this has led to a kind of Dwight D. Eisenhower-Estes Kefauver school of public speaking which ..... and using their technical skills as the patient directs, without seeking to influence the ..... conversation in a city hospital emergency room between a surgical resident who has never .... University of South Florida,. Tampa, FL ...
D A V I D H. S M I T H A N D L O Y D S. P E T T E G R E W
M U T U A L P E R S U A S I O N AS A M O D E L F O R DOCTOR-PATIENT
COMMUNICATION
ABSTRACT. From an ethical point of view, shared decision-making is preferable to either physician paternalism or patient sovereignty. The traditional model of doctor-patient conununicafion is too directive and too unconcerned with the patient's values to support truly shared decision-making. The traditional distinction between rhetoric and sophistic can provide the basis for a new model of mutual persuasion that does not limit communication to information, and that avoids the spectre of manipulation.
Key words: Doctor-patient communication, Mutuality, Rhetoric.
INTRODUCTION
Interpersonal influence is a problem in the individualistic society. The interdependence that the functioning of society requires demands that individuals be influenced by others. Yet the strong value placed on individual rights makes us uneasy about the influence process. The worries that the worse side will be made to appear the better and that the young will be corrupted by their teachers have come to us from the ancients. Conservatives worry that secular humanism or evolution will corrupt the young in our schools. Liberals worry that television advertising manipulates not only our demand for goods and services, but the way we vote in political campaigns. Salesmen have a problematic reputation even when their products are not used cars. Our concern that interpersonal influence may be inappropriate has even bred a mistrust of communication which is too well done. Someone particularly effective with language may be viewed as glib and, consequently, insincere. In the public arena this has led to a kind of Dwight D. Eisenhower-Estes Kefauver school of public speaking which holds that no one inarticulate can really intend to deceive us. Ronald Reagan's communicative skill is held by some to demonstrate ipso facto his lack of understanding. Underlying all this is a common fear that a self-seeking individual can, by using communication effectively, control another and undermine that other's freedom of choice~ In recent years, this uneasiness about communication has been focused on medicine. The role of the healer has involved exercise of authority and power. That role has been misused from time to time by medicine men, charlatans and faith healers. Recent examinations of the physician-patient relationship have argued that even in a profession strongly influenced by TheoreticalMedicine 7 (1986) 127--146. © 1986 by D. ReideI Publishing Company.
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ethical commitments and the best interest of the patient, the traditional relationship has failed to protect the fights of the patient. Yet, of course, the requirements of interdependence in a society mean that people must talk to each other. Not only is freedom of expression an inalienable fight, but communication is also a pragmatic necessity. Someone must tell us about the products we seek to purchase, even used cars. A democratic society requires that politicians communicate with constituents. Teachers must talk with students, and doctors and patients must talk with each other. This paper argues that it is useful to approach the problem of interpersonal influence in the doctor-patient relationship from the perspective of persuasion. In so doing, we distinguish between persuasion and manipulation by drawing on the classical distinction between rhetoric and sophistic. We argue that when persuasion is viewed in the context of mutuality and when it is based on the ethic which has traditionally distinguished rhetoric from sophistic, it provides a way of balancing individuality and interdependence in the physician-patient relationship. This view of persuasion also allows us to consider the value dimension of doctor-patient talk.
BIOETHICAL ISSUES IN THE DOCTOR-PATIENT RELATIONSHIP Let us first consider some of the bioethical issues in the physician-patient relationship. Three concepts are prominent: paternalism, autonomy and shared decision-making. Ethicists and others have voiced concern about paternalism in the traditional doctor-patient relationship. That traditional relationship has been depicted as inconsistent with the patient's right to self-determination and autonomy. Brody (1980, p. 718) tells us that "The traditional concept of the doctor-patient relationship places the patient in a passive, dependent role' with nothing to do but seek competent help and cooperate with the physician in order to get well. The physician, on the other hand, has been granted autonomy and professional dominance." Katz (1984, p. 28) argues that "The history of the physician-patient relationship from ancient times to the present bears testimony to physicians' caring dedication to their patients' physical welfare. The same history, by its account of the silence that has pervaded this relationship, also bears testimony to physicians' inattention to their patients' fight and need to make their own decisions." Clearly, the exercise of physician authority through paternalism can be characterized as in conflict with the patient's desire to exercise self-determination and to maintain autonomy.
