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Available online 5 September 2014
If there is any value in the idea that disease is something other than the mere absence of health then that
value must lie in the way that diseases are classied. This paper offers further development of a view
advanced previously, the Contrastive Model of Disease: it develops the account to handle asymptomatic
disease (previously excluded); and in doing so it relates the model to a broadly biostatistical view of
health (where before the model was neutral in the naturalism debate). The developments are prompted
by considering cancers featuring viruses as prominent causes, since these appear to amount to cases
where the prescriptions of the Contrastive Model could be followed, but arent. The resulting Irrelevance
Objection claims that the Contrastive Model is irrelevant to medical science and practice. The paper seeks
to rebut the Irrelevance Objection.
2014 Elsevier Ltd. All rights reserved.
Keywords:
Cancer
Virus
Disease
Health
Contrastive model of disease
HPV
When citing this paper, please use the full journal title Studies in History and Philosophy of Biological and Biomedical Sciences
assumption is right. A common medical usage refers to any nonhealthy state of a body part as diseased. So we might call the
area of a bone where a fracture occurs diseased, in this sense. And
we would not, in this sense of disease, distinguish the fracture
from the surrounding inammation of soft tissue: both bone and
soft tissue are said to be diseased.
But there are other questions to ask about disease than whether
it is natural or normative, and there is another sense of disease for
which Boorses assumption is incorrect. Having a disease in the
sense of some particular disease entails the absence of health, but
the absence of health entails neither having any particular disease,
nor any disease at all. We clearly do not say that a broken leg is a
disease in this other sense of disease, while we clearly do say that
inuenza is a disease in this sense. And in this sense, we clearly say
that inuenza is a different disease from cholera. This sense of
disease is the one at issue in this paper. It may be that in some
contexts, disease and ill health are synonymous; but there are
other contexts where they are not synonymous. Analogous points
apply to other concepts that can be used both sortally and to
indicate the absence of something else. Robbery is a crime may
mean not only that it is criminal but that it is a distinct sort of
criminal act from theft, fraud or taking without consent (an English
statutory offence introduced to handle joy-riding, which escapes
the denition of theft because there is no intention to permanently
deprive). To take another example more familiar to philosophers,
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
1
By contrast, for some other concepts we indicate these two different but related
senses with different wordsdconsider the usual sense of space and place,
setting aside architectural phrases such as a space. We do not seem to have any
such distinction for time, though, and must clarify with point in or interval.
2
In fact I have my doubts about this methodology in pure metaphysics too, but
that is a wider debate.
251
with grue rather than green then we would have made a lot of false
predictions about the colour of emeralds from 2000 AD on.3
The second feature of Langes approach that gives me difculty
in using it as a building block is that I see the history of the concept
of disease as displaying some considerable variation, whereas he
seems to see the concept of disease as having a single, clear
meaning. On his view, diseases are natural kinds, and they play an
explanatory role. On my understanding, the concept of disease has
differed at different times, and it is too quick to conclude from a few
supporting examples that it has a univocal sense throughout
medical history. Lange writes, for example:
Plausibly, etiology unites various tokens of the same disease and
differentiates them from tokens of other diseases. (Lange, 2007,
271)
While I agree with Lange that this is plausible, I am not satised
either with plausibility as a relevant test for truth in this sort of
inquiry, nor that others nd it equally plausible. The multifactorial
turn in modern medical thinking, informed in part by the growth of
modern epidemiology, has created a situation where it is often
regarded as obvious that diseases should not be classied by their
causes (see also Broadbent, 2009, 306e308, 2013, 145e155). Lange
acknowledges this, and concludes that the concept of disease is
now being abandoned; but I see this as a change in the concept of
disease. This might seem little more than a verbal difference, but I
think my approach is more faithful to the actual usage of the term
disease in medical and especially epidemiological circles.
Recall, moreover, the rst difference between my approach and
that of Lange: he seeks only to describe, while I also seek to prescribe. I think the concept of disease has been useful, and that the
reasons for its usefulness can be identied. This drives me to make
prescriptions about how the concept of disease should be understood and developed in the future, based on those reasons for its
past usefulness. Thus even if I agreed that the concept of disease is
being left behind, I would argue that it ought not to be.
In previous work, I have discussed the history of the concept of
disease, and sketched a theoretical model of disease, which I call
the Contrastive Model (Broadbent, 2009, 308e310, 2013, 157e161).
The immediate purpose of this paper is to develop the Contrastive
Model of Disease by defending it against a specic objection. This is
not as self-serving as it may sound, since the objection will, in one
form or another, stand against any theory of disease. So the larger
purpose of the paper is to show the medical importance of disease
classication, and of a distinction between disease and ill health
more generally.
