Harm as a necessary component of the concept of medical disorder

Wakefield’s harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction (failure of biologically designed functioning) and a value (harm) component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder.

Reply to Muckler and Taylor by Wakefield and Conrad


Neil Feit August 16, 2020 at 12:20 PM

Comment on the Evolution in Wakefield's View of Harm:

Even though I lean toward a naturalist view of medical disorder, I thought this Wakefield and Conrad (W & C) paper was a largely successful defense of the HDA (though the objections given by Muckler and Taylor (M & T) were weak in many ways). I find it interesting how Wakefield’s view of the sort of harm involved in medical disorder has evolved.

First, it seems now that a “mildly harmful dysfunction is … a disorder according to the HDA” (p. 353). In the past, Wakefield required a dysfunction to result in significant harm to the individual if it’s to count as a disorder – in fact, on p. 360, there is a quotation to this effect from Wakefield 2014. One worry about this recent change might be a minor one, but W & C start off by claiming that a benefit of the HDA is that there are endless harmless dysfunctions that nobody considers disorders. If only mild harm is sufficient (with dysfunction) then this benefit becomes weaker, maybe substantially weaker.

Second, I haven’t looked this up but I thought Wakefield used to require actual harm to the individual with the dysfunction (though it could be pro tanto harm). Now, W & C say that the concept of harm in the HDA is a “dispositional concept that pertains to the dysfunction’s typical effects under some range of standard circumstances as judged by social values” (p. 357). So, the tumor that is detected and treated at an early stage is still a disorder because that type of condition is “typically” harmful*, and so is very mild mononucleosis, even if it never harms the individual, since the person is disposed to become extremely fatigued in conditions that don’t actually manifest. (I was hoping for a citation of Limbaugh 2019 here, since this idea is defended there.)

*One concern that I have here relates to a more general concern about the lack of precision in W & C’s account. W & C seem to accept Spitzer and Wilson’s proposal that a condition, brought about by a dysfunction, is a disorder if it is typically harmful “in its full-blown state” (on p. 355 for example, regarding the tumor case). They don’t say enough about this in the paper, I think, but one worry again goes back to the alleged benefit of the HDA that it does not classify these endless harmless dysfunctions as disorders. A lot more of these are going to be disorders under an account that somehow incorporates something along the lines of this “full-blown state” clause.


Bob Kelly August 16, 2020 at 1:54 PM

Neil, first, I agree with the assessment. W&C handled their business pretty well, I thought. Thought you are right that the objections were nothing special, at least in the sense that they seemed to just re-raise the same sort of objection Wakefield has been responding to forever: "Oh, you are a normativist? X doesn't seem harmful (to me), yet it seems that it counts as a disorder." I thought it was an overly generous characterization of M&T's piece when W&C say that they "consider the issue...anew." Going only off the W&C summary of the target article, it was just the same thing we have seen Wakefield respond to over and again, except not done as well (based on the extended quotes). I feel W&C pretty much wiped the floor with them.

Second, just some clarification, I think (maybe I am just hedging; I honestly am not sure). I am interested in your point about the mild vs. significant harm requirement, and to the evolution of HDA in general. I think the evolution of their view is actually a good thing (since I think it is evolving in the right direction), and could probably use a little more evolving (maybe getting away from the social values stuff, or even fleshing it out more so as to provide firmer ground for it). But I wonder if when W&C call the mono case a mildly harmful dysfunction, they are referring to the actual amount of harm one is disposed to (not much) rather than the type of harm one would experience if the triggering conditions were met (which is significant--loss of socially valuable experiences or opportunities, etc.). In other words, the incorporation of degrees they have come to in the evolution of the HDA (mild, moderate, severe) might allow for there to be mildly harmful dysfunctions in a certain sense, but this may be the sense that is directly related to the dispositional nature of the account. How likely is the harm to be triggered? How many different triggering conditions are there? How many distinct different manifestations of harm are there--do I lose 2 types of experience? 5? But the later points about significance of the harm (p. 360 that you refer to; p. 359 when they mention M&T's use of 'significant'; p. 361 when they say the loss of certain possibilities is significant; p. 365 when they provide an example of researchers saying colorblind harm is significant) may not be inconsistent with this because there they are talking about the level of harm one is disposed to endure (not the frequency aspect related to the dispositional property itself, to put it one way).

I'm not sure if that helps, since I am not sure I got your worry exactly right. The evolution itself doesn't seem bad, and the incorporation of the mild, moderate, severe spectrum, in particular, doesn't seem bad. This introduces hard questions, but I agree with W&C that it's the right move. But my point above was to try to suggest that, if this was even one worry you had, it doesn't undermine their other claim that the (sometimes potential) harms have to be significant to count. "Mild" refers to *how* disposed a dysfunction makes one towards the significant harms. What do you think?

Third, and lastly, I couldn't tell if W&C think that no harm at all is required or if they think that the disposition (risk) towards harm that (I am assuming they think) is inherent to the (i.e. that particular instance of a) dysfunction is itself harmful. Pickard & Sinnott-Armstrong make harm (in roughly this dispositional way) a necessary requirement of addiction, but they clarify that if pushed they will (or, more charitably, can) fall back on the idea that the loss of control itself (which disposes one toward harm) is itself harmful. It seems W&C could do that, too, but I can't tell if they do or want to do that.

Neil Feit August 16, 2020 at 3:22 PM

Bob, on your first point, I totally agree. M&T's objections were not new and were weak. Wakefield himself had already discussed the cowpox / preemption issues. The colorblindness and anosmia stuff was especially unpersuasive; a better argument with those would have been along the lines of an "essential pathology" where the person would not even have existed without it. But that's in the literature too, they did not cite Boorse for example. A bit surprising the paper was published, since it's also fuzzy on the value theory issues (harm vs. well-being etc.).

Stephen Kershnar August 20, 2020 at 9:35 AM

I wonder whether Wakefield's theory is compatible with the counterfactual comparative account of harm (CCA). The CCA counterfactual would apply to populations as well as individuals, sometimes perhaps with counterintuitive results. I wonder whether combining CCA with a culturally relative theory of harm would produce odd results with regard to disorders.

Bob Kelly August 20, 2020 at 11:15 PM

Steve, can you say more? Are you thinking that CCA would be incompatible with his idea that social values determine what counts as harmful so that the HDA would have both components? It seems like CCA is an alternative to the social values theory, right? If that is right, then I'm not sure why CCA wouldn't be "compatible" with Wakefield's HDA. Do you just mean that CCA is counterintuitive, and so if HDA had that account then it would be false?

Pat D August 22, 2020 at 6:47 PM

Neil, Bob, and Steve - it seems that everyone is agreed that "M&T's objections were not new and were weak." I haven’t had a chance to review David Limbaugh’s or Neil’s papers on harm or Bob’s on addiction, so I hope that my comments below aren’t too far afield.

Neil Feit August 16, 2020 at 3:28 PM

Bob, on your second point, that is really interesting. Maybe you're right and I was too quick to assume that for W&C, a mildly harmful dysfunction is a disorder even in the absence of it resulting in a disposition to be harmed more significantly. They bring up the mildness claim before they discuss the other issue, so it seemed to me that it was independent but now I'm not sure. Some of the stress that they place on significant harm later in the paper might support your interpretation.


