Jurandir Freire Costa

Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil.

Debate on the paper by Naomar de Almeida Filho


Debate sobre o artigo de Naomar de Almeida Filho



The article by Naomar Almeida Filho confirms what one expects of him. It is rigorous, clear, informative, intelligent, and open to reformulation. It is not easy to outline what might be an all-encompassing theory of health. However, his attempt was successful. Hence the idea of a debate is welcome and timely, and above all pays tribute to the author's effort.

Since the topic is quite lengthy, I will restrict myself to approaching it from a very limited angle, that of the concepts related to the field. I wish to raise an issue, that of cognitive models, in order to hear his opinion.

I believe that the attempt to reconcile the various descriptions of the terms disease, disorder, illness, sickness, and malady is difficult and extremely complicated. Either one leaves out important aspects of the problem or one raises the all-encompassing model to such a level of abstraction that the formal presentation becomes acceptable, but debilitated in its practical effects. By practical effects I mean more or less clear rules, indicating how to conduct research, evaluate results, deal with discussion of the field, etc.

I thus propose renouncing the intention to construct a meta-theory of health in favor of prompt descriptions, subject to revision and further in-depth development. From this perspective, I believe that we might derive theoretical and practical benefit from dividing the health field into two sets, that of physicalist descriptions and that of mentalist descriptions. In the former, we would classify facts postulated as "causally independent" of linguistic meaning and amenable to being approached by quantitative methods, i.e., experimental methods involving control and prediction. This set would include the traditional problems of biological medicine at all levels of complexity. In the second we would classify the facts that were "causally dependent on linguistic meanings", i.e., all of the "qualitative", mentally phenomenic aspects of the health experience. This set would include the facts belonging to the domains of philosophy, anthropology, sociology, history, genealogy, psychology, etc.

The advantage of this model would be to simplify possible research scripts without requiring researchers to undergo the effort of reconciling investigations from very different areas of knowledge. Under the current state of health research, it is extremely difficult to ask experts to have a command over such highly diverse areas. The literature in each field is so extensive that very few are willing or prepared to attempt conciliatory schemata among theories originating from realms of investigation that are so far apart from each other.

The validity of specific investigations would be determined by the canons proper to each area, and the legitimacy of the scientific contests in each of them would be evaluated according to independent ethical criteria. Such criteria would be subject to debate among the researchers and community of citizens interested in the subject. Nevertheless, I suggest that a general principle be adopted, more or less tacit in medical deontology, as the point of departure, namely "minimum suffering with maximum autonomy". The controversies concerning the meaning of "suffering" or "autonomy" would be the object of empirical discussions or epistemological or linguistic clarification. Based on such a principle, we could judge at what moment a given discipline was extrapolating its own field in an ethically legitimate way, which would require a description of the fact criticized according to another vocabulary or terminology.

To grant theoretical autonomy to the research sets means to respect what has already been done, taking better advantage of each one's critical potential. Thus, all discussion of the "quality of experience" of health, sickness, disease, illness, malady, normality, anomaly, etc. could be challenged, adjusted, corrected, improved, denied, etc., according to physicalist constructions and all nomological description of the same problems would be subject to debate according to the forms of knowledge that seek to offer empirical hypotheses concerning acquired beliefs related to the various "meanings" of terms like health, sickness, suffering, autonomy, etc. The difference between the paradigms would be respected without our necessarily having to understand "incommensurability" as a synonym for "untranslatability".

This is the issue in broad terms. If Almeida Filho finds it interesting, it would be extremely helpful to hear what he has to say.

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rio de Janeiro - RJ - Brazil