Contribution
The paper is a direct critique of Kukla’s (2014) proposal to define health and disease purely by social justice. It classes that proposal as moral conceptual engineering (MCE), using the distinction Veit drew with Browning in 2020, and argues that it and “any purely normativist account” (p. 2) fail for two reasons. The first is that an undefined notion of justice turns the concepts into a moral battleground. The second is that without an external constraint, medicine and justice-promotion become one thing. The positive recommendation is pluralism: separate naturalist, social-constructivist and normativist accounts, with health linked to wellbeing and justice empirically, not by definition.
Key insight
A definition of X purely by “whatever it would be good to treat as X” cannot pick X out. Medicine’s tools were built for disease. If the classification follows whatever those tools could usefully address, the tools grow toward whatever justice demands, and the classification follows them. The endpoint is Virchow’s “politics is nothing else but medicine on a large scale” with “on a large scale” removed (p. 16). Anything that stops the drift has to be naturalist or constructivist, so “pure normativism can be ‘pure’ in name only” (p. 16).
Assumptions
- Target definition. Kukla’s institutional definition (quoted p. 11): a condition “counts as a health condition if and only if, given our resources and situation, it would be best for our collective wellbeing if it were medicalized”, and health is a relative absence of such conditions.
- Framework. Veit replaces conceptual analysis with conceptual engineering but explicitly does not argue for the switch. He “merely wish[es] here to announce my alignment” with those who have (p. 6).
- Three projects (pp. 4–5): scientistic (naturalist), social-justice (normativist), and a third that Veit adds, the “social science project”, which is descriptive and relative to a community’s norms.
- Two kinds of engineering (pp. 6–7), quoted from Veit and Browning (2020): NCE, whose stage (i) is “scientific assessment”, and MCE, whose stage (i) is “moral, political, and social assessment”. Stages (ii)–(iv) are identical.
- Premise of the first horn: modern societies do not agree on justice (p. 14).
- Premise of the second horn: medical tools are refined for whatever conditions they are pointed at, so the institution is “inherently flexible” (p. 15). This is an empirical premise that the paper asserts but does not document.
- Premise used against a conceptual link: pathological states are “strongly linked” to reduced wellbeing and autonomy “for evolutionary and empirical reasons” (p. 9, citing Veit and Browning 2021).
Key results
- §2 (pp. 3–5). Kukla’s two-project framing is a “false dichotomy” (p. 5), and a third, descriptive social-science project is added. Boorse’s biostatistical theory is not really evolutionary, since Boorse rejects selected-effects functions, and “may be better classified as a social constructivist account” of medicine’s own usage (p. 8).
- §4 (pp. 9–10). Nothing shows that health must be conceptually linked to justice. An empirical link through wellbeing suffices, and doctors already act on wellbeing regardless of disease status. Hybrid accounts cannot reach consensus because there is “no a priori weighting” between goals (p. 10). Kukla’s appeal to the folk concept’s normativity is conceptual analysis dressed as engineering: “Kukla falls prey to the old ideals of conceptual analysis” (p. 12).
- §5, first problem (pp. 13–14). Kukla’s neutrality about justice, which she offers as a strength (p. 526 of her paper), is “a blatant weakness” (p. 14). In the conservative-majority scenario the definition would license the medicalisations Kukla meant to rule out. So the definition may fail even its own goal of collective wellbeing unless there is moral consensus.
- §5, second problem (pp. 14–16). Suppose justice were agreed. The institutional account still classifies as health conditions “all and only those things that are perceived to be something social justice should address” (p. 15). Medicine then co-evolves into “social justice promotion”, losing the distinctiveness Kukla criticised hybrid accounts for failing to secure: “health would simply become justice” (p. 15).
- §6 (pp. 16–17). Pluralism, with “at least three alternative accounts” (p. 16). For health states to matter morally, “it would be sufficient if these states have some empirical, rather than conceptual, link” with wellbeing and autonomy (p. 17). Justice may still properly inform medical decisions.
Claims
| id | claim | strength | support |
|---|---|---|---|
| C1 | Any definition of health and disease by social justice alone is self-defeating. | moderate | Informal argument in §5 (two horns); the generalisation from Kukla to “any purely normativist account” is asserted (p. 2, p. 17), not shown case by case |
| C2 | If justice is left undefined, the institutional definition could license the medicalisations it was meant to condemn. | moderate | Thought experiment, p. 14 |
| C3 | Without a fixed institution of medicine, medical practice would co-evolve into justice promotion and health would collapse into justice. | weak–moderate | Informal argument, p. 15; the co-evolution premise about how medical tools develop is asserted, with no historical or empirical support |
| C4 | Boorse’s BST is not an evolutionary account and may be better read as social-constructivist. | weak | Informal argument, p. 8, deferring to Griffiths and Matthewson and to Veit 2021a (fn. 3) |
| C5 | Health needs only an empirical, not a conceptual, link to wellbeing and justice in order to matter morally. | weak | Assertion with a brief argument, pp. 9 and 17 |
| C6 | Conceptual analysis in this debate should be replaced by conceptual engineering. | assertion | Explicitly not argued “due to considerations of space” (p. 6) |
| C7 | Kukla’s “list of facts” against building justice on a scientistic concept is mere assertion. | assertion | p. 11; Veit declines to engage “because of considerations of space” |
Concepts
- Naturalist conceptual engineering (NCE) — assessing, and proposing to improve, concepts on scientific grounds; Carnapian explication is one form (pp. 6–7).