Stephen Kershnar August 19, 2020 at 9:17 AM


I wonder which you think would be a better view for W&C.

(1) The individual might suffer no harm but has a disposition to suffer mild or greater harm.

(2) The individual might suffer not harm or mild harm but has a disposition to suffer great harm.

I interpreted them in terms of (1), although thought they did a good job showing that color blindness and anosmia can be significant harms.

Neil Feit August 20, 2020 at 9:07 AM

Steve, I guess I think (1) would be better and it's also how I'm inclined to interpret them.

Bob Kelly August 20, 2020 at 11:32 PM


It's totally possible that I am inadvertently just tweaking or re-interpreting parts of their view in order to respond on their behalf to the worry you raise. So maybe W&C would object to something in my response. And I think it isn't totally clear from the paper. But part of my motivation was that I did think they were clear about stressing that the harm needed to be significant in some way. And I think this sorta raised a flag in my head in the vein of your objection about the inconsistency, so I instinctively tried to remedy it. If nothing else, it's a possible Wakefieldian route one could try to work out. Significance (in terms of something like quality of harm--maybe "morally important harm" is better) gets a dysfunction a seat at the disease table. Then degree--mild, smoderate, sever--is about how much of those harms you endure or are disposed to endure. This would entail that a dysfunction making someone disposed only to insignificant harms (whatever that means--maybe like someone flicking your shoulder?), even if disposed to a severe degree (they'll experience them a lot), would not be a disease. Maybe this response doesn't work, after all. I'm not sure how to work out what a significant and insignificant harm is -- but perhaps the social values component gives them room to do that (even though it seems like it is much worse in other respects).

Steve, I agree with Neil. (1) is both better and how I saw W&C's view.


Stephen Kershnar August 23, 2020 at 10:12 AM

Neil and Bob:

The problem with (1) is that when combined with culturally relative harm, this sets a very low bar for a disorder. Perhaps the biological dysfunction condition will prevent this from being implausible.


Steve K

Bob Kelly August 23, 2020 at 7:39 PM


Or we would just try to work out a better account of harm than the culturally relative one. If we go with the later, I agree that is a problem. But other options are available (of course with their own problems to work out).

Neil Feit August 16, 2020 at 3:34 PM

Bob, on your third point, I can't tell either. It seems clear to me that risk of harm is not harm, and likewise that a disposition to be harmed is not harm. That p. 357 passage that I quoted in my first comment above suggests that, at least as harm figures into the HDA, the disposition toward harm is itself harmful. (They did not take David Limbaugh's advice and call this "damage" instead of harm.)


Jack Freer August 17, 2020 at 12:03 PM

The disposition toward harm is the essential feature of diseases that only represent risk factors for conditions with real harm. The prime examples are hypertension and hyperchosesterolemia. All humans require some blood pressure to stay alive and deliver oxygen and nutients to the organs. Likewise, all cells in the body require cholesterol to form their cell membranes. Empirical observations of blood pressure values, and blood cholesterol concentrations, however, reveal a positive corellation with cardiovascular disease. A high sustained blood pressure or high cholesterol concentration is statistically associated with an increased likelihood of heart attack or stroke. Not all people with heart attacks have high blood pressure or high cholesterol. Not all people with high BP or high chol (or even both) develop these clearly harmful vascular conditions. The statistical correlation is, however, compelling and leads to the treatment with multiple medications to reduce the risk factors. So, is hypertension a disease? Is hypercholesterolemia a disease?

I believe "disease" (or pathological condition, or whatever refinement in language is used) is a social construct. There are multiple terms used by medical professionals for similar entities (disease, pathologic condition, illness, malady, diagnosis, condition, problem). Sometimes they are used interchangeably. Sometimes people split hairs over the differences (disease vs. illness, depending on whose perspective: doctor or patient). The designation of disease changes with the times (masturbation, homosexuality, and a curious disease known only in the antebellum South: drapetomania--propensity for enslaved Africans to try to run away all used to be considered diseases by some). Sometimes behaviors previously categorized as character flaws become disease, such as addiction (Bob, interested in your view of this).

Stephen Kershnar August 19, 2020 at 9:22 AM

Bob, Neil, and Jack:

I wonder if the risk of great harm is itself a harm. I don't think it is. This might even be an analytic truth.

Still, we think that would be an attacker who endangers his would-be victim forfeits his right against defensive violence.

If the attack (or risk it imposes) is not itself an injustice (right-infringement) or harm, then it is hard to see why they forfeit their right.

Similarly, if mono prevents someone from running or working long hours, it intuitively seems to close off options even if the options are not one he notices, values, or wants.

Bob Kelly August 20, 2020 at 11:51 PM


I agree with all of that. Dispositions to harm don't seem like harm, and it does seem like they make that move. I have similar issues with the Pickard & Sinnott-Armstrong view of addiction I mentioned. At the same time, I also know that when I reflect on dispositions to harm and have the intuition that they are not harm, I can sense that what I mean by 'harm' in the latter sense is 'actual harm' or 'realized harm'. I think that matters because, as I think David Limbaugh (who I also agree totally should have been cited and borrowed from) tries to show or imply with "harm in the damage sense," that can't be what W&C mean by 'harm' in the HDA. Not as they have developed it anyways. So I want to be sure I am not just talking past them when I resist dispositions to harms being "harms." I also think this means you are right that they should have went with another term, as DL did. It would help us understand what they are really trying to say, and would force them to be more explicit about the details of the normative component of their account. Diseases only require dispositions to harm (in some worked out way) on their view, and this might not be what you expect when you hear they have a hybrid account with a harm requirement. I don't think there's anything illicit going on. I just think there is a tendency to want to make their harm component *true* harm, and so whatever they have to work into the account they want to also *really* count as harm. I think Limbaugh's approach is more philosophically sound. But as you said, their view is evolving and that means they're still working stuff out.

Bob Kelly August 21, 2020 at 12:18 AM


I definitely see your worries. It seems like there are two, setting aside for the moment the hypertension case. (1) A worry about term usage, and (2) A worry about the disease concept changing with time. And although I didn't read your response until I finished replying to Neil, I think part of what I said in that reply touched on the first issue (or, really, nonissue) of which terms we use. I guess my basic thought is that I don't think it matters what people name something, and so I don't really see that polysemy, or terminological confusion, or term preferences, or whatever explains the various uses, can justify the jump to disease being a social construct. The fact that people use different terms for the same thing or the same term for different things, and likely don't realize this, is just an instance of confusion, or talking past one another. This just happens all the time, in every domain. I don't think it is a reason to remove the entities being talked about from your ontology (your list of things that exist). Experts do the same thing with 'person', but there are people. They might do it with 'house', but there would still be houses. So basically, I don't think conceptual or terminological confusion should make us jump to social constructs and deflationary accounts. We just need to get clearer about what we mean when we use a term. And if they really did that, my guess is these doctors would realize quite often that they aren't disagreeing about anything. I see this all the time in addiction research (without the realizing that they are doing it part). And the same point applies there. The fact that addiction researchers can't get one the same page about what everyone means by their terms is no reason to think there is *really* no such thing as addiction. This is true even if there really is no such thing as addiction.

