Physician - patient argumentation and communication , comparing

This article discusses the application of theories of argumentation and communication to the field of medicine. Based on a literature review, the authors compare Toulmin’s model, pragmadialectics, and the work of Todd and Fisher, derived from American sociolinguistics. These approaches were selected because they belong to the pragmatic field of language. The main results were: pragma-dialectics characterizes medical reasoning more comprehensively, highlighting specific elements of the three disciplines of argumentation: dialectics, rhetoric, and logic; Toulmin’s model helps substantiate the declaration of diagnostic and therapeutic hypotheses, and as part of an interpretive medicine, approximates the pragma-dialectical approach by including dialectical elements in the process of formulating arguments; Fisher and Todd’s approach allows characterizing, from a pragmatic analysis of speech acts, the degree of symmetry/ asymmetry in the doctor-patient relationship, while arguing the possibility of negotiating treatment alternatives. Physician-Patient Relations; Language; Comunications Resumo Este artigo discute a aplicação de teorias da argumentação e da comunicação ao campo da medicina. Com base em revisão bibliográfica procedeu-se à comparação de três enfoques selecionados pela pertença a uma concepção pragmática da linguagem: o modelo de Toulmin, a pragma-dialética, e o de Fisher e Todd, derivado da sociolinguística americana. Os principais resultados foram: a pragma-dialética caracteriza o raciocínio médico de maneira mais integral, incorporando elementos das três disciplinas da argumentação: a dialética, a retórica e a lógica; o modelo de Toulmin ajuda a fundamentar argumentativamente a declaração de hipóteses diagnósticas e terapêuticas e, como parte de uma medicina interpretativa, aproxima-se da pragma-dialética por incluir elementos dialéticos no processo de formulação de argumentos; o enfoque de Fisher e Todd permite caracterizar, por uma análise pragmática dos atos de fala, o grau de simetria/assimetria da relação médicopaciente e sustenta a possibilidade de negociação das alternativas terapêuticas. Relações Médico-Paciente; Linguagem; Comunicação http://dx.doi.org/10.1590/0102-311X00150914 Rivera FJU, Artmann E 2 Cad. Saúde Pública, Rio de Janeiro, 31(12):1-10, dez, 2015 Introduction Theories of language have been acknowledged and appropriated by the field of health 1,2,3,4,5,6,7,8,9,10,11, since they offer an important analytical alternative for the area, whose practices, albeit instrumental, are anchored essentially in language. The importance of language and communication in health is due not only to the relational dimension produced by the relevance of soft and soft-hard technologies, but to the necessary consensuses, including on the use of hard technologies and their impacts on health 7. This article provides a critical review of texts on some approaches in the theory of argumentation and pragmatic analysis of language applied to the fields of medicine and health education: (a) the pragma-dialectical model 12, on which we focus more attention; (b) Toulmin’s approach 13; and, (c) a pragmatic communicational approach derived from American sociolinguistics, represented by the work of Fisher and Todd on doctor-patient communication 5. The pragma-dialectical approach, represented by van Eemeren & Grootendoorst 12 e van Eemeren 14, is founded on the notion of argumentative discourse as a process that links a protagonist and antagonist who seek to resolve their differences and find a consensus represented by recognition of the best argument’s merits. Heavily normative, the approach concedes the need for rules of sincerity and normative correction referring to the formal discursive procedures operating as the warrant of an argumentative process that seeks reasonableness in the Popperian sense reconstructed by Habermas 15, thus tending to be universalist. Toulmin’s model 13 helps characterize the argumentative structure or set of principal elements of what is considered a reasonable argumentative process. These constitutive elements of argumentative reasoning are linked to the need to justify given theses that represent pretensions from the communicational point of view, beyond establishing logical inferences. Fisher & Todd 5 conduct an adaptation of the theory of speech acts (Austin 16 and Searle 17), according to which language is not a mere passive representation of reality, but an action that creates social context. Fisher & Todd 5 seek to characterize doctor-patient communication as determined by the social structure and institutional system (like social organization or power relationship). The authors conduct empirical analyses of the speech acts present in the processes of diagnostic definition and negotiation of patients’ alternatives for treatment and follow-up, highlighting this communication’s heavy asymmetry. The three approaches belong to the field of pragmatic philosophy of language, and this was the criterion used in our selective literature review. In the cases of pragma-dialectics and Fisher and Todd’s approach, this common element is the theory of speech acts of Austin 16 and Searle 17. In relation to Toulmin, authors like Santibañez 18 assume that this approach also has an undeclared pragmatic connotation, assuming