Malady: A New Treatment of Disease

Author(s): K. Danner Clouser, Charles M. Culver, Bernard Gert

Reviewed work(s):
Source: The Hastings Center Report, Vol. 11, No. 3 (Jun., 1981), pp. 29-37
Published by: The Hastings Center
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 WHATDO DEATH,PAIN& DISABILITY
HAVEIN COMMON?
Malady: A New Treatment
by K. DANNERCLOUSER,CHARLESM. CULVER,and BERNARDGERT
--
The definitionof conceptslike diseaseandillnessis an
importantproblemin the philosophyof medicinebecauseof
its inherentconceptualinterestand because of its relation-
ship to many practical matters. For example, it might be
claimed that differentpersons, groups, and culturesdefine
disease-concepts quite subjectively and thus idiosyncrat-
ically. In this view there can be no objective guidelines to
help decide, say, whether such conditions as addictionto
tobaccoor having had a breastamputatedrepresentdiseases
or maladies, and thus whethersmoking clinics or breastre-
constructionsurgery ought to be covered by health insur-
ance. On the other hand, it might be assertedthatthere are
fairly clear and objective universalcriteriafor definingdis-
ease-concepts.It mightthen follow thatthe disease- or mal-
ady-statusof most human conditions can be determined
fairly clearly and that these criteriacan also help explain
why a few conditions are truly borderline.
Therecan also be disagreements,with importantimplica-
tions, among those who believe that objective disease-cri-
teria exist. For example, if one believes that a necessary
criterionfor disease is the presenceof some "abnormality"
in physiologicalfunctioning,then mentalconditionssuch as
phobiasand compulsions will probablybe excluded at the
outset. By contrast,if one claims that "abnormal"physio-
logical functioningis not even a criterionfor determining
whetherphysicalconditionsare considereddiseases, then it
will be an open questionwhetherand to whatextentvarious
mentalconditions satisfy the actual criteriafor disease- or
malady-status.
We believe that there are objective definitionalcriteria,
and that they apply equally to mental and physical condi-
tions. Before presentingthese criteria,though, we want to
discuss the arrayof malady-termsthat exist in the English
language.Threeof the most importantwordsare "disease,"
"illness," and "injury," but there are many more:
"wound," "disorder," "defect," "affliction," "lesion,"
and "disfigurement,"to list a few. While these terms have
distinctthough partlyoverlappingconnotations,which can
be identifiedfairly precisely, there is neverthelessan arbi-
traryelement in the labeling. For example, most of those
conditionsregardedas injuries(such as broken limbs) are
not calleddiseases andvice versa(measles is not an injury),
K. DANNERCLOUSER, Ph.D., is in the departmentof human-
ities, College of Medicine, Pennsylvania State University.
CHARLES M. CULVER, M.D., Ph.D., is in the departmentof
psychiatry, and BERNARDGERT, Ph. D., in the departmentof
philosophy,DartmouthMedical School and DartmouthCollege.
The Hastings Center
- ----~~~~~~~~~~~~~~~~III
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of Disease
but it seems impossible to constructany definitionof dis-
ease that does not include injuries. Indeed an occasional
pathology textbook1does use the term "traumaticdisea-
ses," which is easily comprehensiblethough not ordinarily
used. As an interestingexample of the arbitrarynatureof
this labeling, the conditionexperiencedby deep-sea divers
who returnfrom the depthstoo quickly is referredSo either
as "caisson disease" or "decompression illness," yet es-
sentiallyall the associatedill effects are due to the cellular
injurycausedby nitrogenbubblesformingin variousbodily
tissues.
Illness and disease are closely related, but diseases-
more robust ontologically than illnesses-are regardedas
entities having characteristicsigns and symptoms with
known or discoverableetiologies. Diseases can exist before
the appearanceof symptoms(for example, a cervicalcancer
detectedby a Pap smear),thoughthey nearlyalways lead to
manifestsymptoms.In illnesses, by contrast,symptomsare
predominantand the underlyingpathogenesisis almost ig-
nored;for example, it seems appropriateto speak of a "dis-
ease process"but not of an "illnessprocess." Thus diseases
at a presymptomaticstage (whethercancer or tooth decay)
would not generallybe regardedas illnesses. And someone
who was poisoned (for example, by an overdoseof aspirin)
would generallybe regardedas being ill but not as having a
disease. But this distinctionseems to have no logical basis:
some infections(which areprototypicalexamplesof diseas-
es) exert their deleteriouseffects chiefly throughthe secre-
tion of poisons (toxins).2
Many importantkinds of conditions do not seem to be
diseases, illnesses, or injuries;for example, an ordinaryten-
sion headache or a hernia. A hernia seems more like an
injurybut thatdoes not seem exactly right. Idiopathicmen-
tal retardationdoes not fit any of these threecategories.Nor
is it clearhow to classify someone who is having an allergic
reaction. Even less clear is how to describe someone who
has a significantallergy but is now free of any symptoms.
We believe that all illnesses, injuries, diseases, head-
aches, hernias, and even asymptomaticallergies do have
something in common, and we propose "malady" as the
general term that includes them all. Later we shall offer a
more precise definition,but for now we shall mean by mal-
ady, roughly, any condition in which there is something
wrong with a person.
Some Past Definitionsof Disease
Therehave been many attemptsto set out a formaldefini-
tion of disease, butphysicianshave only rarelyrecognizeda
29
 9 L- --CI I I-- - I
distinction among disease, illness, injury, and related
terms. Consequently,illness is often used interchangeably
with disease, and injuriesare regardedmerely as a subclass
of diseases. Whatmost of the following authorshave in fact
intendedto define is what we call a malady, so thatin addi-
tion to diseases they have includedinjuries,illnesses, head-
aches, and the like in their definitions. However, by not
realizingwhat they have done, they have often been misled
by one or anotherparticularfeatureof the term "disease."
Some definitions are general, vague, and too inclusive.
