The world health organisation needs to reconsider its definition of healthBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7091.1409 (Published 10 May 1997) Cite this as: BMJ 1997;314:1409
- Rodolfo Saracci, director of research in epidemiologya
The World Health Organisation's definition of health seems to work against its effective functioning. When the WHO was established nearly half a century ago the text of its constitution defined health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”1 This by now classical definition of health, conceived in the aftermath of the second world war, when peace and health were seen as inseparable,2 had one merit lasting long beyond the circumstances of origin: it made explicit that disease and infirmity, when isolated from subjective experience, are inadequate to qualify health. Widening health to the psychological and the social dimension was a major advance, but although it was conceptually important, it had no direct operational value. As one commentator put it, “This [definition] is a fine and inspiring concept and its pursuit guarantees health professionals unlimited opportunities for work in the future, but is not of much practical use.”3
Problems with the definition
However, it is at the conceptual level that the definition runs into the most serious problems, which impair its guiding role when the conflict between health needs and resources has become of paramount concern, nationally and internationally. In fact, a state of complete physical, mental, and social wellbeing corresponds much more closely to happiness than to health. These two words designate distinct life experiences. Sigmund Freud, an appropriate reference in psychological matters, saw it clearly when, after stopping smoking cigars for health reasons, he wrote: “I learned that health was to be had at a certain cost…. Thus I am now better than I was, but not happier.”4
Not only are health and happiness distinct experiences but their relationship is neither fixed nor constant. Having a serious disease is likely to make you less happy, but not having a serious disease does not amount to happiness. Common existential problems–involving emotions, passions, personal values, and questions on the meaning of life–can make your days less than happy or even frankly uncomfortable, but they are not reducible to health problems.
The distinction between health and happiness is crucially relevant in terms of rights, in particular “positive” rights or entitlements requiring societal actions to ensure that they effectively and fully materialise.5 Whereas it can be argued that health is a positive and universal human right, it seems impossible to construct an argument that happiness (though not its material and social preconditions) is a positive right simply because happiness cannot be delivered or imposed on a person by any societal action. Happiness is strictly subjective both as an achievement and an appreciation.
Consequences of the definition
Failing to distinguish health from happiness has four main consequences. Firstly, any disturbance to happiness, however minimal, may come to be seen as a health problem.
Secondly, because the quest for happiness is essentially boundless, the quest for health also becomes boundless. This legitimises an unlimited demand for health services. Of course, some people may legitimately decide that they want to pursue happiness as well as health by medical means, as other people may do through music, religion, or love. For example, some people may wish to have their features surgically redesigned to suit some aesthetic ideal. But this preference represents a personal way to happiness rather than a universal right to health.
Thirdly, a point rarely noted, annexing happiness to health and regarding health (in fact, happiness) as a universal positive right introduces an underlying prescriptive view of happiness in society.6 This undervalues personal autonomy and could be established only in totalitarian regimes.
Finally, and by far most important, trying to guarantee the unattainable–happiness for every citizen–will inevitably subtract resources and jeopardise the chances of guaranteeing the gradually attainable–justice and equity in health. The necessary and formidable task of reducing inequalities and achieving equity in health, a growing point in the reformulation of the WHO's programmes of action,7 becomes impossible if it is not even clear what needs to be equitably distributed.
Towards a solution
To remove the fundamental ambiguity of happiness versus health, a descriptor of health would be helpful–for example, “Health is a condition of well being free of disease or infirmity and a basic and universal human right.” This description does not contradict the definition in the WHO's constitution: rather it provides an intermediate concept linking the WHO's ideal to the real world of health and disease as measurable by means of appropriate indicators of mortality, morbidity, and quality of life. By removing the ambiguity between health and happiness and emphasising health as a basic human right, it provides a reference criterion against which to gauge how far health programmes incorporate and meet the requirements of health equity.