as such a concept of language as action. The current article seeks to provide elements for a comparative analysis of the three selected approaches and contribute to the possibility of an argumentative discourse that reinforces the chances (in terms of speech opportunities) of the participants in the interaction, even in conditions of asymmetry of knowledge. The current study prioritizes the context of interaction between patients and doctors and the healthcare team. Forms of application of thepragmadialectical approach of argumentation to public health medicine Authors of pragma-dialectics such as Pilgram 2,19, Schulz & Rubinelli 20,21, Gilbert & White 1, and van Poppel 3,22 apply the theory of argumentation to the medical consultation and health education. They view the medical consultation as a kind of culturally established communicative activity or form of communication with a largely institutionalized format, like a political debate, medical advice, legal defense, or scientific trial. van Eemeren 14 refers to these specific forms as speech events, in which communication is marked by the search for success based on specific audiences, or by persuasion, which consists of gaining the audience’s adherence to a thesis without privileging the arguments’ merits. The authors subscribe to the thesis of the need (in this context) for a strategic maneuver, a term coined by van Eemeren 14 to express the attempt to reconcile the argumentation based on merit, on dialectical grounds, and the persuasive orientation of search for adherence, corresponding to wanting a given position to be accepted by the other (rhetoric). Accordingly, the concept of strategic maneuver corresponds to a way of reducing the gap between the pursuit of success and maintaining reasonableness. The author contends that there is no irreconcilable contradiction between the use of rhetoric and that of dialectics, and that the former should be included subordinately in the dialectical proposal. Pilgram 2 identifies the content of the stages in the process of pragma-dialectical argumentation applied to the medical consultation. In the first PHYSICIAN-PATIENT ARGUMENTATION AND COMMUNICATION: COMPARATIVE APPROACHES 3 Cad. Saúde Pública, Rio de Janeiro, 31(12):1-10, dez, 2015 stage, the trigger of confrontation between doctor and patient is the possibility of lack of agreement vis-à-vis part or all of the doctor’s advice (or prescription), seen as the fundamental element demanded by the patient and supplied by the doctor. We can also consider the patient’s hesitation in following the doctor’s advice as the origin of an argumentative process focused on overcoming differences. In the second stage, definition of the procedural and material points of departure, the author identifies an explicit rule, namely informed consent; the implicit rule of the doctor’s acting as principal protagonist in the discussion; and the search for (and presentation of) facts pertaining to the patient’s health status (material points), which correspond (in the language of pragma-dialectics) to explicitly established concessions such as the results of the doctor’s inquiry into the patient’s health; and to implicitly established concessions like the results of the patient’s physical examination performed by the doctor. The discursive means in this process (third stage) are represented by the argumentation based on interpretation of concessions in terms of medical facts and evidence. The possible products (fourth stage) are: agreement about the patient following the doctor’s advice; referral to a specialist; or requesting a second opinion. In another article, Pilgram 19 points out that in the medical consultation the predominant argumentative scheme is a kind of argument by authority. The following is the representation of the basic scheme in argument by authority: 1 Opinion O is acceptable 1.1 Authority is of the opinion that O 1.1’ The authority’s opinion indicates that O is acceptable According to van Eeemeren & Grootendorst 12 and Rivera 23, an argument is the premise that allows basing the point of view in the act of arguing, where more than one premise may exist, and an argumentative scheme is the specific or conventional way by which the premises or arguments relate to the point of view. Argumentation corresponds further to the relationship between premises/points of view. In the case of argument by authority, an authority’s agreement with a point of view is represented as a sign or mark of acceptance or the characteristic of truth in the point of view (opinion “O” is acceptable because it is defended by an authority on the subject). In other words, this scheme is characterized as a particular type in which the argument’s content (premises 1.1 and 1.1’) is seen as a sign of the point of view’s acceptability. This type of argumentative scheme is known as symptomatic or sign argumentation 12. Argument by authority 19 approaches the appeal to the ethos of rhetoric, where the party that discusses refers to his own capacity to make his point of view more acceptable. At the limit, this scheme can mean both the patient’s effacement as protagonist and a paternalistic relational dynamic in which the doctor knows what is best for his patient. In order for argument by authority to develop an approximation to reasonableness, it must observe certain conditions of argumentative solidity