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This examination of the role of authority and autonomy in the doctorpatient relationship has generated alternative conceptions. Szasz and Hollender (1956) set out three basic models of the physician-patient relationship: (1) Activity-passivity, (2) Guidance-c0operation, and (3) Mutual participation. It is only in the mutual participation model that the mutuality of influence by physician and patient is recognized. Szasz and HoUender's notion of mutual participation leads ultimately to the concept of shared decision-making, particularly as set out by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1982) -- hereafter referred to as the President's Commission. Katz elaborates in great detail on the argument for shared decision-making. " . . . the arrogance that a vision of the healer readily engenders can, perhaps, only be contained if doctors were to recognize that such a vision does not confer on doctors the fight to make crucial decisions, without permission, for another person even if that person is a patient" (1984, p. 226). From the bioethical point of view then a definition of the doctor-patient relationship which denies patients the right to participate in decisions about their own health care is inconsistent with the principle of patient autonomy and the right to self-determination. The paternalism inherent in the traditional doctor-patient relationship prevents patient participation. Hence, a shared decision-making alternative is to be preferred. An argument for patient participation can also be made on the grounds that it leads to better health outcomes. "Studies showing a link between a sense of control or mastery in a situation and ability to tolerate pain, the experience and reporting of physical complaints, recovery from illness, tumor growth, and effective daily functioning support this conclusion and point to an association between assertion or perception of control, and health status. Specifically a more active role in a visit with the physician may relate to a greater sense of control over the disease and therefore a better health outcome" (Greenfield et al., 1985, p. 526). Patients with an internal locus of control are more likely to engage in positive health behavior and to follow physicians' advice (Jaspers et al., 1983; Wallston and Wallston, 1982). Patients who participated in managing post-operative pain required less medication and were discharged sooner than those who did not (Egbert et al., 1963; Egbert et al., 1964). Patients who were actively involved in their care for ulcer disease reported fewer limitations in functional activity (Greenfield et al., 1985). Hence patient participation in decision making may be warranted because it leads to better health as well as because of its ethical superiority.
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IN T H E D O C T O R - P A T I E N T
RELATIONSHIP
Yet the question remains as to how that relationship can best be brought into being. The mechanism for the implementation of relationships is communicative acts (Searle, 1965). One can talk about the structural determinants of the relationship, but even those are inferred from the dynamics of conversation among individuals thought to be exercising roles (Litton-Hawes, 1978). It is not surprising then that conceptions of communication in the doctor-patient relationship should parallel those from bioethics.
THE MEDICAL MODEL
The traditional view of the doctor-patient relationship is often embedded in what is called "the medical model." The medical model emphasizes the doctor acting on the patient to cure the disease. In his discussion of the medical model, Engel (1977) characterizes its limited perspective: it stresses cure rather than prevention; it is concerned with biological disease without intervening social or psychological factors; the role of the physician is dominant while the patient remains relatively passive (Engel, 1977; Haan, 1979). The communication aspects of the medical model stress directives and information. The traditional doctor-patient relationship has been characterized by the giving of orders. Communication is directive. The appropriate response on the part of the patient is compliance. A large body of social scientific research exists based on the notion that compliance is the appropriate response to physician recommendations. There is even a journal, The Journal of Compliance in Health, which exists to report on compliance research. Much of this research attempts to explain the variables that seem to affect patient compliance, but the overwhelming finding is that noncompliance is a frequent result of physician directives (Pendleton, 1983). Patients frequently do not follow orders. Based on his review of the research, Ley suggests that there is one chance in two that a patient will not follow advice (Ley, 1983). From an ethical perspective, this may be good news. We can applaud patients' resistance to the undermining of their own autonomy. From an efficiency perspective, the news is bad. If the directives are not complied with and the orders not followed, the relationship is not likely to achieve the end of improved health for the patient.
