A Doctor's Argument by Authority: Roosmaryn Pilgram

A
Doctor’s
Argument by
Authority
An analytical and empirical study
of strategic manoeuvring in
medical consultation
Roosmaryn Pilgram
A
Doctor’s
Argument by
Authority
An analytical and empirical study
of strategic manoeuvring in
medical consultation
Roosmaryn Pilgram
Pilgram, R.
A doctor’s argument by authority: An analytical and empirical study of strategic manoeuvring in

medical consultation.
Printing: Ridderprint, Ridderkerk, the Netherlands

Design: Esther Ris, Koog aan de Zaan, the Netherlands
ISBN: 978-94-6299-134-7
© Roosmaryn Pilgram, 2015. All rights reserved.

All rights reserved. No part of this publication may be reproduced, translated, stored in a retrieval
system of any nature, or transmitted, in any form or by any means, electronically, mechanically,
by photocopying, microfilming, or otherwise, without the prior written permission from the
author.
A DOCTOR’S ARGUMENT BY AUTHORITY
An analytical and empirical study of strategic manoeuvring
in medical consultation
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. D.C. van den Boom
ten overstaan van een door het College voor Promoties ingestelde commissie,
in het openbaar te verdedigen in de Agnietenkapel
op dinsdag 8 september 2015, te 14.00 uur
door
Roosmaryn Pilgram
geboren te Vlissingen
Promotiecommissie
Promotor: Prof. dr. F.H. van Eemeren, Universiteit van Amsterdam
Copromotor: Dr. H.L.M. Meuffels, Universiteit van Amsterdam
Overige leden: Prof. dr. T. van Haaften, Universiteit Leiden

Prof. dr. H. Hoeken, Radboud Universiteit Nijmegen
Dr. B.J. Garssen, Universiteit van Amsterdam
Faculteit der Geesteswetenschappen

Foreword
First, I would like to thank my supervisors, Frans van Eemeren and Bert Meuffels. As the
authority on the pragma-dialectical argumentation theory, Frans’s guidance was indispensable.
His knowledge of argumentation research, his careful reading of my texts and his helpful
suggestions for improving them elevated this dissertation into something greater than I could
have ever written on my own. Even at times when I imagine it was far from easy for him, Frans
continued to offer his supervision with as much precision as ever.
Bert Meuffels is the authority that I turned to for all methodological and statistical
matters. Without his extensive expertise in quantitative research on argumentation, conducting
the research for the empirical part of this study would have been a much greater challenge.
Throughout his supervision, Bert also kept me motivated and made sure that I did not lose track.
Others have helped a great deal too. I would not have become a scholar of argumentation if
it was not for Leah Polcar. With her energy and enthusiasm, she introduced me to argumentation
analysis during my undergraduate studies in Utrecht. It was Leah who encouraged me to continue
my study of argumentation at the University of Amsterdam.
Lotte van Poppel has helped me by simply being a great colleague and a great friend. Lotte
and I were appointed together as docent-promovendi, which meant that we could discuss classes
together, attend conferences together and solve dissertation problems together. Working on this
research without Lotte would simply not have been the same.
The members of the Department of Speech Communication, Argumentation Theory and
Rhetoric provided me with many constructive comments during the research colloquia and over
drinks. I would especially like to thank Bart Garssen, who helped me with methodological issues,
Francisca Snoeck Henkemans, who helped me to acquire the perfect home office, and Renske
Wierda, who helped me with questionnaire coding.
A special thanks to Lotte and Renske again, and to Ingeborg, Jacky, Eugen, Nanon and
Yvon, who have all been fellow PhD students at some time or other. They made sure that I never
felt lonely when working on my research.
On a more practical level, I thank the Amsterdam School for Cultural Analysis (ASCA) for
making this PhD project possible. I thank the Netherlands Institute for Health Services Research
(NIVEL) for allowing me to use their database of recorded medical consultations. I thank the
undergraduate students who helped me collect data during their BA-thesis seminar. I am very
grateful to Nanon Labrie for letting me use her consultation transcriptions. And I thank Duncan
Harkness for editing my text.
Last, without the support of my family and friends, the process of writing a dissertation
would have been a very difficult one. Thanks to Maaike, Leny, Rob, Lia, Wil, Hanneke, Sytske,
Manon, Fiona, Renske, Lotte and Leon.
5
Table of contents
Foreword 5
1 Introduction 11
1.1 A doctor’s arguments by authority 11
1.2 A pragma-dialectical approach 13
1.3 Aims and methods 15
2 Argumentation in medical consultation 19

2.1 Characterising medical consultation from an argumentative perspective 19
2.2 Communicative activity types 19
2.3 Medical consultation as a communicative activity type 20
2.4 Preconditions for strategic manoeuvring in medical consultation 21
2.5 A case of manoeuvring strategically in medical consultation 25
2.6 Conclusion 27
3 Authority in argumentative discourse 29

3.1 An analytical distinction between variants of authority 29
3.2 Existing ethos 29
3.3 Acquired ethos 32
3.4 Argument from authority 34
3.5 Argument by authority 36
3.6 Variants of authority in practice 40
3.7 Conclusion 41
4 A doctor’s argument by authority as a strategic manoeuvre 45

4.1 An integrated pragma-dialectical approach 45
4.2 The strategic aspects of a doctor’s argument by authority 45
4.2.1 Topical potential: The choice for an argument by authority as a variant 46
of authority argumentation
4.2.2 Audience demand: The argument by authority in response to a 50
patient’s hesitance
4.2.3 Presentational devices: The argument by authority as a means to 53
simplify a medical discussion
4.3 Interaction of the three strategic aspects of a doctor’s argument by authority 54
4.4 Conclusion 57
5 Soundness conditions for a doctor’s argument by authority 59
5.1 The reasonableness of a doctor’s argument by authority 59
5.1.1 General soundness conditions for the argument by authority 60
5.1.2 Specific soundness conditions for a doctor’s argument by authority 63
5.2 A doctor’s argument by authority evaluated in practice 66
5.3 Conclusion 69
6 The perception of reasonableness of a doctor’s argument by authority 73

6.1 Factors affecting ordinary language users’ perception of reasonableness 73
6.2 Soundness as a factor that affects the perception of reasonableness 74
6.3 Contextual factors that affect the perception of reasonableness 74
6.3.1 Higher order conditions 74
6.3.2 Second order conditions: The patient’s pre-set ideas about his health 75
problem
6.3.3 Second order conditions: The severity of the patient’s health problem 77
6.3.4 Third order conditions: The amount of time available to conduct a 78
discussion
6.3.5 Third order conditions: The patient’s required health literacy 79
6.4 Overall organisation of the experiments 80
6.4.1 Set-up 80
6.4.2 Materials 84
6.4.3 Respondents 90
6.4.4 Instruction 91
6.5 Results 91
6.6 Discussion 94
6.7 Conclusion 97
7 The respondents’ justification of their perception of reasonableness 101

7.1 Reasons underlying perceived reasonableness 101
7.2 Overall organisation of the replication 101
7.2.1 Set-up 101
7.2.2 Materials 104
7.3 Results 108
7.3.1 Consistency with the replicated studies 108
7.3.2 Explanatory responses 110
7.3.2.1 A taxonomy for classifying the respondents’ justifications 110
7.3.2.2 Classifying the respondents’ justifications 112
7.4 Discussion 115
7.5 Conclusion 117
8 The perception of effectiveness of a doctor’s argument by authority 119
8.1 Examining the perception of effectiveness 119
8.2 The relation between reasonableness from a pragma-dialectical perspective 120
and effectiveness
8.3 Overall organisation of the experiment 122
8.3.1 Hypotheses 122
8.3.2 Set-up 124
8.3.3 Measuring effectiveness 126
8.4 Results 128
8.5 The empirical relation between perception of reasonableness and effectiveness 131
8.6 Discussion 133
8.7 Conclusion 134
9 Conclusion 137
9.1 Main findings 137
9.2 Implications 141
Summary 145
Samenvatting 149
References 153
Index of names 159
Index of subjects 161

1. Introduction
1.1 A doctor’s argument by authority
In medical consultation, a patient typically requests the doctor’s judgment or advice about a
health problem. The doctor strives to provide a diagnosis, prognosis and/or treatment advice
based on verbal and sometimes also physical examination of the patient. If the patient’s health
problem requires specialist expertise, the doctor can also refer him to secondary care.1 Whatever
the outcome of a medical consultation (diagnosis, advice, referral), by the end of the consultation,
the doctor and patient should be in agreement about how to proceed.
During the consultation, patients do not always agree with a doctor’s medical judgment or
advice. A patient might, for instance, be hesitant to accept a particular kind of medication, even if
a doctor recommends it. From an argumentation theoretical perspective, hesitance is indicative
of doubt or even opposition to the expressed standpoint – i.e., the doctor’s recommendation. To
remove such hesitance, a doctor could advance argumentation in support of his judgment or
advice. From the perspective of the pragma-dialectical argumentation theory, developed by van
Eemeren and Grootendorst (1984; 1992; 2004), the doctor and patient can be said to conduct an
argumentative discussion.
One of the argumentative means that is available to the doctor is to advance an argument
by authority; the doctor can appeal to his medical knowledge or expertise as a sign of the
acceptability of his medical judgment or advice (“It’s best to take these loratadine tablets, because
I have seen them work really well against hay fever”). This could be quite convincing, as the
patient typically requests a medical consultation because he does not exactly know what his
health problem amounts to, how serious this problem is and/or what to do about it, while he
expects the doctor to be able to determine these matters. In other words, the patient ascribes
authority to the doctor on diagnosing and treating his health problem. Even if the patient simply
wants a referral to a specialist, he ascribes authority to the doctor on determining whether such
a referral is in order.2
When advancing an argument by authority in medical consultation, a doctor can be said to
not just aim to reasonably resolve the difference of opinion with the patient, but to also make sure
that the patient accepts his particular diagnosis, prognosis and/or advice. In other words, the
doctor strives to be both reasonable and effective when arguing by authority. From an extended
pragma-dialectical theoretical perspective, a doctor’s argument by authority can indeed be
regarded as a ‘strategic manoeuvre’ (van Eemeren, 2010, p. 40).
Case 1.1 illustrates how a doctor can argue by authority in practice. The case consists of
an excerpt from a Dutch paediatric consultation about the diet of a toddler who suffers from
asthma.
1
For the sake of clarity, the doctor and patient shall be referred to in the third person masculine singular.
Of course, where ‘he’ is used, ‘she’ can be read as well.
2
In addition to crediting the doctor with authority to diagnose whether a referral to secondary care is
appropriate (‘authority of expertise’), a patient who requests a referral also recognises the doctor’s authority
to refer patients to secondary care (‘authority of command’) (see, on different types of authority, Goodwin,
1998, p. 268; Woods & Walton, 1989, p. 22).
11
Case 1.13
Excerpt of an argumentative discussion between a paediatrician (D) and the mother (M) of an
infant patient who suffers from asthma (original conversation in grey)
1 D: By the way, I have to say that, about his, about what he eats, I’m not really concerned to be honest.
(Ik moet trouwens zeggen, over zijn, over wat hij eet maak ik me niet zoveel zorgen eerlijk
gezegd.)
2 M: No.
(Nee.)
3 D: Look, I can imagine that, as mother and as father, you are concerned, but if I look at the way he’s
grown. Well, one of those things you need to grow well is to eat well…
(Kijk, ik kan me voorstellen dat als moeder en als vader je je zorgen maakt, maar als ik kijk naar
hoe hij gegroeid is. Nou één van die dingen die je nodig hebt om goed te groeien, is goed te
eten…)
4 M: Yeah.
(Ja.)
5 D: So he has had, he has had enough in the past few months, so…
(Dus hij heeft, de afgelopen maanden heeft hij genoeg gehad, dus…)
[…]
18 M: No, but yeah, things are sometimes being said about it and in the end you also think like: what
should I do here? Right? One says this. The other that. And then you also think like:
(Nee, maar ja hè, er wordt wel eens wat over gezegd en op het laatst denk je ook van: wat doe ik
hier nou? Hè? De één zegt dit. De ander dat. En dan denk je ook van:)
19 D: It’s also good to come here then.
(Dan is het ook goed om hier te komen.)
20 M: “I’ve had enough now.” You just don’t know what you have to do in the end.
(“Ik ben het nou zat.” Je weet op het laatst niet meer wat je moet.)
21 D: No, that, I can imagine that and, erm, well, if you encounter problems with that again, just say
“I’ve been to the paediatrician”. I’ve studied it, which is the case. And, erm, he said “We do that
this way” and …
(Nee dat, dat kan ik me voorstellen en, uhm, nou, als u daar weer problemen mee heeft, zeg maar
gewoon “Ik ben naar de kinderarts geweest”. Ik heb daarvoor geleerd, dat is ook zo. En, uhm, die
heeft gezegd “Dat doen we zo” en…)
22 M: You [infant] just stop that.
(Hou jij [kind] eens even op.)
23 D: And [incomprehensible] with evidence: he’s growing just perfectly, which is the most important
issue.
(En [onverstaanbaar] met bewijs: hij groeit gewoon perfect, dat is het belangrijkste.)
As is clear from the very first turn of the excerpt in case 1.1, the doctor is not concerned about
the infant’s diet. Although he argues that the parents should not be concerned either (turns 3
and 5), the mother is still hesitant to accept the doctor’s advice; she knows that other people
3
This example, like the other examples in this study, is obtained from a database compiled by the
Netherlands Institute for Health Services Research. The examples are transcribed and translated by me unless
indicated otherwise.
12
believe differently and she does not know what to do when confronted with these different
ideas (turns 18 and 20). The doctor responds to this by advancing an argument by authority: he
assures her that his advice is sound, because he provides it as a paediatrician and has studied to
do so (turn 21). Not only does he thereby emphasise his own expertise to provide the medical
judgment in question, he also strategically indicates that the other people the mother talked to
might not possess such expertise.4
Although a doctor can, in his argumentation, strategically appeal to the authority that a
patient (or in cases like the one in case 1.1 someone representing the patient) ascribes to him, this
does not mean that a doctor’s argument by authority always constitutes a reasonable contribution
in a discussion in medical consultation. In some cases, an argument by authority by a doctor can
be too paternalistic and does not allow for further discussion about the treatment that the doctor
has in mind; a doctor thereby fails his legal obligation to inform the patient (as laid down in the
requirement of informed consent; see, for example, WGBO, 1995, Art. 448(2)). As a consequence,
the doctor might even fail to sufficiently convince the patient to adopt the treatment and adhere
to it. In such a case, the doctor’s argument by authority would not only constitute an unreasonable
discussion contribution, but also an ineffective one.
Although a doctor’s argument by authority has potentially far reaching consequences, it
has, so far, not been established when it can be considered reasonable and whether patients
also accept reasonable instantiations of this argument in actual medical consultation. To
better understand these issues, the main question to be answered in this study is under which
conditions does a doctor’s argument by authority constitute a reasonable and effective strategic
manoeuvre in medical consultation? This question is important from an argumentative as well
as a medical perspective. From an argumentative perspective, answering this question clarifies
how and to what extent the discussion context can affect the evaluation of the reasonableness
and effectiveness of a particular discussion contribution. From a medical perspective, answering
the question clarifies the extent to which doctors can appeal to authority without becoming too
authoritative – which is especially important given the increased emphasis on shared decision
making in medical consultations.5
1.2 A pragma-dialectical approach
To determine the conditions under which a doctor’s argument by authority constitutes a

reasonable and effective strategic manoeuvre in medical consultation, the extended pragma-
dialectical theory, as developed by van Eemeren and Houtlosser (2002a; 2002b) and van Eemeren
(2010), will be used. According to this theory, participants in an argumentative discussion strive
to simultaneously fulfil the dialectical aim of maintaining reasonableness and the rhetorical
aim of being effective. This means that the discussion parties strive to reasonably resolve the
difference of opinion on the merits, while they simultaneously attempt to make the other party
accept their point of view.
4
More is going on in this example, which shall be discussed in chapter 4 (section 4.3)
5
Shared decision making is, for example, stimulated through legislation (such as the American Patient
Protection and Affordable Care Act (‘Obamacare’), sect. 3506), national programmes (such as British Right
Care Shared Decision Making Programme (2012)) and medical textbooks (such as Edwards & Elwyn, 2009).
13
To balance their dialectical and rhetorical aim, each discussion party manoeuvres strategically.
Discussion parties, in other words, perform discussion moves that can be considered maximally
geared at both resolving the difference of opinion on the merits and getting their viewpoint
accepted. According to the extended pragma-dialectical theory, discussion parties will try to do
this by simultaneously making an opportune selection from the topical potential (i.e., the set
of available moves that can be made in the discussion stage at hand), adapting their discussion
contributions to audience demand (i.e., the expectations, preferences and wishes of the other
party) and using the most appropriate presentational devices (i.e., the possible ways in which the
strategic manoeuvre may be phrased) (van Eemeren, 2010, pp. 93-122).
The rules for a critical discussion, as established by van Eemeren and Grootendorst
(1984, pp.151-189; 2004, pp.123-196), specify when a strategic manoeuvre can be considered
reasonable from a pragma-dialectical perspective. The critical discussion rules stipulate how
discussion parties should ideally resolve their difference of opinion on the merits; if the parties
violate any of these rules with their discussion contributions, these contributions are considered
to be fallacious and as such an obstacle to resolving the difference of opinion in a reasonable
way. In the present study, the rules for a critical discussion shall be used as the starting point
in examining the conditions under which a doctor’s argument by authority can be considered
reasonable.
In order to establish the reasonableness conditions that apply to a doctor’s argument by
authority, the specifics of the context of medical consultation need to be taken into account.
Taking into account these specifics is not to say that the pragma-dialectical rules change from
context to context (they are, in fact, general rules); the specifics of the discussion context simply
have to be taken into account to define more precisely the exact conditions under which the
critical discussion rules may be violated.
For example, according to the pragma-dialectical burden of proof rule, a party that
advances a standpoint is obliged to defend it if the other party asks him to do so. What it means to
observe this discussion rule depends on the institutional rules and conventions of the discussion
context. In medical consultation, for instance, the legal requirement of informed consent dictates
that a doctor should obtain the patient’s agreement with a proposed treatment before he can
actually prescribe this treatment (see, for example, WGBO, 1995, Art. 450(1)). If a doctor and
patient enter an argumentative discussion about a treatment, this means that the doctor has to
justify a treatment recommendation not only when a patient asks him to do so, but also when the
patient does not (immediately) accept the doctor’s recommendation.
The concept of the ‘communicative activity type’ can be used to establish the specific
reasonableness conditions that apply to discussion contributions in particular contexts. In the
extended pragma-dialectical theory, this concept is used to characterise culturally established
communicative practices that have become more or less conventionalised and are to a certain
degree institutionalised (van Eemeren, 2010, p. 129). Argumentation can play a vital role in
communicative activity types (such as parliamentary debates or legal pleas, and also in medical
consultations). In these activity types, the institutional characteristics of the activity type provide
a basis for the analysis and evaluation of the strategic manoeuvring in that discussion context.
To examine the reasonableness conditions for a doctor’s argument by authority in
medical consultations, the concept of a communicative activity type will be used to provide an
argumentative characterisation of medical consultation. In line with van Eemeren, (2010, pp.
203-204), the reasonableness conditions that generally apply to the argument by authority shall
be referred to as ‘general soundness conditions’ and those conditions that are specified for the
14
doctor’s argument by authority in medical consultation shall be referred to as ‘specific soundness
conditions’.6
1.3 Aims and methods
As explained in the previous section, the extended pragma-dialectical theory will be used to
establish the conditions under which a doctor’s argument by authority constitutes a reasonable
and effective strategic manoeuvre in medical consultation. In the analytical part of this study, both
the general and specific soundness conditions for this argument are examined. The effectiveness
conditions for the argument is subsequently analysed in the study’s empirical part.
Before the soundness and effectiveness conditions can be examined, however, two
preliminary questions need to be answered. First of all, which characteristics of medical
consultation affect the strategic manoeuvring in the consultation? The answer to this question
clarifies which contextual factors affect an argumentative discussion in medical consultation.
Second, how can a doctor manoeuvre strategically with an argument by authority in medical
consultation? The answer to this question clarifies what an argument by authority by a doctor
exactly amounts to in discussions in medical consultation.
These preliminary questions are answered in the analytical part of the study. In chapter
2, the discussion context of medical consultation is analysed to provide an argumentative
characterisation of this activity type. In chapters 3 and 4, respectively the argument by authority
is defined and a doctor’s use of this argument as a strategic manoeuvre in medical consultation
is analysed.
The analytical part of this study is completed with a discussion of the conditions that a
doctor’s argument by authority should meet for this argument to reasonably contribute to the
resolution of a dispute (chapter 5). First, the general soundness conditions that need to be
fulfilled to argue reasonably by authority are proposed based on the pragma-dialectical rules
for a critical discussion. Second, the general conditions are specified for a doctor’s use of this
argument in medical consultation, thereby establishing the specific soundness conditions. These
specific soundness conditions are established based on the argumentative characterisation of
medical consultation from chapter 2.
In the empirical part of this study, the specific soundness conditions for a doctor’s argument
by authority are used to investigate empirically if their fulfilment influences the extent to which
ordinary language users perceive a doctor’s argument by authority to be effective in medical
consultation. Whether a doctor’s argument is judged as effective is also likely to depend on the
particular consultative situation in which it is advanced. For example, if it is clear that there is
only a limited amount of time available to discuss the patient’s health problem, then ordinary
language users might perceive the doctor’s argument by authority to more effectively contribute
to his standpoint, as it can avoid lengthy discussion and thereby save time.
To test whether the consultative situation indeed has a bearing on the perceived effectiveness
of a doctor’s argument by authority, this argument is empirically tested in a variety of consultative
6
The term ‘soundness’ is used when referring to the general and specific soundness conditions for the
argument by authority, since it is the pragma-dialectical convention to use this term when referring to
arguments – ‘reasonableness’ is used when referring to discussion contributions in general (van Eemeren &
Grootendorst, 1992; 2004; van Eemeren, 2010).
15
situations: in a situation where there is ample opportunity for argumentative discussion; in a
situation in which the patient already has such strong ideas about (the treatment of) his health
problem that he is not fully open to discussing it; in a situation in which his health problem is
severe; in a situation in which there is a limited amount of time to conduct a discussion; or in a
situation in which the patient is insufficiently health literate to conduct a fully-fledged discussion.
Both the patient’s openness for discussion and the severity of his health problem might affect
the fulfilment of what is known in the pragma-dialectical theory as the ‘second order conditions’
for reasonably resolving a difference of opinion (the conditions relating to the psychological state
of the discussion parties (van Eemeren & Grootendorst, 2004, pp. 36-37)). If a patient is not open
to discussing treatment advice, for example, because he has read about an alternative treatment
on the internet, the second order conditions are not fulfilled. The same holds for a situation in
which the doctor wants to discuss a treatment after diagnosing the patient’s health problem while
the patient does not feel like discussing any treatment after all, as his health problem is diagnosed
as less serious than he had expected.
Both the amount of time available for conducting an argumentative discussion and the
patient’s health literacy might affect the fulfilment of the ‘third order conditions’ (the conditions
relating to the external circumstances in which the discussion is conducted (van Eemeren &
Grootendorst, 2004, pp. 36-37)). If there is not enough time to conduct a detailed argumentative
discussion, then the circumstances are obviously such that they hamper the discussion. The third
order conditions are also not fulfilled if the patient is insufficiently health literate to fully discuss
the issue under discussion. Ideally, a doctor and a patient could discuss all of the ins and outs
of diagnoses, prognoses and/or medical advice, but, in practice, discussing these matters may
require more medical knowledge and expertise than the patient possesses.
To analyse whether a doctor’s sound argument by authority is regarded as effective in the
consultative situations relating to the second and third order conditions, the extent to which
this argument is perceived as reasonable by ordinary language users also needs to be taken into
account. After all, if a doctor’s argument by authority is perceived as reasonable, it is likely that
the argument is also effective in getting the standpoint accepted – and if it is not perceived as
reasonable, it is likely that it is ineffective. In chapter 6, the extent to which ordinary language users
perceive a doctor’s argument by authority to be reasonable is therefore empirically examined. The
degree to which this perceived reasonableness depends on the fulfilment of certain second and
third order conditions is additionally investigated empirically. This is done by conducting three
quantitative empirical studies. A replication of these studies is conducted to test the robustness
of the findings and to additionally ask the participants why they perceived the reasonableness of
the doctor’s argumentation the way they say they did (chapter 7).
After conducting the perceived reasonableness studies and their replication, it can finally
be established under which conditions a doctor’s argument by authority can be considered as
effective. As will be explained in chapter 8, this is done by means of a study in which a similar
experimental set-up is used as in the reasonableness studies.
In the conclusion, the main results obtained in the empirical part of the present study are
discussed in conjunction with those obtained in the analytical part (chapter 9). Based on this
discussion, some relevant theoretical and practical implications are brought to attention.
16
2 Argumentation in medical consultation
2.1 Characterising medical consultation from an argumentation perspective
To examine when a doctor’s argument by authority constitutes a reasonable and effective

discussion contribution in medical consultation, it first has to be established which characteristics
of medical consultation influence the argumentative discourse in it. In this chapter, the pragma-
dialectical concept of communicative activity type is used to characterise medical consultation
from an argumentation perspective. This concept is first discussed in general (section 2.2)
and then specifically applied to medical consultation (section 2.3). Subsequently, it is shown
how the characteristics of the communicative activity type of medical consultation affect the
argumentative discourse between a doctor and patient (section 2.4). This characterisation
provides the basis for the actual analysis and evaluation of discussion contributions in medical
consultation. The chapter ends with an analysis of an example of actual argumentation in medical
consultation (section 2.5).
2.2 Communicative activity types
To properly analyse and evaluate argumentative discourse in medical consultation, it needs to

be understood which contextual features of the consultation need to be taken into account when
analysing argumentative discourse in it. Similar to Hymes (1977, p. 3) and Levinson (1979;
republished in 1992), van Eemeren and Houtlosser (2005; 2006) and van Eemeren (2010) introduce
the concept of communicative activity type7 to systematically take the context into account in the
analysis and evaluation of discourse. They conceptualise communicative activity types as culturally
established communicative practices that have become more or less conventionalised, and are
to a certain degree institutionalised. Contrast, for example, the strict way in which the highly
institutionalised witness examination in a court room affects the communication between the
participants with a much more loosely institutionalised journalistic interview.
Van Eemeren (2010, pp. 138-143) distinguishes between communicative activity types
and instances of these activity types. He specifically regards the communicative activity type to
concern – as the term indicates – the type of conventionalised communicative practice (such as
“court proceedings”) and the speech event as the token of such a practice (such as “the plaintiffs’
interrogatories in Greenberg v. Miami Children’s Hospital Research Institute”).
In some communicative activity types, argumentation plays a vital role. This is, for
instance, the case in arbitration. The communicative activity type can then be expected to some
extent to shape the contributions of the discussion parties. In other words, it “discipline[s] the
conduct of strategic manoeuvring” by the parties (van Eemeren & Houtlosser, 2006, p. 385),
because these parties have to take into account the activity type’s rules and conventions when
striving to balance their dialectical aim of resolving the difference of opinion on the merits with
their rhetorical aim of obtaining a discussion outcome that is in their favour.
7
In the extended pragma-dialectical theory, the communicative activity type is also simply referred to as
activity type or, when it is argumentative, as argumentative activity type (see van Eemeren & Houtlosser,
2005; 2006; Mohammed, 2008).
19
Van Eemeren (2010, pp. 152-158) lists several preconditions for strategic manoeuvring that can
differ per communicative activity type. To systematically analyse and evaluate argumentative
discourse, these preconditions need to be specified for the communicative activity type in which
the discourse proceeds. In the next sections, this is done for medical consultation.
2.3 Medical consultation as a communicative activity type
Communication is an important part of medical consultation: adequate doctor-patient

