O SZTUCE KOMUNIKACJI W PRAKTYCE LEKARSKIEJ
Józef Bremer1, Aleksander Sieroń2
1JESUIT UNIVERSITY IGNATIANUM, KRAKOW, POLAND
2INSTITUTE OF PHYSICAL EDUCATION, TOURISM AND PHYSIOTHERAPY, JAN DLUGOSZ UNIVERSITY, CZĘSTOCHOWA, POLAND
“WORDS ARE THE MOST POWERFUL TOOL A DOCTOR POSSESSES,
BUT WORDS, LIKE A TWO-EDGED SWORD, CAN MAIM AS WELL AS HEAL .”
Introduction: The history of philosophy testifies to the applicability of rhetorical techniques to the content of therapeutic interlocution. Our methods of influencing people through processes of verbal interaction have developed over several hundred years, and this has also delivered a fruitful framework for evaluating these processes.
The aim: To carry out an analysis of contemporary philosophical speech-act theories – viewed as elements of a form of therapeutic interlocution – and to interpret their efficiency in this regard.
Materials and methods: We examine the well-known speech-act theories of J.L. Austin and John Searle, but also – albeit indirectly – ideas stemming from Ludwig Wittgenstein. The conception of language they propose is similar to that of rhetoric: namely, viewing language as a tool for accomplishing something. In our case, the relevant goal is that of healing, or helping to heal, patients.
Preview: First of all, we outline what it could mean to “create reality” through making use of the power of words. Thus, we initially seek to outline the main points of Greek rhetoric, before then presenting the “speech act” theory of language: a model of language analogous to rhetoric that makes reference to Wittgenstein’s conception of language games. After that, we illustrate the possibility of using speech-act utterances in doctor-patient interactions and, so to speak, in a kind of mode contrary to speech acts themselves, wherein the unintended expressing of something via words or sentences resembles the effects brought on by a placebo. Finally, in the last part of this article, we anatomize Plato’s model of rhetorical utterance as something employed for the transmission of truth between doctor and patient. We will concentrate there, above all, on the question of what it means to be engaged in telling the patient the truth about his or her state of health.
Conclusions: On the one hand, the reference to speech-act theories provides a philosophical background for the use of words in some specific doctor-patient scenarios, while on the other it serves to exhibit the complex structures of our language itself: e.g. its interwovenness with actions such as touching, or its possible efficacy as a placebo, as in some instances of unintentional expressive utterance. Furthermore, using examples of different kinds of speech act, we can specify a number of truth-related and other conditions in force during doctor-patient interlocution.
Wstęp: Historia filozofii potwierdza możliwość zastosowania technik retorycznych w treści rozmów terapeutycznych. Nasze metody wpływania na ludzi poprzez procesy interakcji werbalnych rozwinęły się na przestrzeni kilkuset lat, a to umożliwia konstruktywną ocenę tych procesów.
Cel pracy: Przeprowadzenie analizy współczesnych filozoficznych teorii aktów mowy − postrzeganych jako elementy formy rozmowy terapeutycznej − oraz interpretacja ich skuteczności w tym zakresie.
Materiały i metody: Analizie poddano powszechnie znane teorie aktów mowy J.L. Austina i Johna Searle’a, a także − choć pośrednio – koncepcje Ludwiga Wittgensteina. Proponowana przez nich koncepcja języka jest podobna do tej retorycznej, a mianowicie do postrzegania języka jako narzędzia do osiągnięcia czegoś. W naszym przypadku właściwym celem jest wyleczenie lub pomoc w leczeniu pacjentów.
Wyniki: Przede wszystkim, nakreślimy, co może oznaczać „tworzenie rzeczywistości” poprzez wykorzystanie siły słów. Dlatego początkowo staramy się zarysować główne punkty retoryki greckiej, a następnie przedstawić teorię „aktów mowy” języka: model języka analogiczny do retorycznego, który odwołuje się do koncepcji gier językowych Wittgensteina. Następnie ilustrujemy możliwość użycia wypowiedzi „aktów mowy” w interakcjach lekarz-pacjent oraz w pewnym sensie, w trybie przeciwstawnym do samych aktów mowy, gdzie niezamierzone wyrażanie czegoś za pomocą słów lub zdań przypomina skutki wywoływane przez placebo. Wreszcie, w ostatniej części tego artykułu, analizujemy model retorycznej wypowiedzi Platona jako coś, co służy do przekazywania prawdy pomiędzy lekarzem a pacjentem. Skoncentrujemy się przede wszystkim na tym, co to znaczy być zaangażowanym w mówienie pacjentowi prawdy o jego stanie zdrowia.
