Journal of Prali,~aati:s 5 (1981) 145-167 North-Holla~td Publ:~hing Company

145

SINCERITY MAY' FRIGHTEN THE PATIENT: MEDICAL DILEMMAS IN PATIENT CARE

PER I~I/~'~E~DE *

The analysis, of doctor-p;~tient communication addresses problems that ~nay be general for h L~man social interaction. Mor~4 and pragmatic aspects of "sincerity" and "honesty" in human commu.nication are presen't ed, together with general re,aarks on doetor-p.~ tient h~te~action. A theoretical model of communication of information is developed from ol:,~erved communica- tion between dcctol and patient. This model is examkqed critically, and an ah~ernative scheme, that relies c,n recent work on discourse analysis and on pragmatic approL.ches 'to studies of human intvracfion is. presented. It is suggested that such a scheme may help prevent some of the dffficulti, i~s in doctor-patient communication that are indicated in the az't~cl,.;.

1. Prologile

F'hysicians are often caught in situations whe~l sincerity and h o n e ' t y become cruciai to, ~:he~ir communicat ion with patients. Many doctors cons:tier qualiti,~s iike hone~!~ty at~A sincerity ha their relationship with patients nc,t on~y to be n~orally important , but also vital for file success of medi:al ir~tervention. However, 7irrdta.. tLons of w.edical katowledge among many patients, cultural and :;oci~d differences ~etween doctor and patient , and different kinds o f language barfi~;rs, together with the uncertainty flint doctors often experien~:e in clinical work, may gen,,~rate d,.'ffi culties in the fulfflmewl o f the ideal form of coramu~ucation between uoctor and patient. Hence, patients may sometimes be led to perceive he, nest and ~incere mes.. sages as CLishonest and insba~:e¢e. When this happens it may adversely affect flee patients ' understanding of their own situations and th~'.ir compliance with the doc-

tor 's advice.

* I am grateful to Aaron V. Cicourel, Hugh Mehan, Don Wayne, and Gwnnar Skirbel6: for their reading of d~adier drafts of this paper and for their helpLul suggestions. The paper was written during a period as post doetorai scholar at the~ Ur!iversity of California, San Diego, Department of S0ciolo~,y. The research was supported by z fellowship from The Norwegian Resear:h Council re:: Science and tihe Humanities. Th,. • empirical material in this. paper is partly based on my own f~eld notes from a research project in a Norwegi~ n general hospital, and partly on video Iecording~ from a pediatric primary care centre in USA (These recordings are used by potmils- si~on from Professor Cicou~eL)

Author's address: University of Troms¢, inst~tu~e of Social Sciences, N-9000 Troms,$, Nc,r- way.

C 378-2166/81/0000-0000/$02 .50 © North-Holl~:nd

146 P. Maseid¢ / Dilemmas ~!n patient car~

This :paper ~vill address problems like t~ese from sociological and cognitive- linguistic point:; of view. This endeavor does not only request us to focus on con- ditions of unsuccessful doctor--patie~.~t h~teraction; it will be equally important to address elements of successful commu'aicatio'n.

In the first part of the paper, a model for ,:ommunicafion of information is con- structed. This model is constructed in order ~ present an abstract version of how doctors communicate with their patients. It~ make-up is based on my selectively chosen empirical examples.

I"o build a straw man like this, whose predestination is to be broken down by arguments, may in some cases be helpful.~The main part of my paper consists of arguments against the straw man. These arguments are pzobably well known to those who are famil!ar with linguistics. Hence, the strategy of using this model is not so much chosen to d~splay the validity of my arguments, as to demonstrate their relevance. This is extremely important when we are dealing with doc to r - patient communication. It is fairly weU-known and accepted among medical .,;ociol- ogists, even among many physicians, that conlmunication pioblems in the d o c t o r - patient relationship do exist. But this is a rath,~r theoretical recognition, and merely reproducing it, however often, will do us no i;ood. It is, however, not always clear why doctor-pat ient communication is probh.'matic - and this is the critical issue wltich should be examined more closely. Such an examination requires a straw man, because it includes an analysis of empirical materiM on doctor-pat ient interaction. This material demonstrates how given doctors inform their patiertts in some partic- ular situaltions. Thu.,;, the straw man makes it possible for me not only to, make the reader understand my arguments, but also for him or her to accept them. My dis- cussion is made relevant through such a device, it is also important to emphasize that this i,.~ an analysis of how language is used in clinical situations - not by trained linguists but by subiects without academic linguistic competence. In addit ion,i t is an attempt to understand why their use of language ~;ometirne,; is less than suc- cesstul.

1.1. In t roduc t ion

The following discussiton is based on a conce 9tual analysis. Theoretical predicates here are partly produced from studies of an extensive first-hand c2ata-base; they are empirically founded only in the sense that observations of clinical activity have led me to this attempt to formulate problems and to establish a conc~ptual description of certain aspects of clit~ical aci:ivities. Examples are not randolrJy but selectively chosen to illuminate the points I try to emphasize. This procedure is deliberately picked - not in order to selectively prese?t material which might support my abstract specu]lations, but in orde~ to perfon~ a "logical analysis" (Feinstein 1973) of clLnical interaction.

St. "ial interaction may be described and aa',dyzed from several different perspec- tives. Two perspecti, ve:; which might be used in extreme ways, are: ( ! ) the moral

P Mgseide i Dilemmas in patient care 147

persi~ective and (2) the perspective of "communicatic,n engineering". Both perspec- fives are central to ray analysis [ 1 ].

An extre~'~e moral perspective may r~ot explicitly take sociolinguistic and cogni- tive factors into coasideration in the evaluation of human interaction. Interaction may be assessed in relation to i.:leal moral claim~ and standards. In everyday s,.'~.ua~ tions it will turn out that - for several reasons - id,~al molal clairi,x may be hard to actualize. Such a persp~;ctive may be too simple and incomplete for analy~es of social interaction.

A~a extreme communica~tion engineering perspective will make human communi- cation into an object of lang~age technology. M¢~rals will not be part of such a per- spective, and successful commu~Lication is undert toed as instrume.atally successfld covamunication. "Ibis perspective, too, may be incomplete.

Both positions are untenable as exclusive perspectives. My intention is not to uncover doctors' "easy" solutions of moral problem,s, but to sho~ how pragmatic prin¢:ip~es, that may be confus~,'d with moral principles, in some c~tses create prob- lem~ for doctors and their patients - espe, ciaUy during delivery of information. Such problems are most ]iikdy a tso influenced by other deierrninants, like difficult work- ing t'onditions, shortage of time, personal problems, etc. My anal!,~s is problem oriented and related to problem ,,,olvin~.. It is therefore theory-driven, and it will employ what has been termed a "top down" model (Cicourel 19"r7). t h e analyt- ical categories are taken from or developed from hit,,her level predicates of othe~ analyses; and these aaialy~es' more abstract proposit?~ons have be,~n fimdament~ tbr rny selection and a~.,aly~.is of a data-base.

~'. 2. General remarks on "sincerity " a n d " h o n e s t y " in human communicat ion

Fir.,;t:, a short d~fir~itic n of the terms "sincere" and "honest" are needed: To be "sincere"' as it is used here, means to be free of dissimulatio~ ' and genuine

in fq~eling; to be "h~ne::t", as it is u~;ed her~, means to be free from fraud and decep-

tion. Sincerity has two level,,; of significance in h u m ~ communication: or. the on~

hand, it is through social interaction that sincerity and honest:/are aetualiz,~d. They are meaningful ethical categories only thr,3ugh social action - like communication. and, as moral values, they can be manifest¢~d only through social inteza¢ tion. On the other hand, sincerity is a v~ital preconditio~l for constructie, n of meanin tful commu..