which are characteristic of dialectical discourse. These conditions are: the protagonist in an argument by authority is required to continue defending his point of view if the antagonist asks him to do so; the protagonist cannot display his qualities to avoid the presentation of more arguments to support his point of view; the antagonist must genuinely acknowledge the protagonist’s authority in a specific field; the protagonist must correctly express previously formulated opinions; and the protagonist must present an argument by authority at a relevant moment in the discourse. Pilgram 19 points out that non-observance of these conditions could turn argument by authority into a fallacy, or a type of argument ad verecundiam, or an argument that violates some rules of dialectical discourse, like the burden of proof rule, meaning failure to produce all the necessary data and evidence, as well as all the relevant arguments aimed at effectively convincing the patient and eliminating any doubts. Schulz & Rubinelli 20,21 describe the medical encounter as a dialogue that combines the search for information with persuasion. The authors emphasize that informed consent requires the doctor to provide the patient with all the necessary information for the latter to freely choose to follow a prescribed treatment. In the doctor’s task of persuasion, informed consent requires that he adapt to the typical rules of a critical discussion. However, the authors suggest that in the doctor-patient relationship, a rhetorical component predominates, to the extent that in this encounter some conditions of argumentation (in the pragma-dialectical sense) do not hold, such as not keeping participants from raising points of view or challenging points of view, not refusing to defend a point of view when asked to do so, etc. The authors contend that there is an asymmetry in medical knowledge which can mean less capacity by the patient to grasp important information pertaining to the argumentative schemes involved in diagnosis and prescription. The authors further point out that although the patient can bring information that he has researched or incorporated, he lacks the means to contextualize this information and promote a more indepth or well-based discussion. To this extent, the authors highlight the tension between given Rivera FJU, Artmann E 4 Cad. Saúde Pública, Rio de Janeiro, 31(12):1-10, dez, 2015 rules of a critical discussion brought by informed consent and a rhetorical function. Gilbert & White 1, in referring to medical reasoning, contend that the model combines elements of the three principal disciplines of argumentation, dialectics, logic, and rhetoric, emphasizing that: (a) the essential logical reasoning of the diagnostic workup is the deductive hypothetical model (categorical syllogism), associated with the evidencebased approach to medicine; (b) the definition of treatment and follow-up forms involves exploring alternatives, and this process reveals the dialectical component of a more critical involvement by patients; and (c) the particular insertion of this form of argument in institutions where “speech events” are processed forces turning to the use of persuasive elements to a greater or lesser degree, in the sense of accommodation to the specific sociocultural contexts that impose certain restrictions. We will examine these aspects next. Reasoning from one or more premises to the conclusion is the basic model for medical reasoning and the argument pertaining to the diagnostic definition. Thus, the reasons leading to a conclusion can be represented as a categorical syllogism, as follows: Premise A (p1) The set of symptoms A and signs B are typical of acute cholecystitis Premise B (p2) The patient presents all the symptoms A and signs B Conclusion C Thus, the patient has acute cholecystitis Diagnostic reasoning is a type of discourse that must be sustained in front of patients and doctors or other health professionals. To justify the declaration of a diagnosis, it is necessary to establish a differential diagnosis, which represents the dialectical component of the specific argumentation. In this case, the scientific community of specialists is convened in a situation of discursive symmetry, to partake of a theoretical discourse focused on choosing an alternative by consensus. For the authors 1, the dialectical point of view is necessary to justify both a diagnosis and the definition of treatment and follow-up modalities, a definition which also requires the widest possible analysis of possibilities. Authors like Blair 24 and Fisher 25 concede that the treatment definition is to some extent a process of negotiation of plausible options. Johnson & Blair 26 suggest that the real justification of a conclusion (for example, a diagnostic decision) depends on something more than the mere articulation of evidence leading to acceptance of a conclusion. To be convincing, an agent also needs to articulate responses to potentially alternative positions or objections to the conclusion that is being sustained. Establishment of the differential diagnosis involves the determination of defining traits of the diagnostic hypothesis, considered in terms of semantic qualifier as the most likely, and discriminating traits, or the descriptors that allow distinguishing between diagnoses. Semantic qualifier is defined here as the strength