiological, account such that these entities
are our own making, that is, inventions.
The debate about whether disease entities are discoveries or inventions is mainly led by the question of whether
diseases are natural kinds. Paracelsus (14931541) was
one of the first to directly abandon the physiological
Hippocratic and Galenic tradition in virtue of opposing
the humoral account of disease. He considered specific
diseases to have a natural unity, similar to varieties of fruit.
Indeed, if diseases were like, for example, minerals or
plants, then they might be distinguishable on grounds of
observation only. If not, then their classification is relative
to human interests. It is interesting to notice that Thomas
Sydenham (162489) perceived medical categories in
analogy to the classification of biological species. He obviously thought of them as natural kinds.
However, it is difficult to maintain this conception once
it is agreed that disease kinds are not independently existing
entities like plants. It seems therefore more plausible that
specific disease categories result from our own making. But

Classic Concepts of Disease

still, the way we draw boundaries between diseases does not

seem to be arbitrary either, but mainly determined by
widely shared interests of medical science such as the
reliability and validity of diagnosis or prognosis.
The debate between ontologists and physiologists has
shown that specific diseases do not exist materially outside
of bodies and therefore not independently of organisms.
They do exist, however, although not materially but as
abstract entities. This is not at all unusual; we are, for
instance, accustomed to using categories like youth and
adolescence to refer to certain processes of organisms.
Specific diseases therefore exist insofar as we gather
processes and conditions that share certain characteristics
in specific categories. Disease entities can change and have
indeed been altered in the history of medicine according
to certain purposes. For example, today we use the concept
of Alzheimers disease, whereas in former times similar
phenomena used to be called senility. Not only the words,
but also the criteria for specific diseases have changed, the
main purpose being reliability and validity.
Dispositions and the Environment
In antiquity, medical theorists developed sophisticated
ideas about how individual and environmental conditions
interact in the constitution of disease. An imbalance of the
humors could be due to particular influences of the seasons. For instance, summer was believed to increase the
level of one of the humors, yellow bile. In addition, individual constitutions were also held responsible as factors
in the onset of disease. So disease was a highly individualized and relative condition.
Further knowledge about the interactions between
environment and organisms in the causation of disease
led to speculations about unhealthy environments. In
some extreme cases, these milieus themselves were
regarded as the site of disease. However, to be strict,
there can only be pathological environments in the
sense that they are instrumentally unhealthy, that is, lead
with a certain (higher than normal) probability to the
outbreak of disease. Environments themselves are not
pathological, but pathogenic, relative to the organism
that lives in these surroundings. For instance, extreme
climates are unhealthy for human beings; but neither are
these conditions diseases nor do human beings who live
in these conditions suffer from a disease only by virtue of
living in pathogenic surroundings.
Another aspect of instrumental health is the individual
disease disposition. Some people are more prone to fall
ill than others, not only because they live in different
environments but also because they differ in their constitution. Again, medical theorists speculated about certain
characteristics of human beings that form the basis of a
particular disposition. A person might, for example, be a
phlegmatic character, hence more likely than others to