Ill The distinction which is made here is an ideal typical one, which to me is analytically irn!p.ortant. One defufition of "communication engineering" may be close to what Hab~rmas hag calU~d "ompiriead pr~tgmatics" (1979), and it is r~strieted to behwdoral and forir al elements of aelion. Apel's use (1976) and Itabermas' definition of "universal pragmatles '~ (19 r9) refer mor~, • to a ex,nception of human communication which s :resses morals and intersu olectr qty as pt¢c 3n- diti,on.,~ for c~mmunicative eompelenee. "Morals" points tG a phenomen,an in ongoing cx,m- m~u~at~tti~an in ~eal life ~ituations, wherea~ "eomrnunicati, on engineering" is a linguistic prag- nmtic ,concept, used in theoretical analysis.

148 P. M~mde / Dilemmas #l petient care

nication. This has led Searle (1969) to establish a "sincerity rule" as a fundanlental rule for succe~ful performance of me~LrtingtiJl speech acts. Communication would break down if participants of social exc;~aange did not have "sincerity" and "honesty" as regulative principles fcr eommLtnicative activity.

Hence, sincerity and honesty reier to both the moral and the communication engineering perspectives irt social interaction.

2. A genend model for clinical Lafo'~aation

2.1. The selective data ba:e for d4.aver.oplng conceptual schemata o f human commu- nication

My first examples are taken from video recordings of clinical intelwie~vs made in an American pediatric primary care center. The first case is a white American mother with a baby suffering from e~r infectiom~ The d,~ctor is a white rnele (table 1).

In this sequence the moEaer 6oes not a~ways accept the intormation she first receives and forces the d6ct~r to psovide more complete information or to find o~er ways to terminate the information-gathering parts of the interview. At the same time, t~e episode also s,.~ggests Lhat "accepl~ability" is conditioning the flow of information from doctor to t-,,,tient. In this case, an informative utterance seems to be accepted because it is incomplete in th,~ re,other's knowledge system, i.e., the mother is not willing to accel::t the doctor's , .~t offer of information, (07), as suffi- dent. Her trust in the doctor is such that she nseds more information in order to accept the raessage - whether it cor~cerns the content or the truth value of the utterance.

Case two is a doctor giving information to the patient's mother after he has examiaed the child (table 2). After speech line 1.4, the information stops. The mother is not aslOng for aaore than this. The case is seemingly simple and the ci~d's problems are probably r,ot very serious. However, it is not clear how this reforma- tion is proce~ed.

The message 1.2 in table 2 is descriptive, ~ot explanatory. Utterance 1.4 in table 2 is more explattatory. In additior~, the doctor here mentions uncertahlty about the child's indigestion. That is particularly problematic. An uncertainty mes- sage may llead to many differejat interpretataons. When the mother does not ask for more here, it could mean that she accepts the doctor's form and content of infor- mation, or t2hat she accepts the message of tmcertainty as a sincere message - not a message t~mt this is something I do not wartt to say anything about yet - or, that she has to~ :much respect for the doctor to ask r~ore questions, or that in this situa- ~on she doe,,L not register the message of unc,ertatuty as significant.

Before ~ddng the rounds in the general hosFital [2], there always was a ~o r t

[2~ ~ y observ~ tions in this Nol~egian ~encral hospi~l! were concentrated on two unit~, one fo~ henmtologi~d diseases, and one for cardiology/.

P. .~Sseide /Dilemmas in patient care

Table 1 Part of recorded clinical hxterview at a pediatric center. M is 'mother , D is 'dot tor'.

!49

Text-base Comments

I II

01 M: This, uh, righ! ear didn't draia at all, it was just this e.ar.

02 D: OK, but that ear IG~,ks fine nOW.

03 M: So, what with tk:e ethel'?

C4 D: The other ear is healing, but it looks like it did h~xe an infeotion in it also.

05 M: Yes, well, that's the only ear.

06 D: Uh, but now it looks like it's gettin' 'better.

07 D: The, uh, hole iJa the mem- brane isn't dangerous, and it will heal by itself ~md, and he will be f'me, and it won' t m~tke any difference for what he hears.

08 M: That's his third ear infection he's had since

09 D: Yes. Some childre, n, uh, file way the ears in a baby is diffi,~r - ent in the way than in th ~ adult, and there is a hole between the ear and the back of' the throat. And i~ a baby it's very, it's very short and it's e~sy just for a, m~ infecfimi if that is blocked, to get into the ear.

10 M: Well.

11 D: There isn't much you can do about it at this point, if he keeps havin' a lot of infections, uh~ whe~ he is sleeping at night, do you give him a bottle? He takm' a bottle?

12 M: Yes

13 D: By himself?

14 M: Yes, he gets up in the middle o f the night, cause he wants to), else he wca't go back to sleep.

hfforms about problem

lrLforms about healing

Pursues problem

Expands information about healing

Pursues problem

Informs about hea~ng

Informs about healing and prospects

Pursues problem

Expands iaformation by qualifying it

Pursues problem

Qualifies statements and offers exglanatiol;

Expands information about problem

Stresses content

Does not accept 02

Strc ~ses content

Stresses co ntent

Stresses content

Rejects inlonnation 0 2 - 0 7

Stresses co atent

Not satisfied with 09

S~resses content

150

Table 1 (contbtued)

P. M~seide / Di,lemmas in pati~mt cam

Text-base Comments

II

15 D: Cause he lies on his back and drinks a bottle? Sometimes when he lies on his back and drinks a bottle of milk, then the milk goes from the back of his throat and into the ears. and some people think that

16 M: Yes, that's what the other doctor

17 D: Thele can be ear refections that wa}' and it is possible that it is Letter if he sits ur and drinks. Sometimes that is not possible, but it

18 M: Yes

Reaches explanation of problem

Indicates that 15 is already known

Expands explanation a~d offers prescrip- tion

Conclusfon of M's activity

Not satisfied with 15

Not satisfied w~.*h 15-17

Note: The doctor starts out by informing the mother about her baby's condition (01). :Mother's re~ponse to this (03) indicates that she is not satisfied with 'the answer, and she ger.s more information (04). She does not seem to be satisfied with this information either (051), and her response tc the expanded statement from ~he d~ ztor (10) raay indicate r.hat she is still not satisfied. T,Sis forces the doctor into offering a.l explanation as an attempt to qu'edffy his information. Neither this seems to satisfy the mc, ther. Her remark (16) suggests that this is ~omcthing she already knows. A last attempt from the doctor to qualify his statement by adai ~.g prescriptions to his presentation of information is probably not accepted by the mother. and she concludes the interview (18).