or degree of certainty of the conclusion or thesis, or its degree of likelihood. The defining traits in the case of acute cholecystitis are: pain in the upper right abdominal quadrant, fever, and chills, among others. Other characteristics would be discriminatory in this case, such as: severe epigastric pain and signs of early or late shock, characteristic of pancreatitis. The identification of these descriptors and their frequency in practice allows linking the qualifiers in relation to the conclusion and its alternatives: “with certainty”, “probably”, and “possibly” can suggest degrees of likelihood 1. On the persuasive and rhetorical component involved in clinical reasoning, Gilbert & White 1 emphasize the diversified and multidimensional nature of medical discourse, which seeks to convince different audiences: users, family members, other physicians, other health professionals, the institution, etc. For each audience, the doctors attempt to adapt the language to the respective concepts, values, and cultural traits in order to be able to explore rhetorical discursive techniques that can threaten to compromise the argument’s normative correction, incorporating manipulative or strategic components. Based on van Eemeren 14, a normative critical approach is recommended in search of a balance between reasonableness and success, the latter represented by the work of convincing particular audiences 1. van Poppel 22 also defends the use of the pragma-dialectical approach for the analysis and design of health education brochures. A brochure does not involve a direct interaction, and it has the clear purpose of modifying behaviors, which encourages a rhetorical orientation. Even so, van Poppel 22 contends that the brochure can be interpreted as an implicit discussion and that pragmadialectics can help create a better balance between reasonableness and success, avoiding the absolute predominance of the rhetorical function. For the author, a health education brochure should observe the same rigorous rules as a dialectical discussion, like avoiding the manipulation of values and emotions, avoiding false or overblown messages, presenting scientific and statistical data that prove the benefits, discuss side effects, and anticipate possible challenges by suggesting responses to potential objections. In another study, van Poppel 3 assumes that pragmatic argumentation predominates in the PHYSICIAN-PATIENT ARGUMENTATION AND COMMUNICATION: COMPARATIVE APPROACHES 5 Cad. Saúde Pública, Rio de Janeiro, 31(12):1-10, dez, 2015 production of health pamphlets, based on a causal relationship. The implicit idea is that some action should be performed because it presents desirable or undesirable consequences. It involves a statement on the consequences of the action referred to in the point of view and a normative statement on the desirability of such consequences. Toulmin’s model applied: the basis for an interpretive medicine A unique application of the theory of argumentation to the field of medicine is the use of Toulmin’s model 13 to analyze the correctness or sensibility of clinical arguments. Horton 4 argues that clinicians’ development of critical reasoning skills is at least as important as the use of evidence-based medicine, and that this skill corresponds to the capacity to interrogate a clinical argument to discover its weak points or the basis for its validity. For Horton 4, Toulmin’s model allows developing this capacity and is a viable and extremely useful approach for managing proof or evidence and defining the degree of generalization (or external validity) of the clinical conclusions. Horton 4 illustrates this model’s application with the diagnosis of acute myocardial infarction as the conclusion. Drawing on this case, he identifies the six structural elements of correct arguments established by Toulmin (Figure 1). An argument proceeds from its grounds (or data) to the conclusion or thesis. The grounds are: dyspnea, chest pain (retrosternal), nausea, and sweats. The conclusion or thesis is: the most likely diagnosis to be considered is that of acute myocardial infarction. The model’s third element is the warrant, or the establishment of a bridge between the grounds and the conclusion. What allows moving from the data to the conclusion or authorizing a particular argument? Clinical experience, together with medical training and a reading of the literature teach that mid-chest pain is a common feature of infarction. The warrant here corresponds strictly to the rule that mid-chest pain suggests myocardial infarction. The fourth element is backing or support for the warrant. Backing helps establish the warrant, i.e., how reliable is the evidence used to authorize the argument? In this cases, how reliable are the personal expertise, medical education, and literature and research consulted? The backing corresponds to these elements. The qualifier, the fifth element, represents the conclusion’s strength or degree of conclusion: what else could be causing this pain? The sixth element corresponds to the conditions of rebuttal or reservation: a normal electrocardiogram and unaltered cardiac enzymes. Toulmin’s method of practical reasoning would help the doctor examine a conclusion on the patient’s management and the meaning of the discoveries reported in a research project. Applied to a clinical decision, this method