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Two mechanisms are supposed to make directives work. First is belief in the authority of the physician to direct the patient's behavior. If the patient accepts the physician's authority, it is thought that the patient will then be compliant. The second basis is physician charisma. Personal admiration will cause the patient to identify with the physician and, hence, to want to do what this admired person recommends. Both the acceptance of authority and admiration for the physician can work to make directives successful. But neither accepts the patient's right to self-determination, nor does their combined power lead to the level of efficiency in achieving improved patient health behavior one should be able to expect from a good communication system. Nor does either involve talk about patients' beliefs and values. The physician is assumed to know what is true and good for the patient. The directives of the physician are designed to lead to achieving the best interest of the patient. It is the physician who is presumed to know what is best for the patient. Hence implementing the doctor-patient relationship through directives and compliance is neither efficient nor value actualizing. The traditional medical model also uses the notion of communication as information. Information is even tied to compliance. The patient comes to the medical interview to inform the doctor about his/her illness. The doctor guides the patient in presenting the most relevant and accurate information (via the medical history). Later, the doctor informs the patient of the diagnosis and informs the patient, through orders, of a specified treatment regimen. If the doctor handles this information task well, the patient will understand the information and comply with the medical regimen ordered. Doctor talk is confined to information. The doctor is controlling, and the patient is acquiescent. The strong preoccupation with communication-as-information obscures the issue of what values are contained in doctor-patient communication. There is, in fact, a strong belief derived from psychiatry that value-laden communication will set up the dynamics of transference and needlessly complicate doctor-patient communication (Eisenberg, 1977). Like the view of communication as directives, the physician knows the appropriate values and acts for the patients' best interests. The bio-psycho-social model Engle presents as an alternative to the traditional medical model the "bio-psycho-social model" (Engel, 1977). While the role of the patient is greatly expanded, and psychological and sociological factors are taken into account in the medical history, several important aspect of the medical tradition remain intact. First, communication is still viewed fundamentally as the exchange of information; social
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psychological data supplements medical information. Second, the locus of influence remains with the doctor; the doctor still knows best. Third, value issues are seen as a part of the patient's sociological background and personality of the patient, not as both the process and outcome of doctorpatient talk. Despite the evidence that the majority of patients who go to physicians visit them for more socially situated exigencies, research on doctor-patient communication from the medical model has emphasized elements of the medical interview rather than the general nature of the relationship (Pendleton, 1983). The best example of this line of research comes from Barbara Korsch and her colleagues (Francis et al., 1969; Freemon et al., 1971; Korsch et al., 1971; Korsch et al., 1968; Korsch and Negrete, 1972). They studied the relationship between patient demographics (primarily those of parents of pediatric patients), doctor communication factors (assessed via Bales' Interactive Process Analysis Scale) and evaluative perceptions of both parents and doctors about the medical interview. The research project omits much qualitative information that would be of interest. The most recent of this research continues the strong bias toward doctor-initiated communication. Communication is still viewed as informarion exchange, e.g., asking leading questions, using jargon, providing clear advice and information, soliciting patient questions, and logical ordering of questions (Werner and Korsch, 1979, p. 126). Throughout the medical tradition, communication serves the medical model. It assists the doctor in finding out from the patient what he/she needs to know to cure the patient, and in giving orders to the patient. The implicit value system emphasizes the doctor treating disease (Illich, 1976) and preparing the patient for treatment. Communication is fundamentally paternalistic. It is the instrument for the physician's goals, beneficent though they may be. Language of the Medical Model Looking at the terminology used in the medical model may also be instructive. The language used to describe medical communication reveals talk is informative, doctor-initiated and controlled, and patemalistic. Four prominent terms are illustrative: "history taking", "doctor's orders", "compliance", and "informed consent." The term "history" implies a series of past events. The history is what happened, the facts. "History taking" suggests that the patient has the facts and the doctor "takes" them, gets them from the patient. The patient does not share them, but gives them up to the doctor who knows their meaning. The facts, history, are objective. Hence the talk is information-orienting, value-limiting not value-creating, concerned with facts and events not with
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feelings and emotions. The patient may know the history but it has significance only for the doctor (Bates and Hoeckelman, 1983). Likewise, the term "orders" reveals the assumptions of the medical view. Communication is directive not persuasive. Clear, unambiguous orders speak for themselves. The task is to get the information, the facts, across clearly to patients. Patients will then do what they have been told. If not, patients are bad, "non-compliant." Finally, the term "informed consent" also represents medicine's view of communication as information. There is a strong, implicit assumption that the act of informing is the most essential obligation the doctor has to the patient. The doctor's job is to inform; the patient's to consent. Notice, consent does not suggest shared decision-making. Informing does not imply "talking things over" or "explaining options." The doctor "discloses" risks and benefits and the patient either consents or does not. Operationally a "consent" is a signed form. One "gets the consent" from the patient just as one "takes" a history. The patient's fears, feelings, and images are not part of the process. Should the patient decide