Exploring Some Elusive Concepts Kenneth M Boyd Edinburgh University Medical School and the Institute of Medical Ethics

Downloaded from http://mh.bmj.com/ on April 6, 2017 - Published by group.bmj.com J Med Ethics: Medical Humanities 2000;26:9–17 Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts Kenneth M Boyd Edinburgh University Medical School and The Institute of Medical Ethics Abstract Let me stay with the dictionary to see what it says Concepts such as disease and health can be diYcult about those synonyms. to define precisely. Part of the reason for this is that Illness has three definitions. Two of them are of they embody value judgments and are rooted in the way the word was used up to the 18th metaphor. The precise meaning of terms like health, century—to mean either “wickedness, depravity, healing and wholeness is likely to remain elusive, immorality”, or “unpleasantness, disagreeable- because the disconcerting openness of the outlook ness, hurtfulness”. These older meanings reflect gained from experience alone resists the reduction of the fact that the word “ill” is a contracted form of first-person judgments (including those of religion) to “evil”. The third meaning, dating from the 17th third-person explanations (including those of century, is the modern one: “Ill health; the state of science). being ill”. The dictionary defines “ill” in this third sense as “a disease, a sickness”. Looking up “sick- (J Med Ethics: Medical Humanities 2000;26:9–17) ness” we find “The condition of being sick or ill; Keywords: Health; disease; healing; wholeness; illness; sickness illness, ill health”; and under “sick” (a Germanic word whose ultimate origin is unknown, but may be onomatopoeic) we find “aVected by illness, Introduction unwell, ailing ... not in a healthy state”, and, of In this paper, I want to explore possible meanings course, “having an inclination to vomit”. of a cluster of words—disease, illness, sickness, There is a rather unhelpful circularity about health, healing and wholeness. Many people have these dictionary definitions. But dictionaries of tried to elucidate what these words mean, but the English language usually only aim to tell us the agreed definitions are often elusive. In what origins of words and how they have been used his- follows I shall begin with some definitions of dis- torically. They do not aim at the much more con- ease, illness and sickness. I shall then try to say testable goal of conceptual clarity. For that we why definitions of disease and health are so have to look elsewhere. In this case, let us look at elusive; and I shall end with some observations on how disease, illness and sickness have been eluci- science and religion, in the light of which the dif- dated first by a medical practitioner, who ought to ficulty of defining health, healing and wholeness know something about the subject; and then, after may make some kind of sense. noting some popular and literary definitions, by a philosopher, who ought to know something about conceptual clarity. Dictionary definitions Dis-ease (from old French and ultimately Latin) is literally the absence of ease or elbow room. The A medical definition basic idea is of an impediment to free movement. Professor Marshall Marinker, a general prac- But nowadays the word is more commonly used titioner, suggested over twenty years ago a helpful without a hyphen to refer to a “disorder of struc- way of distinguishing between disease, illness and ture or function in an animal or plant of such a sickness. He characterises these “three modes of degree as to produce or threaten to produce unhealth’”as follows. detectable illness or disorder”—or again, more narrowly, to “a definable variety of such a “Disease ... is a pathological process, most often disorder, usually with specific signs or symptoms physical as in throat infection, or cancer of the or aVecting a specific location”. That at least is bronchus, sometimes undetermined in origin, as how the New Shorter Oxford Dictionary1 defines it, in schizophrenia. The quality which identifies dis- adding as synonyms: “(an) illness”, “(a) sickness”. ease is some deviation from a biological norm. Downloaded from http://mh.bmj.com/ on April 6, 2017 - Published by group.bmj.com 10 Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts There is an objectivity about disease which Popular and literary definitions doctors are able to see, touch, measure, smell. For some patients, the last of these may be the Diseases are valued as the central facts in the most important. Recently I was handing out to a medical view... class of medical students the General Medical “Illness ... is a feeling, an experience of Council’s booklets on The Duties of a Doctor. The unhealth which is entirely personal, interior to the university janitor who was helping me unpack person of the patient. Often it accompanies them remarked: “As far as I’m concerned the disease, but the disease may be undeclared, as in