Journal of medical ethics, 1987, 13, 62-68 J Med Ethics: first published as 10.1136/jme.13.2.62 on 1 June 1987. Downloaded from Needs, need, needing * David Wiggins University College, Oxford and Sira Dermen, Tavistock Clinic, London not necessarily desire to have y. Whereas with needs Editor's note this implication will hold: I can only need to have x if It is a pervasive assumption that the proper basisfor whatever may be identical with x is something that I medical care is medical need. A further assumption that need. These points arise out of a more general one. doctors andadministratorsfrequently make is that medical What I need depends not on thought or the working of resources ought to be distributed according to medicalneed. my mind (or not only on these), as wanting or desiring But what is need? In this paper it is argued that there are do, but depends on the way things really are. Another two concepts ofneed, often conflated. One is an elliptical notable consequence of this is that, when one wants and instrumental concept - that ofneed relative to some something because it is F, one has only to believe or specified or specifiable desired end. The other concept is suspect that it is F, whereas, when one needs that ofa need taken in a categorical orabsolute sense. Itis something because it is F, it must really be F, whether with this that the author begins, claiming that it can be or not one believes that it is (1). For instance, ifit is true defined in terms ofthe relative sense, andsuggestingthat in that the patient needs medication M because M will the context ofjustifying rights and imposing duties, reduce the blood pressure, then M must really reduce copyright. including those relating to health care, it is the categorical the blood pressure, whether or not the patient or concept and its various further deterninations that are doctor knows or thinks it will. important. 2. Nevertheless, despite these differences, there are 1. Need is often thought of as desire of a special kind, at least two similarities between need and desire. First, (for example, rational desire or strong desire, or one may have no actual lack of that which one desires, http://jme.bmj.com/ whatever). But how can this be right? Certainly need and exactly similarly, one may have no actual lack of will often find its characteristic expression in desire. But that which one needs (2). And secondly, there is a since this expression will sometimes be markedly grammatical affinity in the sorts of language we use to inadequate to the need itself, it is hard to believe that speak ofneed and ofdesire. Just as 'desire' ('want') can needs as such are the same as desires, or that needing as either denote a thing desired (wanted) or denote a such is the same as any sort of desiring. particular given state or condition of desire (want), or It may be suggested that a need is some sort of a stand for that condition in general, so 'need' can either corrected desire: but to make this idea work would denote a thing needed or denote a particular given state on September 27, 2021 by guest. Protected involve much elaboration of the requisite 'correction', or condition of needing or stand for that condition in while drawing relatively little upon the idea of desire. general. (Nor would the suggestion save the extravagant claims sometimes made on behalf of the economic theory of 3. These similarities are insufficient to close the gap revealed preference that depends on so simple a between needs and desires; but they are not for that conception of desire and the springs of action.) It may reason any less important. be better therefore to acknowledge the general Consider the second similarity. In their accounts of distinctness of these notions ofneed and of desire, and need some writers have started out from things needed to accord the full prima facie force to all the various and others from the state or condition of need. This is differences. potentially confusing. But, except where a theory of For consider: I can desire something without need is hopelessly muddled, it is usually possible to needing it (or even thinking or subconsciously extrapolate from the account of the one to the supposing that I do). And I can need something corresponding account of the other. Aristotle, for without desiring it (or without even having heard ofit). instance, characterises a necessity or thing that is Again, if I desire to have x and x is the same as y, I do necessary, in the special sense of 'necessary' corresponding to our 'needed' or 'needful' to which he Key words accords separate recognition, as a thing: Need; necessity; needs and ethics; medical need; basic need. 'without which it is impossible to live (as one cannot Needs, need, needing 63 J Med Ethics: first published as 10.1136/jme.13.2.62 on 1 June 1987. Downloaded from live without breathing and nourishment), or without that stir our sense of importance or excite controversy. which it is not possible for good to exist or come to be It explains admirably what we might mean by saying or for bad to be discarded or got rid of (as for example, 'In spite of the development of in vitro methods of test drinking medicine is necessary so as not to be ill, or and experiment and advances in tissue culture sailing to Aegina so as to get money)' (3). techniques, we still need to perform experiments on live animals'; or what G D H Cole meant in saying of But one may readily deduce that it would have been the Beveridge Plan, 'The outstanding object [of the Aristotle's view that I need to have x if and only if my plan] is to provide as far as possible a unified system of having x is a precondition, things being what they are, income maintenance to cover needs arising from a of my continuing to live and/or a precondition, things variety of causes'; or what was meant in the often being what they are, of my enjoying good or ridding quoted nineteenth century socialist maxim, 'From myself ofevil (4). On this view, my needing x is a state each according to his ability, to each according to his or condition of dependency upon x with respect to need' (7). some (in the situation) non-negotiable good ofavoiding Every adequate account of need will have to some independently specifiable harm. Needing x is a interpret such claims convincingly. Yet if we stopped dependency upon having x in particular. For instance, here, the Aristotelian account would be seriously a thirty-five-year-old woman's need for calcium is a inadequate, and suspicion would gather around the state of dependency, with respect to the avoidance of very idea ofseeing the thing needed, in the way that the independently specifiable harms such as osteoporosis account proposes, as the precondition of some in the or whatever, on the intake of calcium. circumstances non-negotiable or relatively non- Tidying up a little and making one or two further negotiable goal of harm-avoidance. What if I say 'I decisions of theory, it might then be said that I need at need £20,000 to buy that Rolls Royce,' or what if, time t, to have x at time t, if and only if there is some having several suits already but wanting another, I serious harm that I can avoid, and it is necessary, simply say 'I need to find £200', where £200 is the price things being as they actually are during the relevant of the new suit that I want? The Aristotelian account periodp in which ti lies, that, ifI am to avoid that harm, must take these claims as both portentous and false - as I x at t, then have (5). portentous because it seems that the need is being copyright. What has to be added here is that the idea ofharm is represented as in some way connected with survival or correlative with ideas of human life and flourishing life, and as false because the suit is not in fact that each age and each culture has to make what it can indispensable to me. But there is of course a perfectly of; and that, even within a culture at a time, these ideas ordinary way oftaking them as unpretentious and true. are of their nature essentially contestable. That does not And it is this possibility, which is clearly provided for mean that in this area of discourse just anything goes, in language, that has encouraged a rival idea (8), or that the process of determination of harm is simply namely that needing is always by its nature needing for http://jme.bmj.com/ a matter ofcounting ayes and noes. These ideas oflife, a purpose - any purpose at all that may be specified - harm, flourishing are the focus of reasoned argument, and that statements of need which do not mention and ofa rich variety ofopposing analogies, which it can relevant purposes are somehow elliptical (according to still be hoped will converge in agreement over some, dishonestly elliptical) for sentences that do essentials that is both principled and capable of mention them (9). justifying itself. (In this, as in almost everything else, we draw credit in the present upon the prospect of 5. One thing seems right with the elliptical view and on September 27, 2021 by guest. Protected agreement. There is no rational alternative but to do another seems wrong.