But apart from its prima facie plausibility, our trichotomy of treatment -prevention - enhancement is unable to solve all the conceptual problems that arise here, let alone the normative questions that follow in their wake. The next issue to address is how we ought to develop and clarify the difference between interventions that count as treatments (and perhaps preventions) and others that must be considered only enhancements (without being of a disease-preventive character). What basic account of health, disease and treatment should inform our definitions of treatment and enhancement? What is treatment from one perspective may not count as treatment from another. The same holds true for enhancements as well. Take for example a form of psychotherapy aimed at liberating a person from her natural shyness from which she might suffer considerably. In a system where shyness has been sufficiently "medicalised", perhaps simply for the fact that it can be treated like other disorders that certainly count as diseases, shyness can be considered an illness. In a different system where the range of medicalisation does not extend to cover "habit variations" of various sorts, shyness might be considered simply a form of behaviour or a
173 Still, consider the following, admittedly somewhat wild, imaginary case. During a regular appendectomy on a woman, the doctor maliciously, and without the patient's consent, implants the in-vitro-fertilised embryo of another woman completely unknown to the patient, thus causing her to become pregnant. It certainly does not seem too far-fetched to call this the intentional infliction of a physical harm.
174 We ignore the fundamentally different practice of lethal injections by medical doctors in some countries that retain capital punishment. Apart from questions about the legitimacy of capital punishment itself, this practice seems, by all ethical criteria, to amount to a patent misuse of professional medical expertise.
disposition within the normal spectrum of human character traits. In yet a third system where the notion of "illness" is defined by criteria of subjective suffering and potential treatability, we might again consider unusual forms of shyness a disease in need of medical treatment. If we couple this problem with the question of the bounds of legitimate medical practice, we can employ our distinguishing criterion to demarcate the limits of medical necessity as well.
All of this invokes the well-known and long-standing problem of the concept of disease. The labyrinthine subtleties of the recent debate, spanning a period of more than three decades, cannot, and need not, be explored in detail here.175 It is obvious that a concept of disease must fulfill different functions in different contexts of both theory and practice. Consequently, it may also assume different meanings according to the respective context in which it appears.176 For our current purposes, we need, on a very abstract level, a concept of disease which allows us to elucidate the criteria by which we can define the proper limits of medicine as a system of public health (or, on the macro-level, a system of organised medical services). This can only be done by connecting the concept of disease to certain fundamental elements of social justice, which has been the subject of a much longer and much more extensive debate spanning almost the entire history of western philosophy since the time of Aristotle. Despite the longevity of such debates, nothing like a basic consensus has emerged among moral, legal, and political philosophers on the most fundamental questions of social justice. Certainly, it is beyond the scope of the current paper to add to this already extensive literature by arguing for our own principled conception of social justice. Our intention is, instead, to sketch briefly some basic considerations and abstract criteria for what we believe any reasonable attempt to draw macro-level limits to the health care system must take into account. This will yield a fairly well delineated model of health, disease, and treatment that we consider preferable to others as a basic orientation for a system of public health.
175 There is a vast literature on this topic. For a "naturalist" ("realist", "descriptivist") account see the seminal papers of Boorse (1975; 1977; 1997); for a "normativist" ("value laden") account Khushf (1997); Stempsey (2000); Fulford (2001); finally for a differentiating and mediatory account Hofmann (2001); illuminating collections of essays are Caplan et al. (1981) and Humber and Almeder (1997).
176 For instance, a doctor confronted with a patient suffering from some unclear -perhaps organic, perhaps "only" psychogenic or even hypochondriac - cause will probably try to help and, thus, consider the patient's state "diseased", no matter what turns out to be its real cause. For the psychogenic or hypochondriac case, this might be viewed differently by, say, a legislator trying to delineate what is to be part of proper medicine and, therefore, to be covered by social security. Similarly, it might be seen differently again from a judicial court deciding on that question. Nevertheless, all three are dealing with the concept of disease. (And probably none of them would claim that what the other two have to say about this concept was simply mistaken.)
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