T~,is t~ble c o n ~ t s of three columns: one for the text-base, and two for comments. The text- base column cRsplays the recorded verbal activity. The comments columns are graded (1) and (IlL These column: pc~sent "meta-texts" on two levels, of abstraction. Comments (I) ~ves a des~n'iptive interpretation of utterances from the text-base. A~. utterance is h~;re the speech pro- duced in one turn by one participant. As such, the comments are reducing the text-base to macro structures. Commen:s (II) provide interpretations ~,f Comments (I). Thus, they rep,re~,;nt a further abstraction from the text-base. This is needeJ in order to interpret the retd.-base w i ~ m a ~eoret ical frame ar,d ~o .tranffe,' communication into macro speech acts, t..~a't ,can be used ~n sociological analysis. O~fly this abstract informat on makes text data relevaat to macro understanding of social .~nteraction.

The mmm~ry made under the main body of text ha this table is an expanded versio~ of the comments to the text-base.

meeting between doctors and nurses of the unit, so they could discuss ~fferent problems which had to be dealt with when they encountered the patient~L At these meetings one of the nurses would often mention some, thing like, "Mr. biN in room ~o. X w~! ask you abou~ the test results today". When we came to Mr. NN'~ bed,

P Mitseide / Dilemmas in patient care 151

Table 2 .-:xerpt from recorded conversatior, between mother and doctor in a pediatric center.

Text-base Comments

I I1

1 . 0 .

1.].

1.2.

]..3,

1A.

D: He's h a d . . . Is he drinking OK?

M: Yes.

D: -1.2.0. He's drinking, and he drinks his juice, OK.

-1.2.1. Now, about his skin, uh,

-1.2.2. the little white spots are loss of pigmentation. The little ,areas of pig- mentation

-1.2.3. There really isn't much we can do about it, and, uh.

-1.2.4. he probably will have a couple of spots.

-1.2.5. OK?

-1.2.6. But it's not serious or anything

-1.2.7 Uh, he has some irritation

-1 .2 8 it's probat~'.y from his rubber pants

M: OK.

D: -- 1.4.0. Uh, on his fltce he h~,~l a few, uh, little bumps tha'] look like,.uh, they, they just look t a . . . rash.

--1.4.1. And that's I;~robably because he's sleeping on one side.

-.1.4.2. And that als~ isn't serious

-1.4,3. ] don't think he has ~ny skin lesions in these areas

- 1.4A. Uh, I 'm a lit~: :e bit unsure about, uh, h~s, his, ~,', history ym_! gave me about the bcwels

Statement on condition

Introduction of topic

Information about medical problem

OuMification of infor- ntation

information on pros- mcts

Asking if information ~s adequate

Qualifying informatioa

Statement of conditi'~n

Explanation

lnformation~d ~:~ ~ re- merit, a bit uncertain

Explanation

Qualh%cation of infor- mation

Stat~'ment or~ condition

Information about uncertainty

Descriptive infor- mation stressing the locutionary level

Locu tionary description

Qualifier of description

Locutionaxy description

Locutionary ir~formation

152 P. Maseide /Dilemmas in patient care

however , he did not ask, even i i he had told the nurse that he was going to do so.

This happened quite f requent ly , and it hldicates that pat ients may sometime:.

- perhaps of ten - hesi tate to a~.k the doc tor questions, or not ask them at all, ever~

i f they at first in tended to do so. Th,~r¢ may be several reasons for this. One o f

these m a y be that they do not always know' what to ask for - in fact several o f the

pat ients I talked to men t ioned t t ~ as a problem. Another reason may be that the

con tex t o f being a pat ient has a discouraging effect on activities like asking ClUeS-

Table 3

Episode Comments

Case 1. Elderly woman has i~one to hosvital as emergency_ . r ~ . . . . . . n;..~ .... nosis: very malignant lymphatic disease. First time the doctor saw her, he started conversation with, "how ate you today?" Patient's answer: "I think I 'm going *~o leave ~he ho.,,~ital in a ,.,,,,,~¢~'-". Doctor's reply: "So you ,ve~ . . . . . . . . . . . . . . so m l~.a~ you think are going to die". He then told her that she had a disease of her lymphatic system - the word "cancer" was avoided - but her anxiety was not well-founded. They had drugs with good effect for this disease.

Case 2. Female patient with myelomatosis. Several tests were con- ducted on her. The information she got after the tests had been studied: "We have looked at your blood tests today, and they look fine. But with your current blood values, we should rather delay the cure a bit, because - beca-ase it's wise".

Case 3. A doctor gaw: information about a young female leukemia patient's condition. After having listened to him for a while she said, "but tell me, am I getting better or worse?" This question made the doctor repeat his explanation even more detailed. The patient cor~ciuded the episode by saying, "all right".

C~e 4. Elderly wom~m with undecided liver disease. She asked the doctor about what they had found out now, after having kept her in the hospital for more than a week and hasing conducted a lot of tests. The doctor gave a very elaborated and specific reply, especially stressing the uncertainty of his present knowledge. Patient said, "uhu ' . Next day, however, she started by asl'dng him,, "If you think I }ave cancer, you should let me know".

Doctc, i ,Jiuxe concerne0 with soothing than with infolrming. Soothing was done by tone of voice and by presenting state- ments, not evidence. Message form was more important that~ content.

No evidence given for validity of doctor's message.

Information given by doctor by stxessing locutionaty more than illocutionary level of his message.

Informatioa given by doctor by stressing locutionary more, than iUocutionary level of his mess~+.Ig,L

P. M~seMe / Dilemmas in patient care 153

tions - hh~s explanation v, as also suggested by seve~at patients. Table 3 refers to some observed episodes of information processing in the general hospital. The epi:~odes t, re tak:en fi'om my field notes.

2.2o ,4 detivative scheme for communication o f information

A ~iletailed study of the pres~:;nted examnie~. ¢,..t~,~,~u,c~ . . . . ~ ,2 , 3) reveals certain character- istic~; of doctors' communiq:atioa with patients. These characteristics cannot con.. stitute a base for con~tructitm of general sch.~mata for doctors' processing of infor- mation. They may, aevertht~'less, be used for constructing a particular scheme for the way information may be processed in sorae clinical situations.

The examples have been igiven interpretatio~ ~ at different levels of abstra,:ti~n.~ From these abstract le~tel~ it . . . . . :t.~. . . . . . r,,oo,~,,,, to d,:veio 3 a generalized scheme for the way doctors communicate in tht~se six episodes (table 4). In all these examples, the dock:ors are performing iml'.ortant ,:ommunicatiw; tasks - they are infornaing patients about their medical condition. What the), demonstrate is that a doctor

a t ,,=,,~o ,.,,uo~=, a t,~.,a~.,, £.rl ~,=u~t~tastuun~, O| art ttt.~,~tt "hl LIIU p t t U C l l t I.HlOugn spee,::h.

1he doctors a t tempt to ca~a,y through such ende~.vors by 4elivering messages to their patients. Such messages may be descriptive, o~ directed toward guiding the patient's actions.

Ek~scriptive messages aim :~t prese~lting an "objective" medical conte~t to the patient. As such, these messages might, from the doctors' points of view, be con- sidereal honest, since they deal with medi,:al "facts". The doctors may someti.m..e~ not be too interested in indu,:ing other per loc~ionary effects in patients - and perhaps also in other doctors - than those they can take responsibility for. There- fore, they stres~ illocutionary ~brces that may help in establishing their utterances as objective descriptions (table 3, case 3 and 4) [3 ].

In Wunderlich's terms (197'i!: 16f.)ihere are three commitments connected with every assertioh. These must hold, according to me, also for the case of objective medical descriptions [4].