On (2), I feel roughly similar. I don't think that differences in diagnoses or disease concepts across time is reason to think there are no diseases. Think of how the concept of "earth" has changed from flat to round earthers and geocentric to heliocentric views. I would just want to have a bit more before I take things like disease or addiction out of my ontology. For the addiction case in particular, I am not sure the cross-time change even matters. Some still think it is a character flaw (Peele, Dalrymple, Schaler). So lots of people's views changed, but there was always disagreement. I think the main thing is just that we can be wrong, and our fallibility is what makes it the case that mere disagreement (across time, of concepts, of term usage, etc.) is not enough to justify believing that the subject of disagreement is not real.

Bob Kelly August 21, 2020 at 12:25 AM

Steve, I agree. I think you, Neil, and I all have the same intuition about dispositions to harm. And I like your analogy to the self-defense case. It seems like this gives W&C some fodder for buffing up the view in response to this worry. Then again, the 'opportunity' talk seems to suggest that something like an appeal to an objective list is going on. If that is the right way to understand your suggestion, then we would no longer have a *mere* disposition to harm. This would straightforwardly be an actual harm. Thoughts?

Pat D August 22, 2020 at 6:49 PM

I would distinguish risk and disposition. A person who has a stroke that leads to difficulty speaking (aphasia) only manifests that dysfunction when they attempt to speak, not when they are walking, dressing, eating, etc. They have a disposition to disordered speech, just as they had a disposition to normal speech before the stroke. A person with hypertension has a risk for a stroke that could lead to aphasia or other neurologic dysfunction. One obvious difference is that once the stroke has occurred, nerve cells have died; we just don’t draw on that part of the brain for all of our neurologic functioning. There is an underlying ontological problem here. If everything comes down to matter in motion, then risk factors are virtually the same as dispositions. But if physicochemical, biological, psychological and cognitive functioning are distinct, then risk factors pertain to lower level functioning setting conditions for higher level dysfunction to occur, whereas disposition relates to current capacity to function at a biological, psychological, or cognitive level.

Bob Kelly August 22, 2020 at 11:39 PM

Thanks, Pat. First, I agree that Risk (or 'risk factor' if you want) and Disposition are not identical. Though, a Risk is a type of Disposition. Risks seem intuitively to involve harm necessarily -- that is, a risk of X entails that X involves some sort of (possible) harm, however minor. But the risk is still a disposition in the sense that it is to be disposed in a certain way (namely, towards some possibly harmful state of affairs or process/event). The person with hypertension, for instance, has a disposition towards having a stroke, and since this event they are disposed towards (having a stroke) is harmful, the disposition is a risk. (NB: a complete definition/account of 'risk' may involves more than just "a disposition that is harmful," but I don't think it would change its classification as a disposition.) So, while they are not identical, all risks are a subtype of disposition. They are both modal properties that inhere in some entity (its bearer) and explain what their bearers can or must do (where 'explain' is something like a 'makes true').

Second, I don't think I follow the last part of your response, so I may be way off here. But I just don't see how it would matter at all what level of granularity we are dealing with. Electrons have dispositions, cells have dispositions, hearts have dispositions, organisms have dispositions, and maybe even aggregates of entities have dispositions. Nor does it seem like the truth of monism (whether materialist or not) or dualism would matter. As long as an entity can bear a modal property (whether it be a cell, an electron, a human being, an organization, an angel, God, an immaterial soul, a non-physical mind), it can have a disposition. If it can be harmed, it seems like it can bear a risk factor. I may be missing something, but I just didn't see the relevance of whether materialism is true ("everything is just matter in motion") or whether reductionism is true ("if physiochemical, biological...[etc.] are distinct"). Dispositions and risks can occur at any level, given the way I see them being defined. I'm not sure why we would give a separate name to one just because it appears (in virtue of its bearer appearing) at a "lower-level" or "more fundamental level" of reality. Also, I don't think all dispositions are functions either, as your last sentence implies. They are also a subtype of disposition, but differentiated by how they came about and what they are for. But again, I may be misunderstanding something here.

Pat D August 23, 2020 at 7:37 AM

Bob, thanks for these comments. I'll have to work out my terminology more carefully. What I am trying to get at is that disposition in the sense of current capacity (normal or abnormal) is different from risk, which involves a statistical rather than a formal relation between potency and act.

Pat D August 23, 2020 at 8:22 AM

In metaphysical terms, it comes down to recognizing or denying the difference between material/efficient cause and formal/final cause.

Stephen Kershnar August 23, 2020 at 10:21 AM

Neil, Bob, and Pat:

I don't think an opportunity is an objective list good because it does not in itself make someone's life go better. It looks more like an instrumental prudential good.

Also, if I understand them correctly, W&C don't need each individual to be harmed by a disorder - even a pro tanto harm - rather they need a mere disposition to be harmed.

I don't see the difference between a disposition to be harmed and an increased risk unless one views the latter as being purely extrinsic in some cases.

This is one of the reasons that pro tanto harm is best avoided in the discussion of a disorder.


Steve K

Jack Freer August 23, 2020 at 11:01 AM

Rob, thanks for helping to clarify that for me. Confusion about what constitutes a disease is understandable and expected. The social differentiation seems to apply to the question of what kinds of manifestations (physical or behavioral) are even considered diseases (as opposed to, for example, demonic possession).

Bob Kelly August 23, 2020 at 7:53 PM


Well the objective list defender of opportunity is going to disagree with your intuition, right? They'll think it might be true of two doppelgangers with differing opportunities that one is fairing better than the other--merely due to the presence of the opportunity. My guess is you have a differing intuition. But this doesn't mean it is incoherent for it to be on the objective list. The latter simply denies your statement that an opportunity is not intrinsically making the person's life go better since this would straightforwardly be false if opportunity were an objective list good. Can you say what some of the other reasons are for denying this besides intuition about a doppelganger case or similar case? Also, I agree that increased risk just is a disposition to harm. That's what I argued above in my reply to Pat. Risks are a subtype of dispositions (they *are* dispositions). They differ from other dispositions by, at least in part, being for some harmful state or event (I think it is safe to assume that some dispositions are not for harmful states or events, and so the differentiation makes sense).


I don't think I am understanding what you mean by 'statistical' and 'formal'. I think I understand your use of 'statistical' more so than 'formal', but if so then I am confused as to why risks are not dispositions. Dispositions (modal properties of things) can be statistical. The disposition of this radioactive isotope to decay might have some probability (which is statistical). The vase's disposition to break (its fragility) might be such that it manifests only probabilistically in triggering conditions. This happens with so-called "multi-track" dispositions and with "stochastic" dispositions. Not all dispositions determinantly manifest in their triggering conditions. Given that, I don't know how to differentiate your use of 'risk' and 'disposition' still (again, I am not saying they are identical--I am saying the former is a subtype of the latter, like basset hound and dog). What might also be confusing about this to me is that dispositions are very Aristotelian, so I am not sure why my view about risk being a type of disposition would require denying some central Aristotelian thesis. Can you explain that more?