not to consent, the treatment cannot go forward because the patient has been uncooperative. The doctor, the one who acts, cannot do so. Failing to consent is like being non-compliant. It frustrates the doctor's function of directing events toward the cure. Doctor-patient communication is thus doctor-initiated and controlled in both the medical and bio-psycho-social models. When the doctor "takes" the patient's history, gives the patient an "order" or gets "informed consent" the doctor both initiates and controls the communication. The patient's compliance to the doctor's orders is seen as the most legitimate patient outcome. Compliance necessitates a dominant-submissive relationship. Informed consent judges patients competent to hand over their fates to the doctor only after being enlightened by the doctor. Without the doctor's expertise, the patients are incapable of understanding or determining medical results. Values. The medical tradition does not view communication as value clarifying or modifying. Communication plays a distinctly instrumental role in medical practice. Of almost singular concern is medical treatment through the formal canons of modern medicine (Illich, 1976). Considerations of the patient's value system are generally absent from medical terminology and what is regarded as good medical practice. The patient is assumed to value what the doctor values, getting well and maintaining health. Clarity and adequacy of information are stressed rather than understanding the patient's value system and attempting to help the patient
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realize those values. Modifying values through talk is not contemplated. It is not surprising that the "medical history", the interpretation and following of "doctor's orders", the emphasis on "informed consent" to treatment, and the expectation of patient "compliance" are integral to the medical lexicon. All of these terms dramatize the view of communication as restricted to information and compliance. The patient's values need not be considered nor reconciled with medical treatment. Informed Consent. The concept of informed consent deserves more detailed discussion. Although the practical force of the idea comes from the courts' insistence that consent is meaningless if patients don't understand what they are consenting to, the idea has been embraced by those concerned with medical ethics as the best way to implement the concept of patient autonomy. Yet the concept as developed by the courts emphasizes only the physician's obligation to disclose risks and benefits. Consenting is the mildest form of decision-making. It connotes passivity and acceptance, not active engagement and participation. The narrowness of the legal approach has limited the communication to medical fact and information. Those most concerned with patient autonomy may want to push the doctor as informer even further. They may feel that the patient can be in control of his/her own health only if the physician has no role in decision making except as an expert providing information about the risks and benefits of all possible alternatives. The President's Commission refers to this model as "patient sovereignty". "According to this view, practitioners should act as servants of their patients, transmitting medical information and using their technical skills as the patient directs, without seeking to influence the patient's decisions, much less actually make them" (President's Commission, 1982, p. 36). Paternalism is clearly rejected and autonomy can flourish, but the resulting relationship would seem distant, impersonal. The physician's role would almost seem to be that of a piece of software for accessing a data bank. Indeed such programs are being written to replace the traditional history taking. But what of the relationship? The positive aspect of the traditional physician role, beneficence, would be sacrificed along with paternalism. Physicians would no longer be obliged to consider their patients' best interest. Indeed they would be admonished not to. The subordination of self-interest to patient interest that, at times, enobles medicine would be lost. Nor would physicians be expected to "care" about their patients. That caring is highly valued by many patients, but does not fit the concept of physician as detached informer. Shared Decision-Making. For these and other reasons the President's
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Commission went beyond the legal notion of informed consent to espouse the concept of shared declsion-making. Their's is an extension, if not a clear alteration of the informed consent concept. We applaud their sense of the need for mutuality in the relationship. Unfortunately their attempt to ground mutuality in the communication activity of "informing" fails to convince. Relationships become operational through communication. Therefore, the concept of communication must fit the view of the relationship for the idea to work. The idea of communication as information implies impersonal, wholly cognitive means. The Commission is uncomfortable with attempts by physicians to influence decisions. They fear doctors will manipulate patients and undermine the purpose of informed consent. They picture manipulation as having two extreme forms: outright fraud at one end and subtler means of soeech at the other. "... a professional's careful choice of words or nuances of tone and emphasis might present the situation in a manner calculated to heighten the appeal of a particular course of action. It is well know that the way information is presented can powerfully affect the recipient's response to it. The tone of voice and other aspects of the practitioner's manner can indicate whether a risk of a particular kind with a particular incidence should be considered serious" (President's Commission, 1982, p. 67). They go on to say that " . . . the difficult d i s t i n c t i o n . . , is between acceptable forms of informing, discussion and rational persuasion on the one hand, and objectionable forms of influence or manipulation on the other." No tone of voice, word choice, or nuance which could influence the patient is to be used lest the communication fall short of rational persuasion and become manipulation. Such a requirement fits neither human experience nor the Commission's desire for shared decision-making. Neither does it fit the model of talk favored by those who study communication. People cannot talk to each other without choosing words to fit their intentions. Paralanguage and body language are inherent in speech. They are implemented, for the most part, below the level of conscious awareness. We speak to influence the perceptions of others. In so doing our entire bodies are involved. The Commission's admonition would seem to require a neutral, expressionless monotone by the physician delivered in a wooden, motionless way. Such a monotone would call attention to itself as well. Listeners are no more automatons then are speakers. As we listen we are interpreting what we hear, not simply recording it. Hence a patient, hearing little expression in a doctor's talk, would be likely to interpret this unusual absence of affect as a lack of caring or concern. The depersonalized emotionless language that would be used in
