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The Second Fifty Years: Promoting Health and Preventing Disability B Looking for Order Health Promotion, Disability Prevention, and the Disability Classification System of the World Health Organization Ted Miller The field of health promotion and disability prevention (HPDP) is said to lack a conceptual base. Health policymakers complain that rational policy choices cannot be made until there is a widely accepted vocabulary of concepts that will define the conditions to be addressed and inform the development of methods for their modification. Yet a considerable dispute remains over how the conceptual base should be defined. The expectations that inform this dispute are linked to two interwoven sources: the politics between competing modes of health care inside HPDP and the desire to underpin our reasoning with foundational concepts and scientific method. The former topic is briefly discussed here and in Appendix A; the latter forms the core of this discussion, which will explore the philosophical tenets that run through the goals of the World Health Organization's (WHO) International Classification of Impairments, Disabilities, and Handicaps . The place to begin, however, is with the relationship between the difficulties of writing an authoritative synopsis and a classic dilemma associated with the act of generalization. Reports that intend to summarize the state of knowledge and make policy recommendations in immature fields perform a delicate balancing act. A report that leans too heavily toward a definitive description or recommendations that favor a single method risk stifling future, productive approaches. In an effort to arrive at a definitive description of a disorganized field, the report may implicitly suggest that methods currently under development, which could
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The Second Fifty Years: Promoting Health and Preventing Disability be valuable in the future, are no longer worth pursuing. A report that goes too far in the opposite direction risks giving its readers the impression that problems requiring immediate attention admit of no policy solutions. Definitive results are seldom produced by an immature field, but the interim findings available may suggest approaches that are, at least, better than doing nothing. This problem is not simply applicable to summaries of the knowledge of health care. All levels of generalization, from the most catholic conceptions to detailed assertions of scientific research, experience this difficulty. This discussion is concerned with the generalizations of a system for the classification of the consequences of disease. Exploring the expected and unexpected results of system building will illustrate the way generalizations create imbalances that are sometimes redressed. From the seventeenth century onward, Western thinkers have had an ongoing preoccupation with the creation of systems—systems designed to define, refine, and reform philosophy, science, theology, manufacturing, and so forth. The impetus behind most systems is to find fundamental principles of order, simplicity, or efficiency where there seemed to be overwhelming disorder, complexity, or inefficiency. In short, the immediate goal of making things more systematic, with the ultimate goal of making them easier, has motivated many rigorous inquiries in the West. Yet the rigor of such inquiry owes as much to provocation as it does to the desire for ease.7 Systems, especially complex conceptual systems, can be understood as subtle but powerful forms of intellectual provocation. Our standards for accepting systems are generally low. They are, in fact, much lower than the standards most system designers set for themselves—and often much lower than the claims made by the system designer. With the expectation of being more reasonable, straightforward, and efficient in understanding, predicting, and controlling the systematized subject, Western man has been willing to accept the fundamental principles of systems. Such popular acceptance, however, can be a source of frustration for individuals who disagree with the principles of a given system and may eventually provoke a loud and forceful dissent, even as the system is perceived as a source of convenience by the majority of the public. When these dissents unmask discrepancies between the system's performance and its creator's claims, inquiries to judge the principles at the foundation of the system may be set in motion. Systems therefore may unintentionally balance the force of their generalizations by provoking their detractors to expose their deficiencies.