Pat D August 23, 2020 at 9:28 PM

Bob, I meant to indicate above (1) that I accept your point about risk being a type of disposition and (2) that "current capacity" might be a better way to designate an alternative type of disposition (again accepting your point about disposition being the more generic category). In Aristotelian terms, this difference could be construed as the difference between a material disposition and a formal disposition. For example, high blood pressure is materially dispositive toward stroke, whereas stroke is formally dispositive toward neurologic dysfunction (such as aphasia). This is largely consistent with an Aristotelian approach, but Aristotle did not develop a science of the contingent as opposed to a science of what is necessary and universal. Modern science, especially since Darwin, includes a science of the contingent in terms of probability and statistics. I am suggesting that material cause can be thought of in statistical terms as setting conditions for certain types of events to happen on a probabilistic rather than a necessary basis. In contrast to this, it is possible to think of the normal neurologic development as formally dispositive toward the capacity to speak normally and injury to areas of the brain that control speech as formally dispositive to disordered speech. In this case, there is a formal relation between capacity to speak (normally or abnormally) and the way one actually speaks at any given time.

In saying this, I am thinking of risk of dysfunction as opposed to risk of harm. If one has suffered a stroke that causes aphasia, one has already been harmed; the harm is formally related to the dysfunction (aphasia). But there is also the risk of losing one's job due to aphasia, if one is still of working age. The relation between the harm of losing one's job due to stroke is contingent upon age, among other things, and in that sense is statistical rather than formal. (Lonergan uses the terms systematic and non-systematic relations rather than formal and statistical, as I have been doing. Not sure if that clarifies some of these distinctions or raises more questions.)

Neil Feit August 17, 2020 at 12:02 PM

Objection to W & C -- A Risk of Circularity

Following Muckler and Taylor, Wakefield and Conrad try to remain neutral between three main perspectives on well-being. That's all good. But with respect to M & T's cases of mild viral infection, W & C admit they're not harmful on hedonistic and desire-satisfaction accounts (this drives toward their "typically or dispositionally harmful view, which I'll ignore here). W & C do say that given the third type of account of well-being, the objective list account, mild infections are harmful. They defend this claim as follows: "Biologically normal-range physical and mental capabilities would certainly appear on any such list of objective goods" (p. 354). I'd argue that this sneaks in health as an objective-list good. If the concept of health is (1) an essential component of their theory of well-being and (2) analyzable as the absence of disorder, which seems to be the case, then W & T's view is circular. Disorder is analyzed in terms of harm, which is analyzed roughly as a setback of an objective good, which are analyzed in terms of health, and hence disorder.

Perhaps I'm wrong about this, but there seems to be a problem with holding all three of the following views. (A) Disorder is connected conceptually with harm. (B) The objective-list theory of well-being is true. (C) Health is an objective-list good. If I'm wrong about this, then there is some way to get health on the list without using the concept of health in stating the objective-list theory -- maybe there is...


Stephen Kershnar August 19, 2020 at 9:26 AM

I agree it would be circular to include health as an objective list good. In addition, it is an implausible objective list good as health intuitively seems to be an instrumental good.

Even if W&C commit this circularity, I wonder if they need it. They can handle the relevant cases (mono, cowpox, color blindness, and anosmia) without such an objective list good.

Bob Kelly August 21, 2020 at 12:37 AM

Neil and Steve,

I am still unsure if it needs to be circular. I don't have this worked out, but I will give it a shot. I have two thoughts. First, if in analyzing or cashing out harm the objective list theory does not need to actually explain or appeal to the members of the list explicitly (i.e. you can explain the objective list theory without putting any particular thing on the list), then it doesn't seem like 'health' being on there will matter. If it doesn't need to be part of the analysis, then it is not circular. The objective list *theory* explains harm, not the objective list itself. So the general analysis of 'disease' doesn't seem circular. However...

Second, there would seem to still be a lingering circularity possibility at the level of specific cases, though. If the harm that actually came to the person with the dysfunction was losing health, then that would be circular. I guess the worry would become general again if you thought every harm had to do with losing health, which I don't think is true (though I haven't thought about this much). In any case, wouldn't it be circular if you analyzed a particular case, say Mr. Jones' dysfunction, and realized that it was harmful because it was making him unhealthy in other ways? I'm not sure this is even possible or if the analysis would make any sense.

All that said, I think that is a really nice objection. Seems worth pursuing.

Neil Feit August 22, 2020 at 10:06 PM

Bob, that would be the way to go for an objective list theory in this context. Maybe something like Nussbaum's view where objective list goods are something like whichever capabilities are required for human dignity. I don't find a view like that plausible, mostly because it seems to capture instrumental not intrinsic goods.

Stephen Kershnar August 19, 2020 at 9:29 AM


While this steps out of the dialogue, I wonder if some of the J. P. Bullfeathers objections against HDA still succeed. Here are some of them.

Consider the Harmful Dysfunction Analysis (HDA).

Assumption #1: Epicureanism. Epicureanism says that death does not harm the decedent because there is no subject to harm.

The underlying assumption is that an object has to exist to exemplify a property.

(1) If HDA is true, then a death-causing dysfunction cannot be a disorder (because they are not harmful).

(2) In some cases, a death-causing dysfunction is a disorder (for example, a brain aneurism that kills someone).

(3) Hence, HAD is false. [(1), (2)]


David H August 22, 2020 at 4:56 PM


I agree with you. I have used this epistemic possibility, as well as the possibility of diseases sending those who die from them straight to a Heaven that makes all fatalities a benefit. (One then just adds a story so there is no prima facie harm from the death such as one was worse off or already permanently unconscious.) I am surprised you didn't mention that religious pro-lifers should not try to prevent miscarriages. But I suppose JW could say that he is interested not in the mere conceptual possibility of diseases not being harmful but in the metaphysical possibility. He might then insist that the nature of harm and the world is such that it is necessarily the case that both Epicureanism is false and that there is no God. Then the epistemic possibility of such deaths rendering fatal diseases harmless is irrelevant for it doesn't mean it is metaphysically possible to have a disease that is not harmful. If I was a defender of the HDA, I wouldn't want to hang my hat on metaphysical impossibility of death being neither a harm nor a benefit, or the religious afterlife being metaphysically impossible. I think we are interested in the concept of harm, which includes metaphysically impossible worlds, not the metaphysically possibility of harm

Neil Feit August 22, 2020 at 10:11 PM

I find the Heaven objection a lot stronger than one that merely claims death can't be a harm. There are several plausible ways to understand the account W&C are working with so that it makes most deaths harmful, for example one that simply compares the shorter life with the longer, counterfactual one

Stephen Kershnar August 23, 2020 at 10:32 AM

David and Neil:

I realize I differ on Epicureanism than you guys. I don't think the comparison of lives works when the subject doesn't exist during the relevant period of one of the lives. Let us set this long-running disagreement aside.

If I were W&C I would just concede that if Epicureanism is true or people go to heaven, then death-causing dysfunction is not a disorder. I would then say that this just shows that more extreme positions generate counterintuitive results.

If one were to think that harm is impossible were fatalism true (every event is metaphysically necessary) - and I am leaning toward accepting this - then, again, no one can have a disorder. Again, extreme assumptions entail counterintuitive results.