Thus a pathology textbook states: "Disease is any disturb-
ance of the structureor function of the body or any of its
parts;an imbalancebetween the individualand his environ-
ment; a lack of perfect health."3
This seems to offer three separatebut equivalentdefini-
tions. Under the first definition, clipping nails and puberty
would be diseases, as well as asymptomaticsitus inversus
(transpositionof the viscera, with the liver on the left and
the hearton the right)and being tied to a chair. The second
definition is too vague to be of any use, and the third is
circular.
A textbook on internal medicine says: "... disease may
be definedas deprivationor lack of ease, a discomfortor an
annoyance, or a morbid conditionof the body or of some
organor partthereof."4Thereare similarproblemshere. Of
the two separatedefinitionsoffered, the firstis too sweeping
andwould includeinflation,quarrelsomein-laws, poor tele-
vision reception, and ill-fitting shoes; while the second is
circular and depends on the phrase "morbidcondition,"
which is merely a synonym for "disease."
Most books on medicine and pathologymake no attempt
to define disease, which is appropriateenough since the ex-
ercise is irrelevantto theirpurposes. However, it might be
said in their defense that these attemptswere probablynot
meant to be taken very seriously.
One cluster of definitions that is meant to be taken se-
riously utilizes a dynamic metaphorin which a person is
picturedas constantlyinteractingand adaptingto changesin
the environment;disease then correspondsto a failure in
that adaptation.An early expression is found in William
White's 1926 book, The Meaning of Disease:
Diseasecan onlybe thatstateof the organismthatfor the time
being,at least, is fightinga losinggamewhetherthe battlebe
with temperature, water, microorganisms, disappointmentor
whatnot.In anyinstance,it maybe visualizedas thereactionof
theorganismto somesortof energyimpact,additionor depriva-
tion.5
Thus one wrestlerheld down by anotheris sufferingfrom
a disease.
A more modem version is found in George Engel's Psy-
chological Development in Health and Disease:
Whenadaptation oradjustment fail andthepre-existing
dynamic
steady state is disrupted,then a state of disease may be said to
exist until a new balanceis restoredwhich may againpermitthe
effective interactionwith the environment.6
30
I -r,
Aside from the ambiguitiesand the question-beggingin-
herentin "adaptation"and "balance,"the emphasisin this
definition(and the precedingone) on the deteriorationof a
previousmore normalstate seems to rule out all congenital
and hereditarydiseases.
J.G. Scaddinghas writtena series of papers7concerned
with the definitionof disease, in the most recentof which he
offers the following "formaldefinition":
A disease is the sum of the abnormalphenomenadisplayedby a
group of living organismsin association with a specified com-
mon characteristicor set of characteristicsby which they differ
from the normfor theirspecies in such a way as to place them at
a biological disadvantage.8
Scadding'sdefinitionis a step forward.He very explicitly
introducesthe notionof deviationfrom a normfor a species
which, thoughit does not deserve the prominencehe gives
it, is necessaryfor understandingthe essential elements of
the concept of malady. His "biological disadvantage"cri-
terion also points in the right direction, but is too vague.
R.E. Kendell, in a recentpaper, interprets"biologicaldis-
advantage" as meaning decreased fertility or longevity.9
But even Kendell recognizesthathis revisionof Scadding's
definitionleaves one with the "ratherdisconcerting"result
that a condition such as psoriasis would not qualify as a
disease.
Several recent authorshave also correctly identified as-
pects of disease. RobertSpitzerand JeanEndicott'1include
in their definitionof "a medical disorder"that it is intrin-
sically associated with distress, disability, or certaintypes
of disadvantage.We thinkthey are on the righttrack.Don-
ald Goodwinand SamuelGuze11consideras a disease "any
condition associated with discomfort, pain, disability,
death, or an increasedliability to these states, regardedby
physicians and the public as properlythe responsibilityof
the medical profession." We agree with the first part of
their definition but will show later the second part ("re-
garded by physicians . .") is not necessary. Many of these
pointswere anticipatedby LesterKing in a fine olderpaper,
in which he incorporatesboth the notions of various evils
andthe deviationfrom a normin his discussionof disease.12
The Definition of Malady
Having something wrong: maladies and evils. We are
not providing an entirely new account of "disease" or
"malady,"just a more precise and systematicone than has
been providedbefore. In a sense we are going to determine
what a malady is by seeing what it is for a person to have
somethingwrong with himself or herself. Briefly, to have
somethingwrong with oneself is to have a condition, other
than one's rationalbeliefs or desires,* such that one is suf-
*We exclude rationalbeliefs and desires from the evil-causing conditionsthat
count as maladies because we do not think a man has something wrong with
himself if he has a rational belief, e.g., that his wife is dying of cancer, that
causes him pain, or if he has a rationaldesire, e.g., to go mountainclimbing,
that increases his risk of death and disability.
The Hastings Center Report, June 1981
 - I-I-I I --- I ? - as
fering or has an increased probability of suffering some
evil. Further, whatever its original cause, this condition
must now be partof oneself, and hence cannotbe removed
simply by changing one's physical or social environment.
In this section we shall focus on that aspect of maladies
thatlinks them so intimatelywith the sufferingof evils. It is
importantto note that as we use the term, "evil" has no
moral connotations;one could substitutethe term "harm"
for "evil" as in "makesure no harmcomes to him." Many
accountsof disease have linked the concept very closely to
death, pain, or disability.But in none of these accountshas
there been any attemptto draw out the apparentlyobvious
but unexplainedcommon feature.
It may seem odd to ask the question "What do death,
pain, and disabilityhave in common?" but in fact it is an
importantquestion. Part of the problemis that it seems so
obvious that death, pain, and disabilitygo togetherthat no
attentionhas been paid to explaining what they have in
common.
