A critique of the concept of quality of life - CiteSeerX

A critique of the concept of quality of life

Man Cheung Chung University of Wolverhampton, Wolverhampton, UK Anita Killingworth University of Birmingham, Birmingham, UK Peter Nolan University of Birmingham, Birmingham, UK

Taking a philosophical approach, ancient Greek philosophers and Christians began to investigate the concept of quality of life. Later, such philisophical pursuit was replaced by the school of positivism, which indicated that science was and still is the only valid form of enquiry. Through such positivistic science, the metaphysical nature of the concept of quality of life is thought to be uncovered. However, the later Wittgensteinian philosophical thoughts demonstrated that there is no metaphysical understanding of any concepts but there is only knowledge of playing language games. In the light of this philosophy, prior to any scientific investigations, researchers have already understood and agreed on the concept of quality of life by playing language games. From the above philosophical analyses, outlines some implications for health care research.

International Journal of Health Care Quality Assurance 10/2 [1997] 80–84 © MCB University Press [ISSN 0952-6862]

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Introduction One cannot do research without holding onto concepts. They help us to structure the thoughts about reality in certain ways. However, it is often the case that concepts are consequently taken so much for granted that they become gospel truths for researchers. No one dares to question the fundamental assumptions embedded within them. In health care research, such a scenario also emerges of which the concept of “quality of life” is an example. Serious philosophers do not like taking concepts for granted but engage themselves into careful examinations of them. Some find such examinations intellectually challenging but others find them rather tedious. Nevertheless, one cannot deny the importance of the evaluation of concepts, since this is a fundamental step on which new intellectual questions are asked and new answers are found. For this reason, in this paper, we wish to examine briefly the concept of quality of life by using some philosophical thoughts, particularly those from Ludwig Wittgenstein (1889-1951).

Quality of life in the ancient Greek philosophy Attempts to define and measure the quality of life of individuals might be considered a relatively recent development within the field of health care. However, there is evidence that the subject was of interest to scholars many centuries ago. The ancient Greek philosophers devoted much energy to devising guidelines for living which would help individuals achieve an optimum level of functioning. They asked themselves and their students such questions as: What is the meaning of life? What is the best way to live? Aristotle (384-322 BC), aimed for “eudaimonia”, usually translated as “happiness or well-being”, a concept which for Aristotle

meant having an understanding of the best way to live one’s life. Achieving a state of “eudaimonia” is quite different from these self-indulgent imaginings and requires that individuals are active in developing awareness of what they are doing and why they are doing it. Aristotle urged that every act, enquiry and choice which we undertake should have happiness as its good objective. Happiness for Aristotle was the product of activities directed towards clearly defined goals which inform our whole lives rather than being simply short-term. In 322 BC, after the death of Aristotle, the Romans invaded Greek territory and radically different perspectives emerged on what constituted a good life and how it could be achieved. The Romans promulgated worldly philosophies which aimed to tackle the problems of daily living. Over time, various philosophical groups held centre stage: the Sceptics, Cynics, Epicureans, Stoics and the Christians. In essence, the philosophies of Scepticism and Cynicism claimed that human beings can avoid the frustration and guilt associated with a sense of wrong-doing by not believing in anything (e.g. Pyrrho, 360-270 BC). True happiness is achieved through selfsufficiency (e.g. Antisthenes, 445-365 BC; Diogenes, 412-323 BC). Epicurean philosophy took a longer perspective and aimed to achieve a balanced life by resisting impulses and exercising the faculty of reason in order to make choices about one’s life (e.g. Epicurus 341-270 BC). Stoicism proposed that we can enjoy a good life if we accept our fate with indifference, even when it involves suffering, conform to the “divine plan” and carry out what we consider to be our duties (e.g. Zeno of Citum 333-262 BC). Christian belief defined the good life in terms of our willingness to surrender our lives to God’s will. St Augustine (AD 354-430) considered that we have free will to choose between the way of the devil (evil) and the way of God (good).

Man Cheung Chung, Anita Killingworth and Peter Nolan A critique of the concept of quality of life International Journal of Health Care Quality Assurance 10/2 [1997] 80–84

A paradigmatic shift At the Renaissance, the philosophical approaches briefly outlined above began to be complemented or replaced by other modes of thought such as those employed by the great scholar-scientists of the age: Galileo (15641642), Newton (16421727) and Harvey (15781657) undertook the careful quantification of natural phenomena by the application of mathematics. They aimed to make predictions based on empirical evidence and their “method” became the basis of Western scientific thought, later to be adopted by psychologists and psychiatrists in order to establish a science of the mind. In the nineteenth century, Saint-Simon [1] originated the School of Positivism which was developed by Comte[2] into an influential philosophical movement affecting Western thinking well into the twentieth century. Positivism claims that science is the only valid form of enquiry; that facts can be quantified and are the sole possible objects of human knowledge. The aim of philosophy is to establish general principles common to all sciences and to use them as a basis for understanding human conduct and social organization. Thus, scholars at the time referred to themselves as “scientists and natural philosophers” because philosophy and science were considered to share a common understanding of what constitutes a method of inquiry. Positivism does not accept the existence of any forces that do not conform to scientific facts and laws. We can only know and work out the laws of phenomena through empirical verification[3].

