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“Being ill”

Below I intend to describe “being ill” in more detail. Not the professional definition concerns me, but a description of the experiences, behaviors, and signs which identify the ill person to himself and to non-professionals around him. I am aiming here at a sociocultural concept of illness, and at what Baron means when he says “an intuitively based humanly grounded ontology of illness.” “Ill” and “healthy” are concepts that in a polar sense are inseparable because each derives its meaning from the other. Therefore the problem posed above can also be formulated thus: by which criteria can ill and healthy be distinguished? In this question ill and healthy are classifying concepts which require making a short detour and discussing classification. Then a closer look at the hallmarks of being ill and their significance as criteria for ill-healthy will be taken. Finally there will be references to several criteria found in literature.

The paired concepts of “ill” and “healthy” are probably as old as humanity itself. These concepts are/were used by people in all sorts of cultures today and in the past. Many different theories explaining illness have been proposed. It might be redefined as, for instance, a religious or a medical concept. My intention is not to redefine illness itself but to focus on what being ill means.

Being ill is not synonymous to “having an illness.” That would imply inverted reasoning, namely that the “being ill” is derived from the concept “illness.” A consequence of my reasoning is that someone can have an illness without being ill. An example would be the lues latens, and what Taylor, quoting Feinstein, called “lanthanic” illness, such as a physical aberration which is discovered by coincidence, for instance during a medical check-up. Usually such aberrations are minor, which are interpreted as illness due to the predicted prognosis.

When accepting such a definition is not wished, but only being ill in its common meaning, the problem that it is difficult determining whether this concept means more or less the same for everybody in every era and culture is encountered. Nonetheless the experiences, behaviors, and signs by which being ill is recognized in our culture seem to be fairly universal.
“Being ill” can be limited in four ways:
  • Only living things can become ill. Here we will consider only humans.
  • Only individuals are ill. Solely as a metaphor can the concept “ill” be applied to groups, such as the family, Church, and society, or to abstractions, such as mutual relations, the economy, the world.
  • “Being ill” refers to a certain, in principle temporary, change in the ontological condition and existential quality, so a process. Where there is not to some degree a process, the person is not called ill. For instance, someone who is blind or deaf is not considered ill, even though such a disability may have been caused by illness.
  • Being ill is valued in a negative way.* All facts and signs associated with being ill derive their significance from this negative value judgment which is fairly intrinsically connected to it.
Before exploring the hallmarks of being ill in more detail it must be pointed out that it always denotes a special, aberrant event as opposed to the “normality” that is identified as health. “Ill” and “healthy” are two contrasting, in principle mutually exclusive concepts, although they cannot be clearly demarcated from each other. Van Dijk uses Moser’s term, Schwerpunktsbegriffsbildung. In this so-called core concept, concern is with the heart of, for instance, a certain characteristic, process, or state of affairs. The lines between one core concept and another cannot be clearly drawn. So “ill” and “healthy” are considered a polar pair of core concepts.

This implies that the characteristic differences between ill and healthy are at the same time criteria by which we can divide the universal class of living people into two classes: people who are ill and people who are healthy. As the attributes of illness also count as classifying criteria for the ill-healthy distinction, I interrupt my argumentation for some comments about classification.

When dividing a class of objects into two groups is desired according to a certain criterion, for instance, the presence or absence of a certain attribute, then, logically, that criterion must in the first place be unambiguous. In the second place, it must be possible to draw a clear line between the two groups. Thirdly, the entire class must be divisible into the two groups. Taylor posits that these logical conditions are generally not attainable when application of whatever type of classification to the sphere of living beings is attempted. Two important limitations must be taken into consideration.