- Moral conceptual engineering (MCE) — the same four-stage activity with moral, political and social assessment at stage (i) (p. 7). Kukla’s project is MCE.
- Social science project — Veit’s added, purely descriptive study of how a community uses “health” and “disease” at a time and place (p. 5).
- Pure normativism — defining health and disease only by a moral end, with no naturalist or constructivist grounding (pp. 12–16).
- Institutional definition of health — Kukla (2014): a condition is a health condition iff medicalising it would be best for collective wellbeing, given resources and situation.
Connections
The paper builds on Veit and Browning’s (2020) “Two Kinds of Conceptual Engineering” and on Veit’s earlier naturalist defence of biological normativity (2021a) and his experimental philosophy of medicine (2021b). It stands in the Boorse / Wakefield / Glackin / Kingma debate on health and disease. It sides with Glackin (2019) against Kukla but faults Glackin for giving only assertion (p. 11). The enhancement literature (Savulescu et al. 2011) is recruited for the claim that the treatment/enhancement line carries no moral weight (p. 13).
Ethics. The question is applied ethics of an institution: whether the concepts of health and disease ought to be engineered to serve social justice, and whether disease must be intrinsically disvalued in order to matter morally. The position taken is no to both. Moral considerations should bear on medical decisions directly, through wellbeing and autonomy, not by being built into the concept (p. 17). Kukla’s moral motive of preventing medicalised oppression is endorsed. Her means is rejected. The ethics tag is justified as a secondary tag. The paper is centrally about the concept of health, which puts it in philosophy of medicine and so under philosophy-of-science, but a large part of its argument is about what moral conceptual engineering can deliver and who would be served or harmed by a justice-defined concept of disease.
It is a worked case beside LIT-214, which is also about the social effects of reshaping mental-health concepts. LIT-214 is about concept blunting through popularisation. This paper is about deliberate moral redefinition.
Bearing on the record
The paper carries nothing for ML practice. Its only remote relevance is methodological: it is a clean argument that a category defined purely by the desirability of acting on it loses its extension. That pattern could be cited against defining, for example, “harmful content” purely by what it would be good to moderate, but the paper does not make that application, and filing anything in the anthology on its strength would be overreach.
The primary topic, philosophy-of-science, is right. The vocabulary has no philosophy-of-medicine term, and the paper’s subject is the definition of scientific and medical concepts. natural-sciences (which covers medicine) does not fit, because the paper makes no medical claim.
Limitations
- The paper does not engage Kukla’s own later work or any reply. Its only target is a single 2014 chapter, and its page citations to that chapter are inconsistent (see corrections).
- The generalisation to “any purely normativist account” (pp. 2, 17) is argued only through Kukla’s definition. A normativist account with a substantive, specified theory of justice escapes the first horn by construction. Veit grants that the first horn bites only “unless there is complete moral consensus” (p. 17), which weakens it to a pragmatic objection.
- The second horn rests on an unsupported empirical premise about how medical tools evolve (p. 15). No historical case is given.
- The switch from analysis to engineering, which the whole paper relies on, is announced rather than argued (p. 6).
- The pluralist alternative is sketched in one paragraph (p. 16) and not developed.
- The paper has several typographical slips (e.g. “we should we abandon”, p. 2; “pricely”, p. 10; the “opposite sex” example, p. 14). The published version may correct them. That is unverified.
Open questions
- Does a normativist account that fixes the extension by a specified theory of justice (Rawlsian, capability-based) escape both horns? If so, is it still “pure”?
- Is the co-evolution of medical tools toward justice a real historical tendency? Medicalisation studies of, for example, the expansion of DSM categories could test the second horn.
- Can Kukla take the institution of medicine as given without importing a naturalist or constructivist criterion? That is the crux of the “name only” charge. Kukla’s reply, if any exists, would settle it.
- What changed in the published CJP version (pp. 99–119)?
Corrections to the seeded skim
- The skim says the circularity objection might fail because Kukla “can take the institution of medicine as independently fixed, as Veit himself concedes on p. 17”. The full text makes no such concession. Pp. 15 and 17 raise holding medicine fixed as the only escape, and Veit argues that taking it makes the account “a purely normativist account in name only” (p. 17), because the fixing has to come from naturalist or constructivist resources (p. 16). The escape route is the second horn of Veit’s own argument.
- The conservative-majority thought experiment (p. 14) does not medicalise homosexuality or drapetomania. It medicalises “an unwillingess to bear the child of one’s rapist, the desire to love someone of the opposite sex [sic — apparently a slip for ‘same sex’], and the opposition to the dominant religion”. Veit’s point is that Kukla’s proposal “would be used to justify the very things they aimed to condemn”. Homosexuality and drapetomania come in earlier, as cases naturalists and constructivists supposedly fail to condemn (pp. 11–12).
- The skim’s attribution of “§4 (p. 8)” is right, but it leaves out the further point on p. 9. There Veit denies that disease conceptually entails a moral right to treatment, and holds that pathology is linked to losses in wellbeing and autonomy empirically. That link is the positive thesis the conclusion returns to (p. 17).
- The paper’s citation of Kukla (2014) is inconsistent. The reference list gives pp. 539–554 of the Routledge Companion to Bioethics, but every quotation is cited at pp. 515–529. Which is correct is unverified.
- The published version’s title differs, as the skim notes. Its text could not be checked for revisions (see read:).