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following the Commission's recommendation might well approximate the medical jargon which has been so widely criticized as inhibiting effective communication. If words are chosen for emotional neutrality and absence of connotation, they too will distance the physician from the patient. Of course manipulation is to be avoided, but reducing physicians' speech to unnatural, unfeeling, unexpressive, disembodied information does not fit the way people talk to each other. If physicians could actually speak in such a way, the bizarre nature of the speech would render it ineffective for any purpose. Manipulation is not an artifact of the expressiveness of communication, but of the motives and values of the communicator. A kind of mind-body dualism underlies the Commission's position. Information, presented dispassionately, presumably can avoid an untidy entangling of emotions and values with the facts o f the case. Decisions can be made through logic and cognition, hence, rationally. Considerable power and credibility are assigned to the physician role. To these are added the power to obtain and interpret information. Protecting the autonomy of a patient who is faced with such a powerful other requires that the other, the physician, limit the exercise of power in some way. The Commission looks to the isolation of the factual information from other attempts to influence as the means of limiting physician power. By limiting communication to the facts, they hope to preserve the patient's autonomy. They can thus make sure that physician credibility, relational obligations, fears, anxieties, and other non-rational elements do not dictate patient choices. Throughout this consideration the appeal of the mind and fear of the body are clear. But if behavior is organic, if the logical and emotional cannot be separated and if discourse cannot be limited to the rational, then patient self-determination will be compromised. Manipulation will occur. The Commission's program will fail. Yet the mind-body, reason-emotion dichotomy is tenuous. It too fails the test of human experience as well as the test of consistency with both contemporary philosophy and behavioral science. All messages have impact on the total person interpreting them. That person cannot respond as a partial being. Perceptions and responses involve all systems simultaneously. Removing emotion a n d limiting influence to the rational is impossible. Neither physician nor patient can be all mind, no body. Thus patient autonomy cannot be so protected. If the Commission's goal is shared decision-making, the neutral, detached presentation of information is not the communicative act likely to achieve that goal. People fully engaged together in the process of deciding
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share emotions, feelings, values, and arguments as well as data. The frame in which the sharing is set is their relationship. That relationship involves among other factors some mix of caring, respect and expectations about each other. Merely informing might be adequate for consent, but it is insufficient for building mutuality.
THE PERSUASION M O D E L O F DOCTOR-PATIENT COMMUNICATION Communication theorists argue that the content and relationship dimensions of communication occur simultaneously (Watzlawick et al., 1967). All statements have implication for the relationship. The absence of caring and reassurance from physicians' comments speaks just as surely about who they will be to their patients as the presence of such comments. We listen for cues in conversations with others that indicate whether we are respected, liked, and cared about. Stable, secure relationships are likely to feature more candor and directness, not less. An attempt to screen out comments with open relational significance will only lead to inferences about their absence. If mutual decision-making is to occur the full dimension of the relationship must be involved. Both doctors and patients must express their reasons and feelings to each other. Values must be talked about. The doctor must participate openly and freely along with the patient. A measure of spontaneity must be present. Restraint carmot be the dominant physician style. Patients want doctors who will care about them as well as treat them 03udd, 1981; Occhipinti and Smith, 1984). When the concern for paternalism leads to detachment that caring cannot be manifest.
MUTUALITY The positive side of paternalism is beneficence. The physician seeks to serve the patient's best interest. The doctor cares about the patient and wants the patient to do what is best. How can that care and concern be manifest if the physician is limited in ability to demonstrate what is best? How can they act together if they do not explore values and emotions together? If each does not fully try to convince the other of what is wise? If their relationship does not contain open give and take? Suppose a patient makes a decision the physician believes unwise for the patient's best interest. Can a caring doctor, fully committed to a relationship with
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the patient, fail to argue with the patient for a wiser choice? T h e caring relationship requires caring about the choice. Sharing decision-making requires open discussion and argument. The term argument is used throughout in the sense of the informal presenting of reasons and conclusions. It is not used in either the sense of formal argument or the popular sense of an intense disagreement. In discussing whether a physician should go beyond the listing of alternatives and recommend one, the President's Commission (1982, p. 78) answers in the affirmative, but remains concemed that the physician not infringe on patient self-determination by using undisclosed physician values and by using communication skills too well. Communication theory argues, on the other hand, that physicians cannot not communicate and influence (Watzlawick et al., 1967). The rock on which the Commission argument founders is not the goal of shared decision-making. Mutuality is clearly superior to either doctor or patient acting alone. The difficulty is that mentioned at the very outset. Interdependence requires mutual influence, but influence by another seems to threaten individuality. How can the patient retain control if control is compromised by the argumentative skill of the doctor?