communication is positively related to the quality of health outcomes, patient’s adherence to
treatment regimes, and satisfaction of both the doctor and the patient (Brown, Stewart, Ryan,
2003, pp. 141-155; Deveugele et al., 2005, p. 265). Argumentation in medical consultation has
increasingly been studied within the fields of argumentation theory (Labrie & Schulz, 2014),
artificial intelligence (for example, Boegl et al., 2004; Patel et al., 2009), and (informal) logic and
critical thinking (for example, Jenicek & Hitchcock, 2005; Murphy, 1997). The focus in these
studies has predominantly been on the role that argumentation plays in medical consultation,
not on the evaluation of specific types of argumentation. However, since evaluation of specific
types of argumentation is important in clarifying what reasonable doctor-patient discussions
amount to, it should be subject to investigation.
The extended pragma-dialectical theory, as developed by van Eemeren and Houtlosser
(2002a; 2002b) and van Eemeren (2010), provides the means to evaluate argumentative
discourse while taking into account the context in which it occurs. According to the extended
pragma-dialectical theory, in argumentative discourse, discussion parties aim to resolve their
difference of opinion on the merits (their dialectical goal). Simultaneously, the parties strive to
get their point of view accepted (their rhetorical goal). Balancing these goals leads to strategic
manoeuvring (van Eemeren, 2010, p. 40). As discussed in the previous section, the discussion
parties’ strategic manoeuvring is affected by the communicative activity type in which it occurs.
So, to evaluate strategic manoeuvring in medical consultation, it has to be established which
characteristics are particular to the communicative activity type of medical consultation and
what role argumentative discourse plays in this activity type.
Medical consultation can be seen as an institutionalised communicative practice between
a doctor and patient. It only occurs in assigned places (such as hospitals, doctors’ practices and
community health centres) and is strongly regulated by institutions (such as departments of
health and medical professional associations). Medical consultations are conducted in a more
or less conventionalised fashion. Following Heath (1986), ten Have (1991, p. 139) describes
a medical consultation as normally consisting of complaint presentation, verbal and physical
examination, diagnosis, treatment, prescription and/or advice. The consultation generally begins
with the doctor enquiring about the health of the patient, to which the patient responds by
explicating his health problem and, in so doing, requests the doctor’s diagnosis, prognosis and/or
advice about this problem. The doctor then examines the patient and, based on this examination
and his general medical knowledge, the doctor provides the patient with the requested diagnosis,
prognosis and/or advice.8
8
Such advice can amount to treatment recommendation (“You could best use your inhaler each morning
and at bedtime”), but also to a referral to secondary care (“It’s best to consult a dermatologist about this”) or
a proposal to refrain from treatment (“Let’s wait and see”).
20
During this highly conventionalised conversation, the doctor will generally try to minimise a
patient’s anxiety or uncertainty by delivering his advice in a reassuring manner. Tuckett et al.
(1985, p. 7) state that the doctor “is likely to give information to the patient not only about what
he suffers, but at the same time about how it came about, what is to blame, what will happen,
and what should be done”. The conventions of the medical consultation therefore constrain
the communication between the participants. A doctor may proceed quite differently when
informally discussing a health problem – say at home with a family member. In a similar vein,
of course, the patient would likely discuss his health problem differently under these other
circumstances as well. In sum, there are clear constraints and expectations arising from the
communicative activity type of medical consultation.
Argumentation could play an important role in the consultation. There are a number or
reasons for this, some stemming from the patient and others from the doctor. A reason stemming
from the patient would be that even though a patient consults the doctor about his health problem,
that does not mean that he always, immediately and fully accepts the doctor’s diagnosis, prognosis
and/or advice. With the considerable amount of medical information on the internet, a patient
might, for instance, request a medical consultation after gathering information online. If a doctor’s
medical judgement or advice is not in agreement with the opinion that a patient has formed, the
doctor might have to convince the patient by advancing argumentation in support of his judgement
or advice. Also, if a patient is simply hesitant to accept a doctor’s diagnosis or advice (“Are my
headaches really something I shouldn’t worry about too much?”, “Do I really have to start exercising
more?”), argumentation by the doctor will play an important role in the consultation.
A reason why argumentation could play an important role in medical consultation
stemming from the doctor is that a doctor could simply assume that the patient is hesitant
about accepting his medical judgements and advice (or to follow up on this advice). He could
then provide argumentation even if it is not clear that the patient is actually expecting it. A
doctor might even feel compelled to support his judgement by argumentative means because
of legal concerns. By adequately arguing in favour of his medical judgements or advice, he
could practically reduce his professional liability, which might be valuable given the substantial
frequency with which medical malpractice litigation occurs (Bal, 2009).
So, there are several reasons why both patient and doctor may wish to put forward
argumentation within medical consultation. As such, medical consultation can be analysed
as a communicative activity type in which argumentation can play an important role. Schulz
and Rubinelli (2006, n.p.) put it as follows: “it is probably not an exaggeration to claim that
argumentation is actually the only instrument at a doctor’s disposal that makes a reasoned
compliance of the patient possible, where the patient takes a certain course of action advised by a
doctor because s/he has understood and believes in the inner motivation behind it”.
2.4 Preconditions for strategic manoeuvring in medical consultation
Now that medical consultation has been characterised as a communicative activity type in
which argumentation can play an important role, the preconditions for strategic manoeuvring
in this activity type need to be specified to determine how the consultation could affect the
argumentative discourse that occurs in it.
In the extended pragma-dialectical theory, the combination of the following four
preconditions is unique for every activity type: (i) the activity type’s initial situation, (ii) its starting
21
points, (iii) the argumentative means available in the activity type and (iv) its possible outcomes
(van Eemeren, 2010, pp. 152-158). By specifying these preconditions for the communicative
activity type at hand, the relevant opportunities and limitations for discussion parties in the
activity type can be determined. Moreover, this procedure further enables the specifying of the
specific soundness conditions for the evaluation of discussion contributions in the activity type.
The preconditions for strategic manoeuvring in medical consultation are outlined below.
The (i) initial situation in a medical consultation is a lack of agreement between the doctor
and patient about the doctor’s diagnosis, prognosis and/or advice, or the doctor assuming that
the patient is hesitant to fully accept his judgment or advice. This (assumed) lack of agreement
may not only consist of the patient’s hesitation or doubt to adopt the doctor’s claims, but also of
real opposition by the patient to them.
Whether and how the lack of agreement between a doctor and patient can be overcome in
medical consultation is up to both discussion parties. Each of them could, in principle, provide
argumentation about the patient’s health problem or the doctor’s judgement or advice, and
(partly) retract their claims, doubt or opposition. It is important to note here that a (ii) starting
point in medical consultation is that the doctor acts as discussion leader and he is, in this respect,
more influential in the manner in which the lack of agreement is to be overcome.
In medical consultation, it is typical that the doctor and patient differ in the amount of
knowledge and expertise that they possess about health related issues. Although doctor-patient
communication has shifted from a paternalistic approach to a patient-centred one since the early
1970s (Bensing et al., 2006; Goodnight, 2006, p. 79; Zandbelt, 2006, p. 10), which is stimulated by
the patient’s increased access to medical information, this disparity in knowledge and expertise
is still inherently present in the consultation. As a consequence, the doctor largely determines
how the consultation proceeds. Yet, he also has to obtain the patient’s agreement on his proposed
medical advice, which makes the patient the more influential party in determining whether
actual agreement is reached during the consultation.
A variety of other (ii) starting points also affect the argumentative discussion between
a doctor and patient. To present a systematic overview of these starting points, a distinction
between procedural and material starting points has to be made. Procedural starting points
concern the discussion rules and the division of the burden of proof, while material starting
points consist of propositions that the discussants may use in their argumentation (van Eemeren
& Grootendorst, 2004, p. 60). The starting points that have been discussed so far – the doctor
acting as discussion leader and his obligation to obtain the patient’s agreement – are examples of
(implicit) procedural starting points.
Other procedural starting points in medical consultation are explicitly stated rules such as
the legal requirement of informed consent9 and explicitly incurred codes of ethics (such as the
Hippocratic Oath and the Declaration of Geneva). Additionally, the pragma-dialectical theory states
that the division of the burden of proof belongs to the procedural starting points. This division
depends on the kind of roles that the participants fulfil in the discussion. Since the doctor has
to present a diagnosis, advice and/or a prognosis about the patient’s health problem, he can be
regarded as the protagonist in the discussion with the patient. By presenting such medical claims,
9
See, for example, the Canadian Supreme Court’s decision in Reibl v. Hughes [1980] 2 S.C.R. 880
or the American Court of Appeals for the District of Columbia Circuit’s decision in Canterbury v.
Spence [1972] 464 F.2d 772 for relevant case law, and the Dutch civil code’s Wet op de geneeskundige
behandelingsovereenkomst [Law on the medical treatment agreement] (WGBO, 1995, Art. 448) for relevant
legislation.
22
the doctor incurs the burden of proof for them. The patient can be considered to perform the role
of the antagonist: he might, at least, seem to be hesitant about accepting the doctor’s claims.
In practice, a patient might also feel the need to give reasons as to why he has requested
the doctor’s time. A patient could, for instance, argue why the issue about which he asks the
doctor’s diagnosis or advice constitutes a problem, why he thinks this problem is health related
and/or why he could not come up with a diagnosis or solution of the problem himself. Although
a doctor cannot refuse a patient’s request for medical advice about his health problem, the patient
who advances argumentation assumes that the doctor is not fully convinced of the necessity of
investigating this problem. In such cases, the patient acts as the protagonist, while the doctor
can be regarded as the antagonist. Such situations do not, however, typically occur. Indeed,
Goodnight (2006, p. 79) points out that “doctors and patients are protagonists and antagonists.
When reasons matter most, the doctor proposes, the patient disposes”.
To adequately fulfil their discussion roles, the doctor and patient have to establish the
propositions that they can use in their argumentative discourse, i.e. their material starting
points. They can establish these starting points implicitly or explicitly. For instance, to provide
the patient with medical advice about his health problem, the doctor might need to physically
examine the patient. Through such an examination, the doctor obtains information about the
patient’s health. If the doctor and patient proceed to have a discussion about the doctor’s medical
advice, this information serves as a material starting point; it can be used as internal proof in the
argumentation, even if the information has so far remained implicit (“It’s likely that your kneecap
has been briefly dislocated, because it’s swollen and tender here”). The doctor also verbally
examines the patient (“and, as you said, it felt like something in your knee was moving”). From
a pragma-dialectical perspective, the doctor then explicitly establishes material starting points.
Certain material starting points in medical consultation are not established during the
consultation itself, but nevertheless used in the consultation. A clear-cut example of a starting
point that could function as external proof in an argumentative discussion between a doctor and
patient is medical knowledge. The doctor could, for instance, introduce the patient to new scientific
insights into the patient’s health problem. Another example of a starting point that is not established
in consultation itself is the fact that the doctor can be regarded as a medical authority on health
problems. It is exactly this authority that makes the patient seek the doctor’s advice.
As their (iii) argumentative means, the doctor and patient can advance argumentation
based on the internally and externally established material starting points. More specifically, the
doctor and patient may present argumentation based on the interpretation of concessions in
terms of medical facts and evidence. Unlike argumentation in activity types such as negotiation,
the discussion parties cannot (easily) change their starting points to make their argumentation
more effective. For instance, once physical examination shows that a patient suffers from
hypertension, it is difficult for him to argue that this is not the case. It is also important for
the medical judgment and advice of the doctor to be based on medical facts and evidence; the
potential serious consequences of judgment and advice concerning health problems does not
allow for sheer guesswork.
In principle, in medical consultation the doctor and patient advance their argumentation in
cooperative conversational exchanges. They have the opportunity to directly react to one another
whenever utterances are unclear or unacceptable. In practice, however, patients do not always
ask their doctor for clarification, explanation or information about medical advice (Bensing et
al., 2006; Robinson, 2003; ten Have, 1991). This could be explained by the patient’s ‘dependency’
on the doctor, in the sense that the patient is typically dependent on the doctor for insight into
23
what his health problem amounts to or what to do about it. Due to his insecurity about his
health problem and the potential seriousness of this problem, the patient might be hesitant to ask
questions to avoid offending the doctor or out of fear of confirming his worst suspicions.
Because of the cooperative and face-to-face nature of medical consultation, a doctor and
patient generally try to discuss the health problem in a polite manner. In stark contrast with
activity types such as presidential debate, a doctor and patient in medical consultation will
do everything in their power to manoeuvre strategically in a way that limits the other party’s
potential face loss (“I can understand that you’ve forgotten to take the pill sometimes, but it isn’t
wise. Have you ever considered an IUD?” rather than “It’s stupid that you forget to take the pill
sometimes. You should consider an IUD.”)
Once the argumentative discussion in medical consultation has come to an end, the (iv)
discussion outcome could be agreement between the doctor and patient about what the patient’s
health problem is and how to proceed. If the doctor has presented his medical judgement and
advice acceptably to the patient, this agreement comes down to the explicit agreement of the
patient with these judgements, and in cases where the discussion was about medical advice, the
patient’s commitment to following up on this advice.
If the doctor is unable or unsuccessful in presenting his medical judgements or advice
acceptably to the patient, the patient could request a second opinion. Because the patient’s
health problem needs to be ‘solved’ in the consultation (i.e., it needs to be determined what it is,
how serious it is and/or what to do about it), the doctor and patient cannot return to the initial
situation of their discussion; they cannot start the argumentative discussion again from scratch
(which could be done in, for example, informal discussions or philosophical debates). The
doctor and patient could nevertheless start a new consultation once new starting points enter
the discussion (such as the results from laboratory tests or discovery of alternative treatment
options). An overview of the argumentative characteristics that need to be taken into account
when manoeuvring strategically in medical consultation can be found in figure 2.1
Figure 2.1 Argumentative characteristics of medical consultation

Communicative (i) Initial situation (ii) S
tarting points (iii) Argumentative (iv) Possible
activity type (material, means outcomes
procedural)
Medical (assumed) lack of explicit rules (e.g., argumentation based agreement

consultation agreement between informed consent); on interpretation of between the
a doctor and implicit rules (e.g., concessions in terms doctor and patient
patient about the the doctor acts as of medical facts and about the patient
doctor’s diagnosis, discussion leader); evidence; conveyed following the
prognosis and/or explicitly established in cooperative discussed advice,
advice concerning concessions (e.g., conversational or a second
the patient’s health results of a doctor’s exchanges opinion (no return
problem; decision verbal inquiry to initial situation)
up to the parties into the patient’s
health); implicitly
established conces-
sions (e.g., results of
a doctor’s physical
examination of the
patient)
24
2.5 A case of manoeuvring strategically in medical consultation
How the characteristics of a medical consultation can affect argumentative discourse is shown in
an example taken from actual practice, case 2.1. In this excerpt from a paediatric consultation, the
parents of an infant patient with behavioural and developmental problems seek the professional
advice of a paediatrician. This is not the first time that they have visited this doctor. In fact, the
doctor is about to report the results of tests on samples taken earlier.
Case 2.1
Excerpt of an argumentative discussion between a paediatrician (D) and the mother (M) and father
(F) of an infant patient with behavioural and developmental problems (original conversation in grey)
1 D: Erm, [to infant] Mathilda, right? We’re just going to get you [parents] up to date
(Uhm, [tot kind] Mathilda hè? We zouden gewoon even jullie [ouders] bijpraten…)
2 F: Yes.
(Ja.)
3 D: because, of course, I’ve still got some results in a report for you here. And I’d of course like to
know some things from her. But shall I first inform you [parents] about the results? Erm…
(want ik heb natuurlijk nog wat uitslagen voor je, hier liggen in een status. En ik wil natuurlijk
graag van haar wat weten. Zal ik jullie maar eerst op de hoogte stellen van de uitslagen? Uhm…)
4 F: Please.
(Graag.)
[Doctor discusses results of various tests]
12 D: There’s, yeah, there’s a very small indication that there’s an anomaly in that [the infant’s] digestion,
but they [the lab] say that we can only determine or see that if we take another blood test.
(Er is een hele kleine aanwijzing in die stofwisseling [van het kind], maar ze [het lab] zeggen: we
kunnen dat alleen maar bepalen of bekijken als we nog een aanvullend bloedonderzoek doen.)
13 M: But that that doesn’t function well or, or, how do I erm…
(Maar dat dat niet goed zou werken of, of, hoe moet ik dat uhm…
14 D: Roughly speaking, erm, you do have to think about that. That there’s a small mistake somewhere
there in the digestion, which, erm, could explain the problems. But, I’ve got to say, erm, I think it’s
just an indication though. I don’t think like “Oh, now, great; we’ve found something and, erm, we
can work with that”. I’m like “Well, yeah, it’s an indication” and I’m like, well, god, if you get such
a test, and so you already did those steps, and if they advise that – and it’s a good bunch of people
that check that – then I’d be tempted to do that in any case.
(Grofweg, uhm, moet u daaraan denken, dat er ergens in die stofwisseling een klein foutje zou
schuilen waardoor, uhm, de problemen te verklaren valt. Maar ik moet zeggen, ik vind het
ook maar een strohalmpje hoor. Ik heb niet zo van: ‘Oh, nou dat is fantastisch; we hebben iets
gevonden en, uhm, daar kunnen we mee uit de voeten’. Ik heb zoiets van: ‘Nou, tja… het is een
strohalm’. En ik heb zoiets van: nou ja, god, als je zo’n onderzoek doet, en je hebt dus al van die
stappen gedaan, en als ze dat adviseren – het is wel een hele goeie club die dat nakijkt – dan zal
ikzelf de neiging hebben om dat in ieder geval te doen.
15 F: Yes.
(Ja.)
16 M: Yes.
(Ja.)
25
In turns 12 and 14 of this case 2.1, the doctor indirectly advises the parents to let their child
undergo another blood test (respectively “they [the lab] say that we can only determine or see
that, if we take another blood test” and “I’d be tempted to do that in any case”). From the reasons
that the doctor provides for this advice in turn 14 (“if you get such a test, and so you already did
those steps, and if they advise that – and it’s a good bunch of people that check that”), it appears
that the doctor assumes that the parents are hesitant to follow her advice – otherwise there would
be no need for the presented argumentation. The discourse can therefore be reconstructed as an
argumentative discussion in which the doctor acts as protagonist and the parents as antagonists.
The doctor is clearly in control of this discussion: in conformity with the procedural starting
point that the doctor acts as discussion leader, she determines which topics will be addressed and
in what order. However, the doctor seems to realise that she cannot just provide information
and argumentation as she pleases, since that might come across as impolite in the cooperative
conversational exchange that she is engaged in. She consequently actively includes the parents in
the conversation by, for instance, directly asking for their agreement in turn 3 (“But shall I first
inform you [parents] about the results?”). Simultaneously, by asking this question, the doctor
indicates she is concerned about obtaining informed consent.
Interestingly, the doctor uses – amongst other things – the discursive means available to
her in such a way that she argues in favour of the medical advice by emphasising what she would
personally do if she were in the parents’ situation (“I’d be tempted to do that in any case” in turn
14). Because it is a material starting point in medical consultation that the doctor can be regarded
as an authority on the health problem under discussion, this appeal to authority seems to be
an effective way to convince the parents of letting their child undergo another blood test. The
doctor’s reference to her personal behaviour in the parents’ situation indicates that opting for the
blood test is the wise thing to do.
Yet, a precondition for strategic manoeuvring in medical consultation is that the doctor
is an authority on health problems. This raises the question of whether the personal preferences
of the doctor in case 2.1 can be reasonably regarded as part of her authority on health problems.
On the one hand, taking a blood test seems to be a purely medical issue. On the other hand,
as appears from turn 14, it is not the medical knowledge that the doctor presents about the
patient’s health problem, but, in fact, her lack of medical knowledge and trust in other medical
professionals (the lab) that seem to be the reason that she appeals to authority.
The doctor manoeuvres strategically by avoiding making a clear distinction between her
non-professional behaviour and her authority on health problems. Additionally, the appeal to
authority makes it strategically very difficult for the parents to object to the advice. If they do,
they would not only disregard the medical advice of the doctor and laboratory, but also perform
a face threatening act by indirectly disqualifying what the doctor would personally do if she were
the patient’s parent. In reply to the doctor’s strategic manoeuvring, the parents indeed explicitly
accept the doctor’s medical advice in turns 15 and 16.
26
2.6 Conclusion
By analysing medical consultation as a communicative activity type, the characteristics of the

consultation that can affect the possible argumentative discourse between a doctor and patient
have been outlined. Medical consultation can be regarded as a communicative doctor-patient
interaction in which the patient seeks the professional advice of a doctor about a health problem
in designated places (such as hospitals, doctors’ practices and community health centres). This
institutionalised communicative practice shapes the discourse that occurs in it.
Due to, amongst other things, increased health literacy on the side of patients and
increased professional liability on the side of doctors, argumentation can play an important role
in medical consultation. The doctor cannot simply tell the patient what to do, but has to convince
the patient of his advice. The context of the medical consultation affects the manner in which the
doctor does so.
To adequately analyse and evaluate argumentative discourse in medical consultation, it is
necessary to take into account the characteristics of medical consultation. Taking into account
these characteristics does not only provide insight into the opportunities and constraints that
medical consultation offers for the argumentative contributions of its participants, but can also
be used as a starting point for determining the soundness criteria for the evaluation of this
discourse. The characterisation presented in the present chapter is therefore used later to analyse
a doctor’s argument by authority as a strategic manoeuvre (chapter 4) and to establish the specific
soundness conditions for this argument (chapter 5). Before doing so, however, the particular type
of argumentation that is at the heart of this study, the argument by authority, needs to be defined.
This is done in the next chapter.
27
3 Authority in argumentative discourse
3.1 An analytical distinction between variants of authority
As explained in chapter 2, a patient typically requests a medical consultation to have his health
problem investigated by the doctor and, based on this investigation, to obtain medical advice.
By requesting a consultation, the patient generally indicates that he does not know what is the
matter with him, how serious his health problem is or how to best handle this problem, but trusts
that the doctor knows this – or can refer him to a specialist based on a medical examination. The
patient thus ascribes authority over his health problem to the doctor.
The authority ascribed to the doctor influences the way in which the consultation proceeds.
The patient will expect the doctor to guide, and thereby structure, the communicative exchange
in order to reach an appropriate diagnosis, prognosis and/or advice. Moreover, in case of an
argumentative discussion in medical consultation, the authority that the patient ascribes to the
doctor can influence the acceptability of his medical judgment or advice to the patient. First
of all, the simple fact that the patient regards the doctor as an authority on his health problem
might be enough for the patient to accept the doctor’s argumentation about this problem and to
accept his medical judgment or advice. Secondly, the doctor can attempt to convince the patient
of his judgement or advice by emphasising his expertise in the course of the consultation or by
presenting this expertise as an argument in support of these standpoints.
To analyse a doctor’s use of authority in argumentative discourse in more detail, an
analytical distinction is made in this chapter between four ways in which authority can influence
the outcome of a discussion. More specifically, a distinction is made between: existing ethos
(section 3.2), acquired ethos (section 3.3), the argument from authority (section 3.4) and the
argument by authority (section 3.5).10 It is subsequently shown how these analytically distinct
ways can interact in practice (section 3.6). The fourfold distinction is used in chapter 4 to
examine the strategic functions of one particular way in which authority can be used in medical
consultation, namely the doctor’s argument by authority.
3.2 Existing ethos
As said earlier, a patient in principle requests a consultation because of the doctor’s medical qua
lifications. These qualifications for practicing medicine are highly regulated. Council Directive
93/16/EEC (Art. 23), for instance, lays down the following standards that doctors have to meet to
practise medicine in the European Union:11
10
This fourfold distinction is based on personal communication with Frans van Eemeren (2011).
11
Though Council Directives are legislative acts of the European Union, member states are not required
to adopt the exact regulations that are presented in directives. Rather, as long as the member states can
achieve the outcome that is aimed for in the directive within the time specified by the European Council,
the directive can be regarded as adopted by the member state (Treaty on European Union, 1992, Art. 249).
29
The Member States shall require persons wishing to take up and pursue a medical profession
to hold a diploma, certificate or other evidence of formal qualifications in medicine referred
to in Article 3 [an article that lists the required diplomas per EU country] which guarantees
that during his complete training period the person concerned has acquired: (a) adequate
knowledge of the sciences on which medicine is based and a good understanding of the
scientific methods including the principles of measuring biological functions, the evaluation
of scientifically established facts and the analysis of data; (b) sufficient understanding of the
structure, functions and behaviour of healthy and sick persons, as well as relations between
the state of health and physical and social surroundings of the human being; (c) adequate
knowledge of clinical disciplines and practices, providing him with a coherent picture of
mental and physical diseases, of medicine from the points of view of prophylaxis [treatment
intended to prevent disease], diagnosis and therapy and of human reproduction; (d) suitable
clinical experience in hospitals under appropriate supervision.”
Generally speaking, a patient who requests a consultation is unsure as to what his health problem
is, how serious this problem is or how to treat it, whereas the doctor’s qualifications indicate that
he possesses the medical knowledge and expertise to provide adequate diagnosis and advice.
Consequently, in the consultation, there is an asymmetry between the doctor and patient: the
doctor acts as the expert on issues of medicine and the patient as a layman (see, on the intrinsic
nature of this asymmetry, Pilnick and Dingwall, 2011).
The excerpt of the consultation in case 3.1a illustrates this asymmetry in medical expertise
between the doctor and the patient. In this consultation, the patient asks for the diagnosis of a
health problem that he had experienced in the past. He indicates that he expects the doctor to
possess the expertise that is necessary to provide a diagnosis.
Case 3.1a
Excerpt of an argumentative discussion between a doctor (D) and a patient (P) about the patient’s
possible inguinal rupture (original conversation in grey)
1 D: It could be the case that it had been a fracture.

