Posted on September 21, 2018 at 6:25 PM
by Jason N. Batten, Bonnie O. Wong, William F. Hanks & David Magnus
This issue of the American Journal of Bioethics features a target article by Blumenthal-Barby and Ubel that focuses on patients who are unrealistically optimistic, in denial, or self-deceived. In his excellent commentary, Weinfurt points us toward a particular branch of communication theory—pragmatics—as a fruitful way of evaluating statements made by these patients. He and several other bioethicists have contributed to a small but growing literature applying pragmatics to physician–patient communication, research ethics, and our interpretation of empirical bioethics studies. We believe that pragmatics has the potential to transform how we hear and understand day-to-day communication with patients and their families.
The target article and commentaries explore how we should evaluate statements made by patients, and when, if ever, these statements should constitute evidence that a patient is, in fact, in denial. For example, a patient with imminently terminal metastatic cancer who says “I know I will live” is often taken literally; she is thought to communicate something along the lines of “I am 100% certain that I will survive until my cancer is in remission.” If this understanding of the patient’s statement is correct, then we may be justified in using it as one piece of evidence that the patient is in denial, assuming that the patient has been properly informed. But what does the patient really mean by this statement? As Murray points out, physicians and ethicists have an obligation to “ask the extra question to try to ascertain what patients are thinking.” We would frame this as an obligation to go beyond the literal meaning of the patient’s words to the patient’s intended meaning.
Weinfurt utilizes Austin’s speech act theory—a fundamental piece of pragmatics—to give us traction on the patient’s intended meaning. Is the patient expressing confidence in her physician? Is the patient attempting to maintain positive thinking to shift her odds of survival? Or is our initial assumption (that the patient is attempting to accurately communicate her understanding of the clinical situation) correct? Pragmatics thus provides us with a broader “differential diagnosis” of what might be meant by a particular statement, preventing us from misinterpreting it—or at least reminding us of the multitude of possibilities and giving us a measure of epistemic humility.
To put it bluntly, we almost always convey more than we literally say. For example, if an adult male arrives at the hospital accompanied by an elderly man, and tells the doctor, “My father fell from a ladder and has terrible back pain and blood in his urine,” he will normally convey that the man with him is his father, that the back pain started after the fall, and that he thinks the fall caused both the back pain and the blood in the urine. Notice that none of these inferential enrichments are part of what is literally said. Rather, these belong to the class of pragmatic inferences dubbed “implicatures” by Grice. Grice’s approach to conversation is well established in linguistics, linguistic anthropology, and philosophy of language, and has been even more influential than Austin’s speech act theory. Bioethics has much to gain from appropriating insights from both frameworks and applying them to the challenges we routinely confront.
Pragmatics emphasizes that the same words, spoken by the same person, in the same context can convey a variety of different meanings. This is a normal feature of human language and communication. But when every statement can be interpreted so variably, how is it that we are able to generally understand each other—to successfully convey and understand meaning? One important foundation is the interactive context in which words are said. Contexts are multidimensional and include the parties present at the conversation, the physical location of the conversation, the activity in which they are engaged (e.g., morning rounds, a medical update to a family member, a family conference about an important decision), and the conversational sequence in which words are spoken (e.g., what precedes, what follows). Cross-cutting all of these dimensions is the question of what is shared and what is not shared among the parties. Not only is the doctor-patient relationship asymmetric, but different specialties and different cultural and social backgrounds of patients all have consequences for the ability of the parties to understand each other.
For example, consider an elderly patient in the intensive care unit (ICU) with multisystem organ failure who has been intubated for more than two weeks and shows no signs of improvement. During rounds, a fellow asks the attending physician, “Should we put in an order for trach and peg?” The attending responds, “Why would we do that?” Notice that the fellow’s question does not explicitly identify why or for whom the trach and peg would be ordered; these facts are assumed on the basis of the physical location of the conversation (outside of the patient’s room) and the team’s knowledge of the patient’s case. Similarly, while the attending physician has literally asked a question, she may actually have made a statement conveying that the patient is dying and that continued aggressive interventions are not called for. In the context of a different patient, that same question might have conveyed that a tracheostomy is uncalled for because there is still hope of weaning the patient from the ventilator. In either case, it is deep knowledge of the clinical context (e.g., the patient’s clinical situation, the purpose of a tracheostomy, possible clinical trajectories, the personality of the attending physician) that allows the fellow to determine the attending physician’s intended meaning. This dependency between meaning and context is at the heart of pragmatics.
Context is important both on a local scale (i.e., face-to-face interactions and the immediate setting of a conversation) and on a larger global scale (i.e., the institutional, legal, or professional norms that may shape the constraints and resources available). In the hospital, asymmetries of knowledge between doctors and physicians on both of these scales pose formidable challenges to mutual understanding. Conversely, for those who share knowledge and a common horizon of experience, the many dimensions of context provide a reservoir of shared information to draw on. This is what allows speech to convey a disproportionate amount of meaning, and simultaneously, what makes it so vulnerable to misunderstanding.
Therefore, to Weinfurt’s insights about pragmatics, we would add an additional point: we ought to be highly suspicious of our own communication as health care providers (including clinical ethicists). Pragmatics points out that what is ultimately understood from a particular statement is determined by the listener, who actively constructs meaning based on a complex interaction between the words spoken to him or her, the conversational context, background knowledge, and so on. Even when we avoid the usual communication problems (e.g., using clinical jargon, running short on time, not attending to patient emotions), the best communicators are constantly at risk of being misunderstood.
This matters for “diagnosing” mental states like denial. A patient can only be in denial if the patient has been adequately informed; otherwise, as pointed out by Blumenthal-Barby and Ubel, the patient is merely ignorant or uninformed. Even when health care providers literally communicate the necessary information, the patient may pragmatically construct a different meaning from these words. The patient is not wrong to do so: pragmatics describes a ubiquitous and useful feature of human communication. The problem is with a lack of shared context and background between patients and health care providers. Our own forthcoming empirical and theoretical work demonstrates that even simple phrases, such as “There is a treatment available for this,” can unintentionally convey good news about prognosis, quality of life, or physician intention to treat. Our work builds upon prior perspectival and opinion pieces highlighting similar problems with other statements and questions (“Doing everything,” “Withdrawing treatment/care,” “Failing chemotherapy,” “What would your loved one want?,” “We can’t guarantee that you’ll benefit,” etc.).
The target article and its accompanying commentaries provide an opportunity to recognize the potential for pragmatics to cast light on as-yet-unexplored sources of clinical miscommunication that have significant consequences for patient care. By ignoring pragmatics, we risk being unaware of prior miscommunication (as we point out) and misapprehending a patient’s mental state (as Weinfurt points out). Given the vast differences in background knowledge, experience, and perspective between health care providers and patients, and the ability of these asymmetries to short-circuit basic communication, we urge caution and humility before drawing conclusions about the mental states of interlocutors.