{"id":43084,"date":"2018-09-21T16:01:39","date_gmt":"2018-09-21T15:01:39","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=43084"},"modified":"2018-09-28T14:16:30","modified_gmt":"2018-09-28T13:16:30","slug":"jeffrey-aronson-when-i-use-a-word-must-and-should","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/09\/21\/jeffrey-aronson-when-i-use-a-word-must-and-should\/","title":{"rendered":"Jeffrey Aronson: When I use a word . . . Must and should"},"content":{"rendered":"

\"jeffrey_aronson\"<\/a>Sometimes \u201cmust\u201d and \u201cshould\u201d get confused.<\/span><\/p>\n

The IndoEuropean root MED and its o-grade form MOD meant to measure or take appropriate measures, and hence to ponder, judge, or prescribe. Hence modus in Latin, meaning a measured amount of anything, a unit of measurement, a due or proper measure, and hence size, extent, or length, and a limit, boundary, or end.<\/span><\/p>\n

In music a modus was a rhythmic pattern, beat, or metre and therefore a note or tone. Anyone who has ever tried to play Bela Bartok\u2019s pieces for piano collectively titled <\/span>Mikrokosmos<\/span><\/i>\u2014and the early pieces in the collection are simple enough even for a complete beginner\u2014will have encountered the different musical modes in which he wrote some of them: Dorian and Phrygian, Lydian and Mixolydian (Figure 1).<\/span><\/p>\n

\"\"<\/p>\n

Figure 1. <\/b>The first three bars of \u201c<\/span>In Dorian Mode<\/span><\/a>\u201d from <\/span>Mikrokosmos<\/span><\/i> Book 1, by Bela Bartok; the Dorian mode uses seven notes: c, e flat, f, g, a, b flat, and c<\/span><\/p>\n

There is hardly a word in the English language with mod- or -mod- in it that doesn\u2019t come from modus: modal, modality, modem, modicum, and modify, commode, commodious, commodity, and accommodate. Those who are moderate and modest keep to the proper measure. The diminutive of modus is modulus, giving us module and model; and the ablative of modus is modo, just now or recently, giving us modern.<\/span><\/p>\n

To meditate, Latin meditari, is to think in measured fashion.<\/span><\/p>\n

By the Teutonic route we get mete, to measure out, and the adjective meet, commensurate. And related to mete is mote, from an Old English word motan, to have occasion, to be permitted or obliged, giving us the modal verb must, originally the past tense of mote. <\/span><\/p>\n

In syntax, modality is the use of auxiliary verbs, called modal verbs, to modify the meaning of the primary verb. In English, the main (or central) modal verbs are \u201ccan\u201d, and \u201ccould\u201d, \u201cshall\u201d and \u201cshould\u201d, \u201cwill\u201d and \u201cwould\u201d, \u201cmay\u201d, \u201cmight\u201d, and \u201cmust\u201d; the semi-modal (or marginal modal) verbs are \u201cought to\u201d, \u201cused to\u201d, \u201cdare [to]\u201d, and \u201cneed [to]\u201d. Modal verbs have three uses.<\/span><\/p>\n

\u2022 Epistemic modal verbs (Greek \u1f10\u03c0\u03b9\u03c3\u03c4\u03ae\u03bc\u03b7, knowledge) express the truth or likelihood of a proposition, i.e. whether it is possible, probable, or necessarily true. For example: \u201cAspirin may cause Reye\u2019s syndrome\u201d [in general, with a particular probability]; \u201cAspirin might cause Reye\u2019s syndrome\u201d [with a particular probability, in this case]; \u201cThe aspirin must have caused Reye\u2019s syndrome\u201d [for certain, in this case].<\/span><\/p>\n

\u2022 Dynamic modal verbs (Greek \u03b4\u03cd\u03bd\u03b1\u03bc\u03b9\u03c2 power or strength) ascribe ability or volition. For example: \u201cAspirin can cause Reye\u2019s syndrome\u201d [it has the ability in general to do so, even if it didn\u2019t do so in a particular case].<\/span><\/p>\n

\u2022 Deontic modal verbs (Greek \u03b4\u03ad\u03bf\u03bd, binding) express directives or permission. For example: \u201cYou must prescribe aspirin\u201d [an imperative]; \u201cYou should or ought to prescribe aspirin\u201d [preferably, unless something dictates otherwise]; \u201cYou may prescribe aspirin\u201d [in this case or in general, if it seems appropriate]; \u201cYou might prescribe aspirin\u201d [in general, if it were indicated]; \u201cI don\u2019t dare prescribe aspirin for this child\u201d [I fear an adverse reaction]; \u201cYou need not prescribe aspirin in this case\u201d [there is no requirement].<\/span><\/p>\n

The difference between \u201cmust\u201d and \u201cshould\u201d is important. The UK\u2019s General Medical Council (GMC) <\/span>defines<\/span><\/a> \u201cmust\u201d and \u201cshould\u201d in relation to its various pieces of guidance for doctors:<\/span><\/p>\n

\u2022 \u201c\u2018You must\u2019 is used for an overriding duty or principle.\u201d<\/span><\/p>\n

\u2022 \u201c\u2018You should\u2019 [prefaces] an explanation of how you will meet the overriding duty.\u201d<\/span><\/p>\n

\u2022 \u201c\u2018You should\u2019 is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can follow the guidance.\u201d<\/span><\/p>\n

Now, the GMC\u2019s <\/span>document<\/span><\/a> \u201cPrescribing guidance: Reporting adverse drug\/device and other patient safety incidents\u201d states that \u201cYou <\/span>must<\/span><\/i> [emphasis added] inform the MHRA [the UK\u2019s medicines and devices regulatory agency] about \u2026 serious suspected adverse reactions to all medicines and all [sc. suspected] reactions to products marked with a Black Triangle in the B[ritish] N[ational] F[ormulary] and elsewhere using the Yellow Card Scheme.\u201d <\/span><\/p>\n

However, although the word \u201cmust\u201d suggests that reporting in this way is mandatory in the UK, it is not. It is mandatory in some countries, such as <\/span>France<\/span><\/a>, <\/span>Denmark<\/span><\/a>, and <\/span>Korea<\/span><\/a>. However, in <\/span>Japan<\/span><\/a> the proposed introduction of a mandatory system for reporting fatal adverse events led to widespread fear of prosecution and defensive medicine; physicians started to refuse to see high risk patients, and referrals to other hospitals became widespread; medical school graduates began to avoid specialties that were perceived as being legally particularly vulnerable, and various hospitals and clinics had to close. Mandatory reporting to pharmacovigilance agencies, although some might think it desirable, may not be such a good modus operandi.<\/span><\/p>\n

Jeffrey Aronson<\/strong>\u00a0is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford’s Nuffield Department of Primary Care Health Sciences. He is also president emeritus of the British Pharmacological Society.<\/em><\/p>\n

Competing interests:<\/strong>\u00a0None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"

Sometimes \u201cmust\u201d and \u201cshould\u201d get confused. The IndoEuropean root MED and its o-grade form MOD meant to measure or take appropriate measures, and hence to ponder, judge, or prescribe. Hence […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":38359,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5762],"tags":[],"class_list":["post-43084","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-jeff-aronsons-words"],"yoast_head":"\nJeffrey Aronson: When I use a word . . . Must and should - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/09\/21\/jeffrey-aronson-when-i-use-a-word-must-and-should\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Jeffrey Aronson: When I use a word . . . 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