729

develop a humoral imbalance due to too much phlegm. In

modern times, these speculations about character survive,
for example, in beliefs regarding cancer personality a
disposition to develop cancer because of a certain lifestyle
and temperament.
Again, it would be wrong to confuse disposition to
develop a disease with having a disease. Things become
more difficult, however, when we consider an example
such as phenylketonuria (PKU), a condition that involves
the inability to metabolize the amino acid phenylalanine.
It seems to be a clear-cut case of a disease, although
patients can stay unaffected if they follow a strict diet.
The condition results from alterations on a genetic level,
which are usually regarded as pathological. PKU therefore does not seem to be an instance of a disease disposition but disease proper, even though it is treatable in such
a way that it becomes an asymptomatic condition.
Although the distinction between a disease and a bad
disease disposition is often difficult to draw, it seems
plausible to maintain that disease dispositions are not
pathological because they do not necessarily lead to dysfunction under normal circumstances. The need to live on
a special diet is not normal for a human being, therefore
PKU is a disease proper and not just a disease disposition.
This differs considerably to the nowadays popular tests
for individual genetic makeup, which may or may not
come with a certain propensity to develop a disease like
cancer. Here we have instances of disease dispositions, and
it is a mistake to confuse them with diseases themselves.
This being said, it is obvious that knowledge about
dispositions and the pathogenic effects of particular
environments including social conditions such as poverty and lack of education is important for preventing
diseases. Progress in health status has often been due
to these prophylactic aspects, possibly more than to curative medicine. To better health dispositions by public
health measures and changes in individual lifestyle is an
important goal of medicine, but that does not imply that it
is tantamount to treating already existing diseases.
The Distinction between Disease and Illness
It was said earlier that the concepts of disease and illness
differ in that they imply dissimilar perspectives on the
phenomena of ill health. It seems that the concept of
illness refers to the person who experiences an unpleasant
and disabling condition. Patients say that they are ill, not
that they are diseased. Illness is a mode of existence,
whereas disease is regarded as a detachable property of a
person; people have a disease. It is therefore not illnesses,
but diseases that are located in particular organs, cells, or
other sites, and it is diseases that are regarded as categories that can be transferred into specific types, whereas
illnesses are unique and individual affective events in the
life of whole persons. Illness therefore seems to be a

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Classic Concepts of Disease

consciously experienced condition. This, again, is in contrast to disease, which might be present yet unknown to
the affected person. There are no cases of asymptomatic
illness. Nevertheless, the notion of asymptomatic disease
is a rather current idea. For a long time, the presence of
disease meant dis-ease. Diagnosis of ill health was mainly
due to the presence of felt symptoms such as pain or
incapacity. With the advance of scientific methods to
measure objective data of organisms and better understanding of disease processes, it has become easier to
detect disease at stages at which a patient need not feel
ill. Whether this has always served the interests of patients
and society is not for me to discuss, but it can certainly be
claimed that the number of people with diseases has
increased ever since.
The Relation Between Somatic and Mental
Disease
For most contemporaries there seems to be a clear split
between somatic and mental disease. In medicine, there
are two different departments, somatic medicine and psychiatry. Indeed, we are used to considering the mind as an
entity distinct from the body. In that sense, we follow the
path of Rene Descartes (15961650), who famously
founded a dualistic account of mind and body. But we
know today that mental phenomena do not exist in their
own right, but only in virtue of material brain states and
processes, although we still do not know how to solve the
philosophical mindbody problem. The heyday of Cartesian substance dualism is gone; a separate entity, the mind,
cannot be accounted for in a scientific worldview. But
what does that imply for the concept of mental disease
or mental illness?
Scientific medicine accepts only verifiable data as the
basis of a diagnosis of disease. We can usually measure and
sometimes even see pathological alterations of the body.
But pathological afflictions of the mind appear to follow a
different logic. The lack of scientifically valid, objective,
findings in cases of alleged mental disease has even led to
an attack on the soundness of the concept of mental illness
that is unheard of in somatic medicine. Some theorists
hold that there is no such thing as mental illness,
because the mind cannot be afflicted by disease. Since
the latter argument seems to be in line with modern
anti-Cartesianism, psychiatry has responded to this challenge mainly by looking for biological foundations of
mental disease, that is, by somatizing it. But this move
still puts a separate concept of mental disease into doubt.
There does not seem to be mental illness proper, but only
bodily disease, including brain disease, and psychiatry
might dissolve into neurology.
This debate is still going on. A more holistic, less
departmentalized account of the human organism might
be a way to proceed, because it may rid us of the Cartesian
heritage. It is also important to notice that the dismissal of

substance dualism does not force us to give up our

assumption that mental phenomena, hence mental illness,
exist. They might, for instance, be explained as emergent
properties of material processes in the nervous system,
similar to well-established properties such as the transparency of glass, which is due to its underlying chemical
structure. It is also not compelling to give up our common
concepts that we use to refer to the mental, including the
concept of mental disease, since we are not constrained
to the assumption that mind and body are distinct entities
merely by using a psychological language. It is, however,
a tall order to identify valid criteria for diagnosing
pathological afflictions in psychiatry, hence to define the
concept of mental disease. Similarly, the problem of establishing plausible specific psychiatric disease entities is
another area in which theorists of psychiatry still have
much to discuss.