Steve K

David H August 23, 2020 at 2:55 PM


If the world was not just physically determined but metaphysically determined, there might still be harm. One way is claim that the concept harm just requires a conceptually possible world where someone's well-being would have been higher than in the determined world. So even though that world was metaphysically impossible, we can use it to compare to the only physically/metaphysically possible world. This involves more philosophical baggage as we have to then talk about metaphysically impossible worlds being closer than others. I don't know if we can get help by considering it being metaphysically possible to have different initial conditions and a determined world. Probably not

A second position is non-comparative harms. The theory has problems but perhaps it becomes the best theory left standing and philosophy just involves weighing theories, all of which have warts, to mix metaphors

Third, drop talk of harm and replace it with misfortune. If our nature is such that we must wear out and die at a certain age, then it is a misfortune rather than a harm. Or imagine that progeria or Down's syndrome was an essential pathology and to be free of it would have meant a different human being (I don't buy this, for what it is worth for I think there are no essential pathologies). We can still say it is a misfortune. Hopefully, this isn't the same as the earlier appeal to impossible worlds. Maybe misfortune can do some of the work that harm was meant to do. I am not sure what that work is. Do we compensate people or agree that it would be reasonable to regret what couldn't be otherwise

Stephen Kershnar August 19, 2020 at 9:30 AM


Assumption #2: Plant. A plant cannot be harmed because it does not have an interest (see, for example, pleasure, desire-fulfillment, and plausible objective list goods).

(1) If HDA is true, then a plant cannot have a disorder/disease (because they cannot be harmed).

(2) A plant can have a disorder.

(3) Hence, HDA is false. [(1), (2)]


David H August 22, 2020 at 4:24 PM


Wakefield and Conrad write p. 352 “HDA is not committed to any particular theory of well-being or harm…” So, I think they can account for plant harm by helping themselves to an account of flourishing that involves living beings fulfilling their capabilities. Mindless plants, animals, and humans can all flourish. “Flourishing consists in the growth and development of the capacities of a living being” (Kraut: 2007, 148). At times later in that development, the flourishing of human beings will involve the maturation and exercise of mental capacities. But earlier, when mindless, they could be flourishing in the appropriate way for their stage of development. I find it revealing to observe the structural similarities between health and well-being. Diseased plants and animals are described as failing and the healthy as flourishing. We likewise describe conscious organisms who undergo significant drops in well-being as doing poorly and those whose well-being greatly increases as their thriving. Well-being is contrasted with ill-being (Kagan) further suggests a connection between health and well-being. It is not metaphorical to claim that healthy plants are thriving. Even when mindless, it is good for a plant or fetus to be healthy. The causes and constituents of their flourishing are in their interest.

If philosophers don’t accept that non-sentient beings can have welfare and interests then they won’t be able to explain the harms or benefits of themselves losing or gaining consciousness. The standard counterfactual comparative account determines whether an event has harmed or benefitted you by measuring your well-being due to the actual event and comparing it with your well-being if the event in question had not occurred. You are in a harmed state if the event produces a drop in well-being from what would have been the case, a beneficial state if it brings a rise in your well-being. Thus, if the mindless don’t have any level of well-being then we can’t explain why it is a harm to lapse into a coma and why the harm occurs when one is in the coma. Nor can we make sense of why it would be beneficial for someone to come out of coma or, better yet, be in their interest to become conscious for the first time. (A theorist might account for the harm by comparing the actual life of the comatose with a possible life without the coma. While that would deliver the judgment that the comatose individual suffers a harm as his life doesn’t go as well as it could, that doesn’t locate the harm at the time of the coma. Nor, more significantly, can the approach explain why it was good to ever become conscious for the first time without according the mindless possess a level of well-being. There we are not comparing two lives, each with some duration of conscious well-being, but a life without any consciousness to one with conscious periods. In order for that change to be a benefit, the mindless condition must be compared with the conscious state.) So, to make sense of seemingly obvious harm and benefits, we must allow that the mindless have well-being, even if it is zero or negative. Their well-being can’t be measured by experiential states or desire satisfaction for they have none. Yet, if something would be good for them, we can say it is in their interest. Thus, it is wrong to insist that only the conscious can be harmed. Consciousness makes possible pain, not harm. Entities can be harmed by not becoming conscious. Individuals that are supposed to be conscious, but aren’t, can be harmed to degrees not reached by living creatures not designed to develop consciousness.

Pat D August 22, 2020 at 6:52 PM

David, I agree with most of what you say here, but I have a problem with saying that plants have an ‘interest’ in thriving. I think that ‘interests’ pertain to conscious functioning, which do not pertain to plants. I have referred in the past to Robert Wachbroit’s ~1992 paper on biological norms as distinct from statistical or valuational norms. I think that a plant that is not thriving is biologically abnormal (or pathological). Disease pertains to living things, not inanimate things (like chemical isotopes). Animals and humans manifest higher levels of function over and above the biological.

This also has something to do with asymptomatic diseases being harmful even though the affected individual is unaware of what is going on. For example, individuals with hepatitis C have extensive liver damage (which is biologically harmful) long before they become symptomatic or consciously aware of this.

Bob Kelly August 22, 2020 at 11:50 PM

Pat, I think we can easily avoid your worry, which seems terminological at bottom. Just call what David H is talking about a 'biological interest' and call what you are talking about a 'conscious interest'. Here is a quick stab at fleshing out 'biological interest'. An organism has a biological interest in M when it has some disposition or set of dispositions D, such that the realization/manifestation, M, of D contributes to the organism's flourishing (filled out however you want). Plants are not conscious, so of course on your understanding of 'interest' they will straightforwardly not have any interests. But I don't want us to get hung up on the terms. If they have biological interests (as described), and frustration of these biological interests can properly be understood as harms (which seems totally consistent with the HDA), then the HDA can account for plant disease.

The hep C example is easily captured by including (pace Kershnar) non-experiential harms, which clearly the HDA does (perhaps must) given the dispositional component of the view.

David H August 23, 2020 at 12:35 AM

Advice for Wakefield on disorders in mindless organisms

Jerry can accept that mindless plants and the like have well-being and can flourish when they are functioning properly and are healthy, and are suffering from a disorder when they are dysfunctional and failing and have "ill-being" and disposed to more likely die or fail to reproduce So that keeps disorder involving dysfunction and harm in the mindless even though it has nothing to do with societal values. Health for the mindless just is functioning properly. Then he can apply analogues of his dysfunctions that don't harm patients - streptococcus pneumonia in the nose and sinuses as opposed to the lungs, polio virus that doesn't paralyze, Epstein-Barr virus that does't cause mono etc. - to argue that dysfunction is necessary but not sufficient for disorder. I don't know anything about botany or bacteria or protozoans so I can't give any analogues. But he just needs instances of Nordenfelt's one dead cell in a plant.

Is there a problem in combining different theories of harm - one for humans with the societally relative values that Jerry is attracted to, with the health as a sort of objective goods approach for mindless organisms? Perhaps one should just try to incorporate certain pleasures as objective goods and fulfillment of desires with obtaining the objectively desireable. Anyway, I am more concerned with just providing the HDA a way to handle objections that Chris Boorse and Steve K make about plants and other mindless organisms

Pat D August 23, 2020 at 7:42 AM

Bob, we're agreed about hep c and non-experiential harms. I prefer to limit the attribution of interests to things that are conscious, but I understand that it is used in a broader sense as you suggest.

