What is health?
Antonio Pardo.
department de Humanities Biomedicas, University of Navarra.
Article published in Revista de Medicina de la Universidad de Navarra, 1997;41(2):4-9.
Although there has been much discussion in the medical literature about what health is, there is no agreement on the subject. However, the question is not a trivial one: if health care is to pursue health, it is essential to be clear about what health is. Only a correct version of its nature can result in good medical practice. This necessarily brief paper aims to show the basic coordinates that must be kept in mind when conceiving what health is, and will leave aside, for reasons of length, many other interesting questions, such as the background and historical evolution of the concept of health, its relation to the mentality of each era, etc.
Definition of health
The classics had no particular difficulty in reaching a clear idea of what health was. They spoke Latin, and the word salus alone gave them an idea of its meaning. We must go back to the etymology to reach what was obvious to them. Salus and salvatio, very much the same in Latin (consider that the U and the V, whose sounds and spelling we now distinguish, were one letter for the classics), mean "to be in a position to overcome an obstacle". From these Latin words we derive their Spanish equivalents: salud and salvación1. The term Spanish "salvarse" includes the original meaning of "to overcome a difficulty", and applies both to natural difficulties (salvation from a fire, for example) and to supernatural ones (salvation from the dangers that the present life poses to the life of the soul). However, the term health is not currently understood as being linked to this meaning of "overcoming a difficulty". Hence the great variety of definitions, sometimes deeply discordant, sometimes more or less from agreement on some points, and almost always eclectic, which limit themselves to grouping together the most fashionable opinions on the question.
If we recover for the term "health" the original and genuine meaning of "overcoming a difficulty", we obtain a fully-fledged definition: health is the habit or bodily state that allows us to continue living2 , that is, that allows us to overcome the obstacles that living finds in its path. Because, in fact, living is not simply "being", as a stone is. Living implies an internal activity of the living being that manages to maintain a certain independence and differentiation from its external environment: the maintenance of homeostasis, characteristic of living beings, is an active process that is carried out against the difficulties that the environment presents3. Only a healthy organism is in a position to overcome these difficulties; the sick organism encounters problems in the environment that are difficult to overcome, which can lead to failure in the maintenance of its own individuality, that is, to death, after which the organism becomes progressively confused with the environment: its temperatures equalise, its proteins decompose, its various organic compartments and their contents dissolve and homogenise with the external environment, etc.
But maintaining individual identity is not the only way of living goal : in a way, identity is also maintained when the animal reproduces. By reproducing, it manages to keep alive, in another individual of the same species, what it will not achieve in itself: to live always with the life of its own species. For this reason, the possibility of reproduction must be considered to be included in the definition of "continuing to live". An animal that can live but cannot reproduce is not healthy.
Finally, it must be considered that there are alterations in the normal functioning of the animal organism which, without completely preventing it from living or reproducing, cause discomfort or difficulties for the normal activity of the animal development . Minor illnesses or injuries, which are not life-threatening, can be considered as diseases, because the discomfort they cause hinders the normal activity of the animal's life. In other words: health includes a certain Degree of physical well-being, and of pleasure in the activity that is necessary for living (psychological well-being); however, health is not well-being. Rather, well-being is, to a certain extent, a part of health, i.e. it is one of the necessary means to be able to continue living.
The case of the man
Human life is not reduced to the merely biological aspects we have been referring to. Biological life, together with its psychological aspects, is in man imbued with intelligence and free decisions: with spirituality, in a word. Human living is not exclusively biological, but a complex reality: biological, psychological and spiritual. Therefore, to continue to live, in the case of man, is not only to be able to maintain biological life, to be able to reproduce, and a certain Degree of well-being sufficient for these purposes. It is, equally or even more importantly, to be able to act with his intelligence and will, carrying out activities that animals cannot do: work, study, etc.
Thus, the definition of health given above, which is valid for animals, must be reinterpreted for humans. Basically, a person can be said to be healthy when he or she is able to carry out normal human activities: going to work, taking care of the home or children, reading, etc.
In man, however, being healthy is not a mere juxtaposition of animal and more typically human health considerations. Properly human activities cannot be carried out without adequate physical and psychological functioning. For this reason, what we might call purely animal health is at the service of higher activities: it is an instrumental good for spiritual activity. Thus, the paradoxical situation can arise where, examined from the purely animal point of view, there is no health, and yet, considered from the human point of view, it can be said that there is health.
It is common to find dialogues that reflect this apparent paradox. When asked a polite question about their state of health, a person often replies: "I'm fine; well, with the aches and pains that come with age, but I'm fine". This recognises that, although there are minor aches and pains, they are not enough to prevent development from carrying out normal activities. Thus, a person who lacks the ability to reproduce, or who has some slight physical or psychological alterations (such as a slight instability of the ankle joint or a slight transient anxiety) can, on many occasions, carry out their life normally. Depending on the activity performed, these disturbances, which would be disease in the animal, may or may not constitute disease in that person.