Wnioski: Z jednej strony, odniesienie do teorii aktów mowy stanowi filozoficzne tło dla użycia słów w niektórych konkretnych scenariuszach lekarz-pacjent, podczas gdy z drugiej strony służy do przedstawienia złożonych struktur naszego języka jako takiego: np. jego przeplatanie się z działaniami takimi jak dotykanie lub jego potencjalna skuteczność jako placebo, jak w niektórych przypadkach niezamierzonej ekspresywnej wypowiedzi. Ponadto, używając przykładów różnych rodzajów aktów mowy, możemy określić szereg uwarunkowań związanych z prawdą i inne uwarunkowania obowiązujące podczas rozmowy lekarz-pacjent.
Wiad Lek 2018, 71, 8, -1455
What is language? How does it function? Answering such questions is no simple matter. Language forms the basis for our individual and social being, and it is very difficult, if not impossible, to go beyond it. Amongst all of the philosophers and scientists, perhaps no one knew this as well as the Austrian philosopher Ludwig Wittgenstein (1889-1951). His name is associated with the phrase “linguistic turn”, which groups together philosophy with the rest of the humanities in terms that grant primacy to research concerned with the relationship between language and philosophy on the one hand, and language and the world on the other. His own struggles with language found their expression in two philosophical works: his early publication the Tractatus Logico-Philosophicus, and the later Philosophical Investigations . Each of these works displays a different conception of language of the sort that figure in philosophical research centred on language: on the one hand, there is the Tractarian idea of an artificial language and of descriptive, truth-oriented sentences, and on the other there is the conception found in Philosophical Investigations, where language is conceived in terms of language games woven together into one or more forms of life. The kind of language that matches the first of these is usually encountered in the natural sciences and in mathematics, while that which fits with the second is typically present in the social and humanistic sciences, as well as in common-sense communication. Both of these ways of thinking about language, moreover, as conceived by Wittgenstein, have figured in some way or other in the history of philosophy and continue to inform contemporary philosophy and linguistics.
The classical rhetoricians stood for a conception of language that is, in this regard, quite similar to a part of what contemporary philosophers of language have in mind: both would, after all, unhesitatingly assert that language should make a difference. In what follows, in discussing contemporary philosophers, we shall have in mind the likes of John L. Austin and John Searle, but also – albeit indirectly – the later Wittgenstein. The conception of language they propose involves viewing it as a tool for doing something, as is the case with “speech acts”.
In this article, we will first outline the issue of what it could mean to “create reality” through making use of the power of words. Thus we initially seek to outline the main points of Greek rhetoric, before then presenting the “speech act” theory of language: a model of language analogous to rhetoric that makes reference to Wittgenstein’s conception of language games . After that, we illustrate the possibility of using speech-act utterances in doctor-patient interactions and, so to speak, in a kind of mode contrary to speech acts themselves, wherein the unintended expressing of something via words or sentences resembles the effects brought on by a placebo. Finally, in the last part of this article, we will anatomize Plato’s model of rhetorical utterance as something employed for the transmission of truth. We will concentrate there, above all, on the question of what it means to be engaged in telling the patient the truth about his or her state of health. Throughout the article, we seek to adhere to the principle of only making use of examples taken directly from actual medical practice. To be ill we understand as to be in a state of need. Such a state of being expresses itself as a cry for help.
Already, in the dialogue “Gorgias”, Plato distinguishes two kinds of use and understanding of language: 1. descriptive language, through which we inform somebody about something, and in which the importance of the truth or falsity of sentences remains central, and 2. the language of rhetoric. Plato understood the latter as serving to “create a conviction” in somebody about something. As Gorgias the rhetorician, convinced of the efficacy of skilful language use, tells Socrates:
Oh yes, Socrates, if only you knew all of it, that it encompasses and subordinates to itself just about everything that can be accomplished. And I’ll give you ample proof. Many a time I’ve gone with my brother or with other doctors to call on some sick person who refuses to take his medicine or allow the doctor to perform surgery or cauterization on him. And when the doctor failed to persuade him, I succeeded be means of no other craft than oratory .
A rhetorician, according to Gorgias, has the ability to speak against everyone on every subject, so as to be all the more persuasive in any sort of social gathering, and when discussing just about anything. But the fact that he has the ability to despoil doctors or other craftsmen of their reputations doesn’t give him any more of a reason to actually do it. He should use rhetoric justly, as he would any competitive skill. Gorgias trusts in the power of spoken words. Socrates, on the other hand, views rhetoric from another perspective, connecting as his does the act of speech with the question of truth. Classical rhetoric, meanwhile, sought an answer to the question of how, with the help of language, one might bring about any kind of change (e.g. in the emotions), accomplish something, or create social institutions.
Aristotle sees the rhetorician as a person who is able to consistently discern what will count as persuasive. Hence, rhetoric is specified as the ability to see what is potentially persuasive in every given case. He distinguishes three kinds of persuasion in this field:
Of the modes of persuasion furnished by the spoken word there are three kinds. The first kind depends on the personal character of the speaker [ethos]; the second on putting the audience into a certain frame of mind [pathos]; the third on the proof, or apparent proof, provided by the words of the speech itself [logos]. Persuasion is achieved by the speaker’s personal character when the speech is so spoken as to make us think him credible .