THE RHETORICAL
T R A D I T I O N IN C O M M U N I C A T I O N
The problem is not a new one. Two terms in the study of communication in the ancient world may be helpful to us in dealing with this dilemma. The first is the term "rhetoric." Rhetoric was for the ancients the discovery of the available means of persuasion (McKeon 1941). Those who wrote on rhetoric attempted to describe how the citizenry could arrive at decisions in the absence of certainty and where the assent of a number of individuals was required. In our time, the term rhetoric is occasionally used in a perjorative sense to mean empty oratory or overblown language. That is not at all the sense in which we use it in this essay. It also is occasionally used to mean techniques of effective writing. Again, that is not the meaning we give to the term. Rather, we are concerned with the use of the term in the classical tradition to describe a system of persuasive communication with a strong ethical component. Among those who taught communication skills in ancient Greece were a group of itinerant teachers called sophists. There was a great deal of difference among the sophists (Brake 1969), but as a group they came to be regarded, largely through the comments of Plato in the Gorgias, as being interested only in empty oratory, and in providing personal fame and
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success for the speaker. It was the sophistic notion of communication which was associated with making the worse side appear the better and being willing to manipulate, distort and lie in order to achieve success. The term "sophistic" then comes to us in contrast to the term "rhetoric" to mean irresponsible influence or manipulation rather than responsible persuasion. If considered in the tradition of the classical notion of rhetoric, the term "persuasion" can provide us with a useful way of regarding the relationship between doctor and patient. Conceiving of persuasion without the overtones of manipulation will be helpful. We will now discuss persuasion, as we mean to use it in the rhetorical sense. Scott and Brock define rhetoric as the human effort to induce cooperation through the use of symbols (Scott and Brock, 1972). Hunt defines rhetoric as the study of men persuading men to make free choices (Hunt, 1955). Such definitions clearly imply the presence of choice in the person who is to cooperate or be persuaded. Bitzer argues that rhetoric does not exist when the intended receiver lacks the power to act in accordance with the intent of the message (Bitzer, 1968). Such choice, if it is to be real choice, must be apparent to the chooser. A change in the behavior resulting from the application of subliminal stimulation or operant conditioning principles would not be rhetorical for these means do not rely on choice-making. Free choice on the part of the object of persuasion is based on ideas, values, arguments, and information. A certain measure of reasonableness is implied, but one that accepts emotions and values as inseparable from reasons. One chooses freely and with a measure of reason even when one finds it difficult to articulate the reasons. Persuasion viewed as rhetoric also assumes that the attempt to influence choices employs symbols. Discourse is the stuff of rhetoric. It is the discourse that one provides for the other that may influence the other's choice-making. In the doctor-patient context the talk of the physician is an attempt to persuade the patient. The doctor provides messages to influence the choice-making of the patient. Rather than being an object for doctors' orders, the patient is a person whose choices will be influenced if the doctor mounts the proper arguments. But the listener remains active, not passive, in choosing among messages, reasons, and actions. The rhetorical view of doctor-patient communication differs from that in the medical tradition. Unlike the medical model, the patient as choicemaker is not subject to control by the physician. Rather the patient's decisions are influenced by proper discourse. The rhetorical view is also different from the psychological model. The patient's act is not the product of an unconscious process, perception, attribution, personality construct,
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or conditioning patterns, but is an open, free choice based on reasons. These reasons can be influenced by appropriate discourse. The rhetorical view contrasts with the sociological tradition as well. Because individual acts are the product of choices based on reasons, then roles, belief models, subcultures, or discourse rules are subordinated to choice. The patient will choose and may do so in a way the physician believes is beneficial to the patient if the physician can find the right things to say. Mutual Influence. There is nothing in the rhetorical view to suggest that the physician is the only persuader and the patient the only choicemaker. Indeed we would argue that patients seek to influence physician's choices. They often come to physician's specifically to influence physicians choices. They may want a particular medication, sleeping pills, valium, amphetamines, etc. They may want approval for admission to school, to play on an athletic team, to qualify for a job, to merit life insurance, to receive worker's compensation, to generate an insurance settlement, or to earn a jury award. Patients come wanting doctors to relieve their pain, to ease their