A CENTRAL PROBLEM OF UNIVERSAL CONCEPTS OF HEALTH: THE GAP BETWEEN DIAGNOSIS AND SENSE OF WELLBEING

The World Health Organization's current and well-known definition of health sees health as a “state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity”.¹

But if we ask someone about his or her state of wellbeing, we may find that the person feels well and healthy. And yet, despite this satisfactory subjective picture, our individual may well harbour serious diseases.²

Even in cases of such impressive somatic impairments as bronchial asthma we find, empirically, only low levels of correlation between subjective quality of life and functional respiratory parameters such as one-second forced expiratory capacity (FEV₁).³ In the case of cardiac insufficiency the correlations between wellbeing and cardiac function (ejection fraction) even tend toward zero.⁴ The literature indicates that in the majority of cases there is a large gap between medical diagnosis (medically “determined” state of health or sickness) and expressed sense of wellbeing (experienced sense of health/sickness).⁵

This is also confirmed in a study of ours covering over 4000 patients with very different kinds of chronic diseases. We found that it was in fact the patients without any major organic diagnosis, for example patients with neurotic depression or somatisation disorders, who rated their health as relatively poor. In contrast, patients with chronic somatic diseases such as diabetes mellitus or hepatitis C were found to be entirely satisfied with their health and not to differ from “healthy” students in this respect.⁶

DISEASE AND HEALTH

The discrepancy between one's state of wellbeing and the actual state of one's health can be explained with reference to the relative nature of the concept of health in relation to sickness. Health is not a state that once attained then remains stable, it is an unremitting capturing of health and overcoming of sickness. This notion stems from Friedrich Nietzsche who pointed out that health is “surmounted sickness” and that humans experience only degrees of health and sickness, never their pure form.⁷

“Health and morbidity: be careful! The measure is the body's efflorescence, the mind's impetus, courage, and exuberance—but of course also how much of the morbid it can take on and overcome—render healthy. That which would destroy persons of a more frail nature is a constituent of the stimulants of great health.”

(Human) life is constituted in such a way as always to be threatened by sickness, and from the moment of their birth individuals are forced to deal with pathogens, with physical and chemical substances, as well as with psychosocial influences. Only those who prove sufficiently adaptive, who can tolerate and grow beyond the health disorders and sicknesses that occur, will at some time have a reasonably functioning biological and mental “defensive system,” or system of self regulation.

When you are “in good health,” you can fall ill, recover and then be faced with the challenge of coming to grips with the next illness. And the quality of individual health can also be measured in terms of the severity of that sickness with which the individual can just cope. Seen in this way, sickness is at the same time a deficiency and an accomplishment of the individual or the organism.

The neurologist Kurt Goldstein pointed to this relation between health and disease in his main work, Der Aufbau des Organismus, The Structure of the Organism. He there describes the dynamics of disease as “catastrophic reactions” that continue until the organism has attained a new equilibrium of performance (often at a level different from the previous one). According to Goldstein, this new level of stability represents a degree of individual health⁸:“Health thus means being able to respond in a well-ordered fashion, and this is possible despite the previous impossibility of accomplishing this or that. However, ... the new health is not the same as the old. ... Recovering one's health despite a given deficiency is invariably bound up with a loss of substance on the part of the organism; and at the same time with the restitution of order. This will amount to a new individual standard.”

Goldstein built on Nietzsche's idea of individual health as surmounted sickness. With few exceptions, however (for example Schwarz⁹ and Weizsäcker¹⁰), this German neurologist has not been acknowledged and productively appropriated by the field of medicine in Europe. Owing to his Jewish extraction Goldstein was forced to emigrate to the US, where he assumed teaching duties in 1934 and was to become an influence on neurologists such as Oliver Sacks.¹¹ Goldstein's (and Nietzsche's) notions of heath as surmounted sickness have been broadly discussed in French philosophy. The writings of Aron Gurwitsch,¹² Maurice Merleau-Ponty,¹³ or George Canguilhem,¹⁴ for instance, make explicit reference to these models and theories.

EQUILIBRIUM AND HEALTH

In terms of what we have noted thus far, health can be seen as an individual, fragile equilibrium in which the weight of pathology on the one side of the scale is always essential. We do not sense this health as we do symptoms or disorders of our state of wellbeing; it is instead latent, and becomes manifest only in sickness and the surmounting of sickness.