The Epistemology of Disease

Epistemology focuses on theoretical aspects of knowledge. Central epistemological questions regarding disease
are (1) the causation or etiology of disease, (2) generalities
versus individual cases, (3) the role of norms in the determination of the concept of disease, and (4) the relation
between health and disease.
The Causation of Disease
In order to treat patients properly it is vital to know about
the causation of disease. We have already discussed the
role of the environment and individual dispositions.
A more general problem in etiological theory is the
potential confusion of the causes and the consequences
of disease with disease itself. Take for instance the ancient
account of disease as imbalance of humors: Is it a sign of a
disease, like fever can be a sign of an inflammation, or is
the imbalance the disease? Doctors often deal with signs
and symptoms as the basis of a diagnosis of disease. But
these seem to be consequences of disease and not diseases
themselves.
Similarly, the causes of disease sometimes get mixed up
with disease itself. People have always speculated about
the causes of disease. They came up with ideas about
invading evil spirits or material causes such as contaminated food and contagious bodies; they also reflected on
internal forces that may play a role in the onset of disease,
for example specific bad desires, or depletion in the case
of Chinese medicine. Some of these causes became identified with disease itself, for example when people began to
see particular sexual behavior or lifestyles as pathological
and not as potential contribution to the onset of diseases
such as syphilis.
A disease is preceded by a series of events, which can be
interpreted as elements of the etiology of disease. Very

Classic Concepts of Disease

rarely, these causes are individually sufficient for the onset

of disease, more likely they are necessary causes that
together add up to a sufficient proximate basis of disease.
For example, Robert Koch (18431910) identified Mycobacterium tuberculosis as the cause of tuberculosis. We know
today that this bacterium is not sufficient for the outbreak
of tuberculosis but needs a particular organismic environment. The bacterium is, however, a necessary condition for
most cases of tuberculosis. The earlier-mentioned ideas
about potential causes of disease need therefore not be
regarded as conflicting causal explanations, but can be
seen as building different links of a chain of events that
eventually lead to disease. The obvious problem, then, can
be stated: What exactly is disease if we do not confuse it
with either causes or signs and symptoms? It seems clear
that it is an internal state of the organism.
Generalities versus Individual Cases
Doctors have always realized that each patient is different
and unique to a certain degree. But they have also known
that patients can be afflicted in similar ways by disease.
The first viewpoint seems to conflict with the notion of
generalities in medicine, the second to support it. Sydenham famously said that a disease of a Socrates and a
simpleton lead to the same phenomena; hence he assumed
that diseases follow a general pattern. More recently,
Friedrich Curtius (1959) argued that disease is a singular
event and that there can be only an individual pathology.
As noted earlier, this issue is related to the question of
the level at which we identify disease, for example, the
person, organs, or tissues. There might be recognizable
generalities, even law-like regularities, for instance on a
cellular level, but only individual phenomena if we take
the whole person into account. Again, there does not need
to be an inconsistency involved. Disease can both follow a
general pattern and at the same time be an individual
event, depending on the perspective we take on the
afflicted organism. The same disease can have very different significance for a Socrates in contrast to a simpleton.
This has repercussions on debates about nosology:
Regularities in the onset, course, and effects of disease
seem to build a valid basis for subsuming them into
specific disease categories. But this works only insofar as
we ignore individual aspects of these diseases such as
personal evaluations or patient narratives, for example.
Some theorists have argued that we should therefore
think about new ways of classifying diseases.
The Role of Norms
The distinction between health and disease depends on
norms. Disease is usually regarded as abnormality, or
subnormality, to be precise, because perfection is also
abnormal but still healthy. An important epistemological
question in medicine is how we can know and justify