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The Second Fifty Years: Promoting Health and Preventing Disability As noted earlier in the report the committee has chosen to use WHO's International Classification of Impairment, Disability, and Handicaps 16 system for classifying the consequences of disease. The WHO system embraces two unrealized goals: to ease the flow of information about the consequences of disease through a widely acceptable set of standard terms and to guide clinical decision makers to interventions that go beyond the cognizance of the traditional clinical search for causes, signs, symptoms, and cures. Why haven't these goals been realized before? Disability, after all, has been the subject of health and public policy for years. One reason is the dissonance between different factions within the health care communities over the purposes of health care. THE GOAL OF HEALTH CARE The difficulties of arriving at an acceptable conceptual base are in part due to a lack of consensus over the goals of HPDP. Disagreements within the health care community can be traced roughly to the philosophies of two groups: advocates of an acute care model and those who follow more social modes of health care. The latter comprises several subgroups that find their goals in the traditions of the American public health movement, preventive medicine, rehabilitation, and long-term care. Which of the various health care communities that stake their claim in this field have the most influence in laying its foundations, and what might these foundations look like? The ends of acute and social modes of health care overlap at many points, however they diverge in their broader goals. The boundaries that define the goals of acute care traditionally expand very slowly and cautiously. The boundaries that enclose the ends and means of social modes of care have gone well beyond acute care into social ills and broader notions of prevention and rehabilitation. The differences among these groups can be gauged by contrasting their criteria for successful care. Acute care givers are oriented toward curing their patients, where ''curing" has often meant attacks on hidden, yet physically determined causes of disease.3,4,15 The social groups succeed when their patients have been assisted or have learned to cope with their difficulties, or when society takes action to accommodate their needs. To understand the dynamics of the disagreement between these groups, it is also necessary to know the status of the groups relative to each other. Acute care medicine has most heavily influenced the orientation and goals of American health care. A sign of its great weight is the common and automatic association between health
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The Second Fifty Years: Promoting Health and Preventing Disability care in general and acute care. Indeed, the public's image of health care begins with acute care medicine. The majority of services covered by Medicare are acute care interventions.11 In a new journal that focuses exclusively on aging and health—and not, implicitly, aging and disease—an article complains of the prevalence of acute care thinking in health care for older patients.9 The automatic association also exists in theories of health care. The majority of bioethical questions begin with the assumption of acute care situations.5 This assumption is also reflected in the ongoing debate over how to define and care for the mentally ill. For example, Siegler and Osmond argued for an approach to mental illness that follows a "medical model" in which acute care is taken as the heuristic ideal. (Since that time, "medical model" has become much broader and less determinate owing both to critics of Siegler and Osmond's philosophy of psychiatry and to other authors who have chosen to define the model in their own terms.) Today, however, health care policymakers are now being asked to develop a world view that will suit the needs of an aging population, and there is a growing belief that the acute care understanding is not sufficient.16 Health care analysts are convinced that the increased longevity and growing proportions of the elderly will be accompanied by significantly greater demands for health care for the chronically ill and disabled.10 It is in the face of these quantitative changes in the population and the qualitative changes in their health service needs that alternatives to the acute care framework are being proposed. Health promotion and disability prevention must be counted among these alternatives, and the WHO system provides a conceptual structure that informs its goals, but each is still upstaged by acute care thinking. THE PHILOSOPHY OF HEALTH CARE Our notions of how health care research ought to behave as a body of inquiry are influenced by a great and muddled conceptual complex. Within this complex, which philosophic traditions inform our expectations for a system designed to classify the consequences of disease? The professed motive behind WHO's International Classification of Impairments, Disabilities, and Handicaps is the desire to bridge the "ability-capability gap, the discrepancy between what health care systems can do and what they might do." The classification system is designed to serve this end by improving the quality of our