anxieties, to slim their bodies, to change their habits, to extend their lives, to keep their secrets, and to tell them they are doing the right things. It can fairly be said that no patient seeks medical care without a desire to influence the physician. The patient wants some words spoken or written, some act performed. Medical communication from the rhetorical stance is a persuasive situation involving both physician and patient in both the roles of persuader and persuadee. Each is attempting to generate messages which will influence the choice-making behavior of the other. Neither is passive or controlled; neither is immune to effective arguments and good reasons. Decision-making is shared via the process of mutual persuasion. Contrary to other traditions the patient is regarded as in the more powerful position of the two. Patients apparently find it easy to ignore a physician's recommendations through non-compliance and to visit other physicians when their physicians have failed to give them arguments sufficiently persuasive to influence their choice-making. In the classic work on rhetoric, Aristotle sets out the enthymeme, the rhetorical syllogism, which forms the base of persuasive discourse (Mckeon, 1941). The enthymeme derives its premises from the beliefs and values of the audience (Bitzer, 1959). Persuasion, then, implies that effective doctor-patient communication takes into account the fundamental beliefs and values of the other. Physicians must know and attempt to act on what their patients believe and value; patients must know and attempt to act on what their physicians believe and value. Shared Realities. Effective persuasion necessitates concern for the
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existential world of the other. Physicians acting rhetorically must learn what is important to their patients. Those very beliefs and values form the basis for what they say to their patients. The patient is no longer an object. Similarly, patients are required to learn the orientation of their physician's beliefs and values if they are to b e successful in their influence attempts. An atmosphere of mutual persuasion emerges which requires attention to the values and beliefs of the other. One could hardly expect to be successful in persuading the other in such a situation without being open to persuasion oneself. In considering the beliefs and values of the other, one must understand those beliefs and values as they are understood by the other. One then becomes open to the influence attempts of the other. In such a circumstance, new and modified values will emerge as part of the ongoing process of talk. When these values emerge together for both parties they become the premises for arguments which both can accept and act upon.
PERSUASION AND ETHICS
Those who equate persuasion with manipulation fail to understand fully the importance of mutuality in the process and the necessity for the effective persuader to be involved with, and accepting of, the belief and value system of the person to be persuaded. If both parties are active choice-makers, neither can be truly said to b e manipulated by the other so long as the inluence process employed is persuasive discourse, not coercion, hidden psychological process, or group pressure. The rhetorical view of persuasion is most likely to actualize our best ethical notions of the importance of individual autonomy and free choice. Indeed, concern for the ethical aspect of persuasion, for rhetoric, is part of the classical distinction between rhetoric and sophistic. Golden, Berquist, and Coleman (1978) argue that a rhetoric grounded in choice carries a strong ethical dimension. The rhetorical tradition demands that persuasion must not only take into account the values and beliefs from which premises of arguments can be derived, but must also recomm~.nd choices which are consistent with those values and beliefs. It is the persuader acting in his own selfish interest rather than in the interest of the other who becomes the sophist, the manipulator. The rhetorical tradition by contrast requires an ethical concern. The patient cannot be viewed as an object of standardized medical practice or a source of income. Nor can the physician be properly seen as just another source of amphetamines. The persuader must attempt to assist the
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persuadee in making choices that further the values of the persuadee by showing how choices are linked with existing beliefs and values. To do otherwise is to act unethically and to engage in the sophistic tradition rather than the rhetorical tradition. Further, to do otherwise is to fail to persuade, for persuasion arguments link conclusions to accepted premises. This ethical imperative is consistent with the traditional values of the medical profession. Physicians are admonished to choose in the best interests of the patients. The tradition of beneficence is a long and honorable one. It emphasizes concern for the other and even self-sacrifice. When extended to the realm of the communication process itself, such a principle yields something very much like the rhetorical tradition. The admonition would be to take the best interest, beliefs and values of the other into account in the presentation of good arguments. Doctor communication in the rhetorical tradition is listener-centered both in the derivation of what to say and in the objective the communication seeks to serve.