Stephen Kershnar August 23, 2020 at 10:44 AM

David, Pat, and Bob:

I do not think David H's solution works. Here is what he says, "[I]f the mindless don’t have any level of well-being then we can’t explain why it is a harm to lapse into a coma and why the harm occurs when one is in the coma."

Let's assume a person is a brain or a body. If so, there is a subject of harm. The person in the coma. He has 0-level of well-being. This is similar to a period of dreamless sleep.

If a person has a well-being level only when he has the capacity for experience, then we have to get into the weeds as to whether a person in a coma has the capacity for experience. By analogy, do I have the capacity to run a sub 3:30 marathon?

In contrast, consider my well-being level in 1865 or in Thailand today. I have no well-being level because the relevant subject - me - is not located in these temporal and spatial locations. Metaphysical principle: an object can have a property only in that location in which it exists.

Here is the basic problem David H's theory has.

(1) How well someone's life goes is a function of, and only of, some combination of pleasure, desire-fulfillment, or objective list goods. At most, objective-list goods include things such as knowledge, love, moral responsibility, and virtue (otherwise it has implausible results with regard to people).

(2) Plants and mindless animals have a well-being level and an interest in things.

Propositions (1) and (2) contradict each other. (1) is rock solid.


Steve K

David H August 23, 2020 at 2:36 PM


First, healthy function is an objective list good. Developing (certain) capacities is good for organisms. This view of well-being unifies plants and animals and human welfare. There is no need to talk of plants flourishing without well being or giving them metaphorical or analogical well-being. Nor do we have to say that health is in the non-literal interest of the mindless humans and then becomes literally in their interests after they become conscious.

Second, plants don't have an interest in things but there are things in their interests.There is no contradiction between 1 and 2 probably construed.

If minimally minded newborns don't have interests other than in what they desire or could desire, then it isn't wrong to forgo surgery and let them die painlessly in the near future. If they have an interest that they can't conceptualize or desire when they are minimally minded, then they had that interest before they were conscious. Consciousness is doing no work in the minimally minded if they interests that they don't conceptualized. So if the minimally minded have interests they are oblivious of, so do the mindless. Things that have interests have well-being.

Zero well-being can't capture the changes mindless organisms go from healthy to unhealthy. Anyway, zero well-being is a level of well-being. Wallets and rocks don't have zero well-being but no level of well-being. If a rock or computer could become conscious, it is not a benefit (since there is no comparative benefit of going from no well-being to some level of well-being) or in their interest to become conscious. It is in the interest and to the benefit of the mindless human to become conscious. You wrong a human being if you prevent consciousness. You don't wrong a computer if you prevent it from being consciousness. zero well-being approach can't capture that if you think every mindless being has zero well-being. I think zero well being is only had by mindless beings who are not doing well nor poorly, but are healthy for that reference class (species member of certain age and sex). If you think mindless artifacts have zero well being, then they are benefited by being made conscious and harmed if they aren't. That is counter-intuitive to say the least

Bob Kelly August 23, 2020 at 8:04 PM

Steve and David,

I am inclined to agree with David's response to the worry raised above.


You say, "I prefer to limit the attribution of interests to things that are conscious, but I understand that it is used in a broader sense as you suggest." If we keep in mind that, using your definition from above, by "interests" you mean something that necessarily entails a conscious subject of that interest, then it makes complete sense why you would limit the attribution in that way (i.e. limit the use of the term for talking about such entities). But the "broader sense" you are referring to, like David's talk of plants having "interests" is not assuming that axiom that the subject must necessarily be conscious. Do you just mean you don't like that term being used for non-conscious things? If you take the definition I gave of "biological interest", then we are not attributing any consciousness to plants. We can remove the term "interest" if you want and call them "biological benefits" or whatever sounds best. But I still just don't see what the objection is since you are just defining consciousness right into the word "interest." That's fine if you want to reserve that term, but it's not an objection to plants having the things which David H suggested they have. These don't require consciousness.

Pat D August 23, 2020 at 9:41 PM

Bob, I agree with you almost completely. As far as my preferred usage, I wouldn't say that I define consciousness "right into the word interest." I would say that interest is both dependent on and expressive of the capacity for conscious functioning.

Stephen Kershnar August 19, 2020 at 9:33 AM

Assumption #3: Context. A disorder is not so contextual as to support Egyptology and Reverse Egyptology.

If HDA is true, then whether something is harmful to an individual depends on a series of contextual facts.

a. It depends on harm to past people (Egyptology) and future people (Reverse Egyptology).

b. It depends on an individual having a natural function or biological design that in turn is function of natural selection. For a different type of individual, consider Blade Runner cyborgs. They have a human but not biological (evolutionary) design.

c. It depends on an individual not being the first of its kind and resulting from random genetic mutation. For a different type of individual, consider Godzilla. He is the result of massive random mutation and, thus, does not have a biological design.

(1) If HDA is true, then whether an individual has disease depends on facts about the ancient Egyptians and the 22nd Century Egyptians.

(2) If HDA is true, then Blade Runner cyborgs and Godzilla cannot have disorders.

(3) Whether an individual has a disease does not depend on facts about the interests of ancient and future Egyptians. In addition, Blade Runner cyborgs and Godzilla can have diseases (consider, for example, pneumonia).

(4) Hence, HDA is false. [(1)-(3)]

Stephen Kershnar August 19, 2020 at 9:35 AM


Assumption #4: Reproductive Fitness. Biological design depends on, and only on, reproductive fitness.

Note that a psychological pattern, X, might increase reproductive fitness and yet decrease longevity, cause severe harm to X-type individuals, and stunt physical performance. Consider, for example, psychopathy, narcissism, or a strong genetic-based propensity to rape.

(1) If HDA is true, then X is not a disorder.

(2) X is a disorder. [Intuition]

(3) Hence, HDA is false. [(1), (2)]

David H August 22, 2020 at 3:51 PM

Increasing One’s Downloads and H-Index

I think we can all learn a lesson from Jerry’s 30 keywords and 18 self-citations in the first paragraph of his paper. Most of us provide 3-5 keywords but I think we would have more downloards and readers if we listed 30 keywords. Most of us writing articles that mention Jerry’s hybrid account of disease mention his HDA and provide a reference to his 1992 paper. But he introduces the HDA with the 1992 citation followed by 17 others within the same parentheses!

David H August 22, 2020 at 3:55 PM

Concerns about Taylor and Muckler Article.

What’s New?

I read the T & M paper very quickly since the blog is about W & C response. So my haste may mean that I may have missed something but my cursory read didn’t reveal much new in the T and M article about diseases being harmful or not. Wasn’t it already well-established that JW’s HDA only needed a typical disposition to harm (so not every instance of a type of dysfunction had to be a disorder) and then for the harms to be prima facie? Appeals to mild mono don’t show us that mono is not a harmful disease since mild mono is not a different disease distinct from non-mild mono. A harmless token is no more interesting than an asymptomatic stage that never reaches the harmful stage because of some intervention or its merely probabilistic nature. What would be interesting is if there were 1) dysfunctions that were never harmful or 2) dysfunctions typically not harmful as these would then not be diseases by the HDA’s lights.

Problems with the CCA of Harm?