Apples, peaches, pears, andplums are all fruits,but what
is the genus of which death, pain, and disability are spe-
cies? The answer is: no one wants them. In fact everyone
wants to avoid them. Thus what unites death, pain, and
disabilityis the attitudethat people take towardthem. But
there are times when persons actually seek death, and
willingly endure pain or disability. Generally these times
occur when somethingelse has gone wrong;thatis, persons
seek deathwhen life has become too painful, or they endure
pain or disabilityto save theirown lives or the lives of those
they love. Thus a qualificationmust be added: all persons
avoid death, pain, and disability, unless they have some
reason not to avoid them.
As we use the term, "reasons"are conscious beliefs that
can be used to justify-make rational-actions that would
otherwise be irrational.We have already indicated some
things that will count as reasons, for example, beliefs that
someone will avoid death, pain, and disability. But beliefs
that someone will avoid loss of freedom, opportunity,or
pleasurealso count as reasons, as do beliefs that someone
will gain increasedabilities, freedom, opportunity,or pleas-
ure. Note thatnot all reasonsare egoistic; beliefs thatothers
will avoid death, pain, and disability also count as rea-
sons.13
It now seems as if all personswill avoid death, pain, and
disability,unless they have a reason not to do so. But even
this is not completelyaccurate,for some personssometimes
act irrationallyand do not avoid, indeed sometimes even
seek, death, pain, or disabilityfor no reason, for example,
severely depressedpersons. We do not deny that there is a
psychodynamicexplanationfor theirirrationalactions, only
that they have any conscious beliefs about benefitingany-
one such that theirharmingthemselves counts as acting ra-
tionally. We must say then that death, pain, and disability
are always avoidedby personsacting rationallyunless they
have a reasonnot to do so. Thoughsomewhatcumbersome,
The Hastings Center
this descriptionis a sufficientaccountof what death, pain,
and disabilityhave in common and what distinguishesthem
from almost everythingelse-for example, books, chemis-
try, and love. However, we can eliminatethis cumbersome
descriptionby simply defining an evil (or harm) as "that
which all persons acting rationallywill avoid unless they
have a reasonnot to." We can now say, as we actuallydid
at the beginning of this discussion, that death, pain, and
disability are evils. Evils are the genus of which death,
pain, and disabilityare species. What death, pain, and dis-
abilityhave in commonis normativeandthus "malady"is a
normativeterm.
In so saying we meanthatit is not a matterof indifference
whetherwe or someone we care for has a malady;maladies
are regardedas bad-things to be avoided. But we are not
holding the view that what counts as a maladyis culturally
determinedin a parochial sense, that is, that each culture
determinesits own uniqueset of maladies. Maladyis a uni-
versal concept. Every society regardsdeath, pain, and dis-
ability as evils or harms. In no society do any rational
personsseek these things;ratherthey all avoid them, unless
they have a reasonnot to. In particularcircumstances,many
societies provide reasons for seeking death, pain, or dis-
abilitythroughreligious or culturalbeliefs aboutthe benefit
to be gained by sufferingsuch an evil. But anthropologists
studyinga culturealways requiresome explanationfor any
practicethat involves killing, causing pain to, or disabling
oneself. They do not requireexplanationsfor saving one's
own life, relieving one's own pain, or preventing dis-
abilities to oneself.
A maladyis a conditionthatinvolves the sufferingor the
increasedrisk of sufferingan evil. Differentsocieties may
not know that a particularconditionis a maladybecause it
may be so endemicthatthey regardit as a normalfeatureof
the species;but they can be mistakenaboutthis, just as they
can be mistakenaboutany othermatterof fact. This is why
we cannot include as part of the definitionof malady that
the conditionbe regardedas the responsibilityof the medi-
cal profession. Similarlysome societies may considerhav-
ing a given malady as a good thing, perhapsbecause they
regardit as a sign of the favor of the gods. This too does not
conflict with our analysis. Someone may have a good rea-
son for having a maladybut it is still a malady. For exam-
ple, it may be to a soldier's advantageto be sick when his
cohorts are being picked for a particularlydangerousas-
signment. Considered simply by itself, a malady is nor-
mally avoided;we do not deny thatthereare circumstances
in which it can come to be regardedas somethinggood. To
put it in classical philosophicalterms, though maladiesare
intrinsicallybad, they can be instrumentallygood.
Death, pain, and disability are not the only basic evils.
Loss of freedomor opportunity,and loss of pleasure, must
be addedto the list. By pain we meannot only physicalpain
but also the unpleasantfeelings of anxiety, sadness, and
displeasurein their various manifestations.Similarly, dis-
31
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abilities should not be limited to physical disabilities, but
shouldalso includementaldisabilities,such as aphasia,and
volitionaldisabilities,such as compulsionsandphobias. All
the items on this list are basic evils: every person acting
rationallywill avoid these things unless he or she has some
reasonnot to. Thus, the list of evils is not arbitrarybut one
in which all memberssharea commonfeature.The concept
of an evil is not one that is simply developed ad hoc to
account for the concept of a malady.14
Having somethingwrong with oneself: maladies and the
absence of distinct sustaining causes. On our account, not
just anythingthat causes or increases the risk of suffering
an evil is a malady. One is suffering a malady if and only
if the evil, or increasedrisk thereof, one is suffering is not
in continuing dependence upon causes clearly distinct
from oneself. (We are also excluding rationalbeliefs and
desires, for reasons discussed earlier.) We will use the no-
tion of "sustainingcause" (roughly as used by Aquinas in
his ThirdProof) to referto a cause whose effects come and
go simultaneously(or nearly so) with its respective pres-
ence and absence. Thus a wrestler's hammerlockmay be
painful, but it is not a malady. Similarly, thoughbeing in a
runawaycar significantlyincreases one's risk of incurring
pain, disability, and death, one is clearly not suffering a
malady-yet. A smoke-filled room can cause labored
breathing and increase the risk of suffocation; extreme
cold can cause pain and the loss of ability to move one's
limbs easily. Nevertheless, these conditions are not mal-
adies. However, if these situations affect a person so that
he or she continues to suffer the evils, or is at increased
risk of suffering them, even when these special situations
are no longer present, then that person has a malady.