Defining quality of life Positivism still remains the dominant approach to defining and measuring concepts in human sciences. This includes the concept of “quality of life” in present-day health care research. How then, is such concept being investigated within the positivistic paradigm? Quality of life has been defined in terms of how individuals respond to physical and emotional illnesses[4] and how well they function in their psychological, social, occupational and physical domains[5]. Some would consider it as a measure of the intellectual and affective components of being[6], and its loss as reflected in illness[7]. Literature suggests that at least 800 possible dimensions of quality of life have been identified and attempts made to measure them[8]. Quality of life researchers have tried to cluster these many dimensions into

subjective and objective categories. The subjective dimension of quality of life has been defined as the individual’s ability to perform and enjoy social roles, work roles, family roles, and community roles[9]. It has also, for some researchers, incorporated personal satisfaction, “spiritual rewards” and moral and social well-being[10-12]. In the objective dimension, economic status contributes to quality of life[10]. McDowell and Newell[12] describe quality of life in material terms” related to income, possessions and career success. Kaplan et al.[13] discuss the impact of health on well-being and note that access to health care can increase life expectancy and improve quality of life.

Measuring quality of life Such diversity on the definition and measurement of the concept of quality of life generates widespread disagreement about its interpretation[4,5,11]. Such a multifaceted and ambiguous concept[6] is extremely difficult to measure as Wade[14] stated: We all think we know what we mean by the quality of life but no one can define it. And without a definition, it is impossible to measure it (p. 92).

The above difficulties, however, did not prevent researchers from trying to measure empirically what they observed and thus the discovery of underlying laws and principles which may predict quality of life. Working with their own most favoured definition of quality of life, researchers have decided on who would constitute an appropriate survey population. Subsequently, many scientific instruments and tools have been developed. The approach taken to quality of life measurement varies along a continuum from completely quantitative to completely qualitative methodologies, with many variations in between. One example, at the extreme end of the quantitative methodologies, is the costeffectiveness approach outlined by Williams[15]. He suggests that bidders for special funding should be required to produce evidence of expected benefits to patients in terms of survival and/or quality of life. The quality adjusted life year (QALY) is proposed by Williams[15] as a suitable method of measurement but this is a contentious method which, if taken to its limits, could result in all resources being switched from dialysis to hip replacements. Some other instruments include the QL-index[7], the Quality of life index[16] and the Sickness impact profile[17]. Other instruments have been designed to measure particular dimen-

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sions of quality of life such as the Profile of mood states[18], the Hospital anxiety and depression score[19], and the Index of wellbeing. McDowell and Newell[12] have provided a comprehensive guide to tools and scales used for measuring social and psychological well-being and functioning. Qualitative approaches to measuring quality of life have also been developed and usually use interviews to determine what is important to the individual and so to measure quality of life individually[20]. However, a combined approach using interviews and quality of life scales offers comprehensiveness and validity which can be lost if one approach is used in isolation[21].

Understanding quality of life through Wittgenstein Quality of life remains under constant investigation within a positivistic research framework as investigators engage in a struggle to describe a human phenomenon, the metaphysical structure of which cannot easily be understood. The word metaphysical means a study of the essence of things, i.e. the things in themselves, within reality. The metaphysics of the knowledge which “knowers” possess is not necessarily always known to them, but we can only live within the academic world as if what is unknown metaphysically is known. Otherwise, communication with and exchange of ideas between academics would become impossible. In the pursuit of a better understanding of the concept of quality of life, the philosophy of language expounded by Wittgenstein may be helpful. Wittgenstein’s early thinking as embodied in Tractatus[22] proposed that the reality of the world and the reality of language correspond to each other. Thus, in order to understand the reality of the world, a metaphysical approach which can uncover the essence and single underlying logic of language is needed. Wittgenstein called this approach the picturing theory. Later in his life, Wittgenstein considered this approach an intellectual mistake and his philosophy abandoned the metaphysical pursuit of knowledge. In Philosophical Investigation[23], he proclaimed that it is mistaken to attempt to analyse or uncover the essence of language because that essence is not hidden. It is therefore inappropriate to seek to penetrate phenomena by analysing forms of expression. Wittgenstein considered that language is not uniform in nature but rather enables a multiplicity of activities. Language can be used to describe and report, to ask and