(1) A strong commitment - w.hic'~ implies that the doctor who gives an obje,: live description must be ready lo give reas~ms, argum~nta, and evidence in support of his or her descriptive assertic,ns. (2) A weak cemmitment - which implies that the doctor must be ready to accept everything that ear, be concluded from t;is assertions, or to reject everythkLg that cax~ coafl~ct with what is being asserted, as

[ 2l I The t©rms "i~locuUonaty" a~t:] "perlocutttm~ry" Ire here taken from Austin's speech act theory (Austin 1962).

[4 ] Wundedich's work refers her,s to speech act and Lysis. My own units o f analysis ate mes- sages and utterances. A fundamental ~iticism n a y be d rected against use o f speech act models in an~dy~;is of social interaction (Cicoarel 1980; Streect 1980). If we look upon utterances and meua$es as macro speech acts, howev.'.r, it may be us~fu! to apply concepts and categories from ~eech a0t analysts.

154 P. Maseide / Dilemmas in patient care

Table 4 Generalized scheme for doctor's communication with patients.

Table 1

Table 2

Table 3 Case 1

Case 2

Case 3

Case 4

Doctor informs mainly by stressing the descriptive content aspect of communica- tion.

Doctor informs mainly by stressing the descriptive content aspect of communica- tion. Qualifies his descriptions by providing possible, not elaborated explanation.

lllocutionary aspects stress more than con(ent of message.

[llocutionary force taken for granted little emphasis on content of message.

Doctor informs mainly by stressing the descriptive content aspect of communica- tion.

Doctor informs mainly by stressing the descriptive content aspect of communica- ~:ion.

long as thL,; is done with reference to certain standaxds of inference. When the doctor wanls to deliver descriptive messages, his or her commitment is restricted to the descriptive content of his message. Howevel, even if the do~:tor fulfdls these two commitments , it will be difficult to secure successful communication of infor- mation. Descriptions may be unoerstood as a communicative mode, determined by the doctor 's emphasis on objective medical content, which he or she can produce arguments (¢omrr:itment 1) for and accept inferences from, within a giv~,n, accepted scheme for medical k.nowledge systems (corranitment 2). But when the description is produced and presented for another person - be it a dc,ctor or a patient - a third commAtment should be included. (3) A cont,~xtual commitment , which means that, if an assertion is made in a given context, ~ e speaker must accept all weak con- textual impiicatures that are made, relative ~o the context on the basis of the asser- tion. ~ has to do with the soci¢ ~:ultural context of doctor - patient communica. tion.

In my examples the doctors have been concerned with either the descriptive commitment , or with a, so to speak, "one~way" construction of perlc, cutionary effects, within a hmRed contextual commitme, nt (table 3, cases 1 and 2).

The communicative scheme which can be derived from these examples is charac- terized by two features:

(1) There is a distinction between descriptive and contextual commitment:i;. (2) There is a te)ldency not to accept other s ta,~dald,,: of inference for strong/weak

commitment:~ than those that are maintahled by the doctors themselve.%

Both factors raay greatly influence th~,se doctors' attempls to cent.eel pedocu- tionary effects of their descriptive and i:ff~,rn~tive messages.

t'. M~seide /Dilemmas in patient care 155

Infoz.nat :~on

U n e e r t clit~

Descriptive

Me t a- ob ]ect- lev~l level

L'escrl pt xve Perlocut ionary content elT feet

oJ. in~liilcere

Acti on guiding

Ot~3ect- level level

J~sc~ii~tive Ferlocu t io:lat-f contez%t ef~ oct

Fig. I. "[entative scheme for communication based descriptive content qualities.

Thus, in the examples presented, information is delivered by giving descriptive content without stressing the message's perlocutionary effect; or, information is delivered by aiming at a certain effec: without caring too much for descriptive content.

A scheme for this kind of communication may cover two properties of informa- tion processing: information may be delivered as "elements of perlocutionary effects", or information may be deli~vere,:l as "elements of descriptive content".

This analysis sugg,:,sts a view of :nformation as an "entity" or "package" which can ~e tr~msferred. When information, ac:ording to such a view, is sincere, it should be conwTed in a form that is close to t;: e sender's commitments to his or her mes- sage.

When :he message: is uncertain or not :ompletely sincere (which sometimes may be the case)but certain effects are desirat le from the delivering of information, per- locutionary forces may be emphasized me re in the speech than descriptive content.

.~m iraplication of this is that atthough informatior~ may be faked k is still con- strueted according to standards for since ,ity which the speaker under:;tands as so general that they might secure the intended effect of the message.

The t,;atative scheme in fig. 1 sugges:s that information may exist elmer as descriptive or as faked content. To transfi!r these "packages" of informatkm, ~han- nels are n~eded that allow the informatio,~ to pass undisturbed, and a formaJ lan- gauge might be developed to assure precise, perlocutionary effects and inform;..tion about the ,:ontent.

This so.home, however, presupposes tha~ speaker and listener haw~ esseo*' I .,, an identical background, and that informational content, ~hen properly delivered, will have the same moaning for both of them - .~ omoflling which would be possible only' if meaning were supposed to be an implicit quality of message content.

156 P. Mltseia'e [ Dilemma~ in patient care

Implications of these views are that communication between doctor and patient is not influenced by the problems of sincerity or honesty and that cognitive or social processe~ of communication do not i~ave to be addressed. The problem of information delivery would then, mainly be technical.

In order for this model to function, socM interaction would have to be organ- ized in accordance w~th prhlciples of formal logic - principles that themselves are constituted through ir, teraction.

3. Elements of an alternative model for comrnunicatio,n of information in medical settings

3.1. Patieng~' knowledge and understanding o f seiemific meaicine

Evans-Pritchard has asserted that our scie~ tific would view is a function of the culture (1934) It is not so much scientific un6erstand.ing as it is cultural acceptance and internalizat on of culturally inherited knowledge which make most of us look upon scientific medicine and medical professions and institutions as representing rationality. We may be well infi~rmed of pathogenic factors, such as bacteria, germs, and viruses. It is, however, doubtfnl zhat many individuals are so well informed that they fully comprehend the structure, function, and general physiological effects of such pathogeni.: organisms (Morley 1978).

The average patient knows little about what has caused the disease; he or she knows little about the available cures, or about the rationality of each cure or examination, or about the evaluation of his or her own condition, future prospects, .'rod prognosis. If the patient is supposed to have information about these things, the doctor must provide it.

Often the doctor needs the patient's cooperation in order to attain a successful diagmosis or tr.=atment. In ord,:r to secure this, he or she has to make the patient accept his or her views on what needs to be done. Therefore, besides being sincere and honest, information should also be functional iq securing a foundation for decision-making in the patient which the doctor may find acceptable and reliable. The establishing of a propositional message may be functional in this respect. Such a message may also be very detailed; perhaps 'all these details are subsequently sup- posed to coalesce into a non-ambiguous unit of meaning. Nuances, however, are often avoided. A doctor told me that he usually preferred not to reform patients about their exact blood tour, ring or their exact blood pressure, etc. because he did not rely upon their ability to make judgments from such information. Instead, he would say, "your blood pressure is fine", or, "you are a bit low in hemoglobin", and so on. That is, information wag presented at a hi~ler level of abstraction in order to control and secure the penocutionary effect. In cases with such abstracted information processing the patient is forced to accept or not to accept the informa- tion.