Thus a person suffering a malady must have a condition
not sustained by something distinct from himself. The
condition may well have been originally caused by factors
distinct from the person, but it is not now in a state of
continuingdependenceon those distinctfactors;ratherit is
present even in their absence. We could say that to be a
malady the evil-producing condition must be part of the
person. However, for reasonsof conceptualrigor, we state
it more formally in the negative:the personhas a maladyif
and only if the evil he or she is suffering does not have a
sustainingcause that is clearly distinct from the person.
Admittedly, distinct sustaining causes cannot be deter-
mined without some residual vagueness. Precise simul-
taneity of cause with its effect, and of deletion of cause
with deletion of its effect, are rare. Effects often have
slight time lags: a suffocating person might not imme-
diately recover upon receiving sufficientair;or a person in
a grossly overheatedroom might still feel overheatedafter
leaving the room. Nevertheless, in principlethe distinction
can be made, and practice falls in line. If the time lag
before recovery is brief, the person does not have a mal-
ady; on the other hand, if it is highly probablethat a mal-
32
Y
ady will develop from a currentdistinct sustaining cause,
we may respond as though the malady already existed.
Our account of a clearly distinct sustaining cause may
suggest that those causes are always external elements,
that is, not inside one's body. However, an increased risk
of evil may have a sustaining cause that, though "clearly
distinct" from the person, is nevertheless within the per-
son; for example, a poison capsule held in the mouth.
What if the poison capsule is swallowed but is still un-
dissolved? At what point does a "clearlydistinct" sustain-
ing cause become not so clearly distinct from the person?
For example, suppose a man were dying from poison that
had been dissolved, absorbed, and spread throughouthis
body but that the poison could be quickly removed from
his body by some chelating agent which would then very
rapidlyreturnhim to normal. Would that make the poison
a "clearlydistinct" sustainingcause and consequentlypoi-
soning not a malady?If so the next step might be to con-
sider viruses and bacteria in the same way, namely, as
sustainingcauses distinct from the person, the removal of
which would lead to immediate cure. But that would be
absurd, since the presence of these harmfulorganismsin a
person paradigmaticallyconstitutes a malady. When poi-
son, viruses, germs, and the like have become biologically
integratedor cannot be removed quickly and easily, then
we do not regardthem as distinct sustainingcauses, but as
part of the person.
When the evil-causing element is within the person, two
distinct factors determine whether the person has a mal-
ady. Is the element biologically integrated?Can it be re-
moved easily and quickly without special skill or
equipment? If it is either biologically integrated or not
easily and quickly removable, then the person has a mal-
ady. Whereintegrationor assimilationof a substancetakes
place, we always consider it a part of the person: body
cells are invaded and interactedwith, injuryis done, bio-
chemical exchanges take place, body defenses react. On
the other hand, it may seem counter-intuitiveto regardan
unassimilatedforeign substance (such as a small marble)
as part of.the person. Many such items are swallowed, do
not actually penetrate the body (do not traverse the gut
epithelium) and are excreted harmlessly. However, if the
object is causing harmand if its total removal without sub-
sequent detrimentis not possible without special skill or
equipment, the person has a malady (for example, food
caughtin the tracheawhich can only be removedby some-
one who knows the Heimlich maneuver).
Of course, certain vaguenesses remain because "easily
and quickly removable" and "special skill or equipment"
are not precise expressions and may sometimes be subject
to cultural differences. Nevertheless, they give definite
and helpful guidance in making distinctions at an other-
wise confusedjunction. Thus a tongue depressoror a proc-
toscope, though causing pain, would be clearly distinct
from the person and hence not part of a malady. However
The Hastings Center Report,June 1981
I I I - - - - -
a surgical patient, with a clamp mistakenly left inside,
causing pain or disability, has a malady since the clamp is
not easily removable and thus is not clearly distinct from
the person.
These matters have of course always caused labeling
problems. Marbles and clamps, unless they are presently
causing some evil, are ordinarily simply called "acci-
dents," without reference to disease, malfunctioning,
pathology, lesion, or any of the othermalady labels. How-
ever, in examiningthe subtletiesof what constitutesa mal-
ady, we are making distinctions at a level not ordinarily
recognized or considered, so our ordinarysense of the lan-
guage does not give us sufficient direction.
Abnormalityand distinct sustaining causes. It is often
claimed that one is suffering a malady if one is abnormal
in either structureor function. We believe that abnormal-
ity, though crucial, is relevant to the concept of malady
only indirectly, as a necessary feature in explaining dis-
ability, increased risk, and distinct sustaining cause.s1
When a person is sufferingan evil we decide whetherhe
or she has a malady by determiningwhether members of
the species characteristicallysuffer a similar evil, or in-
creasedrisk thereof, in this environmentor circumstance.
For example, if a woman is suffering because she has
walked into a hot boiler room she does not have a malady;
ratherthe environmentis abnormaland should be regarded
as the cause of her suffering. However, if a woman is in
moderatediscomfortbecause a cat to which she is allergic
has walked into the room, then she has a maladybecause it
is she who is, in at least this respect, abnormal. Her al-
lergy is the cause of her suffering. In our use of cause,
which is the ordinaryuse ratherthan the scientific, we re-
gard the abnormalelement as the cause.
Abnormality,though crucial, is relevantto
the conceptof maladyonly indirectly..
By environmentand circumstanceswe mean those fea-
tures of the situationthat are distinct from the person. It is
normal for all persons who have digested a significant
amountof cyanide to be suffering evils and increasedrisk
of evils, but thatdoes not mean they do not have a malady.
The cyanide is no longer distinct from them, hence their
suffering has no distinct sustaining cause.
