Abstract
Neil Messer declares his aim at the outset of this ambitious book: This book has the modest aim of answering a simple-seeming question and indicating what some of the practical consequences of the answer might be. The question is: From the perspective of a Christian theological tradition, what should we understand by “health,” “disease,” “illness,” and related terms (p. xi).
But of course he already knows (and soon ably demonstrates that he knows) that there is an extensive and inconclusive philosophical and sociological literature attempting to define such terms as health, disease and illness. This literature is inevitably inconclusive because at the outset there is no agreement about whether to take a broad, inclusive, functional approach to such definitions or a narrow, exclusive, substantive approach. As a result philosophers can never reach a consensus on what ‘philosophy’ is nor can sociologists reach a consensus on what ‘religion’ is. Neither can theologians reach a consensus on what ‘theology’ is. So what hope is there that any of us will ever agree on any definition of ‘health’, ‘disease’ or ‘illness’? So we know at the outset that Messer is bound to fail. Yet he does so graciously and thoughtfully.
His first chapter, occupying a quarter of the book, examines carefully various definitions, starting with the well-known 1948 World Health Organization’s claim that health is ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’. As many others have argued he concludes that this is hardly a definition at all. It substitutes the undefined ‘well-being’ for ‘health’ and sets an unattainable target by adding ‘complete’. He contrasts this overly broad concept of health with the seemingly value-free and narrower, albeit influential, attempt of Christopher Boorse to define health and disease in terms of statistical normality. Yet he finds this too narrow and at odds with Boorse’s own evaluative language. Accounts and critiques of Nordenfelt, Fulford, Toombs, Law, Widdows, Wakefield and others follow. Overall this chapter is a useful guide to the literature.
In the second chapter Messer focuses specifically upon the important area of disability and particularly upon the tensions between social and medical understandings of disability. Medical understandings might focus, say, upon cochlea implants for the congenitally deaf or electric wheelchairs for those with cerebral palsy, whereas social understandings tend instead to challenge society at large to accept those who are deaf or living with cerebral palsy as they are, to treat signing as a distinctive language and to remove mobility impediments from public buildings. Again he offers a detailed and useful account and critique of differing exponents such as Mike Oliver and Tom Shakespeare, albeit without fully endorsing any of them. Instead he ends this chapter with a series of questions: ‘Are we too ready to attribute any lack of flourishing to individual and medical, rather than social, political, or economic, causes?’; ‘Do we tend to misrepresent bodily diversity as pathology?’; ‘[W]ho has the authority to determine whether a condition should be considered a disorder or an expression of diversity?’ (p. 99).
In the second half of the book, chapters 3 and 4, Messer turns specifically to his theological task, offering a careful analysis of theological accounts of health and illness. The first of these chapters is the longest in the book, offering a critical account of a number of recent theological explorations of ‘health’ and ‘wholeness’, a largely uncritical analysis of Karl Barth’s ethics of creation and a sympathetic but more critical account of teleology in Aquinas. He is not persuaded by the distinction between ‘healing’ and ‘curing’ defended by John Pilch and others, regarding this as anachronistic when applied to New Testament healing stories. Perhaps he misses Pilch’s point that this distinction helps us (or at least some of ‘us’) to appropriate these stories in a twenty-first-century context of evidence-based medicine (a context that presumably even a critic such as Stanley Hauerwas shares in his private life). Not all of the theological strands here come together, as Messer acknowledges (p. 161), but this chapter does provide a platform for the theological definition of disease and health provided in the fourth chapter.
Messer is commendably humble at this crucial point and offers only a tentative definition of ‘disease’: ‘An internal state, condition, or process, which tends to disrupt a physical or mental function such that the fulfilment of a proximate end of embodied creaturely human life is hindered or threatened’ (p. 184).
For ‘health’ he simply adopts Barth’s definition as ‘the strength for human life’. Rather than arguing with Barth it might be more profitable for me to focus upon Messer. What does his theological definition of ‘disease’ add to or correct in secular definitions? And what are its own limitations?
Addressing the first question, the term ‘fulfilment’ adds a teleological element that he finds missing in many (but not all) secular definitions, but it is qualified very properly with the theological caveats that this fulfilment is only ‘of a proximate end’ and that this is ‘of embodied creaturely human life’. Sub specie aeternitatis how could this be otherwise? So ‘disease’ is what disrupts this embodied and proximate fulfilment and, by implication, ‘health’ is what enables embodied and proximate fulfilment. Or, more accurately, but more confusingly, ‘disease’ is an internal state, condition or process, which tends to disrupt a physical or mental function such that the fulfilment of a proximate end of embodied creaturely human life is hindered or threatened. The added italics here bring out the tentativeness of this definition and perhaps some of its vagueness.
This leads to my second question. What are the limitations of this definition? It is not simply vagueness that bedevils it but rather the sort of over-inclusiveness that he criticises in the 1948 World Health Organization’s definition. For example, there are doubtless many physical and mental functions of our lives—such as ageing, irritability, inconsiderateness, innumeracy—that may hinder proximate and embodied fulfilment, but we do not usually regard them as ‘diseases’. Nor, despite his extended discussion of disability, is it clear how his definition clarifies the ongoing dilemmas in that area.
Messer I am sure would be the first to acknowledge these limitations. He disarmingly depicts his definition as ‘rough-and-ready’ (p. 184) and acknowledges that it does not ‘enable us to separate out diseases from non-diseases unambiguously’ (p. 185). Of course if it cannot do the latter it cannot really be a definition of ‘disease’.
Taken as a whole this is a book to ponder and enjoy. As ever Neil Messer is thoughtful and well-read.