P. M~seide / Dilemmas in paaent care 157

Acceptance, however, does not necessarily imply understanding, even if under- standing probably depends upon acceptance. It is very difficult for the patient to test the truth of received medical information. Sometimes patients may wish to know something about the doctor's sincerity. However, if the patient recognizes that the doctor is not presenting nuances of information, this meta4nsigh~ may make him/her suspicious, and he/she may start wondering what the reason is for this, and why something is apparently hidden. A patient I talked to, who was examined in preparatory to possible open heart surgery, turned down th~ dcctor's advice because he felt the decision to go ahead with surgery, called for subt'e~ con- siderations, which were not offered. In such cases, a doc,or's sincere wish to per- form sincerely may be hard to realize, because contextual and prag~na'dcal aspects of the message are not part of the scheme used for processing of information.

In the particular ward where I made my observations, the doctors dlemanded that informaiion released to patients not only should be honest, but also medically adequate. The principle seemed to be: if information is medically inadequate, then i t ~ al~c~ nc~t hones t I f ~ii ~a t i~n t$ ix:~r~ f lnotnr¢ this m i n h t b e a . . . . . a ,,,..,~,.~ The claims on medical adequacy of the content of the information message, how- ever, might under present conditions invalidate the claim of honesty, since it w.o not possible to evaluate its content in relation to truth c,r sincerity. The only way then to guarantee this is the doctor's socially recognized :espectability. Here [ refer to the princip'e of distinguishing between communicative levels (Watzlawick et aL

1968; Bateson ? 972). Communicative acts transfer two kinds of information: infor- mation about c~mmunica~.ive content - which is conveyed at an object level by descriptive con~mitment, and information about social relations - which is c'm- veyed at a met~4evel by contextual commitment, and is called meta-communica- tion. The medically adequate content is communicated to the patient at an object- ievel; but when ~his object communication is not properly received by the patient, 'he decoding of the message may not be conditio,~ed by the descriptive content t.spect. Even if object-comm~.mication has no signficant function for the decoding of the message, the message still will be decoded. What ~obably happens then, is that the received information is transformed into me~aoinfermation. The utterance becomes understandable on the meta-communicative level and opens up for several possible interpretations, interpretations that do not address the information con- tent, but have to do with how the doctor is behaving - what kind of relationship is the doctor trying to establish? Does his or her conduct, mean that he or she is teLling the truth, or is he or she hiding something?

The importanz point is that the message colttains r.o instructional device that the patient can use in order to dec~de how to interpret the meta-communicative mes- sage. What rentains is the doctor's social position and other elements from the patient's social context. If this is so, it might support a claim ;¢hich has been made, that acceptance will always be part of a subject's understanding of utterances (van Dijk 1977a; Maas 1972: 298) both in a semantic-eoli~nitive and in a pragmatic way. In clinical communications between doctors and patients, both linguistic, semantic,

158 P. MSseide / Dilemmas in patien, care

and pragmatic acceptance are necessary to establish a message as a meaningful speech act.

In communication between doctor and patient, where an incongruence in knowl- edge often exist:;, pragmatic acceptance will be the most important kind of accept- ability. The listener's acceptance of a message, without complete understandirtg of its content, will be imflueneed by sociological factors, such as the doctor's role and the conditions of the scene, or by analogous communication, such as kinetics or tone of voice. Hence, 'honesty' and 'sincerity' - given their diverse functions in social ,;nteraction - are conditioning, and conditioned by, the complex phenome- non of social interaction.

3.2. Some comments on the concepts o f "honesty "and "since~ty"

An utterance needs certain quali':ies to be accepted as an utterance about a specific topic, and it needs cer t . , , specific qualities to have a successful social function in an int,.+ractional situatio~. These are ideas similar to those expressed in Grice's "Cooperative Principle" (Braunr,ath et al. 1975; Grice 1975). The idea is that the

u,,,,,~,,~+ IS not u , ~ u ~uteiy on sVntacuca~ and semantical rules or strategies, but also on prag~aatical rules, conditions and structures (van Dijk 1977a).

An utterance could be evaluated by itself as a true utterance, and as such con- stitute in honest utterance. But as part of a discourse it might be possJible that the listener did not comprehend o~ accept the utterance as honest or as sincerely uttered in that case the utterance would not be considered a successful honest ,.nteran,:e. This is so because honesty and sincerity are interpersonal phenomena. To make a sincere promise is of little use if the receiver does not undecstand one's ~peech lot as a promise or does not believe the speech act to have been sincerfly performed.

The receiver of an utterance has not always the same opportunities as ~ae speaker to judge tl-e honesty of a message, and he or she rarely has the possibility of judging the sincerity of the utterance.

For the :lector, this means that if he or she finds it important to give honest information, it will not only be important to be able to convey a message, such as "~fis is a case of pneumoeia". The sincerity of the act must also be communicated, so that tiae patient will receive a message like "This is an honest utterance, so you're not suffering from cancer". To succeed in this may sometimes be problematic, because "sincerity" is not implied in the text of an utter~,nce. The utterance, "This is a pnee.monia", is a successful communi=ative act onl5 + :~f the patient is able to, or willing to, accept or comprehend it as an honest utterance. Since the patient usually has no insight into the particuhtr decision process leadin~.g up to the diagnosis, the acceptance of such messages would depend on such factox~ as: (a) the listener's compet.el~ce to decode the meardng of the spoken sentence; (b) th,; listener's ability to evaluate the descriptive content of the received message; (c) the listener's rela-

P. ~3seide / Dilemmas in patt~ent care 159

tionship to, and confidence in the speaker; (d) the listener's comprehension and ,~tructuring of the social context of the received ~es,,~age.

All of these factors are related to each other. F~Lctor (a) dependo in many ways upon the following factors. It has, of t:curse, to do with language competence, but ~,.lso with the listener's cognitive structazes: to what degree does the received infor- raation fit into the receiver's schemata? If it does not, the receiver may, under cer- t.~in circumstances, nevertheless accept the infonnation~ even if it is incomprehen- sible. Factor (b) is closely related to (c) in ,the way communication on the object level always depends on communication at a meta-leve! OVatzlawick et al. 1968). Ftctor (d) covers phenomena such as cultural background and differences between sl~ eaker and listener, am-1 corwtextual aspects, such as ace called "macro structures" ot ongoing social interaction (van Dijk 1977b). These macro structures are the se~luences into which the subjects structure the di:~course in order to make single utterances or events and strings of utterances and eveners into meaningful or accept- ~bi'e utterances or occurrence:s (M~seide 1979). All these factors imply confidence as a necessity for making successful speech acts. The fact that the message actually se ~. ms to reach a patient who lacks the kno~,ledge :needed to understand the med- ica utterance suggests that the patient does not have to understand the message in orcer to perform some sort of dec(,ding. BtLt he or she has to accept it a~ relevant ant honest information which is :~incerely delivered. This indicates a necessary di,,,', ~nction between a sincere performance and a performance of sincerity.

i!~y a "lzerformance of sincerity" ~he doctor conveys his message to the patient as an honest or sincere performar~ce. But whereas "sincere performances" are ho~'~est, a "performance of sincerity" does not haw; to be honest. In fact, "perfoi. m~ aces of sincerity" are a necessary part of all successful acts of deceiving, trickery ~ humbug, etc. It is a rhetorical element, and as such it must be evaluated according to function, not to truth. It is probably not enough to secure a successful honest speech act by trying to act in accordance with some possible formal rule - like Austin's "performative formula" (Austin 1962) - of structurally adequately per- formed speech acts. "Perfi)rrrance nf sincerity': is not ~ linguistic phenomenon but a social-behavioral one, which should be linked to social conventions and insti- tutionali2ed social retationstdps --not to formal linl~n~ tic-semantic rules.