The description of a person's environment or circum-
stances can be complex and here too the concept of abnor-
mality can play a role. Someone is not in normal
circumstancesif he or she has not eaten for several days. A
person who is suffering in these circumstances does not
necessarily have a malady. We would determinewhether
the person is suffering from a malady by seeing whether
changing the circumstanceswould ratherquickly remove
the suffering. Thus if after eating a meal, a man who had
The Hastings Center
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not eaten for several days were no longer suffering any
significantill effects, then we would regardthe evils suf-
fered as having had as their sustaining cause not the per-
son's state but his circumstances. However, if a meal did
not clear up the problems, then we would regardthe cir-
cumstances as having caused a change in the person, so
that the evils suffered no longer had a distinct sustaining
cause, and we would say that the person had a malady, for
example, malnutrition.
Abnormality and disability. The concept of disability
also depends on abnormalitymore than it might originally
seem. Is the lack of the ability to walk a disability? The
obvious answer seems to be yes. But if that answer is ac-
cepted, then all infants in their first year of life are dis-
abled. In order to avoid this conclusion the concept of
normalitymust be used to distinguishdisabilities from in-
abilities. Infants suffer from an inability to walk rather
than a disability. Similarlythe lack of ability to fly is not a
disability in humans but an inability. Both inabilities and
disabilities involve the lack of abilities, but a lack of abil-
ity is an inability ratherthan a disability if either (1) it is
characteristicof the species or of members of the species
priorto a certainlevel of maturationto lack that ability;for
example, the lack of ability of humans to fly without me-
chanical aid, or the lack of ability of infants to walk;16or
(2) the lack of the ability is due to the lack of some special-
ized training not naturally provided to all or almost all
membersof the species; for example, instructionin tennis
or chess.
The clearestcase of a disabilityis a personwho once had
an ability that is characteristicof the species (such as the
ability to walk) and then lost it because of a disease or
injury. Childrenborn deaf or blind are born disabled and
have not lost an ability that they once had; but a woman
who, throughrigoroustraining,once had the ability to run
a mile in five minutes and then lost that ability by discon-
tinuing trainingwould not therebybe disabled, for having
this ability is not characteristicof the species.
We can also distinguish varying levels of an ability.
Thus a person may have the ability to walk, but only five
or six steps at a time; the ability to speak, but only five or
six words; or the ability to see, but only vague shapes and
colors. Persons with such very limited abilities are usually
thoughtof as sufferingfrom disabilities. But if a man lacks
the ability to walk a mile, is he sufferingfrom a disability?
The existence of some person of the same species with no
special trainingwho can walk a mile is not sufficient rea-
son to say the first person has a disability. For we know
that some people have naturalabilities that far outstripthe
naturalabilities of most of the species, and we would not
want to be forced to the conclusion that most of us are
therefore suffering from a disability.
This question shows the close connection between the
concepts of disability and of normality, or of what is char-
33
 I?L-?ILIII - -- Ld L- - - ill I
acteristic of the species. Though some clear cases of dis-
ability present no problems, such as someone who cannot
walk at all, in many cases it is genuinely a matterof deci-
sion whether or not to call a low level of an ability a dis-
ability. However, there can still be guidelines for making
that decision. We know that in the absence of widespread
environmentallycaused injuryor disease, the fact that the
vast majorityof the members of the species (of the appro-
priategender, if relevant)lack an ability shows that such a
lack is not a disability but an inability. It is somewhat less
clear what percentage of nondiseased, noninjuredmem-
bers of a species must have ever had a specific ability in
orderto make that ability characteristicof the species and
hence the lack of that ability a disability. Notice that the
phrase "have ever had a specific ability" is used rather
than "have a specific ability": we determine whether an
ability is characteristicof the species not by seeing what
percentage now have the ability but by seeing what per-
centage had the ability in their prime.
A simple majority(55 percent) having had the ability to
walk ten miles is not sufficient. An overwhelmingmajor-
ity of nondiseased, noninjured members of the species
must have had that ability for it to be characteristicof the
species. Assuming that the ability to walk is distributed
along a normalcurve, with the ability to walk a yard, two
yards, and so on, up to 100 miles or more representing
points on the curve, then clear disabilities will be present
when there is some discontinuity at the lower end of the
curve, and people below the discontinuity will count as
disabled. If there is no discontinuityobviously there will
be some arbitrarinessin deciding where to draw a line so
that those below the line count as disabled while those
above it are thoughtof as simply having minimal abilities.
Something like this is alreadydone in general intelligence
testing, where 100 denotes averageintelligence;those hav-
ing lesser scores (70-80) are not regardedas mentallydis-
abled (retarded) but merely as having lesser abilities,
while those scoring 69 and underare regardedas mentally
disabled (retarded)in varying degrees.
We conclude that a person is suffering a disability when
he or she lacks an ability that is characteristicof the spe-
cies, or when he or she has an extraordinarilylow degree
of that ability. The distributionof that ability is obtained
by determiningthe presence or absence of that degree of
ability in all persons at any time duringtheir prime, in the
absence of environmentally caused disease or injury.
Given the presence of a distributionof degrees of ability
obtainedin this way, someone is disabled if he or she is at
the extreme lower end of the curve. Note that those lacks
of ability thataredue to not having reachedthe appropriate
state of maturitymust be excluded. However, once one
has reached the state of maturitythere is no furtherrela-
tivizing of the concept of disabilities. It does not matterif
100 percentof living ninety-nine-year-oldpersons lack the
ability to run; their lack of ability is still a disability. But
34
I I I , _ i, L.__ L ' 1 - -
given our decision to count only the extreme low end of
the curve as disabled, aging will not normally result in
disabilities until the sixties or seventies or later. This
seems to us a welcome conclusion, for we do not normally
regardthose in theirforties and fifties, with obviously less-
ened abilities, as being disabled.
Abnormalityand increased risk. We have defined mal-
ady in such a way that a person not only has a malady
when suffering an evil without a distinct sustainingcause,
but also when at increasedrisk of sufferingsome evil with-
out such a cause. Without "increasedrisk" our accountof
malady would fail to include many conditions that almost
everyone regards as maladies, for example, high blood
pressure.
As with disability, one must choose between interpret-
ing "increasedrisk" as increase in risk over the previous
state of the person or over what is characteristicof the
species, even thoughin the clearestcases they go together.