The German philosopher Hans-Georg Gadamer who, together with an internist at the Berlin Charité hospital, Paul Vogeler, published a seven-volume anthropology in the 1970s which discusses Friedrich Nietzsche and his ideas on individual health, also wrote a book called Über die Verborgenheit der Gesundheit, On the Hiddenness of Health.¹⁵ In it he notes that states of health are marked by “Verschwiegenheit”—tacitness, and that the individual is wholly unaware of such states and forced to rely on indirect parameters (absence of pathological symptoms or standardisable values for somatic functions). Accordingly, whether the individual is capable of maintaining the equilibrium of health or whether it tips toward pathology, depends on a variety of factors, including the following: individual constitution and disposition; individual immune status, and the pathogenic force of viruses, bacteria, fungi, toxins, and mechanical traumas, though it also depends on an individual's moods, feelings, affects, and life-guiding convictions.

Nietzsche had already pointed to many of these connections. In his The Gay Science (1882) he radicalises the construct of “individual health”¹⁶:“For there is no such thing as health in itself, and all attempts to define a thing in that way have lamentably failed. It is necessary to know the aim, the horizon, the powers, the impulses, the errors, and especially the ideals and fantasies of the soul, in order to determine what health implies even for the body. There are consequently innumerable kinds of physical health.”

Nietzsche was acquainted with many of the results of the physiological and anatomical research conducted in the 1860s and 1870s and was therefore familiar with the rule-boundness and uniformity of the structure and functions of the human body. But in connection with his concept of the body (as an animated and social body with the capacity to develop mind and reason) he furthermore attributed to matter and nature, in their bodily form of organisation, the capacity to develop qualities on the order of individual philosophies and self reflection. In Nietzsche “bodies” assume unique and inimitable perspectives and orientations that are in part determined by their individual life histories, social relations, value orientations, and epochal frameworks. For Nietzsche, these “bodies” themselves contribute to developing the status of an individual “great health”.

Nietzsche's construct of “great health” includes the whole of an individual's “plastic powers”. These plastic powers enable the individual, in the course of his biography, to productively cope with a variety of pathogenic, noxious, and traumatic influences (pathogens, abuses, losses, congenital and acquired physical handicaps, traumas of all kinds) in the sense of surmounting or at least resisting them¹⁷:“Great health—a health that one not only has but constantly acquires and must acquire, because one again and again relinquishes it, must relinquish it!”

The “plastic powers” and “great [individual] health” to which they give rise can, according to Nietzsche, hardly be comprehended as standard values or deviations. It is, rather, they that ground the differentness and no more than very relative comparability of individuals, and they may also be referred to as an individual's specific “will to power”. Former Princeton philosophy professor and Nietzsche expert Walter Kaufmann, who left Germany in 1939, elaborates this idea in his book, Nietzsche. Philosopher, Psychologist, Antichrist.¹⁸

In this book he establishes a connection between individually lived biography and individual health. Because matter and nature experience and configure in the human body a unique history, one that occurs only once in a given, specific form, bodies too display wholly individual nuances in their health status or the course of their diseases—an idea that in turn carries on Nietzsche's construct of individual health¹⁶:“... the more one again permits the unique and unparalleled to raise its head, the more one unlearns the dogma of the `equality of men', so much the more also must the conception of a normal health, together with a normal diet and a normal course of disease, be abrogated by our physicians”.

Nietzsche's concept of “plastic powers” can be found, in altered form, in a good number of contemporary concepts of coping,¹⁹ though these concepts of course depict various coping styles (for example fighter/non-fighter²⁰) which neglect the individual contours of health and “plastic powers” and instead categorise and typify the persons concerned, failing to do justice to the demands raised by Nietzsche (and subsequently Gadamer and Kaufmann) concerning the description of and consideration due to individual health.

IMPLICATIONS FOR HEALTH CARE AND MEDICAL PRACTICE AND RESEARCH

Our remarks lead us to the following reflections and consequences:

1. What is needed for a health research paradigm in line with reality is to widen the established scientific methods of medicine to include scientific approaches that adequately depict and model individuals and their senses of wellbeing, their thinking and experience. Such a “science of individualities” (ideographic science) should be made an integral part of the “sciences governed by universal laws” (nomothetic science).

2. Apart from the typical and universal (as elaborated for example in the framework of EBM), diagnostics and therapy in the field of medicine must seek to integrate the particular and individual of each single patient as the measure and aim of their activities.

3. In the second half of the 20th century science and medicine were been dominated by Anglo-American pragmatism and utilitarianism. There are great doubts as to whether the scientific and health care issues that presently face us can be adequately dealt with or solved on the basis of these approaches alone. What is called for here is a look back to concepts and theories such as Nietzsche's construct of individual health as well as an intensification of the scientific dialogue between philosophy and medicine.