I also was never was that sympathetic to the critique of CCA of harm (found in Bradley and others) that failing to benefit wasn’t a harm. I just chalked that up to overmoralizing harm and failing to distinguish immoral harms from morally justified harms (e.g. failure to benefit, punishment, competition of businesses, athletes, romatic rivals etc.)

Values and Environment Choice:

I don’t see why T & M think the choice of normal environment is a value judgment. It is not a value judgement to point to design environment, long term habitat, eco system etc. I don’t think they have in mind Kingma’s harmful situations mentioned below

Soviet Red Herring: Pathologizing Dissidence

Naturalists frequently pat themselves on the back and criticize normativists because the former provide a definition of health and disease that avoids being coopted by Soviet psychiatry while the latter are allegedly without the semantic tools to prevent such abuse. I don’t think the prevention of Soviet abuse of psychiatry necessarily requires naturalism, only a better ethics. Perhaps if one’s ethic is of the social relativist sort, then naturalism is needed. But one can be a realist about ethics and believe the treatment of the Soviet dissidents was unjust and thus they weren’t ill on purely normativist grounds

Missing Literature: Blaming JMP’s Backlog?

I am surprised the Taylor and Muckler didn’t engage, the 2014 JMP Wakefield article “The Biostatistical Theory Versus the Harmful Dysfunction Analysis, part 1: Is Part-Dysfunction a Sufficient Condition for Medical Disorder?” - and that the referees didn’t insist that they do - since with all the examples on dysfunctions without harms. I am also the authors didn’t engage with Kingma’s thorough and provocative article “Naturalism about Health and Disease: Adding Nuance for Progress” where she discusses value judgments in choosing the reference class (age and sex of the species) and goals (reproduction and survival) and where to draw the line between suboptimal diseased and below average healthy functioning; and the problem of harmful environments. The later arises “because normal ranges of function are different for different situations, for example, heartrate or cardiac output during sprinting and sleeping, or LH production during the fifth and fourteenth day of the modal menstrual cycle. So Kingma says that ‘normal function’ must be redefined as “the range of quantitative functional output that is statistically normal in a particular situation, environment or circumstance.’ Then she shows that this results in the problem of harmful situations. for example, exposure to large quantities of pathogens, environmental stress, toxic substances, etc. Harmful situations are a problem because the reinterpreted BST must label the statistically normal range of function in these situations as healthy.” Maybe this is due to JMP’s backlog. Phil and I discovered that if an article has been accepted in the last five years, that there is a 95% chance that it will be published posthumously

David H August 22, 2020 at 3:58 PM

Viruses that are Harmless dysfunctions vs. Viruses that aren’t Dysfunctions

W & M appeal to viruses as dysfunctions that aren’t harmful and thus not considered diseases by health science professionals. The Epstein-Barr virus may not cause mono, the polio virus may infect without causing paralyzing polio disease and the same is true for non-viruses such as the bacterium streptococcus pneumonia that need not cause a disease when in the sinuses and nose. wonder if this is susceptible to the same critique that we made when discussing JW’s 2014 paper in preparation for his Romanell keynote debate with Boorse. JW claimed Typhoid Mary was dysfunctional but not diseased as she merely carried but wasn’t harmed by Salmonella typhi bacteria. But it seemed that the replication in the gallbladder didn’t necessarily interfere with her gall bladder’s function. So, I wondering if the same thing is going on with the harmless viruses. Perhaps they are not interfering with cellular functions but using “excess cell capacity”. Perhaps our Romanell Fellow MDs, Jack and Pat, can correct me but I am open to the possible that some viruses aren’t dysfunctions and that is why their carriers are healthy, not because they aren’t harmed. Here is a quote from a 2010 Kaminisky et al paper “To Kill or not Kill: How Viruses interfere with the cell Death Machinery” in the Journal of Internal Medicine: “most viral infections eventually result in the death of the host cell, the cause of death includes cell lysis, alternation to the cell’s surface membrane and various mode of programmed death… Some viruses cause no apparent change to the infected cell. Cells in which the virus is latent and inactive show few signs of infection and often function normally. This causes persistent infection and the virus is often dormant for many months or years. Some viruses cause cells to proliferate without causing malignancies.” So, it seems that some viruses won’t even cause a dysfunction, much less harm. Thus Wakefield needs it to be the case that there is dysfunction without harm, not infection without dysfunction and harm

The Kaminsky paper made me more suspicious so I actually read the first of the articles that W & C mention on page 358 by Wylie et al 2014 that is referred to as showing that there are harmless disorders. Wylie et al write “We have not formally demonstrated that the viruses are replicating…(they go on to say that they inferred replication from being located where replicated viruses show up, the persistence of the virus over time, and finding some viral elements in intermediate form characteristic of replication ). They go on to write that “virome may confer benefits on the host the way the bacterium contingent of the microbiome does…members of the virome may paly some similar roles in the maintenance of human health.” Their conclusion states “This study does not distinguish active from latent infections.” So, it may be that there are latent viruses as well as beneficial viruses. Ergo, the presence of dormant or beneficial viruses don’t entail cellular dysfunctions.



Pat D August 22, 2020 at 6:55 PM

Infection is a process of interaction between a microorganism and a host. The mere presence of microorganisms within the confines of a multicellular organism does not constitute infection, although that distinction is not often made in everyday/informal speech. The microbiome in our gut is actually beneficial to our health – the relationship is symbiotic rather than pathological. Similarly, there are carrier states that do not involve a detrimental immune reaction on the part of the host. Younger kids who don’t get sick with SARS-CoV-2 would be an example. Typhoid Mary is another example, but in that case the microorganism was bacterial rather than viral. Latent infection is something else again – for example varicella virus leading to chicken pox on first exposure and then to shingles when immunity wanes in later life. On first thought, I would take the latent state to be a disposition rather than a risk factor, but I might need to think that through better.

Bob Kelly August 22, 2020 at 11:57 PM

Pat, just a quick clarifying question. You start your response by defining 'infection' as follows: "Infection is a process of interaction between a microorganism and a host." But then you go on to cite gut microbiome, young kids with SARS-CoV-2, typhoid Mary, and "latent infections" as examples (I think) of non-infections. My confusion is that each of these seems to meet your definition at the start of the reply. So, what do you mean by 'interaction' and 'host' that would make these not count as infections (on that definition you gave)?

Pat D August 23, 2020 at 7:46 AM

Thanks, Bob. I should qualify my definition to say that infection is a process of *antagonistic* interaction between a microorganism and a host organism.

Neil Feit August 23, 2020 at 9:12 AM

I had never heard of commensal viruses before reading this article but also considered that a good case might be made that in such cases there is no dysfunction. I just don't know enough about the relevant issues to make a call

Jack Freer August 23, 2020 at 10:43 AM

David, I think host cell "excess capacity" is a good way to characterize viral replication that does not harm the host. From the virus's perspective, utilizing the host cell to replicate without harming the organism itself seems ideal (since it leaves the means of its own reproduction intact). A surviving thriving host (some of who's cells have been hijacked to replicate viruses) seems not to be harmed. It is not so clear to me, however, that it does not undergo dysfunction. Certainly some of its constituent cells are not functioning as designed, even though the organism as a whole may still be functioning normally.