A man who develops high blood pressurehas an increased
risk of suffering an evil in both senses. Similarly, a
woman who has ingested dioxin, which is now stored in
her fat, might not now be suffering any evil but she has
significantly increased the risk of such suffering, because
dieting or continuedphysical exertion may cause the fat to
become metabolizedby the body, thus allowing the poison
to take its toll. The woman's risk is increased both over
what it was prior to ingesting the dioxin and over what is
characteristicof the species. However, if a woman has
been in extraordinarilygood shape due to some training
regimen, including both diet and exercise, and then dis-
continues this regimen, she may come to have a greater
risk of suffering some evil than she did formerly. But
though now at increased risk compared with her former
state, she may not be at any greaterrisk of sufferingan evil
than what is characteristicof the membersof the species in
theirprime. Clearlyshe does not have a malady. Further,a
man may be born with a genetic defect that puts him at
increased risk of suffering some evil comparedwith what
is characteristicof the species, even though quite clearly it
is not increased'overwhat it was for him formerly. Such a
man would be suffering a malady. Thus "increasedrisk,"
as the phrase is used in the definition of malady, must be
understoodas "increasedover that which is characteristic
of members of the species," not as increasedover what it
was formerly. "Increasedrisk," like disability, depends
upon a concept of abnormality. But again abnormality
does not enter directly into the definition of malady, but
only indirectly by determiningwhat counts as a disability
or an increased risk.
Though our definitionof malady makes no explicit men-
tion of the severity of the evil suffered, or of the signifi-
cance of the increased risk, actual usage does take these
matters into account. We do distinguish between major
maladies (for example, terminal cancer, a broken leg, or
The Hastings Center Report, June 1981
?i----ILI
BIIBrsBeP%"e8lerrrt?i IUCI-C
severe migraineheadaches), minormaladies (for example,
a mild case of German measles, a sprainedthumb, or a
mild tension headache) and those conditions in which the
evil is so slight and transitorythat one may prefer not to
regardit as a malady at all (for example, a slight reaction
to a vaccine or a slightly stiff muscle due to a hard work-
out). There are structuraldeviations thatare not associated
with any increased risk of evil at all, and hence are not
maladies, such as the absence of one's appendix.
Similarly, there are at least two kinds of pragmaticcon-
siderationsthat influence where, along the continuum of
increasing risk, the label "malady" should be applied.
First, how severe will this evil be if it does occur?If it will
be slight we tend to require a significantly increased risk
before labeling the condition a malady. However, if it
might be severe, we accept a much lower probability of
occurrence. Second, can we help prevent the evil from'
occurring?If early treatmentwould result in lessened risk
or lessen the severity of the evil if it did occur, we would
be much more likely to label the condition a malady.
Abnormalityand the other evils: loss of pleasure and
loss offreedom or opportunity.The evils (or increasedrisk
thereof) most commonly present in maladies are death,
pain, and disability. However, as we saw earlier, there are
other evils-the loss of pleasureand the loss of freedomor
opportunity.
Although the loss of pleasure (anhedonia)can be a dis-
tinct symptom of schizophrenia (and is distinguishable
from the negative feelings of sadness or anxiety), its pres-
ence is neithernecessary nor sufficient for making the di-
agnosis of schizophrenia. However, were there a human
condition characterizedsolely by the loss of pleasure(per-
haps secondary to some stroke of the limbic system), it
would qualify as a malady according to our definition.
Loss of freedom or opportunityis an evil not uncom-
monly encounteredin life but most frequentlyit is due to a
distinct sustainingcause. A man locked up in jail is suffer-
ing from a loss of freedom, but he does not therebyhave a
malady, for it is clear thathis loss of freedomhas a distinct
sustainingcause. Similarly, a woman threatenedwith vio-
lence unless she refrainsfrom an action is not regardedas
having a malady, for her loss of freedom has a distinct
sustainingcause-the threatof violence by another.How-
ever, there are interestingcases where the threatof harmis
due not to the actions of another, but to something about
oneself. There is no question, for instance, that when one
is suffering from an allergic reaction, one has a malady.
But what aboutthose times when one is not exposed to the
allergen?There may still be an increased risk of suffering
an evil because of the allergy. But if it is relatively easy to
avoid the allergen, it does not seem accurate to say that
one is really at increased risk. However, no matter how
easy it is to avoid eating fish or fava beans, one still lacks
the freedom to eat these items.
The Hastings Center
-- -CIIII-?U--??-Q----???_-2* I -r I IIC-?IC- ?I IPIP
The man who moves to Arizona to be free of allergic
reactions has avoided the pain and discomfort usually
associated with his allergy, but he still suffers from a loss
of freedom or opportunityto live in certain parts of the
country and thereforehas a malady.17Even if he has no
desire to leave Arizona so that he is not bothered by his
loss of freedom, he still has lost that freedom, just as a
prisonerwith a life sentence who wants to stay in jail has
still lost his freedom.
Both abnormalityand the loss of freedom and opportu-
nity play an importantrole in the case of serious disfigure-
ment. Though serious disfigurementalmost always causes
psychological suffering, anxiety, and/or depression, we
wish to regardsomeone sufferingfrom such disfigurement
as having a malady even in those very rare cases when he
or she is not suffering psychologically. Serious disfigure-
ment is a malady because in a normal environmentone is
deprivedof some freedom or opportunity,even though in
a special environmentone may feel no actual loss. Note
that simply by labeling the condition as serious disfigure-
ment we are making a judgment that the person's ap-
pearance is significantly outside some norm. Since we
count somethingas a serious disfigurementonly if it would
cause, at least initially, an unfavorablereaction in others,
we regard serious disfigurementas a malady because it
either causes the loss of freedom and opportunity,or in-
creases the risk of such a loss. Thus in this case we are
regardingthe reactions of others as normal and hence we
are not regardingtheir reaction as the key element in the
loss of freedom or opportunity;ratherthe key element is
the serious disfigurementof the person and hence it is the
cause of the loss of freedom or opportunity.
