Journal of Medicine and Philosophy

2000, Vol. 25, No. 5, pp. 605638

0360-5310/00/2505-0605$15.00
Swets & Zeitlinger

Fuzzy Health, Illness, and Disease

Kazem Sadegh-Zadeh
University of Mnster, Germany

The notions of health, illness, and disease are fuzzy-theoretically analyzed. They present
themselves as non-Aristotelian concepts violating basic principles of classical logic. A
recursive scheme for defining the controversial notion of disease is proposed that also
supports a concept of fuzzy disease. A sketch is given of the prototype resemblance theory
of disease.
Key words: prototype resemblance theory of disease, deontic constructs, disease, fuzzy
disease, fuzzy health, fuzzy illness, health, illness, logic of medicine, Meinongian objects,
nosology, patienthood

All humans are likely to find good reasons for holding angina or sarcoma
to be disease states, because they cause pain and circumscription of our
goals, whether or not they have a positive or negative bearing on the
survival of our species (Engelhardt, 1976, pp. 265f).

I. INTRODUCTION
In the last quarter of the 20th century we have been witnessing an intense
discussion on the nature of health, illness, and disease and on the meaning
of these three basic notions of medicine.1 The discussion seems to have
ended up in a blind alley, however. The harvest we have received thus far
may be summarized by a few labels: normativism, descriptivism, nave
normalism, fictionalism, metaphorism, and philistinism.
Normativism says that the classification of certain groups of phenomena
as illnesses or diseases is based on value judgments (Engelhardt, 1975;
1976; Margolis, 1969;1976). The concept of disease is not merely descriptive, but normative. It says what ought not to be (Engelhardt, 1975, p.
127).
Correspondence: Kazem Sadegh-Zadeh, University of Mnster Medical Institutions, Institute for Theory and History of Medicine, Waldeyer St. 27, 48149 Mnster, Germany.

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ABSTRACT

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KAZEM SADEGH-ZADEH

According to a second, also widespread assumption:

health and disease are opposites in that they are dual and mutually
exclusive attributes. It is said that health is the absence of disease and
vice versa.
In this paper, I will demonstrate that the assumptions above are not true.
First, the concepts of health, illness, and disease are not amenable to

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Descriptivism or naturalism holds the opposite view. Disease is statistically species-subnormal biological body function, and health is the absence of disease. The classification of human states as healthy or diseased
is an objective matter, to be read off the biological facts of nature without
need of value judgments (Boorse, 1997, p. 4).
According to nave normalism, prevailing in medical schools and textbooks, health is normality and diseases are abnormalities. What normality
is remains unclear.
The fictionalism of Franco-German origin says that Disease is a genuine fiction (Koch, 1920, pp. 130-131), for there are no diseases, there are
only sick people (Armand Trousseau, 1801-1867).
Thomas Szasz metaphorism, confined to psychiatry only, regards concepts of mental illness as mere myths and metaphors (1960; 1970). Mental
illness does not exist.
Philistinism, proudly argued and represented by Germund Hesslow
(GH, a philistine, 1993, p. 2), holds that the three notions of health,
illness and disease are superfluous in medicine and irrelevant to clinicians
and medical scientists (p. 3). For there is no biomedical theory in which
disease appears as a theoretical entity and there are no laws or generalizations linking disease to other important variables (p. 5).
Something omitted in the controversial debate above is the logical analysis of the three notions mentioned. It is this omission that has led the
discourse to a dead end. In the present paper, a logical analysis of these
three notions is undertaken that reveals a misconception underlying almost all past philosophy on health, illness, and disease. The misconception may be described as follows. First, it is commonly assumed that the
concepts of health, illness, and disease are amenable to classical, bivalent
modes of reasoning of the Aristotelian type, based on the principles of
excluded middle and non-contradiction. According to this assumption:
an individual is healthy or she is not healthy, but not both at the same
time;
an individual is ill or she is not ill, but not both at the same time;
an individual has a disease or she does not have it, but not both at the
same time.

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607

II. FUZZY-THEORETIC TERMINOLOGY2

I will prefer the extensional mode of inquiry to the intensional one. That
means that instead of considering an attribute itself I will consider the set
of objects which bear that attribute. For example, I will talk about the set
of healthy people instead of talking about health. Whatever else health,
illness, and disease may be, it is common belief that their bearers form sets
with clear-cut boundaries (see, e.g., Feinstein, 1976, pp. 156-209). I will
abandon this received paradigm and will reconstruct them as fuzzy sets
instead.3
A fuzzy set is a collection of objects with grades of membership (Zadeh,
1965a; 1965b). It does not have sharp boundaries between members and
non-members. For example, given two individuals, one of them may be
young to some degree, whereas the other may be young to a lesser degree
than the former. Thus, these two individuals are to different degrees members of the same set of young people. The membership degrees of the set
smoothly decrease in the direction of zero; i.e., non-membership. The set
of young people is thus fuzzy. There is no dividing line between this set
and the set of non-young people. Each of the following terms also denotes
a fuzzy set: beautiful woman, tree, bush, big orange, much larger than 5,
healthy, ill, diseased (see Figure 1). An individual who is young to a

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classical logic. It may well be that a person is healthy and not healthy at
the same time; that she is ill and not ill at the same time, and that she has a
disease and does not have it at the same time. And second, health and
disease are not dual and mutually exclusive. It may well be that a person is
healthy and has a disease nonetheless, or that she is not healthy without
having any disease.
That means that health, illness, and disease are non-classical attributes
violating both bivalence and non-contradiction and, as such, they call for a
conceptual framework that takes account of this non-Aristotelian circumstance. In what follows, a fuzzy-theoretic approach is taken to provide a
conceptual framework of just that virtue. In the next section, some preliminaries are presented to prepare the intended fuzzy-theoretic approach. A
novel theory of health, illness, and disease will then follow. It cannot, and
will not, be anticipated here. The core idea it rests upon is the view that
health is a matter of degree, illness is a matter of degree, and disease is a
matter of degree. They can, therefore, not be dealt with appropriately by
Aristotelian YES or NO principles. They are subject to the principle of
graduality to which I now proceed.

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KAZEM SADEGH-ZADEH

particular extent, is not young to another particular extent, though the

latter may amount to zero. The same applies to individuals who are members of the sets of healthy, ill, or diseased people. For instance, a person
who is healthy to a particular extent, is not healthy to another particular
extent. To elaborate this intuitive idea, let us arrange some terminology.
Considering a set A as a fuzzy set means that an object x is to some
degree a member of that set. Let us express this membership degree by
(x, A), to be read as the degree of membership of object x in set A,
conveniently abbreviated to A(x). The symbol A is referred to as the
membership function of set A which assigns to an object x its membership
degree A(x). The membership degree A(x) of object x in set A is supposed to be a real number in the unit interval [0, 1].4 Thus, the expression
young(Alf) = 0.7 says that Alf is to the extent 0.7 a member of the set of
young people, or equivalently, that he is young to the extent 0.7.
A function f is an assignment rule that assigns to a member of a set X a
unique member of a set Y, also called a map from X to Y and simply
illustrated by f: X Y. We will use this illustration to indicate that f is a
map from X to Y. Let be any set of objects. A fuzzy set A is obtained
by a membership function A that maps members of to the unit interval
[0, 1] according to the following definitions:
Definition 1. If is any set, A is a fuzzy subset of if there is a function
A such that
1. A: [0, 1],
2. A = {(x, A(x)) | x }, that is, A is the set of all pairs (x, A(x)) such
that x is a member of and A(x) is the degree of its membership in A.

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Fig. 1. Gray, fog, and cloud as symbols of a fuzzy set. The more a member of the set is in
the gray area the lesser is the degree of its membership in the set.

