Elementary concepts of medicine: I. Medicine: challenges with its concepts

Medical activity, no one doubts, requires thinking. In fact, ‘action without thinking [is] unimaginable’ (von Mises 1966, p. 177). Thinking, in turn, requires concepts: The human intellect is open only from below, so that all it receives must come, in some way, from the sense faculties. . . . The intellect begins to function when we first apprehend the abstract or general meaning of the things about us. . . . [T]he normal human eventually comes to develop general concepts, which, though based on experience, are independent of any particular experience (McCall 1963, pp. 1, 3). A concept embodies the essence of a thing (McCall 1963, p. 4), expressed by the concept's definition (McCall 1963, p. 7). Given consciousness of a concept, ‘the mind does not rest in it, but must go on to think something about[it], to make a judgement’ (McCall 1963, p. 6). This is expressed verbally by a proposition (McCall 1963, p. 39). Let us consider, as an example, the judgement about radiology expressed by the proposition that radiology is a specialty of medicine. This particular judgement presupposes the concepts – apprehension of the essence – of medicine, specialty of medicine, and radiology. We take it that medicine is the aggregate of the arts – specialty disciplines – of getting to know about the health of a client and on this basis teaching the client about their own health (Miettinen 2001a). In these terms, we take a specialty of medicine to be any one of the disciplines of such pursuit of knowing, and teaching based on the knowing, notably in the meaning of special expertise in this component discipline of medicine. Taking this proposition about the essence of a medical specialty as the major premise, and coupling it with the minor premise that radiology has that essence, we deduce the judgement above as the conclusion. This deduction obviously is formally correct; but its substantive or material and hence total correctness also requires that both of the premises are correct. One may question, in particular, whether the concept of radiology indeed is one of the pursuit of knowing about a client's health and on this basis teaching the client about their own health; or whether it is, instead, merely one of acquiring facts relevant to such knowing (by another type of specialist), assisting in their acquisition, intervening on the course of health, and assisting in this – with the use of radiography, other indepth imaging and/or radionucleotides the defining essence of this. As that example illustrates, even most elementary thinking about medical matters can become challenging once we set out to be even moderately serious about the concepts involved in our thoughts; and the challenges posed by medicine's most elementary concepts, even, are pervasive indeed. Hence the concern here – in the short essays to follow – to try to consolidate some elementary concepts of medicine. The set of concepts that we cover in this series is quite limited, but it is our hope that it will put the reader on a path to critical examination also of concepts that this series does not cover. Whenever possible, the definition of a concept is to express its proximate genus and its specific difference within the proximate genus (McCall 1963, p. 8). Above, we posited for medicine the proximate genus of aggregate of related arts, specialty disciplines; and the specific difference for all of them (within this genus) we took to be the aim to know and on this basis to teach the client about their own health. A concept is verbally expressed by a term, which is a word or a group of words (McCall 1963, p. 25). When a single word expresses a concept, this word thereby is categorematic (McCall 1963). ‘Medicine’ thus is a categorematic word. In addition to terms, a definition involves syncategorematic words, such as ‘the’ and ‘and’ (McCall 1963). The parts or elements in a definition that, in proper order as a whole, express the concept – the essence imbedded in it – are in logic termed notes (McCall 1963, p. 7). Given a thing – concept – thus defined, a property of it is: a characteristic which ‘flows from the essence’ of [it]– that is, either it can be deduced from the very nature or meaning of the thing, or at least its logical connection with the nature as known is evident. Not only is it found invariably whenever the essence is found, but, it is a specific property, it can be true of no other kind of thing (McCall 1963, p. 10). Thus, as per the definition above, a property of medicine is that by availing oneself of its offerings one may learn something less-than-obvious about one's own (or someone else’s) health, including how it might be changed for the better. Another, related property: medical ideas about a person's or community's health, are not subject to questioning from the vantage of any other discipline (whereas medical actions, based on these ideas, are). Another example of particular note is the properties of diagnostics. A diagnostic may be defined as a procedure aimed at informing diagnosis; that is, providing a fact (or factoid, multidimensional perhaps) informative about the presence/absence of a particular illness (or a subtype of it); that is, for changing/updating the probability of the presence/absence of the illness (or its subtype) at issue through the fact it