We realize that if serious disfigurementis regardedas a
malady and if there is no way to avoid at least some
cultural differences in what is considered seriously dis-
figuring, maladies will sometimes differ in different cul-
tures. But even in the case of disfigurement, cultural
relativity will only be importantin the marginal or bor-
derline cases of maladies, not in the centralor core exam-
ples. We do not think it culture-boundto hold that there is
often still somethingwrong with severe burnvictims, even
if they have recovered all their abilities and are no longer
in pain. We regardtreatmentof their serious disfigurement
as treatmentof a malady.
Another kind of difficult case is that of someone who
formerlysuffereda chronicmalady which is now perfectly
controlledby availabletherapyso that he is no longer suf-
fering or at increased risk of suffering an evil. For exam-
ple, consider a man with hypothyroidism. If it were
possible to implant a lifetime supply of completely safe
and effective replacementhormone, should we count him
as having a malady? So far, we have few medications or
artificialorgansor health aids that completely eliminateall
evils and any increasedrisk. Thus at presentalmost every-
one who depends upon continuing implanted medication
35
PPc?-wursalssrsl- ,-- -_-----c F --BBY--------sPC--- -- --?-
or artificialimplants will have a malady according to our
definition.However as technology improves, the situation
we are now only imagining may become common. Do we
want to say that such persons, whose evils and increased
risk thereofhave been eliminatedby continuingtreatment,
do not have maladies? On our account, if the artificialaid
were in the body we would say they have no malady.*
However, if they were dependenton external medication
we would say they still have a malady since this external
source limits their freedom.
Advantages of the Definition
What are the conceptual advantages of our account of
malady? One advantage is the introductionof a general
word-malady-which refersto the genus of which all the
related conditions (such as disease, illness, dysfunction,
handicap,injury, sickness) are species. The term malady,
though more general than the commonly used terms, is
neverthelessexplicit, precise, and usable.
A person has a malady if and only if he or she has a
condition, other than a rational belief or desire, such that
he or she is suffering, or at increased risk of suffering, an
evil (death, pain, disability, loss of freedom or opportu-
nity, or loss of pleasure) in the absence of a distinct sus-
taining cause.
The conceptof maladycan be universaland objectiveand
at the same time have values as an integralpart, namely,
those values that are universal.Thus our explicationshows
the inadequacyof the currentfashion of regardingdisease
as being heavily determinedby subjective, cultural, and
ideological factors.18We have also tried to show the logic
of culturalinfluencesin those few instances where they do
occur.
One possible ambiguity about our claim to universality
and objectivity should be clarified. Some might claim that
diseases are simply humaninventionsor humanconstructs,
that "disease"is the way humansconstruesome of nature's
processesthatthey do not like. Naturein itself, independent
of human interests, has no diseases, they would say. For
them "objective"and "universal"would seem to mean "in
the natureof reality," or "trueof the world apartfrom the
humanmind." Now, what the world is like apartfrom the
existence of humansand from a human'sknowing of it, we
would not ventureto say. But a second and more important
sense of something'sbeing objective is that there is agree-
*Metalplates surgically implantedto cover bony defects in the skull do seem
to constitutethe eliminationof a malady. Suppose a pacemakerwere developed
that resultedin no increasedrisk. Then a defective pacemakerwould be partof a
malady if its malfunctioning were directly causing evils or increased risk of
evils. Though this may seem at first counter-intuitive,we suspect it is because
the use of synthetic or man-made materials integratedinto the human body is
relativelynovel, and our languagehas not yet adjusted. It is an advantageof our
concept of malady that it will cover the malfunctioning, breaking, decomposi-
tion, or clogging of pacemakers, artificial hips, synthetic materials, or trans-
species arteries.
36
--?I;,- IC-O?nP\RIP
?s --------- -----s _ _ F-B-??? -l?qse?-18ls
ment aboutit by all rationalpersons. Colors are not objec-
tive in the first sense but they are in the second. It is in this
second sense that the evils are objective and universal.Just
as all rationalpersons agree on the color of most objects,
they also agree that certainthings are to be avoided unless
one has a reason not to. Both mattersare universaland ob-
jective, not based on personalor subjective influencesbut
on featurescommon to all rationalpersons.
The concept of a distinct sustaining cause allows us to
limit what counts as a malady to what seems intuitively
accurate:namely, to those conditionsof the personthat are
not dependentupon a continuingenvironmentalstate. Addi-
tionally, incorporatingthe notion of "increasedrisk" in our
accountof a maladyallows us to include as maladies such
conditionsas high blood pressure.
Ourexplicationis also meantto clarify the role of abnor-
mality. Abnormalityis often taken as centralto the concept
of maladybut it actuallyplays a less direct role, that is, it
helps us decide what counts as a disability, an increased
risk, or a distinctsustainingcause. Therehas been a general
tendencyin the medical-scientificworld to establisha nor-
mal range for this or that (some element of the human
body), and ipso facto to have "discovered"two new mal-
adies-hyper-this or that and hypo-this or that.19Our ac-
countmakesit clearthatthis use of abnormalityrepresentsa
misunderstandingof the concept of malady.
Our accountof malady is based on elucidatingthe com-
mon elements in such conditionsas disease, and so on, ill-
ness, injury, and so on. Using pain, death, and disability,
along with the absenceof a distinctsustainingcause as nec-
essary featuresof any malady, considerablylessens the in-
fluence of ideologies, politics, and self-serving goals in
manipulatingmalady labels. We do not mean to suggest
that our concept of a maladyis without vagueness. Indeed
we have discussed some of the difficultcases. But now we
know more precisely where those gray areasare, why they
exist, and what variableswould have to be decided to re-
solve the question in particularcases.