The first limitation is that no criteria for classification will be equally and unambiguously valid for all items in the class. In the biological sciences classification criteria are generally established by combining several different factors into a cluster. When the cluster is composed of factors which must all be present the criterion is called conjunctive. More often, however, the criterion is disjunctive, that is to say, there is a certain amount of leeway expressed by the and/or formula. This is because there are always organisms to which not all the criteria included in the cluster apply. The more of the cluster’s elements apply to the entity, the more certain that entity’s classification is. Taylor reported that Beckman formulated two rules for biological classifications:
  1. The classification is formed by a cluster with a fairly large number of features.
  2. Each entity inside the realm is required to show only a certain amount of these features.
The second limitation is that the nature of the classifying criteria usually do not allow drawing clear lines between different classes. Taylor quotes Körner’s work about this. Körner indicates that even when an empirical class is demarcated from another one by a conjunctive criterion, the lines between the classes remain blurred to a certain extent. Where the line is finally drawn is unavoidably to a certain degree arbitrary. The arbitrary choice is determined as much as possible in accordance with the division’s factual state of affairs, and also by pragmatic considerations.

Clearly these limitations have to be accepted when seeking criteria for the ill/healthy classifications as well.

After these auxiliary remarks about classificatory aspects we can discuss the characteristic hallmarks of the “ill” concept. I will discuss these hallmarks from three points of view: the experiences; the behavior; and the attributes which distinguish the ill person from the healthy person. By consistently reasoning through each of these three angles, Fabrega developed three different concepts of illness. I will not do that here. I will describe the aspects drawn from these different angles as phenomenological, behavioral, and biological aspects of illness.

Phenomenologically – and here I limit myself to that which is experienced – being ill means a discontinuity in someone’s life. Feelings of being unhealthy impose themselves on ill people with an experiential quality that surrounds them and changes their lives, whether they wish it or not. Other experiences can join this general, imposed feeling of indisposition, such as pain or shortness of breath. Ill people feel powerless, their role is passive – it is happening to them. They experience being unfree, unable to do what they wish, having lost their autonomy. Ill people lose interest in more distant or abstract matters which normally engross them. Their mental horizon narrows. In serious illness the change in the way the world is experienced can be intense and far-reaching, so that it is massively restricted, even to the point of reduced consciousness or coma. In addition, being ill is ominous. The situation could worsen. There is always the possibility of an unfortunate outcome. The specter of approaching death, or of permanent disability, always hovers around people who are severely ill. Being ill can also evoke all sorts of other feelings, in ill people themselves as well as those around them. Ill people may feel worry and a need for care, but sometimes also guilt (being ill is sometimes associated with sin), anxiety, suspicion, anger, rebellion, resignation. The people around an ill person may feel a need to help, to comfort, to nurse, and to treat. But there can also be fear, for instance of contagion, hesitance, trivialization, accusation, or resentment.

In summary, this entire complex of experiential changes with negative value judgments can be called suffering, this word being used as a key word denoting the entire complex. In general, it can be said that being ill brings suffering. So suffering is a necessary condition for being ill. Someone can also suffer from, for instance, dismal social or economic conditions, or political pressure. Suffering alone is not a sufficient condition for being ill.

From the angle of behavior and behavioral change being ill means a discontinuity in people’s behavior and functioning. Typically, people who are ill will remain in bed, abandoning their normal activities and responsibilities. In general the change of behavior is such that all sorts of normal and habitual behaviors and functions are performed less well or do not succeed at all anymore. Achievement levels drop. There is an inclination to withdraw from social contacts, etc.

I will call this decline in behavior and functioning as compared with being healthy dysfunction. Although being ill does not always result in poorer functioning, it can be posited that in general a certain degree of dysfunction is a necessary condition for illness. Conversely, dysfunction as seen in ill people can also occur in healthy people, for instance, in the case of overwhelming fatigue or conditions of loss of liberty. So dysfunction alone is not sufficient for being ill.

Szasz does not consider this behavioral criterion significant for being ill in itself but only for the voluntary acceptance of the social role of illness, the “sick role.” Indeed the behavior of ill people is not determined by being ill only, but also by social, cultural, and personality factors. The point at which an ill person decides to stop working and remain in bed is illustrative of this. Drawing a clear line between the social role of the ill person and the behavioral criterion for being ill is practically speaking very difficult. Yet it can be concluded that the nature and severity of being ill on the one hand, and social, cultural, and personality factors on the other, can be considered two complementary series of factors which together determine the manifest behavior. Szasz also here chooses dichotomy (see Chapter IV, 3): the social role of illness is chosen voluntarily, while illness is a biological condition, which happens to a person. This applies more or less to the “heavy cold” which he chooses as an example, but had he chosen a more serious illness as his example, such as a stomach perforation, then his assertion would not have applied anymore.