In fact, Aristotle’s three kinds of persuasion could be adapted to apply to almost every sort of instance of speaking. They function to invoke and enhance credibility, evoke and stir up emotion, and prompt action. They constitute appeals to character (ethos – appealing to the authority or honesty of the speaker), emotion (pathos – appealing to the audience’s emotions), and logic or reason (logos – used to describe facts).
Rhetoric is, furthermore, not exhausted by thinking of it as just some form of psychologically captured prodding or exhortation. Behind the rhetorician’s idea of one’s being able to exert a linguistically effected influence on somebody, or on the world itself, stands a wider theory, which is concerned with how an interpersonally constituted world comes to be created. It is about a process of creation that, to be sure, emerges from the psychological immediacy of one’s beliefs and instances of persuasion, but which is also ultimately about bringing somebody into a permanently altered state – about wielding strong-minded influence.
Still, the fact remains that we have two competing conceptions – both introduced by Plato – of the function and nature of language. In the first of them, words serve the description of the objective world, and the sentences created from them are liable to evaluation according to the categories of truth and falsehood. For supporters of the second conception, on the other hand, language is first of all a tool for accomplishing something, and the utterances created in language are, in the first instance, speech acts. We do not evaluate them according to the categories of truth and falsehood, but rather in terms of those of appropriateness or effectiveness (as this pertains to some activity or other).
Accepting the second conception in no way entails rejecting the first. The question about the descriptive meaning of the words used, and about the truth-conditions of sentences uttered, are in such cases approached in the context of research into the function which the language performs in concrete forms of social interaction. Speech act theory tries to understand the ways in which meaning is created within a given speech-context. Consequently the term “speech act” refers not only to an utterance’s being performed, but also, in the appropriate way, to the complete situational context surrounding it. This permits us to consider the fact that whenever we say something we are also accomplishing something.
Where speech acts are concerned, then, such sentences come to be known as performative utterances. In English the transitive verb “to perform” is used not only to describe something occurring within a given reality, but also something that may itself count as changing social reality. Cf. the following dictionary definition: “to do in a formal manner or according to prescribed ritual”,. Their surface appearance may remind one of statements (they are, after all, grammatical correct indicative sentences), but they do not in fact describe or affirm anything: they are not reports, so they are neither true nor false. In his definition of performatives, J.L. Austin mentions two characteristics:
1. Performative utterances are neither true nor false – that is, they are not truth-evaluable; instead, when something is wrong with them then they are said to be “infelicitous”, while if nothing is wrong they are considered “felicitous”.
2. The uttering of a performative is, or is part of, the carrying out of a certain kind of action, the performance of which, again, would not normally be described as just “saying” or “describing” something [7, 8].
The uttering of a performative is not in the first instance a mere transferring of information, but rather a certain type of act of issuing a statement: one that we accomplish by employing the right words, with the right intention (purpose) and in the right context (circumstances), as these pertain to the performing of some action or other. An utterance that performs an act or creates a state of affairs does so simply by virtue of its having been uttered under conventionally established or otherwise appropriate circumstances. For example, a competent person can name a newly built ship just by stating aloud “I name this ship ‘The Sun’!” – thus performing the act of naming a ship as it figures within the ship-naming ceremony. Similarly, just uttering the words “I promise” is tantamount to performing the act of promising. A speech act might include just one word, as in “Sorry!”, or a number of words or sentences, as in “I’m sorry I forgot your name day. I really don’t know how it happened.” An example of a request would be “Could you close the door, please?”
We perform speech acts when we issue an invitation, an apology, a greeting, a request, a complaint, a compliment, a consolation, etc. “Do not lose hope!”, spoken by a doctor in conversation with the patient or his or her family, is itself an act of consolation,.
Features of speech act theory have made their mark in a lasting way across a variety of different disciplines, including epistemology, social philosophy, theories of culture, jurisprudential theory and the philosophy of justice. Prior to anything else, in and amongst the sentences of natural language Austin has enabled us to recognize performatives as a distinct class, classifiable not in terms of truth-value but rather according to their efficacy.
Austin’s and Searle’s classifications of speech acts
Indeed, Austin went further than this, using a more complex classification to speak about three potential aspects of speech acts. According to him, there are three levels of speech act: [9, 10]:
a. locutionary acts are acts of uttering a sentence with a meaning. For example: “It is cold outside!” Locutionary acts are the most basic utterance acts generating meaningful expressions;
b. illocutionary acts are performed via the (conventional) communicative issuing of an utterance. Such an act of utterance is performed with some kind of function in mind: e.g. to request that the bus driver stop the bus. Someone might issue an utterance in order to make an offer, to furnish an explanation, or for some other communicative purpose. Illocutionary acts refer to locutionary acts, since underlying them is the communicative force of some locutionary act itself;
c. The third and last aspect of speech acts is their perlocutionary force, meaning the effect of the utterance on the hearer, construed as something that depends on specific circumstances (in short, the speaker’s achieving certain intended effects). Perlocutionary acts would include such outcomes as persuading, embarrassing, intimidating, boring, irritating, or inspiring the hearer.