731

standards of normality. Are they objective, purely

biological, based on facts about human organisms, or do
they depend on certain values found in a particular society? This question is continuously raised in psychiatry.
Here there seems to be no other basis than value judgments, which are used to determine what is normal. But
similar points about the dependence of medical norms on
values have been made in respect to somatic disease as
well. Attempts to determine norms on a purely quantifiable basis, which can be found in the history of medicine,
seem to be futile.
Norms in medicine rely on biological findings about
physiological and psychological functions and statistical
considerations, because biological subnormality, or dysfunction, has to fall under a certain minimal threshold in
order to count as pathological. There are also specific
human interests that influence the norm. For instance,
high blood pressure can be biologically and statistically
abnormal but still count as normal, that is, healthy, for
certain cultural reasons. In times of shortage of resources,
perceptions of health and disease might be altered. We also
know from historical examples that even the most extreme
abnormalities might be regarded as healthy or beautiful.
Bound feet, for instance, which resulted in severe deformities, were highly praised in ancient China. So medical
norms can, in the final analysis, be seen as value-laden.
They cannot be just read off from nature. To acknowledge
these elements does not, however, commit us to maintain
that medical norms are arbitrary or unscientific.
The Relation between Health and Disease
A corollary of the problem of determining the norm of
health is how to account for the division between health
and disease. There seems to be continuity between the
two conditions, which puts a straightforward polarity into
doubt. To be sure, in many acute cases disease is clearly
the opposite of health. But there are some, specifically
chronic, conditions, where health seems even to be congruent with the presence of disease. People can adapt to
impairments and ailments in such a way that some of them
do not feel ill. To stress disease in these circumstances and
only focus on lack of health does not seem to do justice to
the patients situation.
Another aspect of the relation between health and
disease is the possibility of defining health as an ideal.
For example, the World Health Organization famously
defined health thus: Health is a state of complete physical, mental and social well-being and not merely the
absence of disease and infirmity. If we would insist on
conceiving of disease and health as contraries, persons who
were not in a state of complete physical, mental, and social
well-being, which would probably include everyone, had
to be regarded as being ill. But this rather undesirable
result can be avoided if we acknowledge the difference
between health as an ideal and health as a minimal norm.

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Classic Concepts of Disease

In the latter interpretation it can be seen as incongruent

with disease. Many medical theorists therefore account
for health in a negative and minimal sense as the absence
of disease.

The Axiology of Disease

Axiology is the theory of value. Disease is often regarded
as a value term, with negative connotations. (1) There is an
ongoing debate in philosophy of medicine about whether
disease really is an evaluative concept. (2) Other value
aspects include the relation of disease to human wellbeing and (3) normative consequences of disease.
Is Disease an Evaluative Concept?
The philosophical discussion on the concept of disease
has been focused on whether a reference to values is
necessary to state what disease is or if disease can be
defined in a value-neutral way. The two main competitors
in this debate are called normativism and naturalism.
Normativism states that disease is unpleasant and
undesired. In short, disease is harmful. Health, on the
other hand, is a condition in which we feel well. Both
concepts can only be defined by reference to our evaluations. This is the basic claim of the normativists: disease
and illness always are negatively evaluated conditions.
Normativism can easily explain historical and cultural
differences in the ascription of disease. For example, masturbation and homosexuality were regarded as mental
illness for a long time because they were negatively valued. Today our values have changed insofar that only very
few would see them as medically relevant problems.
Depending on how the involved value-judgment is interpreted, that is, whether universal values are believed to be
possible, the normativist theory is also relativistic.
Naturalists start their account from the fact that
humans are part of nature just as other organisms are.
Their basic claim is that there are certain mental and
bodily processes that may not work in the way they
usually do. If this is so, we speak of a pathological condition. Thus, the concept of disease is value-neutral according to the naturalists. From the naturalist perspective, it
can be explained why there should be universal disease
judgments. Since human beings just as other organisms
of a respective species are similar in structure, they are
affected in the same way by a disease if deviations from a
natural norm occur. Nevertheless, there remains the possibility of variety regarding disease in the naturalistic
interpretation. Although nature delivers the standard of
medical normality, it may have a different content in
different environments. For example, supposing conditions of severe anxiety were universally regarded as
pathological, it may nevertheless express itself in different
ways in different cultures. So there may be culturally

