Four interpretations of the World Health Organization’s definition of health
Wojciech Czabanowski1
1 Faculty of Philosophy, Jagiellonian University, Krakow, Poland.
Corresponding author: Wojciech Czabanowski, PhD fellow in philosophy, MA in philosophy, law student;
Telephone: +48516 244354; Email: czabanowski.wojciech@gmail.com
Abstract
The article focuses on the definition of health according to the World Health Organization. Since the definition is made of vague and general notions, four interpretations clarifying its meaning are presented. The question provides logical space within which there may be granted four most general answers: i) everyone decides; ii) only some decide; iii) only some people do not decide; iv) nobody decides. Each of the four interpretations is based on presumed concepts of equality and harm which have their political consequences for healthcare systems.
Keywords: definition of health, healthcare systems, World Health Organization.
The World Health Organization’s definition of health and its problems
The contemporary definition of health proposed by the World Health Organization [WHO] (1) is derived from the rejection of the privative concept of health understood as absence of disease. Such an approach to the problem – however appropriate substantially, politically and ethically – poses a number of conceptual problems. Privative definition of health allows one to easily distinguish between the states referred to as health and those defined as a disease. Diseases have, after all, their symptoms, which – if observed – prejudge that a person is certainly not healthy. The modern definition of health is constructed differently. It is built with general concepts, which do not allow an easy way to unambiguously determine which human conditions that we encounter could be undoubtedly classified as health and which could not. It is because one cannot uncontroversially determine the limits within which there is welfare.
The problem I am talking about, however, is not irremovable. The WHO definition of health, as I said in my previous article (2), is a formal definition (3), defining only the framework within which you want to see a specific content. If the definition does not determine by what procedure this content is to be selected, there is a certain degree of freedom of interpretation. In the case of the definition of health the difficulty relates to specify the very imprecise concept of the “physical, mental and social well-being”.
Following the teleological interpretation, we can assume that the generality and vagueness of the concept of welfare was intended by the author to avoid prejudging its material content. The concept devoid of material content cannot be used effectively, because it does not allow to distinguish objects (in the case of health: states) that meet the definition from those that do not comply with the definition. Although, however – according to the teleological interpretation – interpreting this concept one should not prejudge its material content, it does not mean that we cannot make the definition practically useful, using a subjective criterion. One should therefore not ask under what circumstances there is welfare – that is, in order to ask about the objective conditions, but ask about who decides when it occurs.
Four interpretations
The question gives us the logical space within which there may be granted four most general answers: i) everyone decides; ii) only some decide; iii) only some people do not decide; iv) nobody decides. Each of these answers is briefly outlined below.
i) Everyone decides
According to such an interpretation of the definition of health, each and every one of us is the best person to determine whether he/she is healthy or not. In its most basic form, such a view is based on the belief that everybody knows best what is good for him/her, but at the same time – if it happens after the time that his diagnosis was false or simply he/she changed their mind – he/she is to blame and bears responsibility. In extreme forms this interpretation can fulfil the postmodern intuition that the disease is only a derivative of one’s beliefs (4). This point of view can be called the liberal interpretation.
ii) Only some decide
This interpretation implies that there are some individuals or bodies which, by virtue of their properties or knowledge are better prepared to determine when we deal with the physical, mental and social well-being, and when not. In various embodiments of this interpretation such groups can be doctors, the relevant state authorities or international organizations (e.g. WHO). According to this position, a citizen is not able to independently decide what is healthy for him and what is not, because he/she simply does not have sufficient competence. The citizen is thus in need of help from specialists. This interpretation can be called the strong paternalistic interpretation.
iii) Some people do not decide
This interpretation is a compromise between the two previous ones. It assumes that, in principle, all citizens are able to correctly identify the state of well-being, but there are some vulnerable groups who for compelling reasons lack such capabilities. These may be addicts, children, incapacitated persons or persons with mental disorders. This interpretation can be called the weak paternalistic interpretation.
iv) Nobody decides
Although logically possible, the fourth interpretation of the definition is de facto a denial of the modern definition of health and a return to the privative definition. Since no one is able to determine when discussed welfare occurs, it means that we are able to speak only of diseases. Health, therefore, can be reasonably understood as merely the absence of disease. This interpretation can be described as sceptical.
Two concepts of equality
Of course, none of the four described above interpretations is truer than the other, the choice between them is of political nature and every political choice has an underlying axiological conviction. In this case it is an ethical conviction which specifically relates to the understanding of harm and equality.
It should be noted that both paternalistic interpretations are alike, just as similar to each other are the two remaining ones. In fact, what makes them different at first glance is the attitude towards equality. In the case of the liberal and sceptical interpretations we deal with the concept of formal equality.
Formal equality is equality which in no way promotes or discriminates any subjects, regardless of their individual conditioning. The legal situation of each individual is the same in every way. The examples of formal equality in other areas of law may be: the universal right to vote or the right to purchase alcoholic beverages for all above a certain age.