The theory of speech acts presented here aims to do justice to the fact that even though it is the case that words (sentences) encode information (locutionary acts), we do more with words than just convey information (illocutionary act), and that when we do convey information, we often actually convey more than the words themselves encode. While the emphasis of speech act theory has been on utterances, and mainly on those performed in conversational and other face-to-face situations, the phrase “speech act” should be taken generically as standing for any sort of language use, be it oral or otherwise. Speech acts, whatever the medium of their performance, fall under the extensive category of intentional action, with which they share certain general features.
Austin’s analysis focuses on the performance of illocutionary acts, since perlocutionary acts have long been studied in the domain of rhetoric. An illocutionary act is neither true nor false, but it can be felicitous or infelicitous, in that the performance of the act depends on conditions of satisfaction being met.
A particularly pertinent feature here is that when one acts intentionally, one generally has a set of nested intentions. Suppose, for example, that a nurse on duty in a hospital ward utters the words “The ward will be closed in ten minutes”. She is thereby performing the locutionary act of saying that the ward will be closed in ten minutes (from the moment of speaking). In saying this, the nurse is also performing the illocutionary act of informing the patients’ visitors of the approaching closure, and presumably also that of urging them to bring their conversations to a speedy end. In fact, then, the nurse intends to perform the perlocutionary act of causing the visitors to believe that the ward is about to close, and of getting them to say goodbye. She performs all these speech acts just by uttering certain phrases in certain circumstances.
This, of course, prompts one to wonder about exactly where, and when, a realized action can be acknowledged as a speech act. One answer to this is proposed by John Searle, who analyses the act of promising. Searle introduces his listing of the conditions needed to actualize a speech act (which we shall summarize below) in the following terms: “If a speaker S utters a sentence T in the presence of a hearer H, then, in the literal utterance of T, S sincerely and non-defectively promises that p to H if and only if…” [11, 12].
Searle’s conditions may be briefly stated as follows:
1. hearer (H) and speaker (S) both know how to speak the language, and are both conscious of what they are doing (normal input and output conditions);
2. S expresses the proposition that p in the utterance of T;
3. in expressing that p, S predicates a future act A of S;
4. H would prefer S’s doing A to his not doing A, and S believes H would prefer his doing A to his not doing A;
5. it is not obvious to both S and H that S will do A in the normal course of events (the act must have a point);
6. S intends to do A;
7. S intends that the utterance of T will place him under an obligation to do A;
8. S intends (i-I) to produce in H the knowledge K that the utterance of T is to count as placing S under an obligation to do A; S intends to produce K by means of the recognition of i-I, and he intends i-I to be recognized in virtue of (by means of) H’s knowledge of the meaning of T;
9. The semantical rules of the dialect spoken by S and H are such that T is correctly and sincerely uttered if and only if conditions 1-8 obtain.
After specifying the necessary conditions for a speech act of promising, Searle sets out to determine the Semantical Rules for Promising, which are as follows:
a. Propositional Content Rule – P is to be uttered only in the context of a sentence the utterance of which predicates some future act A of the speaker S;
b. Preparatory Rule 1 – P is to be uttered only if the hearer H would prefer S’s doing A to his not doing A, and S believes that about H;
c. Preparatory Rule 2 – P is to be uttered only if it is not obvious to both S and H that S will do A in the normal course of events;
d. Sincerity Rule – P is to be uttered only if S intends to do A;
e. Essential Rule – the utterance of P counts as the undertaking of an obligation to do A.
These are all constitutive rules, although only (e) is expressed as a “counts as” rule. Conditions 1-9 are known as ‘felicity’ conditions: speech acts, as we saw, cannot be ‘true’ or ‘false’, but they can be felicitous or infelicitous. For example, if a doctor tells a patient that he or she must stay in hospital for a medical inspection, then we (although perhaps not the patient!) might consider this felicitous – the doctor is in a position of professional competence that enables him to perform this action. However, if somebody went up to someone in hospital and said “You must stay in hospital!”, then we would probably judge this infelicitous, as the speech act of keeping someone there cannot usually be performed by a random person.
According to Austin, every linguistic act has both “conditions of felicity” (under which it is appropriate) and “conditions of satisfaction” (under which it is completed). Searle’s overall classification of speech acts is presented below.
• Assertives: these commit the speaker to something’s being the case. The different kinds are: suggesting, putting forward, swearing, boasting, and concluding. E.g. Doctor (D): “Some of the fMRI pictures that I’ll take from you today will be looked at in medical centre, and from these I’ll decide whether you require treatment or not.” Assertive speech acts are utterances in which the speaker’s words mirror the world truthfully.