Being ill from a biological angle means biological discontinuity in living. In this perspective the word illness denotes an abnormality of form, structure, and/or function of some part, process or system of the individual. All sorts of phenomena may occur that ill people or others consider abnormal – compared to how those people used to be when they were still healthy; compared to others who are healthy; and sometimes also compared to ideal conditions. Health is sometimes typified as a static-normal and other times as an ideal-normal condition. Being ill is never normal. The converse is also true: when for instance in a different culture something is considered normal, then in that culture it does not count as an illness. Abnormality of structure or function is a necessary condition for calling somebody ill. On the other hand, many matters are considered abnormal without being dubbed ill. So abnormality alone is not a sufficient condition for being ill.

Three factors are given for being ill, namely suffering, dysfunction, and abnormality. In addition, to qualify as illness, they must be present in a certain severity. These three factors are independent of each other and their scientific investigation, as sketched above, is carried out in different ways: those of phenomenology, behavioral science, and biological and physical science.

It has been attempted to find other factors besides these three. The way people react to their own being ill, and the way the people around them react, is in different aspects typical. In our culture the social role of the ill person is marked by Parson’s four postulations:
  1. Ill people have both the right and the obligation to be free of some or all of their usual social role responsibilities according to the nature and severity of their illness. People who do not take their being ill seriously enough may be told that they should stay in bed or that a physician will be summoned more or less against their will. So being ill can be validated by others, which has the social function of guarding against simulation.
  2. Ill people are not regarded as responsible for their illness, nor for their possible lack of recovery.
  3. Being ill is undesirable. Ill people are expected to want to become “better.”
  4. Ill people are expected, depending, of course, on the gravity of their condition, to seek competent assistance, normally from a physician, and they are expected to cooperate with him in order to recover.
Taylor considers “therapeutic concern” the most characteristic of all these factors, and proposes making this a conjunctive classification criterion. The evocation of ill people’s need for treatment, and the need of those around them for such treatment, is fairly consistent in our culture. In other eras and cultures the response to being ill could be very different, for instance banishment of ill people (leprosy, mental retardation), causing the criterion of “therapeutic concern” to decline in value. The use of this feature as a criterion would provide society and physicians with excessive opportunity to call all sorts of deviants ill. It would also unavoidably lead to the following circular reasoning: Why does someone evoke in me a need for treatment? Because he is ill. But why is he ill? Because he evokes in me a need for treatment. Finally, if investigatigation is desired regarding to what extent the judgment of physicians and psychiatrists declaring people to be ill is valid, then this judgment itself as a valid criterion for being ill cannot be accepted.

Redlich proposes a similar definition. He defines psychiatric patients as people who need help. Even more than Taylor’s, Redlich’s definition raises the question on what moral ground it is based, particularly when he follows that this help is sometimes voluntary and sometimes involuntary. Who decides that help is necessary? And who extends that help? If the answer to these questions is: the physician (or: the psychiatrist), then what distinguishes this physician from a paternalistic despot who by definition is always right?

De Jonghe mentions the criterion of maladjustment as a conjunctive criterion for the existence of disease. The broad definition which he assigns to this word encompasses not only the dysfunction factor but also abnormality. In my opinion this criterion should be supplemented with suffering, as this experiential complex with a negative value judgment is not necessarily maladjustment. Besides, the technical meaning of the word risks its being applied to that which is in fact deviant.