The realisation of this reality has led many authors to conclude that health is something subjective, which depends solely on the individual's assessment. As we will comment below, this conclusion is erroneous: the state of health does not depend on how the subject feels, but on the way he or she lives. And this way of life can and must be known to the doctor, who is thus in a position to make an objective assessment of the patient's state of health. However, this objective assessment is not the same as finding no lesions in the patient's physical examination or no alterations in the psychological diagnostic tests. The objective assessment of the patient's state of health depends on an appreciation of the problems that the injury(s) may pose to the patient's daily life. In other words, the judgement of a person's state of health depends on an understanding of his or her personal way of life.
Some implications for the practice of medicine
The above basic ideas have very direct consequences on the practical way of practising medicine: in determining the end to be pursued, the technical means to be employed (the performance of medical interventions) must be in accordance with the end pursued. Nowadays, we often observe ways of practising the profession that reveal an erroneous concept of health. We will refer to only three particularly frequent deformations: the obsession with well-being, extreme autonomism and egalitarianism.
The search for well-being
The WHO, in its definition of health, established that health is a state of perfect physical, mental and social well-being, and not only the absence of injury or disease. In this definition, two of the aforementioned elements appear: physical integrity and well-being (although with some modifications that prevent their perfect equivalence with the meaning of these factors in the classic definition). However, what is most striking is that any reference to the person's way of life is completely absent. It considers only the absence of injury and well-being, that the patient feels well.
As a consequence, the most important problem with this definition is its restriction to the purely animal or hedonic aspects of human life. Health care, if this WHO idea is followed, would have an object similar to that of veterinary medicine: to fix physical injuries (in a very mechanistic way, like car repairs are done in the garage), and to make the patient feel at ease. In the latter goal, doctors with a little common sense include, as if in a drawer, all the other aspects of human life (something similar to what happens with the expression "quality of life"); the use of the term well-being thus becomes dangerously misleading; from this lack of terminological precision, I think, follows much of the confusion that prevails in scientific articles when theorising about health.
However, the WHO definition, taken strictly, does not allow for such a sensible interpretation. It is obviously an incorrect, biased definition, and a potential generator of bad clinical care: if the doctor practices to make the patient feel good at all costs, result would be the medical care described in Brave New World, and the total solution to human problems, a drug like "soma", which makes you feel good and does not cause a hangover. And it is not surprising that, in this way of understanding things, medicine should procure the death of the sufferer, if plenary session of the Executive Council wellbeing cannot be achieved, a solution that is routinely carried out by veterinary medicine, since the latter only has to pursue physical integrity and wellbeing. It is clear that those who defend the WHO definition of health must, at the very least, make an interpretation of it contrary to its explicit literal meaning, which will necessarily fall into the ambiguity of the term "welfare".
Health "subjectivity" and autonomism
As an almost obligatory complement to the WHO definition of health, the subjectivity of health appears in the medical field. Who can say whether he or she is well, at ease? The patient himself. Therefore, the practice of medicine can only be carried out by asking the patient how he or she is and what he or she wants, or, in other words, what ailment has made him or her go to the doctor. However, this question, which is at the beginning of any clinical relationship, adopts, within the WHO definition of health, a different nuance to that given by the common sense of clinicians: the patient must be asked about his or her well-being because this is the only way to find out what has no objective answer, since what pleases some people does not please others. Health, therefore, is a purely subjective matter, at least as far as well-being is concerned.
If, as the WHO advocates, health is basically wellbeing, then the patient's requests will have a great preponderance in medical care. This is the autonomism that can be seen today in the aggressive and demanding attitudes of some patients: they are the ones who decide; what they say is done. This way of behaving is often linked to a commercialisation of medicine: it is conceived as another consumer good, something to be bought with money and which must meet the client's expectations of satisfaction (or wellbeing). In the United States, this commercial requirement has been dressed up in an ethical garb that makes doctors feel less manipulated by the money they are paid: they prefer to speak of respect for patient autonomy where often, in certain specialities or interventions, there is almost no residue of concern for the patient, but merely a commercial do ut des.
Obviously, the patient's rightful autonomy is a reality that must be respected; it is another way of saying what we mentioned in the classic definition: being healthy depends on the way a person lives, and the doctor must take this way of life into account when approaching a treatment. But this is radically different from accepting that the patient is always right, as if he or she were a customer in a department store, where one buys what one likes best, for no other reason than taste. The doctor also has a say in the doctor/patient relationship, and is not a mere salaried employee under the patient's orders, nor is his only goal to cause wellbeing. Therefore, just as the doctor is expected to respect the patient, respect in the opposite direction should be expected. What one would not be obliged to find in a tradesman is what should be expected of the doctor: refusal to apply treatments that he knows to be ineffective or harmful, refusal to act against his moral principles, etc. These refusals, rather than impositions on the patient, are precisely his defence: if the doctor were to accede to all requests, the real good of the patient would be left without a lawyer.
For some it means that a person can organise his or her life as he or she pleases, without any constraint, placing medicine at the service of his or her taste, while for others it means that each person has a different way of life, which must be taken into account by the doctor in his or her clinical practice. While the former is unacceptable, the latter is essential in good medical practice.