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609

Definition 2. A is a fuzzy set, also called a fuzzy set in or over , if A is a

fuzzy subset of . The set is referred to as the base set.
For example, given the base set {a, b, c, d} of four male doctors and a
function proficient-doctor that assigns to any x {a, b, c, d} the degree of his
proficiency, then the following set is a fuzzy subset of our base set {a, b, c,
d}, and thus a fuzzy set:
Proficient doctor = {(a, 0), (b, 0.4), (c, 0.8), (d, 1)}.

(1)

Ac(x) = 1 A(x).
That is, Ac = {(x, Ac(x)) | x and Ac(x) = 1 A(x)}. For instance, the
complement of the fuzzy set proficient doctor mentioned in (1) above is
the fuzzy set:
Not proficient doctor = {(a, 1), (b, 0.6), (c, 0.2), (d, 0)}

(2)

Of two numbers m and n the smaller one is called min(m, n), and the larger
one is called max(m, n). These two functions, min and max, are defined as
follows:
min(m, n)

= m, if n m
= n, otherwise.

max(m, n) = m, if m n
= n, otherwise.
For example, min(5, 3) = 3 and max(5, 3) = 5. Two fuzzy sets A and B in
a base set may have any relationships with one another. For example,
their intersection, denoted by A B, is a fuzzy set defined by the minima
of their joint membership degrees; i.e., by the following membership function AB:
AB(x) = min(A(x), B(x)).

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Since the interval [0, 1] is uncountably infinite, a base set may be

mapped to [0, 1] in innumerably different ways. There are thus uncountably infinite fuzzy subsets A, B, C, ... of a base set . Given any such fuzzy
set A in , the negation of A, called its complement and denoted by Ac or
Not A, is a fuzzy set that is defined by the following membership function
Ac :

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KAZEM SADEGH-ZADEH

That is, A B = {(x, A B(x)) | x and A B(x) = min(A(x),

B(x))}. And their union, denoted by A B, is a fuzzy set defined by the
maxima of their joint membership degrees; i.e., by the following membership function AB:
AB(x) = max(A(x), B(x)).
That is, A B = {(x, A B(x)) | x and A B(x) = max(A(x),
B(x))}. A few examples will illustrate this terminology:

The intersection A B represents a fuzzy conjunction (A and B). The

union A B represents a fuzzy disjunction (A or B).
A base set itself is the fuzzy set {(x, (x) = 1) | x } all of whose
members have the membership degree 1. On the other hand, the empty
fuzzy set, written , is {(x, (x) = 0) | x } all of whose members have
the membership degree 0. Regarding the base set = {a, b, c, d} of our
four male doctors above, for instance, we have:
= {a, b, c, d},
Male = {(a, 1), (b, 1), (c, 1), (d, 1)} = ,
Female = {(a, 0), (b, 0), (c, 0), (d, 0)} = .
The fuzzy theory is a non-Aristotelian system because it does not accord
with the laws of excluded middle and contradiction. This is easily seen
from the evidence that the union of a fuzzy set A and its complement Ac
need not necessarily be the base set, and their intersection need not necessarily be empty:
A Ac
A Ac

violation of the law of excluded middle

violation of the law of contradiction.

(3)
(4)

(The symbol negates equality and reads does not equal.) For instance, regarding the two example fuzzy sets mentioned in (1) and (2)
above, we have:

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= {a, b, c, d},
Proficient doctor = {(a, 0), (b, 0.4), (c, 0.8), (d, 1)},
Young doctor = {(a, 0.9), (b, 0.5), (c, 0.3), (d, 0.7)},
Proficient doctor Young doctor = {(a, 0), (b, 0.4), (c, 0.3), (d, 0.7)},
Proficient doctor Young doctor = {(a, 0.9), (b, 0.5), (c, 0.8), (d, 1)}.

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611

Proficient doctor Not proficient doctor

= {(a, 1), (b, 0.6), (c, 0.8), (d, 1)}

(5)

Proficient doctor Not proficient doctor

= {(a, 0), (b, 0.4), (c, 0.2), (d, 0)}

(6)

The union in (5) falls short of the base set, the middle is not excluded;
and the intersection in (6) exceeds emptiness, A does not contradict not
A. (For details, see Kosko, 1997; Sadegh-Zadeh, 2000a; forthcoming a).

In what follows, I will construct a framework that makes health, illness,

and disease amenable to fuzzy theory (Sadegh-Zadeh, 1997). To this end,
a few new terms will be introduced to enhance the clarity of the context,
whereas some other, traditional terms and relationships will be abandoned.
To begin with, I will not consider disease as an opposite of health. The
opposite of health is malady (German Leiden) that is a much broader
class than disease, containing besides disease also injury, wound, lesion,
defect, deformity, disorder, syndrome, disability, impairment, and the like
(Sadegh-Zadeh, 1982). Although it is not difficult to achieve agreement
about how to define the non-disease parts of this class of maladies, a
recalcitrant problem to medicine is generated by the question: What is
disease?
The persistent mistake made in treating this foundational question is a
typical petitio principii in that to define the notion of disease, one seeks
after common characteristics of its individual referents, i.e., of phenomena
such as hepatitits, multiple sclerosis, etc., that in our textbooks are
classified as diseases. However, such entities will come into being qua
individual diseases after a notion of disease one is seeking for has already
been defined, but not before. A concept of disease-in-general must, therefore, precede the inclusion and exclusion of phenomena as individual
disease entities. That means that the question of What is disease? can
only be decided prescriptively, not descriptively; i.e., it must be tackled
axiomatically, not empirically. The attempt to define disease descriptively is a philosophical sin because it is a conceptual Unsinn (SadeghZadeh, 1977).5
In what follows, a method is outlined that may assist in resolving this
basic problem of medicine. To this end, a concept of disease will be
introduced extensionally-recursively. The notion of health will be treated

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III. FUZZY HEALTH

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KAZEM SADEGH-ZADEH

patienthood(x)
health(x)

= degree of patienthood of x,
= degree of health of x,

where health is defined as follows:

Definition 3. health(x) = 1 patienthood(x),
and yields the health fuzzy set:
H = {(x, health(x)) | x }.
For example, according to the arrangements above, an individuals degree
of health is 0.6 if she has a patienthood of 0.4. Since that individual is to
the extent 0.6 a member of set H, and to the extent 0.4 a member of its
complement set P, she is to the extent min(0.6, 0.4) = 0.4 a member of the
fuzzy set intersection H P. Hence, the intersection of health and patienthood, H P, is not empty. That means that health and patienthood are
complementary in a fuzzy sense, but not disjoint and contradictory in a
bivalent, Aristotelian sense.
As I will argue, health and disease also are not dual and contradictory. It
is not true that an individual is either healthy or diseased, and never both at
the same time. It may be that someone, e.g., Anne, has a particular disease
such as calcinosis circumscripta of her thyroid gland, whereas she is abso-

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separately, independent of disease so defined. It will be based upon a

novel concept of patienthood of which the notion of health will be the
additive inverse in the following sense. Health = 1 patienthood.6
Let be the set of human beings at a particular time. Suppose there is a
fuzzy subset P of whose members are to various extents characterized
by discomfort, pain, endogenously threatened life, loss of autonomy, loss
of vitality, and loss of pleasure. The extent to which an individual is a
member of this fuzzy set P is called the degree of her patienthood (Sadegh-Zadeh, 1982). This degree of patienthood of an individual x is
indicated by the fuzzy set membership function patienthood such that
patienthood(x) is a real number in the unit interval [0, 1]. That provides the
following map: patienthood: [0, 1], which yields the fuzzy set P announced above: P = {(x, patienthood(x)) | x }.
The complement of patienthood, Pc, is referred to as health (the set of
healthy people) and is written H instead of Pc. The degree of health of an
individual x is indicated by the membership function health. The
terminology is thus:

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613

lutely healthy because of her health(Anne) = 1. A disease that does not

raise patienthood is not detrimental to health. (See Section V.)

