Rik van der Linden

Although pain is considered a central object of medicine, it remains poorly understood. This is especially true for chronic pain conditions, in which an underlying cause often cannot or can no longer be found. Over the past decades, new scientific, technological, and social developments have led to the reconceptualization of chronic pain. In the latest edition of the International Classification of Diseases (ICD-11), chronic pain conditions are ascribed to a separate nosological category. Importantly, cases of chronic primary pain are now defined as a ‘disease in its own right’. This is in stark contrast to how pain has traditionally been understood in medicine: as a symptom/sign of tissue damage. While this conceptual shift is considered an important landmark in pain medicine, the reconceptualization of chronic pain has also been criticized. This is especially so because the conceptual shift was primarily explained by its practical benefits, while the etiology and pathophysiological mechanism remain unclear. Hence, the disease status of chronic pain remains unclear. In this paper, we argue that the understanding of chronic pain as a disease can be defended from a philosophical pragmatist perspective. By looking through the lens of philosopher of science Ludwik Fleck, we demonstrate that (1) the problematic status of chronic pain is historically contingent upon the mechanistic ‘Cartesian’ conceptualization of pain, but not problematic in itself; and (2), the view of chronic (primary) pain as a disease in its own right can be justified on pragmatist grounds.

Instead of defining health and disease in a traditional analytic fashion, the medical-philosophical debate is now refocusing on explicating, specifying and contextualizing concepts, which implies adapting, improving or replacing them. This new view on pragmatically formulating definitions for health and disease concepts lines up with what has recently come to be known as conceptual engineering. In this paper we analyze and evaluate the concept of Positive Health by applying the methodology of conceptual engineering. Positive Health is a concept that was developed by healthcare researchers and professionals in response to problems experienced in medical practice, and that has gained significant popularity within the Dutch healthcare system and beyond. By means of a combined historical-philosophical approach, we first explore the reasons for re-engineering the concept of health, the kind of actors involved and the outcomes and effects of this re-engineering. We then evaluate the adequacy of this reconceptualization, using Carnapian explication and ameliorative analysis. We argue that conceptual engineering supports the pragmatist approach towards health and disease concepts and complements it by providing tools for critical analysis and evaluation. In turn, conceptual engineering can learn from case studies from the medical domain, such as Positive Health.

In this chapter, the research group on the project “Health and disease as practical concepts” set out the main tenets of their research program and discuss the connection of their approach with the classical American pragmatists. In this pragmatic vein, the project seeks to identify, articulate and address problematic situations from clinical practice that involve concepts of health and disease. Some of these problematic situations are briefly described, as they served to inspire the contributions to the edited volume.

In line with recent proposals for experimental philosophy and philosophy of science in practice, we propose that the philosophy of medicine could benefit from incorporating empirical research, just as bioethics has. In this paper, we therefore take first steps towards the development of an empirical philosophy of medicine, that includes investigating practical and moral dimensions. This qualitative study gives insight into the views and experiences of a group of various medical professionals and patient representatives regarding the conceptualization of health and disease concepts in practice and the possible problems that surround them. This includes clinical, epistemological, and ethical issues. We have conducted qualitative interviews with a broad range of participants (n = 17), working in various health-related disciplines, fields and organizations. From the interviews, we highlight several different practical functions of definitions of health and disease. Furthermore, we discuss 5 types of problematic situations that emerged from the interviews and analyze the underlying conceptual issues. By providing theoretical frameworks and conceptual tools, and by suggesting conceptual changes or adaptations, philosophers might be able to help solve some of these problems. This empirical-philosophical study contributes to a more pragmatic way of understanding the relevance of conceptualizing health and disease by connecting the participants’ views and experiences to the theoretical debate. Going back and forth between theory and practice will likely result in a more complex but hopefully also better and more fruitful understanding of health and disease concepts.

Despite the longstanding debate on definitions of health and disease concepts, and the multitude of accounts that have been developed, no consensus has been reached. This is problematic, as the way we define health and disease has far-reaching practical consequences. In recent contributions it is proposed to view health and disease as practical- and plural concepts. Instead of searching for a general definition, it is proposed to stipulate context-specific definitions. However, it is not clear how this should be realized. In this paper, we review recent contributions to the debate, and examine the importance of context-specific definitions. In particular, we explore the usefulness of analyzing the relation between the practical function of a definition and the context it is deployed in. We demonstrate that the variety of functions that health and disease concepts need to serve makes the formulation of monistic definitions not only problematic but also undesirable. We conclude that the analysis of the practical function in relation to the context is key when formulating context-specific definitions for health and disease. At last, we discuss challenges for the pluralist stance and make recommendations for future research.