Patient Education and Counseling 83 (2011) 180–184

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Communication Study

Lifestyle, health and the ethics of good living. Health behaviour counselling in
general practice
Liv Tveit Walseth a,b,*, Eirik Abildsnes b, Edvin Schei b
a
Research Unit for General Practice, Uni Health, Bergen, Norway
b
Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-
Received 29 October 2009 centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may
Received in revised form 12 April 2010 obstruct or enhance the possibilities for ethical dialogue.
Accepted 25 May 2010
Methods: The theoretical part is based on theory of common morality and Habermas’ communication
theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by
Keywords: interviews of doctors and patients. Analysis: Identification of two contrasting consultations holding
Lifestyle change
much and little ethical dialogue, ‘‘translation’’ into speech acts, and interpretation of speech acts and
Ethical dialogue
Communicative action
interviews guided by theory.
Patient-centred medicine Results: General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical
Decision-making clarification was asked for, and was enhanced by the doctor using communication techniques such as
interpretation, summarization, and exploration of the objective, subjective and social dimensions of the
patients’ lifeworlds. However, to produce concrete good decisions an additional reflection over
possibilities and obstacles in the patient’s lifeworld is necessary.
Conclusion: Consultations concerning lifestyle changes hold opportunities for ethical clarification and
reflection which may create decisions rooted in the patient’s everyday life.
Practice implications: The study suggests that GPs should encourage active reflection and deliberation on
values and norms in consultations concerning lifestyle changes.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Strategies building on patient-centred medicine (PCM) and

Changes of lifestyle may prevent and limit a range of diseases
such as apoplexy, diabetes mellitus, heart disease and musculo-
skeletal disorders. Lifestyle, i.e. our everyday habits, preferences
and indulgences is, however, deeply rooted in identity, culture and
the structure of everyday life, interwoven with perceptions of
personal freedom and pleasure [1]. Changes in lifestyle affect
visible and invisible structures in people’s personalities and
perceptions of a good life. Everyday patterns and routines may
be seen as ‘‘natural’’, and thus difficult or impossible to change.
Hence, implementation of desired changes, where uncertain, hard-
earned future health benefits of a potential nature are weighed
against the perceived immediate gains of indulgence, is a
challenging task both for the patient at risk and for the doctor.
The resilience of lifestyle patterns is reflected in research showing
low patient compliance with lifestyle interventions concerning
diet, physical activity and smoking [2]. Compliance decreases
further when several factors are targeted at the same time [2].
theories of health behaviour improve compliance [2,3]. Motiva-
tional interviewing (MI), focusing on inner motivation rooted in a
person’s core values, is also shown to have an impact on lifestyle
change [4–6]. Despite this body of knowledge, physicians find
consultations concerning change of lifestyle challenging and at
times overwhelming [7,8]. Practical guidance on how to conduct
consultations addressing lifestyle change is needed.
Our premise is that lifestyle is patterned by everyday decisions
rooted in the individual’s ethical assumptions and aspirations. This
is normatively founded in ethical theory [9,10], described below,
and pragmatically founded in inner motivation theory [6]. The aim
of this article is twofold: (1) to present the outline of a theory that
sheds light on the relevance of ethics for lifestyle interventions and
(2) to illustrate (1) by presenting results from a qualitative study
exploring how doctors obstruct or enhance the possibilities for
ethical dialogue in consultations concerning lifestyle change.
1.1. A matter of ethics

* Corresponding author at: Ole Bulls gt. 32, 4630 Kristiansand, Norway.
1.1.1. Common morality
Tel.: +47 92281131; fax: +47 55586130. Ethics concerns what is perceived as right and wrong, good and
E-mail address: liv@walseth.no (L.T. Walseth). bad. Ethics constitutes a foundation for the goals of life and for the

0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.05.022
 L.T. Walseth et al. / Patient Education and Counseling 83 (2011) 180–184
daily decisions about what to do and how to act. According to
Tranøy’s theory of common morality people share certain tacit
strategies for ethical decision-making in everyday life [9]. The goal
of this common morality is not to enact a consistent ethics, free of
contradictions, but to allow running decisions one can live with [9].
