Principles

 

The Glossary has been developed on the following principles

The Meaning of Words

The Royal Victoria Infirmary in Newcastle, the hub of hospital care in the north-east for many years – solid, Victorian, dependable. The hospital’s honest, uncompromising and practical atmosphere might strike you as an unlikely setting for the 20^th century’s most influential philosopher, but Ludwig Wiggenstein was employed as a laboratory technician there during the Second World War. He showed such great promise as a laboratory investigator that attempts were made to persuade him to take up a scientific career. However, he chose to return to philosophy, linguistic philosophy in particular:

• proposing, in his tantalising prose, that arguments and differences of opinion resulted from a failure to recognise that
• the two sides were using the same word with different meanings

 

Defining words by words

The definition of a word is the summary of its meaning by a lexicographer such as Dr Johnson, some time Fellow of Pembroke College, Oxford, and compiler of the first great English Dictionary. It was another Fellow of an Oxford College, Dr James Murray, first Editor of the Oxford English Dictionary, who decided that a dictionary should contain not only definitions but also the meanings of the words by providing examples of the word in use, arranged chronologically to that the evolution of the meaning of the word could be understood. The meaning of a word is often different from its definition and can best be understood by observing its use. Murray’s policy was at first fiercely resisted by some of the Delegates of the Oxford University Press because of the effect this policy had on the magnitude, and therefore cost, of the exercise. Both were correct; the Delegates because the task was immensely long (by the time of Murray’s death many years after the commencement the Dictionary had reached no further than the letter O), and Murray because the enduring success of the Oxford English Dictionary has changed for ever the way we think and find out about meanings(1).

Defining words by their usage.

 

The principles of James Murray and the philosophy of Ludwig Wittgenstein are very similar. Wittgenstein’s philosophy is difficult to read and the two great works, the Tractatus Logico Philosophicus (2) and Philosophical Investigations(3) consist of lean, numbered propositions, arranged hierarchically in the former and as a single sequence in the latter, but the absence of long paragraphs does not make them easy to understand. Easier access is provided by the numerous books about the twentieth century’s most influential philosophers, for example Antony Kenny’s book called Wittgenstein(4).

There is no meaning of a word that is always and indubitably the right meaning. There are only uses which are clear and uses which are not clear, uses which are new and uses which are not new. The need to observe how a word is used in order to understand its meaning is one of the principles of Wittgenstein’s philosophy that underpins this book, and rather than expecting the reader to buy Lasts’s Dictionary of Epidemiology(5), excellent though that is, we have endeavoured to make it clear how we are using particular terms.

Two other of Wittgenstein’s principles are also relevant to decision-makers.

• New words such as “Internet”, or new uses of words such as “World Wide Web” can clarify, confuse and be useful, but as the term becomes more widely used by more people, its use becomes increasingly diverse and there may come a point at which the term causes more confusion than clarity and should no longer be used. Consider, for example, how often you have heard the term “evidence” used when it was obvious that it was being used with a different meaning from the way in which you would use it.

 

• Many arguments, Wittgenstein believed all arguments, result from a failure to appreciate that the people involved have failed to agree on the meaning of the terms being used. Consider, for example, how often you have heard arguments about the proposition that “evidence-based medicine destroys clinical freedom” without time being taken to reach agreement on the terms “evidence-based medicine”, “destroys”, and “clinical freedom”.

 

Decision-making can be improved and arguments prevented, therefore, by prefacing the debate with statements such as:

“When we use the word “evidence” we mean “knowledge derived from research”, when we use knowledge derived from our own experience, we shall make that clear.”

Defining words by examples – Ostensive definition

 

Wittgenstein also emphasised the need to show how a word was being used

“When they (my elders) named some object, and accordingly moved towards something, I saw this and grasped that the thing was called by the sound they uttered when they meant to point it out. Their intention was shewn by their bodily movements, as it were the natural language of all peoples: the expresxsion of the face, the play of the eyes, the movement of other parts of the body, and the tone of voice which expresses our state of mind in seeking, having, rejecting, or avoiding something. Thus, as I heard words repeatedly used in their proper places in various sentences, I gradually learnt to understand what objects they signified; and after I had trained my mouth to form these signs, I used them to express my own desires…

 

 Let us imagine a language for which the description given by Augustine is right. The language is meant to serve for communication stones: there are blocks, pillars, slabs and beams. B has to pass the stones, and that in the order in which A needs them. For this purpose they use a language consisting of the words “block”, “pillar”, “slab”, “beam”. A calls them out; B brings the stone which he has learnt to bring at such-and-such a call. Conceive this as a complete primitive language. We could imagine that [this] language … was the whole language of A and B; even the whole language of a tribe. The children are brought up to perform these  actions, to use these words as they do so, and to react in this way to the words of others.

An important part of the training will consist in the teacher’s pointing to the objects, directing the child’s attention to them, and at the same time uttering a word; for instance the word “slab” as he points to that shape. (I do not want to call this “ostensive definition”, because the child cannot as yet ask what the name is. I will call it “ostensive teaching of words” – I say that it will form an important part of the training, because it is so with human beings; not because it could not be imagined otherwise). This ostensive teaching of words can be said to establish an association between the word and the thing.”

Source: Wittgenstein L (1958) Philosophical Investigations. UK: Basil Blackwell Publisher(p.2,3,4)

Word euthanasia

 

Sometimes it is necessary to take steps to discontinue the use of a term which is consistently and frequently the cause of confusion and as such prevents understanding and progress. This is less frequently necessary in management than in clinical practice because management decision-making involves many terms which are created and enter widespread use until they themselves become displaced by later fashions. “Benchmarking” and “modernising” are examples of such terms, and the same fate may, heaven forfend, befall “evidence-based decision-making”, but if it does cause more confusion than clarity then it should be dropped from decision-making discourse. Even in clinical practice, however, terms can cause confusion and may need to be deleted from debate.