• Directives: these try to make the addressee perform an action. The different kinds are: asking, ordering, requesting, advising, inviting and begging. E.g. D: “Could you close your eyes?” or D: “Just let me have a look at you! Come and sit opposite to me, open your mouth, head slightly forward!”
• Commisives: these commit the speaker to doing something in the future. The distinct kinds are: promising, opposing, planning, vowing, and betting. E.g. D: “I’m going to read the history of your illness.” D: “I promise you that you’re safe here, you’re in competent hands.”
• Expressives: these express how the speaker feels about the situation. The distinct kinds are: thanking, welcoming, apologising and deploring. E.g. D: “I’m very sorry to tell you that your dad is ill.”
• Declaratives: these change the state of the world in an immediate way. E.g. D: “In the future you really must stop drinking; so long as you keep on drinking you’ll have more problems with your stomach”.
In the speech act theories presented above, the multidimensional structure of such actions is taken into consideration. In doing anything at all, we are governed by such questions as: For what purpose? In what way? To what effect? Theories of speech acts seek to take into account all of these questions.
Say, for example, that the doctor speaks to the patient in a language with which both of them are familiar (see conditions 1-9 above): “I promise you that I really will take a good look at the history of your illness”. This implies that he is speaking about a future action, that the patient wills that the doctor should have a look at the history of his illness, that with the normal course of events the doctor will do it, that the doctor will remain true to his promise, and that if he said “I promise that…”, then he has indeed made a commitment to take a look at the history of the illness.
The doctor’s intention was to generate in the patient the knowledge that when he says “I promise that…” he himself then has an obligation to have a look at the history of the patient’s illness. If we also take into account rules (a) – (e), then we also have a speech act thanks to which there comes into being, between the patient and the doctor, the reality of having promised. There is a real difference between this and a merely locutionary informing of the patient that “The history of your illness will be reviewed tomorrow”.
More and more often, medical personnel are coming to see that the art of healing depends not only on the role of medicines and computer-based technology as these figure in modern-day medicine, but also on the adoption of a sensitive, human-centred approach to suffering and pain. This is the principal message of the abovementioned book by Lown. Where the human face of medicine is concerned, what is really fundamental is our conscious employment of words. The theoretical background to this, together with appropriate examples of such use, can be uncovered in the theory of speech acts.
Speech acts in the context of their surroundings: touch
Some speech acts (e.g. expressives or declaratives) are often loaded with emotional significance and convey information about the interpersonal relation(s) involved. When we have exhausted the power of speech acts themselves, we can extend them by inducing a change in our surroundings. We can reinforce their effectiveness through non-verbal communication: e.g. through touch . The expressiveness of touch is well captured in our everyday vocabulary: “keep in touch!”, “don’t touch!”, “out of touch”, “a touch of frost”, “her death touched nobody”, or “I’m touched by your nice words”. In ordinary speech we engage the sense of touch to create metaphors for physical and psychic closeness or distance, and for the desired presence or untouchable absence of the other. The circumstances that bear on one’s exhibiting empathy are, ultimately, one’s connection with the other, affirmed frequently through touch, which may vary from a handshake (e.g. “a handshake with both hands”, “a handshake with shoulder”, “a handshake with a bow”), through clasped hands, to caressing somebody.
Aristotle insists that touch is the most acute of man’s senses . And touch is certainly more definite, more “pressing”, and somehow more ancient than our other senses. Touch appears such a natural way to characterize our psychic being that we name our inner states, as well as the entire dynamic of our affective lives, “feeling”. Unlike with our other senses – we can, for example, watch and not see, hear an utterance but not attend to it, speak and not be heard – touching is a double-sided affair. It has an essential nearness: one cannot touch without being touched by what one is touching. In touching, the doctor and the patient are simultaneously a subject and object, they are being active and passive, a toucher and a receiver of a touch.
A recent study suggests that touch establishes a complex and differentiated signalling system. It communicates distinct emotions (anger, fear, happiness, sadness, disgust, love, gratitude, and sympathy) and does so in a robust fashion . Moreover, the accuracy rates for the emotions ranged, on average, from 50% to 70%, which is comparable to the accuracy rates observed in facial and vocal studies of emotion. After all, particularized coding has documented specific forms of tactile behaviour that are associated with each of the emotions.
Each instance of touch is analysable not just at the level of expression, but also at that of meaning. If the physical form of tactile gestures is to be described in terms of bodily configuration and movement, the semantic structures are to be analysed as a form of communicative meaning. The gestures in question could be investigated using ideas and terminology taken from the speech act theories, yielding a taxonomy of physical-contact gestures using the concepts already developed by Austin and Searle. We might thus have a comparative correlation of sorts between certain speech acts and certain tactile acts (Tab. 1) .
Tactile gestures have speech-like properties, and 1. communicate in a similar fashion, 2. reinforce the causal effect. Body movements that substitute for speech in the form of touch can be interchanged with or linked to spoken utterances, and they can configure, similar to speech, a rule based, learnable, and culturally determined symbol system.