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The Second Fifty Years: Promoting Health and Preventing Disability conceptions of the consequences of disease. This goal, and the means of achieving it, show signs of the influence of Descartes. The first principle of Cartesian inquiry is to be skeptical. The root of this skepticism is a very rigid dualism between the thinking mind and the physical world outside. How then are we aware of things outside the mind? The outside world is presented to the mind through our senses. The world outside the thinking mind cannot penetrate the barrier between mind and the corporeal but is represented to it—as if making retinal images on the "eye of the mind." Descartes' argument can be seen as reasoning with the assumption of two different worlds, one inside the mind and a world outside that makes images supplied by the senses on the internal eye.14 The senses, however, are unreliable, and this is why Cartesian dualism gives rise to a persistent skepticism. The knower can never be sure of the existence or accuracy of the images of the outside world. The senses are doubted because the images they present of the outside world can also be presented by the mind to itself, as in dreams. This capacity of the mind raises the possibility that representations of the outside world by the senses are distorted or fictitious. The goal of Cartesian inquiry is to ensure that this sort of self-deception will not occur. Put another way, the Cartesian intellect begins with the assumption that all representations of the outside world are dubious until proven to be true. These assumptions prompt a search for criteria with which to identify truths. According to Descartes, the truth about the outside world is represented before the mind's eye when it is clear and distinct or when it is indubitable. As examples, Descartes provides the a priori knowledge of the existence of a supreme being, of ourselves, and of the most basic elements of matter. According to Descartes, then, the means of obtaining knowledge lie in the recognition of clear, distinct, and indubitable representations. The new task for inquiry is thus to discover the universally true qualities of the representations of the outside world by searching out the clear, the distinct, and the indubitable. The implications of Cartesian dualism are faintly echoed in the goals of the classification of impairments, disabilities, and handicaps. One of WHO's purposes in creating these categories was to provide more relevant information about the consequences of disease (and the health care systems that deliver care for people suffering from these consequences). Yet this statement may lead us to ask, "relevant to what?" Ultimately, the answer is "relevant to the way these things really are." Implicit in this notion is the Cartesian suspicion
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The Second Fifty Years: Promoting Health and Preventing Disability that things as they are represented to the mind of the policymaker are perhaps a distorted or fictitious version of the truth. The fear is that a policymaker's decisions, lacking a clear and distinct picture of the consequences of disease, will be made subjectively. That is, the decisions might have been made differently had another person—with his or her own self-deceptive perceptions—been charged with the task of deciding. The Cartesian intellect seeks objective decisions—that is, decisions that do not depend on untrustworthy perceptions but on qualities of the object agreed upon by all to be truthful. Other important goals of Cartesian inquiry also inform the WHO system. It is not simply skepticism that is embraced but the need to coherently frame and organize the phenomena of disability. The second and third principles of Cartesian inquiry are to "divide each problem into as many parts as is feasible, and was requisite for a better solution," and "to direct thoughts in an orderly way; beginning with the simplest objects, those most apt to be known, and ascending little by little, in steps as it were, to the knowledge of the complex." This procedure for attaining knowledge carries with it the notion that the complexities of nature must be broken down into their separate elements before clear and distinct images of the world can be represented to the mind. Once this elemental level has been reached, the third step instructs one to reconstruct the subject into a coherent order. It is clear that the order of the WHO system is not a fresh reconstruction of physical, psychological, and social domains. Rather, the system's creators have deliberately attempted to accommodate the framework of the system to long-standing methods for disease classification.16 Through the system, they have borrowed their terminology from established health care sciences. Thus, the WHO system cannot be said to be completely Cartesian in its approach, although it shows signs of the Cartesian spirit of organization. The consequences of disease are divided into very small components; impairment, disability, and handicap are only the beginning of the organizational structure. Each of these major divisions is further divided into subcategories and, in the case of disabilities and impairments, multiple categories beneath these. Because the study of the consequences of disease is only beginning to attempt a systematic, Cartesian approach to this problem, the philosophical influences involved are difficult to characterize. However, these influences have been operating for years in the neighboring effort to define the concept of disease. Perhaps the development of concepts of the consequences of disease will follow a similar path.
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The Second Fifty Years: Promoting Health and Preventing Disability Most analysts agree that the Cartesian influence has been instrumental in developing systematic means of discovering, explaining, predicting, and controlling somatic illness. Among those who view medicine from philosophical perspectives, however, there is a consensus that the Cartesian influence has brought a reductionist spirit to medicine and psychology.6,12,13 Indeed, it is tempting to compare Descartes' own attempt to reduce man to medical-mechanical theory with attempts to ground all human behavior in the laws of chemical reactions. The preoccupation with diagnosis over cure has been a sign of some of the dangers of the Cartesian influence; others have complained that medicine has demonstrated a preoccupation with pursuing single and elemental causes.13 In the introduction to the WHO classification system manual,16 its authors indicate their sensitivity to the reductionist problems of the acute care framework and emphasize the incompatibility of the inherent goals of the conceptual order of WHO's International Classification of Disease and the goals of the health care delivery systems designed to address the consequences of disease. It would have been strange if the creators of the WHO system had not applied a similar skepticism toward their own project, but is it possible to specify the conditions under