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Medicine as an essentially contested concept
  1. C McKnight
  1. School of Philosophical Studies, Queen’s University, Belfast, Northern Ireland, UK; philosophy{at}qub.ac.uk

    Abstract

    W B Gallie’s notion of essentially contested concepts remains of philosophical interest. I argue that medicine is one such concept and look at the consequences of this as regards the inappropriateness of looking for definitions and necessary and sufficient conditions to settle debates about what medicine is and is not.

    • contested concepts
    • medicine

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    The notion of essentially contested concepts was introduced in the 1950s by W B Gallie1 and has become the object of renewed interest in recent years. Having given a brief summary of Gallie’s criteria for essential contestedness, I shall argue that medicine is a prime candidate for being such a concept and discuss briefly the consequences of that proposal.

    Gallie gives the following conditions for concepts to be essentially contestable:

    1. They are appraisive.

    2. They denote an essentially complex activity.

    3. They are initially variously describable and differences are likely between their users about the relative importance of different elements in the complex activity.

    4. They are open ended and subject to considerable modification in the light of changing times and such modification cannot be predicted or prescribed in advance.

    5. Each party in a dispute recognises that its own use of the concept is contested by those of other parties. To use an essentially contested concept means to use it against other users. To use such a concept means to use it aggresssively and defensively.

    6. Such concepts must be derived from an original exemplar (or exemplars) whose authority is acknowledged by all the contestant users of the concept. This condition is required to ensure that we are dealing with a single concept and not two or more distinct or confused concepts.

    7. Use of these concepts requires the probability or plausibility of the claim that the continuous competition for acknowledgement as between contestant users enables the original exemplar’s achievement to be sustained and/or developed in optimum fashion.

    Gallie gives as examples of such concepts “art”, “democracy”, “social justice”, and “religion” but the one with which he works most extensively is “championship”. In the first place, (1) “champion” is appraisive. Champion is a good thing to be. (2) To be champions, a team must play a game which will have many elements in the appraisal of the players. (3) Championship is certainly multiply describable. Being champions is not simply a matter of getting the highest scores; there will be considerations of style, technique, sportsmanship, and so on involved. And there is likely to be disagreement about the importance of these and the extent to which they are manifested by different teams. (4) The concept is definitely open ended—new champions can emerge at any time who may displace earlier ones and there is no reason to think that it will be predictable in advance who the new ones will be. (5) Claimants to the title of champion will almost certainly recognise that their claim is contested by other parties. “We are the champions” and “you are not the champions” are most certainly used aggressively and defensively. (6) It is quite plausible that a game needs acknowledged exemplars whom everyone will agree to be champions. Anyone who understands the concept at all must acknowledge that—for example, Don Bradman, Gordon Richards, and Stanley Matthews were champions. (7) Defensible claims by new candidates for championship status must show that they are continuing the traditions of these players and developing them in suitable ways. And there is unlikely to be consensus on what those ways are and what constitutes optimal progress and development.

    MEDICINE

    Let us see how medicine matches up to these conditions of essential contestedness.

    (1) It is clear I think that “medicine” is appraisive. Medicine is a good thing to practise and a doctor is a good thing to be. (2) It hardly needs arguing that any branch of medicine you care to think of will involve internally complex activities. Condition (3) too seems clearly met. Even within a particular discipline, say surgery, there will be a number of aspects to the activities involved. Speed, dexterity, sensitivity to patient’s feelings, and up to date knowledge of the subject may all be part of what makes a good surgeon. And there will inevitably be disagreement about the relative value and importance of these aspects. We all know the sort of disputes: Mr X is the best surgeon because he takes the most notice of what patients say, “Yes but he is amazingly slow and puts lives at risk unneccesarily. Mr Y is quicker”; “But Mr X has a lower death rate”; “That’s because the majority of his patients are young and otherwise healthy, while most of Mr Y’s come from deprived backgrounds”. There is no reason to think that these disputes are essentially resoluble. (4) What counts as medicine clearly changes over time. With changes in technology, availability of drugs, economic progress etc, medicine today looks very different from even 100 years ago let alone the time of Hippocrates. There is every reason to think that new activities will come under the aegis of medicine in the future and that perhaps some will depart from it. And such changes are certainly not predictable or prescribable in advance. (5) It is true, I believe, that parties who disagree about whether such and such an activity counts as “medicine” do, or should, recognise that their use is contested by other parties. Someone who claims—for example, that psychiatry (really) is medicine is using the concept of medicine defensively against those who deny it. Equally, those like Dr Szasz who claim that mental illness is not (really) illness and psychiatry not (really) medicine are using the concepts aggressively. (6) It is not plausible to suppose that mastery of the concept requires the acknowledgement of any single exemplar about which there must be consensus. But it would seem arguable that anyone who refused to accept that what—for example, Hippocrates or Lister or Magdi Yacoub practised was medicine simply lacked the concept. Equally perhaps with anyone who refuses to acknowledge that—for example, surgery counts as a branch of medicine (but what about cosmetic surgery?) (7) Those who claim that what they practise is medicine can certainly be understood as claiming that their activities are a continuation of and probably an improvement on those of the great and the good of the past. Those who dispute the claim may be understood as questioning the historical continuity. Psychiatry is (is not) medicine because it does (does not) have enough in common with other disciplines historically acknowledged to be medical.