One of the greatest losses resulting from the abandoning of forms of intimate tactile interaction with patients is the loss of the sort of human bonding that can engender confidence and trust. Speaking, listening and touching connect doctor and patient, helping to define their distinctive medical-social identity as human beings.
Tactile communication correlates with the use of speech in communication. One thing that should be kept in mind is that tactile action involves an invasion of privacy (of another person’s personal sphere). Therefore, it can either be unwelcome or construed as harassment, or be very welcome, as when it reflects being wanted and warmth. The physical gesture needs the spoken word, for otherwise it becomes aggressive or invasive, and may even restrict freedom of choice by making impartial judgement impossible and creating emotional bonds that lack any basis in a harmony of understanding.
Words and their placebo effect
Speech acts are conscious actions, based on premeditated utterings of performatives. Some performances used by doctors in their practice show that words uttered in nonintentional, accidental ways can also lead to the creation of a new reality and, in medical circumstances, to the gradual improvement of health. These are cases that begin to diverge from those of speech acts themselves.
The situation with such an understanding of verbal utterance could be compared with the opposite of the placebo: namely, the nocebo. In many cases it happens that the patient receives a substance or treatment that is without any active therapeutic effect. A placebo may be given to a person or a patient in order to mislead the recipient into thinking that it is an active treatment. Even though they do not act on the disease, placebos affect how some people feel. It should be mentioned that when using a placebo the effect sometimes goes in the opposite direction, in that it seems to cause unpleasant symptoms (such “side effects” as, say, headaches or nervousness). The unpleasant effects that occur after receiving a placebo are sometimes called the “nocebo effect”. There could also be another, third sort of case, in which the belief that something does harm to the patient may lead not only to his or her feeling worse, but also to an impairment of his or her physical condition.
Let us now turn to a relevant example of such a placebo effect. Dr Lown believes that the “placebo effect” isn’t limited only to the giving of medical substances or treatments. It is a far broader phenomenon. The words of doctors and other medical personnel are the most potent placebos of all. The capacity of a doctor’s words to either heal or maim is determined by the physician’s behaviour – the certainty with which information is communicated, the level of empathy displayed, and, above all, a readiness to listen.
The placeboic power of words was brought home to Dr Lown by a critically ill sixty-year-old patient. Two weeks after a heart attack, he was still in a coronary intensive-care unit. He had experienced nearly every complication in the book. He could not sit up due to dizziness and near-syncope. Breathless and weak, he had no energy to eat; he also lacked appetite, as the smell of food provoked nausea. Sleep was restless and disrupted. He was cyanotic and periodically gasped for air as though drowning.
Each morning, medical rounds were like visitations from a morose bunch of undertakers. Dr Lown’s team had exhausted all of the encouraging platitudes. In any case, Dr Lown believed that any reassurance would have insulted the patient’s intelligence and further undermined his trust. The team sped up the morning visits to avoid his scared, questioning stare. Every day the situation worsened. One morning, however, the patient looked and claimed to feel better and, indeed, his vital signs had improved. Dr Lown could not account for the change, but had him transferred to a care unit. The patient was discharged a week later.
After about six months he showed up in Dr Lown’s office, looking remarkably fit. The doctor was astonished and puzzled. “A miracle?” “Hell! No! This was no miracle!” the patient responded. “What happened?” asked Dr Lown.
The patient specified precisely when the so-called miracle happened. He was aware that the team had reached the end of its possibilities as far as helping him was concerned. Dr Lown’s team had convinced him that it had given up hope. The patient continued: “One Thursday morning… you come in with your gang, surround the bed, and look as though I was already in a casket. You put your stethoscope on my chest and urge everyone to listen to the ‘wholesome gallop’. Ifigured that if my heart was still capable of a healthy gallop, I couldn’t be dying, and so I got well” [17, 18]. So – according to the patient – it was no miracle. It was mind over matter. The patient was, of course, unaware that a gallop was a bad sign. A wholesome gallop is an oxymoron, and Dr Lown had been referring to the galloping sound of his heart – paradoxically a poor prognostic sign in relation to conditions involving heart failure.
Words are the most powerful equipment a doctor possesses. As Dr Lown writes: “Patients crave caring, which is dispensed largely with words” (see the previous footnote). Although talk can be therapeutic in itself, it more often affects health outcomes indirectly by, for example, building trust and increasing adherence . It is one of the most underestimated tools in the physician’s toolbox. Medical experience constantly furnishes examples to remind us of the healing power of carefully chosen words.
Nevertheless, the doctor’s possibilities for performing the role of a placebo are not limited to words: they also involve nonverbal gestures. Minimizing the waiting time begins the process. Greeting a patient with a warm handshake, followed by an unhurried, uninterrupted visit, further enhances the placebo effect. A careful history, taken without disruption to the patient’s state, fosters trust. Affirmative behaviour, a ready smile, a positive word, speech that is direct rather than equivocating, all help the doctor connect with other persons and form a durable relationship.