The objection arises when the criteria proposed for classifying
diseases do not match up with the way diseases are in fact classied, either by practical medicine or medical science. This suggests
that the proposed criteria for the classication of disease are
irrelevant to the goals of practical medicine, or alternatively of
medical science. I call this the Irrelevance Objection, and I will
defend my Contrastive Model against it, since that is the theoretical
model I believe in; but an Irrelevance Objection can be raised
against any theory of disease classication that says something
more than that a disease is whatever medicine or science calls a
disease. Defeating the Irrelevance Objection will go a long way
towards explaining the point of classifying diseases according to
the classication criteria proposed by the Contrastive Model, and
3
Nelson Goodman famously argued that we have as much evidence for the claim
that all emeralds are grue as we do for the claim that they are all green, where grue
was dened as green and rst observed before 2000 AD, otherwise blue (Goodman,
1983, 59e83).
252
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
4
Annemarie Jutel distinguishes statistical and nosological classication, and
traces these two traditions back to John Graunt and Thomas Sydenham respectively
(Jutel, 2011, 190). This is not quite the same distinction as I am drawing, I think, but
there are surely connections, which I regret that I do not have the space to explore
here.
5
I assume, of course, that gives birth to live young is part of the denition of
mammal. If you nd the assumption objectionable then substitute some other
denitional characteristic of mammals.
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
253
254
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
6
This, roughly, is the line I have taken elsewhere (Broadbent, 2009, 308e310,
2013, 157e161).
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
body. The same virus can cause cancer of the penis and of the anus,
but it is not unreasonable to hypothesise that the very different
social signicances of these body parts would tend to make a
classication of one disease aficting all three (cervix, penis and
anus) less likely.
It might be countered that the classication cervical cancer
has a much more straightforward public health goal. In support,
one might note that cancers of the penis and anus represent
much less signicant public health risks, especially in the developing world. Cervical cancer is the leading cause of cancer
deaths in sub-Saharan Africa (Ramagola-Masire, 2010, 93). But
this counter becomes implausible when one considers that many
of the public health measures to combat these three cancers
caused by HPV are the same. In particular, because the cancers
arise from the same virus acting on different parts of the body,
HPV vaccines appear to offer both women and men the same
protection against anal cancer that they offer women against
cervical cancer. This suggests that there is not a strong public
health reason to distinguish cervical cancer sharply from cancer of
the penis or anus, and that it may even be counterproductive to
do so, since that may make it harder to persuade men to have the
vaccination.7
Thus if there is resistance to classifying cervical cancer as the
same disease as cancers of the penis and anus, then the source of
this resistance may not be medical at all. It is plausible that there
would be a social resistance to thinking that the same disease can
afict the penis, the anus, and the cervix. These are body parts with
very different social signicances, which we are prone to project
onto the biology and pathology of the human body.
I am not saying that this is the source, let alone the only source,
of resistance to reclassifying cervical cancer along the lines suggested. (Indeed, my second reply will suggest another source of
resistance.) I am saying, rather, that one cannot necessarily infer
from the fact that medicine classies an afiction in a certain way,
that this is the most medically useful classication. To infer this
without further argument would be to assume there are no inuences apart from medical utility on the medical classication of
disease. But the assumption that the ostensible purposes of medicine are in fact served by contemporary medical classicatory
systems is clearly open to challenge. Medicine is subject to the
pressures and taboos of the societies in which it operates. This point
has been thoroughly discussed in relation to vaccination programs
for cervical cancer (see the essays in Wailoo, Livingston, Epstein, &
Aronowitz, 2010).
The second, and I think stronger, reply to the Irrelevance Objection is that the classication HPV disease is not in fact recommended by the Contrastive Model, contrary to Premise 2. The
Contrastive Model doesnt make recommendations about the
choice of contrast, whose cause is to be sought, and used to classify
the disease. If a general explanation of a contrast between healthy
and unhealthy persons is available, but medical practice does not
use it to classify the unhealthy persons as suffering from a common
disease, then that might be because the contrast is not medically
important. Until that possibility has been closed down, it will not
follow that the Contrastive Model is making an irrelevant
recommendation.
HPV infection is a very poor explanation of the contrast between people with cervical cancer and people without, because
exposure to the virus is so widespread. The situation is akin to a
classic example in the literature on scientic explanation.
7
In case it is wondered whether a distinction may be based in differences between treatment regimes for these cancers, note that there is no very effective
specic treatment regime for cervical cancer, once it has developed.
