Elodie Giroux

Christopher Boorse’s bio-statistical theory of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST’s binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article’s central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology—alongside physiology—in defining health

Canguilhem criticized the concept of “public health”: health and disease are concepts that only apply to individuals, taken as organic totalities. Their extension to a different level of organization is purely metaphorical. The importance assumed by epidemiology in the construction of our knowledge of the normal and the pathological does, however, call for reflection on the role and the status of the population level of organization in our approach to health phenomena. The entanglement of the biological and the social in human life and in contemporary societies justifies this level of analysis for better understanding the complexity and the interaction of health determinants both at the level of individuals and their interactions and at that of the population. But is this population level just a useful level of analysis that makes it possible to bring to light the social determinants of health at the individual level, or does it rest instead on characteristics of the population that are irreducible to individual characteristics, but which are nevertheless important for understanding and taking action with respect to both population and individual health? Defending this second alternative, I show how the epidemiological point of view, and in particular that of social epidemiology, leads us to rethink the possibility of a concept of “population health” that is not reducible to the sum of individual instances of health.

Cancers rely on multiple, heterogeneous processes at different scales, pertaining to many biomedical fields. Therefore, understanding cancer is necessarily an interdisciplinary task that requires placing specialised experimental and clinical research into a broader conceptual, theoretical, and methodological framework. Without such a framework, oncology will collect piecemeal results, with scant dialogue between the different scientific communities studying cancer. We argue that one important way forward in service of a more successful dialogue is through greater integration of applied sciences (experimental and clinical) with conceptual and theoretical approaches, informed by philosophical methods. By way of illustration, we explore six central themes: (i) the role of mutations in cancer; (ii) the clonal evolution of cancer cells; (iii) the relationship between cancer and multicellularity; (iv) the tumour microenvironment; (v) the immune system; and (vi) stem cells. In each case, we examine open questions in the scientific literature through a philosophical methodology and show the benefit of such a synergy for the scientific and medical understanding of cancer.

La possibilité d’une définition naturaliste de la santé et d’une distinction entre le normal et le pathologique qui ne repose pas sur des normes culturelles, sociales ou subjectives est au cœur des débats en philosophie de la médecine. Or le concept statistique de la normalité, fondamental pour une définition objective de la santé, soulève d’importantes difficultés. Christopher Boorse défend une « théorie bio-statistique » qui, en articulant ce concept à une notion non normative de fonction biologique, résoudrait ces difficultés. L’identification de la santé et de la normalité au sens statistique demeure toutefois centrale dans sa définition. Après avoir précisé le rôle que joue la normalité statistique dans la BST, nous dégageons, à partir de l’épidémiologie contemporaine, un certain nombre de problèmes et questions que cette définition naturaliste soulève.The liability for a naturalist definition of health and for a value-free distinction between the normal and the pathological is at the core of discussions on health and disease in philosophy of medicine. But the statistical concept of normality, a central one for any objective definition of health, raises numerous problems. Christopher Boorse argues for a « biostatistical theory » which aims at solving these difficulties by articulating a statistical concept of normality and a non-normative concept of biological function. However the BST is still based on identifying normality and health with the most frequent. After analyzing in details the true role of statistical normality in BST, I will show how results and data from modern epidemiology can be mobilized to reveal several limits and difficulties with respect to this naturalist definition of health and disease.

This article presents a comparative analysis between Georges Canguilhem’sEssay on Some Problems Concerning the Normal and the Pathological, published in 1943 and the English language debate that started in the 1970s between the naturalists and the normativists. Seemingly, this comparison illustrates the opposition between the French historical epistemology and the Anglo-American philosophy of sciences. However, I put into perspective what is generally considered an opposition between the two traditions by analyzing certain conceptual similarities.

English summary: Based on the famous essay by Georges Canguilhem on what is normal and pathological (originally published in 1943), extensive philosophical literature (mainly Anglo-Saxon) has attempted to define these concepts and analyze their status. The main discussion focuses on the following question: can you describe health and illness as natural phenomena or are they states that are determined by values? French text. French description: Depuis le celebre essai de Georges Canguilhem sur le normal et le pathologique publie initialement en 1943 et dont l'un des objectifs etait la clarification des concepts de sante et de maladie, une litterature philosophique abondante, principalement anglo-saxonne, s'est attachee a definir ces concepts et a analyser leur statut. Le principal debat de ce domaine emergent de la philosophie de la medecine porte sur la question: peut-on decrire la sante et la maladie comme des phenomenes naturels ou s'agit-il d'etats qui sont determines par des valeurs? Tous les textes presentes dans ce volume ont participe de cette controverse. Ceux de la premiere section accordent une part importante a la composante biologique. Ceux de la seconde donnent le primat a la notion d'action. Ceux de la derniere section mettent en question l'utilite ou la possibilite meme de definir les deux concepts.