IV. FUZZY ILLNESS

The State-of-Health Variable

Properties of an object that do not remain constant are called variables.
Distinguish between two types of variables: numerical and linguistic. A
numerical variable, such as height, assumes numbers as values. For
example, the height of David is 175 cm. A linguistic variable, on the
other hand, assumes linguistic entities, such as words or sentences, as
values (Zadeh, 1975a; 1975b; 1976). For instance, color in the statement
the color of blood is red is a linguistic variable. Its possible values are
color terms such as red, yellow, green, etc. The totality of the possible values of a linguistic variable v is referred to as its term set and
written T(v). In the present example we have T(color) = {red, yellow,
green, ... }.7
State of health will be construed as a linguistic variable whose term
set may be conceived of as something like {well, not well, very well, ill,
not ill, ...}. To elaborate this idea consider a simple example. The age of
people may be described by statements such as:
David is 19 years old,
Theresa is 99 years old,

(7)

on the one hand, and by statements such as:

David is young,
Theresa is quite old,

(8)

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Usually an individual is said to be either healthy or ill, but not both at the
same time. This dichotomous terminology is inadequate and misleading,
however, for illness and health are not conceptual opposites. Ill health
and well health, i.e., illness and wellness, are particular fuzzy states of
health besides many other ones. To uncover this rich fuzzy structure of
health, I will reconstruct the syntax of the phrase state of health. To this
end some terminology may be in order. I will briefly explain the notions of
linguistic variable and semantic operator and will then return to the theme.
(For details of the theory, see Sadegh-Zadeh, 1997; 1998; forthcoming a.)

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KAZEM SADEGH-ZADEH

on the other. Relationships of this type may be conceptualized by introducing two variables, a numerical variable age and a linguistic variable
Age. The former assigns numerical age to an individual, as in (7):
age of David is 19 years
age of Theresa is 99 years,
whereas the latter assigns a linguistic term, as in (8):

The range of the numerical variable age is a set of integers such as {0, 1, 2,
..., 120, ...}. The term set of the linguistic variable Age is a set of linguistic
age labels such as T(Age) = {very young, young, not young, adult, old,
quite old, more or less old, ....}. One may try to understand the relationship
between these two variables in the following way. (See Figure 2.)
The linguistic variable Age operates upon the numerical variable age
and transforms subsets of its values {0, 1, 2, ..., 120, ...} into fuzzy sets
which are termed young, old, quite old, etc. That is, any term i of the
term set T(Age) is the name of a fuzzy set over the set of numerical ages. A
name i such as young thus subsumes an entire set of different numerical
ages under a single fuzzy set label. It is, therefore, quite reasonable to ask
of any particular numerical age such as 19 to what extent it is a member of

Fig. 2. The values of the linguistic variable Age are young, not young, old, etc. Each of
the latter ones is a label for an entire fuzzy set of numerical ages. See text.

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Age of David is young,

Age of Theresa is quite old.

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615

that fuzzy set I; e.g., of the fuzzy set young. How young is 19? How old is
it? (See Figure 3.)
By analogy, state of health may be construed as a linguistic variable,
symbolized by state-of-health, whose term set may be conceived of as
something like:
{well, not well, very well, very very well, extremely well,
ill, not ill, more or less ill, very ill, very very ill, extremely
ill, not well and not ill, etc. }.

(9)

The variable operates over the fuzzy set health introduced in Section III. It
assigns to degrees of health, i.e., to health values, elements of its term set
(9). Each element i of this term set is thus the name of a particular fuzzy
set that is a fuzzy subset of health. It subsumes an entire set of different

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Fig. 3. A tentative illustration of the fuzzy sets young and old over the base set of the
numerical ages. The x-coordinate axis represents the set of numerical ages = {0,
1, 2, ..., 100, ..}. The y-coordinate axis displays the degree of membership, i(x),
of numerical ages in any of the fuzzy sets young and old. The curves visualize
these two fuzzy sets. For instance, a newborn is young to the extent 1. The same is
true of the numerical ages 10 and 20. However, a man of 35 years is young only to
the extent 0.4, and old to the extent 0.1. Thus the membership functions young and
old, here represented by i, map the set of numerical ages {0, 1, 2, ...} = to the
closed interval [0, 1] generating two fuzzy subsets of the base set that we call
young and old, respectively. The statement that an individual of 35 years old is
young to the extent 0.4 thus means young(35) = 0.4. And analogously, old(35) =
0.1 says that she is old to the extent 0.1.

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KAZEM SADEGH-ZADEH

Fig. 5. A tentative illustration of the fuzzy set well and of its complement not well =
unwell. The x-coordinate axis represents the fuzzy set health with its membership
function health. The y-axis demonstrates the compatibility degrees of values of
health with the fuzzy sets well and unwell, both represented by the membership
function i where i is a place-holder for the terms well and unwell. According
to this tentative demonstration, we have well(0.3) = well(health(Pope)) = 0.1, and
thus unwell(0.3) = unwell(health(Pope)) = 0.9. Note that complementation is a
mirror image at point 0.5 of the y-axis.

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Fig. 4. Analogous with Fig. 2, the values of the linguistic variable state-of-health may be
very well, well, not well, ..., ill, not ill, ... , etc. Each of them is a label for an entire
fuzzy set of degrees of health. See text.

FUZZY HEALTH, ILLNESS, AND DISEASE

617

health values of the type health(x) under a single fuzzy label i such as
well, ill, etc. (See Figure 4). For instance, let the term well designate
one of those fuzzy sets. One can ask how compatible with this set well the
health value of a particular individual, such as health(Pope) = 0.3, may be.
If the membership function of the fuzzy set well is denoted by well, the
question then reads: What is the value of well(0.3), i.e., of
well(health(Pope))? (Plots of two examples are displayed in Figure 5.)

1.
2.
3.
4.

complementation: not,
connectives: or and and,
quantifiers: all, almost all, most, about half, a few, etc.
linguistic hedges: very, more or less, quite, fairly, extremely,
etc. (Zadeh, 1972; Lakoff, 1973).

Categories 1 and 2 have already been dealt with earlier. Category 3 will
not be used here. A linguistic hedge such as very, when applied to an
operand like well, concentrates the meaning of the latter, whereas a
linguistic hedge such as more or less dilates the meaning of its operand:
concentration of a A(x)
dilation of a A(x)

is
is

[A(x)]2
[A(x)] 1/2 = A(x)

That means that if A is a fuzzy set,

very A
is a fuzzy set with very(A)(x) = [A(x)]2 concentration
more or less A is a fuzzy set with more-or-less(A)(x) = [A(x)]1/2 dilation.