(Het kan zijn dat het misschien een breuk was.)
2 P: Yes.
(Ja.)
3 D: But that is also not sure.
(Maar dat is ook niet zeker.)
4. P: No, no, but I thought that doctors could feel that just like that.
(Nee, nee, maar ik dacht dat doktoren dat zo effe konden voelen.)
In case 3.1a, the statement “but I thought that doctors could feel that just like that” (turn 4) shows
that the patient requests the consultation because of his expectations about the doctor’s medical
expertise. The doctor does not completely live up to this expectation: he cannot determine for sure
whether the patient suffered from an inguinal rupture in the past (turns 1 and 3). Nonetheless,
the doctor possesses the knowledge and expertise to judge whether and with how much certainty
he can diagnose the possible fracture – as opposed to the patient, who requested the consultation
because he lacks the medical expertise to diagnose the problem himself.
30
The asymmetry in medical knowledge and expertise between the doctor and the patient can
influence the acceptability of the doctor’s medical judgment or advice. A patient will generally
find argumentation on medical issues presented by a doctor more acceptable than the same
argumentation presented by someone who is not a doctor. The authority of the discussion party
on the issue under discussion then renders his argumentation more acceptable. Walton (1996, p.
64) puts it as follows: “An expert in a particular domain of knowledge is in a special position to
know about propositions in that domain, and therefore the expert’s opinion on some propositions
of this kind generally has a weight of presumption in its favor”.
The potential effect that a speaker’s authority has on the acceptability of his argumentation
was studied in classical rhetoric.12 The rhetorical term ethos is used to denote the persuasiveness
of a person’s character. This term stems from Aristotle (The Art of Rhetoric – henceforth Rhetoric
– I2-1356a), who distinguishes ethos from pathos (the persuasiveness of an appeal to emotions)
and logos (the persuasiveness of argumentation by examples or enthymemes).13 Traditionally,
a distinction is made between ethos derived from a person’s expertise (“what one knows”) and
ethos derived from his status (“what one is”) (Tindale, 2011, p. 343). In medical consultation,
a doctor’s medical knowledge and expertise can, thus, contribute to his ethos in the first sense
(ethos derived from a person’s expertise).
The doctor can also be expected to possess ethos in the second sense (ethos derived from a
person’s status). Even though the doctor’s role in medical consultation has changed since the 1970s
from a paternalistic one to one in which he acts as the patient’s guide (Helmes, Bowen & Bengel,
2002, p. 150), doctors can still be said to possess professional status because of their advisory
role on issues of medicine (which they fulfil based on their recognised medical qualifications).
According to Scanlon (2011, p. 18), “The most widely recognised of all professionals are doctors.
Nurses and teachers still struggle for professional acknowledgement; however, their professional
status is widely questioned amongst the clients they serve and amongst scholars. The status of
doctors remains largely intact although there is growing public critique and scepticism”.
To uphold their professional status, doctors have to provide medical advice that is in the patient’s
best interest. In case 3.2, the doctor makes this explicit after an apparently hypochondriac patient
expresses doubt about the way in which doctors practise medicine.14
Isocrates (Oration XV278) notably emphasises the importance of a speaker’s character:

12
The
man who wishes to persuade people will not be negligent as to the matter of character; no, on the
contrary, he will apply himself above all to establish a most honourable name among his fellow-citizens;
for who does not know that words carry greater conviction when spoken by men of good repute than
when spoken by men who live under a cloud, and that the argument which is made by a man’s life is of
more weight than that which is furnished by words?
In Roman rhetoric, the speaker’s character is discussed in a similar fashion. Quintilian (De Institutio
Oratoria XII1-1), for instance, states that the ideal orator should be “a good man, skilled in speaking”.
13
It should be noted that Aristotle has a different conception of ethos than Isocrates and Roman rhetoricians
such as Quintilian. According to Aristotle (Rhetoric, I2-1356a), “Proofs from character are produced, whenever
the speech is given in such a way as to render the speaker worthy of credence – we more readily and sooner
believe reasonable men on all matters in general and absolutely on questions where precision is impossible
and two views can be maintained. But this effect too must come about in the course of the speech, not
through the speaker’s being believed in advance to be of a certain character”. Contrastingly, Isocrates cum
suis do not believe that the ethos should be constructed in the course of a speech; it should already be in
place before the speech is delivered.
14
Transcription by Nanon Labrie, my translation from Dutch.
31
Case 3.2
Excerpt of an argumentative discussion between a doctor (D) and a patient (P) who complains
about doctors (original conversation in grey)
1 D: You know, we truly try our utmost to do it as well as possible for you […] And you do have to
trust that.
(Weet je, wij doen echt ons best om ’t zo goed mogelijk voor je te doen […] En daar moet je toch
op vertrouwen.)
2 P: Yes.
(Ja.)
3 D: Because that really is the case.
(Want dat is wel zo.)
In case 3.2, the doctor makes explicit that she and her colleagues do everything in their power
to adequately diagnose and advise the patient (turn 1). This is a rather exceptional situation:
characteristically, doctors do not make their good intentions explicit in the consultation;
these intentions are simply presupposed. Codes of conduct, such as the Hippocratic Oath and
the Declaration of Geneva, in principle, safeguard the doctor’s good intentions.15 The doctor’s
professional status, thus, generally provides him with ethos. However, in case 3.2, the patient
complains about doctors, which leads the doctor to offer assurance that there is no reason for the
patient to distrust them (turn 1).16
3.3 Acquired ethos
For the analysis of a discussion party’s ethos, it is necessary to distinguish between ethos that
the party possesses at the start of the argumentative discourse and ethos that he acquires during
this discourse. A discussion party can acquire ethos during the discourse by demonstrating his
authority, expertise, knowledge, professionalism, status, trustworthiness, etcetera (“I was just
explaining to a colleague how he could better consult his client when it occurred to me that …”).
This type of ethos is acquired when a discussion party demonstrates or constructs authority in
the discussion, so it is not simply already in place like the type of ethos discussed in section 3.2.
A discussion party’s acquired ethos affects the discourse differently than the ethos that
he already possesses. The reason is that the acquired ethos is constructed in the discourse itself,
which means that the discourse is – however briefly – not about the issue under discussion, but
about the discussion party’s expertise, status, etcetera. This change of topic is not the case for
argumentative discourse in which a discussion party’s existing ethos makes his standpoint more
acceptable; this ethos can affect the discussion outcome while the discourse is only about the
discussion topic. The fact that the discussion party who acquires ethos by definition refers to his
presumed authority can also have further consequences for the discourse: through appealing to
15
In the Hippocratic Oath, the statement “Whatever houses I may visit, I will come for the benefit of the
sick” (Edelstein, 1943) safeguards the doctor’s good intentions. The modern counterpart of this provision
can be found in the Declaration of Geneva, namely “The health of my patient will be my first consideration”
(WMA, 2006).
16
The doctor’s assurance can, therefore, be reconstructed as an attempt to (re-)establish her ethos. As is
discussed in the next section, I shall regard (re-)established ethos to constitute ‘acquired ethos’.
32
authority, the question of whether the discussion party does indeed possess this ethos can, for
instance, become the central issue in the discussion (“You keep saying you’ve treated such cases
before, but can you tell me exactly which cases they were?”).
Because these types of ethos affect the discourse differently, it is useful to analytically
distinguish between ‘acquired ethos’, referring to ethos that is constructed in the discourse itself,
and ‘existing ethos’, referring to ethos that is already in place at the start of the discourse. This
distinction is comparable to Aristotle’s distinction between artistic proofs (entechnoi pisteis;
sometimes also translated as ‘intrinsic proofs’ or ‘technical proofs’) and inartistic ones (atechnoi
pisteis; also ‘extrinsic proofs’ or ‘non-technical proofs’). The artistic proofs are the verbal
persuasive means that the speaker uses within the discourse, while the inartistic proofs are the
persuasive means that are already in place. So, acquired ethos is comparable to Aristotle’s concept
of artistic proofs, while existing ethos is comparable to his concept of inartistic proofs.
It should, however, be noted that Aristotle (Rhetoric, I2-1356a) himself sees ethos as only an
artistic proof. According to him, “proofs from character are produced, whenever the speech is
given in such a way as to render the speaker worthy of credence”. Aristotle indeed emphasises
that the persuasive effect of ethos “must come about in the course of the speech, not through
the speaker being believed in advance to be of a certain character”. According to Aristotle
(Rhetoric, II6-1378a), a speaker can construct ethos by demonstrating that he possesses practical
wisdom (phronesis; sometimes also translated as ‘common sense’ or ‘prudence’), virtue (arete;
also ‘excellence’) or goodwill (eunoia).
Case 3.3 illustrates how a doctor can acquire ethos in medical consultation.17 The case
consists of an excerpt of a paediatric consultation in the Netherlands in which the paediatrician
is in the process of diagnosing an infant patient with behavioural and developmental problems.
Case 3.3
infant patient with behavioural and developmental problems (original conversation in grey)
1 D: There’s, yeah, there’s a very small indication that there’s an anomaly in that [the infant’s] digestion,
but they [the lab] say that we can only determine or see that if we take another blood test.
(Er is een hele kleine aanwijzing in die stofwisseling [van het kind], maar ze [het lab] zeggen: we
kunnen dat alleen maar bepalen of bekijken als we nog een aanvullend bloedonderzoek doen.)
2 M: But that that doesn’t function well or, or, how do I erm…
(Maar dat dat niet goed zou werken of, of, hoe moet ik dat uhm…
3 D: Roughly speaking, erm, you do have to think about that. That there’s a small mistake somewhere
there in the digestion, which, erm, could explain the problems. But, I’ve got to say, erm, I think it’s
just an indication though. I don’t think like “Oh, now, great; we’ve found something and, erm, we
can work with that”. I’m like “Well, yeah, it’s an indication” and I’m like, well, god, if you get such
a test, and so you already did those steps, and if they advise that – and it’s a good bunch of people
that check that – then I’d be tempted to do that in any case.
(Grofweg, uhm, moet u daaraan denken, dat er ergens in die stofwisseling een klein foutje zou
schuilen waardoor, uhm, de problemen te verklaren valt. Maar ik moet zeggen, ik vind het
ook maar een strohalmpje hoor. Ik heb niet zo van: ‘Oh, nou dat is fantastisch; we hebben iets
17
A longer excerpt of this example was discussed in chapter 2 (example 2.1) to show how the characteristics
of medical consultation can affect the argumentative discourse in such a consultation.
33
gevonden en, uhm, daar kunnen we mee uit de voeten’. Ik heb zoiets van: ‘Nou, tja… het is een
strohalm’. En ik heb zoiets van: nou ja, god, als je zo’n onderzoek doet, en je hebt dus al van die
stappen gedaan, en als ze dat adviseren – het is wel een hele goeie club die dat nakijkt – dan zal
ikzelf de neiging hebben om dat in ieder geval te doen.
In case 3.3, the doctor implicitly puts forward the standpoint that the mother should allow her
daughter to undergo an additional blood test: in turn 1, she asserts “They [the lab] say we can
only determine or see that if we do an additional blood test”. She subsequently strengthens this
position by stating “I’d be tempted to do that in any case” in turn 3. From the reasons that the
doctor provides for this advice in turn 3 (“If you get such a test, and so you already did those
steps, and if they advise that – and it’s a good bunch of people that checks that”), it appears that
the doctor assumes that the mother is hesitant to adopt her advice.
In this consultation, the doctor acquires ethos by showing that she is knowledgeable about
problems in the digestive system. After the mother indicates that she does not fully understand
what it means for her daughter to have an anomaly in her digestion (“But that, that it wouldn’t
function well or, or, how do I erm”, in turn 2), the doctor explains what such an anomaly could
amount to (“there’s a small mistake somewhere there in the digestion which, erm, could explain
the problems”, in turn 3) and tells the mother with how much certainty she can say the daughter
suffers from this anomaly (“I think it’s but a tiny indication”, in turn 3).
The doctor in case 3.3 also acquires ethos by demonstrating that she is considerate in
providing her advice (“I’m like “Well, yeah, it’s an indication” and I’m like, well, god, if you do
such a test and so you’ve already done those steps, and if they [the lab] advise that – it’s a good
bunch that checks that – then I’d be tempted to do that in any case”, in turn 3). By emphasising
that, given the circumstances, it makes sense to allow the infant patient to undergo an additional
blood test, she demonstrates her practical wisdom (phronesis) – and appeals to that of the mother.
Additionally, by saying “I’d be tempted to do that in any case” (turn 3) the doctor makes
explicit that she has the patient’s best interests at heart. Since the doctor herself would be tempted
to let her own child undergo the additional test if she were in the mother’s position, then surely
it is best to let the patient undergo this test. The doctor’s earlier remark that “there’s a very small
indication [that there is an anomaly] in that [the infant’s] digestion, but they [the lab] say we
can only determine or see that if we do an additional blood test” (turn 1) functions in the same
way. It implies that the doctor has done everything in her power to examine whether there is an
anomaly in the patient’s digestion, but the only way in which this can be determined for sure is
by letting the patient undergo an additional blood test. In these contributions, the doctor can be
said to build ethos by stressing her goodwill (eunoia).
3.4 Argument from authority
Acquired or existing ethos should not be confused with authority argumentation. In authority
argumentation, a discussion party presents the opinion of a supposed authority on the issue
under discussion as a sign of the acceptability of his standpoint (van Eemeren & Grootendorst,
1992, p. 163; Garssen, 1997, p. 11; Schellens, 2006, p. 347). The opinion referred to in this type
of argumentation indicates the acceptability of the standpoint because this opinion shows that
an authority on the discussion topic agrees with the standpoint at issue. Figure 3.1 provides a
representation of the argument scheme of authority argumentation.
34
Figure 3.1 The argument scheme of authority argumentation
1 X is acceptable.
1.1 Authority A is of the opinion that X.
1.1’ A’s opinion indicates that X is acceptable.
In this scheme, the standpoint (1) “X is acceptable” is supported by the premises “Authority A is
of the opinion that X” (the minor premise, 1.1) and “A’s opinion indicates that X is acceptable”
(the major premise, 1.1’). An example of an authority argument would be: “It would be best to
undergo psychosomatic physiotherapy, as I’m sure you’ll benefit from it greatly”. In this example,
X amounts to treatment advice (“It is acceptable that it would be best to undergo psychosomatic
physiotherapy”) and the discussion party presents himself as an authority on this treatment
and its outcomes (“I’m sure you’ll benefit from it greatly”). This example shows that X does not
need to be an assertive, but can also be a recommendation (“It would be best to…”). In fact,
X in the argument scheme of authority argumentation could be any proposition (assertive,
evaluative, appellative). What does not appear from this particular example, but is nonetheless
the case, is that the authority referred to does not have to make opinion X explicit; he could
also simply indicate it. This would be the case if the example had been: “I advise you to undergo
psychosomatic physiotherapy, as I have very positive experiences with it”.
From a pragma-dialectical perspective, authority argumentation is a subtype of the main
type of symptomatic argumentation (van Eemeren & Grootendorst, 1992, p. 163; Garssen, 1997,
p. 11).18 In symptomatic argumentation, a discussion party presents that which is claimed in the
argument as a sign of that which is claimed in the standpoint. For authority argumentation, this
main scheme can be specified by regarding the authority’s opinion as the sign of the acceptability
of the standpoint.
By presenting premises 1.1 (“Authority A is of the opinion that X”) and 1.1’ (“A’s opinion
indicates that X is acceptable”) of an authority argument, the discussion party performs the speech
act of asserting.19 To felicitously perform this speech act, the discussion party needs to fulfil the
responsibility condition that he can be held responsible for believing the asserted proposition
to be true (van Eemeren & Grootendorst, 2004, pp. 77-94; see also Searle’s (1969, pp. 66-67)
sincerity condition). A discussion party who presents authority argumentation can, hence, be
held accountable for believing that the supposed authority really possesses relevant and sufficient
authority on the subject matter and can be held accountable for viewing this authority’s opinion as
a sign of the acceptability of the standpoint. He therefore needs to take on the burden of proof for
these premises if the antagonist indicates doubt about or opposition to them (“Tell me why you are
an authority on this matter” or “But why does this prove your point?”). Herein lies the difference
between authority argumentation on the one hand, and acquired and existing ethos on the other.
18
The other main types of argument schemes that are distinguished in the pragma-dialectical theory are:
causal argumentation (in which that which is asserted in the argument is presented as the cause or effect of
that which is asserted in the standpoint) and analogy argumentation (in which that which is asserted in the
argument is compared to that which is asserted in the standpoint) (van Eemeren & Grootendorst, 1992, p.
97; Garssen, 1997, pp. 8-24).
19
In practice, a discussion party does not always make both premises explicit. If one of them is left implicit,
it can be made explicit based on the concept of logical validity and pragmatic principles (van Eemeren &
Grootendorst, 1992, pp. 60-72). The unexpressed element is, then, reconstructed as an indirect assertion, to
which the discussion party can be held committed.
35
In contrast to an authority argument, a discussion party’s ethos does not support a specific (sub-)
standpoint. The party’s ethos is, in fact, potentially persuasive on all levels of the argumentation,
influencing the effectiveness of every proposition that he puts forward. A discussion party’s ethos
could, for instance, make his standpoint more acceptable regardless of the argumentation that he
advances in support of it, but his ethos could also increase the acceptability of the arguments or
sub-arguments at the same time. This is because a discussion party does not claim that his ethos is
a sign of the acceptability of the standpoint.20 For this reason, he does not have a burden of proof
for the justificatory force of his ethos. This lack of a burden of proof is in stark contrast with the
burden of proof that a discussion party incurs when advancing authority argumentation: a party
who advances authority argumentation commits himself to the premise “Authority A’s opinion
indicates that X”, which he needs to support if asked to do so.
In the literature, the authority that a discussion party refers to in an authority argument is
typically an external source – such as an expert in the field, a dictionary or an official institution
(Walton, 1997, pp. 63-90). The argument in such cases takes the form “He should change his
diet, because the dietician said so (and the dietician’s opinion indicates that he should change
his diet)”. In case 3.3, the doctor presents such an authority argument. In this consultation, the
doctor refers to the advice of the laboratory in support of the standpoint that the infant patient
should undergo an additional blood test (“They [the lab] advise that – it’s a good bunch that
checks that” in turn 3). Figure 3.2 provides a reconstruction of this argument.
Figure 3.2 Reconstruction of the doctor’s argument from authority in case 3.3
(1) (You [the mother] should let your daughter undergo an additional blood test.)
(1).1 They [the lab] advise that.
((1).1’) (The lab’s advice indicates that you should let your daughter undergo an additional blood test.)
In the remainder of this text, I shall call authority arguments in which the authority referred to is
an external source ‘arguments from authority’.
3.5 Argument by authority
Instead of referring to an external source in an authority argument, a discussion party can

also present himself as the authoritative source in this type of argumentation. For example, in
the authority argument in case 3.4, the doctor refers not to others (as is the case in arguments
from authority), but to himself as the authority. The example is taken from a consultation about,
amongst other things, the patient’s atheroma cyst (a slow-growing, non-cancerous tumour or
swelling of the skin) in a general medical practice in the Netherlands.
20
Whether the discussion party has a burden of proof for claiming to possess ethos depends on whether
his ethos is of the existing or the acquired kind. In case of existing ethos, the discussion party does not have
a burden of proof, as he does not establish his ethos in the argumentative discourse. In case of acquired
ethos, the discussion party might have this burden of proof, depending on the manner in which he acquires
his ethos in the discourse. A discussion party who acquires ethos by speaking eloquently, for example, does
not have to take on the burden of proof for this ethos; he merely demonstrates it by his manner of speaking.
Contrastingly, a discussion party who acquires ethos by explicitly claiming to be knowledgeable about the
discussion topic has a burden of proof for it.
36
Case 3.4
Excerpt of an argumentative discussion between a doctor (D) and a patient (P) about the removal
of the patient’s atheroma cyst (original conversation in grey) 21
1 P: And then I wanted to ask something else right away.

(En dan wilde ik gelijk nog iets vragen.)
2 D: Yes?
(Ja?)
3 P: Is it possible to get a referral note to the hospital for that lump on my head or, erm, do I just have
to let it be done by you here?
(Is het mogelijk om een verwijskaart te krijgen naar het ziekenhuis voor die bobbel op m’n hoofd
of, uhm, moet ik ’t toch gewoon hier bij uzelf laten doen?)
4 D: Well, you don’t have to do anything, but…
(Nou, je moet niks, maar…)
5 P: No, the point is, yeah, my mother had had it removed in the hospital and she says “Dear, go to the
same, it…”
(Nee, het punt is, ja, mijn moeder heeft het weg laten halen in het ziekenhuis en zij zegt ‘Joh, ga
nou naar dezelfde, ’t…’)
6 D: I think that I can do it just as well as and perhaps even better than those people at the hospital. It
was such a, such a, such an atheroma cyst on your head, wasn’t it?
(Ik denk dat ik het net zo goed en misschien nog wel beter kan dan die mensen in het ziekenhuis.
Het was toch zo’n, zo’n, zo’n atheroomcyste op je hoofd?)
7 P: Yeah, it becomes yes, my mother, she, erm, she brings it up every day of course…
(Jaha, hij wordt ja, m’n moeder, die, uhm, die komt iedere dag daarmee natuurlijk…)
8 D: Well…
(Tsja…)
9 P: Yes…
(Ja…)
10 D: You don’t have to let it be removed by me, but I’m telling you, to be sure, I can do it just as well as
someone at the hospital. I’ve removed a dozen of those things and it’s, in itself, a piece of cake.
(Je moet ’m er niet bij mij uit laten halen, maar ik zeg het ik kan het zeker zo goed als iemand in
het ziekenhuis. Ik heb al tientallen van die dingen weggehaald en het is, op zich, een fluitje van
een cent.)
11 P: Yes.
(Ja.)
In case 3.4, the doctor implicitly advises the patient to allow the atheroma cyst on his head to
be removed by the doctor himself, rather than at the hospital. Even though the doctor does not
present his advice explicitly – he, in fact, emphasises that it is up to the patient to decide by whom
he allows the cyst to be removed (turn 4) – the doctor’s advice can be inferred from his reaction
to the patient’s request for a referral note (turn 3). The doctor points out that there is no need
for such a referral: he could perform the surgery “just as well as and perhaps even better than”
they could do at the hospital (turn 6). The doctor indeed argues that he has a lot of experience of
removing atheroma cysts (turn 10).
21
Transcribed by Nanon Labrie, my translation from Dutch.
37
The doctor’s argument that he could remove the atheroma cyst just as well as and perhaps even
better than the people at the hospital constitutes an authority argument. The doctor explicitly
emphasises his expertise in removing atheroma cysts in support of the advice that the patient
should allow him to remove the cyst, thereby presenting his authority on this matter as an
indication of the acceptability of his advice.22 The argument can be reconstructed as follows
(figure 3.3).
Figure 3.3 Reconstruction of the doctor’s argument by authority in case 3.4
(1) (It is advisable to let me [the general practitioner] remove the patient’s atheroma cyst.)
(1).1 I think that I can remove an atheroma cyst just as well as, and perhaps even better than, people at
the hospital.
((1).1’) (The GP’s opinion indicates that the patient should let the GP remove the patient’s atheroma cyst.)
The authority argument in case 3.4 differs from the argument from authority in case 3.3. In case 3.4,
the doctor refers to his own authority, whereas, in case 3.3, she refers to the authority of an external
source (“the lab”). In order to accurately analyse these different variants of authority argumentation,
I shall distinguish between them by using the term ‘argument by authority’ exclusively for the
variant of authority argumentation in which the authority referred to is the discussion party that
presents the argumentation (as in case 3.4) and ‘argument from authority’ exclusively for the variant
in which the authority referred to is a source outside of the discussion (as in case 3.3).
From a pragma-dialectical perspective, these two variants of authority argumentation
should not be analysed as distinct types or subtypes of argumentation. In the pragma-dialectical
theory, argumentation (sub)types are distinguished based on the different critical questions that
need to be asked when evaluating them (van Eemeren & Grootendorst, 1992, p. 98; Garssen,
1997, pp. 7-8). For example, the question of whether the authority that is referred to is correctly
interpreted is relevant for the evaluation of authority argumentation, but not for the evaluation
of other symptomatic argumentation, causal argumentation or comparison argumentation As
soon as the evaluation of the argumentation requires different dialectical testing procedures,
arguments belong to distinct pragma-dialectical argumentation (sub)types. Because a discussion
party uses the same pragmatic principle in an argument by authority as in an argument from
authority (“Authority A’s opinion indicates that X”), the same testing procedure should be
followed in the evaluation of these arguments. They therefore belong to the same pragma-
dialectical argumentation subtype, namely that of authority argumentation.
To adequately analyse the argument by authority and the argument from authority,
they can nonetheless be conceptualised as different ‘variants’ of authority argumentation. By
‘variant’ I mean that these arguments differ in their minor premises (1.1), but not in their major
premises (1.1’). So, although an antagonist has exactly the same dialectically relevant possibilities
available to respond to these distinct argument variants, there is always a difference in the kind
of propositional content of these forms. This difference needs to be taken into account in the
analysis and evaluation of the argumentation, as it provides a discussion party with distinct
22
The doctor also draws a comparison between the medical professionals at the hospital and himself (“just
as well as and perhaps even better than”). As the comparison is part of the authority argument and the focus
of this study is only on the way in which the authority argument supports the standpoint, the comparison
shall not be taken into account in the analysis.
38
possibilities for strategic manoeuvring and allows soundness conditions to be specified for each
particular variant.
With respect to possibilities for strategic manoeuvring, a discussion party can, for instance,
strategically acquire ethos by referring to his own expertise in an argument by authority, while
he cannot acquire ethos about his own expertise by referring to someone else in an argument
from authority (see chapter 4). With respect to the evaluation of authority argumentation, the
condition that an authority should be cited correctly, as stipulated by van Eemeren (2010, p. 203),
can, for instance, in principle be regarded as automatically fulfilled for an argument by authority
(since the discussion party refers to his opinion himself and is unlikely to make a mistake in that
opinion), but not for an argument from authority (see chapter 5).
In the case of the variants of authority argumentation, the difference in propositional
content amounts to a difference in the kind of authority that is referred to in the argument – the
protagonist in an argument by authority and an external source in the argument from authority.
The two examples in figure 3.4 illustrate this.
Figure 3.4 The argument from authority (a) and the argument by authority (b)
(a) Example of an argument from authority

1 He should get some rest.
1.1 His doctor is of the opinion that he should get some rest.
1.1’ The doctor’s opinion indicates that you should get some rest.
(b) Example of an argument by authority

1 He should get some rest.
1.1 I [his doctor] am of the opinion that he should get some rest.
1.1’ The doctor’s opinion indicates that you should get some rest.
In the arguments in figure 3.4 (a) and (b), the standpoints and the major premises are the same:
the protagonist gives advice (1) and supports this by reference to the doctor’s opinion (1.1’). The
difference between these examples is that in (a), the protagonist refers to an external source (“his
doctor”) as the authority, whereas in (b), the protagonist refers to himself (“I”) as the authority.
Figure 3.5 shows how the various variants of authority argumentation differ from existing
and acquired ethos. In this figure, a summary is provided of the fourfold analytical distinction
between the ways in which authority can influence a discussion outcome.
Figure 3.5 Four ways in which authority can influence the outcome of an argumentative
discussion
The discussion party’s authority that is in place at the start of the
Existing ethos:
argumentative discussion.
The discussion party’s authority that he constructs during the argumentative
Acquired ethos: discussion, but that he does not present in support of a specific (sub-)
standpoint.
The argument in which a discussion party refers to an external source’s
Argument from authority:
authority to support a specific (sub-)standpoint.
The argument in which a discussion party refers to his own authority to