In a series of papers published in the 1970s, Christopher Boorse proposed a naturalist theory of health, mainly based on a value-free concept of ‘biological function’, a concept of ‘reference class’ and the notion of ‘statistical normality’. His theory has profoundly shaped the philosophical debates on the concepts of health and disease. It could even be said that the numerous criticisms of his 'biostatistical theory' are at the centre of what is usually referred to as the debate between ‘normativists’ and ‘naturalists’. Today, the predominant naturalist theory of health is still Boorse’s biostatistical theory. This volume offers the first comprehensive review and critical assessment of the nature and status of naturalism in the philosophy of health. It explores the notion of biological normativity and its relevance for the philosophy of health, and it analyses the implications of the philosophical theories of health for healthcare and the debate on health enhancement. In the first section, several contributions identify the kind of ‘naturalism’ the biostatistical theory belongs to and offer further criticisms or possible modifications, such as the concept of function that is required by this theory, and whether a comparativist approach to health is more relevant than a non-comparativist one. The second section explores natural or biological ‘normativity’ and some possible accounts of health that could be based on this concept. The third and final section focuses on the implications of naturalism in healthcare. 'Goals of Medicine’ is the first paper in which Christopher Boorse ventured toward analysing the implication of his biostatistical theory of health on the practice of medicine, the difficult issue of the goals of medicine and the boundary between treating and enhancing. Other papers in this section critically evaluate Boorse’s account and analyse the importance of a positive concept of health.

Christopher Boorse's biostatistical theory of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST's binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article's central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology -- alongside physiology -- in defining health.

Evidence-Based Medicine (EBM) and Personalized Medicine (PM) share a common goal: reducing the gap between the results of biomedical research and their clinical application. PM is, however, often presented as a “new paradigm” for medicine, just as EBM was in the 1990s. It covers a wide variety of projects but the core idea that generally unites them is the ambition of better taking account of individual specificities than did EBM with its statistical and population-centred approach. In this article, I concentrate on PM in cancerology, the essence of which is to target treatments based on the molecular profile of the patient. This targeting is made possible by gaining better knowledge about the molecular mechanisms of cancers. The classification of patients as a function of their molecular profile entails the creation of patient sub-groups. This creates a problem for the traditional evaluation of therapeutic treatment promoted by EBM, in particular the use of randomized trials using sizeable cohorts. But a better understanding of the mechanisms and the greater precision of treatments could reduce the need for these trials. Does PM thus represent the revenge of a physio-pathological and mechanistic culture in clinical research against the statistical and empirical one of EBM? My objective is to show how current practices of PM leads to epistemological changes in our estimation of what count as relevant types of information and proof in medicine, in particular in the field of therapeutic evaluation. I defend the idea that PM, far from obviating the need for statistical approaches and the search for correlations, ultimately poses new challenges for EBM. PM drives EBM to strengthen the articulation and the integration of statistical and mechanistic data with a view to providing a better service for each patient.

The goal of this chapter is to describe the philosophical style of Jean Gayon through my own experience as a Ph.D. student. I show how Gayon’s work represents a unique synthesis of two main traditions in philosophy of science: analytical Anglo-American philosophy of sciencePhilosophy of science (Anglo-American) and biology and French historical epistemologyGayon, JeanOn historical epistemology. HisHistorical epistemology openness and curiosity towards the Anglo-American tradition led him to believe that a genuine dialogue between these traditions could benefit both. Jean also encouraged his graduate students to draw on multiple philosophical approaches, with an eye toward the sciences. In this chapter, I propose to characterize his own style as a historically grounded analysis of concepts. The analytical style he promoted is underpinned by historical reflection in which it finds a concrete and living substratum.

L’exposome réfère à un domaine émergent de recherche qui a pour visée de développer une science intégrée de l’ensemble des expositions auxquelles est soumis un individu tout au long de sa vie et qui influencent sa santé. Deux principales orientations se font jour. L’une se concentre sur l’étude de l’exposome interne qui permettrait d’identifier l’essentiel des expositions impactant la santé en mesurant avec précision les effets au niveau de l’environnement biochimique du corps. L’autre entend intégrer les expositions sociales, écologiques et les expositions biologiques et internes, ou autrement dit, faire davantage de place à l’étude de l’exposome externe et ainsi développer un modèle holiste de la santé environnementale. À partir de l’examen de la littérature scientifique, de l’analyse de la première génération d’études exposomiques (2010-2020) et d’entretiens menés auprès d’épidémiologistes engagés dans ces recherches, cet article propose un état des lieux des promesses et réalisations de ce domaine émergent quant à l’intégration des expositions, tout en ayant l’ambition d’apporter un regard critique sur ces dernières. Après avoir présenté l’exposome et ses diverses interprétations, nous examinerons quel type d’intégration est en jeu dans chacune de ces deux orientations et nous en questionnerons l’intérêt et la pertinence. Notre analyse se concentre plus particulièrement sur la seconde orientation : quels gages cette tendance la plus holiste donne-t-elle en vue d’un renouvellement de nos manières d’intégrer les facteurs environnementaux et génétiques, sociaux et biologiques, dans notre approche des expositions et de l’explication des maladies?