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answer questions, to sing and tell stories, as well as to express emotions and ideas. All these are what Wittgenstein called “languagegames”. The mastery of a language enables the speaker to participate in many different language-games. Grasping the meaning of an expression does not mean that understanding has arisen from something that lay before one’s mind like a picture or image, or from having had an experience such as being angry or feeling pain. Experiences are not the whole of the expression’s meaning or of one’s understanding of it. Rather, to understand or grasp the meaning of an expression is to know how to use it. Thus, there are important connections between the concepts of understanding, meaning and use. Wittgenstein’s concept of language-understanding implies acquiring techniques and following the rules of language. That is, our understanding of the meaning and nature of things through words depends on our knowing how to use expressions in the languagegame by following rules. Rules evolve and become embedded in the customs and agreements of a community. When we follow the rules, we are adhering to a standard of correctness which is based on popular agreement because language is the product of agreement among members of the community. Human beings decide what truth and falsity are and embody these agreements in the language they use. This is part of what Wittgenstein called a “form of life”. So you are saying that human agreement decides what is true and what is false? – It is what human beings say that is true and false; and they agree in the language they use. That is not agreement in opinions but in form of life[23].

Later, Wittgensteinian thoughts undoubtedly cast new light onto scientific methods which also make quality of life researchers question their metaphysical approach to this concept. The concept remains an issue for debate, with its essential basis or defining principles not yet agreed on. Different propositions and narratives have been constructed by different researchers using their own techniques, but in the light of Wittgensteinian philosophy, such a “private” use of language cannot hope to create a common understanding of the concept of quality of life. Indeed, Wittgenstein’s philosophy states that even if a definition or measure of quality of life could be agreed, we may still be in no position to understand the metaphysical structure of quality of life. Wittgenstein encourages investigators to abandon the search for metaphysical understanding. Understanding the concept of quality of life is entirely dependent on our knowing how to


use words and play language-games and thus, without engaging in empirical studies, researchers have already understood the concept of quality of life because they are able to communicate about it in their daily dialogues and research publications. In other words, doubt in quality of life research is only possible within the context of a language-game and can only post-date belief. It is necessary to accept a frame of reference for our daily living in the same way that we are using a frame of reference when we discuss quality of life. Psychologists, psychiatrists, oncologists, cardiologists and many other practitioners can no longer ask “What is quality of life in a metaphysical sense?”. They have already accepted it prior to any investigations, in the same way as children accept that the earth exists long before they have had any geography lessons. Experiments can only take place after the proposition has become embedded in language[24]. Rorty[25], the US post-modernist, takes up Wittgenstein’s philosophy when he claims that only sentences can be true and that human beings create truths by making languages within which sentences/propositions can be constructed. He rejects a truth out there waiting to be discovered, a truth such as quality of life, arguing that we have no prelinguistic consciousness and that consciousness is merely a disposition to use the language or the metaphors of our ancestors. He sees intuitions as being no more than platitudes, the habitual use of certain terms. Rorty believes that what scientists are doing is writing “metaphoric redescriptions” rather then having “insights” into the intrinsic nature of things. It is important to resist the temptation to believe that scientists can offer redescriptions of reality (the ultimate reality of quality of life) which are closer to “the things themselves”, i.e. less “mind-dependent”, than the redescriptions provided by history or sociology. Rorty proposes that a belief can still regulate the actions of people who are fully aware that their belief is the product of contingent historical circumstances. He sees history as a series of revolutions, without continuity or coherence, resulting from accidental shifts in the central metaphors employed within different cultures. As there is no unity in history, there can be no eternal standards or constraints which we inherit from our ancestors and which should regulate our actions or inquiries. That is, the scientific methods that we use to understand quality of life today are only redescriptions of phenomena for which our

ancestors used different metaphors or language-games. According to the philosophy of Wittgenstein, it is no longer appropriate to study the concept of quality of life using traditional psychological methods (characterized by a positivistic approach). It is a concept which is beyond the positivist dichotomy of facts and which cannot be interpreted either through appeal to universal laws of behaviour or through penetration of the individual psyche. Rather, the term quality of life can be seen as a contemporary vocabulary redescribing what the ancient philosophers understood by “eudaimonia”.

Implications The above philosophical analyses bear some important implications for health care researchers. • The aim of these analyses is not set out to encourage health care researchers to abandon the concept of quality of life. We do acknowledge the fact that the usage of this concept is almost inevitable, particularly in the present climate of health care quality assurance research. What we wish to achieve, however, is to raise some awareness that concepts in research are, after all, humanly-made arbitrary products. As one is thinking of using them as standard measures to the effectiveness of health care services, one needs to realize that the end results only provide an arbitrary glimpse of reality which is liable to change. • Health care researchers should remain critical about the usage of concepts and keep re-examining them. With such critical attitudes, researchers will look at such a topic as quality of life with new perspectives which generate new insights. However, such critical attitudes do not lead researchers to arrive eventually at a perfect understanding of concepts. Rather, they will lead researchers to keep updating the way in which they perceive and use concepts. This is indeed an important step for research development. • From the above analyses, we hope that we have demonstrated that philosophy has a role to play in understanding some issues in health care research. Philosophical ideas are not exclusively for academic philosophers. Some of these ideas can be used to increase one’s awareness of problematic assumptions embedded in daily used concepts in health care research and of alternative areas of research generated by new understanding of concepts.

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