Even in the most far gone situation one can discover a ray of hope. This, as with speech acts, has little to do with truth or falsehood. It flows from the deepest aspiration of doctors, which is to help the patient rise to the circumstances. “Even when a cure is impossible, that does not mean healing is impossible” .The very sick are not taken in by fictitious optimism, but they are eager for the warmth of touch and the caress expressive of human concern. While medical science has limits, hope does not. Dr Lown believes in the maxim proposed by the physician Edward Trudeau about a century ago: “To cure sometimes, to relieve often, to comfort always.” Miracles, for Dr Lown, reside in our capacity for comforting and healing. Doctors are only reclaiming their medical professionalism by resuming the role of a “placeboist” .
Natasha Campbell and Amir Raz call physicians “walking placebos”, and use language that could easily fit with that of Dr Lown: “One can be both a scientific physician and a walking placebo; that is, a physician’s bedside manner and personality can be as scientifically informed and astute as their knowledge of, for instance, the treatment of respiratory infections. Through this perspective, we frame the distinction between curing and healing: physicians can cure abnormalities of the body and heal the problems that arise from a patient’s subjective experience of those abnormalities” . Physicians have the competence to change expectancy, effect, experience and outcome, by capitalizing on certain socially conditioned cues, and choosing their words wisely, in order to create the most helpful healing environment.
Acts of truth versus acts of satisfaction
How – using speech act theory – to tell the patient the bad news that he or she has cancer or is dying? The theory of speech acts has brought to the philosophy of language a conception of truth in which the concept of truth turns out to be much less robust and consistent than in the well-known classical definition of truth as adaequatio rei et intellectus (“the intellect (of the knower) must be adequate to the thing (known)”).
For Searle, “Wherever the illocutionary force of an utterance is not explicit it can always be made explicit” . The latter judgement is, for Searle, an instance of the principle of expressibility, which states that whatever can be meant can be said, and – what follows – whatever can be implied can be said. So whatever can be meant as true can be said as true, and consequently each true sentence can be the object of an utterance .
Searle notes the parallelism between the structure of speech acts and the structure of intentional states. Just as speech acts have propositional content that determines their conditions of satisfaction, with the latter being truth conditions in the case of belief, obedience conditions in the case of commands, and fulfilment conditions in the case of promises, so intentional states also have conditions of satisfaction, these being truth conditions in the case of belief, fulfilment conditions in the case of desire, and so on. Much as the typical analytical philosopher engaged in analysing a sentence will analyse it in terms of its truth conditions, on Searle’s account, in which this is further generalized, speech acts themselves can be analysed in terms of their conditions of satisfaction .
When we reflect on this generalization we realize that the satisfaction conditions of elementary illocutionary acts cannot be reduced to the truth conditions of their propositional contents. An important contribution made by Searle to the theory of meaning thus consists in precisely this analysis of satisfaction, in that it entails the need for an expansion or refinement of the classical notion of truth conditions so as to allow for the incorporation of all forms of illocutionary force.
Using examples of different kinds of speech act, we can specify a number of truth and other conditions operative in doctor-patient communication:
a. Performatives such as “I say” and “I apologize” are self-referential (i.e. in such a context the verbs “say” and “apologize” refer to what the speaker (doctor/patient) of the utterance is doing now), they are self-verifying (meaning they include their own truth conditions), and they are non-falsifiable (i.e. they can never be untrue).
b. Some cases of such performatives as [doctor says:] “I hereby promise you that I will use appropriate medical procedures!” – spoken somewhere or other – will not make sense, if the relevant felicity conditions are not observed. Felicity conditions apply pre-eminently to performatives associated with formally defined events. In the example analysed here, the utterance can only be appropriately and successfully uttered by a special person (the doctor) in a specified clinical situation.
c. Felicity conditions making speech act (b) count as successful would doubtless include:
– that there be a conventional medical procedure with an expected (by doctor and patient) conventional effect,
– that the clinical circumstances and both of the persons be appropriate,
– that the procedure be executed flawlessly and exhaustively, and
– that doctor and patient have the requisite thoughts, feelings and intentions. If the implementation of any further medically significant practices is specified, then patients will also be obliged to undergo this.
The doctor-patient conversation is a process that generates various requirements as regards satisfaction generally and felicity in particular. Thus, on a speech-act account of language we have requirements for truth that are self-referring with respect to the speech-situation, requirements for truth that refer to the objective world (germ-line theory, medicaments, Evidence Based Medicine – EBM [8, 24, 25]), requirements for normative validation pertaining to the social circumstances (medical ethics, informed consent, cooperation, trust), and requirements for sincerity referring to the subjective world of the patient (attempting to convince or console without resorting to cheap tricks or strategic manouvres, etc.).