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The State-of-Health Operations

The term set T(state-of-health), as it has been partly displayed in (9) above,
is a large set of linguistic terms that is based upon only a few primitives
such as well which we may call the primary terms of the variable. The
remaining elements of T(state-of-health) are composite terms such as very
well, not well, not well and not ill, etc. They are composed of primary
terms to which semantic operators such as very and not have been applied
to modify their meaning (Sadegh-Zadeh, 1998). A subset of T(state-ofhealth), e.g., the minimum term set {well, borderline}, may be used as a
set of primary terms from which the remainder of T(state-of-health) may
be obtained by definition.
Semantic operators comprise:

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KAZEM SADEGH-ZADEH

For instance, regarding the previous example fuzzy sets:

Proficient doctor = {(a, 0), (b, 0.4), (c, 0.8), (d, 1)},
Young doctor = {(a, 0.9), (b, 0.5), (c, 0.3), (d, 0.7)},
one obtains by concentration (very) and dilation (more or less):
Very proficient doctor = {(a, 0), (b, 0.16), (c, 0.64), (d, 1)},
More or less young doctor = {(a, 0.94), (b, 0.7), (c, 0.54), (d, 0.84)}.

very well = well2,

more or less well = well1/2,
ill = very(more or less ill) = very very unwell = unwell4 etc.,
by
very-well(x) = (well(x))2,
more-or-less-well(x) = (well(x))1/2,
ill(x) = ((ill(x))1/2)2 = (very(unwell(x)))2 = (unwell(x))4.
(See Figure 6.) Thus, illness may be construed as a particular fuzzy set
over health; i.e., as the following state of health:
very(very(not(well))) = unwell4,
which is a concentration of concentration of the complement of the fuzzy
set well. It has become clear what it means to say that illness is not the
conceptual opposite of health.
Due to the additive-inverse relationship between health and patienthood, according to Definition 3 in Section III above, the state-of-health
fuzzy sets as illustrated in Figure 6 may also be based upon patienthood as
the base variable. They will in this case reverse their positions to appear as
mirror images of those in Figure 6. (See Figure 7.)

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According to these standard approximations, one obtains from the primary

term set {well, borderline} a wide range of derived terms for T(state-ofhealth), such as the following:

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619

Fig. 7. The same state-of-health fuzzy sets as in Fig. 6 based upon patienthood.

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Fig. 6. A tentative illustration of some state-of-health fuzzy sets. All of them may be
defined by complementation, dilation, and concentration of the primary fuzzy set
well. Even borderline cases may be construed as some sort of not well and not
ill. Concentration by very lowers membership degrees generating a deeper curve.
Dilation by more or less raises membership degrees generating a higher curve.
Note that illness is very(very(not(well))) = unwellness4. For instance, a health
value of 0.4 corresponds to an illness of degree 0.5. An individual who is healthy
to the extent 0.4, is ill to the extent 0.5, i.e. healthy and ill at the same time. Hence,
health and illness are not contradictory and disjoint. And interestingly enough, the
same individual is also not ill to the extent 0.5. Hence, being ill and not being ill at
the same time is possible, though a contradictory state. The logic of clinical language, and consequently the logic of medicine, is a non-classical one that admits
of contradictions (see Section VII).

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KAZEM SADEGH-ZADEH

V. FUZZY DISEASE

David is young
man is a mammal
two and three is five
not true is false

a Y,
Man Mammal,
(2 + 3) = 5,
not true false .

membership:
subsethood:
equality:
equivalence:

For this reason the question What is disease? is by no means clear and is
thus usually misunderstood. Let us, therefore, reformulate it: How could
the term disease be defined if one were to define it?
The word disease, like any other term, may be defined in n = different ways. For example, x is a disease if and only if x = 33. None of these
innumerable possible definitions is right or wrong. For a definition put
forward is not subject to verification or falsification according to any
scientific standards, but to the acceptance or rejection by those people
whose lives it affects. For this pragmatic reason, a concept of disease for
use in medicine should not be constructed irrespective of potential patients
and non-patients whose lives will be affected by that concept (SadeghZadeh, 1977, p. 39).
In contrast with a linguistic definition introduced and printed in a publication, the decision of the public about how to use a concept may be
termed a social definition. For example, by their opposition to classifying
several types of sexual behavior as diseases, people in Western societies
have changed medicines concept of disease during the last four decades.
This political behavior of the public demonstrates a social definition of the
notion of disease.
Any concept of disease that, in medical literature and communities, may
underlie medical practice and research exists for the sake of the public, not
for medicines own sake. In order for a linguistic definition of such a
concept to be comprehensible to the public and to guide their social definition, it should orient itself to their real lifeworld, needs and interests.

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Suffering abounds in the human world. But it falls within the responsibility of medicine only if it is a facet of patienthood and phenomenologically
appears as a state of ill health = ill state of health = illness as explicated in
the last section and illustrated in Figures 6 and 7. Illness in this sense, or
sickness, may be generated by a multitude of causes from among the class
of maladies, including a cause of a particular type called disease. What is
disease?
In natural languages the predicate is plays at least four logically different roles. It indicates

FUZZY HEALTH, ILLNESS, AND DISEASE

621

Basis:
Induction:

any element of the base set {D1, D2, ..., Dn} is a disease;
any event that is similar to a disease with respect to the
criteria {C1, C2, ..., Cm} is a disease.

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According to this axiom of functionality, it is advisable to ground the

disease language of medicine not on abstract, unworldly concepts, such
as quantum field theory or the evolution of the species, which the commonsense would be unable to assess, but on something that people unquestionably consider a disease. In this way, all philosophical pseudoproblems that medicine and some of its philosophers generate in connection with the concept of disease will disappear. Despite all paradigm shifts
in the last three millennia, no rational human being since Hippocrates
times would deny that there are instances of death caused by dramatic life
events such as heart attack, stroke, and breast cancer, or would disagree
with labeling such a real-life drama a dis-ease = disease. That means that
obviously there are some anthropological constants which all rational
human beings would be prepared to label a disease by pointing to them
and declaring, look: this is a disease!. Why not use such generally accepted, demonstrable prototypes as a point of departure? I will do so and
will choose this lifeworldly grounded, paradigmatic-extensional approach
in hopes of furthering constructive inquiry (Sadegh-Zadeh, 1982; 1997;
forthcoming c).
Potential candidates for disease are complex human conditions like
heart attack, stroke, breast cancer, etc. Such complex human conditions
are not, and should not be, merely confined to biological states of the
organism. They may be viewed and represented as large fuzzy sets which
also contain parts that may refer to the subjective, religious, transcendental and social world of the ill, such as, for example, pain, distress, feelings
of loneliness, beliefs, behavioral disorders, etc.
Suppose there is a small set {D1, D2, ..., Dn} of about n = three, five or
ten human conditions such as {myocardial infarction, stroke, breast cancer, tuberculosis of the lung, malaria, ...} each of which in a particular
human society is accepted as a disease because of a finite set of m 1
criteria {C1, C2, ..., Cm} they may have in common to varying extents.
Criteria of this kind may include, for example, being a bodily lesion,
causing pain, distress, discomfort, incapacity, dependency, premature death,
and the like. It is in principle possible for members of any such human
society to achieve consensus about both the small base set {D1, D2, ..., Dn}
and the few criteria {C1, C2, ..., Cm}.
Upon such a linguistically firm ground in that society one may tentatively seek for a quasi-inductive definition such as the following:

622

KAZEM SADEGH-ZADEH

differ(A, B) =

i max(0, A(xi) B(xi)) + i max(0, B(xi) A(xi))

c(A B)

In the denominator, c is the fuzzy set count and means the sum of a sets
membership degrees. For example, let X = {(x, 0.6), (y, 0.9)} be a fuzzy
set, its count is c(X) = 0.6 + 0.9 = 1.5. Accordingly, given two fuzzy
sets:
X = {(x, 0.6), (y, 0.9)},
Y = {(x, 0.7), (y, 0.4)},
then according to the definition above we have:
differ(X, Y) = [(0 + 0.5) + (0.1 + 0)]/(0.7 + 0.9) = 0.6/1.6 = 0.375.
Thus, set X differs from set Y to the extent 0.375. The notion of difference
captures the gross deviation of membership degrees of sets A and B from
one another, averaged over the union count c(A B). The degree of
equality or similarity beween two fuzzy sets A and B, denoted by similar(A,
B), is the additive inverse of their difference:
Definition 4. similar(A, B) = 1 differ(A, B).
The less two fuzzy sets differ from one another, the more similar they are.
The two example fuzzy sets X and Y above are similar to the extent 1
0.375 = 0.625. Fuzzy set difference and similarity are real numbers in the
interval [0, 1]. A very convenient method of computing similarities is
provided by the following interesting theorem that cannot be proved here
(Sadegh-Zadeh, 1999a):
Theorem 1. similar(A, B) = c(A B)/c(A B).