The reasoning of common morality is horizontal, addressing all
relevant factors in the present by weighing benefits and drawbacks
of multiple potential decisions, leaving some problems with an
ideal solution and others without. In contrast, vertical ethical
thinking focuses on right or wrong concerning a single topic.
Thinking vertically, doctor and patient may easily agree that
changing to a healthier lifestyle is a good thing, or even a matter of
life and death. However, when it comes to practical implementa-
tion the ethical issue at stake for the patient is to act in ways that
allow life as a whole to be reasonably good. As an example, the
possibility for a moment of well-being and community with a
friend through sharing coffee, chocolate and cigarettes may trump
the long-term goal of good health. Or, commitment to help the
children with their homework and drive them to leisure activities
may trump the commitment to get more physical activity. Every
decision of how to act is rooted in considerations of an ethical
nature, but mostly on an unconscious level.
1.1.2. Habermas’ theory of communicative rationality (TCR)
The insight that actions are based on ethical considerations may
be of use for doctors in charge of lifestyle interventions. The aim of
such interventions is to help the patient create good decisions and
carry them out. According to Habermas, an ethically sound
decision should originate in a respectful explorative dialogue,
where the participants consider the relevant concerns from three
dimensions of the patient’s ‘‘lifeworld’’: The objective concerns are
those that make a decision practicable, the subjective concerns
denote personal wishes and feelings, and the social concerns
include perceptions of right and wrong ways to act towards other
people [10]. A good dialogue should aim at an exploration of and
reflection upon the patients’ reasons for his or her opinions and
acts. The reasons are constituted of values and norms that the
patient uses to direct her or his actions, and can be clarified by
questions like: What is practically possible for you? What is good
for you to do? What is right for you to do? The goal is to reach a
reflective equilibrium where an ethical judgment has evolved from
reflecting jointly upon the patient’s context and his or her moral
and personal experience [11].
When decisions emerge from a respectful dialogue that clarifies
the relevant objective, subjective and social considerations, they
constitute what Habermas calls ‘‘communicative rationality’’ [10].
Increased insight and a new understanding of the situation may
arise, and the field of possible action is expanded [10,12].
According to Habermas, decisions involving human beings should
ideally be based on communicative rationality, thereby increasing
the potential for ‘‘fulfilling one’s dreams and ambitions’’ [10].
In the present empirical study, we use Habermas’ TCR as a
framework for analyzing the communication in general practice
consultations concerning lifestyle changes. Habermas’ theory has
been used in previous empirical research, emphasizing lifeworld
exploration as a whole [13,14]. Our starting point is that Habermas’
model and the three lifeworld dimensions have an additional,
largely unexplored potential for improving clinicians’ manage-
ment of lifestyle consultations.
2. Methods
The empirical study is qualitative, and concerns lifestyle
interventions in general practice. Twelve consultations dealing
with lifestyle changes were audio taped and transcribed verbatim.
The first author attended the consultations as a passive observer.
181
This article is based on consultation transcripts. All doctors and
patients were interviewed individually immediately following the
consultations. A comprehensive analysis of the subsequent inter-
views is not the aim of the paper, but a few quotations from doctors
and patients, in response to open-ended questions concerning the
consultations, are used. The recruitment of doctors was pragmatic,
based on oral open invitation among colleagues. The consultations
were planned to contain lifestyle interventions by the respective
general practitioners within a running therapeutic engagement.
The analysis was performed in three steps:
(1) Using the template method [15], two contrasting consultations
were identified, holding respectively few and many text
elements concerning ethical clarifications or reflections upon
the patients’ wishes and feelings, social and practical context,
identifiable from TCR [10]. Clarification was defined as simple
mapping, and reflection was defined as weighing or discussing.
(2) The two contrasting consultations were then ‘‘translated’’ into
separate speech acts. A speech act consists of a single
independent statement, or a summary of several subsequent
statements constituting one single act. Examples of speech acts
are: to inform, to summarize and to confirm. These refer to the
performative function of language, in which the informants are
defined as doing something through saying something [16].