Patient inequality
The influence of a person's habitual activity on the consideration of his or her state of health or illness leads to a consequence that is currently not widely accepted by doctors: not all organic lesions should be treated with the same intensity, and the Degree of effort to eliminate lesions depends on the subject of the patient's life. The term "subject of life" should be understood here in its broadest sense, i.e. encompassing not only aspects of individual activity (mainly professional), but also other economic, family, cultural, religious and social considerations.
On the other hand, currently, misinterpreting the letter of the deontological norms that require non-discrimination between patients4 , it is assumed that all patients are equal, and the available means are used with them to produce organic healing, with the criterion, in case of scarcity of means, of "first come, first served". This attitude demonstrates a reductionist conception of man and human health.
For us all to be truly equal in the face of illness, we would need to be indistinguishable from one another, equalised by a common pattern of activity, which could be likened to the instinctive activity of animals. For them, getting sick is always the same, and the veterinarian can treat them equally: by curing their injuries so that they can carry out the instinctive goals of their species, or by killing them if they cannot be cured or pose a danger to their caretakers or to other animals.
The doctor-patient relationship, on the other hand, is not the blind application of ideal physiological patterns to be restored, like someone repairing a machine. It is, first and foremost, a dialogue with the patient and knowledge of the patient as a person, with a particular way of life, hobbies, environment, culture, religion, etc. In this dialogue, the doctor assimilates this vital originality and thus learns from his patients and matures as a person in the course of his professional practice. The doctor then kindly proposes a technical financial aid for the human problem that has caused the organic or psychological disorder. And, as the human problem is different in each case, the proposal of financial aid technique will vary greatly, depending on the person.
This is not discrimination, because financial aid is proposed with the best will towards the patient. Precisely because the doctor tries to "care with the same conscience and concern "5 for all his patients, he does not propose solutions that are the same, but adapted to the particular case. It is goodwill that makes financial aid proposal different.
Thus, to give an example, in the case of a serious illness, he will propose drastic measures that may achieve a cure at the cost of a large expense and without much chance of success to the young patient, with serious family or professional responsibilities in which he cannot be substituted. However, if the patient is older, with no family ties, and expresses the idea that life no longer has much meaning for him, it is reasonable to refrain from proposing expensive, aggressive, uncomfortable and only marginally effective curative treatments. For these reasons, the good doctor will refrain from recommending treatments that are too painful, or that go against the conscience or cultural sensitivity of his patient.
In order to be able to arrive at this committee adapted to the patient, dialogue, so neglected in contemporary practice, is fundamental. The patient's personal finding , family or cultural peculiarities, hobbies, are not peripheral or irrelevant questions in the anamnesis, as they can make a decisive change in the therapeutic orientation. A side effect of a medication or a surgical intervention, which may seem trivial to the doctor, may be of great importance to the patient, and this importance must be made known through dialogue.
Perspective
The terminology currently used to refer to the various aspects of health and our relationship with the patient is ambiguous. We have already mentioned this ambiguity with regard to the terms "wellbeing", "quality of life", "objective standards", "autonomy". Others can be included, such as "informed consent": by using this expression, we are implying that the patient receives information on his condition and a proposal treatment to which he gives his acquiescence or refuses, unconditionally and autonomously; thus, the whole dialogue with the patient that allows the doctor to assimilate his peculiarities and that makes therapeutic activity a common action of doctor and patient is blurred in the shadows. Continuing to talk about informed consent leaves behind a completely inadequate conception of health and health care.
Biases in the conception of their activity that many doctors acquire by repeating certain terms can be avoided by using some of them only in their specific sense (such as "goal" or "well-being"), and replacing others with their unambiguous equivalents that adequately express the reality of health and of the doctor/sick person relationship; Among them, we could mention "respect for the patient" instead of "respect for the patient's autonomy", "state of health" instead of "quality of life" (which may even include issues as unrelated to health as the absence of regrets, fulfilled life projects, etc.), and "quality of life" instead of "quality of life" (which may include issues as unrelated to health as the absence of regrets, fulfilled life projects, etc.).). The terms I have just mentioned are only a preliminary proposal . Undoubtedly, there are better solutions, which can be reached with an adequate employment of Spanish; but this will only be possible if we do not lose our critical sense and do not allow ourselves to be dragged along by the prevailing terminology , coming mostly from the American sphere, where the doctor-patient relationship has undergone a strange evolution that is not paradigmatic of what our professional activity should be.
Notes
(1) Cfr. Alarcón E. Teoría de la vida orgánica (Apuntes de Psicología). Pamplona: pro manuscripto, 1988. The same is true in English, where we have the terms health, salud, holy, santo, and in Germanic languages, where we have the terms Heilen, curar and Heilig, santo.
(2) Thomas Aquinas. Summa Theologiæ, I-IIae, q. 50, a. 1, c.
(3) Cfr. Alarcón E. Op. cit. Cfr. Choza J. guide de antropología filosófica. Madrid: Rialp, 1988.
(4) Spanish Medical Association. Code of Medical Ethics and Deontology, Article 4.2: "The physician shall care for all patients with equal conscience and concern, without distinction as to birth, race, sex, religion, opinion or any other personal or social condition or circumstance.
(5) Ibid.