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The first step says that D1 is a disease, D2 is a disease, ..., and Dn is a

disease, such as, for example, Myocardial infarction is a disease, stroke
is a disease, ... malaria is a disease. This basic step is unproblematic
because it rests on consensus in that society. It would provide the members
of the society with the prototype elements of a quasi-inductive set to be
constructed and called disease. The only problem to resolve may lie in
the similarity relationship required in the induction step. There is fortunately an excellent concept of similarity that will assist us in this task
(Kosko, 1997; Sadegh-Zadeh, 1999a). Fuzzy set difference indirectly defines similarity. The degree of difference between two fuzzy sets A and B,
denoted by differ(A, B), is defined as follows:

FUZZY HEALTH, ILLNESS, AND DISEASE

623

That is, the degree of similarity between set A and set B equals the count
of their intersection divided by the count of their union. Regarding our two
example sets X and Y above, we have, according to this theorem:
similar(X, Y) = (0.6 + 0.4)/(0.7 + 0.9) = 0.625.

myocardial infarction\{(C1, a1), (C2, a2), , (Cm, am)},

gastric ulcer\{(C1, b1), (C2, b2), , (Cm, bm)}

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Similarity, thus defined, is a relationship between fuzzy sets. Hence, to

determine the similarity between any of the prototype diseases {D1, D2, ...,
Dn} above and any other phenomenon requires that they all be formulated
as fuzzy sets (for details see Sadegh-Zadeh 1997; forthcoming c).
For example, a human condition, such as myocardial infarction, may be
construed as a set consisting of a large number of attributes, such as
{myocardial ischemia, arrhythmia, abnormal ECG, elevation of LDH enzyme, chest pain, fear of death, ... etc. ...}. In comparison, another human
condition, such as gastric ulcer, may be another set consisting of another
large number of attributes. Although phenomena of these divers kinds are
in principle comparable with one another, they are not easily comparable
in their entirety. For this practical reason, I am not interested in similarityin-general, but am seeking for similarity-in-some-particulars. Therefore,
in comparing those phenomena to determine the degree of their similarity,
one does not compare them as a whole. One compares them only with
respect to a particular set of criteria, that is, with respect to a comparable
subset of their attributes. For example, one asks how similar they are with
respect to being a bodily lesion and causing pain, distress, discomfort,
incapacity, dependency, and premature death, say, criteria {C1, C2, ..., Cm}
with m 1. In other words, in comparing two large, possibly incommensurable human condition sets Di and Dj, we ask: everything else left aside,
how similar are Di and Dj with respect to the few criteria {C1, C2, ..., Cm}
they share to varying extents? This kind of similarity confined to particular criteria such as {C1, C2, ..., Cm} is referred to as partial similarity with
respect to this set of criteria.
Let A be a fuzzy set of arbitrary length, and let X be part of it. We write
A\X to indicate that A is a fuzzy set with X being part of it. For example,
A\{(z, 0.7)} in a particular context may stand for fuzzy set A = {(x, 0.5),
(y, 0.6), (z, 0.7)}. In this way, it becomes possible to arrange human
conditions such as myocardial infarction and gastric ulcer as uniform fuzzy
sets with respect to their comparable criteria {C1, C2, ..., Cm}:

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KAZEM SADEGH-ZADEH

as, for example:

myocardial infarction\{(bodily lesion, 1), (pain, 0.7), (distress, 0.8)}
(10)
gastric ulcer\{bodily lesion, 1), (pain, 0.3), (distress, 0.5)}
and to compare them with respect to their uniform, terminal criteria segments:

Their remaining, initial, segments pertaining to ECG, blood pressure, enzyme disorders, bacterial infection, etc. may not be comparable and are,
therefore, not considered here. Partial comparisons sketched thus far reveal degrees of partial similarity, symbolized by p-similar(A\X, B\Y), according to the following definition.
Definition 5. p-similar(A\X, B\Y) = r if and only if similar(X, Y) = r.
For instance, according to Definition 5 and Theorem 1, the two examples
in (10) display the following partial similarity:
p-similar(myocardial_infarction\X, gastric_ulcer\Y) = 0.72.
That means that with respect to their terminal criteria sets X and Y, myocardial infarction and gastric ulcer are p-similar to the extent 0.72.
I am now in a position to elaborate the previously envisaged quasiinductive definition of disease. Let {D1, ..., Dn} be a small set of human
conditions such as {myocardial infarction, stroke, breast cancer, tuberculosis of the lung, ..., malaria} each of which in a particular human society
is accepted as a disease because of a finite set of criteria {C1, ..., Cm} they
may have in common to varying extents. A concept of disease for that
society may be constructed quasi-inductively if in that society there is a
consensus on a degree of p-similarity that will serve as a pillar of the
construction:
Definition 6. 1. Any element of the base set {D1, ..., Dn} is a disease;
2. A human condition H\X is a disease if there is a disease
Di\Y {D1, ..., Dn} and an > 0 such that p-similar(H\X,
Di\Y) .

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X = {(C1, a1), (C2, a2), ..., (Cm, am)},

Y = {(C1, b1), (C2, b2), ..., (Cm, bm)}.

FUZZY HEALTH, ILLNESS, AND DISEASE

625

Suppose, for instance, that the following set:

myocardial infarction\{(C1, 1), (C2, 0.7), (C3, 0.8)}

(11)

hemorrhoids\{(C1, 0.9), (C2, 0.2), (C3, 0.55)},

then we have:
p-similar(hemorrhoids\X, myocardial_infarction\Y) = 0.66.
Thus, hemorrhoids may also be labeled a disease. Regarding any other
human condition one may proceed analogously.
Note that, due to the continuity of the similarity degree appearing in
the quasi-inductive scheme of Definition 6, the number of theoretically
possible concepts of disease-in-general is infinite because there are infinite options to choose an (Sadegh-Zadeh, 1977, p. 15). The smaller , the
larger the class of emerging diseases. So the question arises: What to
choose and who will decide about this question to obtain a particular
concept of disease for use in health care? From what has already been said
above, the answer to this question is clear: not medicine, but the public,
will have to make that decision.8
The class of diseases ensuing from a general concept of disease according to the scheme of Definition 6 is not fuzzy, for a human condition such
as those listed in (10) above either definitely is, or definitely is not, a
disease according to that scheme. From a particular theoretical perspective
it may appear desirable to have a concept of fuzzy disease, however. An
individual disease entity produced by such a concept would not be a categorical, YES or NO, disease any more, but a graded one, i.e., a disease to
a particular extent. This option is demonstrated by the following, modified quasi-inductive scheme.
Definition 7. Let H be the set of human conditions. A fuzzy set D over
H is called the set of diseases if and only if there is a subset {D1, ..., Dn}
of H and a function D such that:

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is an element of the base set {D1, ..., Dn} and thus a disease according to
clause 1 of Definition 6. The question as to whether or not something like
hemorrhoids, bald head, pregnancy, homosexuality or drapetomania that
is not contained in the base set {D1, ..., Dn} is a disease is easily decided by
determining the least degree of partial similarity required in clause 2 of
Definition 6. If, for example, = 0.6 is required and there is a human
condition such as:

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KAZEM SADEGH-ZADEH

D : H [0, 1]
with:

and D = {(Hi, D (Hi)) | Hi H }.