In his highly praised biography, Ray Monk describes how Wittgenstein, when a technician in a research laboratory in Guy’s Hospital in 1941, joined a Medical Research Council team whose leader had observed that “there is in practice a wide variation in which application of the diagnosis of “shock” without an agreed meaning of the term” which was harmful to patients and “renders it impossible to assess the efficacy of the various methods of treatment adopted”. He argued that “ there is good ground, therefore “ or the view that it is better to avoid the diagnosis of “shock” and to replace it by an accurate and complete record of a patient’s state and progress, together with the treatment given.

Wittgenstein was himself influenced by a physicist, hertz, who proposed dropping the use of the term “force” from the vigorous debates of the time, accepting that if this were done “the questions as to the nature of force will not have been answered but our minds, no longer vexed, will cease to ask illegitimate questions”. Wittgenstein, in paying homage to this approach, said that “in my way of doing philosophy, its whole aim is to give an expression such a form that certain disquietudes disappear”. He also proposed that if Dr Grant was required to include the word “shock” in his Annual Report, as some authorities wished, the word should be printed “upside down to emphasize its unsuitability”.

Defining words by numbers

 

Vienna at the end of the Hapsburg Empire was in the final stages of its glory, already turning a little rotten on the bough. Although rottenness implies decay, decay is necessary for the creation of new life forms. Wittgenstein was a product of Vienna or, to be more precise, of the intellectual and wealthy Jewish community living in Vienna; so too was Malinowski (7). Malinowski argued contrary to Wittgenstein that knowledge was created, not by the lonely intellectual sitting at his desk, as Wittgenstein did through the English winters, but by groups of people taking and using language to create new knowledge.

The Vienna School of Philosophy flourished as Wittgenstein left the city and became very influential, particularly in Britain, where it gave rise to what is known as “logical positivism”, the leading figure and most eloquent reporter of which as AJ Ayer. In Language, Truth and Logic (8), Ayer took an approach to the definition of a term that did not rely on words at all.

He proposed that instead of trying to understand the meaning of a proposition by analysing the meaning of the individual terms that compose it, another approach should be taken.

“The criterion which we use to test the genuineness of apparent statements of fact is the

criterion of verifiability. We say that a sentence is factually significant to any given

person, if and only if, he knows how to verify the proposition which it purports to express – that is, if he knows what observations would lead him, under certain conditions, to accept the proposition as being true, or reject it as being false. And with regard to questions the procedure is the same. We enquire in every case what observations would lead us to answer the question, one way or the other; and, if none can be discovered, we must conclude that the sentence under consideration does not, as far as we are concerned, express a genuine question, however strongly its grammatical appearance may suggest that it does.”

The logical positivists believe that no term should be examined in isolation – a study of the term “efficiency” would be pointless – but investigated in the context of propositions, such as “this hospital is more efficient than the hospital. To define the meaning of this proposition, a logical positivist would not have recourse to a dictionary but instead seek to agree on the data that would need to be collected to confirm or refute it. Thus, for this particular proposition, the debate immediately becomes: “How would you measure efficiency?”. Options include:

• cost per case;
• throughput per bed
• percentage of costs spent on administration.

 

Meaning, reality and language

The traditional view of language was that it described reality. This is undoubtedly true for physical objects such as “a table” or “a chair” unless, one belongs to the more sceptical school of philosophy which holds that everything ceases to exist when one closes one’s eyes. For social constructs, however, language does not simply describe reality; it creates it.

The clearest description of the relationship between language and reality comes from anthropologists, notably Benjamin Lee Whorf (9), who worked as a loss adjuster for The Hartford Fire Insurance Company and studied the language of the Hopi Indians. He created the theory of linguistic relativity, which proposes that language creates social realities such as “the future” or “the quality of evidence! – or, indeed, “evidence-based healthcare”. Through the use and evolution of language comes social change and social reality. The work of the anthropologists such as Wharf and Edward Sapir, whose Wharf Sapir (10) hypothesis of linguistic relativity is the best articulation of this concept, for example, in the statement that “the fact of the matter is that the ‘real world’ is to a large extent unconsciously built up on the language habits of the group”, has been developed by sociologists. The most accessible sociological text is the Social Construction of Reality by Berger and Luck man(11).

Words have meanings but the meaning create and change reality as well as expressing it.

Indefinite definitions

Throughout this book, we have tried to give a clear definition of a term without implying that our definition is the definition; caveat lector, let the reader beware.

1. Winchester S. The Meaning of Everything: The Story of the Oxford English Dictionary. UK: Oxford University Press, 2003.
2. Wittgenstein L. Tractatus Logico-Philosophicus. UK: Routledge Classics, 2001.
3. Wittgenstein L. Philosophical Investigations (2^nd edition). UK: Basil Blackwell Ltd, 1958.
4. Kenny A. Wittgenstein. UK: Pelican Books, 1975.
5. Last J.M. A Dictionary of Epidemiology (2^nd edition). UK: Oxford University Press, 1988.
6. Monk R. Wittgenstein. UK: Vintage Press, 1991:445-7.
7. Gellner E. Language and Solitude: Wittgenstein, Malinowski and the Habsburg Dilemma. UK: Cambridge University Press. 1998.
8. Ayer A.J. Language, Truth and Logic. UK; Victor Gollancz Ltd, 1951.
9. Whorf B.L. Language Thought and Reality. USA: Massachusetts Institute of Technology, 1956.
10.  Sapir E. Language An Introduction to the Study of Speech (paperback). UK: Book Jungle, 2008.