David H August 22, 2020 at 4:21 PM

Harmless Viruses as akin to the One Dead Cell objection to the Naturalists

Let’s assume some of the other articles mentioned by W & C do cause premature cell death without any harm. This is akin to the Nordenfelt’s one cell objection to Boorse’s naturalism. One way to take a little sting off the one dead cell objection is to point out that Wakefield’s HDA also “suffers” from the death of one cell being a disorder of the patient. Recall, that JW believes there is a a disorder if it is likely that there will be harm, but there doesn’t always have to be harm to count as a disorder. So, imagine a viral infection or mutation that usually produces a harmful disorder but in the rare case doesn’t. So, a single cell death of a mutation or virus that usually replicates malignantly does not. This rarity doesn’t keep it from being a disorder, just as the lucky hemophiliac who never gets bruised or cut still has the disease. Likewise, for the first virally infected cell that does spread and cause harm. There was a disorder present with the first cell death. So both Boorse and JW’s accounts have to admit that one dead cell can be a disease for the patient as a whole, not just evidence of an earlier disease of the now deceased cell.

David H August 22, 2020 at 4:22 PM

Parts and Wholes:

Boorse’s view is that one dead cell makes someone pathological. He just takes the “disease plus” or “pathology plus” view so the pathological person would have a harmless or asymptomatic pathology or disease. Why not call the whole patient literally pathological because of a diseased part? Wakefield needs there to be a semantic rule that diseases of parts are not diseases of wholes because they are not harmful. But we generally don’t so qualify ascriptions of parts to wholes. We call someone a blonde because they have a part, blonde hair, and there are countless other examples. There is no fallacy of composition here as when new say someone has a big or heavy part, so they are big or heavy. That is akin to saying your leg weighs 30 pounds so you weigh 30 pounds or an ingredient by itself is nasty tasting so the meal will be nasty tasting. Moreover, Wakefield has to admit that there are diseased human parts, cells, which will be diseased without harm to the patient as a whole; so if one has diseased parts that are harmless to their possessors, what’s the problem with diseased patients as a whole that are not harmed? It seems like nothing explains the resistance to this other than practitioners of medicine are concerned with those who show up in their offices because they are bothered by dysfunctional conditions

David H August 22, 2020 at 4:22 PM

Medicine as a social construct:

Wakefield and Conrad conclude their article on p. 367 “Nonetheless, the profession of medicine is a social artifact created to address certain conditions people care about, and this involves values along with science at the core of its classification system.” While medicine may be created to address certain diseases that people care about, the disease concept extends far beyond what we care about as it covers plants and other life forms. The concept extends not just because we are concerned about infectious viruses jumping from animals to us, or bacteria that is dangerous to us and our livestock. We apply the disease concept to creatures in the past that existed before we did and extend the concept to living creatures in a possible future in which we no longer exist.

David H August 22, 2020 at 4:25 PM

Value Pluralism

The authors begin their paper’s conclusion with the claim that ‘The attractions of naturalism are clear. values are debatable and variable cross-culturally in ways that scientific facts are not. In a pluralistic society, value diversity threatens the stability of any concept that is value laden.” Does JW every really address the problem of changing societies in the sense of moves as well as internal changes in the society make a dysfunction cease to be or to become a disorder? I always thought that was a reductio of normativism or hybrid account. I think the closest he comes to this is that he endorses Spitzer’s(?) rationale of the removal of homosexuality from the DSM as a disorder due to changing attitudes towards sexuality and the downplaying the importance of the tie of sex to reproduction (thus the lessening of harm of an infertile homosexual union) and the increasing important role of sex in emotional union. Perhaps if one will accept one can be diseased in a traditional society but not in a modern Western one, then moves from one community to another won’t be a bullet to bite. More sarcastically, I would suggest that it is only an anemic theory that finds such bullets nourishing



Pat D August 22, 2020 at 6:58 PM

Normativity of human relationships is not limited to biological norms - the inverse of biological harm applying to plants that do not function consciously. A critical philosophy needs to account for historical development (and decline) as well as biological development. That doesn't mean that anything goes, but as Flannery O'Connor said, "The good in us is under construction."

David H August 23, 2020 at 3:47 PM

Many instances of disorder without harm within HDA- Too many epicycles?

Let's take stock of all the epistemically possible instances of disorder without harm. One can fine tune or add epicycles - depending on your view of the project's direction, or just help yourself to Boorse's "disease plus" adjectival approach

1. Harmless dysfunctions - one dead cell - are going to be cell disorders. so human cells can be disordered and diseased and pathological without harm. So why can't humans as a whole be disordered without harm? Lots of work to be done here explaining why human parts are diseased/disordered without harm but human wholes are not diseased/disordered without harm. Alternatively, one adopts a theory of mindless cells undergoing harm which many readers will not be attracted to.

2. Dysfunctions Disposed to likely cause harm are disorders. Some instances of disorders (the lucky hemophiliac) will not be harmful but the dysfunction is a disorder because most are. The lucky hemophliliac is not even harmed by living like a bubble boy and giving up normal activities but is really, really lucky without giving up everyday activities.

3. Mindless plants and animals can't be diseased because harm requires sentience or one must accept controversial account of mindless harm, or relativize the the harms to us or just analogically extend "disease" to non-human bacteria, plants, protozoans etc

4. overdetermination and preemption and back ups. One can finesse the concept of harm (plural harm), except non-comparative harms, insist there is still some small harm (of disrespect? bodily integrity violation? in such cases), argue most cases of the disease don't involve overdetermination thus helping oneself to ideas in #1

5. One dysfunctional cell that was likely to be the first of many but is the exception. This involves a dysfunctional mutation or infection that typically spreads, infects, duplicates etc. so it is a disease on the likely disposition to harm view. But it is the statistical unlikely exception so there is no harm in this rare case of disease. This involves the normativist and hybrid having to bite their own version of the one dead cell objection leveled against Boorse's BST

6. Epistemic possibility of epicureanism or heaven. This makes all fatal diseases if unversalism is true, perhaps most death unless some harsh Calvinism view of the select few is true , good for people. This will make the many clearly fatal diseases into non-diseases, leaving disease to non-fatal conditions (which, incidentally, perhaps makes it harder to define disease as suboptimal contributions to survival). One can appeal to prima facie harm but we can offset that if the person was miserable or unconscious and then the fatal disease struck without any prima facie harm. Alternatively, one claims these are metaphysically impossible as death is a harm and an afterlife is impossible

7. Asymptomatic diseases are regularly detected and cured. So most diseases will not harm. We can offset the response that they would have harmed if medicine had not intervened by imagining the body's own defense mechanism keeps the disease from reaching the harmful state. one could insist that is not a disease but that seems a stretch if it is the body fighting off the malignancy or infection. Imagine the majority of times the body succeeds, but in a minority of times it fails to stop the dysfunctions from spreading to more cells and rising to a harm. Do we really want to say that the majority of instances with no harm is not a disease but there is a disease only in the minority of instances which progress to harms harms when it is the same kind of mutation or infection? It seems arbitrary or ad hoc to allow that when majority of dispositions are harmful that render the non harmful minority into diseases but not the reverse

Why not just accept CB's adjectival approach to disease and distinguish harmful diseases from harmless diseases and so on?