This is in accordance with Habermas, who uses Austin’s
language theory as a basis for his theory of communicative
action [10].
(3) The speech acts were interpreted and rearranged in order to
crystallize significant descriptions of what happened in the
consultation [17]. The interpretation as a whole was guided by
the TCR [10] within the larger framework of PCM [18].
The results were discussed by the authors until agreement was
reached.
The study was approved by The Regional Committee for
Medical and Health Research Ethics.
3. Results
An important overall result was that purposeful, systematic
ethical clarification and reflection was recorded in none of the 12
consultations. However, all consultations contained stray elements
of ethical clarification. The two most contrasting consultations, A
and B, are presented below:
3.1. Presentation of two contrasting consultations
Consultation A:
Duration 34 min. A hypertensive, obese man in his forties has
his fourth consultation with a relatively inexperienced male
doctor who is substitute for the regular doctor. The doctor offers
general advice, rarely adjusted to the patient’s situation, and takes
few initiatives to explore or comment on the patients’ lifeworld.
The patients’ speech acts repeatedly introduce lifeworld issues.
The doctor counters this by changing the subject (4 times),
interrupting (twice), offering general advice without changing the
subject (4 times), exploring objective lifeworld (twice), and
supporting a theme from the patient’s subjective lifeworld (once).
The doctor performs 34 speech acts, the patient 18. The topics of
the doctors’ advice were: diet, activity, the importance of using
time, lifestyle change is difficult, and lifestyle changes have to be
individualized.
Condensed extract of interaction sequence in consultation A:
D: Informs that losing weight is difficult but necessary to
prevent diseases (interrupted by incoming phone call).
182 L.T. Walseth et al. / Patient Education and Counseling 83 (2011) 180–184
P: Informs that this is exactly his point. He was on a course, lost
weight, but then he gained weight again.
D: Offers general advice: Follow up appointments, log food
intake and activity.
The doctor measures height, weight and waist.
P: Takes initiative to reflect over his adolescence with a lot of
cookies and a sedentary life because of asthma. Mentions fear of
early death like his grandfather.
D: Explores a complementary genus history without respond-
ing to the patient’s narrative.
P: Starts to talk about his worry last summer when he thought
he had a venous thrombosis, he can still feel something in his
leg.
D: Responds: ‘‘mmm’’. Measures blood pressure.
...
D: Offers general advice: Recommends daily physical activity
half an hour, and weight lifting.
P: Objects, he wants to walk, having bad experience with
training studios.
D: Supports this.
Explicit decisions made in the consultation: The patient gets a
referral to a weight control project at the hospital, a referral to
blood-tests and a new appointment with his regular doctor. A plan
for physical activity is made.
The doctor, in the subsequent interview: ‘‘I feel I have a message
I consider important, that it takes time, and then I try to give advice
. . . and I try to find out what the problem is’’.
The patient, in the interview: ‘‘I thought . . . when the doctor
told me to quit with that, that recipe is too simple, . . . I know, ‘yes,
you can say that’, but at the same time I want to go deeper in
myself, I have to really own what is being said’’.
Consultation B:
Duration 23 min. A woman in her thirties sees her female doctor
for the fourth time, she is an experienced doctor. The patient is
overweight, has fibromyalgia, a tremendously stressful situation at
home, and needs help to find a new job accommodated to her
health. The doctor performed 50 speech acts, the patient 37.
Typically the doctor summed up and interpreted the patient’s
statements concerning her situation. The patient responded with
confirmations, typically adding more information concerning
everyday life. The doctor explored emotions in seven speech acts,
explored the objective setting in nine speech acts and explored the
social setting in one speech act. The patient answered adequately
to this exploration.
Condensed extract of interaction sequence in consultation B:
D: Summarizes what bothers the patient: Pain in the leg and a
stressful situation at home.
P: Confirms. Adds that it is hard not to be able to work.
D: Interprets. ‘‘Must be frustrating’’.
P: Confirms. Adds she feels nothing happens. Last year she was
on a diet and was physically active. Because of her stressful
home situation she discontinued. Expresses despair.