produces. From this essence, diagnostic informativeness flows as the specific, unique property of a diagnostic (Miettinen 2001b). Naturally, the properties of all medical procedures/actions, in this logic-meaning of ‘property’, are the respective desired, useful properties of these (Miettinen 2001b,c,d). In the sense of logic, thus, a medical action's useful property may be said to be the property of it – distinct from its incidental, generally undesired characteristics. Definition by proximate genus and specific difference is not always possible in medicine; and in these situations, it is necessary to resort to a generic definition (specifying proximate genus) supplemented by more-or-less specific but less than unique characteristics, thus achieving a merely descriptive substitute for a genuine definition (McCall 1963, pp. 9–10). Descriptive definitions of general practice and general internal medicine may serve as examples, notably when focusing on the distinction(s) between the two. While medical activity obviously requires concepts, study of these, and hence medical thought itself, is held back by the unfortunate reality that the definitions of various elementary concepts, even including that of medicine itself (Miettinen 2001a), are very commonly inconsistent, confusing and also logically untenable. One class of anomalous concepts in medicine is characterized by what in logic is termed ‘category error’. The error can have sheer ignorance as its foundation. A prime example of this is the concept of modern practice of medicine as science, an error founded on the authoritative yet ignorant concept of science as something definable by its unique method together with the equally ignorant notion that this very method characterizes scientific practice of medicine (Miettinen 2001e); or alternatively, this error is founded on the idea that ability suitably to explain practice makes it science (Miettinen 2001e). In some other instances, the category error is wholly incomprehensible as to its origin in cognitive error, prime examples of this being the concepts of a diagnostic's use and screening as interventions (Miettinen 2001b,c,d). Another class of anomalous concepts is characterized by ‘logical malformation’. A prime example of this is the commonly touted properties of diagnostics – of the form of conditional frequency/probability taken to be singular in magnitude despite relevant non-singularity of the condition (Miettinen 2001b). As a remedy to this anomaly (also illogical), there is a tendency to make these properties specific to this or that ‘patient mix’ (quite ill-defined), even though diagnostics are applied to individuals, as individuals, one at a time. Some of the now-prevailing concepts in medicine plain miss the unique essence of that which is at issue. Of this, there is no more compelling an example than that of medicine itself, already alluded to above. In the prevailing definitions (Dorland 1994; Stedman 1995), medicine is said to be about prevention and treatment of illness (in addition to diagnosis). In these terms, the traffic police practises preventive medicine (as to injuries), and the ambulance technician practises therapeutic medicine, etc.; but they themselves do not agree with these implications of those notes in the prevailing definitions of medicine, nor do doctors. We hold, as we implied above (cf. Miettinen 2001a), that intervention is not definitional to medicine. As for knowing about health, engineers and military officers know about health risks and professionally engage in prognostication regarding injuries; but their prognosis is founded on inputs different from that which is prone to characterize medical knowing about the client's health – in-depth knowledge (abstract) about the human body in respect to health of it and illness in it. and when professionals other than doctors know, their concern is not to teach any client on this basis. Finally, various concepts of medicine remain incompletely understood on account of anomalous form of their definitions in medical dictionaries. Quite commonly, medical dictionary definitions list some components without reference to the higher-order concept under which these are but an unintentionally incomplete specification, as when referring specifically to diagnosis instead of simply to gnosis (n.o.s.), or specifically to prevention and treatment instead of simply to intervention (which encompasses rehabilitation as well). More fundamentally medical dictionary definitions are liable to involve statements of what usually is the case, thus violating the principle that a definition is to express the invariant and unique essence imbedded in the concept at issue, this and nothing but this. Very commonly, as will become evident, the definition's pleonastic quality takes away from the ability to grasp the essence that the definition is to specify. Inconsistencies between alternative sources are not only a further source of confusion but prima facie evidence of it. In the essays that follow, we critically examine some elementary concepts relevant to thought in each genuine specialty of medicine, concepts beyond that of medicine itself. The aim is to thereby facilitate and advance thinking among doctors and among those concerned with medical matters from whatever professional perspective.

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