A more subtle benefitof this new technicalsense of mal-
ady is that it is the first explicit term in any language with
the appropriatelyhigh level of generality.No languagethat
we have investigated(English, French, German, Russian,
Chinese, or Hebrew) contains a clearly recognized genus
term of which disease and injury are species terms. Each
term in the usual clusterof malady terms has specific con-
notations that guide and significantly narrow its use. Of
course, thatis as it shouldbe if specificityis whatis desired
and justified. Disease, injury, illness, dysfunction, and
other such terms overlap somewhat, yet each has its own
distinct connotations.
A final advantageof our explication is that its basic ele-
ments, concepts, principles, and argumentsare the same
when appliedto mentalmaladiesas to physical ones. Pain,
disability,and the absence of distinct sustainingcauses are
applicableto the psychological domain as well as to the
The Hastings Center Report, June 1981
-- -?LI1 lls
physical. We expect that our analysis will help draw critical
distinctions in the realm of "mental illness" labeling, but
this must remain a promissory note to be redeemed later.
REFERENCES
Preparationof this paperwas aided by NEH grant21041-75-79 (Prof.
Clouser) and NEH NSF grant OSS-8018088, sustained development
award (Prof. Gert).
'ThomasM. Peery and FrankN. Miller, Pathology. 2nd ed. (Boston:
Little, Brown, 1971).
2A numberof philosophers have distinguished illness from disease,
but we do not think this distinctionis relevantto the point that concerns
us here. See, however, ChristopherBoorse, "On the Distinction Be-
tween Disease and Illness," Philosophy and Public Affairs 5 (1975)
49-68; H. TristramEngelhardt,Jr., "Ideology and Etiology," Journal
of Medicine and Philosophy 1 (1976), 256-68; and Joseph Margolis,
"The Concept of Disease," Journal of Medicine and Philosophy 1
(1976), 238-55.
3Peery and Miller, p. 1.
4PeterJ. Talso and AlexanderP. Remenchik, Internal Medicine (St.
Louis: C.V. Mosby, 1968).
sWilliam A. White, The Meaning of Disease (Baltimore: William
and Wilkins, 1926).
6George L. Engel, Psychological Development in Health and Dis-
ease. (Philadelphia:Saunders, 1962).
7J.G. Scadding, "Principles of Definition in Medicine with Special
Reference to Chronic Bronchitis and Emphysema," Lancet 1 (1959)
323-25; "Meaning of Diagnostic Terms in BronchopulmonaryDis-
Hastings Center Summer Workshops
The Hastings Center is sponsoring two summer
workshops-one on applied and professional ethics
(July 5-11, at Colorado College, Colorado Springs),
and another on institutional review boards and
human subjects research (July 12-18, also at Colo-
rado College). In addition, it is cosponsoring, with
the Center for Philosophy and Public Policy at the
University of Maryland, a workshop on ethics and
public policy (June 21-27, at Bowdoin College,
Brunswick, Maine).
The workshop on applied and professional ethics
is open to anyone with a serious interest in the
subject. The workshop will be organized to provide
for discussions of some common, selected prob-
lems. There will be special seminars in particular
professions-law, business, nursing/allied health,
journalism, military, social work, and pre-profes-
sional-for participants in these fields to spend time
working together.
The workshop on institutional review boards and
human subjects research is intended for IRB mem-
bers, research administrators, lawyers, and all oth-
ers interested in the ethical and regulatory problems
of research involving human subjects. The program
will include lectures, panel discussions, and small-
group discussions on a range of topics including the
ethical concepts of rights of persons, beneficence,
The Hastings Center
?- u -- I---?l?uls -- sr - I? I------?I--- --`."I-98p
ease," British Medical Journal 2 (1963), 1425-30; "Diagnosis: the
Clinician and the Computer,"Lancet 2 (1967), 877-82.
8Scadding, "Diagnosis," p. 877.
9R.E. Kendell, "The Concept of Disease and its Implications for
Psychiatry,"British Journal of Psychiatry 127 (1975), 305-15.
I?RobertL. Spitzer and Jean Endicott, "Medical and Mental Dis-
order:ProposedDefinitionand Criteria,"in RobertL. Spitzerand Don-
ald F. Klein (eds.), Critical Issues in Psychiatric Diagnosis (New
York: Raven, 1978), pp. 15-39.
1Donald W. Goodwin and Samuel B. Guze, Psychiatric Diagnosis.
2nd ed. (New York: Oxford University Press, 1979).
'2Lester S. King, "What is Disease?" Philosophy of Science 21
(1954), 193-203.
'3See BernardGert, The Moral Rules. 2nd ed. (New York:Harper&
Row, 1975), Chapter2 for a fuller discussion of reasons and rational
action.
14For a fuller account of evils, see chapter 3 of Gert.
'SThuswe disagree significantlywith Boorse who makes abnormality
the central feature of disease. See ChristopherBoorse, "Health as a
TheoreticalConcept," Philosophy of Science 44 (1977), 542-73.
16There are also sexual differences which are characteristicof the
species, so that it is an inabilitythat men cannot bear children. See also
Boorse, "Health as a TheoreticalConcept."
'7Thuswe disagree with Spitzer and Endicott who explicitly regard
such a person as not having a medical disorder (malady).
'8Cf. Peter Sedgwick, "Illness -Mental or Otherwise," Hastings
Center Studies 1 (1973), 19-40.
'9Edmond A. Murphy, The Logic of Medicine (Baltimore: Johns
Hopkins University Press, 1976); Alan Bailey, David Robinson, and
A.M. Dawson, "Does Gilbert's Disease Exist?" Lancet 1 (1977),
931-33.
and distributive justice; and practical problems in
IRB review of protocols (informed consent, protec-
tion of confidentiality, selection of subjects, deter-
mining risk/benefit, protecting special populations,
complying with federal regulations and monitoring.
For more information on these two workshops,
contact Workshops, The Hastings Center, 360
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The workshop on ethics and public policy is
intended for teachers, scholars, and practitioners.
Participants will discuss three issues where norma-
tive concerns and public policy join; the nature of
applied ethics; and the position of public policy
within a theoretical political framework. The first
half of the week will focus on two topics of domes-
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37