main duty of a doctor is to give me a sick note, the early stages of cancer or tuberculosis or otherwise I won’t get sick pay”. A week later, on a diabetes. Sometimes illness exists where no train, I met a recently unemployed man who disease can be found. Traditional medical educa- recounted to me at some length how he had tion has made the deafening silence of illness-in- cajoled his general practitioner into signing him the-absence-of-disease unbearable to the clini- oV for a few months longer, so that he could keep cian. The patient can oVer the doctor nothing to on getting sick pay until he got to pensionable age. satisfy his senses... And according to Hystories, by the American critic 3 “Sickness ... is the external and public mode of Elaine Showalter, new ways of getting recognised unhealth. Sickness is a social role, a status, a as sick are being found all the time. Modern cul- negotiated position in the world, a bargain struck ture is continually spawning hysterical between the person henceforward called ‘sick’, epidemics—in the pre-millennial years, ME, Gulf and a society which is prepared to recognise and war syndrome, recovered memory, multiple per- sustain him. The security of this role depends on sonality syndrome, satanic abuse and alien abduc- a number of factors, not least the possession of tion. These, a sympathetic reviewer of the book that much treasured gift, the disease. Sickness explained, were examples of: based on illness alone is a most uncertain status. “the conversion of emotional pain and conflict But even the possession of disease does not guar- into the camouflaged but culturally acceptable antee equity in sickness. Those with a chronic dis- language of body illness... Typically, individuals ease are much less secure than those with an acute who are unhappy or unfulfilled in their lives one; those with a psychiatric disease than those develop diVuse and evolving nervous complaints with a surgical one ... Best is an acute physical and eventually seek help. A physician, or some disease in a young man quickly determined by other scientific authority figure, concocts ‘a recovery or death—either will do, both are equally unified field theory providing a clear and coherent regarded.”2 explanation for the confusing symptoms’, as well as a new and a memorable name for the sydrome. Disease then, is the pathological process, devia- This explanation draws on contemporary disease tion from a biological norm. Illness is the theory, usually viral and immunological ideas. An patient’s experience of ill health, sometimes when individual case or two, often involving a well- no disease can be found. Sickness is the role known public personality, provides a popular negotiated with society. Marinker goes on to paradigm for the new synthesis of symptoms. A observe that a sizeable minority of patients who best selling novel ..., soon to become a major regularly consult general practitioners, particu- motion picture, first advertises the syndrome to a larly for repeat prescriptions, suVer from none of large audience. Magazine stories and television these modes of ill health. They appear, rather, to documentaries further publicise the symptoms. be seeking “to establish a healing relationship High-profile books for persons seeking infor- with another who articulates society’s willingness mation appear, as do patients’ autobiographies. and capability to help”. So a “patient”, in the Most recently, daily talk-shows, those agencies of sense of someone actively consulting a doctor mass pop psychotherapy, unite suVerers and rather than just being on the books, does not nec- therapists in order to dramatise their life stories essarily mean someone who has a disease, feels ill, and to explain the meaning of their disorder for or is recognised to be sick; and of course there are millions; in the process, participants cite enor- other more mundane reasons, short of wanting to mous projected numbers of the aZicted and encourage others to come forward... These are establish a healing relationship, why a patient may 4 consult a doctor—to be vaccinated before travel- acutely communicable diseases... .” ling abroad for example. Most patients most of So the reviewer, expounding Showalter, claims. the time however, probably can be classified as People with ME and Gulf war veterans, by having a disease, or feeling ill, or being recognised contrast, understandably might contest this view as sick. of what they are suVering from; and more Downloaded from http://mh.bmj.com/ on April 6, 2017 - Published by group.bmj.com Boyd 11 scientific findings about the veterans’ health5 have Marinker suggests, disease is the most tangible appeared since Hystories was published in 1997. mode of unhealth. When they talk about disease, Showalter’s argument nevertheless helps to illus- they know what they mean. Philosophers are less trate Marinker’s useful distinction between sure.

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