impregnated diseases despite universal disease-judgments,

for example, the syndrome called Koro that occurs only in
South and East Asia. Affected people suffer from the specific anxiety that their genitals are shrinking and possibly
retracting into the body, thereby causing death.
Usually normativism and naturalism are regarded as
mutually exclusive positions. But both accounts seem to
be important in their own right, since they reflect two
different perspectives on medical phenomena. Naturalism
is focused on the living organism and its functioning or
dysfunctioning the internal mechanisms an individual is
or is not able to perform. Normativism concentrates on
the evaluation of a specific condition, that is, what it
means for a person to be suffering from an illness. One
may even say that both accounts use different concepts, a
theoretical and a practical one. As I have stated before, the
different notions disease and illness capture these different perspectives.
The Relation of Disease to Human Well-Being
To state that a certain condition is pathological alone
does not establish whether and why this situation might
be harmful. This needs to be clarified from an evaluative perspective. According to this perspective we must
address, for example, the important question: who is to
evaluate, the affected person herself, the doctor, or society?
Can a person be wrong about his or her own well-being? Is a
patient in a specific pathological condition able to evaluate
his or her condition? There is often a clash between evaluations of pathological conditions from the subjective point of
view and an external view, for example, the stance of
medical professionals. For instance, some people with disabilities reject the common assumption that they are
harmed by a medical impairment and insist that their disadvantages are only due to alterable social arrangements.
What we need, seen from an evaluative perspective, is a
convincing argument why these people might be wrong in
the assessment of their own well-being. This is a tall order,
since it seems to demand an objective account of human
welfare. Although it may be that there are convincing
arguments against the individual subjective evaluation of
a patient, a finding of medical abnormality as such cannot
establish whether a condition is harmful. The concept of
harm is not straightforward; it cannot be determined by
medical standards alone. It is as much in need of clarification as the concept of disease and therefore points to
another genuine philosophical problem in relation to the
concepts of disease and illness.
Normative Consequences of Disease
There are mainly two normative consequences of using
the concept of disease: The first establishes the social role
of a patient; the second entitles a patient to the use of
medical resources.

Classification of Mental Disorders: Principles and Concepts

In modern societies the notion of disease serves as

a prerequisite for particular rights and obligations. For
instance, to be entitled to sick leave depends on the
status of being a patient. Again, people who commit
criminal offences may be sentenced under consideration
of the insanity defense if they are incapacitated by mental
illness.
Another function of the concepts of health and disease
is to work as a gate-keeper in the access to medical
resources. In most of the developed countries the acknowledgment of disease functions as a prima facie entitlement
to publicly funded treatment. To be sure, when resources
are scarce and not all diseases can be treated, further
criteria to prioritize or ration medical resources are
needed. If a person is healthy, however, he or she does
not usually have a claim to these resources because he or
she is not regarded as a person in medical need.
There is yet another related normative consequence of
the medical concepts. They work as a barrier for legitimate medical interventions by implying a distinction
between treatment and enhancement. Treatment of disease is regarded as a proper goal of medicine while the
improvement of features of organisms over and above the
mere removal of pathological conditions is not seen to be
within the remit of medicine. However, this distinction
between treatment and enhancement seems to rely on a
clear-cut definition of the concept of disease and its
opposition to health. As we have seen in this article,
both tasks are difficult to accomplish.
See also: Resource Allocation: Justice and Resource
Allocation in Public Health; Resource Allocation: International Perspectives on Resource Allocation; Health and
Disease, Concepts of; The Worlds Medical Schools:
Past, Present and Future; Mental Illness, Historical Views
of; Happiness, Health and Altruism; WHO Definition of
Health, Rethinking the.