D: Summarizes and explores further.
P: Confirms and adds more information concerning her
situation.
D. Interprets. ‘‘Yes, you’re struggling . . . to know what to do . . .
and to know how this is going to end’’.
P: Confirms. Adds more details.
...
D: Summarizes: It is hard to find the way forward. Reminds the
patient to take care of herself. Asks if her cohabitant participates
in chores at home.
P: Answers that the cohabitant participates, but he is often busy
with other things.
Clear decisions made in the consultation: The patient is going to
start with psychomotor physiotherapy, continue her work training,
and get a new appointment. She is not going to increase physical
activity.
The doctor, in the subsequent interview: ‘‘This time there was
some structure, at least some program, that’s what I tried to
support and build upon’’. ‘‘Consciously I chose not to mention her
weight problem . . . she is very vulnerable about that’’.
The patient, in the interview after the consultation, reveals a
twofold reaction: ‘‘Such things need time, the trust you ought to
have to a doctor . . . it needs time you know (draws her breath
deeply) . . . but . . . of course I appreciated the way she (the doctor)
acted today . . . for Gods’ sake, I really want to meet that every time.
. . . but . . . (deep breath) . . . it feels meaningless (breath), actually.
Yes, we talk, talk, talk, talk, talk. Then . . . I go home, and things are
exactly the same . . . [I want] to go out from there with something
. . . a plan’’.
3.2. Interpretation and evaluation
The interpretation seeks to identify mechanisms in the doctors’
speech acts and consultation strategies that obstruct or enhance
the possibilities for ethical clarification and reflection.
3.2.1. General advice and instrumental rationality
In consultation A the doctor had adequate biomedical
knowledge about lifestyle changes and advised the patient
accordingly, also sharing his knowledge that such advice should
be individualized. In the interview he said that he tried to identify
the problem in order to individualize the advice. However, this is
not what he actually did. In the consultation he lectured in general
terms and initiated very little exploration of the patients’ lifeworld.
He characteristically returned to general advice even when the
patient was trying to share and discuss issues concerning everyday
life. By not talking about the particulars of the patient’s situation
the doctor obstructed the possibilities for patient-centredness and
ethical clarification, and made ethically founded decisions difficult.
In the interview following the consultation the patient explicitly
expressed that general advice and information is ‘‘too simple a
recipe’’. He wanted, and did really try, to go deeper into his
lifeworld in order to ‘‘own’’ the topics and goals they were talking
about. The superficial general advice resulted in an instrumental,
‘‘vertical’’ rationality that did not appear helpful to the patient. The
only exception was the doctor’s support of the patient’s objections
to the proposed physical activity, leading to a concrete decision
adjusted to the patient.
3.2.2. Exploration, interpretation, patient-centredness
In consultation B the doctor frequently summarized and
interpreted what the patient was saying. This was characteristically
followed by the patient’s confirmation and addition of more
lifeworld information. A good spiral of verbal interaction was
created. Also, the doctor explored the patients’ lifeworld actively.
Altogether, a number of objective circumstances, subjective wishes
and emotional issues were clarified. By asking about the cohabitant’s
share in the difficult home situation, the doctor explored the social
lifeworld dimension. Overall, consultation B was clearly patient-
centred, and the mapping of biopsychosocial circumstances created
possibilities for communicative rationality to emerge. But, even if
the patient appreciated the way she was met, she still characterized
it as ‘‘talk, talk, talk’’, and wanted something more concrete, a plan.
The question of how precisely the patient was going to effect some
change, the central issue of the consultation, was left unanswered.
 L.T. Walseth et al. / Patient Education and Counseling 83 (2011) 180–184
3.2.3. Lack of ethical reflection obstructing good decisions
Both patients stated in the interviews that important issues
were not addressed in the consultations. Doctor A created a
dialogue allowing instrumental rationality without individualiza-
tion, while patient A wanted ‘‘ownership’’ of the advice by going
deeper into his lifeworld. This gives rise to the question: How does
a patient achieve ‘‘ownership’’ of health related expert advice?