3.3. "Social rules" for the performance o f sincerity

Different kinds of rules for human communication may be distinguished:

(1) The linguistic rules for performance of structurally adequal_e utterances. (2) The rules or conventions, formal and ~nfi3rmal, of social relationships. (3) Meta-rules that imply knowledge ,~bout rules and their use.

These conununicative rules are interpe:rsonal phenomena, so that one perso~x's rules are only valid and functional in conversation or interaction if they are com- prehended and accepted by the other person.

460 P. Maseide / Dilem,nas in p~ztient care

If we use an example flora my obserw tions - a hemophilia patient who asked the doctor why it was so important to always measure his blood pressure, the doctor answered: "Becau.~ie of your bleedings'". To me, the patient seemed to a:cept this answer since he did not pursue the raatter. A more thorough examhaa- tion of the episode however might c~'eate doubts about what were the implications of the utterance. Did Lhe doctor m:an bh eciin$~ in general, or specific bleedings, perhaps serious bleedir:gs in file sense tha~ ~hey might mean acute danger, or be fatal? If the doctor by "bleeding" referred to cerebral hemorrhage, that would be very different from those less fatal bleedhtgs (from joints or other areas of the body) from which a he ~.ophilia patient of:en suffers. The doctor never specified the kind of bleedings ~eferred to. And if tae patient did not have the additional knowledge that could indicate what kind of bleedings the doctor had meant, this was a message so incomplete, that it could hardly have been evaluated as true or sincere. Apparently, it excluded important information which the doctor might have intended to withhold from the patient. The doctor assumed perhaps that for the patient it was be'ter not to know about the possibility of a sudden strox~.. Assumptions like that are connected to modern medicine's dubious tasks. Six:ce healing is not always possible, an acceptable goal for clinical medicine may be to improve a patient's "qu~dity of life" - for shorter or longer tirae. This is because lengthening the patien!'.~; life even for aver) short period, may be considered an acceptat le profit in the perspective of clinical medicine. Under these conditions, Io witl-~hol¢~ information cc, uld be interpreted as a morally defensible act, which m~y be instrt:menta[ in realizing one of the primar ¢ goals of clinical medicine. In some diseases where a significant possibility of a suc den stroke or other sudden, possib]y fatal blcedings actually exists such as in act te leukemia, this possibility is not always communicated to the patield.

The hemophilia patient seemed to accept the message he received from the doctor. This was, however, neither because ot the structural form of the message nor because of its descriptive content. It is the special relationship that exists between the profession:d and the client which f)r the participants secures th,.~ social functioning of an utterance as an imnest utterance.

This, however, need not guarantee performance of honesty. Some patien',s' ruil~.~ competence implies the recog~.~tion of possible dishonesty or insincerity in doctor- pa~:ient relationships. Fhis ru!e competence, dso called "meta-competence", is related to the sociological theory of roles. It irdicates that speaker and hearer do not only need linguis~:ic competence in order to communicate, they also need knowledge aboug the participants' soci;d roles (,Yunderlich 1971). nacre has to be some mutual, interper~,.onal recognition and acc,.~ptance of the communicative rules and meta-rules, in order to have mean.agful, honest speech acts. In some medical settings these preconditions may be difficult to 6dfill.

P. M~seide / Dilemmas in patient care 161

3.4. A typology for honest vs. non-honest utte,ances

When a doctor makes a statement in order to inform ,~r advise a patient, two forms are involved, a~ far as the statement could be evaluated in relation to hon- esty.

(1) The doctor may on the one hand want to convey honesty, without taking rhetorical and pedagogical elements into consideration, even if these may be tile pleconditions for successful conveyance of honesty to tke patient. This is what I would call "optional honesty". Here is an example. A doctor I knew wanted to inform a young man and his family a;9out the disease which had struck him, a rather uncon~mon disease, called "hair-cell leukemia". Since this disease should not be mistaken for "ac:ute leukemia" (which is a more malignant form of "leukemia") he did not use the 'word "leukemia" at all. Later, however, the patient's wife called the dector and asked ang~-ily why he d,d not inform them that her husband suffered from "cancer of t21e blood". She had accidentally become acquainted with lb, e formal diagnosis, and what she had been told by t]ae doctor meant nothing to her compared to her associations with the term '`leukerrda". A popular understa~a_ding of this term among many Norwegian,,; is tha~ it means "cancer of the blood". Medi- cally, however, this is not correct: "leukemia" is a label used for several dit'fi:,'rent diseases. The doct~r wanted to ~ve his n:~edicaily adequate description of the disease, whereas the, patient, it turned out, was not ready to accept his description. One possibility for the doctor would have been to try to describe the illness from tlae pat~ient's perspt:ctive; but in ma:ay cases - like the one above -- this is not acceptable from a medical professional point of view. In this particu!ar case, the emphasi,-mg of the medicall:¢ corre:t content of rite message led to a confidence crisis. The doctor had a sincere wish to be honest, Later on, however, when we dis- cussed the episode :t turned out, that he, fo:~ professional reasons, could not accept rhetoric as a mean,'; to successfully comra~ni~:c, te this honesty to his patient.

(2) On the other hand, when the doctor wishe~ his or her patient to underst~md ;~tis other utterance as honest, he or she may ease his or her own clainas to an honest utterance, or he or sh,~ may emphasize the meta-comm~icative ~lements of in¢ot - marion conveyance rather than the medical content t~t the utterance, so that he or she can secure a perlocutionary effect. This I would call "consequential honesty". In a way this is what happens when doctors try to popularize their medical expiia- nations so that they may be more acceptable to the patients.

D~livered messages require a receiver in order to have any communicative func.. finn. The patient's understanaing is not totally dependent on the doctor's verbal activity. The doctor~' attempts at estab!is]~ng perloeutionary effect through thei~ utterance,,; may not ahvays be succ, essful. "[hey ma~, sometimes put the stress on elements of discourse that the patient, is not looking for, or perhaps not even cap.. able of beiing influenced ' by in the irttended way.

The fourfold table (table 5) indicates types of discourse rclai,~d ~o perception and honesty. Art the four variants might be fou~ld in doctor-patiient commmfic~i,~..

162 P. MSseide / Dilemmas in patient c~.re

Table 5 Typologies of honesty in human communication. The term "non-honest" is censtructed to sis- nify something different from "dishonesty". A non-h m~.'st utterance may be mitsleading, but it need rot be of the same moral modality as a ~iisnones~ uttera"ce, beeaus~ it may not have been intended as insincere or dishonest.

Message is

Pt~ ceived Non-per( eived

Me:;sage is Honest (i) (ii) ~lon-honest (iii) (iv)

tion, but i think that 0):is the least dominant. (i) This is the perfect "dialogue" in the Pla~ onian sense. This kind of situat~ior~

would also be established, according to our tentative scheme (fig. 1), if techni,::a~ conditions were optimal. However, beck.use of Lhe nature of modern medicine. ~ts highly developed technology and biophys'~cal lcmwledge, the institution of profits.. sionalism, and the development of complemenlary relationships, it is difficult ax:~d often impossible to have such communi,-ation in doctor-patient interaction.