This modified scheme does not require a limiting threshold similarity. It
produces a fuzzy set of the type D = {(D1, D (D1)), ..., (Dq, D (Dq))}
consisting of individual disease entities that are members of the set D to
different degrees, i.e., diseases to different degrees. The membership degree D (Di) ranges from 1 to 0. According to this method of concept
formation, an individuals health condition:
hemorrhoids\{(C1, 0.9), (C2, 0.2), (C3, 0.55)},
as compared to a prototype disease like (11) above may turn out to be a
disease to the extent 0.66, whereas another individual with
hemorrhoids\{(C1, 0.2), (C2, 0.1), (C3, 0.1)}
will have a disease of negligible degree 0.16.
It is evident from these examples that a person who has a disease of a
particular degree r, has a non-disease of degree 1 r at the same time. The
reason is that an occurrence that according to Definition 7 is a disease Di to
the extent r, is a non-disease to the extent 1 r because to this extent it
belongs to the complement fuzzy set D c. An individuals having the
disease Di to the extent r therefore means that she does not have it to the
extent 1 r. Thus, fuzzy disease is non-Aristotelian. You both have it and
do not have it. The existence of contradictory states of this kind damages
the trust in the acceptability of classical logic that is based upon the principle of non-contradiction (see Section VII, D below).

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1, if Hi\X {D1, , Dn}, called a prototype or core

disease;

D (Hi\X) = , if there is a prototype disease Hj\Y with

p-similar(Hi\X, Hj\Y) = , and there is no prototype
disease H k\Z with p-similar (H i\X, H k\Z) > ,

FUZZY HEALTH, ILLNESS, AND DISEASE

627

VI. THE PROTOYPE RESEMBLANCE THEORY OF DISEASE

myocardial_infarction\{(bodily_lesion, 1), (pain, 0.7), (distress, 0.8)},

gastric_ulcer\{(bodily_lesion, 1), (pain, 0.3), (distress, 0.5)},
hemorrhoids\{(bodily_lesion, 0.9), (pain, 0.2), (distress, 0.55)},
bald_head\{(bodily_lesion, 0.1), (pain, 0), (distress, 0.01)},
pregnancy\{(bodily_lesion, 0.1), (pain, 0.2), (distress, 0.4)},
homosexuality\{(bodily_lesion, 0), (pain, 0), (distress, 0)},
drapetomania\{(bodily_lesion, 0), (pain, 0), (distress, 0)},
being_in_love\{(bodily_lesion, 0), (pain, 0), (distress, 0)}.
And let a partial difference function for fuzzy sets, p-differ(Hi\X, Hj\Y), be
defined by:
p-differ(Hi\X, Hj\Y) = r if and only if differ(X, Y) = r.
This partial difference function measures the distance between any two
human conditions with respect to their criteria:
X = {(C1, a1), (C2, a2), ..., (Cm, am)},
Y = {(C1, b1), (C2, b2), ..., (Cm, bm)},
and thus provides a metric d over H (see Sadegh-Zadeh, 1997; 1999a;
1999b; forthcoming b). The structure <H , d> becomes a metric space
with:
d: H H [0, 1],

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Building upon the conceptual preliminaries above, one may also speculate
about the entities that in a human society are termed diseases, using a new
paradigm that among other things may assist in developing new approaches to nosology. (For details, see Sadegh-Zadeh, 1997; forthcoming b).
A disease in a human society is a point in a multidimensional ball
centered around a value-laden prototype human condition undesirable in
that society. The undesirability of the prototype determines the content of
the ball through similarity relationships. This anthropological hypothesis
in favor of the normativist perspective on disease may be explicated in the
following way.
Let H = {H1, H2, ...} be the set of human conditions. Its elements H1,
H2, ... may be formulated as partial fuzzy sets Hi\X of the type above, such
as Hi\{(C1, a1), ..., (Cm, am)} where an ak is the degree of membership of
the criterion Ck in the set Hi, for example:

628

KAZEM SADEGH-ZADEH

where H H is the set of all pairs comprising pairs (Hi, Hj) of human
conditions, and the distance between two such human conditions equals
their partial difference, i.e.:
d(Hi, Hj) = p-differ(Hi\X, Hj\Y) = differ(X, Y).
Given any element Hi of H and any particular degree of partial difference, a ball of radius , called a -ball, centered at the point Hi and denoted
by B(Hi), may be defined in the following way:
an open -ball,
a closed -ball.

The latter, closed -ball, for example, reads: the set of all human conditions Hj whose distance from Hi equals at most.
Seen from this perspective, any non-fuzzy concept of disease that is
introduced according to Definition 6 with {D1, ..., Dn} as the set of its
prototype diseases creates for each prototype disease Di {D1, ..., Dn} a
closed -ball D i = B(Di) of diseases centered at the point Di, where = 1
with being the minimum similarity required in the definition. Thus,
one obtains the following balls of diseases:
B(D1) = D 1
B(D2) = D 2
.
.
B(Dn) = D n

(12)

such that each disease ball Di yields a metric space <D i, d> with:
d: D i D i [0, 1], where d(Dj, Dk) = p-differ(Dj\X, Dk\Y).
The set (12) of the balls D 1, ..., D n comprises disease balls of different
size and structure. Their entirety may be termed the nososphere of the
generating concept of disease. They may, or may not, be co-centered at the
cluster {D1, ..., Dn} of prototype diseases. In the former case, an overall
ball D = D 1 ... D n of diseases will ensue. (For details, see the
geometry of disease in Sadegh-Zadeh, 1997; forthcoming b).
The expressive power of this framework enables one to define nosology
as an endeavor that deals, over the setH of human conditions, with closed
-balls of diseases centered at the chosen prototype diseases, D1, ..., Dn. If

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B(Hi) = {Hj | d(Hi, Hj) < }

B(Hi) = {Hj | d(Hi, Hj) }

FUZZY HEALTH, ILLNESS, AND DISEASE

629

VII. MEDICAL AND PHILOSOPHICAL PERSPECTIVES

Thus far, I have taken only a first step toward a new logic of the concepts
of health, illness, and disease. Although this novel, fuzzy-theoretic perspective seems to be promising enough to provide a fertile ground for
substantial inquiries, I have not yet been able to say anything about the
nature of health, illness, and disease as they may now appear. This potential of the framework may be examined by future research and criticism.
Here only a few practical and theoretical aspects will be outlined.
Fuzzy Nosology
First, individual disease entities, such as myocardial infarction, gastric
ulcer, and multiple sclerosis, may be conceptualized as fuzzy sets (see
Section V). Disease criteria, symptoms, and signs would then belong to an
individual disease to particular extents. Thus, an individual disease would
appear as a multidimensional cloud rather than a clear-cut phenomenon. It
would manifest itself quite differently in different patients and at different
stages. The myriad of individual patients presenting a particular disease,
such as myocardial infarction, are just the scattered points of manifestation of such a multidimensional cloud. The main source of misunderstandings and disagreements both in nosology and in the philosophy of health
and disease is basically this inherent fuzziness of the subject that has not
yet been sufficiently recognized to evoke the need for an appropriate conceptual apparatus and methodology. (For a multidimensional geometry of
disease, see Sadegh-Zadeh, 1997; forthcoming b.)
For the sake of simplicity, I have in this non-technical paper presented fuzzy disease concepts as fairly primitive sets, such as, myocar-

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you change any one of these prototypes or your , you will generate a new
nososphere, and your nosological system and your health care will change.
Also, any fuzzy concept of disease that is introduced according to Definition 7 with a set of prototype diseases {D1, ..., Dn}, yields closed -balls
centered at the points {D1, ..., Dn}. In this case, the balls are cloudy. A ball
may extend as far as = 1 and house gradual diseases. The disease intensity of a human condition decreases as it moves from the core to the
periphery of the ball. In the realm of such a fuzzy nosology, a human
condition is medically treated not because it is a disease, but because it is
a disease to a particular extent that is no longer tolerable. Presumably,
real-world health care rests upon such a fuzzy nosology (Sadegh-Zadeh,
1997; forthcoming c).