‘‘Ownership’’ may be interpreted as a process whereby the advice
is accommodated to the practical circumstances, values and
identity of the patient, and congruent with her or his feelings,
wishes, social settings and commitments. That is, decisions deeply
rooted in the three dimensions of the patient’s lifeworld.
Doctor B’s consultation style allowed a mutual understanding
of important dimensions of both the objective, subjective and
social aspects of the patients’ lifeworld to unfold. The question
concerning the cohabitant had a potential for revealing norms and
rules of action of the relationship between the patient and her
cohabitant, potentially turning the conversation into a reflection
concerning right and wrong. The doctor did not further explore
this, which may have been a wise decision. It takes a profound
relation of trust to discuss rules of action in relationships. As
confirmed in the interview, the patient needed more time to fully
trust the doctor. Despite doctor B’s implementation of patient-
centredness and revelation of some values, patient B was not
satisfied, and attributed this to a lack of concrete plans and
decisions. In this concrete situation, doctor B could have been more
active in searching for even more values and norms through
exploration of reasons, and she did not actively use the rich
information mapped out in the consultation. Lifeworld informa-
tion and reasons for decisions, attitudes and opinions need to be
applied in a concrete common reflection, addressing ambivalence
and judgments of what is good and right and practically feasible.
Reflection includes discussion of advantages and drawbacks, using
horizontal ethical thinking. Thereby a realistic, mutually accepted
plan of action that can change the patient’s state of hopelessness
and helplessness may be created, and a reflective equilibrium with
practicable, ethically anchored decisions may evolve. In consulta-
tion B, an opportunity for communicative rationality was created
but not fully exploited beyond ‘‘talk, talk, talk’’.
3.2.4. Contrasting a Habermasian interpretation with other models
The interpretation of findings is done within a PCM framework,
with Habermas’ communication theory added as our magnifying
glass. PCM emphasizes the importance of using the relationship,
offering empathy, searching for common ground and exploring the
patients’ biopsychosocial perspective (corresponding to the three
dimensions of lifeworld), ending in shared decision-making. PCM
lacks, however, the two important steps of exploring reasons to
reveal values and norms, and reflecting towards a decision that is
good, right, and practically feasible, emphasized by Habermas.
Consultation B is patient-centred, but lacks these distinct steps,
while consultation A lacks even the exploration phase.
We can also compare our approach with that of MI, where the
patient’s Desires, Abilities, Reasons of change and Needs (DARNs)
are to be explored in an empathic, attentive way, followed by a
weighing of pros and cons, focusing on resistance to allow a value-
based inner motivation to emerge. Consultation A does not qualify
for a MI. Consultation B reveals some DARNs but lacks the active
seeking for DARNs and a focus on resistance and reflection. MI
clearly overlaps with the Habermasian model, but could be
supplemented by emphasizing that decisions should be rooted in
all three dimensions of the lifeworld, including not only values but
also norms and practical conditions.
Decision analysis (DA) is yet another model of lifestyle
counselling. In DA, the importance of the patient’s preferences is
quantified into a decision-tree, using the calculated risk of heart
183
disease or other complications (ref). However, DA does not offer
guidelines for how the communication as a whole should be
conducted. Also, the ‘‘translation’’ of values and norms into
numbers can contribute to an instrumental rationality that
reintroduces the vertical, one-dimensional ethical reasoning that
seems to hamper change processes, and which is avoided by the
theory of communicative rationality.
4. Discussion and conclusion
4.1. Discussion
This article has presented a theoretical perspective on lifestyle
counselling, and a qualitative study of general practice consulta-
tions. Habermas’ TCR points out that daily life is constituted by
decisions and actions with ethical connotations and consequences,
where ‘‘ethics’’ denotes that which is considered right and good to
do. To implement difficult changes, it may be of crucial importance
to engage in dialogues that reflect upon individual values and
norms and how they interact with practical circumstances,
emotions and social circumstances. Empirically the study has
shown that general advice without individualization may obstruct
possibilities for ethical clarification. Ethical clarification is en-
hanced by communication techniques such as interpretation,
summaries and direct questions concerning the patient’s objective,
subjective and social lifeworld. Further, the empirical study shows
that such clarification may be insufficient in itself. We suggest that
to achieve realistic, ethically anchored decisions about lifestyle
change, information produced through clarification must be used
by the doctor and reinvested in a common reflection over possible
choices and the values and norms affected by them.