Argument by authority:
support a specific (sub-)standpoint.
39
3.6 Authority in practice
The fourfold distinction between existing ethos, acquired ethos, the argument from authority
and the argument by authority is an analytical one, meaning that it is helpful for an adequate
analysis of (the use of) authority in argumentative discourse: by using this distinction, how
the authority of a particular source influences the discussion outcome can be analysed more
appropriately. In turn, this analysis provides the basis for the soundness evaluation of (the use of)
authority. For example, analysing a discussion contribution as an argument by authority means
that the discussion party can be held accountable for claiming that his authority indicates the
acceptability of his standpoint. As a consequence, evading the burden of proof for this claim
should be evaluated as fallacious.
In practice, the analytically distinct ways in which authority can influence the outcome
of an argumentative discussion might coincide and interact. For example, in case 3.1b, which is
a continuation of the argumentative discussion between the doctor and patient from case 3.1a,
the doctor acquires ethos by affirming part of the existing ethos that the patient ascribes to him.
Case 3.1b
Excerpt of an argumentative discussion between a doctor (D) and a patient (P) about the patient’s
possible inguinal rupture (original conversation in grey)
4 P: No, no, but I thought that doctors could feel that [an inguinal hernia] just like that.
(Nee, nee, maar ik dacht dat doktoren dat [een liesbreuk] zo effe konden voelen.)
5 D: If it really is a big fracture, then you can see it just like that.
(Als het echt een grote breuk is, dan zie je hem zo.)
6 P: Yeah.
(Ja.)
7 D: I mean, then, then I can do it with my eyes closed.
(Ik bedoel, dan, dan kan ik het met m’n ogen dicht doen.)
8 P: Oh.
(Oh.)
9 A: But if something is really small, then you sometimes just miss it. So it’s a doubtful case then. But
okay, so you keep having problems with it and we don’t actually know what it is, because I haven’t
felt that it was a fracture for sure. If it were a clear fracture, then I’d have felt it. True.
(Maar als iets heel klein is, dan zie je hem soms net niet. Dan is het dus een twijfelgeval. Maar
goed, dus je houdt er last van en we weten eigenlijk niet wat het is, want ik heb niet zeker gevoeld
dat het een breuk was. Als het een duidelijke breuk was, dan had ik het gevoeld. Klopt.)
In case 3.1b, the patient indicates that he expected doctors to be able to simply diagnose the
presence or absence of an inguinal hernia by physically examining him (turn 4). So, he can be
assumed to believe the doctor’s existing ethos to consist of the expertise to diagnose whether
a patient suffers from an inguinal rupture by means of a physical examination. In reaction to
this, the doctor plays down the extent to which doctors possess expertise on this issue: they
cannot always diagnose such a rupture with certainty (“But if something is really small, then you
sometimes just miss it. So it’s a doubtful case then”, turn 9). By downplaying these expectations,
the doctor at the same time acquires ethos by showing that he knows exactly what he is and is not,
medically speaking, capable of diagnosing. Indeed, the doctor affirms that, in the case of a big
40
fracture, doctors can “see it just like that” (turn 5) – or, at least, he can (“I mean, then, then I can
do it with my eyes closed”, turn 7). The doctor, thereby, reinforces the idea that he is competent
in diagnosing certain inguinal hernias. This reinforcement can be analysed as a way of acquiring
ethos; after all, the doctor does not simply depend on his existing ethos, but stresses this ethos by
stating that he can diagnose a big inguinal rupture with closed eyes. Thus, the doctor’s existing
ethos and acquired ethos coincide.
In fact, for acquired ethos (and also for an argument by authority), it is imperative that the
discussion party possesses the authority that he claims to have in the discourse. If it is clear to the
other party that a discussion party does not possess the ethos that he tries to acquire (because he is
boasting or lying), his attempt at acquiring ethos is unlikely to be convincing. Indeed, Cicero (De
Oratore II182, my italics) remarks: “feelings are won over by a man’s merit, achievements or reputable
life, qualifications easier to embellish, if only they are real, than to fabricate where non-existent”.
Additionally, the ways in which authority can influence discussion outcomes can coincide in
practice because a discussion party can acquire ethos by presenting an argument by authority or an
argument from authority. In the case of an argument by authority, the discussion party’s authority
as referred to in the argument could influence the acceptability of his later contributions to the
discourse, even though the discussion party does not specifically present his authority in support of
them. The doctor’s argument “I advise you to undergo psychosomatic physiotherapy, as I have very
positive experiences with it” could, for instance, function in this way. Before the doctor presents
this argument, the patient might not be aware of his experience with psychosomatic physiotherapy
– he might not actually know that this form of physiotherapy concentrates on the relation between
physical and psychological problems. In such a situation, the argument brings the doctor’s expertise
explicitly to light, which may positively affect the doctor’s subsequent contributions (“With all his
expertise, he must know what he’s talking about”).
In the case of an argument from authority, in referring to the authority of an external
source, the discussion party could acquire that party’s ethos in a similar manner. The discussion
party can show that he is knowledgeable (“I’m familiar with the work of Aristotle”) or that he
is well connected (“I know these experts”) by presenting an argument from authority (“The
practice of medicine should be regarded as a practical art, since Aristotle considered it as such”
or “The bird flu virus can cause a worldwide pandemic, as my colleagues from virology showed
at our research colloquium”).
Although the various ways in which authority can influence a discussion outcome can
overlap in practice, it is helpful to separate them analytically. Each way provides the discussion
party with distinct possibilities for strategic manoeuvring, due to differences in directness and
the burden of proof it places on the party. These differences should be made clear to adequately
evaluate the soundness of (the use of) authority in argumentative discourse.
3.7 Conclusion
In this chapter, a fourfold analytical distinction was presented to distinguish between the various
ways in which authority can influence the outcome of an argumentative discussion: a discussion
party could affect the discussion outcome through his (i) existing ethos, by (ii) acquiring ethos,
by (iii) arguing from authority, or by (iv) arguing by authority. When applying this fourfold
distinction to argumentative discourse in medical consultation, the doctor’s authority on medical
matters can be expected to influence the discussion outcome in the following ways.
41
First of all, the doctor’s (i) existing ethos can positively influence the patient’s evaluation of
his argumentation about the health problem at issue. After all, the patient regards the doctor
as an authority on health problems – otherwise he would not have requested a consultation.
Additionally, the patient might ascribe existing ethos to the doctor because of the doctor’s
status as a medical professional. Secondly, the doctor can (ii) acquire ethos during the medical
consultation. Through his discussion contributions, he might, for instance, demonstrate that he
is trustworthy or that he possesses the necessary medical knowledge and expertise to deal with
the patient’s health problem. Thirdly, the doctor can refer to his authority to render his diagnosis,
prognosis and/or advice acceptable by means of an (iv) argument by authority. The doctor then
presents his authority as an indication of the acceptability of his medical judgements.
The remainder of this study concentrates on the analysis and evaluation of the doctor’s
argument by authority. Given that medical consultation has become more and more patient-
centred, it is important to determine the exact conditions under which such an argument can be
considered as a reasonable and effective strategic manoeuvre. When does a doctor’s argument by
authority become too paternalistic? When do patients still accept this argument? The conditions
under which a doctor’s argument by authority can be considered a reasonable and effective
strategic manoeuvre are examined by first analysing how a doctor can manoeuvre strategically
with an argument by authority in medical consultation (chapter 4), then establishing the specific
soundness conditions for this argument in medical consultation (chapter 5), and subsequently
empirically testing ordinary language users’ perception of reasonableness of the argument’s
reasonableness and effectiveness (chapters 6-8).
42
4 A doctor’s argument by authority as a strategic
manoeuvre
4.1 An integrated pragma-dialectical approach
In medical consultation, a patient with a health problem consults a doctor as an expert on medical
issues. If a doctor expects or knows that the patient will be hesitant about or even opposes his
medical judgment or advice, he can make use of his expert position by advancing an argument
by authority. As explained in chapter 3, the doctor then presents his authority as an indication of
the acceptability of his diagnosis, prognosis and/or advice. For example, the doctor could argue
that the patient should make dietary changes by presenting his experience in the field of nutrition
as an indication of the acceptability of this advice.
From the perspective of the integrated pragma-dialectical theory, the doctor’s argument by
authority can be analysed as a strategic manoeuvre. The argument can be considered as the result
of his attempt to resolve the difference of opinion with the patient on the merits (his dialectical
aim) and simultaneously to have his medical judgment accepted by the patient (his rhetorical
aim). As explained in chapter 2, balancing between these two aims, which sometimes seem to be
at odds with each other, is coined ‘strategic manoeuvring’ in the integrated pragma-dialectical
theory (van Eemeren, 2010, p. 40).
In this chapter, an analysis is presented on how a doctor can manoeuvre strategically
with an argument by authority in medical consultation. Specifically, the strategic advantages of
using this argument are examined with reference to the three aspects of strategic manoeuvring:
selection from the topical potential (section 4.2.1), adaptation to audience demand (section
4.2.2) and use of presentational devices (section 4.2.3). Although these aspects work together in
practice, they are distinguished analytically to give a detailed account of the doctor’s argument by
authority as a strategic manoeuvre (section 4.2). Subsequently, an illustration is provided of how
these aspects interact in medical consultation in practice (section 4.3).
4.2 The strategic aspects of a doctor’s argument by authority
Based on the characterisation of the communicative activity type of medical consultation

provided in chapter 2, a doctor can be expected to pursue the dialectical goal of putting the
acceptability of his diagnosis, prognosis and/or advice to the test in the argumentation stage
of a discussion in a consultation.23 At the same time, he pursues the rhetorical goal of getting
the patient to accept his medical judgement and/or advice. More precisely, this rhetorical goal
constitutes the inherent interactional effect of the doctor’s argumentation; it is the immediate
interactional effect that the doctor strives for when performing the complex speech act of
23
According to the pragma-dialectical theory, ideally, a discussion passes through four stages: the
confrontation stage (in which the discussion parties establish that they have a difference of opinion), the
opening stage (in which the parties establish the starting points of the discussion), the argumentation stages
(in which the parties advance argumentation and express doubt or criticism) and the concluding stage (in
which the parties establish whether the difference of opinion has been resolved and in whose favour) (van
Eemeren & Grootendorst, 1992, pp. 34-35; van Eemeren et al., 1993, pp. 26-28).
45
argumentation in a medical consultation.24 The subsequent goal of getting the patient to follow
up on the diagnosis, prognosis and/or advice constitutes the consecutive interactional effect; the
more comprehensive effect of the complex speech act on the further behaviour of the patient (van
Eemeren & Grootendorst, 1984, p. 24). So, if a doctor argues that the patient should take some
rest, the inherent interactional effect that the doctor strives for by advancing his argumentation
would be that the patient accepts that taking some rest is needed and the consecutive interactional
effect would be that the patient really does take some rest in practice.
The doctor needs to realise his dialectical goal and rhetorical goal within the institutional
constraints of the consultation, such as the limited time that is typically available for the
consultation and the characteristic asymmetry in medical knowledge and expertise between
the patient and himself (see chapter 2). In realising the dialectical and rhetorical aims within
these constraints of the consultation, the doctor can, amongst other choices that he has to make,
choose to advance an argument by authority.
4.2.1 Topical potential: The choice for an argument by authority as a variant of

authority argumentation
A doctor who chooses to advance an argument by authority selects this argument from the
topical potential consisting of the range of arguments that he could have advanced in support
of the diagnosis, prognosis and/or advice. By selecting an argument by authority, the doctor
strives to choose the line of defence that is, in his view, most convincing to the patient (for a
detailed explanation of topical selection, see van Eemeren, 2010, pp. 96-108). Such a selection
encompasses several choices: the doctor has to choose which (sub)type of argument scheme
to use (for example, authority argumentation), which can include choosing which variant of
this scheme to use (for example, an argument by authority), and which necessarily includes
choosing what reasons to present in the argument (for example, “I have successfully undergone
this treatment myself ”).
To analyse what strategic functions the doctor’s choice for an argument by authority can
fulfil in general, first of all, his choice for the argument scheme of authority argumentation (in
contrast to a choice for another argument scheme) is analysed. Secondly, the doctor’s choice
for the argument by authority as the variant of this scheme (in contrast with a choice for an
argument from authority) is examined. Since the focus of this study is on the doctor’s strategic
choice for an argument by authority over other (variants of) argument schemes in general, the
particular reasons that the doctor chooses to provide in the argument will not be concentrated
on in the analyses.
First of all, when selecting a particular argument scheme from the topical potential,
the protagonist has to take into account that the antagonist needs to be able to evaluate the
acceptability of the argumentation presented by means of the selected scheme. This means that,
in a medical consultation, the patient has to be able to understand the issues that the doctor
refers to in his argument. For example, if a doctor argues “I’d advise you to take sulfasalazine, as
this reduces the synthesis of eicosanoids and cytokines”, the patient needs to understand how the
synthesis of eicosanoids and cytokines relates to his health problem to evaluate the acceptability
24
In the pragma-dialectical theory, ‘argumentation’ is regarded as a complex speech act, since it consists
of a constellation of speech acts (for example, two assertions by which the premises of an argument are
expressed) that only function as argumentation when taken together (otherwise they, for example, simply
remain assertions) (van Eemeren & Grootendorst, 1984, pp. 29-35; van Eemeren & Grootendorst, 1992, pp.
28-30)
46
of the advice. Because of the potential complexity of the doctor’s reasons for a particular medical
judgment, in addition to the typical asymmetry in knowledge and expertise between the doctor
and patient, a patient might not always be able to evaluate the soundness of these reasons. A
doctor who expects a patient to be insufficiently able to evaluate the medical reasons that he has
for his judgement can strategically circumvent discussing and elucidating these reasons at length
by choosing to use the argument scheme of authority argumentation.
To accept a standpoint based on an authority argument, the antagonist needs to determine
whether he deems the opinion of the referred to authority to be an indication of the acceptability
of the standpoint. Whether this is the case or not depends on whether the patient considers the
referred to authority to possess authority in a relevant field, and not on the patient’s understanding
of a particular medical issue (see, for a discussion of the soundness conditions for authority
argumentation, chapter 5). In a medical consultation, precisely this characteristic of authority
argumentation can be used to avoid having to rely on the patient’s understanding of specific
medical issues. For instance, by means of an argument from authority, the doctor who advises a
patient to take sulfasalazine could avoid going into detail about the synthesis of eicosanoids and
cytokines by arguing that “research has shown that it’s an effective medicine for patients with
Crohn’s disease”. In a similar vein, the doctor could avoid going in detail about this medical
matter by advancing an argument by authority (“In my experience as a doctor, it’s an effective
medicine for patients with Crohn’s disease”).
In contrast, when using the argument scheme of causal argumentation, other subtypes of
symptomatic argumentation25 or comparison argumentation, the doctor relies on the patient’s
health literacy on particular causes, effects, symptoms or comparisons concerning the medical
judgment and/or advice to convince the patient of the acceptability of this judgement and/or
advice. If the doctor chooses the argument scheme of causal argumentation, the patient needs
to be able to evaluate whether that which the doctor presents as a cause in the argumentation
indeed leads to that which he presents as the effect (van Eemeren & Grootendorst, 1992, p. 102;
Garssen, 1997, p. 20). The doctor, for instance, uses causal argumentation when he supports the
advice to take sulfasalazine by arguing: “this medicine reduces the synthesis of eicosanoids and
cytokines”.26 As the doctor claims that a reduced synthesis of eicosanoids and cytokines is
desirable to the patient, the patient needs to evaluate whether this is indeed the case in order to
accept the doctor’s advice. To critically do so, the patient needs to understand what a reduced
synthesis of eicosanoids and cytokines means in general, and what it means in particular for his
health problem.
When a doctor chooses to use symptomatic argumentation that is not authority
argumentation, the patient needs to be able to evaluate whether that which the protagonist
presents as a characteristic, sign or symptom of the standpoint in the argument is indeed an
indication of the acceptability of this standpoint (van Eemeren & Grootendorst, 1992, p. 101;
25
As discussed in chapter 3, from a pragma-dialectical perspective, authority argumentation is a subtype
of the main type of symptomatic argumentation (van Eemeren & Grootendorst, 1992, p. 163; Garssen, 1997,
p. 11). Other subtypes of symptomatic argumentation are, for instance, ‘argumentation by example’ and
‘argumentation by definition’ (see, on these subtypes, Garssen, 1997, pp. 11-12).
26
More precisely, in this example the doctor advances pragmatic argumentation. From a pragma-
dialectical perspective, pragmatic argumentation is a subtype of causal argumentation. In this subtype, an
inciting standpoint (“You should…”) is supported by reference to the desirability of following up on this
standpoint (van Eemeren & Grootendorst, 1992, p. 97; van Eemeren, Grootendorst & Snoeck Henkemans,
2002, pp. 101-102; Garssen, 1997, pp. 21-22; van Poppel, 2013, pp. 66-69).
47
Garssen, 1997, p. 9). For example, for a critical evaluation of the argument “I’d advise you to
take sulfasalazine, as you suffer from Crohn’s disease”, the antagonist needs to have knowledge
about medicines for treating Crohn’s disease (“Is it normal for patients with Crohn’s disease to be
treated with sulfasalazine?”).
When a doctor chooses to use the argument scheme of comparison argumentation, the
patient needs to be able to determine whether there are not any significant differences between
the issues that the doctor compares in the argumentation (van Eemeren & Grootendorst, 1992,
p. 102; Garssen, 1997, p. 15). For example, for the evaluation of the argumentation “I’d advise you
to take sulfasalazine, as that is comparable to mesalamine”, the patient needs to have a sufficient
understanding of sulfasalazine and mesalamine to critically compare them with each other (“Are
there not any significant differences between sulfasalazine and mesalamine?”).
Of course, the health literacy that is required to critically evaluate the acceptability of a
particular argument does not solely depend on the specific argument scheme that is used. It may
very well be the case that to answer the relevant critical questions for arguments of the same
scheme, the antagonist needs a different kind of knowledge or a different level of understanding.
Instead of advancing the causal argumentation “I’d advise you to take sulfasalazine, as this
medicine reduces the synthesis of eicosanoids and cytokines”, the doctor could also have
argued “as this medicine reduces the severity of inflammations in the intestine”, thereby
requiring less specific medical knowledge of the patient. Still, in case of the argument scheme
of authority argumentation, there is less diverse and detailed knowledge needed to evaluate the
acceptability of the argument: the antagonist only needs to possess the knowledge required to
determine whether the authority that the protagonist refers to in the argument indeed indicates
the acceptability of the standpoint. This means that to evaluate the acceptability of authority
argumentation the antagonist does not need to possess a specific understanding of the medical
issue under discussion.
The protagonist can make strategic use of the fact that the antagonist who is confronted
with authority argumentation does not need to possess a specific understanding of the discussion
topic to evaluate the argument. From a dialectical point of view, the antagonist can always request
further argumentation for, or clarification of, the arguments that support the protagonist’s
standpoint. A patient who needs to evaluate the acceptability of a medical judgment based
on the doctor’s argumentation can, from a dialectical point of view, always simply ask for (an
explanation of) the medical reasons for it. However, in practice, providing such an explanation
is not always feasible, as the doctor’s clinical reasons potentially require a detailed understanding
of medicine and the human body that, in general, the patient does not have and cannot obtain in
the limited consultation time. A further difficulty is that patients will not always ask for further
information during the consultation (Bensing et al., 2006; Robinson, 2003; ten Have, 1991); they
might fear making a bad impression through appearing ignorant or impolite. A doctor could
strategically avoid these difficulties by choosing to advance authority argumentation.
It should be noted that even though the doctor can strategically avoid too detailed a
discussion about the diagnosis, prognosis and/or advice by advancing authority argumentation,
this does not mean that he automatically fails to pursue his dialectical goal of putting the
acceptability of his medical judgment and/or advice to the test. A doctor’s authority argument
can, in principle, provide a sound indication of the acceptability of the judgement. In other words,
authority argumentation is not by definition fallacious. After all, the authority that is referred to
in an authority argument could possess specific knowledge or expertise that makes him a more
reliable judge on the issue under discussion than someone who lacks this knowledge or expertise.
48
Whether the opinion of the authority that is referred to indeed indicates the acceptability of the
standpoint should be determined by asking the critical questions for this type of argumentation
(“Is the referred to authority a relevant authority on the advice?”, “Does the discussion party not
advance authority argumentation to shut down any further discussion?”, etcetera (see, for the
soundness conditions of authority argumentation, chapter 5)).
The second choice that a doctor intending to advance authority argumentation has to
make is which variant of the argument scheme to use: an argument by authority or an argument
from authority? Each of these variants has specific strategic advantages and disadvantages in the
process of resolving a difference of opinion. In what follows, these advantages and disadvantages
are examined by contrasting a doctor’s argument by authority with a doctor’s argument from
authority.
The doctor’s choice for the argument by authority instead of an argument from authority
depends on, in the first place, which authority is relevant for the argumentative discussion
concerned. If a doctor decides to use authority argumentation and he is the only authority on
the issue under discussion, then he cannot but choose an argument by authority. If he himself
is not an authority, but someone else is, then he cannot but choose an argument from authority.
For example, if a doctor has never treated a patient with Addison’s disease, but his colleague is an
expert on this disease, the doctor cannot advance an argument by authority, but he could refer
to his colleague in an argument from authority. Assuming that it is possible for the doctor to use
either variant of authority argumentation, what would be the strategic advantage of choosing an
argument by authority over the argument from authority?
The strategic advantage of using an argument by authority instead of an argument from
authority lies in the different ways in which a protagonist appeals to ethos by means of these
variants of authority argumentation. As discussed in section 3.6, a protagonist who uses an
authority argument can, by means of this authority argument, acquire ethos or draw attention
to his existing ethos, so that reinforcement of his authority takes place. If a protagonist uses an
argument by authority, he can directly acquire ethos or draw attention to existing ethos. The
protagonist then explicitly appeals to his authority, instead of only hinting at it, because in
an argument by authority the protagonist refers to himself as the authority on the discussion
topic. This direct appeal to ethos can be expected to make the protagonist’s argumentation more
persuasive. For example, if a doctor advances the argument by authority “I advise you to undergo
psychosomatic physiotherapy, because my expertise lies in the field of this kind of therapy”, the
patient might accept the advice not just because of the argument’s propositional content and
justificatory force, but also because the argument makes it clear that the doctor possesses ethos in
the field of psychosomatic physiotherapy.
If a protagonist uses an argument from authority, he can only indirectly acquire ethos
or indirectly draw attention to his existing ethos. In other words, he does not literally claim to
possess authority, but merely hints at or indicates his authority. This is because in an argument
from authority the protagonist refers to an external source as the authority on the discussion
topic. By reference to this external source, the protagonist cannot directly claim that he possesses
ethos or that the antagonist should ascribe ethos to him. Yet, by arguing from authority, the
protagonist can still show that he is knowledgeable about or well connected on the issue under
discussion. He can, thereby, indirectly acquire ethos (if the antagonist had not yet been aware of
the protagonist’s knowledge or connectedness) or point to his existing ethos (if the antagonist had
already been aware of this knowledge or connectedness). For instance, by means of the argument
“A maternal vegetarian diet in pregnancy is associated with hypospadias, since researchers of
49
the ALSPAC study team showed this”, the protagonist can indicate his expertise on nutrition,
pregnancy or hypospadias, or he can indicate that he is knowledgeable about or connected to the
ALSPAC study team, but what he cannot do is directly claim that he possesses this knowledge or
is this well-connected (as he could have done in an argument by authority).
The advantage of directly appealing to ethos by means of an argument by authority over
indirectly doing so by means of an argument from authority is that there is no doubt about what
the protagonist’s ethos amounts to in case of an argument by authority, while the antagonist
might fail to infer the protagonist’s ethos from the argument from authority. So, if in medical
consultation a straightforward reminder of the doctor’s existing ethos or a strengthening of this
ethos is desirable (for instance, because the patient refers to incorrect medical information that
he has found on the internet), it is strategically preferable for the doctor to advance an argument
by authority.
Additionally, a doctor might strategically choose to advance an argument by authority
to make use of the patient’s politeness considerations. The direct reference to the doctor’s ethos
in this argument places the patient in a position in which it is undesirable for him to express
(further) doubt about the doctor’s medical advice: by expressing doubt, the patient not only
indicates that the argument insufficiently supports the standpoint, but further implies that, in
his view, the doctor does not possess sufficient authority to make the advice acceptable. Such
an implication would be undesirable in a conversation that is not part of a medical consultation
since conversation parties generally aim to refrain as much as possible from threatening each
other’s face (Brown & Levinson, 1987, pp. 61-64). However, it can be expected to be even more
undesirable in a medical consultation, as the patient in such a consultation depends to a large
extent on the doctor for the diagnosis and treatment of his health problem. Because of this
dependency on the doctor, the patient might be wary of questioning or opposing the doctor’s
argument by authority. The doctor’s reference to ethos in the argument by authority, consequently,
puts rhetorical pressure on the patient to accept this argument.
In contrast, the rhetorical pressure on the patient to accept argumentation out of politeness
considerations can be expected to be less substantial when a doctor chooses to advance an
argument from authority. Since in this case the doctor does not explicitly appeal to his ethos (but
only indirectly acquires ethos or points to his existing ethos), it is possible that the patient does
not infer the doctor’s ethos from the argument from authority. This means that, in response to the
doctor’s presentation of an argument from authority, the patient could express doubt about this
argument without considering it to constitute a threat to the doctor’s positive face (his desire to
belong, to be agreed with).27
4.2.2 Audience demand: The argument by authority in response to a patient’s hesitance

From a pragma-dialectical perspective, the doctor’s choice to present an argument by authority
from the available topical potential should also be viewed as an attempt to adapt his argumentation
to the demands of the audience (van Eemeren, 2010, p. 108). By making his choice, the doctor tries
to take into account the expectations, preferences and wishes of the patient in the consultation.
These ‘demands’ of the patient are largely dependent on the argumentative situation. For example,
27
Indeed, a patient could express doubt about the doctor’s argument from authority without posing a
threat to the doctor’s positive face even if he infers the indirect reference to the doctor’s existing or acquired
ethos: he can just express his doubt about the argument from authority, pretending that he has not perceived
the ethos that the doctor indirectly conveyed by it.
50
a musician who consults a doctor because of hearing loss has different preferences and wishes
than a construction worker with the same problem.
Regardless of the specific argumentative situation, two factors influence a doctor’s
choice for an argument by authority as a means to adapt to the patient’s demands: the doctor’s
consultation style and the patient’s demands.
First of all, in health communication, the doctor’s ‘consultation style’ refers to the
perspective from which a doctor consults the patient. Traditionally, a distinction is made between
‘illness-centred’ (also referred to as ‘disease-centred’ or ‘doctor-centred’) and ‘patient-centred’
consultation styles. Illness-centred doctors primarily focus on the biomedical aspects of the health
problem that they deal with, while patient-centred doctors additionally take into consideration
the social and psychological aspects associated with this problem. Balint et al. (1970, p. 26), who
introduced the term ‘patient-centred medicine’, describe these two consultation styles as follows:
Illness-centred medicine means that the doctor has to understand the patient’s complaints,
as well as all the symptoms and signs that he can find, in terms of illnesses, that is, in terms
of a pathologically changed part of the body or of a part-function of the body. The danger of
this orientation is that it may not give enough consideration to the patient as a unique human
being with his own personal conflicts and problems. On the other hand, it must be admitted
that this illness-centred orientation, scientific medicine, has had spectacular successes, having
in fact, almost doubled the average expectancy of life in the Western world during the last
hundred years. The other way of thinking, patient-centred medicine, tries to understand the
complaints offered by the patient, and the symptoms and signs found by the doctor, not only
in terms of illnesses but also as expressions of the patient’s unique individuality, his tensions,
conflicts, and problems.