733

Citation
Curtius F (1959) Individuum und Krankheit: Grundzuge einer
Individualpathologie. Berlin, Germany: Springer.

Further Reading
Ackerknecht EH (1968) A Short History of Medicine. revised edn.
Baltimore, MD: Johns Hopkins University Press.
Bynum WF and Porter R (eds.) (1993) Companion Encyclopedia of the
History of Medicine (2 vols.). London: Routledge.
Canguilhem G (1991) The Normal and the Pathological. New York: Zone
Books.
Caplan AL, Engelhardt HT Jr. and McCartney JJ (eds.) (1981) Concepts
of Health and Disease: Interdisciplinary Perspectives. Reading MA:
Addison-Wesley.
Conrad IC, Neve M, Nutton V, Porter R, and Rear A (1995) The
Western Medical Tradition (2 vols.). Cambridge, UK: Cambridge
University Press.
Engelhardt D von (1995) Health and disease: History of the concepts.
Reich W (ed.) Encyclopedia of Bioethics (5 vols). New York: Simon &
Schuster, Macmillan.
Grmek MD (ed.) (1998) Western Medical Thought from Antiquity to the
Middle Ages. Cambridge, MA: Harvard University Press.
Hudson RP (1983) Disease and Its Control: The Shaping of Modern
Thought. New York: Praeger.
Humber JM and Almeder RF (eds.) (1997) What Is Disease? Totowa, NJ:
Humana Press.
King LS (1982) Medical Thinking: A Historical Preface. Princeton, NJ:
Princeton University Press.
Kraupl Taylor F (1979) The Concepts of Illness, Disease and Morbus.
Cambridge, UK: Cambridge University Press.
Nordenfelt L (1995) On the Nature of Health: An Action-Theoretic
Approach. 2nd edn. Dordrecht: Kluwer.
Reznek L (1987) The Nature of Disease. London: Routledge.
Riese W (1953) The Conception of Disease: Its History, Its Versions and
Its Nature. New York: Philosophical Library.
Rothschuh KE (ed.) (1975) Was ist Krankheit? Erscheinung, Erklarung,
Sinngebung. Darmstadt: Wissenschaftliche Buchgesellschaft.
Sigerist HE (1951) A History of Medicine (2 vols.). New York: Oxford
University Press.
Temkin O (1977) The Double Face of Janus and Other Essays in the
History of Medicine. Baltimore, MD: Johns Hopkins University Press.
World Health Organization (1981) Constitution of the World Health
Organization. In: Caplan AL, Engelhardt HT Jr. and McCartney JJ
(eds.) Concepts of Health and Disease: Interdisciplinary
Perspectives, pp. 8384. Reading, UK: Addison-Wesley.

Classification of Mental Disorders: Principles and Concepts

stun, World Health Organization, Geneva, Switzerland
TBU
2008 WHO. Published by Elsevier Inc. All rights reserved.

Introduction
The diagnosis and classification of mental disorders has
been a controversial issue throughout history. Multiple
philosophical and theoretical approaches have been put
forward to understand the nature of mental disorders in
their various forms and types. Only in the last half of the

twentieth century have systematic efforts toward an operational classification enabled scientific studies regarding
the description, possible causes, and treatment responses
to mental disorders. A common way of defining, describing, naming, and classifying mental disorders was made
possible by the International Classification of Diseases
(ICD) Mental Disorders (World Health Organization,