630

KAZEM SADEGH-ZADEH

dial_infarction\{(C1, a1), ..., (Cm, am)}, which entails a disease criterion Ci

with a single, sharp membership degree ai. In a more realistic and viable
way a fuzzy disease D may be represented by a more intricate type of
fuzzy set, such as:
D\{(C1, [0.4, 0.8]) , (C2, [0, 0.9]), ..., (Cm, [0.6, 1])},

Fuzzy Diagnosis and Therapy

Fuzzy nosology yields fuzzy diagnosis and fuzzy clinical decision-making
(Sadegh-Zadeh, 2000b). First, one may be given a patient who displays
her complaints, symptoms, and signs at different levels of severity, intensity or clarity, such as {(cough, 1), (fatigue, 0.5), (fever, 0.7), (hypercholesterolemia, 0.6), ...}. She may thus belong to different fuzzy disease
classes at the same time and to different extents. Appropriate methods of

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giving for each criterion Ci a membership interval [ai, bi] with a lower
bound ai and an upper bound bi of membership. Alternatively, this complex membership indicator [ai, bi] may be replaced with an even more
complex one, i.e., a fuzzy number.9
However, I have preferred not to go into technical details here. It may
only be noted that methods of this type would enable us to come to grips
with vague disease descriptions, such as: ECG is usually normal, but
heart beat is slightly accelerated, cholesterol is moderately increased, red
blood count is highly decreased .....
As Definition 7 demonstrates, the class of disease-in-general itself may
also be conceived of as a fuzzy set, such that being or not being an individual disease entity may itself be handled as a matter of degree. In this case,
a disease entity may be graded as being, for example, of degree 1, of
degree 0.9, of degree 0.8, etc., or by using linguistic fuzzifiers such as
severe, moderate and mild, which may also be further diversified by applying modifiers such as very and the like. The practices of tumor staging
and malignancy grading are examples of this kind of fuzzy nosology that
have already developed independently of fuzzy theory.
The next step in fuzzifying a nosological system would consist in allocating an individual disease entity to different fuzzy classes of diseases.
For example, gastric ulcer may turn out to be a disease of the digestive
tract to the extent 1, an infectious disease to the extent 0.8, and a psychosomatic disease to the extent 0.3.
In any event, fuzzy nosology would present itself as the science and art
of framing, structuring, and analyzing the mutidimensional nososphere
that an underlying concept of disease generates (Sadegh-Zadeh, 1977).

FUZZY HEALTH, ILLNESS, AND DISEASE

631

Health, Illness, and Disease as Meinongian Objects

As I have argued in the preceding sections, fuzzy health, illness, and disease
are non-Aristotelian attributes because they violate the principles of excluded middle and non-contradiction. I consider fuzzy disease as an example
which shows that health, illness, and disease are not only subjects of medical and philosophical concern, but also intriguing ontological objects.
Let a particular disease such as gastric ulcer be reconstructed as a fuzzy
disease. We have seen in Section V that a patient suffering from fuzzy
gastric ulcer both does and does not have it at the same time. But a statement of the form x has A and x does not have A is a classical-logical
contradiction. A state of affairs described by such a contradiction is usually viewed as impossible, and thus as non-existent, because the classicallogical principle of non-contradiction, initially formulated by Aristotle,
precludes its existence.11 It is, therefore, said that an impossible state of
affairs does not exist. However, fuzzy disease states demonstrate that the
impossible does exist. All diseased patients and all recovering patients
indeed exhibit such existent impossibles every day. Hence, the principle
of non-contradiction is not true. This is lethal to classical logic.
To put it positively, we may also suggest that health, illness, and disease
are Meinongian objects. Alexius Meinong, an Austrian psychologist and
philosopher (1835-1920), developed a highly original and controversial
theory of objects according to which there are objects that do not exist ...
(Meinong, 1904; Grossman, 1974). Every such object, he said, may be
described nonetheless (for example, a round square). Something is a round
square if it is round and if it is square. If it is round, it is not square. Thus,
it is square and it is not square: a contradictory object.

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analysis will be necessary to handle these modes of fuzzy multi-class

membership. This kind of investigation is currently emerging in the area
of medical knowledge-based systems research.10 A prerequisite for fruitful work will be a medical epistemology which clearly suggests how medical knowledge nosological, symptomatological, pathophysiological, diagnostic knowledge, etc. may be represented in fuzzy terminology. This
will bring with it the next prerequisite: i.e., a logic that would enable us to
deal with fuzzy knowledge. Fuzzy logic, the logic part of fuzzy theory,
seems to be a suitable candidate (see below).
Second, due to the ineluctable vagueness of physician and patient
preferences, goals, and constraints in clinical settings, on the one hand,
and to uncertainties in treatment efficacy evaluations, on the other, treatment decisions also are likely to become subject to fuzzy decision-making
(see Bellman and Zadeh, 1970).

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KAZEM SADEGH-ZADEH

In Meinongs theory of objects, an impossible object is one that violates

the principle of non-contradiction: e.g., a round square. And an incomplete
object is one that violates the principle of excluded middle. In this sense,
health, illness, and disease states of individual human beings are Meinongian objects. And because they exist in the real world, I call them real
Meinongian objects. A serious consequence of this finding may be briefly
sketched in the next subsection.

Diseases are Deontic Constructs

According to this approach to the concept of disease, what is considered a
disease is relative to human societies. A particular human condition may
be classified as a disease in a particular society and as a non-disease in
another one. The question of who is right and who is wrong does not make
sense because class boundaries are not independent of the classifier. A

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The Logic of Medicine

A domain such as medicine that entails real Meinongian objects generates
inconsistent theories in the sense of classical logic. Inconsistencies trivialize a theory and destroy its meaning in that such a theory classical-logically implies anything (ex falso quod libet). Therefore, one cannot reasonably
subscribe to both and must abandon one of them, either the theory or
classical logic.
Classical logic may be a useful tool in consistent areas, though it is
obviously not an appropriate tool for medicine as a whole. Medicine is too
non-homogeneous an area. The theories produced by its subdomains such
as anatomy, physiology, pathophysiology, clinical disciplines, etc., are
conceptually, syntactically and semantically too different from one another to assume one and the same logic. As I have shown elsewhere (SadeghZadeh, 1994; forthcoming c), anatomical knowledge can be represented
and handled below the level of modal logics because it is void of any
modal operators such as possible, necessary, and the like; pathophysiological and nosological knowledge will at least require temporal predicate
logic, probability theory and fuzzy theory because it describes time-varying, probabilistic, and fuzzy processes. Also, the appropriate understanding, representation and use of diagnostic and therapeutic knowledge requires at least a fuzzy deontic logic or another system of paraconsistent
deontic logic.12
This means that there is no general logic of medicine. Any particular
medical theory or knowledge domain may require its own, specific logic.
This is tantamount to logical relativism, pluralism, and instrumentalism
(Sadegh-Zadeh, 2000a; forthcoming c).