which the consequences of disease have been adequately covered? Thomas Kuhn's The Structure of Scientific Revolutions8 provides useful preliminary insights that may be directed toward answering this question. The paradigmatic theory of scientific revolution is an interpretation of the history of mature sciences, for example, physics, chemistry, or optics. These fields are said to operate under an overarching theory that provides a coherent framework for explaining a previously muddled set of facts. Once such a theory, or paradigm, is established, the activity of mature sciences—what Kuhn calls "normal science"—consists of "mopping up" facts into the paradigm's framework. Mopping up in normal science is Kuhn's metaphor for analytically fitting the details accounted for by the paradigm into theoretical constructs that are a part of the overall theory or that are at least compatible with the paradigmatic world view. Another way of expressing this relationship is through the notion of articulation. The paradigm is said to supply the scientific field with a stock of partially unarticulated theories and phenomena. The mopping up—or the practice of fitting details to theory—can be understood as the articulation of the paradigm on the level of minutiae. Health care is an art, but it is an art that borrows from and that frequently strives to emulate science. It is when health care borrows
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The Second Fifty Years: Promoting Health and Preventing Disability scientific theory and method to achieve its ends or when these means are subordinated to the ends3,15 (or vice versa) that Kuhn's analysis is most helpful. The various theories of health, disease, assessment, and disability—the majority of which are hidden in the implicit assumptions of journal articles and medical textbooks—begin with overarching concepts that attempt to coherently frame health phenomena. The following Kuhnian description of normal science applies equally well to these specialized health care research projects: "we shall want finally to describe that research as a strenuous and devoted attempt to force nature into conceptual boxes." Thus, it would seem that the consequences of disease have been adequately covered when there is a coherent and widely accepted system to describe them. Yet we must ask if there is not a price to be paid in employing reductive thinking and conceptually rigid paradigms. Do our efforts to systematically organize information concerning disabilities force us to conceptualize disabilities in a way that is suited to the epistomological standards of health care science but inimical to the needs of people with disabilities? This discussion does not end with a true conclusion; rather, it is a kind of prelude to a question that should be taken seriously by those health professionals who now express interest in disability. To the extent that disability classification systems attempt to organize scientific knowledge, there will be an inevitable squeezing and twisting of subjects to suit the order of a system struggling to represent nature clearly and distinctly. Yet disability is a concept that makes sense only in the context of ability, and ability has an endless capacity for defying coherent description. No sooner do we attempt to determine the essence of an individual's abilities than they escape the confines of our determination. Ability makes us unique. Thus, the question that must be asked is this: What is lost when we struggle to force the long-term disabilities and abilities of individuals into conceptual boxes? REFERENCES 1. Caplan, A. Is medical care the right prescription for chronic illness? In: S. Sullivan and M. E. Lewin (eds.), The Economics and Ethics of Long-Term Care and Disability. Lanham, Md.: University Press of America, 1988, pp. 73-89. 2. Descartes, R. Descartes: Philosophical Writings, trans. E. Anscombe and P. T. Geach. Indianapolis: Bobbs-Merrill, 1971. 3. Engelhardt, T. Causal accounts in medicine: A commentary on Stephan Toulmin. In: E. Cassell and M. Siegler (eds.), Changing Values in Medicine: Papers Delivered at the Conference on Changing Values in Medicine, USA. Lanham, Md.: University Publications of America, Inc., 1979.
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The Second Fifty Years: Promoting Health and Preventing Disability 4. Engelhardt, T. The concepts of health and disease. In: A. L. Caplan, T. H. Engelhardt, and J. J. McCartney (eds.), Concepts of Health and Disease: Interdisciplinary Perspectives. Reading, Mass.: Addison-Wesley, 1981. 5. Jennings, B., Callahan, D., and A. Caplan. Ethical challenges of chronic illness. The Hastings Center Report 1988; 18(1):1-16. 6. Kass, L. Towards a More Natural Kind of Science. New York: MacMillan, 1985. 7. Kierkegaard, S. Concluding Unscientific Postscript, trans. D. Swenson and W. Lowrie. Princeton: Princeton University Press, 1971. 8. Kuhn, T. The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1970. 9. Levkoff, S., and Wetle, T. Clinical decision making in the care of the aged. Journal of Aging and Health 1989; 1(1):83-101. 10. Manton, K. Epidemiological, demographic, and social correlates of disability among the elderly. Milbank Quarterly 1989, 67(Suppl. 2, No. 1):13-58. 11. Medicare Coverage Issues Manual. Health Care Financing Administration Publ. 6 through Rev. 33 (PB89-955099). Washington, D.C.: U.S. Department of Health and Human Services, 1988. 12. Pellegrino, E. Humanism and the Physician. Knoxville: University of Tennessee Press, 1979. 13. Pellegrino, E., and D. C. Thomasma. A Philosophical Basis of Medical Practice: Towards a Philosophy and Ethic of the Healing Professions. Oxford: Oxford University Press, 1981. 14. Rorty, R. Philosophy and the Mirror of Nature. Princeton: Princeton University Press, 1979. 15. Toulmin, S. Causation and the locus of medical intervention. In: E. Cassell and M. Siegler (eds.), Changing Values in Medicine: Papers Delivered at the Conference on Changing Values in Medicine, USA. Lanham, Md.: University Publications of America, Inc., 1979. 16. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. Geneva: World Health Organization, 1985.
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