Wittgenstein, Ludwig

Ludwig Wittgenstein
Ludwig Wittgenstein

Philosophy with The VALiens: Ludwig Wittgenstein’s theories of language

This short discussion paper will examine the applicability of Wittgenstein’s two theories of language to understanding the nature of diagnoses.

It can be argued that ‘the diagnosis’ is the elemental concept of clinical medicine. Without it little analysis is possible, and such analysis as is possible slides around uncertainly among arguments so metaphysical as to be meaningless. Diagnoses are the hooks on which we hang all of medicine.

As a newly qualified doctor I believed not only in the utility of diagnoses but also in their objective reality. The patients on the ward with a prolactinoma, heart failure or clinical depression had those conditions. Their illnesses were as real as their pyjamas. Indeed, as a student of medicine, those patients were defined by their diagnosis.

As I progressed in medicine my view of the nature of ‘the diagnosis’ changed.

The first realisation on the ward round was that the definitive diagnosis was made by the doctor at the apex of the pyramid of authority. The consultant neurologist’s diagnosis of ‘ice-pick headache syndrome’ was the gold standard. There was nothing to measure it against. This was diagnosis defined by authoritative opinion.

The next realisation was that the biological variation of disease and people means that diagnostic labels sometimes have limited meaning. What exactly do we mean when we make the diagnosis of ‘heart failure’ in an 84-year-old with multiple comorbidities, each of which affects her biochemistry, organ function, response to treatment and prognosis? The question becomes particularly pertinent when the label carries with it a requirement to be treated according to protocol in order for the practitioner to meet externally set targets.

The last realisation was of the huge and potentially distorting power that comes with legitimising illness. Giving ‘disease status’ to a person’s suffering confers social advantages (and sometimes psychological risks) and is an immensely powerful process. In its most frequent and benign form it is manifest as the patient who always has ‘sinusitis’ or ‘flu’ rather than a head cold. More infrequently, but more seriously in its consequences, it is manifest in the proliferation of unexplained clusters of symptoms with authoritative diagnostic labels — myalgic encephalitis (ME), multiple chemical sensitivity, post-traumatic stress disorder (PTSD). If anyone doubts the legitimising power of these diagnostic labels then let them try stating in print that these ‘diagnoses’ do not have an objective existence and then wait for the response.

Diagnoses are, in the end, merely classifications. They are not meant to establish absolute truths. They are practical ways of grouping medical phenomena in order to allow comparisons and promote understanding.The social advantages that come with a ‘medical label’ for our misfortune often distort this essential truth.

However, this minimalist idea of diagnosis as classical taxonomy over simplifies the process and potentially ignores key elements. Professor Dinant in the Oxford Textbook of Primary Medical Care defines a disease as a set of closely related symptoms with a specific aetiological background, a plausible physiological pathway, a predictable natural history and the need for a specific therapy. This definition certainly covers illnesses like hypothyroidism or the fractured femur. It fails, though, to capture such loose entities as fibromyalgia, mechanical low back pain or chronic fatigue syndrome. The definition does not acknowledge that diagnoses are made within the structure of a society and have value judgments implicit within them. This is particularly apparent with psychiatric diagnoses. Thus soldiers from the Boer War were cowards, soldiers from the First World War had conversion hysteria and those from the Vietnam War had PTSD.

Wittgenstein was concerned with the relationship between language and the ‘real’ world of objects and emotions. His analysis of the relationship of language to the external world has many analogies with the relationship of diagnosis to illness.

In the early part of his professional life Wittgenstein developed the ‘picture theory’ of language. He believed that there were ‘atomic propositions’ in language which mirrored the structure of reality. Language thus described an independent reality and, indeed, the structure of reality could be inferred from the structure of language. Wittgenstein believed, however, that only ‘fact stating’ language could be said to be meaningful. He believed that all philosophical problems (and many personal ones) arose because people used language in circumstances when it had no meaning. He was advocating a highly technical and restrictive use of language to avoid error. ‘Of that which we cannot speak, thereof we must be silent.’

This theory is analogous to the biophysical model of a diagnosis. In this form a diagnostic label mirrors some biochemical or physical process that leads to malfunction of the organism. Some doctors believe, like the early Wittgenstein, that serious errors arise when we stray from this formal discipline and create ‘woolly’ diagnostic categories that do not mirror biophysical reality.

Wittgenstein wrote his first work — the Tractatus Logico-Philosophicus — while in the trenches on the Eastern Front in the First World War. With typical Wittgensteinian humility he believed he had solved the problems of philosophy with this work. After the war he gave up philosophy, gave away his massive inherited fortune, and became a (bad) primary school teacher in rural Austria.

When he returned to philosophy in Cambridge in 1929 his thinking was dramatically different. Wittgenstein had come to believe that language did not represent a reality ‘out there’ but was an instrument or tool woven into human practice. In the Tractatus Logico-Philosophicus he believed that the meaning of language came from its logical form. His later belief was that language is an elastic, social, and sometimes ambiguous structure that necessarily defies simplistic definition because of its scope and complexity. Language’s meaning, he believed, is defined by how it is used in daily life rather than by any logical structure that underlies it. It is meaningless to look at language divorced from the society within which it takes place. Wittgenstein had shifted from believing that language reflected reality, to seeing language as a metaphor for reality. It is in its very messiness and adaptability that Wittgenstein believed the essence and power of language lies.

I believe that there are useful analogies between Wittgenstein’s theories of language and the nature of diagnosis in medicine. Arguments about the existence and definition of diagnoses like ‘ME’ and ‘PTSD’ have striking similarities between themselves, and with the philosophical problems of existence and definition that preceded Wittgenstein.

A diagnosis of a fractured femur is different from a diagnosis of depression in both content and form. The attributes that make each a ‘diagnosis’ are very different. Errors can arise if we use the same tools (of evidence-based medicine, for example) to analyse these entities as though they have objective reality and commonalities as ‘diagnoses’. For example, diagnoses that are more ‘biosocial’ than ‘biophysical’ are more meaningful when applied to a class of patients than to an individual. We are potentially just as much in error if we say that ‘chronic fatigue syndrome (CFS)’ does not exist, as if we say that ‘ME’ has the same attributes as a disease as mumps encephalitis. It maybe helpful if we, like the later Wittgenstein, recognise that our categories of ‘diagnosis’ are more complex entities than mere mirrors of an external biophysical reality.

A diagnosis is, in the end, defined by its utility in both medicine and society rather than by any formal categorisation. Attempts to ‘define away’ loose diagnostic entities, such as post-traumatic fatigue syndrome or ME, fail to make explicit these social and utilitarian aspects of ‘the diagnosis’. However, it is equally unhelpful to treat iron deficiency anaemia and CFS/ME as though they are the same type of categorical entities.

—- original source http://www.ncbi.nlm.nih.gov —-

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