With respect to strategic manoeuvring, a doctor’s consultation style can be expected to influence
his perception of the patient’s demands in medical consultation: an illness-centred doctor will
assume that the patient wishes to solely be consulted about the medical aspects of his health
problem and wants to get the best advice from a purely medical perspective, while a patient-
centred doctor will also expect the patient to want to discuss the psychosocial aspects associated
with his problem and would appreciate advice that takes these aspects into account.
Because illness-centred doctors perceive the patient’s demands differently from patient-
centred doctors, a doctor’s consultation style will influence the way in which he adapts to
audience demand in medical consultation. If a doctor is (predominantly) illness-centred, he shall
(mainly) present argumentation that is about the medical aspects of the patient’s health problem.
Due to this focus on medicine, the asymmetry in knowledge and expertise between the doctor
and patient that is typically present in medical consultation will take a prominent position in the
consultation. The doctor can strategically use this asymmetry by arguing by authority as a way to
adapt to the patient’s demands. After all, the doctor can emphasise this asymmetry by referring
to himself as the authority in the argument by authority. The argument by authority is, hence, of
particular strategic use to an illness-centred doctor.
Even though the argument by authority can be of particular strategic use for an illness-
centred doctor, this does not mean that it cannot be used strategically by a patient-centred doctor.
Despite the fact that the doctor’s expertise does not take as prominent a position in patient-
centred medicine as in doctor-centred medicine, the patient might prefer an authoritarian
consultative approach by the doctor – or the doctor might assume that the patient prefers such an
51
approach. A study by Blanchard et al. (1988) on hospitalised adult cancer patients, for instance,
shows that about one in four of the interviewed patients preferred the oncologist to take an
authoritative approach and wanted the oncologist to make the treatment decisions. If the patient-
centred doctor knows that the patient prefers such an authoritative approach, he can adapt to
audience demand in a discussion with this patient by using an argument by authority.
Thus, whether it is strategic for a patient-centred doctor to advance an argument by
authority depends on the patient’s actual demands. The patient’s expectations, preferences and
wishes can be such that it is strategic for a doctor to argue by authority. For instance, in general,
elderly, less well-educated and male patients participate less actively in the treatment decision
making process than others (Say, Murtagh & Thomson, 2006, p. 112). Because the doctor can
avoid a lengthy and detailed discussion by arguing by authority (see section 4.2.1), he can adapt
to the demands of patients who prefer not to be actively involved in treatment decisions.
In contrast, some patients are involved in the treatment decision making process to such an
extent that they start self-diagnosing or determining what treatment they need before consulting
the doctor. With the increasing amount of medical information available on the internet, this
group of patients continues to grow. Brabers, Reitsma-van Rooijen and de Jong (2012, p. 359)
found, for example, that in 2012, three quarters of the Dutch patients in their survey (N =
808) looked up health information online at least once in the six months before the survey was
conducted. About half of them (51.7%) used the internet in preparation for a consultation with
their GP and 8.7% requested a prescription for particular medication from their GP based on
the information that they had found online.28 Furthermore, 11.3% of the patients who searched
for information about their health problem online decided to refrain from consulting the doctor
based on the information that they had found, while 3.6% decided not to adhere to the doctor’s
medical advice based on the online information (Brabers, Reitsma-van Rooijen & de Jong, 2012,
p. 359).
Although increased access to health information could enable patients to more adequately
participate in a discussion about complex health issues in medical consultation, they might
also arrive at incorrect diagnoses and prognoses, or request inadequate prescriptions based on
the health information that they found; the information that they found could be incorrect or
they could have interpreted it incorrectly. In such a situation, the doctor has to show why his
medical judgment about the patient’s health problem is to be preferred over that based on the
information that the patient found elsewhere. It is then strategic to advance an argument by
authority: not only does this argument provide an indication of the acceptability of the doctor’s
medical judgment, but it also emphasises that the doctor possesses the knowledge and expertise
to make such judgments and therefore that he is a trustworthy source of information on the
patient’s health problem. Thus, the argument by authority serves as a means to adapt to the
patient’s demand for argumentation in support of the doctor’s medical judgment as well as the
patient’s demand for argumentation in support of the idea that the doctor’s judgment should be
preferred over the patient’s judgment.
Finally, it should be noted that, regardless of the extent to which patients actively participate
in the treatment decision making process, at a certain point in the argumentative discussion,
28
Searching for health information online is not just a Dutch trend: Suziedelyte (2012, p. 1828) observes
that “a large and increasing proportion of the population in developed countries use the Internet as a health
information source”. She illustrates this with percentages from the US – for instance, in 2008, 61% of the US
adult population looked up online information about a health or medical issue.
52
a doctor will have to appeal to his medical authority. As a consequence of the asymmetry in
knowledge and expertise that is characteristic in medical consultation, patients generally do not
possess the knowledge and expertise to discuss all aspects of (the treatment of) their health
problem. When arriving at the point in the discussion in which a fully-fledged discussion is no
longer feasible, the doctor can present an argument by authority as a way to adapt to audience
demand. As such, he still provides a reason based on which the patient can accept his diagnosis,
prognosis and/or advice without allowing the discussion to become too technical or detailed.
4.2.3 Presentational devices: The argument by authority as a means to simplify

a medical discussion
A doctor who has selected an argument by authority as a means to adapt to audience demand
needs to decide how to present this argument in the consultation. To do so, he can be expected to
select what he deems to be the most convincing presentational devices. According to van Eemeren
(2010, p. 119), “Exploiting the possibilities of presentational variation in strategic maneuvering
in agreement with one’s topical choices and adjustments to audience demand boils down, in
my view, to “framing” one’s argumentative moves in a communicatively and interactionally
functional way”. For the presentation of an argument by authority, this means that the doctor will
strive to use those presentational devices that are maximally comprehensible (communicatively
functional) and acceptable (interactionally functional) to the patient.
The argumentative situation largely determines the effectiveness of the presentational
means used in an argument by authority. What is considered comprehensible and acceptable by
patient A will not necessarily be considered as such by patient B. In any case, to communicate in
as comprehensible a way as possible, it is important that the doctor takes into account differences
in medical knowledge and expertise between himself and the patient. In the Oxford Textbook of
Primary Medical Care (vol.1, p. 179) “simple messages given with short words, in short sentences,
and avoiding jargon” (my italics) are listed as a means to provide medical information to a patient
in a clear manner. A doctor could avoid using medical jargon by means of an argument by
authority, as he does not have to go into causes, effects, comparisons or symptoms concerning
the medical advice. The doctor’s presentation of an argument by authority is, therefore, a
communicatively functional way of convincing patients with varying degrees of knowledge and
expertise of the health problem in question.
However, a doctor’s reference to his authority in an argument by authority is not always
interactionally functional. On the one hand, by explicitly referring to his authority, a doctor
can remind the patient of the reason why he requested the consultation with the doctor
(emphasising or strengthening the doctor’s ethos). On the other hand, such a reference could
be counterproductive: the patient might become suspicious of the doctor’s authority precisely
because of the reference to it, meaning that he would not be convinced by the argument by
authority.
Whether a doctor’s argument by authority is counterproductive in this way depends on
two factors: first, on whether the doctor refers to existing ethos or acquires ethos in the argument,
and, secondly, on whether the patient already considers the doctor’s existing ethos to constitute
a reason for accepting his standpoint. In a doctor’s argument by authority in which the reference
to authority is counterproductive, this reference functions in the patient’s mind as a violation
of the Gricean maxim of quantity (“Make your contribution as informative as is required (for
the current purposes of the exchange)” (Grice, 1989, p. 26)). In such a case, the reference does
not provide any new information at all: it comes down to affirming the ethos that the patient
53
had already ascribed the doctor, i.e. the doctor’s existing ethos. Assuming that the doctor is a
cooperative conversational partner, the patient will try to interpret the reference in a way that
makes it relevant to the conversation. This is the case for the interpretation that the doctor is,
in fact, not a real authority on the issue under discussion (“Why does the doctor emphasise
it? There must be something wrong with it!”). Although such an interpretation provides the
patient with new information, it would render the argument by authority of which it is a part
unacceptable. Such a violation of the maxim of quantity only occurs if the doctor refers to
his existing ethos in the argument by authority; if the doctor acquires ethos by means of this
argument, new information is provided to the patient.
Still, not all arguments by authority in which a doctor refers to his existing ethos will
be judged as counterproductive. This judgement additionally depends on whether the patient
already considers the doctor’s existing ethos to constitute a reason for accepting the standpoint
supported by it. If the patient (or an antagonist in general) had not yet considered the doctor’s
existing ethos as such, then the doctor’s argument by authority (or a protagonist’s argument in
general) does not violate the maxim of quantity. The rationale here is that when advancing an
argument by authority, the doctor does not only claim to possess authority (premise 1.1 in the
reconstruction of the argument scheme, see figure 3.1 in chapter 3), but also claims that this
authority indicates the acceptability of the standpoint (premise 1.1’). In other words, the doctor’s
reference to his existing ethos in an argument by authority provides new information if the
patient had not yet considered this ethos to be an indication of the acceptability of the standpoint.
So, a doctor can strategically present an argument by authority because this argument, in
principle, constitutes a communicatively functional means to support standpoints about health
issues since it is a means to avoid medical jargon. When strategically presenting an argument by
authority, the doctor nonetheless has to take into account that the argument by authority can
only be interactionally functional if he acquires ethos by it or if the patient has not realised that
the doctor’s existing ethos indicates the standpoint’s acceptability.
4.3 Interaction of the three strategic aspects of a doctor’s argument by authority
In the previous sections it was argued that a doctor’s argument by authority can be analysed as
an opportune choice from the topical potential, consisting of all (variants of) argument schemes,
as a means to adapt to the perceived expectations, preferences and wishes of the patient, and, at
the same time, as a device to present argumentation in a communicatively and interactionally
functional way. Indeed, in practice, a discussion party’s opportune choice from the topical
potential, adaptation to audience demand and use of presentational devices is intertwined in
every single strategic manoeuvre. As van Eemeren (2010, p. 94) puts it: “No strategic maneuvering
can occur without making simultaneous choices regarding how to use the topical potential, how
to meet audience demand and how to employ presentational devices”.
The excerpt presented in case 4.1 illustrates how the aspects of strategic manoeuvring
work together in a doctor’s argument by authority.29 This excerpt is taken from a paediatric
consultation in the Netherlands about the diet of an infant boy who suffers from asthma.
29
This case was already presented in chapter 1 (as case 1.1) to give a general idea of what a doctor’s
argument by authority could amount to. For convenience’s sake, the complete excerpt is presented again (as
case 4.1).
54
Case 4.1
infant patient who suffers from asthma (original conversation in grey)
1 D: By the way, I have to say that, about his, about what he eats, I’m not really concerned to be honest.
(Ik moet trouwens zeggen, over zijn, over wat hij eet maak ik me niet zoveel zorgen eerlijk
gezegd.)
2 M: No.
(Nee.)
3 D: Look, I can imagine that, as mother and as father, you are concerned, but if I look at the way he’s
grown. Well, one of those things you need to grow well is to eat well…
(Kijk, ik kan me voorstellen dat als moeder en als vader je je zorgen maakt, maar als ik kijk naar
hoe hij gegroeid is. Nou één van die dingen die je nodig hebt om goed te groeien, is goed te
eten…)
4 M: Yeah.
(Ja.)
5 D: So he has had, he has had enough in the past few months, so…
(Dus hij heeft, de afgelopen maanden heeft hij genoeg gehad, dus…)
[…]
18 M: No, but yeah, things are sometimes being said about it and in the end you also think like: what
should I do here? Right? One says this. The other that. And then you also think like:
(Nee, maar ja hè, er wordt wel eens wat over gezegd en op het laatst denk je ook van: wat doe ik
hier nou? Hè? De één zegt dit. De ander dat. En dan denk je ook van:)
19 D: It’s also good to come here then.
(Dan is het ook goed om hier te komen.)
20 M: “I’ve had enough now.” You just don’t know what you have to do in the end.
(“Ik ben het nou zat.” Je weet op het laatst niet meer wat je moet.)
21 D: No, that, I can imagine that and, erm, well, if you encounter problems with that again, just say
“I’ve been to the paediatrician”. I’ve studied it, which is the case. And, erm, he said “We do that
this way” and …
(Nee dat, dat kan ik me voorstellen en, uhm, nou, als u daar weer problemen mee heeft, zeg maar
gewoon “Ik ben naar de kinderarts geweest”. Ik heb daarvoor geleerd, dat is ook zo. En, uhm, die
heeft gezegd “Dat doen we zo” en…)
22 M: You [infant] just stop that.
(Hou jij [kind] eens even op. )
23 D: And [incomprehensible] with evidence: he’s growing just perfectly, which is the most important
issue.
(En [onverstaanbaar] met bewijs: hij groeit gewoon perfect, dat is het belangrijkste.)
In the very first turn of the excerpt in case 4.1, the doctor puts forward the standpoint that he
is not really concerned about the infant’s diet. He assures the parents that they should not be
concerned about it either (turn 3), and subsequently advances the argumentation that the boy
has eaten enough in the past few months (turn 5), because he has sufficiently grown and “one of
those things you need for growing well is eating well” (turn 3).
55
Despite the doctor’s argumentation, the infant’s mother seems uncertain whether to agree with
him. As illustrated in turns 18 and 20, she does not know what to do (turn 20), because of the
conflicting advice that people have given her (turn 18). In other words, she is not completely sure
who to listen to when it comes to her son’s diet and she is rather desperate (“You just don’t know
what you have to do in the end”) and frustrated (“I’ve had enough”) about this (turn 20).
In response to the mother, the doctor assures her that it is good that she consulted him
(turn 19). He tries to take away the mother’s doubts by arguing that she can trust that his
judgment about the infant’s diet is correct, because he, as a paediatrician, has studied in order
to evaluate dietary problems in infants (turn 21). This argumentation can be reconstructed as
an argument by authority: the doctor presents his knowledge as a paediatrician as an indication
of the acceptability of his standpoint. Additionally, the doctor’s assurance that he studied to
examine dietary issues in children serves as a subordinative, symptomatic argument in support
of the implicit major premise. Figure 4.1 provides a reconstruction of the argumentation.
Figure 4.1 Reconstruction of the doctor’s argument by authority and subordinative

symptomatic argument in case 4.1
1 There is no need to be concerned about the infant’s diet.

1.1 As a paediatrician, I am of the opinion that there is no need to be concerned about it.
(1.1’) (My opinion as a paediatrician indicates that there is no need to be concerned about it.)
(1.1’).1 I have studied to provide advice about infants’ diets.
The doctor’s argument by authority in case 4.1 can be analysed as a strategic choice from the
topical potential to adapt to the mother’s demands: because the mother indicates that she is
unsure who to listen to when it comes to her son’s diet (turns 18 and 20), the doctor has to stress
the existing ethos that he possesses on infants’ diets as a paediatrician. By advancing an argument
by authority instead of some other (variant of an) argument scheme, the doctor can directly
emphasise the ethos that the mother ascribed to him by virtue of requesting the consultation,
while simultaneously indicating the acceptability of his medical advice.
What is more, the doctor’s use of an argument by authority also serves as a way to avoid
comparing the potentially complex or, in this case, perhaps irrelevant reasons behind the
conflicting advice that the mother has received and his own advice. This is because by arguing by
authority, the doctor presents the difference in judgments about the infant’s diet as consequences
of a difference in expertise between those who advise the mother – which is strategic, since the
doctor can point to the fact that he has studied to examine the dietary needs of infant patients
(turn 21), which the other advice givers presumably have not.
Furthermore, it is striking that the doctor presents the argument by authority as something
that the mother could rely on if she encounters people who advise her differently (“if you
encounter problems with that again, just say…”, turn 21). In this way, he acts as though there is no
difference of opinion between him and the mother. Instead, he suggests that the mother agrees
with his evaluation that there is no need to be worried about what her son eats. Yet, the mother, in
fact, does not ask for the doctor’s advice on how to justify this evaluation if she encounters people
who advise her differently: she states “You just don’t know what you have to do in the end” (turn
20, my emphasis), not “You just don’t know what to say”.
The doctor’s presentation of the argument by authority as something the mother can say in
response to those who think that there is something wrong with her son’s diet strategically avoids
56
the argument by authority as being perceived as a violation of the Gricean maxim of quantity. As
explained in the previous section, a doctor could violate this maxim if he refers to his existing
ethos in an argument by authority and the patient had already regarded this ethos as an indication
of the acceptability of the doctor’s medical judgment and/or advice. The doctor in case 4.1 avoids
violating the maxim of quality by presenting the argument by authority as something new that
the mother could say to other people.
4.4 Conclusion
A doctor can manoeuvre strategically in medical consultation by means of advancing an

argument by authority in support of a diagnosis, medical advice and/or prognosis. The reason
is that a doctor can advantageously select the argument by authority from the topical potential
consisting of all other (variants of) argument schemes: his selection enables a discussion with
patients who are insufficiently health literate to conduct a detailed discussion about their health
problem and makes strategic use of the patient’s politeness considerations.
At the same time, a doctor can adapt to audience demand by advancing an argument by
authority. The argument provides a means to adapt to the expectations, preferences and wishes
of patients who do not wish to be actively involved in the treatment decision making process,
of patient’s who disagree with the doctor due to information they have obtained from sources
other than the doctor, and of patients for whom the discussion of their health problem would
otherwise become too technical or detailed.
Finally, a doctor’s argument by authority can be regarded as a presentational device to
present argumentation in a communicative and interactionally functional way. The argument
can be used to avoid medical jargon and to remind the patient of the reason why he requested the
consultation in the first place: the doctor’s existing ethos on issues of medicine.
These aspects of the strategic manoeuvring explain why it could be strategic for a doctor
to advance an argument by authority in medical consultation. Yet, so far, the specific conditions
under which it is reasonable for a doctor to advance this argument have not been examined.
These conditions should, however, be established, as the patient’s acceptance of a doctor’s
medical judgment and/or advice presumably depends on the reasonableness of the doctor’s
argumentation. In the next chapter, the specific conditions that a doctor’s argument by authority
should meet for this argument to reasonably contribute to the resolution of a difference of
opinion in medical consultation are therefore discussed.
57
5 Soundness conditions for a doctor’s argument by
authority
5.1 The reasonableness of a doctor’s argument by authority
Accepting a standpoint based on authority argumentation can be perfectly reasonable. A

discussion party might simply not have sufficient expertise, knowledge, or time to conduct a
meaningful discussion about a particular discussion topic without making recourse to the
opinion of an authority. Woods and Walton (1982, p. 87) point out: “Often, through lack of
time or resources for independent investigation by everyone involved, we are forced to accept
the sayso of suitably qualified experts. You may question your physician’s diagnosis, or ask for
a second or third opinion – but in the end, you listen to your doctor. It is rational to trust the
diagnosis of well-qualified practitioners, which seem to have more authoritative value than your
own inexpert speculations”.
Even though it can be rational to accept a standpoint based on authority argumentation, it
does not always have to be the case. The following conversation, taken from the Dutch comedian
Herman Finkers (2009, p. 77; my translation from Dutch), illustrates this:
My grandfather lay on his deathbed and, at a certain moment, the doctor said: “Yes, he died”.
At which point my grandfather opened his eyes and said: “I’m no’ dead yet”.
To which my grandmother replied: “Hol’ yer tongue Wilm, the doctor’d know it better than
yeh”.
The potentially comical effect of the exchange is a result of the grandmother’s problematic use of
an argument from authority: the doctor in question is, in this particular case, not a sufficiently
reliable authority. What is more, the grandmother uses the argument from authority as a
means to shut down the discussion even though the difference of opinion about whether the
grandfather has passed away remains unresolved between her and – as strange as it may sound
– the grandfather.
In practice, authority arguments in argumentative discourse may not be as obviously
problematic as in the example taken from Finkers. They can, nevertheless, be problematic for
similar reasons (referring to an authority that is not sufficiently reliable and shutting down the
discussion). In this chapter, it is determined what conditions a doctor’s argument by authority
should meet for the argument by authority to reasonably contribute to the resolution of a dispute.
The specific soundness conditions that, from a pragma-dialectical perspective, can be said to
apply to the doctor’s argument by authority in medical consultation are examined.
To be able to determine these specific soundness conditions, the general soundness
conditions that apply to an argument by authority are outlined (section 5.1.1). These general
soundness conditions are derived from the literature on fallacies, specifically on the argumentum
ad verecundiam.30 Next, the general soundness conditions are specified for a doctor’s argument
by authority in the particular communicative activity type of medical consultation, resulting in
30
Following pragma-dialectical practice, the Latin term argumentum ad verecundiam shall be reserved for
fallacious authority arguments and the term authority arguments when the soundness of these arguments
has yet to be evaluated (see van Eemeren & Grootendorst, 1992, pp. 135-139).
59
the formulation of the specific soundness conditions for this particular argument (section 5.1.2).
Finally, it is demonstrated how these specific soundness conditions can be used in evaluating a
doctor’s argument by authority in practice (section 5.2).
5.1.1 General soundness conditions for the argument by authority

In the literature on fallacies, various conditions have been proposed to evaluate whether
an authority argument is fallacious or, in other words, an instance of the argumentum ad
verecundiam (van Eemeren & Grootendorst, 1992, pp. 135-139 and 160-163; Schellens, 1985,
pp. 179-189; Walton, 1997, pp. 199-225; Woods & Walton, 1982, pp. 88-91). To evaluate the
fulfilment of these soundness conditions, the context in which the argument occurs should be
taken into account. Who or what counts as a genuine authority depends on the communicative
activity type in which the authority argument is put forward and the specifics of the discussion
context. A paediatrician can, for example, be considered a relevant authority in a discussion
about an infant’s health problems, but in all likelihood not on geriatric problems of the infant’s
grandparents.
In the pragma-dialectical theory, fallacies are viewed as moves in argumentative discourse
that, given the communicative activity type and the specifics of the context, frustrate or hinder a
reasonable resolution of the difference of opinion at hand. A discussion party commits a fallacy if,
in manoeuvring strategically, the party disregards the pursuit of the dialectical goal of reasonably
resolving the difference of opinion to obtain the rhetorical goal of being effective. In such a case,
the discussion party’s strategic manoeuvring derails into fallaciousness because the party violates
one or more of the pragma-dialectical rules for a critical discussion (van Eemeren, 2010, p. 198).
Van Eemeren and Grootendorst (1992, p. 167) identify three different pragma-dialectical
rule violations that can be at the heart of an argumentum ad verecundiam. First, the protagonist
can violate the pragma-dialectical burden of proof rule (rule 2) if he provides a personal guarantee
of the rightness of the standpoint by means of the argument. The protagonist thereby disregards
the rule that “A party that advances a standpoint is obliged to defend it if the other party asks him
to do so” (van Eemeren & Grootendorst, 1992, p. 208).
Second, the protagonist can violate the relevance rule (rule 4) if, instead of advancing
arguments related to the standpoint at issue, he only parades personal qualities by means of
the authority argument. The protagonist thereby disregards the rule that “A party may defend
his standpoint only by advancing argumentation relating to that standpoint” (van Eemeren &
Grootendorst, 1992, p. 208).
Third, the protagonist can violate the argument scheme rule (rule 8) if he appeals to an
authority who is not an expert in a relevant field. The protagonist thereby disregards the rule
that “A party may not regard a standpoint as conclusively defended if the defence does not take
place by means of an appropriate argument scheme that is correctly applied” (van Eemeren &
Grootendorst, 1992, p. 209).
To evaluate whether the argument scheme rule (rule 8) is violated by a discussion party’s
authority argument, van Eemeren and Grootendorst (1992, p. 163) state that it should be
determined whether the appeal to authority really warrants the standpoint in support of which
it is advanced. They point out that this requires answering the question: is the authority that is
appealed to a genuine authority in a relevant field? Other requirements that van Eemeren (2010,
p. 203) lists are: the discussion parties should, in principle, agree on appealing to the authority
that is referred to in the discussion and they should cite this authority correctly at a point in the
discourse where this is relevant.
60
These general requirements can be said to constitute the general soundness conditions for the
argument by authority as well as the argument from authority (see section 3.5 for the distinction
between these variants). In the particular case of an argument by authority, the condition that
the discussion parties agree on the possibility to appeal to a particular authority can be more
specifically formulated.31 In an argument by authority, the protagonist refers to himself as the
authority on the issue under discussion. So, when advancing an argument by authority, the
protagonist can presumably be held accountable for being a genuine and relevant authority
on this discussion issue. Therefore, the requirement that the discussion parties agree on the
genuineness and relevance of the authority that is referred to in authority argumentation can be
reformulated as a general soundness condition for the argument by authority as:
The antagonist should agree on the genuineness and relevance of the authority of the
protagonist on the issue under discussion.
In addition, for an argument by authority, the requirement that the authority should be
cited correctly at a point where this is relevant is, in principle, fulfilled. The protagonist can
be expected to refer to the authority’s opinion(s) in a correct manner and not out of context,
since the protagonist is this authority himself and presumably will not misrepresent his own
opinion. An exception to this automatic fulfilment should be made for an argument by authority
in which the protagonist cites (an) opinion(s) that he expressed before – as opposed to during
– the argumentative discussion at hand. In such an argument, the protagonist could provide an
incorrect citation – for example, because he misrepresents or forgets exactly what he had said.
The requirement that van Eemeren (2010, p. 203) lists concerning the correctness of the citation
can, hence, be specified as a general soundness condition for the argument by authority as:
A protagonist who cites (an) opinion(s) that he expressed before participating in the
argumentative discussion should do so correctly at a point where this is relevant.
In contrast to the automatic fulfilment of the citation condition, the requirement that the
protagonist may not parade his own qualities instead of advancing arguments related to the
standpoint might seem to be automatically unfulfilled in an argument by authority. In an
argument by authority, the protagonist might seem to parade his personal qualities instead of
advancing arguments related to the standpoint by virtue of arguing by authority. This could be,
but is not necessarily, the case; this distinction depends on whether the personal quality that the
protagonist refers to in the argument by authority is relevant to the standpoint under discussion.
If this quality is indeed relevant, then the protagonist cannot be judged as parading his own
qualities instead of advancing arguments related to the standpoint. In such cases, the argument
by authority in fact constitutes an indication to accept the standpoint, and can thus be seen to
function as an argument. For instance, such an authority argument in which a doctor refers to
his experience with a particular treatment (“My experience with these tablets is that the sores will
disappeared in a couple of days”) can be perfectly acceptable support for a standpoint about this
treatment (“It is best to take zelitrex tablets”) .
31
Although this soundness condition can be more specifically formulated for the argument by authority, it
should still be regarded as a general soundness condition (not a specific one), as it applies to the argument
independently of the activity type in which it is presented (van Eemeren, 2010, pp. 200-207).
61
Apart from the two aforementioned conditions (“The antagonist should agree on the genuineness
and relevance of the authority of the protagonist on the issue under discussion” and “A
protagonist who cites (an) opinion(s) that he expressed before participating in the argumentative
discussion should do so correctly at a point where this is relevant”), none of the other general
soundness conditions for authority argumentation need to be further specified for the argument
by authority. Rather, it only has to be precisized that these soundness conditions do not just apply
to any authority, but specifically to the protagonist himself. Figure 5.1 provides an overview of the
general soundness conditions for arguments by authority. For convenience’s sake, each condition
is named after the aspect of the argument by authority that it applies to.
Figure 5.1 General soundness conditions for an argument by authority
1. Burden of proof condition: The protagonist who advances an argument by authority in support of
a standpoint is obliged to continue the defence of this standpoint if the antagonist asks him to do so.
2. Relevance condition: The protagonist may not parade his own qualities in order to avoid advancing
argumentation relating to the standpoint at issue.
3. Credibility condition: The protagonist may not regard a standpoint as conclusively defended if the
defence takes place by an appeal to his authority that does not warrant the standpoint in support of
which an argument by authority is advanced.
a. The antagonist should agree that the protagonist’s authority is genuine.
b. The antagonist should agree that the protagonist is an authority in a relevant field.
4. Appropriateness condition: A protagonist who cites (an) opinion(s) that he expressed before
participating in the argumentative discussion should do so correctly at a point where this is relevant.
The list of general soundness conditions presented in figure 5.1 can be regarded as exhaustive from a
pragma-dialectical perspective. Other conditions for the evaluation of authority argumentation that
are mentioned in the literature are either subsumed by them (and thus already taken into account)
or not required to reasonably resolve a difference of opinion (and are thus not unreasonable from a
pragma-dialectical point of view). This, for example, holds for Walton’s (1997, p. 223) requirements
that, in an argument from expert opinion, the expert should possess expertise (“How credible is
E as an expert source?”) and the opinion of the expert should be consistent with that of other
experts (“Is E consistent with what other experts assert?”). In the general soundness conditions as
listed in figure 5.1, the extent to which E is an expert is subsumed under the credibility condition
(The antagonist should agree that the protagonist’s authority is genuine and in a relevant field); if
the credibility condition is fulfilled, then the answer to Walton’s question would be that the expert
referred to is sufficiently credible. Whether the opinion of the expert referred to in the argument
is consistent with that of other experts does not matter at all for the reasonable resolution of a
difference of opinion. Essentially, as long as the discussion parties agree, rightly or wrongly, that
the expert is genuine and relevant, they can resolve their dispute in a reasonable way. After all,
they have sufficient common ground to do so ex concessu (i.e., on the basis of concessions): the
standpoint can be made acceptable or criticised based on the commitments of the discussants.32
32
The idea that a discussion should be resolved ex concessu is in line with other dialectical approaches to
argumentation. For example, Hamblin (1970, p. 263) introduces the notion of the discussants’ commitment-
store and deems it necessary for “the operation of a satisfactory dialectical system.” Barth and Krabbe (1982,
pp. 56-68) adopt a similar concept, the discussants’ set of concessions in their formal dialectical theory.
62
5.1.2 Specific soundness conditions for a doctor’s argument by authority
Van Eemeren (2010, p. 203) points out that, “More often than not, fallacy judgments are (or
should be) in the end contextual judgments that depend on the specific circumstances of situated
argumentative acting”. To evaluate the soundness of an argument by authority that is presented
by a doctor in medical consultation, the general soundness conditions that were discussed in
the previous section need to be precisized or specified for the communicative activity type of
medical consultation33 – making them specific soundness conditions. The characteristics of the
communicative activity type of medical consultation that were discussed in chapter 2 will be
used as a basis for determining these specific soundness conditions. For the sake of clarity, the
prototypical case of a doctor’s argument by authority in support of a particular treatment advice
will be used as a point of departure in the analysis.
An important requirement in a medical consultation about specific treatment advice is
that a doctor needs to obtain the consent of (a representative of) the patient about undergoing
this treatment before it can be prescribed. This requirement is laid down in legislation or case law
on informed consent. The Dutch civil code’s Wet op de Geneeskundige Behandelingsovereenkomst
(“Law on the Medical Treatment Agreement”), for instance, stipulates that obtaining the patient’s
agreement with the advised treatment is required before administrating this treatment (WGBO,
1995, Art. 450(1)).34
The requirement of informed consent has been shown to influence the way in which
argumentative discourse proceeds in medical consultation (Goodnight, 2006; Goodnight &
Pilgram, 2011; Pilgram, 2009; Schulz & Rubinelli, 2008). What will be argued here is that this
requirement can also be used to specify the soundness conditions for a doctor’s argument by
authority in medical consultation. The ‘consent’ part of the requirement of informed consent
helps in specifying the burden of proof condition (condition 1 in figure 5.1) and the ‘informed’
part of this requirement in specifying the relevance condition (condition 2 in figure 5.1).
First, the doctrine of informed consent can be used to specify the burden of proof condition
for a doctor’s argument by authority (“The protagonist who advances an argument by authority
in support of a standpoint is obliged to continue the defence of this standpoint if the antagonist
asks him to do so”). This requirement specifies what the resolution of a difference of opinion
about a medical treatment should amount to: an expression of consent by the patient. So, because
a patient explicitly consents to a particular treatment advice only if he accepts it, a doctor should
33
Following Naess (1953, pp. 60 & 64-65), a will be regarded as more precise than b if (and only if) “There
is no interpretation of a that is not also an interpretation of b, whereas there is at least one interpretation
of b which is not an interpretation of a, and there is at least one interpretation of a” and a will be regarded
as more specific than b if (and only if), “as interpreted by [person] P in situations S, what is asserted by
b is explicitly or implicitly asserted by a, but by a something more is asserted [and] as interpreted by P
in situations S, both a and b express assertions (propositions) about the same subject”. This means that
specific soundness conditions that are the result of the precisation of general soundness conditions do not
yield principally different judgments of the soundness of strategic manoeuvre X across different activity
types because no amendments or supplementations are made to the general conditions. In contrast, specific
soundness conditions that are the result of the specification of general soundness conditions might yield
different judgments of the soundness of strategic manoeuvre X across different activity types exactly
because the general soundness conditions are amended or supplemented in the specification procedure.
34
Informed consent need not always be obtained. There are four exceptions to this requirement: a doctor
does not have to obtain the patient’s informed consent (1) in case of an emergency, (2) if a patient gives
up his right to informed consent, (3) if being informed would harm the patient, or (4) when a patient is
incompetent (Appelbaum, Lidz & Meisel, 1987, p. 66). In the analyses in this section, it is assumed that these
exceptions do not apply.
63
interpret a patient’s lack of consent as a request for further argumentation in support of the
advised treatment. The burden of proof condition that generally applies to arguments by authority
can therefore be specified for the doctor’s argument by authority in medical consultation as:
i
The doctor who advances an argument by authority in support of treatment advice is obliged to
continue the defence of this advice if the patient has not consented to the treatment subsequent to the
doctor’s argument by authority.
Second, the doctrine of informed consent can be used to specify the relevance condition for a
doctor’s argument by authority in medical consultation (“The protagonist may not parade his
own qualities in order to avoid advancing argumentation relating to the standpoint at issue”).
This is the case because the requirement of informed consent lays down what it exactly means
for a patient to be informed.
In Canterbury v. Spence [1972] 464 F.2d 772, a classic American tort case about informed
consent, the court specifies that doctors need to provide information on five issues in the
treatment decision making process: (1) the patient’s health problem, (2) the nature and character
of the advised treatment, (3) the expected treatment results, (4) possible alternative treatments,
and (5) the risks and benefits of undergoing the advised treatment, alternative treatments or
refraining from treatment altogether (Murray, 2012, p. 564).35 If a doctor fails to provide
sufficient information about these matters, a patient cannot be regarded as being informed when
consenting to treatment.
For the interpretation of the relevance condition for a doctor’s argument by authority in
medical consultation, it is now clear what the doctor has to do in the discussion to obtain a
patient’s informed consent. First, he has to make acceptable the proposition that, given the effects
and risks of the advised treatment, this treatment can be expected to be beneficial to the patient.
After all, the doctor should recommend the particular treatment that is best for the patient.36
In making acceptable the proposition that the advised treatment is beneficial, the doctor has
to address the patient’s health problem, the nature and character of the advised treatment, the
expected treatment results, and the risks and benefits of undergoing the advised treatment.
Second, the doctor should make acceptable to the patient that, in view of the patient’s
particular condition and situation, the advised treatment is more beneficial than relevant
alternative treatments or non-treatment. If a doctor wants to convincingly recommend a
particular treatment and adhere to the requirement of informed consent, he has to address
possible alternative treatments, and the risks and benefits of undergoing the advised treatment,
alternative treatments or refraining from treatment altogether. If a doctor fails to address
these issues in his argumentation, he is either not convincing in recommending the treatment
(“Anucort-HC and hytone cream are equally effective against eczema, so it’s best to prescribe
hytone cream”), or the doctor is not informing the patient sufficiently (only mentioning the
effectiveness of hytone cream, not that of anucort-HC).
Advancing an argument by authority as a means to avoid discussing the benefit of the
advised treatment over alternatives or non-treatment can thus be considered unreasonable. For
35
These requirements are also recognised in other case law and legislation on informed consent (see, for
example, WGBO, 1995, Art. 448(2)).
36
Indeed, ethical codes, such as the Hippocratic Oath and the Declaration of Geneva, commit doctors to
providing medical advice that is in the patient’s best interest.
64
a doctor’s argument by authority in medical consultation, the relevance condition can therefore
be specified as:

ii
The doctor may not parade his own qualities in order to avoid advancing argumentation that indicates
that the advised treatment is beneficial and to be preferred over relevant alternative treatments or
non-treatment.
For the specification of the credibility condition (“The protagonist may not regard a standpoint
as conclusively defended if the defence takes place by an appeal to his authority that does not
really warrant the standpoint in support of which an argument by authority is advanced”), a
different characteristic of medical consultation comes into play: the fact that the patient requests
a consultation with the doctor because he seeks the doctor’s professional medical advice on his
health problem.
By virtue of requesting the consultation, the patient can be assumed to regard the doctor
as a genuine and relevant authority on his health problem.37 Even if the patient merely requests a
consultation to get a referral to specialist care – as typically happens in medical systems in which
a doctor is the gatekeeper to secondary care, such as in the Netherlands and the UK – the patient
regards the doctor as able to judge whether such a referral is indeed necessary (Is the patient’s
health problem serious? Can this problem not be solved in primary care? If not, is the problem
in the field of the desired specialist?). In addition to the medical authority to pass this judgment,
the doctor possesses the institutional authority to grant a referral.
So, the condition that the patient agrees that the doctor is a genuine and relevant authority
is, in principle, automatically fulfilled within medical consultation. Nonetheless, during the
course of the consultation, a patient can become dissatisfied with the doctor’s authority – for
example, because the doctor cannot provide a diagnosis with certainty or because he provides
different treatment advice than the patient had expected. In such a situation, the patient might
start to doubt the genuineness or relevance of the doctor’s authority. As a consequence, the
general credibility condition needs to be specified for a doctor’s argument by authority as follows:
iii The doctor may not regard treatment advice as conclusively defended by an argument by authority
if the patient has indicated doubt about the genuineness or relevance of the doctor’s authority on the
treatment advice during the medical consultation.
Finally, the general appropriateness condition (“A protagonist who cites (an) opinion(s) that he
expressed before participating in the argumentative discussion should do so correctly at a point
where this is relevant”) needs to undergo only minor changes. There is no reason to amend this
requirement as it is just as necessary for an argument by authority in medical consultation as it is
in any other communicative activity type. Only a precisation of this condition is needed, so that
it is clear that the condition specifically applies to the doctor in a consultation. This results in the
following specific soundness condition:
37
Of course, with good reasons: a doctor should possess relevant qualifications to practice medicine and
these qualifications are, as a rule, highly regulated (see, for example, Council Directive 93/16/EEC (Art. 23)
– as discussed in section 3.2).
65
iv A doctor who cites (an) opinion(s) that he expressed before participating in the argumentative
discussion in medical consultation should do so correctly at a point where this is relevant.
In figure 5.2, an overview is provided of the specific soundness conditions for the argument by
authority.
Figure 5.2 Specific soundness conditions for a doctor’s argument by authority in medical
consultation
1. Burden of proof condition: The doctor who advances an argument by authority in support of treatment
advice is obliged to continue the defence of this advice if the patient has not consented to the treatment
subsequent to the doctor’s argument by authority.
2. Relevance condition: The doctor may not parade his own qualities in order to avoid advancing
argumentation that indicates that the advised treatment is beneficial and to be preferred over relevant
alternative treatments or non-treatment.
3. Credibility condition: The doctor may not regard treatment advice as conclusively defended by an
argument by authority if the patient has indicated doubt about the genuineness or relevance of the
doctor’s authority on the treatment advice during the medical consultation.
4. Appropriateness condition: A doctor who cites (an) opinion(s) that he expressed before participating
in the argumentative discussion in medical consultation should do so correctly at a point where this
is relevant.
5.2 A doctor’s argument by authority evaluated in practice
Based on the specific soundness conditions discussed in the previous section, the soundness
of a doctor’s argument by authority can now be evaluated in discussions in actual medical
consultation. In this section, it is demonstrated how such an evaluation can be provided by
means of an example taken from general practice (case 5).
In the example presented as case 5, the doctor advises the patient about his sprained ankle.
The patient sprained his ankle during an indoor soccer match a month ago, and the ankle is still
stiff and swollen. Also, walking is painful for the patient. The excerpt in case 5 occurs just at the
end of the physical examination by the doctor.
Case 5
Excerpt of an argumentative discussion between a doctor (D) and a patient (P) about a sprained
ankle (original conversation in grey)38
1
D: Maybe you’ve actually got a small tear here in the outer ankle. I had that once too and, in my case,
that also erm appeared much later, so I think that we’ll just have to take an x-ray of it.
(Misschien dat je toch een heel klein scheurtje hier in die buitenenkel opgelopen hebt. Ik heb dat
zelf ook ’ns een keer gehad en dat kwam bij mij ook pas veel later uhm naar voren, dus ik denk
dat we er maar even een fotootje van moeten laten maken.)
38
Transcribed by Nanon Labrie, my translation from Dutch.
66
2 P: Really?
(Ja?)
3 D: Yes. Because there isn’t a lot of space per se in those ankles, right, that you think like, well, those
ankle ligaments are terribly weak, but this really is very pressure sensitive.
(Ja. Want op zich zit er niet heel veel ruimte op die enkels hè, dat je zegt van nou die enkelbanden
zijn hartstikke slap, maar dit is wel heel erg drukpijnlijk hoor.)
4 P: Yes.
(Ja.)
5 D: We really have to take an x-ray of this. It’s okay to get off [the examination table].
(Hier moeten we echt een fotootje van laten maken. Kom er maar af hoor [van de onderzoekstafel].)
In the very first turn of case 5, the doctor advises that an x-ray be taken and provides reasons for
this standpoint: he once had a small tear in his outer ankle and, just as in the patient’s case, the
problems with his ankle only appeared after a while (“I had that once too and, in my case, that
also erm appeared much later”). The doctor indicates that an x-ray would help in diagnosing
whether the patient also suffers from a tear in his outer ankle (“So I think that we’ll just have to
take an x-ray of it”).
From this single turn, the conversation can already be reconstructed as part of an
argumentative discussion: the doctor provides reasons for taking an x-ray of the ankle, so he can
be said to assume that the patient does not immediately accept this recommendation. From the
patient’s reaction in turn 2, it appears that the doctor was right; the patient asks “Really?”, thereby
indicating that he is indeed hesitant to accept the doctor’s advice and would like to hear more
about it.
In reply to the patient’s question, the doctor advances further argumentation – as is evident
from the indicator “Because” at the beginning of turn 3. He specifically emphasises that it would
be good to take an x-ray, because the alternative explanation for why the ankle is so pressure
sensitive, that its ligaments are weak, does not apply (turn 3).
The patient rather ambiguously responds with a “Yes” (turn 4) to the doctor’s additional
argumentation. With this affirmation, the patient either expresses agreement with the doctor’s
proposal to take an x-ray, or with the evaluation that his ankle is very pressure sensitive. The
doctor seems to interpret it as an expression of agreement with his proposal, as he rounds off the
discussion in the subsequent turn (“It’s okay to get off [the examination table]” in turn 5).
For this study, the most interesting contribution in this consultation is the doctor’s reference
to his personal experience in turn 1. This reference can be reconstructed as an argument by
authority: the doctor presents his experience as an argument in support of his advice to take an
x-ray of the ankle (figure 5.3).
Figure 5.3 Reconstruction of the doctor’s argument by authority in case 5
1 We have to take an x-ray of your ankle.

1.1 Based on my personal experience with diagnosing a small tear in the outer ankle, I think that we have
to take an x-ray of your ankle.
1.1’ (The doctor’s opinion indicates that taking an x-ray of the patient’s ankle is acceptable).
Interestingly enough, in this argument by authority, the doctor does not, as one might expect,
refer to his professional expertise. Instead, he refers to his personal expertise. To what extent
67
can this reference to personal expertise be considered a reasonable discussion contribution? To
answer this question, it needs to be determined whether the specific soundness conditions for a
doctor’s argument by authority in medical consultation have been fulfilled (see, for an overview
of these conditions, figure 5.2).39
First, the doctor in case 5 fulfils the specific burden of proof condition (“The doctor who
advances an argument by authority in support of treatment advice is obliged to continue the
defence of this advice if the patient has not consented to the treatment subsequent to the doctor’s
argument by authority”). The doctor meets the patient’s request for further argumentation
(“Really?” in turn 2) by arguing that the alternative explanation for the patient’s sensitive ankle
does not hold (“There isn’t a lot of space per se in those ankles” in turn 3).
Second, the specific relevance condition (“The doctor may not parade his own qualities in
order to avoid advancing argumentation that indicates that the advised treatment is beneficial
and to be preferred over relevant alternative treatments or non-treatment”) is also satisfied. The
doctor’s personal experience with ankle problems is relevant to the issue at hand, i.e. deciding
whether or not an x-ray of the patient’s outer ankle should be taken. His personal experience
shows why such an x-ray is beneficial, as, based on his personal experience, the doctor knows
that it is needed to identify a possible tear in the outer ankle. Also, the doctor continues to argue
that an x-ray is to be preferred over the only available alternative, which is not undergoing an
x-ray.40 He shows why he cannot explain what causes the sensitivity of the patient’s ankle based
on just his own physical examination (“Because there isn’t a lot of space per se in those ankles,
right, that you think like, well, those ankle ligaments are terribly weak, but this really is very
pressure sensitive” in turn 3).
Third, it is less straightforward to determine whether in case 5 the doctor also fulfils the
credibility condition (The doctor may not regard treatment advice as conclusively defended by
an argument by authority if the patient has indicated doubt about the genuineness or relevance
of the doctor’s authority on the treatment advice during the medical consultation). In principle,
this condition seems to be fulfilled: the patient does not ask whether the doctor really suffered
from an ankle injury in the past or whether that injury was really similar to the one that he has.
What nevertheless complicates the evaluation of this particular argument by authority is that the
specific credibility condition was formulated under the assumption that by virtue of requesting a
consultation, a patient ascribes authority to the doctor based on the doctor’s medical knowledge
and expertise. Yet, in requesting the consultation in case 5, the patient did not automatically
ascribe authority to the doctor based on the doctor’s personal experience of having ankle
problems. Can the specific credibility condition in this case still be considered to be fulfilled?
The answer to this question is yes. The credibility condition can be considered to be
fulfilled. First, as just observed, the patient did not question the genuineness or relevance of the
doctor’s experience during the consultation. The fact that he did not object to the genuineness
or relevance of the doctor’s experience is important, because starting points (such as those
39
It should be noted that, strictly speaking, the argument by authority in case 5 does not concern ‘treatment
advice’ (for which the soundness conditions were specified in section 5.1.2). After all, the doctor advises
taking an x-ray in order to diagnose the patient, but he does not provide a cure for the health problem.
Nevertheless, when interpreting ‘treatment’ not just as a ‘process aimed at curing a health problem’, but
more broadly as a ‘medical process or procedure’, the specific soundness conditions as formulated in 5.1.2
can also be applied to the doctor’s argument by authority in case 5.
40
However, the doctor could have more explicitly said that a possible tear in the ankle can only be
determined by taking an x-ray.
68
about who counts as an authority and why) cannot always be established before conducting a
discussion. Discussion parties simply cannot always predict which turns their discussion will
take and, therefore, which starting points are needed. Argumentative discussions in medical
consultation are no exception: before conducting the consultation, the doctor in case 5 did not
know that the patient would request advice about a similar problem to one he had personally
experienced in the past.
The protagonist (in case 5, the doctor) can nevertheless still use starting points about issues
that the parties did not prepare for as long as the antagonist (the patient) does not object to
these starting points. If the antagonist does not object, these starting points can be added to the
discussion parties’ set of common starting points, which means that the difference of opinion can
still be resolved in a reasonable manner (ex concessu). So, the lack of objection or questions from
the patient about the doctor’s experience in case 5, in combination with the patient’s consent to
having an x-ray taken (in turn 5), can be reconstructed as an indication that the patient credits
the doctor with authority based on the doctor’s personal experience.
What is more, the idea that the patient ascribes authority to the doctor based on medical
knowledge and expertise when requesting a consultation is a reason why the doctor’s personal
experience can be seen as relevant for his advice. The doctor has, after all, used his medical
expertise to reach the conclusion that the patient’s problem with his ankle is similar to the problem
that he himself had in the past (“I had that once too and, in my case, that also erm appeared much
later” in turn 1, my italics). This is an additional reason to regard the relevance part of the specific
credibility condition (“The doctor may not regard a treatment advice as conclusively defended
by an argument by authority if the patient has indicated doubt about the […] relevance of the
doctor’s authority on the treatment advice during the medical consultation”) as fulfilled.
Fourth, the specific appropriateness condition (“A doctor who cites (an) opinion(s) that he
expressed before participating in the argumentative discussion in medical consultation should
do so correctly at a point where this is relevant”) does not apply, since the doctor does not cite
any opinion. This condition can therefore be omitted from the evaluation.
In sum, the doctor’s argument by authority in case 5 can be regarded as sound. It fulfills
the specific (i) burden of proof condition, (ii) relevance condition and (iv) credibility condition.
In this particular case, the (iv) appropriateness condition does not apply. Of course, to evaluate
other arguments by authority in medical consultation, it needs to be determined whether the
appropriateness condition applies based on the specific presentation of the argument.
5.3 Conclusion
Based on the pragma-dialectical rules for a critical discussion, the following specific soundness
conditions have been formulated to evaluate a doctor’s argument by authority in support of
treatment advice in medical consultation: (i) the burden of proof condition (“The doctor who
advances an argument by authority in support of treatment advice is obliged to continue the
defence of this advice if the patient has not consented to the treatment subsequent to the doctor’s
argument by authority”), (ii) the relevance condition (“The doctor may not parade his own
qualities in order to avoid advancing argumentation that indicates that the advised treatment is
beneficial and to be preferred over relevant alternative treatments or non-treatment”), (iii) the
credibility condition (“The doctor may not regard treatment advice as conclusively defended by
an argument by authority if the patient has indicated doubt about the genuineness or relevance
69
of the doctor’s authority on the treatment advice during the medical consultation”), and (iv)
the appropriateness condition (“A doctor who cites (an) opinion(s) that he expressed before
participating in the argumentative discussion in medical consultation should do so correctly at
a point where this is relevant”). If a doctor who advances an argument by authority in medical
consultation fulfils these specific soundness conditions, the argument by authority should be
regarded as pragma-dialectically sound. If he fails to fulfil one or more of the specific soundness
conditions, he can be said to commit an argumentum ad verecundiam fallacy.
The conditions as specified in this chapter can be used to evaluate whether an argument
by authority can be considered as sound – more precisely, as sound from a pragma-dialectical
theoretical perspective. To determine whether a doctor’s pragma-dialectically sound argument
by authority can also be effective in medical consultation, it needs to be established whether
ordinary language users perceive pragma-dialectically sound arguments by authority as
reasonable and whether they judge a doctor’s pragma-dialectically unsound arguments (ad
verecundiam-fallacies) as unreasonable.
In the next two chapters, the perceived reasonableness of a doctor’s sound arguments by
authority is examined by means of four quantitative empirical studies. In three studies presented
in chapter 6, an analysis is conducted to determine whether there is a correlation between
pragma-dialectical evaluations of reasonableness of a doctor’s use of an argument by authority
and ordinary language users’ perceptions of the argument’s reasonableness. In this analysis,
various consultative situations are taken into account (such as situations in which there is a
limited consultation time and situations in which the patient’s health problem is very serious).
In chapter 7, ordinary language users’ reasons for regarding certain arguments by authority as
reasonable and others as unreasonable are examined.
70
6 The perception of reasonableness of a doctor’s
argument by authority
6.1 Factors affecting ordinary language users’ perception of reasonableness
In the previous chapter, the soundness conditions that specifically apply to a doctor’s argument
by authority in medical consultation were established. If these conditions are fulfilled for the
argument, this argument can, from a pragma-dialectical perspective, be regarded as a reasonable
discussion contribution.
Van Eemeren, Garssen and Meuffels (2009) show in their quantitative empirical research
that ordinary language users consistently evaluate sound discussion contributions as reasonable
(in an absolute sense), and as significantly more reasonable (in a relative sense) than fallacious
discussion contributions (which are judged as unreasonable in an absolute sense). Language
users that do not have a background in argumentation theory (“ordinary language users”)
can therefore be expected to perceive a doctor’s arguments by authority that fulfil the specific
soundness conditions as reasonable.
The research conducted by van Eemeren, Garssen and Meuffels (2009) does not specifically
take into account the particular opportunities and constraints of institutionalised contexts, such
as medical consultation. However, the characteristics of the communicative activity type of
such a context may influence the perception of reasonableness of a discussion move. Appealing
to limited discussion time, for example, might be perceived as more reasonable in medical
consultation than in a philosophical debate.
In this chapter, an empirical investigation is presented on whether various characteristics
of the communicative activity type of medical consultation influence how ordinary language
users perceive the reasonableness of a doctor’s argument by authority. This investigation is a
necessary step in analysing the link between soundness and effectiveness of a doctor’s argument
by authority: if the characteristics of the activity type affect the way in which language users
perceive the reasonableness of a doctor’s argument by authority, then it can be expected that
these characteristics, in addition to the argument’s soundness, will also affect ordinary language
users’ perception of the effectiveness of this argument. Meuffels (2006, p. 21) shows that there is
indeed a strong positive relation between a discussion move’s perceived reasonableness and its
perceived effectiveness.
Before presenting the empirical studies on perceived reasonableness, it is determined
whether or not the soundness of a doctor’s argument by authority can be expected to be perceived
as reasonable by ordinary language users (section 6.2). Subsequently, four potentially prominent
contextual factors that affect reasonableness are analysed (section 6.3.1): the patient’s reference
to a source contradicting the medical advice (section 6.3.2), the severity of the health problem
(section 6.3.3), the available time to discuss the medical advice (section 6.3.4) and the patient’s
required health literacy (section 6.3.5). Next, the design and results of the empirical studies in
which these factors are examined are presented (sections 6.4 and 6.5, respectively).
73
6.2 Soundness as a factor that affects the perception of reasonableness
To empirically determine whether and to what extent contextual factors in medical consultation
influence the ordinary language users’ evaluations of reasonableness of a doctor’s argument
by authority, other factors that might have a bearing on this evaluation need to be controlled.
Based on quantitative empirical research concerning the pragma-dialectical rules for a critical
discussion, one of these factors is already known: the soundness of the argument. By means of a
number of experiments, van Eemeren, Garssen and Meuffels (2009) demonstrated that ordinary
language users evaluate sound discussion contributions as more reasonable than their fallacious
counterparts (see, for empirical research on the specific discussion rules, van Eemeren, Garssen
& Meuffels, 2000, 2001, 2002 on the freedom rule; 2003b on the obligation to defend rule; 2003a
on the argumentation scheme rule; 2004 on the concluding rule; 2009 for an overview). What is
more, they have established that, even in a non-comparative, absolute sense, sound discussion
contributions are consistently judged as reasonable by ordinary language users, while fallacious
contributions are consistently deemed to be unreasonable.41
Thus, when empirically examining the way in which contextual factors influence the
evaluation of reasonableness of a particular discussion contribution, it is important to control
the soundness of this contribution, otherwise the obtained reasonableness scores might not be
due to the examined contextual factors, but to the soundness of the discussion contribution.
For the present study, the soundness of the doctor’s argument by authority needs therefore to
be controlled. As no presumptions have been made as to how the contextual factors that are
discussed in the following sections interact with a violation of the pragma-dialectical rules for
a critical discussion (Do they make the violation ‘more unreasonable’? Do they obscure it? Do
they counter it?), the ‘neutral’, non-fallacious instances of this argument are tested first. The
expectation is that these sound instances will be evaluated as reasonable. More precisely, it is
hypothesised that they will be evaluated as reasonable both in an absolute and a relative sense:
H1a: Ordinary language users perceive sound instances of a doctor’s argument by authority as reasonable.
H1b: Ordinary language users perceive sound instances of a doctor’s argument by authority as more
reasonable than a doctor’s fallacious discussion contributions.
These general hypotheses were tested in a number of experiments in which additional hypotheses
concerning various contextual factors were tested. Before explaining the setup and results of
these experiments, these additional hypotheses are discussed.
6.3 Contextual factors that affect the perception of reasonableness
6.3.1 Higher order conditions