    CONSEQUENCES

    There is a reasonable case to be made, then, for the idea that medicine is an essentially contested concept in Gallie’s sense. Let us look at some consequences of this.

    1. “Essentially contested” means “essentially contestable”. From reading Gallie it is clear that what interests him is not whether use of a concept is actually contested but whether it could be. Suppose—for example, that no one at present actually disputes that Manchester United are the champions. That does not render the concept “champion” uncontestable. The point is that at any time someone could contest it and could have good reasons for doing so; even if only one user remains alive the concept would be contestable though not actually contested. The force of “essentially” is to mark off this kind of contestedness from contests which are simply contingent or accidental, perhaps resulting from ignorance, which can in principle be resolved. To claim that a concept is essentially contested is to claim that disputes over its use are not resoluble even in principle.

    2. Where we are dealing with essentially contested concepts it will be of no help to search for necessary and sufficient conditions. The open endedness of the concepts concerned means that we cannot lay down in advance rules for their future application and any attempted statement of such conditions will be itself disputable. Someone who states—for example, that “a government is a democracy if and only if every citizen over 21 has a single vote” automatically excludes—for example, governments with different voting ages, governments which allow plural voting, and governments who do not see voting as being crucial to democracy at all from being candidates for the description “democratic”. And to do so indicates a misunderstanding of the concept of democracy. Anyone who understands its essential contestedness will realise, however committed he may be to the sort of democracy described above that there will be other people with different commitments who use the concept equally well and with equal right.

    3. Closely connected with (2) is the observation that where we are dealing with essentially contested concepts definitions will not usually be of help. When discussing the question “is the USA a democracy” or “is Zimbabwe one” it is no use saying “let’s first define ‘democracy’ and then look and see whether the US or Zimbabwe fits the definition”. This is so because the definition itself, whatever one we use, will beg the question against those who use “democracy” differently though quite properly and correctly. The same goes for those who ask, for example, “is the US really a democracy” or “what is the essence of democracy”.

    4. The fourth observation concerns rationality. Where a use is disputed there is room for rational debate between the disputants. If we return to the “champion” example, there may well be what Gallie calls “floaters” who waver between the championship claims of say Manchester United and Liverpool. Supporters of each team may hope to sway them by pointing to factors which indicate the superiority of their side and some may change allegiance and perhaps change back again if the allegiance was lukewarm. Such discussions will be rational and appeal to relevant reasons. It is unlikely, though, that diehard supporters of either team will be swayed. The rationality involved is not such that one might expect it to lead to agreement even in the long run as might be expected (or have been expected in Gallie’s time) of the rationality involved in scientific disputes.

    A recent volume of this journal contained not only a debate on the notion of mental illness between Dr Szasz and Mr Brassington,2,3 but also a critique of the “biomedical” model for medicine by Dr Greaves4 in which he indicates a preference for a more “humanistic” model. If it is indeed true that the concept of medicine is essentially contested such debates are unlikely to terminate. But the debates are not therefore rendered futile. There is room for rational discussion between defenders and opponents of Dr Szasz as there is for those who disagree about the correct model (the “essence”?) for medicine. Each side will call in aid factors involved in activities which everyone agrees to be medical. “Floaters” may be convinced by the strength of arguments on one side or the other but diehards will remain unconvinced. Disagreements will not be resolved by saying “let us first lay down necessary and sufficient conditions for something to be medical and see whether psychiatry satisfies them” or “let us define ‘medicine’ and see whether psychiatry fits the definition”. Such procedures will simply beg the question in favour of one side of the debate rather than resolving it. And everyone who fully understands the concept will realise that whatever account is given will remain contestable

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