(~i) This is a very important kind o! commuaicative situation. According to tt~ scheme in fig. 1, non-perception here would be due to technical deficJiencies of th ~. employed language, or the communicative chanr els in use.

(iii) These are the more difficult situations, l:erhaps for both doctor and patien:. According to the scheme in fig. 1, this might silaply be the case where the informl, tion ,lid not contain the qualities of "sincerity" or "honesty", or when these qual~ ities were not "added" to the text. However, ir. cases where the patients have been supplied with additional information, they miy make decisions that are not sc~ much dependent on the doctcr, and that ma) even diverge from the suggestions made by the doctor.

(iv) This situation is, in principle, not very dissimilar to (ii). Most often I o b . served this l~ind of communication as a form of under-communication, Le. the d e c tor leaves his patient uninformed, not by telling semething untrue, but by nel gi~'ing all the information that it is possible to give. Sir~ce to inform about a medica~ condition is to in!brm about reality, to withhold information is to influence the creation of reality;thus, it may be classified as s rategi: intezaction.

By demonstr~tlng the distinctions of this tYl~ology, it is po~;sible to suggest thai at least ~ ree types c~f situations, (ii), (iii), and (iv), may generate communication where confidence becomes a critical issue. In a tdition, the table demonstrates that different situations, which means different c(,ntextual conditions, influence the communication process in a way which tl~e sche ne of fig. 1 cannot explain.

P. M~seide /Dilemmas m paIient care i!63

4. Conc l~d ing discuss ion

The seq!JLences of doctor-patient communication which I have referred to abov~:; all repr(~ll;ent attempts at communicating information to patients. '!['he fo:rm of th~s commtmication i:~ chosen to successfully sc.cu~ cel tain peflocutionary effects; they are not necessarily u~ed to comnmnicate aonesty or since~tty.. Instead, the~ are used to create an impression of si~acerity ~r honesty. This leads to some thoughts about the phenomena of sincerity" ~ an~. ho~,e~ty in hL~man conuuunication.

(1) There may often be a discrepancy between "sent" hones~ty and "perceived" honesty. In the doctor's scherr~a, outlined above, this discrepancy would exast only because of technical deficiencies of 1.anti, age and/or commurdcative chanpels. It v~ould not address the question of coglfitive or sociological-pragmatical circam. stances (,f human communication. Eence, importazlt aspects o:[" information pro- cessing n~ight not have been taken int~, coi~sidera:~ion at all.

(2) One of the important abstract characteristics of the doctor-patient relation- ship is that it belongs to ~he class of "pr~fessional--c~.ient relationships". GenejaJ~ly, this means a formal dependency on ~he part of the client in 1the profession .... a dependency which also may be intert~alized by the client. Freidson has shown ~:this dependel~cy to exist in doctor-patien~ relations (1970). In this relationship, a lot of information is conLveyed which by itself car~aot be evaluated according to sin- cerity or honesty. The information is supposed to transfer a reality to the patient, which the patient does not haw. • direct acc~',ss to - and sometimes does not accept having direct access to. Many patients obvi,)usly waist to rely on the doctor as the mediator to that reality and as a problem soi~:er.

The clinical reality (leads w~Lth healfi~ and illness, pathogenic and patholo:~ical phenomena, cures, etc., as they are described ~nd understood in. terms of modern sc~er~ific medicine. "[tfi.s reality needs a competent "reality ~tgency" - t~e doctor - t..,) be succe~fully mediated to the patient. The patient is often ¢,)mpletely will~:ag to let go of his own perception of medical reality in favor of the doctor's.

"lhe scheme of fig. ]i has a simpler notion of reality and conveyance or reality. Since sh)cerity and honesty are properties of the processed content, and the pro- cessed descriptive cont en~: is ~the "realit~" - or a close representation of reality - institutional or c;ognitive variables will not influence a patient's received "reality".

(3) ~1~en the doctor reaches his patien;:: with his sincere performance, most ofr.en this means that he ~mkes the patiient accept partially comprehensible or even incomprehensible utterances as honest. T~is is like accepting a scientific work, not on read~Lng the complete report, but on reeding the abstract:. Such cases reflect a

firm belJief or confidelace in the author, or th~ profession he or she represents. !Honesty and non4,tonesty are not so rr, uch comprehendec as accepted, and this

acceptance is ~: quesllion of acceptance of a definite relatioxlship. Comprehens:ion or acceptance would play a different part in the doctor's scheme. They wo~ld depend on the quali:ty of messages sent~ not on perception, understanding, ~ d decoding on the part of the receiver.

164 P. M~seide / Dilemmas in patient care

(4) In human communication, when sinceri :y is to be expressed - and as a con- stitutive element c f successful conmmnication this needs to be expressed regularly - the speaker cannot rely solely on a wish to c mvey honesty and the verbal formu- lation of the sincere message (what I have called "optical honesty" above); he or she must also rely on and take into consideralion ;he nature of the social relation- ship of the communicating parts (which implies that what 1 have called "conse- quence honesty"). The speaker cannot assu ne that honesty is conveyed by a descriptive commitment. The meaning of the descriptive content relies heavily on the relational meta-aspect of communication.

Using the scheme ha fig. 1, this problem cou :d not be identified at all. (5) Acceptance of a message will be conditioned by several things, like the

ability to distinguish between communicative levels ia specific situations, schemata structure, contextual knowledge and understanding, e : c .

The percei~,ed medical messages are often :'~ot decoded as meax~hagful or metal- ingless messages, but as acceptable vs. unacceptable messages. It is dkely that the rules and criteria which make a m~ssage meaJtingful are different from those that make it acceptable.

The scheme in fig. 1 would probably use "acceptance" and "understanding" in a more specific way than is done here -- which might mean that "understanding" covers technical aspects of the act, and "accei~tance" refers to the logical aspect of the act. These two notions may, howevel, refer to different kinds of activities. There is a difference between not understandi ag a message because it is surrounded by too much noise (a technical problem) and not understanding it because it is too complicated or because it may be misunders :ood for different reasons. The same holds true for "acceptance". There is a dfff,;rence between accepting something because it does not contradict what you kaaow to be true, possible or rational, and to accept something because of the person wh,) delivers it, his or her social status or role, and/or the situa~ion or context of deliver/.

Since the scheme for information processing that is generated from my examples suggests that information, meaning, reality, e t :. do exist as elements of information content - a content which is not constituted or constructed by eognitiw; and socio- linguistic aspects of information processing - this analysis could be considered superfluous or meaningless. Information conveyance would then be secured through the perfection of a speaker's use of i,.nguage and through the establishing of "clean" communicative situations.

This conception of communication, however, leaves out a very important ele- ment of social interaction: the act of receiving information is st ~pposed to be active in constituting meaning and reality, hence the aspects, elements and processes which influence and constitute reception ~nd decoding of messages should be studied.

t: M~.~°.ide / Dilemmas in patient care 165

5. Epilogue

I have discussed human communication in general, and doctor-patient interact:ion h, partic:ular, and through my examples, 1 have contras~ted this commtmication with an abstract understanding.

This analysis has then generated three mairl propositions abom theoretical aspects of doctor--patient communication, and perhaps also of general social inter- action.