Material equality, the one behind the paternalistic interpretations, is equality which implies that there are significant differences between individuals, causing that leaving them with just formal equality would lead to actual inequality, favouring certain individuals, and working to the disadvantage of others. This situation calls for affirmative actions towards certain underprivileged groups or introduction of restrictions for those who are too privileged. Examples of material equality in other areas of law can be such as maternity leave or scholarships for students from poor families.
Both concepts of equality are also associated with different ways of understanding harm. Proponents of material equality argue that it is necessary to have sufficient knowledge that can come only from the outside to be able to properly assess what is good for us. Hence, on the basis of the concept of material equality one can use the concept of false consciousness. False consciousness is a condition in which the subject internalizes ideologies favourable to other subjects, losing sight of their own objective interests (5). An example of false consciousness in health, among others, is the patient’s belief that cigarettes are harmless and sexy. While smoking or – even better – buying a tobacco product, a patient fulfils the economic interests of major corporations, unaware of the objective loss for his/her own health. Therefore, taking the model of material equality, it is particularly important for the health care professionals to educate patients, and help them overcome false consciousness. Harm within the framework of this concept is thus a condition in which – regardless of their own belief – one bears an objective damage, injury or loss.
On the other hand, proponents of formal equality argue that there is no such thing as an objective harm or even if it exists, the only person who can properly recognize it is the one concerned. The consequence of this approach is the conclusion that if the patient does not perceive their condition as problematic, not only nobody has the right to interfere with his/her condition, but their condition should not be considered problematic in the first place. Such a view may be derived from at least two traditions. Firstly, it can be derived from the liberal tradition, which emphasizes freedom of the individual and individual responsibility for own actions. The second may be derived from the postmodern tradition. Arguments within the postmodern tradition will proceed differently: what basis does anyone have to say that they have better knowledge than others and legitimacy to take action on that basis, while in terms of my small narrative – which I have the right to believe in – the condition is evaluated differently (6)? Harm within the framework of this concept is thus a condition in which another entity imposes on us some action or belief against our will.
Implications for health systems
As I said, the choice of an appropriate interpretation of the definition of health is of political nature. It is political, not only in its substance but also in its consequences. It seems that in countries with universal public health care system, the only rational choice would be one of the paternalistic interpretations. It allows you to conduct a rational prevention policy, because the State decides what health is and has the right to run campaigns aimed at promoting it, which also limits any subsequent treatment expenses.
Strong paternalistic interpretation, however, may raise serious objections. To implement this policy consistently, the state would not only have to prohibit smoking, but also, for example forbid eating unhealthy foods or drinking beverages containing too much sugar. It is difficult to expect that such actions will meet the approval of the society – perhaps misled by its false consciousness. Probably, it is easier to settle for the weak paternalistic interpretation.
Countries that have chosen not to introduce a public universal national healthcare system are likely to implicitly agree with one of the two remaining interpretations.
Of course, such a link, although convenient, is not necessary. There are examples of institutions making other choices. The Theptarin hospital for diabetics in Bangkok (7) works as an excellent example. The hospital, while being a private company, performs extensive preventive actions and raises awareness not only among its own patients, but also the local population. Such actions show that you can – while remaining a private institution – choose to be guided by the paternalistic interpretation of the definition of health.
Paternalism and orthobiosis
In my previous article in the Albanian Medical Journal I devoted a large part of the work to the concept of orthobiosis, the doctrine of a healthy life. In the light of the foregoing, it is clear that the fulfilment of the health-conscious society can only be achieved with the strong paternalistic interpretation of the definition of health. This interpretation may raise objections among liberals, but it should be noted that health and life are values much more fundamental than economic interests – which is both the subject of reflection and dispute among Marxist and liberal theorists. Life and Health, which is a prerequisite for any other human activity, should not be a political fair.
Conflicts of interest
None declared.
References
1. World Health Organization. “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Constitution of the World Health Organization – Basic Documents, Forty-fifth edition, Supplement, October 2006.
2. Czabanowski W. Civic health consciousness in the information society. Albanian Medical Journal 2013;4:89-92.
3. Kant I. Groundwork for the metaphysics of morals, tr. Thomas Kingsmill Abbott. Peterborough, Ont.; Orchard Park, NY: Broadview Press, 2005.
4. Baudrillard J. Simulacra and Simulation, Ann Arbor: The University of Michigan Press, 1994.
5. Engels F. Letter to Mehring, 1893.
6. Lyotard JF. The Postmodern Condition: A Report on Knowledge, tr. Geoffrey Bennington and Brian Massumi. Minneapolis: University of Minnesota Press, 1984
7. Theptarin Hospital & Foundation for the Development of Diabetes Care. Available at: http://www.theptarin.com/en/theptarins-story/ (accessed: February 02, 2014).