THE COMMUNICATION
SITUATION
One final element in the rhetorical tradition may be useful. That is the importance of the situation. The rhetorical situation is not defined, as it is in sociology, on the basis of the place, the demographic variables represented by the individuals, or other contextual factors. Rather the situation is determined by the exigence, the urgent reason for communicating (Bitzer, 1968). It is the imperfection, the need to be met, the defect, the desire for change, that makes it important to enter into communication. The nature of that exigence will determine the situation and, hence, the nature of the appropriate discourse. The requirements for appropriate persuasion will change with the situation. We cannot list all the possible variations here but a hurried conversation in a city hospital emergency room between a surgical resident who has never before met the patient who is suffering from painful, bleeding head wounds differs markedly from a regularly scheduled consultation between the family physician in a suburban office with a wealthy diabetic housewife who has been a patient for twenty years. The situation differs because the urgent need to communicate differs. The difference in the talk in these two situations reflects different urgency as to time for action, detailed understanding of the other, self-disclosure, attempts to establish credibility, and promises of future contact. It is not the place, but the communicative demand which dictates the situation.
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These different encounters generate different situations, but they do not reflect underlying ethical differences. In both cases, the responsibility of the parties to serve the values and beliefs of each other is the same despite the fact that the difference in exigence may manifest itself in differences in the communication. In summary a rhetorical view ot doctor-patient communication would (1) emphasize persuasion; (2) of another choosing freely; (3) on the basis of reasons; (4) The persuasion is brought about by discourse; (5) which takes its premises from the beliefs and values of the other; (6) and accepts the ethical imperative of attempting to serve the ends of those beliefs and values; (7) The persuasion is a mutual process; (8) in which the one who would persuade must also be open to persuasion; (9) Much of the character of the communication will be derived from the exigence of the situation; (10) but the underlying ethical commitment will not vary. The view of doctor-patient communication as mutual persuasion offers significant advantages. It solves the reason-emotion dilemma underlying the attempt to extend informed consent to shared decision-making. The arguments given in mutual persuasion involve both cognitive and affective elements simultaneously. Hopes, fears, anxieties, dreams, beliefs and values join the facts as premises from which conclusions are drawn. Mutual persuasion also solves the problem of variability in the expectations both doctors and patients have about the relationship. These expectations become part of the premises for their talk. Some physicians justify paternalism by arguing that some of their patients want to be dependent, not participative. Each relationship takes on its own character because of the beliefs and values of the parties to it. Hence, variability in the desire of patients for dependence upon or independence from physicians can be accomodated. The talk differs with the parties. The differences in beliefs and values create different premises and lead to different arguments. Persuasion in the rhetorical tradition can be freed from the manipulative connotation which often plagues it and can be seen as a useful basis for describing a mutual relationship between physician and patient. Each is free to attempt to influence the opinions and actions of the other. But that influence will be based upon an exploration and .understanding of the beliefs and values which underlie an opinion or action. Persuasion takes, at its very base, an acceptance of the beliefs and values of the other. It offers good reasons to demonstrate why a recommended course of action is consistent with that which is important to the person persuaded. If both patient and doctor are engaging in such activity simultaneously and each is trying to influence the other toward actions consistent with the
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other's values, the problem of influence and interdependence is eliminated. Influence does not become a means of commanding the other, whether patient or physician, into action. It rather becomes a means of linking value and action. At the same time, persuasion allows for active participation for both physician and patient in the communication. The physician is not forced to limit comments to the presentation of information in a detached form but is free to manifest caring for the patient by showing concern that the patient make good decisions. That concern must be manifest in the exploration of a patient's values and the ability to demonstrate how those values are linked through good reasons to the actions the physician would recommend. The patient too feels free to offer reasons and recommend acts, both for the patient and the physician. The concern for the other is not manifest by avoiding an engagement with the other's views, but rather by actively pursuing that engagement. Doctor-patient communication becomes a value-centered activity with a clear ethical commitment. A free society requires responsible persuasion in both public and private life. In actual practice, of course, persuasion often falls short of the ethical ideal suggested here. That fact should not lead us to conclude that attempts by physicians to influence patients, and vice versa, must be done in an irresponsible and manipulative fashion. Such a conclusion would lead to acceptance of a model of doctor-patient communication which drives a wedge between the two. We cannot recommend the patient sovereignty model. It would sacrifice, in the name of avoiding manipulation, the opportunity for expression of physician caring, the opportunity for mutual influence and exploration, and the opportunity for what could really be called a relationship between physician and patient. Reducing the physician to the role of an expert reporting data would rob that profession of part of its richest tradition and would rob the patients of reassurance and caring. Interdependence demands responsible interaction, not separation. Viewing the doctor-patient relationship as mutual persuasion, not as information and consent, can offer us a useful alternative to the directives and orders of paternalism. D A V I D H. S M I T H and L O Y D S. P E T T E G R E W
Department of Communication, University of South Florida, Tampa, FL 33620, U.S.A.
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