• Health Economics

We are grateful for the thoughtful attention the commentators and editors have given our paper. They raise many substantive points that warrant a response, but for reasons of journal space our reply must be brief. In our paper, we argue for an amended hybrid account of ‘disease’ in human medicine that takes normative ethics seriously, guards against pernicious classifications of disease and reconnects the concept with the goals of healthcare institutions in which disease diagnosis is embedded. Carel and Tekin, in their respective pieces, raise issues about the objectivity and effective operationalisation of our account, Agar makes an ‘evolutionary’ case for disease concept eliminativism in mental health, and Wakefield and Conrad contend that our proposed modification to the harmful dysfunction account is unnecessary and undesirable. We will respond to each in turn.

The rational moral justification component of our account raises difficult moral epistemological questions regarding which reasons are the weightiest ones and who should be allowed to participate in the rational justification process (though so too, we would note, does much bioethical inquiry). Carel suggests that inevitable disagreement on this point undermines the alleged objectivity of our proposal. We agree with Tekin, however, that this is a feature of our account rather than a bug. What constitutes a good reason in moral deliberation is a question that goes to the very philosophical foundation of ethics (see1 for a recent discussion); but disagreement over which reasons are the weightiest ones does not prevent ethicists and policy makers from objectively assessing the strength of moral arguments by evaluating their empirical adequacy and logical structure, and this can take us a long way toward adjudication. The fact that rational justification has been used to support immoral practices and institutions does not warrant abandoning a reason-based approach to ethics any more than …