In pragma-dialectical terms, soundness conditions for the argument by authority can be regarded
as ‘first order’ conditions for the reasonable resolution of a difference of opinion; they need to be
41
Sound discussion contributions consistently receive scores of in between 5 and 6 (‘fairly reasonable’
and ‘reasonable’, respectively) on a 7-point Likert scale measuring reasonableness; fallacious contributions
a score of in between 1 and 4 (‘very unreasonable’ and ‘neither unreasonable, nor reasonable’, respectively)
(van Eemeren, Garssen & Meuffels, 2009, p. 223).
74
fulfilled to resolve a dispute on the merits (van Eemeren, 2010, p. 35). In addition to these first
order conditions, contextual factors can also affect the critical resolution process. If a discussion
party does not have a ‘free mind’, or if the circumstances are such that he is not allowed to speak
his mind, a reasonable resolution of a difference of opinion cannot occur. Those conditions that
enable a reasonable resolution of a difference of opinion and pertain to the discussion parties’
internal state of mind are considered ‘second order’ conditions, and those that pertain to the
external discussion situation are considered ‘third order’ conditions (van Eemeren, 2010, p. 35,
following Barth & Krabbe, 1982, p. 75).
Whether and to what extent the higher order conditions have been fulfilled depends on,
amongst other factors, the communicative activity type in which the argumentative discourse
takes place, because the constraints that the activity type places on the argumentative discussion
may be such that the higher order conditions cannot be completely fulfilled. For example, the
limited amount of time in the communicative activity type of medical consultation could be
such that there is insufficient time for a reasonable resolution of a difference of opinion between
a doctor and a patient, which constitutes a non-fulfilment of the third order conditions. The
characteristics of the activity type can also affect the degree to which the higher order conditions
are fulfilled: the asymmetry in knowledge and expertise between a doctor and a patient in medical
consultation might, for instance, be a reason for the doctor to not take a patient’s ideas about a
medical treatment seriously, thereby not completely fulfilling the second order conditions.
To deal with the characteristics of the activity type that hinder the fulfilment of the higher
order conditions, a discussion party can choose from the topical potential, use presentational
devices and adapt their moves to the audience in such a way that the reasonable resolution of
the difference of opinion is least hindered. Such strategic manoeuvres can be expected to be
perceived as more reasonable than those in which the discussion party does not try to diminish
the negative effects of the activity type’s characteristics on the fulfilment of the higher order
conditions. Based on this assumption, four hypotheses are formulated about a doctor’s argument
by authority in the following sections.
6.3.2 Second order conditions: The patient’s pre-set ideas about his health problem
In medical consultation, some of the characteristics of this specific activity type could hinder the
fulfilment of the second order conditions for a critical discussion. Rather than stimulating an
open discussion between the doctor and patient, these characteristics make conducting such a
discussion even more difficult. For example, if a patient is in a lot of pain, an extensive discussion
about what the doctor should do is less viable and less desirable. Another factor is becoming
more and more important nowadays due to patients’ increased access to health information,
namely a patient’s self-diagnosis or pre-set ideas about the required medical treatment.
As already pointed out in chapters 2 and 4, a few decades ago, patient access to information
about health problems was almost exclusively available from their doctors, but with the rise of
the internet, health information is presently widely accessible to patients (Brabers, Reitsma-van
Rooijen & de Jong, 2012, p. 359; Suziedelyte, 2012, p. 1828). Although this increased access to
health information could enable patients to more adequately participate in a discussion about
complex health issues in medical consultation, there is also a downside: patients who request a
prescription for a particular medication based on information gained from a source other than
the doctor can have such strong, pre-set (and sometimes incorrect) ideas about the required
medication that they are not open to discussing alternatives. Think, for instance, of a patient who
is convinced that he needs antibiotics while he is actually suffering from a viral infection (see, for
75
examples of such a situation in paediatric consultations, Labrie, 2012, pp. 179-189; and Elwyn
et al., 1999, pp. 110-111). In argumentative terms, the patient does not fulfil the preconditions
of the second order. A similar situation arises when patients are so convinced of a self-diagnosis
that they are not open to discussing possible alternative diagnoses. In the worst-case scenario, the
patient could refuse treatment for medically unsound reasons.
Because patients typically do not have a background in medicine, they run the risk of
arriving at wrong medical conclusions about their health problems when considering information
from a source other than the doctor: the information is not always reliable and, even if it is,
patients might find it difficult to interpret. So, a doctor may provide a patient with a diagnosis or
medical advice that contradicts what the patient had in mind based on the health information
that the patient obtained from a source other than the doctor. It is the doctor’s task to show that
his diagnosis or advice is to be preferred over the patient’s ideas. Advancing an argument by
authority provides a strategic means for a doctor to do this.
As discussed in section 3.6, a strategic advantage of arguing by authority is that the
protagonist not only indicates the acceptability of the standpoint, but also acquires ethos or
draws attention to his existing ethos by advancing this argument. Given that the patient ascribes
authority on health problems to a doctor by virtue of requesting a medical consultation, a doctor’s
argument by authority would, in principle, function as a means to draw attention to his existing
ethos. After all, it reminds the patient of the reason why he consulted the doctor in the first place:
because of the doctor’s medical knowledge and expertise. Since the patient regards the source
that provided the contradicting information (for example, a particular website) as sufficiently
credible to oppose the doctor, the doctor’s argument by authority is also not superfluous. It does
not constitute a violation of the Gricean maxim of quantity, because the patient does not already
accept that the doctor is the more credible authority on his health problem. Thus, in such cases,
there may be a need for the doctor to show that he is indeed a credible authority, which he can do
by advancing an argument by authority.
When advancing an argument by authority in this consultative situation, the doctor, in
fact, kills two birds with one stone: he provides an indication of the acceptability of his own
diagnosis or advice and, at the same time, emphasises indirectly and implicitly that the patient
lacks the required medical expertise to determine which diagnosis or advice should be given
(while making clear that he himself does not lack this expertise). The fact that the doctor does
not explicitly say that the patient lacks the required medical expertise also somewhat lessens the
threat that such a message would pose to the patient’s positive face.
The doctor reminding the patient of his medical expertise can also be regarded as strategic
in another way. A patient’s reference to a contradictory source can indicate hesitance or even
doubt about the doctor’s expertise. By emphasising that he possesses the medical expertise
about the health problem at hand, the doctor makes clear that the patient should abandon his
hesitance or doubt. The argument by authority then serves as a rebuttal of a counterargument by
the patient of the kind “you do not possess sufficient expertise or experience to make this claim”.
This rebuttal takes place on the sub-level of the argumentative discussion (the level on which
arguments support other arguments) in order to take away hesitance or doubt about the medical
advice on the main level of the discussion (the level on which arguments support the standpoint).
Additionally, advancing the argument by authority can be regarded as a tit-for-tat strategy: the
patient refers to an alternative source as authority, so the doctor refers to his own authority.
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Because the doctor’s argument by authority is a strategic means to acquire ethos or draw attention
to existing ethos and simultaneously counter the reference to a contradicting source by the
patient, it is hypothesised that:
H2: Ordinary language users perceive a doctor’s argument by authority as more reasonable when the
patient refers to a source that contradicts the (support of the) doctor’s medical advice than when the
patient does not do this.
This hypothesis is empirically tested in study 1. Before explaining which methods were employed
in this study, the other tested hypotheses concerning the higher order conditions for reasonably
resolving a difference of opinion are first detailed.
6.3.3 Second order conditions: The severity of the patient’s health problem
Another characteristic of medical consultation that can influence the fulfilment of the second
order conditions is the severity of the patient’s health problem. Diagnosis of a severe health
problem (such as an HIV infection) can, for instance, stimulate discussion of the available
treatment options, while a problem that is not severe (such as a common cold) can be too trivial
or straightforward to be discussed at all. In pragma-dialectical terms, the second order conditions
are fulfilled in the former, but not in the latter.
Indeed, Stewart et al. (2000, pp. 359-360) show that patients suffering from ovarian cancer,
a severe condition that is the fifth leading cause of death from cancer in women, have an increased
need to discuss their health problem with their doctors. The study found that a vast majority of
women (82 to 90%) suffering from ovarian cancer wished to get detailed information about their
health problem throughout the various stages of consultation (at diagnosis, during treatment and
after treatment).42 Furthermore, a majority of the women wanted to share the treatment decision
making with their doctor (62.9% of them at diagnosis, 59.6% during treatment and 61.9% after
treatment).43 At the core of the shared decision making process is a discussion of the pros and
cons of a particular medical decision. From an argumentation theoretical perspective, this
means that the majority of the women in the study preferred to conduct a detailed argumentative
discussion about their health problem with their doctors in the consultation.
What is more, Stewart et al. (2000, p. 360) established that “the more serious the course
of the ovarian cancer, the more likely women were to want a shared decisional role about how
the illness should be managed”. In a more general exploratory study, Müller-Engelmann et al.
(2011, p. 243) confirmed that patients, GPs and health administration research professional
alike are of the opinion that shared decision making is more appropriate the more severe the
disease is.44 From an argumentation theoretical terms, this finding is further evidence that there
is an increased need to conduct a detailed argumentative discussion about the patient’s health
problem if this problem is severe.
42
Only 10 to 18% of the women suffering from ovarian cancer wanted to receive brief information and
virtually no-one (< 1%) preferred to receive no explanation at all (Stewart et al., 2000, p. 359).
43
Much fewer women only wanted to passively participate in the decision making process and have the
doctor make decisions after seriously considering the treatment possibilities (22.9% of women at diagnosis,
23.1% during treatment and 21.9% after treatment) or wanted to make their own (autonomous) decisions
(14.3% at diagnosis, 17.3% during treatment and 15.2% after treatment) (Stewart et al., 2000, p. 360).
44
With the exception of end-of-life decisions, which some of the patient participants regarded as the
exclusive domain of the patient (Müller-Engelmann et al., 2011, p. 243)
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In such a detailed discussion, the doctor could advance an argument by authority. However, as
discussed in section 4.2.1, such an argument constitutes a strategic means to avoid a detailed
discussion of the medical reasons for a certain treatment proposal. This characteristic does
not stimulate argumentative discussion of all the pros and cons of a particular treatment or its
alternatives. Rather, it simply provides an indication of the acceptability of the doctor’s medical
claims. As a consequence, it can be expected that a patient suffering from a severe health problem
will perceive the argument by authority as less reasonable than a patient who does not suffer
from a severe problem. Conversely, if a doctor informs the patient that his health problem is not
severe, his argument by authority in support of a medical advice will presumably be perceived as
more reasonable. Indeed, the fact that he tells the patient that his problem is not severe provides
a reason as to why the doctor argues by authority.
Because the argument by authority constitutes a strategic means to avoid a detailed
argumentative discussion about medical advice, the following is expected:
doctor indicates that the patient’s health problem is not severe than when the doctor does not indicate
this.
This hypothesis was empirically tested in study 2, which is detailed after introducing the
hypotheses concerning the third order conditions for a critical discussion in medical consultation.
6.3.4 Third order conditions: The amount of time available to conduct a discussion
Not only the discussants’ internal states of mind, but also the external circumstances in which
they conduct their discussion need to be such that the difference of opinion can be resolved in a
reasonable manner. The conditions concerning the external circumstances that need to be fulfilled
to reasonably resolve a difference of opinion are, in terms of the pragma-dialectical theory, the
third order conditions (van Eemeren, 2010, p. 35). An example of a third order condition is that
there needs to be sufficient time to conduct the argumentative discussion in question.
In medical consultation, this time condition is not always fulfilled. A doctor and
patient are confronted with a limited amount of time for the consultation due to practical
considerations, such as the vast amount of patients in the doctor’s care and the reimbursement
of the consultation time by health insurance companies. In the Netherlands, an average of 2,529
patients was registered per GP in 2005 (see Kroneman, Van der Zee & Groot, 2009, p. 26). This
means that Dutch GPs need to conduct their consultations efficiently, especially because there
is a difference in the fixed tariffs for consultations under and over 20 minutes (Nederlandse
Zorgautoriteit, 2014) – due to which the longer consultations are not always fully reimbursed
by health insurance. In the Netherlands, the average consultation in 2001 lasted just under ten
minutes (see duration consultation for a GP with 2,500 patients in Van den Berg, 2004, p. 321).
GPs in other countries are confronted with a similar situation and research shows that
this has been the case for some years. Between 1996 and 1999, the average consultation time
was only 10.7 minutes (SD = 6.7) for general practices in Germany, Spain, the United Kingdom,
the Netherlands, Belgium and Switzerland – with the shortest consultations in Germany (7.6
minutes on average, SD = 4.3) and the longest in Switzerland (15.6 minutes, SD = 8.7) (Deveugele
et al., 2002, p. 329). In 2001, almost half of all general practice consultations took between six and
ten minutes, 40% longer than ten and about 14% less than six minutes (Cardol et al., 2004, p. 12).
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In this limited amount of time, the doctor not only has to provide the patient with medical advice,
but also has to inform him about the reasons for this advice, alternative treatment options and
possible consequences of refraining from treatment altogether. Accordingly, if an argumentative
discussion about the patient’s health problem arises, from the doctor’s perspective, it has to be
conducted as efficiently as possible.
For the same reasons that underlie the hypothesis about the severity of the patient’s health
problem (see section 6.3.3), it can be expected that ordinary language users will perceive a
doctor’s argument by authority as more reasonable when a doctor indicates that there is a limited
amount of time left to discuss the patient’s health problem. After all, a doctor can avoid a detailed
– and hence lengthy – discussion about the health problem by arguing by authority, which would
save time. Nonetheless, the doctor can in principle still be seen to be pursuing his dialectical goal
of reasonably resolving the difference of opinion with the patient. As when making explicit that
the patient’s health problem is not severe, the reference to a lack of time for further discussion
may be seen as justification of the doctor’s use of an argument by authority.
Because the doctor can avoid a lengthy discussion of the patient’s health problem by
advancing an argument by authority without automatically losing sight of his dialectical goal, it
is hypothesised that:
doctor indicates that there is not enough time available to conduct a discussion about the medical
advice than when the doctor does not indicate this.
This hypothesis was empirically tested in study 3, which is detailed after introducing the other
hypothesis concerning the third order conditions for a critical discussion in medical consultation.
6.3.5 Third order conditions: The patient’s required health literacy

In medical consultation, the external circumstances in which an argumentative discussion
takes place also need to be such that the characteristic asymmetry in medical knowledge and
expertise between a doctor and a patient does not hinder the reasonable resolution of a difference
of opinion between them. Since medicine has become increasingly complex because of better
understanding of health problems and the development of more and more advanced treatment
options, discussions in medical consultation can become rather complex as well. In such complex
discussions, it is the doctor’s task to adapt his discussion contributions to the patient’s level of
health literacy, thereby removing hindrances to the resolution of the difference of opinion on the
merits.
A discussion of medical advice can require a high level of health literacy from the patient
for various reasons. The clinical reasoning behind the medical advice could, for instance, be
quite technical, while the advice itself may be perfectly simple. Take a doctor who recommends
“Take one metoprolol tablet every day” to a patient suffering from hypertension with the
argumentation “Metoprolol interferes with the binding of epinephrine to the beta receptor. It
therefore diminishes stress responses, thus lowering your blood pressure”. In this example, it is
not so much the advice that makes the discussion complex as the argumentation supporting it.
From an argumentative perspective, the complexity arises from the sub-level of the discussion,
rather than the main level.
The reverse is also possible: a high level of health literacy can be required because of
the complexity of the medical advice, while the argumentation supporting it is relatively
79
straightforward. For example, a doctor could advise a diabetes patient to perform at least four
glucose tests a day by obtaining a small blood sample (pricking a finger) and determining the
glucose concentration in this sample (with a reflectance photometer); the patient should then
record the outcomes and compare them to the target ranges (70-130 mg/dl before meals and
less than 180 mg/dl after meals). The doctor might support this rather complex advice with the
argumentation “This will give us insight into the way food intake influences your diabetes and
enables you to adjust your glucose level if it is outside the target range”. In such a case, complexity
of the discussion derives predominantly from the main level of the discussion.
To complicate matters, complex advice could also be supported by complex argumentation.
This would have been the case in the example in which the doctor advises the patient to self-
monitor his glucose levels if the doctor had provided argumentation about the way in which
injecting insulin affects the patient’s measurements (“Self-monitoring enables you to adjust
your glucose level if it is outside the target range, as you can lower the glucose level by injecting
insulin, as this would inhibit the release of glucagon”). The required level of health literacy then
derives from both the main and the sub-level of the discussion.
Of course, a doctor cannot simply change his medical advice just because the patient is
insufficiently health literate to conduct a discussion about it. Yet, it is not always possible for the
doctor to sufficiently increase the patient’s health literacy in practice due to the inherent complexity
of particular health problems. In such a case, the doctor could adapt his argumentation to the
patient by advancing an argument by authority in the medical consultation. As pointed out in the
previous two sections (6.3.3 and 6.3.4), a doctor who argues by authority can strategically avoid
a detailed discussion of the clinical reasons that he has for his medical advice. When arguing by
authority, he provides an indication of the acceptability of the advice rather than going into detail
about the mechanisms underlying it.
As a consequence, it can be expected that a doctor’s argument by authority in medical
consultation will be perceived as more reasonable if the doctor indicates that the patient is
otherwise insufficiently health literate to conduct an in-depth discussion about the patient’s
health problem. Hence, it is hypothesised that:
doctor indicates that the patient is insufficiently health literate to conduct a discussion about the
patient’s health problem than when the doctor does not indicate this.
This hypothesis is tested for argumentative discussions in which the medical advice is relatively
straightforward. This is done in study 3. In the following section, the organisation of this study is
discussed together with the organisation of studies 1 and 2.
6.4 Overall organisation of the experiments
6.4.1 Set-up
The hypotheses discussed in section 6.2 and 6.3 were tested by means of a pencil-and-paper
test in which respondents had to rate the perceived reasonableness of a doctor’s contribution
in short dialogue fragments of an argumentative discussion in medical consultation. This
contribution consisted of either the doctor’s argument by authority, a sound argument by the
doctor that is not authority argumentation, or a fallacy committed by the doctor. In this way, the
80
perceived reasonableness of the doctor’s argument by authority (the dependent variable) could
be contrasted with the control items: other sound arguments and fallacies.
The hypotheses were tested by systematically varying whether the patient refers to a
contradicting source, the amount of consultation time, the severity of the patient’s health problem
and the required health literacy to discuss the medical diagnosis or advice (the independent
variables). These variables were manipulated in three separate studies, each testing the main
hypotheses – H1a (Ordinary language users perceive sound instances of a doctor’s argument by
authority as reasonable) and H1b (Ordinary language users perceive sound instances of a doctor’s
argument by authority as more reasonable than a doctor’s fallacious discussion contributions) –
and two of the hypotheses concerning the higher order conditions. The present set-up with three
separate studies made sure that the questionnaires did not become too extensive or give away too
much of the purpose of the experiment.45 An overview of the hypotheses tested in each study can
be found in figure 6.1.
Figure 6.1 Overview of the hypotheses tested in the three studies
Studies 1-3: - H1a (about the absolute perception of reasonableness of a doctor’s argument by authority)
- H1b (about the relative perception of reasonableness of a doctor’s argument by authority)
Study 1: - H2 (about the effect of the patient’s reference to a contradicting source on the reasonableness
perception)
- H4 (about the effect of the limited consultation time on the reasonableness perception)
Study 2: - H3 (about the effect of the severity of the patient’s health problem on the reasonableness
perception)
- H5 (about the patient’s required health literacy)
Study 3: - H4 (about the effect of the limited consultation time on the reasonableness perception)
- H5 (about the patient’s required health literacy)
The hypotheses were distributed in such a way that in the first two studies, both a hypothesis
concerning the second order conditions and a hypothesis concerning the third order conditions
were tested. Study 3 provided an extra test of two of the hypotheses of the preceding studies: H4
and H5. These hypotheses were selected because the independent variables in these hypotheses
(limited consultation time and patient’s required health literacy, respectively) are at play in every
single medical consultation, while a patient does not always refer to a contradictory source and
likewise the severity of his health problem is not always an issue.
45
The questionnaires would have become far too extensive if all five hypotheses were tested in one single
experiment. To test these hypotheses, a repeated measurement design in combination with a multiple
message design is necessary to safeguard the internal validity of the research (Jackson, 1992) and avoid the
language-as-a-fixed-effect fallacy (Clark, 1973; Meuffels & Van den Bergh, 2005; 2006). Yet, a combination
of these designs when testing all five hypotheses in one experiment with sufficient control items would
mean that the questionnaires become at least twice as long, and it already took respondents about 20 to
25 minutes to fill them out in the current set-up (testing the two main hypotheses and two hypotheses
concerning the higher order conditions).
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In all three studies, a repeated measurement design in combination with a multiple message
design was used. In each study, the questionnaires consist of 48 dialogue fragments in which
a doctor argues in support of a diagnosis or medical advice. In one out of four fragments, the
doctor advances an argument by authority (the items of interest). The other fragments consist of
either a doctor’s sound argumentation in which he does not make use of the argument scheme of
authority argumentation, or of a fallacy committed by the doctor (the control items).46 Figure 6.2
provides an overview of the distribution of the dialogue fragments.
Figure 6.2 Overview of the dialogue fragments in the questionnaires
a. 12 dialogue fragments in which the doctor advances an argument by authority

b. 12 dialogue fragments in which the doctor advances a sound argument that is not authority
argumentation
c. 6 dialogue fragments in which the doctor commits an ad baculum fallacy
d. 6 dialogue fragments in which the doctor commits a fallacy of evading the burden of proof
e. 6 dialogue fragments in which the doctor commits a direct ad hominem fallacy
f. 6 dialogue fragments in which the doctor commits a fallacy of declaring the standpoint taboo
The idea behind the distribution of the 48 dialogue fragments is that a generalizable set of
arguments by authority can be tested by means of the questionnaire without giving away
the purpose of the research. This is important because if the respondents were to guess this
purpose, both the internal and the ecological validity of the experiments would be jeopardised.
It is known that, in general, respondents will attempt to fill-out a questionnaire in the way they
think confirms the hypothesis at hand – this effect is also known as ‘subject-bias’, or ‘S-bias’ for
short (see, amongst others, Lester, 1969; Orne, 1962) – resulting in pseudo-confirmation of the
hypothesis.
By presenting the respondents with 12 dialogue fragments in which a doctor advances
an argument by authority, it is possible to include several instantiations of this argument in
the different consultative situations needed to test the hypotheses regarding the higher order
conditions. Table 6.1 provides an overview of the consultative situations that are tested in these
12 fragments.
Of the 36 dialogue fragments in the questionnaire in which no authority argumentation
is advanced, one-third consist of sound arguments by the doctor and two-thirds of fallacious
discussion contributions. This is done to balance the amount of sound arguments against the
amount of fallacious arguments – in the final design, together with the dialogue fragments in
which a doctor argues by authority, the questionnaire consists of one half of dialogue fragments
in which no violation of the rules for a critical discussion occurs and of the other half of fragments
in which one of these rules is violated.
46
It should be noted that the argumentum ad verecundiam, the fallacious counterpart of authority
argumentation, was not tested in the present studies. The reason for leaving this fallacy out is that in items
in which a doctor commits an argumentum ad verecundiam, the doctor’s standpoint needs to be changed
from advice about the patient’s health problem to advice on something outside of the medical field (holiday
destinations, cars, hairdos, etc.). Therefore, the dialogue fragments might come across as artificial (it is
not the doctor’s task to give advice on those other fields). In the replication of the present studies, ad
verecundiam-items were nonetheless incorporated in order to control for the argument scheme in the tested
sound and fallacious items (see chapter 7).
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The respondents had to rate their perception of reasonableness of both the sound and fallacious
dialogues in exactly the same way as they had to rate for the dialogues in which a doctor advanced
an argument by authority. The ratings for these sound and fallacious dialogue fragments
provide a framework against which the evaluations of the doctor’s argument by authority can be
interpreted: these ratings can be used to create a reasonableness scale – ranging from sound to
fallacious – on which the evaluations of these arguments by authority can be placed.
Table 6.1 Overview of the consultative situations tested in the dialogue fragments in which
the doctor advances an argument by authority
Study 1 Study 2 Study 3
(H2 + H4) (H3 + H5) (H4 + H5)
4 items the patient there is the doctor the patient is the doctor the patient is
in which refers to a & enough indicates & sufficiently indicates & sufficiently
(in each): contradicting time. that the health that there is health
source health literate. not enough literate.
problem is time
severe
4 items the patient the doctor the health the doctor there is the doctor
in which does not & indicates problem is & indicates that enough & indicates that
(in each): refer to a that there not severe the patient is time the patient is
contradicting is not insufficiently insufficiently
source enough health health
time. literate. literate.
4 items the patient there is the health the patient is there is the patient is
in which does not & enough problem is & sufficiently enough & sufficiently
(in each): refer to a time. not severe health time health
contradicting literate. literate.
source
To avoid creating distinctly different consultative situations, which would prevent an adequate
comparison, the situations for the control items were kept similar to those in the items in which
the doctor argues by authority. More precisely, the various values of the independent variables
were assigned at random to control items; in some of these items, the doctor and patient have a
discussion about a severe health problem, in others, the doctor mentions that he does not have
enough time to fully discuss the health problem, etcetera.
The selection of the particular fallacies included in the control items (ad baculum threats,
evasions of the burden of proof, direct ad hominem attacks and instances of declaring the
standpoint taboo), depended on the reported reasonableness scores of these fallacies in the
literature and on their perceived authenticity when being committed by a doctor in medical
consultation. First, only fallacies were selected that consistently received low reasonableness
scores in previous studies (van Eemeren, Garssen & Meuffels, 2009, p. 223). The reason for
their inclusion is that the scores for these fallacies create a clear baseline against which the
reasonableness scores of the doctor’s arguments by authority can be compared.
What is more, these reasonableness scores provide a measure for the reliability of the
present research. Significant differences from the baseline scores for these fallacies would suggest
low reliability in the present study, unless these differences could be explained by the change in
83
communicative activity type in which the fallacies are tested (for instance, if it were found that
ordinary language users find everything that a doctor says to be reasonable). In principle, the
obtained scores can, thus, be used to check the external validity.
Second, of the fallacies with consistently low reasonableness scores, only those were selected
that a doctor can, in principle, commit without compromising the authenticity of the medical
consultation. Particularly in a highly institutionalised activity type such as medical consultation,
certain fallacies automatically render a discussion artificial. Due to the institutionalised nature of
these activity types, there is a clear demarcation between the discussion moves that are allowed
and the ones that are not. Fallacies that constitute moves that are not allowed would render
the discourse in such an activity type inauthentic. An example of such a fallacy in medical
consultation would be a doctor who commits an argumentum ad misericordiam (“Please, don’t
refuse this treatment; I’ve been working on it for such a long time”). The danger of including
such fallacies as control items is that respondents might find them unreasonable because of their
inauthenticity rather than their fallaciousness. Therefore, they were left out of the present studies.
6.4.2 Materials
The questionnaires used in each of the three studies consist of hypothetical three-turn dialogue
fragments of a discussion between a doctor (a general practitioner) and a patient in medical
consultation. To safeguard the internal validity of the studies, the dialogue fragments have a fixed
pattern (see figure 6.3).
Figure 6.3 Schematic representation of the dialogue fragments in studies 1 to 3
Background information on why the patient is consulting the doctor and, if necessary to understand
the dialogue fragment below, what has happened before the fragment occurs.
1. Doctor: Gives diagnosis or medical advice

2. Patient: Expresses doubt about this diagnosis or advice [and, in some cases, refers to a contradicting
source]
3. Doctor: Advances a sound argument in support of the diagnosis or advice given in turn 1 / commits
a fallacy [and, in some cases, indicates that the health problem is severe / there is not enough
time / the patient is insufficiently health literate]
As shown in the schematic representation in figure 6.3, at the start of each dialogue fragment,
a brief description is given of the reason the patient is visiting the doctor: “A patient has been
suffering from a piercing ache in his lower back”. If needed to understand the dialogue, information
is provided about what happened before the dialogue fragment occurs: “The GP examines the
patient thoroughly and is running out of time because of that. He establishes an inguinal hernia,
for which he refers the patient to the hospital”. These descriptions are provided to clarify the
starting points of the argumentative discourse that follows. Hence, alternative interpretations
of the dialogue fragment are excluded as much as possible, so that the respondents interpret the
dialogue fragments in a uniform manner. Moreover, by presenting the information about the
patient’s health problem and medical history as a given, the respondents will be steered to judge
the argumentative aspects of the dialogue fragments that follow rather than the clinical aspects.
In the first turn of the dialogue, the doctor provides the patient with a diagnosis (“I’m afraid
you’re suffering from a bladder infection”) or medical advice (“It’s wise to preventively remove
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this birthmark”). In argumentative terms, this is the turn in which the doctor presents his
standpoint. In line with the characteristics of medical consultation, the doctor explicitly expresses
his diagnosis or advice – in medical consultation it is the patient’s goal to obtain this diagnosis
or advice, so it would be quite unrealistic and unsatisfactory for the doctor to leave it implicit.
Subsequently, the patient reacts to the doctor’s standpoint by expressing doubt about the
diagnosis or medical advice in turn two (“Is that really necessary?”). In this standard set-up, the
doctor and the patient can, thus, be said to have a non-mixed difference of opinion (a difference
of opinion in which the antagonist doubts the protagonist’s standpoint, but does not oppose it).
After all, the doctor’s standpoint is met with the patient’s doubt. By expressing doubt, the patient
requests the doctor to provide argumentation in support of his standpoint. The expression of
doubt indicates that the standpoint is not immediately acceptable to the patient, even if the
question is intended as a purely informative one.
An exception to this design is made in order to test H2 (the hypothesis concerning the
patient’s reference to a contradicting source). To test this hypothesis, the patient refers to a
contradicting source in turn two of the dialogue fragments (“But I read on the internet that
antibiotics would work best”). Consequently, the difference of opinion between the doctor
and the patient can be reconstructed as mixed (a difference of opinion in which the discussion
parties oppose each other’s standpoints) – although it should be noted that the patient does
not explicitly put forward a negative standpoint; he only indicates his negative position to the
doctor’s diagnosis or medical advice.
In the next turn of the dialogue fragments, turn three, the doctor advances an argument
in support of his diagnosis or advice (“As a doctor, I know that a couple of days rest is really the
best thing to do in your situation”). This is the crucial turn, because it is precisely this turn that
the respondents have to rate. In the items of interest, the doctor specifically advances a sound
argument by authority. In the control items, the doctor either advances a sound argument that is
not authority argumentation or commits a fallacy.
To test H3 to H5, the doctor also indicates, in turn three, whether the problem is severe
(“This is too serious a matter to just…”), whether there is enough time (“In view of the limited
time…”) or whether the patient needs specific medical comprehension to discuss the diagnosis
or medical advice in detail (“It’s a bit too complicated for now, but…”). In the control items, the
doctor refers at random to the severity of the health problem, time restraints or the difficulty of
the issue under discussion.
Figure 6.4 provides an example of each of the different consultative situations in the
dialogue fragments.47 Figure 6.4a shows the ‘neutral’ consultative situation: a consultative
situation in which a patient does not refer to a contradicting source and the doctor does not
indicate that the health problem is severe, or that there is a lack of time or that specific medical
comprehension is necessary. The doctor simply recommends that he removes the patient’s warts
(turn 1), the patient asks for support of this advice without referring to other sources (turn 2) and
the doctor advances an argument by authority to provide this support without saying anything
about the severity of the health problem, time limitations or required health literacy (turn 3).
Dialogues like this were used as a comparison for the reasonableness scores for the arguments by
authority in the other consultative situations.
47
The dialogue fragments in figure 6.4 only serve as illustration of the used material. Of course, more
instantiations were included in the questionnaires.
85
Figures 6.4b-e provide an illustration of the other consultative situations: in figure 6.4b, the
patient refers to a contradicting source (“I read on the internet that…” in turn 2); in 6.4c, the
doctor indicates that the health problem is severe (“Well, a lump can be very severe” in turn 3); in
6.4d, he indicates that there is not enough time (“Unfortunately, due to the time, I can’t elaborate
on it…”) and in 6.4e, he indicates that the patient is insufficiently health literate (“Well, that’s
quite a technical issue...”).
Figure 6.4 Examples of a doctor’s argument by authority in the tested consultative situations
Figure 6.4a The ‘neutral’ consultative situation

A patient visits the doctor with several small warts on his hands. The doctor examines the warts and
says that he can best immediately remove them.
1. Doctor: I can best remove those little fellows immediately; a bit of nitrogen on them and they’re gone
within a second.
2. Patient: Don’t I have to go to the hospital for that?
3. Doctor: No, really, I’ve removed them so often, it’s a piece of cake.
Figure 6.4b The patient refers to a contradicting source

A patient consults his doctor because, for the past couple of days, he has had an itch in his nose. The
doctor thinks that it might be an allergic reaction.
1.
Doctor: You can best make an appointment with my assistant so that we can do an allergy test.
2. Patient: Is such a test really necessary? I read on the internet that you can determine what you’re
allergic to just by looking at the symptoms.
3. Doctor: Well, as a doctor, I can assure you that such an allergy test is medically required.
Figure 6.4c The doctor indicates that the health problem is severe
A patient visits the doctor because she feels a lump in her breast. The doctor examines the patient
and advises her to go to the hospital.
1. Doctor: You will have to get a mammography, an ultrasound and a puncture.

