W is for Wellbeing and the WHO definition of health

Although we are prepared to spend dizzying sums on health care no one seems quite sure what health is. The World Health Organization made a bold offer in 1948. Their definition of health is ‘not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being’. But this utopian vision is an unattainable ideal, bearing no relation to the struggles of real people in an imperfect world. Its faith in an attainable Nirvana is touching, but not credible. It is a flagrantly modernistic statement, and, like a statue of Lenin, it appears now as the ironic icon of a bygone age.

The WHO definition sees us as closed, knowable systems where imperfections should be fixed. Logically, as none of us is in this complete state of wellbeing, we are all in need of medical intervention to correct ‘abnormalities’. But should we view any deviation from perfection as pathology requiring treatment?

A biomedical approach to health is to define it by norms. ‘Two legs good, one leg bad.’ Certainly I have no desire to lose any limbs, but if I did could I not be healthy afterwards? Yet it is the only definition that makes sense within a biomedical model, and we are seeing our profession driven increasingly down a razor-sharp but narrow biomedical path. Disease is the model we use as doctors. But what matters to patients is whether they feel ill, or their function is impaired.

Could health be a more positive concept? Can we go beyond facts and admit values into our concept of health? Dietrich Bonhoeffer defined health as ‘the strength to be’. Bonhoeffer was saying that health is the ability to pursue our life story without insurmountable obstruction from illness. Unless I am an Olympic skier I can be healthy even after the loss of a leg. If I am Olympic skier I can regain health — I can still flourish — by seeking the courage to rewrite my life script. Thus health can be seen as the ability to flourish without being unduly impeded by illness or disability or, if necessary, by overcoming illness or disability.

There are three main concepts of health on offer. The WHO definition. The narrower biomedical model — health as the absence (or cure) of biomedical abnormalities. Or we can accept a more functional model — health as unimpaired flourishing, as ‘the strength to be’ — as in, free of obstacles, or to be able to surmount obstacles, to my dynamic life plan.

So I would offer this goal for health care. Health care should aim for the state of least possible illness or disability, or of maximal functional adaptation to illness or disability. Notice that I have not mentioned disease, only illness and disability — the things that matter to patients. This definition does not decry the role of biomedicine, but rather redirects our attention to the purpose and proper function of biomedicine. Let’s help people to be well, not just tell them they are sick.

• © British Journal of General Practice 2014