Patient-centredness is an acknowledged ideal in general
practice, and has in various forms been shown to improve outcome
of consultations [19,20]. Mishler has argued that ‘‘the voice of the
lifeworld’’ should be heard more in medical encounters [13].
However, doctors frequently have difficulties implementing a
patient-centred approach [14]. Doctor A, explicitly acknowledging
the importance of individualizing advice, may not have learned, in
practice, how to do it. The long check lists characteristic of medical
education, of what to ask, what to inform about and what to do,
may obstruct a patient-centred focus. The present study reflects
some of the challenges of medical education, while also showing
possibilities for implementing patient-centredness and letting
‘‘the voice of the lifeworld’’ be heard and acted upon.
The normative assumption in this study is that communicative
rationality, and the ethical reflection embedded in this, is a goal.
One might say that in everyday life there are many disturbing
factors, making this theory too ideal, difficult or impossible to
apply. That being so, Habermas’ TCR may serve as an ideal that can
give ideas, directions and aims to strive for in practical medical
work [21].
Habermas has emphasized the importance of continuing a
dialogue until a common understanding on the value-level is
reached, in order for a strong communicative action to occur. In a
consultation the doctor is, of course, not supposed to thrust his or
her own values onto the patient. Still, inherent in the situation is an
opportunity to reflect upon ethical concerns. Without attempting
to reach full agreement, the doctor might help the patient to clarify
and reflect upon his or her values, facilitating a more conscious
calculation of the available advantages and drawbacks through
horizontal ethical thinking. The floating, conflicting and individu-
alized definitions of values in our time may increase the need for
such conscious exploration and weighing of hidden assumptions
[12]. To avoid an overly vertical, instrumental rationality to
dominate, the doctor can position herself as an active reflection
partner and thereby contribute to decisions rooted in the patients’
184 L.T. Walseth et al. / Patient Education and Counseling 83 (2011) 180–184
identity and context [12]. By this, a broadened sense of patient
autonomy is created [22].
The study is strengthened by being performed in ordinary
general practice, by researchers with long experience as general
practitioners. However, being observed during the consultations
by an experienced colleague may have stressed the participants of
the study. The aim of the study was not to perform a
comprehensive analysis of the consultations or of the doctors’
patient-centredness, but to illustrate mechanisms obstructing or
enhancing communicative rationality. Concerning this aim, the
results are considered to be transferable and valid. Transferability
to everyday practice may, however, be constrained by lack of time
and by organisational features of different health care systems.
4.2. Conclusion
The rich information produced by clarifying the patients’
lifeworld through questions, interpretations and summaries can
give rise to reflections and deeper understanding of what really
matters for the patient, what s/he considers right and wrong, good
and bad, attractive and repulsive, and practically implementable in
the run of everyday life. The doctor thus helps the patient to perform
a conscious horizontal search for solutions, in accordance with the
theory of common morality [9]. Lifestyle changes affect identity,
personality and context, that is, a person’s lived life. In-depth
exploration of possibilities and obstacles inherent in the patient’s
lifeworld creates opportunities for good, feasible decisions.
To invite patients into a dialogue like this is possible, although it
does require time. Time can be created by offering repeated
consultations with this subject on the agenda. This may give
consultations concerning lifestyle a positive twist, by creating an
unflustered moment where doctor and patient together search for
deeper understanding of how a good and healthy everyday life can
be achieved for the unique individual in question - a difficult but
exciting challenge, worth struggling for.
Conflicts of interest
None.
Acknowledgements
The study was supported by he Norwegian Medical Associa-
tion’s fund for research in general practice.
We confirm that all personal identifiers have been removed or
disguised so that the persons described cannot be identified
through the details of the story.
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