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VIII. CONCLUSION
We seek clear and enduring criteria for our judgments about the world. It
is no different with respect to our interest in health and disease (Engelhardt, 1976, p. 267). I have proposed a basic concept of patienthood and

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concept of disease operative in a particular human society generates its

own peculiar nososphere in this society (see Section VI). The basic generators of its nososphere are those human conditions which are considered
prototype diseases in this society. They generate the nososphere through
similarity relationships.
A prototype disease in a human society is what that society accepts as a
disease by naming it a disease: this is a disease (see clause 1 of Definitions
6 and 7). Thus, it is a collective performative, and as such, a deontic construct of the society itself (Sadegh-Zadeh, 1983; forthcoming c). A deontic
construct in a society is a state of affairs brought about by members of this
society if there are moral or legal rules (deontic norms), such that the actions they perform or omit to bring about that state of affairs are required or
forbidden by these deontic norms. For example, being literate is a deontic
construct in Germany because going to school is legally required in Germany. A prototype disease in a society is a deontic construct of this society
because it emerges, qua disease and not qua an entity, from deontic norms
of the society. As a particular human condition, such as heart attack, it
evokes actions of members of the society to rescue the afflicted, to help her,
and to ameliorate her condition. Such a human condition is designated a
disease simply to have a name for this type of action-provoking state of
affairs. Its primary characteristic is its being action-provoking. It is actionprovoking not because it is a disease in the interpreted sense of this term,
but because the members of the community where it occurs share basic values and attitudes such as sanctity of life, benevolence, love, compassion,
sympathy according to which rescue, relief, help, remedy and care are
deontically required in such circumstances. By their remedial and preventive actions and attitudes they bring about the collective act of treating
something as a disease which without this act would not be a disease.
The notion of disease thus deserves action-theoretical analysis. It is
questionable if human monads who would not live in polyads, i.e., human
communities, would ever consider themselves as having any disease. That
means, by analogy to the Wittgensteinian impossibility of private language,
that there are no private diseases. Diseases are, as deontic constructs of a
society, essentially social artifacts. That is why disease naturalism is wrong.

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KAZEM SADEGH-ZADEH

ACKNOWLEDGEMENT
I thank my son Manuel for drawing the figures for this paper.

NOTES
1.

See, for example, Boorse, 1975; 1977; 1997; Caplan et al., 1981; Cassell, 1991;
DAmico, 1995; Engelhardt, 1975; 1976; 1985; Hesslow, 1993; Kendell, 1976; Khushf,
1995; Lennox, 1995; Margolis, 1969; 1976; Mordacci, 1995; Nordenfelt, 1987; Pellegrino and Thomasma, 1981; Reznek, 1987; Rothschuh, 1972; Sade, 1995; Toombs,
1992.
2 . Fuzzy theory, popularly misnamed fuzzy logic, is a rapidly-developing, multidisciplinary science of uncertainty and vagueness inaugurated by Lotfi A. Zadeh at the
University of Berkeley in 1965 (1965a; 1965b; Yager et al., 1987; Dubois and Prade,
1980; Klir and Yuan, 1995; 1996).

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concepts of fuzzy health, illness, and disease which deviate from the traditional ones in several respects. They are many-valued concepts, and thus
they do not fit archaic YES-NO patterns of thought and do not obey the
simplistic principles of excluded middle, contradiction, and non-contradiction. The framework presented breaks new ground in the philosophy of
health and disease, making nosology, diagnosis and clinical decision-making directly amenable to fuzzy theory and non-classical logics. Besides the
methodological advantages it provides, it makes tractable the genuinely
philosophical problems associated with the notions of health and disease:
e.g., the value-ladenness of diseases and the ontological question of whether
diseases are invented or discovered. I have addressed these problems elsewhere (Sadegh-Zadeh, 1997; 1999b). I have argued that, despite all rational and irrational skepticism, it is indeed possible to construct a concept of
generic disease that may gain acceptance in a community on the grounds
that it rests on consensus in that community. To this end, I have reconstructed human conditions as fuzzy sets and have introduced a novel method of concept formation dubbed quasi-inductive definition. This methodology not only allows for serious discussions on the subject, but also
enables inquiries into theoretical nosology, including the theory, methodology, and epistemology of nosological systems (Sadegh-Zadeh-1997;
1999b). As an example, a sketch has been given of a prototype resemblance theory of disease. Another example is the explication of Ludwig
Wittgensteins family resemblance concepts as quasi-inductive similarity
structures in the vein of our fuzzy-theoretic construction (Sadegh-Zadeh,
2001).

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3. A set is a collection of any objects referred to as its members or elements. We

distinguish between classical sets and fuzzy sets. A classical set such as the set of
even numbers or the set of ones siblings has clear-cut boundaries. An object is
definitely a member of the set, or it is definitely not a member of the set. There is no
object at an intermediate point between definite membership and definite non-membership. Sets are represented by Roman capitals. Their members are represented by
lower case letters. If an object a is a member of a set X, we write a X. And we write
a X, otherwise. A set whose members are characterized by a particular attribute A
is represented by {x | x is A} using two braces { }, to be read as the set of all x such
that x is A. For example, the set of healthy people is {x | x is healthy}. If a set is finite
consisting of n 1 members x1, ..., xn, it may also be represented by enumerating its
members between two braces such as {x1, ..., xn}. For instance, {Hippocrates, Hodgkin, Virchow, Osler} is the set of four well-known physicians.
4. An interval between two numbers m and n, written [m, n], is the set of all numbers
from m through n, where m < n.
5. German Unsinn = nonsense.
6. The neologism patienthood is a handy substitute for being afflicted by a malady
(Sadegh-Zadeh, 1982). I coined this term because malady is too vague and semantically biased.
7. Other names of these variables used in philosophy and methodology are quantitative
(= numerical) and qualitative (= linguistic) variables.
8. One may in Definition 6 also require a soft degree of similarity, such as sufficiently
similar instead of a sharp degree . The decision to determine what is sufficiently
similar would in that case be left to the individual doctor. Maybe the real-world
medical practice functions just according to this tacit rule.
9. Fuzzy numbers are a novel type of numbers constructed by fuzzy theory. A fuzzy
number, such as approximately 5, does not have clear-cut boundaries like our traditional numbers. (For details see Kaufmann and Gupta, 1991.)
10. See, for example, the journal Artificial Intelligence in Medicine at www.elsevier.com/
locate/artmed.
11. ... that it is necessary in every case either to affirm or to deny and that it is
impossible simultaneously to be and not to be (Metaphysics, Book 2, 996b2630).
12. Paraconsistent logics are inconsistency tolerant systems of logic which do not contain a principle of non-contradiction. They originated around 1910 with the Russian
physician Nikolaj A. Vasiliev (1880-1940) who at the beginning of the 20th century
taught philosophy at the University of Kazan, Russia. Inspired by Nikolaj Lobachevskis
non-Euclidean geometries, in which the Euclidean parallel postulate is not valid, he
attempted to construct new Imaginary Logics by discarding some of the basic laws
of Aristotelian logic (Arruda, 1977). These logics would enable us to study a large
class of imaginary worlds which are impossible to classical logic, but nevertheless
quite well imaginable. After Stanislaw Jaskowskis interlude (1969), specific research in this new field of non-classical logics was initiated by the significant work of
the Brazilian logician and philosopher Newton C.A. da Costa (1963; 1974). The
name paraconsistent logic was coined by the Peruvian philosopher F. Miro Quesada
in 1976. (For more comprehensive accounts of the subject, see Priest et al., 1989;
Grana, 1983; Sadegh-Zadeh, 2000a.)
Deontic logic deals with the deontic operators obligatory, forbidden, and permitted. (For a paraconsistent deontic logic, see Grana, 1990.) The logic of clinical
reasoning is at least a kind of deontic logic because diagnostic-therapeutic knowledge, as a framework of indications and contra-indications, consists of deontic statements. (For details see Sadegh-Zadeh, 1994; forthcoming c.)

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