Sport-related concussion research agenda beyond medical science: culture, ethics, science, policy.

The Concussion in Sport Group guidelines have successfully brought the attention of brain injuries to the global medical and sport research communities, and has significantly impacted brain injury-related practices and rules of international sport. Despite being the global repository of state-of-the-art science, diagnostic tools and guides to clinical practice, the ensuing consensus statements remain the object of ethical and sociocultural criticism. The purpose of this paper is to bring to bear a broad range of multidisciplinary challenges to the processes and products of sport-related concussion movement. We identify lacunae in scientific research and clinical guidance in relation to age, disability, gender and race. We also identify, through multidisciplinary and interdisciplinary analysis, a range of ethical problems resulting from conflicts of interest, processes of attributing expertise in sport-related concussion, unjustifiably narrow methodological control and insufficient athlete engagement in research and policy development. We argue that the sport and exercise medicine community need to augment the existing research and practice foci to understand these problems more holistically and, in turn, provide guidance and recommendations that help sport clinicians better care for brain-injured athletes.

Why Health-enhancing Nudges Fail.

Nudges are means to influence the will formation of people to make specific choices more likely. My focus is on nudges that are supposed to improve the health condition of individuals and populations over and above the direct prevention of disease. I point out epistemic and moral problems with these types of nudges, which lead to my conclusion that health-enhancing nudges fail. They fail because we cannot know which choices enhance individual health-properly understood in a holistic way-and because health-enhancing nudges are often themselves bad for our health. They can be bad for our health because they assume inferior agency in their targets and accordingly regularly lead to appropriate resentment and anger-strong emotions which go along with an increased risk of health impairments. Briefly, health-enhancing nudges fail because they are based on persistent ignorance and on a presumptuous attitude.

The Metric and the Threshold Problem for Theories of Health Justice: A Comment on Venkatapuram.

Any theory of health justice requires an account of what areas of social life are important enough to be of public concern. What are the goods that ought to be provided as a matter of justice? This is what I will call the metric problem. The capabilities approach puts forward a particular solution to this problem. In this article I will discuss some issues of such an approach in relation to Sridhar Venkatapuram's well-known theory. Another problem I examine is how to determine a threshold of provision within a theory of justice. What is enough in terms of health justice? I argue that we need such a threshold to avoid healthism, the expansion of the pursuit of health over and above the treatment and prevention of disease. This is an especially pertinent problem in public health, which is also the context of Venkatapuram's theory.

Health as Complete Well-Being: The WHO Definition and Beyond.

The paper defends the World Health Organisation (WHO) definition of health against widespread criticism. The common objections are due to a possible misinterpretation of the word complete in the descriptor of health as 'complete physical, mental and social well-being'. Complete here does not necessarily refer to perfect well-being but can alternatively mean exhaustive well-being, that is, containing all its constitutive features. In line with the alternative reading, I argue that the WHO definition puts forward a holistic account, not a notion of perfect health. I use historical and analytical evidence to defend this interpretation. In the second part of the paper, I further investigate the two different notions of health (holistic health and perfect health). I argue that both ideas are relevant but that the holistic interpretation is more adept for political aims.

'I hope that I get old before I die': ageing and the concept of disease.

Ageing is often deemed bad for people and something that ought to be eliminated. An important aspect of this normative aspect of ageing is whether ageing, i.e., senescence, is a disease. In this essay, I defend a theory of disease that concludes that ageing is not a disease, based on an account of natural function. I also criticize other arguments that lead to the same conclusion. It is important to be clear about valid reasons in this debate, since the failure of bad analyses is exploited by proponents of the view that ageing is indeed a disease. Finally, I argue that there could be other reasons for attempting to eradicate senescence, which have to do with an evaluative assessment of ageing in relation to the good life. I touch on some reasons why ageing might be good for people and conclude that we cannot justify generalized statements in this regard.

Rational suicide, assisted suicide, and indirect legal paternalism.

This article argues in favour of three related claims: First, suicide is not an immoral act. If people autonomously choose to kill themselves, this ought to be respected. Second, we can deem the desire to die comprehensible, and even rational, when the person contemplating suicide does not see a meaning in her life. This assessment is not based on a metaphysically dubious comparison between the actual life of a person and the supposed state of being dead. Third, from the first two theses it does not automatically follow that we should allow other people to help someone who autonomously and rationally chooses to die to pursue this plan. To argue against indirect legal paternalism, the practice of legally preventing someone else to assist a person to perform a suicide or to be killed on request, needs additional reasons. It is argued that assisted suicide and voluntary active euthanasia can indeed be justified by establishing a claim of persons who want to die but are not able to kill themselves. This mainly means that being really free to die should be interpreted as involving the means to fulfil one's desire to die.

On the autonomy of the concept of disease in psychiatry.

Does the reference to a mental realm in using the notion of mental disorder lead to a dilemma that consists in either implying a Cartesian account of the mind-body relation or in the need to give up a notion of mental disorder in its own right? Many psychiatrists seem to believe that denying substance dualism requires a purely neurophysiological stance for explaining mental disorder. However, this conviction is based on a limited awareness of the philosophical debate on the mind-body problem. This article discusses the reasonableness of the concept of mental disorder in relation to reductionist and eliminativist strategies in the philosophy of mind. It is concluded that we need a psychological level of explanation that cannot be reduced to neurophysiological findings in order to make sense of mental disorder.

Can we define mental disorder by using the criterion of mental dysfunction?

The concept of mental disorder is often defined by reference to the notion of mental dysfunction, which is in line with how the concept of disease in somatic medicine is often defined. However, the notions of mental function and dysfunction seem to suffer from some problems that do not affect models of physiological function. Functions in general have a teleological structure; they are effects of traits that are supposed to have a particular purpose, such that, for example, the heart serves the goal of pumping blood. But can we single out mental functions in the same way? Can we identify mental functions scientifically, for instance, by applying evolutionary theory? Or are models of mental functions necessarily value-laden? I want to identify several philosophical problems regarding the notion of mental function and dysfunction and point out some possible solutions. As long as these questions remain unanswered, definitions of mental disorder that rest upon the concept of mental dysfunction will lack a secure foundation.

Should we prevent non-therapeutic mutilation and extreme body modification?

In this paper, I discuss several arguments against non-therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of 'aberration' that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of duties to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations.

A qualified defence of a naturalist theory of health.

The paper contrasts Lennart Nordenfelt's normative theory of health with the naturalists' point of view, especially in the version developed by Christopher Boorse. In the first part it defends Boorse's analysis of disease against the charge that it falls short of its own standards by not being descriptive. The second part of the paper sets out to analyse the positive concept of health and introduces a distinction between a positive definition of health ('health' is not defined as absence of disease but in positive terms) and a positive conception of health (health is seen as an ideal). An objection against Nordenfelt's account is developed by making use of a specific example of an ambitious athlete. It is stated that Nordenfelt's conceptualisation includes too many phenomena under the umbrella of ill health. An ideal conception of health like Nordenfelt's is in danger of supporting medicalization. In conclusion, although Nordenfelt's theory is not altogether rejected and even seen in congruence with Boorse's account, it is claimed that the naturalistic framework should obtain conceptual priority.

The significance of the concept of disease for justice in health care.

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well.