Significantly, these different requirements link up dialectically within the actual communicative speech-act scenario connecting protagonists as co-participants in the interaction. As regards the requirements for truth pertaining to medicine as it relates to the human body, even though doctor-patient communication is not a relationship of equal communicative opportunities, this asymmetry can be diminished thanks to education, the accessibility of medical information, sociocultural development, and medical evolution influenced by pressure from more demanding participants, be they patients or doctors.
Over and above this, within the speech-act context (as one which is both constructed and regulated in accordance with rule-based norms and necessary conditions), medical authority holds legitimate sway, as does the patient’s right to receive a second opinion and clear and correct information. For example, patients are normally assessed by teams consisting of specialists who must also maintain a symmetrical relationship with one another, as is typical for the kind of contexts in which assertive speech acts are required to be oriented towards specialized diagnostic rigour and the weighing up of alternative treatments. Despite the basic asymmetry, both doctor and patient can, within the speech-act-based communicative scenario, meet the inherent demands corresponding to other requirements pertaining to normative validation and authenticity.
It is necessary to notice that the doctor-patient relationship inhabits certain socio-economic horizons, its importance being grounded in the acknowledgement it receives from a normative body that institutionally confirms the right to health, to receiving whatever positive information may be necessary to ensure patient-involvement in decision-making, and to Narrative-Based Medicine (NBM), whose language is based on illocutionary and perlocutionary speech acts. Despite the asymmetry and the unequal grasp of medical knowledge here, it is in fact possible, based on normative linguistic considerations, to have a maximally balanced doctor-patient relationship. This view allows for an approach to doctor-patient communication that falls reasonably between mere acts of communication on the one hand, and mere argumentative discourse on the other.
Within the field of Narrative Based Medicine, we may note that both the conscious use of language in speech acts and the unconscious uttering of words may engender the “placebo-effect” described here, which may be said to have its roots at least partly in ancient rhetoric. The patient is viewed as a narrator, and as someone capable of understanding and operating with the different kinds of language game encountered in the context of artificial language, truth-oriented descriptive language, and language as conceived in speech act theory. Medical procedures based on evidence (Evidence Based Medicine) are, quite often, treated as more basic when it comes to assuring proper healthcare. Speech act theory – as used in the Narrative Based Medicine – throws light on the social aspects of language, and through this on the interpersonal relations obtaining between doctor and patient. Words have the power to influence, to heal and to affect and control others, but can also reflect their power back to speaker as a reaction to his or her words.
Speech acts, as one model form of language game, can be used as a theoretical tool to describe how to go about handling patients with care. At the same time, this theoretical tool is embedded in a multifaceted system of rules and conditions that is, more often than not, also supported by nonverbal forms of behaviour.
In spite of being prone to elaboration, narratives also figure in and are created by communication – which also means “speech acts”. As we saw, speech acts engender a unique sort of textual genre, with a linguistically unique textual structure quite different from other such genres –for instance, a descriptive argument or a report. These patterns can also emerge in the course of a doctor-patient medical consultation or conversation. We may thus specify some features of how narrative may figure in speech acts relevant to medical practice.
As regards the use of speech acts in medical praxis, and considering this form of interaction from the doctor’s perspective, we may observe that he or she always has a particular recipient in mind (so that an utterance can never be performed in exactly the same way twice), and always has an individual patient – one who brings with them their own particular experiences and feelings. Such speech acts, moreover, relate to discernibly distinctive stages of the healing process: orientation, complexity, consultation and evaluation. If the speech-act situation contains information that is not an essential part of the conversation, the doctor must register this fact and react accordingly. But he or she can also – with nonverbal elements – reinforce the illocutionary power of some act or other. The content is the speaker’s choice, what he or she regards as relevant to the patient’s narrative, and thus is an act of meaning creation. The speech act possesses an attractive force, “pulling one into the speech-event” and, as a consequence, enabling the experience of “being involved” and not just “being informed”.
Narratives at the level of the speech act follow an inherent drive for perfection: to impart the relevant contextual information, to dispense with irrelevant information, and to take into consideration the rules of interaction mentioned above – and, in this way, to achieve the concluding of the conversation within a reasonable time-frame. This last consideration is highly important for medical specialized personnel operating under rigorous time constraints, who may well fear being overwhelmed by their patients’ stories if they (the doctors) happen to tap into an extensive source of unforeseen troubles or problems the patient has. Theoretical knowledge about speech acts can, moreover, itself form an element of the larger narrative that unfolds in the doctor-patient encounter. Taking all of this into account, it seems crucial to recommend a form of medical training that will impart both a grasp of the appropriate use of words and an appreciation of their healing power.
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Conflict of interest:
The Authors declare no conflict of interest.
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Table1. Relations between speech act and touch act.
Locutionary act: Utterance
“The drugs and the alcohol will kill you!”
Doctor shakes hand with elbow
Perlocutionary act: Causal Effect
“Yes, I know”
Patient shakes doctor’s hand more strongly