Normal functioning: political not metaphysical (1) The general idea.

We begin this inquiry by assuming that Daniels fails to adequately justify the choice of Boorse’s BST definition of normal functioning as a constraint for society’s obligation to meet the health needs of its citizens. We assume that politically reasonable people may reject the idea that BST delivers a value-free definition of normal functioning. If so, its employment in the context of political theory requires a different justification from the one Daniels provides.

We claim that, however, there can be a notion of normal functioning which can be used for practial polical purposes (e.g. in defining justice-related obligations to meet health needs). This notion must be understood as a political, value-laden notion.

We want apply Rawls’s constructivist approach to the notion of normal human functioning. From the values and ideas embedded in the culture of liberal political and medical institutions we derive,  through a procedure of construction embedding reasonable constraints of equity, a concept of human functioning that, if our conjecture is valid, can form the basis for an overlapping consensus of all reasonable theories/definitions/analyses of health and disease. (A theory of health and disease is reasonable (def) iff it presupposes, at most, the shared political values and ideas of (Rawls’s) political liberalism).

The core notion for the construction is Boorse’s Bio-statistical Theory (BST) of health as human functioning. We choose BST as our starting point. From the formal point of view, the BST provides a type of concept – a normal functioning concept – which, in one form or another, is often implicit in the ideas of health and disease used both in our political culture and in the medical tradition.

We deny that the details of the BST concept of health (the way it defines functions and reference classes, for instance) are the focus of general agreement. But we claim that something like the general form of the normal-functioning concept of the BST must be preserved by any reasonable analysis of health.

The choice of a normal functioning notion is also dictated by the needs of Rawlsian political theory, as Justice as Fairness can be extended to cover health needs only by supplementing it with a concept of normal functioning.

The BST definition of disease involves the following elements:

1. an account of the functional organization of a living being, understood as a hierarchical organization of functions under certain overarching goals (in the BST, survival and reproduction)

2. an account of reference classes, viz. “natural classes of organisms of uniform functional design” (in BST, age group and sex, possibly race)

3. the normal function of a part or process, defined as its statistically normal contribution to the goals of which in (1) within members of a reference class (of which in 2)

4. disease, defined as the reduction of one or more functional abilities below typical efficiency.

5. typical efficiency, defined as “efficiency above some arbitrarily chosen minimun in its species distribution” (p.6 Boorse, Christopher. “A Rebuttal on Health.” BIOMEDICAL ETHICS REVIEWS (1997): 1-134).

We claim that the definition of theoretical parameters of at least 1, 2, and 5 (and derivatively 3 and 4) is value laden. More specifically:

1) the choice of overarching goals if value laden

2) the choice of reference classes is value laden

5) the choice of the cutoff point for typical efficiency is value-laden (as Boorse himself writes, it is an arbitrarily chosen minimum in species distribution)

We arrive at a political definition of normal functioning by revising the BST in the light of the shared political and medical values of liberal democracies. More precisely, we undertake to provide a normative justification of parameters 1, 2 and 5.


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