Kendell proposes a conjunctive criterion for being ill which he adopts from Scadding as follows: an individual is ill when he has an abnormality which constitutes a “biological disadvantage.” According to Kendell a biological disadvantage is present when there is an increased risk of death or a decreased chance of procreation. He posits that for example sufferers of schizophrenia and manic-depressive psychosis are at increased risk of death. However, for a large part this increased risk of death was caused by what was done to these people: being locked up in institutions where in those days a frequent cause of death was tuberculosis possibly influenced mortality more than the schizophrenia itself. The same holds true for the drastically reduced chance of offspring among psychotic people. Their stay in institutions, and not primarily their disease, reduced their opportunity for producing progeny. Moreover, in my opinion it is unsatisfactory that according to this criterion homosexuality would be a rather spectacular example of illness while in our culture it is nowadays generally denied that homosexuality is a disease. To maintain his criterion, Kendell has to bend over backwards. He posits that we should omit consideration of pure social and cultural factors insofar as they influence a person’s chance to die. The increased risk of death has to be present even when others do not notice the abnormality and treat the person as they would treat anybody. I note that this would actually mean that (abnormal) behavior as a criterion for illness has to be abandoned as others respond to abnormal behavior, which would conceal judgment of the existence of a “real” biological disadvantage. Even so, omitting consideration of behavior in psychiatric disorders is usually equal to making reality imaginary as the diagnosis is usually determined mainly on the basis of behavior. Who would dare diagnose a fellow citizen schizophrenic when his behavior in no way strikes others as abnormal, and who therefore is treated like everybody else? As far as psychiatry goes, this criterion puts us back where we started. Furthermore, omitting consideration of cultural and social factors means that the omission of evaluation of certain cultural phenomena is wished. That is unsatisfactory because cultural influences on what is called ill and healthy are so abundantly evident. It seems to me that every attempt to describe ill and healthy as facts must fail because the value judgment, which is so wished to be reasoned away, is precisely essential. I will return to this in 2.2.

Interestingly, Szasz’s response to this publication by Kendell is limited to noting with satisfaction that Kendell admits that psychiatrists have claimed too wide a territory for themselves. (Schizophrenia, pp. 94-95) However, Szasz misses the point of Kendell’s proposal when he concludes that Kendell wishes also to exclude homosexuality from the realm of illness.

Possibly other criteria could be established in addition to these. It is interesting that such a generally occurring complex of phenomena as being ill is so difficult to describe unambiguously and satisfactorily. No doubt one reason is that being ill is subdivided in categories of illness, so that the general, all-encompassing concept “ill” draws less attention than the notion that a certain disease should be treated in a certain way (see also 2.2). Another possible explanation may be that we are dealing not only with observable and describable phenomena but also with value judgments. That explains why the realm of being ill has/had different limits in different places and in different times.

Above three different criteria were found for being ill: suffering, dysfunction, and abnormality. Although it can be posited that these criteria are necessary conditions for being ill – in spite of the exceptions which exist for each – none of the three was in itself a sufficient criterion for being ill. Now the question is whether these three together can count as a usable cluster for the classification of disease and health.

If these criteria are generally necessary conditions for being ill then it must be logically concluded that being ill in the absence of these criteria is not possible. The complementary position, i.e. that these criteria also suffice for demarcating the domain of being ill from other unpleasant and ominous processes can be falsified only by circumstances or processes that meet these criteria and yet can evidently not be called illness. All sorts of dysfunctions and forms of suffering which result from externally imposed limitations on liberty can cause someone to become ill. They cannot in themselves be called illness because they do not occur spontaneously but are imposed. Impending natural disasters, lack of food or finances, and social crises can impede people in all sorts of ways but here the circumstances are abnormal, not the people themselves, while that is what is meant by “ill.” A process of mourning or deep sorrow does not meet the criteria of being ill because, although someone going through it may feel “ill,” it is not abnormal to mourn as a reaction to serious loss. Trimbos notes that mourning is definitely not a circumstance of illness although according to him it would be considered illness in terms of Van Dijk’s “The medical model in social context.”

The conclusion is that the three proposed criteria together form a cluster which is useful as a classification that distinguishes ill from healthy. As all three factors must be present to some degree the cluster is conjunctive.

* In English, the word “ill” also literally means bad, as in “ill manners” or “ill fortune." – translator
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