255
256
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
CASES
CONTROLS
This development of the Contrastive Model allows for asymptomatic disease. In place of a requirement of symptoms, the Revised
Contrastive Model requires a deviation from normal functional
ability, where that is understood in terms of statistically typical
contribution to survival and reproduction, relative to a reference
A. Broadbent / Studies in History and Philosophy of Biological and Biomedical Sciences 48 (2014) 250e257
class. The intuition underlying the original requirement of SYMPTOMS was that cases of disease must at least be cases of ill health.
The advantage of substituting a well-worked out account of health
for the simplistic requirement of SYMPTOMS is that it enables this
intuition to be given proper expression, and does not saddle the
account with an implausible commitment to the effect that all cases
of disease show symptoms.
One might object that this move saddles the account with an
even more implausible commitment: the commitment to Boorses
biostatistical theory of health, and with it, naturalism about health.
I do not propose to deal with that objection here, since to do so
would be to defend the biostatistical view of health, and naturalism
with it; and that is not the topic of this paper. But I do note two
points in favour of this alliance between naturalism about health
and contrastivism about disease. First, the Revised Contrastive
Model is not committed to every detail of Boorses account (indeed
it contradicts Boorses account of disease), but only to the viability
of some account of health based on the idea that health is a certain
kind of statistical normality. The extension of the reference classes,
and the justication for choosing those reference classes, may be
altered and amended without disturbing that basic insight, as may
the choice of survival and reproduction as the goals relative to
which normal function is dened.
Second, I note that a causal model of disease is a natural t for a
naturalistic view of health, such as the biostatistical model is. The
Contrastive Model recommends classifying diseases by complexes
of causes. This is in keeping with the naturalists view that health
and disease are out there, and not features of cultural or personal
preference. I have not sought to argue that nature dictates just one
way to do this, but I have urged that there are sometimes empirical
facts concerning which disease classications are better. Empirical
evidence always underdetermines theory, but it does not follow
that theory choicedor here, choice of classication scheme for
diseasesdis entirely a psychological or sociological matter.
A nal doubt one might have about the revised Contrastive
Model concerns the new denition of CONTROLS, which species
the Boorsean reference class as default. The discussion of Section 2
made it sound like investigators could simply stipulate the extension of CONTROLS, setting aside cases that required further investigation, and my treatment of immunity (elsewhere) relies on this
feature (Broadbent, 2013, 159). How is this compatible the spirit of a
biostatistical theory of health? Conversely, what is the rationale for
populating CONTROLS with members of the reference class, even
by default?
The rationale for starting with CONTROLS populated by the
reference class is that these are healthy individuals, by the denition of the biostatistical view. The rationale for deviating from this
default is to permit the sort of exceptionalism that is an inevitable
part of any real-world attempt at classication. The spirit of the
Contrastive Model is served provided that exceptions are explained
at some stage as cases of immunity, with another application of the
contrastive structure (Broadbent, 2013, 159). The spirit of the
biostatistical model is preserved because the human element in
choosing what falls under CONTROLS is ultimately subject to the
tribunal of experience, when the resulting disease classication
system is put into medical practice.
7. Conclusion
There is an important distinction to be drawn between disease
and mere absence of health. One way to draw that distinction is by
classifying diseases according to their causes, and one way to do
257
this is by classifying diseases according to causes that explain differences between healthy and unhealthy groups of medical interest. I have defended the Contrastive Model of Disease against the
objection that medical practice and science do not do what the
model says would best serve their interests, focussing on the case of
cervical cancer. I have argued that, contrary to appearances, the
Contrastive Model does not recommend reclassifying cervical
cancer as HPV disease. But I have also argued that even if it did, that
would not be fatal to the model. If the cases of HPV infection
without cancer were the result of stochasticity, then HPV-itis
would still be our closest thing to classication backed by a general
causal explanation. The cancer-less cases of HPV infection could be
incorporated as cases of asymptomatic HPV-itis. In order to
accommodate the latter, I have sought to develop the Contrastive
Model so that it handles asymptomatic disease, and in doing so
have aligned it with a broadly Boorsean biostatistical view of
health, which, however, I have not defended here.
Acknowledgements
A version of this paper was presented as part of a symposium on
cancer and viruses at the 2013 meeting of the International Society
for the History, Philosophy and Social Studies of Biology. I am
grateful to Mael Lemoine, Dean Peters, Anya Plutynski, Robin
Schefer, Danielle Swanepoel, and Michael Vlerick for helpful discussions, and to anonymous reviewers for helpful comments. Part
of this research was supported by a grant from the National
Research Foundation (Incentive Funding for Rated Researchers) of
South Africa.
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