- It is possible to confuse principles of morals with principles o:r pragmatics in human communication. The moral principles ar~, ~ dependen~ on ?ragmati~: prin- ciples to be successfully actualized. The exemplal'y scheme do~,s not suggest a distinction like thJLs, and thus, ideal proper moral conduct is nol ~ understood in relation to actual pragrnaiic conditions. Hence, recognition of the moral act on the part of the conununication partner is more (:asual thap it p~:thaps ought to be, and instances of "inexplicable" lack of success in communicating honesty or sincerity may result.

- Clinical messages are, at least for patients, more accepted than understood. Acceptance is the, result of a patient's pragmatic competence, and h~s or her general knowledge system - a l s o called schemata systems (Rumelhart 1975). The propositional content of a message is thus of ].ess hnporta.nce than what might be suggested by the tentative scheme of my examples. Crucial elements of information processing are therefore not taken into considerat:ion when deci. sions are made about how to convey a certain men,sage as morally adequate and as medically efficient as possible.

- There exists a distinction between "performance of sincerity" and ':'sincere per- formance". This difference signi0t;s a divergence between propositional and pragmatic aspects of human communication. A "sincere performance" is a prop- ositional quality, and as such, it ne,~ds the qualification of pragmatic elements to be socially, felicitous. "Performance of sincerity" is the pragmatic quality which symbolizes "sincerity". This distinction is not part of the sche:a~e in fig. 1.

The above three main points indicate that there is a distiactio:a of "pragmatical" and "propositic.nal" aspects which is needed in order to understand human commu- nication:

(1) The '~pragmatical" aspec,: is connected to the notion of "acceptance" and to "performance of sincerity" through illoeutieaaty and perlocutionary condi- tions of so~:ial interaction.

(2) The "proposifiomd" aspec~ is connected to ideal moral claim% shlcere perfor- mance, and "understanding" through descripti~,e content aspects of utterances.

Thus, two diffe~'ent schemata may be suggesteu: First, the on~ w~dch is tenta- tively derived from my examples, and which is mainly connected to the seeon:i pat-

166 P. M~ "de / Dil,'mn~s in patient c~ire

tern presented above. 1"his ~heme ignores that processing of infc~mation is social interaction which includes pragmatic ~:leme,nts. Second, a scheme - which is nc ~. made "explicit - may be constituted |hrou:[~ interaction between pragmatic and propositional ~lements, so that a ~ore cons~:ious consideration of fllocutionary and perlocutiorta~y d ~ , . ~ . . , --'* ~"""" ...... for successful social exchange may take place.

The conclasion from this analysis may also have some implicalions for medical ethics. It is suggested here that fulf'dment of moral claims through social irtteraction may be interfered with by forms of ~ocial organization and by cognitiwe and lin- guistic-pragmatic princip]¢~ for commttnicat~c,n; all these aspects ~re often beyond the control of the individu~d actors. Thus, cfinical conduct shouic~ be evaluated by ethical standards which a~'e developed ::n accordance with such an underst~nding.

Referet~ce~

Apel, K.O. 1976. 'Sprechaktlheorie and tra ~szendentale Sprachpragmatic - zur Fr~e et_hi_~her No~'nlen'. In: K.O. Apel, ed., Sprachprsgmatik und Philosoph/e. Frankfurt am Main: Suhx- kamp. pp. 10-173.

Austin, J.L 1962. How to do things with ~ ~rds. Oxford: Oxford Universit.~: Press. Bateson, G. 1972. 'A theory of play and fantasy'. In: G. Bateson, Steps to an ecology of mind.

New York: Bal~ntine Books. pp. 177-~ 93. Brau~oth, M. et al. 1975. Ansa'tze und Aufgaben der linguistischen Pragmatik. Frankfurt am

Main: Fischer Atheneum. Cicou~el, A.V. 1977. 'Discourse, autononous grammars, and contextuldJzed processing of

in~'orm~ttion'. In: D. Wegner, ed., Gespr~:ch.~analysen. Hamburg: Buske. Cicourel, A.V. 1980. Three models of dis~ ourse analysis: the role of social structu:re. Disc~mrse

Pro~esses 3: 101-132. Evans-l?ritchard, E. 1934. Levy-Bruhl's the3ry oY primitive mentality. Bulletin of the Fa~ ulty of

Ar~, University of Egypt. pp. 79-80. Feinstein, A.R. 1973. An analysis of diagr ostic reasoning, !1. The strategy of intermediate deci-

sions. Yale Journal nf Biology and Med icine 46: 264-283. Freidso n, E. 1970. Prof~essi, mal dominance. New York: Atherton. Grice, H.P. 1975. 'Logic attd col~versatio~'. In: P. Cole and J. Morgan, ed~;., Syntax and seman.

tics, 3. New York: Academic Press. pp. 41-58. Haberm~, J. 1979. 'What is universal prigmatics?' In: J. Habermas, Communic~tion and the

evolution of society. Boston: Beacon. l'P. 1-68. M~as, U 1972. 'Notizen zu den ]~otizen'. [Comment on D. Wunderlich's 'Manaheimer Sotizen

zur Prasmatik'.] In: U. Maas and D, Wunderlich, Pragmatik und sprachliches Handeln. Frankfurt am Main: Atheni/um. pp. 294-306.

M~[seide, P. 1979. An exercise in the anai) sis of doctor- patient relationships. University of Cali- forni;l, Sen Diego, Department of Soci :>logy. (U npublished paper.)

Morley, P. 1978. 'Cuiture and the cognittve world of txaditional medical beliefs: some prelimi- ne:y considerations'. In: P. Morley ar d R. Wallis, eds., Culture and curing. Anthropological perspectives on traditional medical beliefs and practices. Pittsburg: University of Pittsburgh Press. pp. 1 - 18.

Rumelhart, D.E. 1975. *Notes on a sehenLa for stories'. In: D.G. Bobrow ~nd A.M. Collins, eds., Rep~sent~tion and understanding: steadies in cognitive science, New York: Academic Press. pp. 2,11-236.

P. Maseide / Dilemmas tn pa~ :ent cave 167

Searle, J. 19'69. Speech acls. An essay in the philosophy of language. London: Cambx~dge Uni- versity Press.

Streecl,:, J. 1L980. Sp*~ech acts in interaction: a eritiqt~e 9f Searle. Discourse Processes 3: 133- 154.

van Dijk, T.A. 1977a. 'Aec:cptability in context'. I'a: S. Greenbaum, e6., Aeeeptabililry in lan- guage. The Hague: Mouton.

van Dijk, T.A. 1977b. Text and context. Er~plorations in the semantic,I and pra~mati~:s of dis- course. London and New York: Longman.

Watzhwich, P. et al. 1968. Pragmatics of human communication. London: Fal per and I ~ abet. Wunderlieh, D. 1971. 'Zum Status der Soziolinguistik'. In: W. Klein and D. Wunderlich, Hrsg.,

Aspekte tier Soziolinguistik. Frankfurt am Main: Athen/ium. Wunderlieh, D. 1977. Assertions, conditional speech acts, and practical inferences. Journal of

Pragmatics 1" 13-46.

Per MSseide, Norwegian sociologist. Born 1944. Has done research on commt nication in met tal institutions and in general hospitals. Research interest in cognitive and linguistic approaches to studies of social interaction and social orgaili:ations. Teaches medical sociology at the Univer- sity of Troms~.