2. Patient: Do I have to? I really dread all those procedures.
3. Doctor: Well, a lump can be very severe. Based on my expertise as a doctor, I know that you really
need to undergo these procedures.
Figure 6.4d The doctor indicates that there is not enough time available to fully discuss the
medical advice
A patient has been suffering from a severe, throbbing headache for some days now. The doctor
establishes that the patient is suffering from sinusitis. At the end of the consultation, the doctor
rounds the conversation off as follows:
1. Doctor: You could best take a couple of days rest.

2. Patient: Is that really necessary?
3. Doctor: Yes, it is. Unfortunately, due to the time, I can’t elaborate on it, but trust me that a couple of
days rest is best.
86
Figure 6.4e The doctor indicates that the patient is insufficiently health literate
An asthma patient consults his doctor because he makes a wheezing sound when breathing. At
present, he uses the medicine Seretide, but he wonders whether his medication should be changed.
1. Doctor: We can’t just stop with the Seretide. What we can do is increase the level of corticosteroids in it.
2. Patient: But why can’t we just stop with it?
3. Doctor: Well, that’s quite a technical issue, but take it from me that we can’t just do that.
As the overview in figure 6.4 illustrates, the consultation topics in the questionnaire vary from a
simple headache to a potentially malignant tumour. This variety is included to faithfully reflect
the issues that arise in primary care and, hence, to ensure ecological validity. By consulting
literature on medical practice, it was ensured that, in the selection of the health problems for the
dialogues, these problems were realistic (Would a patient consult his GP for the health problem
in question?) and the doctor’s diagnosis or advice was clinically correct (Is the doctor’s advice and
argumentation medically viable?).
A similar variety of health problems was discussed in the control items. This is illustrated
in figure 6.5. More precisely, 6.5a provides an example of the items in which a doctor advances a
sound argument that is not authority argumentation and 6.5b-e provide examples of the items in
which the doctor commits a fallacy.
Figure 6.5 Examples of control items
Figure 6.5a Sound argumentation that is not authority argumentation

A patient takes the Diane-35 birth control pill, but wants to change to another contraceptive because
the Diane-35 brings a high risk of causing blood clots.
1. Doctor: If you want to change to another birth control pill, I can recommend Microgynon-30.
2. Patient: Is that pill safer than the Diane-35?
3. Doctor: Yes, Microgynon-30 brings a much lower risk of causing blood clots.
Figure 6.5b The doctor commits an ad baculum fallacy

A patient consults his doctor about severe coughing and shortness of breath. The doctor asks her if
she has been smoking. The patient indicates that she has been smoking for about thirty years now.
1. Doctor: Given your age and the number of years that you’ve been smoking, I think you’re suffering
from chronic bronchitis.
2. Patient: Well, surely, it can’t be that bad, can it?
3. Doctor: I’m afraid it can be. And if you don’t quit smoking now, I’m afraid you’ll have to find
yourself another doctor.
Figure 6.5c The doctor evades the burden of proof

A patient suffers from intestinal problems, weight loss and is constantly tired. The doctor diagnoses
him as follows:
1. Doctor: I’m afraid that you’ve got celiac disease, meaning that you’re gluten intolerant.
2. Patient: Can’t it be something else? I read on the internet that it might have to do with iron deficiency.
87
3. Doctor: No, it’s too technical an issue to fully discuss here, but it speaks for itself that we’re
dealing with celiac disease.
Figure 6.5d The doctor commits a direct ad hominem fallacy

For the past couple of days, a patient has had a very high temperature and has vomited a lot. He
decides to consult the doctor.
1. Doctor: You’ve caught the flu, so it’s best to drink a lot of water and get plenty of rest.
2. Patient: Is there nothing else I can do? I’ve heard that Tamiflu might help.
3. Doctor: Well, you don’t have a background in medicine, do you? In your case, Tamiflu won’t help.
Figure 6.5e The doctor declares the standpoint taboo

A patient consults her doctor about sudden, severe, one-sided headaches that are accompanied by
nausea. The doctor establishes that she is suffering from migraines.
1. Doctor: I’ll give you a prescription for Naproxen against the headache and Metoclopramide against
the nausea.
2. Patient: Aren’t there any homeopathic remedies that I could use?
3. Doctor: I’m sorry, but I won’t discuss homeopathic remedies out of principle.
As in the dialogue fragments in which the doctor advances an argument by authority, these
control dialogue fragments proceed in such a way that, in turn 1, the doctor gives a diagnosis or
medical advice and, in turn 2, the patient indicates hesitance to directly adopt the standpoint (and
sometimes refers to a source that contradicts the doctor’s diagnosis or advice). However, rather
than advancing an argument by authority in support of the medical advice, the doctor presents
a sound argument that is not authority argumentation (“Microgynon-30 brings a much lower
risk of causing blood clots”) in 6.5a, an argumentum ad baculum (“And if you don’t quit smoking
now, I’m afraid you’ll have to find yourself another doctor”) in 6.5b, an evasion of the burden of
proof (“it speaks for itself that we’re dealing with celiac disease”) in 6.5c, a direct variant of the
argumentum ad hominem (“Well, you don’t have a background in medicine, do you?”) in 6.5d, and
an instantiation of declaring the standpoint taboo (“I won’t discuss homeopathic remedies out of
principle”) in 6.5e. Furthermore, in the same way as in the items with authority argumentation,
the doctor indicates in turn 3 of some of the control items that the health problem is severe, that
there is not enough time or that the patient is insufficiently health literate.
The dialogue fragments were constructed collaboratively with students of speech
communication and a colleague (a pragma-dialectician) at the University of Amsterdam and
underwent three rounds of revision before being deemed suitable for inclusion in the study.
In the construction of the fragments, attention was first and foremost paid to whether the
doctor contributes to the discussion in the intended way (does the doctor really advance sound
argumentation of the intended type / commit the intended fallacy?). Additionally, also the
authenticity of the way in which the discussion is conducted was taken into account (does it befit
the activity type of medical consultation?). Attention was also paid to the length of the dialogues:
the dialogues were kept as concise as possible to ensure that filling out the questionnaire would
not take too much time (can the dialogue not be kept shorter?).
During the revision process, the overall uniformity of the dialogue fragments (does the
conversation in the dialogues proceed in an identical manner?) and their stylistic variety (do the
88
doctor and patient present their discussion contributions in a sufficiently diverse manner?) were
also evaluated. Dialogues that proceeded in too diverse a manner were made more uniform. For
instance, if a doctor advanced argumentation in the first turn of the dialogue, this argumentation
was removed or moved to the third turn. At the same time, variation was introduced in the way in
which the doctor and patient express themselves. Figure 6.6 illustrates the various formulations
used for the presentation of a doctor’s argument by authority in the dialogue fragments.
Figure 6.6 Overview of the different formulations used by the doctor to advance an argument
by authority in the dialogue fragments (original Dutch formulations in grey)
a. As a doctor / GP, I know / am of the opinion that…

Als arts / huisarts weet / vind ik dat…
b. Based on my medical experience(s) / expertise / knowledge / proficiency / skills …
Op basis van mijn medische ervaring(en) / expertise / kennis / deskundigheid / vaardigheden …
c. I have done / encountered / performed / seen X many times before.
Ik heb X vaak gezien / gedaan / uitgevoerd / Ik ben X vaak tegengekomen.
d. From a professional point of view, I advise / recommend you to… / think that…
Vanuit professioneel oogpunt adviseer ik u / raad ik u aan om… / denk ik dat…
e. (You can) take it from me that…
U kunt / mag van mij aannemen dat… / Neemt u maar van mij aan dat… / Neem van mij aan dat…
f. (You can) trust me…
U kunt op mij vertrouwen… / Vertrouwt u mij maar dat… / Vertrouw maar op mij…
After each dialogue fragment, the respondents were asked how reasonable they would find
the doctor’s last contribution to the conversation (consisting of the argument in support
of his medical advice / diagnosis) if they were the patient in the dialogue. To make sure that
the respondents concentrated their evaluation on the turn in which the doctor advanced the
argument, respondents were explicitly asked to evaluate the doctor’s last contribution (made in
turn 3) to the conversation. Additionally, this contribution was printed in bold type to emphasise
that the respondents had to evaluate this part of the dialogue fragment.
Figure 6.7 Reasonableness scale in studies 1 to 3

If you were the patient in the conversation above, how reasonable would you find the doctor’s last
contribution to this conversation?
very unreasonable fairly neither fairly reasonable very

unreasonable unreasonable unreasonable, reasonable reasonable
nor reasonable
O O O O O O O
As depicted in figure 6.7, the respondents had to indicate their reasonableness judgments on
a 7-point Likert scale, ranging from “very unreasonable” (= 1) to “very reasonable” (= 7). In
the pragma-dialectical theory, the concept of reasonableness is a binary concept; a discussion
contribution is either reasonable (and hence sound) or unreasonable (and hence fallacious) (see
van Eemeren & Grootendorst, 1992, pp. 104-106; 2004, p. 190). However, ordinary language
users have a more gradual conception of reasonableness (van Eemeren, Garssen & Meuffels,
89
2009, p. 57). Therefore, asking them whether or not a discussion contribution is reasonable
would not do justice to their actual perception of reasonableness.
Van Eemeren, Garssen and Meuffels (2009, p. 57) indeed argue that a binary question about
reasonableness would lead to difficulties in quantitative experimentation, because answering it
introduces a lot of random error. Some of the respondents may evaluate a discussion contribution
as “unreasonable” when they do not find it perfectly reasonable (and so the “reasonable” option
does not fully apply), while others may evaluate it as “reasonable” because it is not completely
“unreasonable” (and so the “unreasonable” option does not fully apply). Indeed, van Eemeren,
Garssen and Meuffels (2009, p. 57) have shown in their empirical research that even a 5-point
scale insufficiently corresponds with the respondents’ conception of reasonableness. They
therefore opted for a 7-point scale, which provides sufficiently consistent reasonableness scores.
For that reason and to enable fair comparison with the studies conducted by van Eemeren,
Garssen and Meuffels (2009), such a scale will be used in the present studies as well.
To be able to compare the respondents’ reasonableness evaluations in studies 1 to 3 with
the findings of the research on fallacies conducted by van Eemeren, Garssen and Meuffels (2009),
exactly the same (Dutch) formulations were used to describe the anchor points on the scale.48 The
reliability of the present studies can, in this way, be determined by analysing whether the scores
for the control fragments do not significantly differ from the scores in the previous research – if
they do not, this indicates reliability in the present study.
6.4.3 Respondents
A total of 295 respondents took part in the studies: 95 respondents in study 1, 100 in study 2
and 100 in study 3. To ensure that the respondents had experience of taking part in a medical
consultation, and are therefore representative of ‘patients’ in general, respondents were not
recruited from groups of secondary schools pupils – which is often done in quantitative research
on argumentation. Instead, the students conducting the experiments asked acquaintances,
(former) colleagues, friends, family, neighbours and fellow train passengers to participate in the
studies.49
Respondents were between 17 and 74 years old, with an average age of 38 (SD = 13.5).
A slight majority of the respondents were female (54.1%). The majority of the respondents
were higher educated (73.3% higher educated versus 24.8% lower educated)50 A minority had
received education in the medical sciences (7.5%) or worked in the medical sector (6.8%). The
respondents selected had not been taught argumentation theory, so they can be regarded as
48
O On the Dutch scale that was used, 1 indicated uiterst onredelijk, 2 onredelijk, 3 vrij onredelijk, 4 noch
redelijk, noch onredelijk, 5 vrij redelijk, 6 redelijk and 7 uiterst redelijk.
49
In study 1, 23 respondents consisted of employees of the Dutch Inspectorate of Education, 7 of the
Community Health Services, 17 of ICT company Lost Lemon, 18 respondents were acquaintances, and
30 were neighbours of one of the students’ parents. In study 2, two thirds of the respondents consisted
of employees of the Bonhoeffercollege in Castricum and the Vellesan College in IJmuiden. The other 33
respondents were employees of various companies in interactive media or acquaintances. In study 3,
the respondents consisted of employees at Schiphol airport (air hostesses, pilots and military police),
acquaintances, and Dutch train passengers on a train trip from Amsterdam to Berlin.
50
Respondents were considered to be ‘higher educated’ if their highest educational level consists of:
university education (wo), pre-university education (vwo) or higher vocational education (hbo). They were
considered to be ‘lower educated’ if their highest educational level is: intermediate vocational education
(mbo), higher general secondary education (havo), lower vocational professional education (vmbo) or
primary school (basisschool). Respondents who indicated that they did not complete any of these educational
programmes or failed to indicate their highest completed educational level were categorised as ‘other’.
90
“naive” from an experimental perspective. It took the respondents 20 to 30 minutes to complete
the questionnaire.
6.4.4 Instruction
At the start of the questionnaires, a page with instructions was provided. The respondents were
informed that the dialogue fragments they were about to evaluate consisted of hypothetical
conversations between a patient and a general practitioner during a medical consultation.
They were, furthermore, told that the dialogues concerned a problem about which the patient
consulted the doctor. It was neither mentioned that the fragments consisted of argumentative
discussions, nor that the respondents had to evaluate the doctor’s argumentation. This was left
implicit to avoid disclosing too much about the goal of the study. To nonetheless provide some
explanation as to why this research was conducted, it was emphasised that people have different
ideas about what is reasonable and what is not, and that the way in which they differ in their ideas
about reasonableness was being investigated in the present study.
Respondents were told that they did not need to have any medical expertise to give their
judgments of reasonableness and that there are no right or wrong answers (“it is exclusively about
your own opinion about the (un)reasonableness of the last conversational contribution of the
GP”). The respondents were, in this way, encouraged to provide their own evaluations, rather
than what they think is expected of them – which would in all likelihood have resulted in S-bias.
They were also instructed to assume that in the dialogue fragments the doctor and patient were
always sincere, so that they were encouraged to give a literal interpretation of the items – thereby
safeguarding internal validity.
To make sure that the respondents take the specifics of each item into account, it was
stressed that they should put themselves in the situation described in the fragment (“Because
content, context and discussion style can differ per fragment, I would like to ask you to
constantly put yourself in the described situation and, based on that, evaluate the conversational
contributions”). The respondents were reminded of this instruction in every single item (“If
you were the patient in the conversation above, how reasonable would you find the doctor’s last
contribution to this conversation?”, my italics).
6.5 Results
Now that the set-up of the studies has been explained, the results are reported. First, with respect
to the general hypotheses, H1a (Ordinary language users perceive sound instances of a doctor’s
argument by authority as reasonable) and H1b (Ordinary language users perceive sound instances
of a doctor’s argument by authority as more reasonable than a doctor’s fallacious discussion
contributions), the average reasonableness scores for a doctor’s argument by authority have
to be respectively compared with those for a doctor’s sound argument that is not authority
argumentation and those for a doctor’s fallacies.
Table 6.2 shows the average reasonableness scores in the three studies combined and per
study separately. In general, the doctor’s argument by authority received a score of 3.99 (.99),
which translates to an evaluation of “neither unreasonable, nor reasonable” on the scale that
was used in the experiments. This is a very surprising result: based on van Eemeren, Garssen
and Meuffels (2009), it was expected that the doctor’s sound use of an argument by authority
would receive a much higher score, a score indicating that this argument is “reasonable” or,
91
at least, “fairly reasonable”. In their experiments, they consistently obtained such scores for
sound argumentation in their empirical research. Yet, a simple one sample t-test shows that
the reasonableness score that the doctor’s argument by authority received in the present studies
differs significantly (p< .001) from a score of 5 (“fairly reasonable”). 51 This result means that
H1a (Ordinary language users perceive sound instances of a doctor’s argument by authority as
reasonable) has to be rejected.
Table 6.2 The average reasonableness scores for a doctor’s argument by authority, other
sound argumentation and fallacious contributions in the three studies combined
and per study separately
Discussion contribution Study 1-3 Study 1 Study 2 Study 3

by the doctor (combined) (H2 + H4) (H3 + H5) (H4 + H5)
Argument by authority 3.99 3.41 4.27 3.66
(.99) (.84) (.77) (.88)
Other sound argumentation 5.54 5.67 5.47 5.47
(.68) (.66) (.66) (.71)
Fallacious contributions 2.40 2.43 2.37 2.39
(.72) (.62) (.68) (.86)
Scale values are means with SD between brackets
What is more, as shown in table 6.2, the average reasonableness score for a doctor’s sound
arguments in which he does not make use of the scheme of authority argumentation is 5.54 (.68)
for the three studies combined, which corresponds with a score between “fairly reasonable” and
“reasonable” on the scale used in the experiments. Compared to the average reasonableness scores
for the doctor’s argument by authority, the other sound arguments by the doctor are perceived
as significantly more reasonable (F’study1 (1, 24) = 49.99; p< .001; ES = .44; F’study2 (1, 25) = 11.42;
p< .001; ES = .44; and F’study3 (1, 22) = 16.50; p< .001; ES = .27).52 These significant differences
underline how remarkable the reasonableness scores for a doctor’s argument by authority are:
at first sight, there is no theoretical reason to expect such a difference between the argument
by authority and other sound arguments, for both are correct instantiations of an appropriate
argument scheme. They could, nonetheless, have to do with the specific characteristics of the
particular activity type of medical consultation.
Although the respondents did perceive the doctor’s argument by authority as less
reasonable than other sound arguments, they did not perceive the argument by authority as
equally unreasonable as the fallacious discussion contributions by the doctor. On average,
respondents gave fallacious discussion contributions a score of 2.40 (.72) in the three studies
combined (see table 6.2), meaning that they regarded the fallacious contributions to be between
“unreasonable” and “fairly unreasonable”. In each of the three studies, the respondents judged the
doctor’s argument by authority as significantly more reasonable than the items in which a doctor
commits an argumentum ad baculum, evades the burden of proof, commits a direct argumentum
ad hominem and declares the standpoint taboo combined (F’study1 (1, 23) = 4.35; p< .05; ES = .07;
51
To be sure, the mean score of 3.99 (.99) for the doctor’s argument by authority does not significantly
differ from a score of ‘4’ (“neither unreasonable, nor reasonable”) (t(288) = -1.64; p>.05).
52
These quasi-Fs are calculated per study to check for reliability.
92
F’study2 (1, 24) = 27.94; p< .001; ES = .32; and F’study3 (1, 23) = 4.08; p ≈ .05; ES = .09).53 Therefore,
H1b (Ordinary language users perceive sound instances of a doctor’s argument by authority as
more reasonable than a doctor’s fallacious discussion contributions) can be accepted.
The following conclusions can be drawn about the hypotheses concerning the second
order conditions for conducting argumentative discussions in medical consultation (H2 and H3).
H2 (Ordinary language users perceive a doctor’s argument by authority as more reasonable when
the patient refers to a source that contradicts the (support of the) doctor’s medical advice than
when the patient does not do this) has to be rejected. Despite the fact that the respondents did
judge the reasonableness of the doctor’s argument by authority as more reasonable when the
patient refers to a contradicting source, as shown in table 6.3, this difference proved not to be
statistically significant (F’(1, 6) = 2.14; p> .05).
The other hypothesis concerning the second order conditions, H3 (Ordinary language users
perceive a doctor’s argument by authority as more reasonable when the doctor indicates that the
patient’s health problem is not severe than when the doctor does not indicate this), also needs to be
rejected. When the doctor indicated that the health problem was severe, respondents perceived the
reasonableness of a doctor’s argument by authority as 4.98 (.96) (“fairly reasonable”) (see table 6.3).
It seems that the relationship between the severity of the patient’s health problem and the perception
of reasonableness of the doctor’s argument by authority is the opposite of what is hypothesised, but
this cannot be concluded since this difference is not statistically significant (F’(1, 7) = 4.43; p> .05).
In sum, ordinary language users’ perception of reasonableness of a doctor’s argument by authority
is not significantly influenced by the severity of their health problem.
Table 6.3 The average reasonableness scores for the various consultative situations
in which a doctor advances an argument by authority
Consultative situation Reasonableness score

Neutral situation 3.99
(.99)
Contradicting source (H2) 4.64
(1.11)
Severe health problem (H3) 4.98
(.96)
Not enough time (H4) 2.56
(.94)
Insufficiently health literate (H5) 3.64
(1.06)
With respect to the hypotheses about the consultative circumstances affecting the fulfilment
of the third order conditions, H4 (Ordinary language users perceive a doctor’s argument by
authority as more reasonable when the doctor indicates that there is not enough time available
to conduct a discussion about the medical advice than when the doctor does not indicate this)
has to be rejected. Remarkably, the respondents perceived the doctor’s argument by authority
as significantly less – instead of more – reasonable when the doctor indicated that there was not
53
In fact, even in an absolute sense, a doctor’s argument by authority was not perceived as unreasonable:
it received a significantly (p< .001) higher reasonableness score than 3 (“fairly unreasonable”).
93
enough time (see table 6.3; 2.56 (.94)) than when he did not indicate this (F’(1, 6) = 12.45; p<
.05; ES = .26). This means that, in fact, the opposite of what was hypothesised seems to hold
true: ordinary language users perceive a doctor’s argument by authority as less reasonable when
the doctor indicates that there is not enough time available to conduct a discussion about the
medical advice than when the doctor does not indicate this.
Similarly, H5 (Ordinary language users perceive a doctor’s argument by authority as more
reasonable when the doctor indicates that the patient is insufficiently health literate to conduct
a discussion about the patient’s health problem than when the doctor does not indicate this),
the other hypothesis concerning the third order conditions, also has to be rejected. When the
doctor indicates that the patient is insufficiently health literate, the respondents perceived this
argument by authority to be “neither unreasonable, nor reasonable” (see table 6.3; 3.64(1.06)). A
quasi-F test shows that this score does not differ significantly from the reasonableness score that
respondents provided for a doctor’s argument by authority when the doctor does not indicate
that the patient is insufficiently health literate (F’(1, 6) = 1.35; p> .05). How this result and the
results previously presented in this section can be explained is discussed in the following section.
6.6 Discussion
The results presented in the previous section indicate that patients perceive a doctor’s sound
argument by authority as less reasonable than his sound use of other argument schemes. This
was unexpected, since there is, from a pragma-dialectical perspective, no difference between the
sound use of the argument by authority and other appropriate argument schemes; in principle,
neither frustrates or hinders the reasonable resolution of a difference of opinion. What might
nevertheless explain the obtained difference is that a doctor’s use of an argument by authority
influences the way in which patients perceive the fulfilment of his institutional obligations, while
the other sound arguments do not.
The doctor’s choice to advance an argument by authority could be perceived as going
against his obligation to obtain informed consent (to provide the patient with all possible
considerations and details about his health problem or the treatment thereof). After the change
from a paternalistic approach to a more patient centred approach (see chapter 2), a doctor’s
argument by authority might be perceived as too paternalistic. So, rather than regarding this
argument as less reasonable from an argumentative perspective, the respondents might have
regarded it as less reasonable from an ‘institutional perspective’.
This tentative explanation can only hold if the unexpected lower scores for sound argument
by authority cannot be explained by problems with the design of the studies. However, it is unlikely
that problems with the design explain the lower scores, since the perceived reasonableness scores
for the control items are quite similar to those in the studies by van Eemeren, Garssen and Meuffels
(2009). Both the respondents’ reasonableness scores of the doctor’s sound argumentation that is
not authority argumentation and each individual fallacy (ad baculum, evasion of the burden of
proof, direct ad hominem and declaring the standpoint taboo) are in line with what was found in
the cited studies (see table 6.4), thereby indicating the reliability of the present studies.
What is notable in the evaluation scores of the fallacies obtained in the present studies is
that, apart from evasions of the burden of proof, each of the fallacies receives a lower score than
in the research by van Eemeren, Garssen and Meuffels (2009). These lower scores support the
idea that respondents evaluated the argumentation partly from an institutional perspective. A
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possible explanation is that in the activity type of medical consultation, a doctor is institutionally
charged with behaving rationally and for taking the patient and his health problem seriously. As
a consequence, committing a fallacy could be held against a doctor more than against discussion
parties in less institutionalised activity types. It is, for instance, unpleasant if a friend commits an
ad baculum in a discussion with you, but presumably even worse if your doctor does this.
Table 6.4 The average reasonableness evaluation for each discussion contribution in the
present studies contrasted with the average score it received in the experiments
by van Eemeren, Garssen and Meuffels (2009, pp. 94, 131 & 185)
Discussion contribution Study 1-3 Van Eemeren, Garssen and Meuffels

(combined)
Sound argumentation 5.54 5.88
(excluding authority argumentation) (.68) (.73)*
Argumentum ad baculum 2.26 2.79**
(.94) (.60)
Evasion of the burden of proof 3.38 2.06***
(.83) (.86)
Argumentum ad hominem (direct) 1.98 2.91
(.86) (.64)
Declaring the standpoint taboo 2.01 2.79
(.82) (.66)
Scale values are means with SD between brackets; * see note 54; ** see note 55; *** see note 56
Interestingly, a closer look at the data reveals that not every respondent evaluated the
reasonableness of a doctor’s argument by authority in the same manner. Respondents aged 60
and over evaluated this argument on average with a score of 4.53 (1.37) (in between “neither
unreasonable, nor reasonable” and “fairly reasonable”), while respondents under the age of 60
gave it on average a 3.95 (.95) (“neither unreasonable, nor reasonable”). This difference turns out
to be significant (F(18, 283) = 4.09, p< .05; ES = .02).
54
To give a comprehensive overview, only one score for sound argumentation (excluding authority
argumentation) is reported in table 6.4: the score for the evaluation of sound (non-populistic) argumentation
from van Eemeren, Garssen and Meuffels’s (2009, p. 184) empirical research on the argumentum ad populum.
This score is indicative of the general reasonableness scores that they obtained for sound argumentation –
for example, a score of 5.27 (.60) and 5.32 (.60) in their research on the argumentum ad consequentiam, a
score of 5.31 (.66) in their research on the fallacy of the slippery slope, and a score of 4.74 (.83) in their
research on the fallacy of false analogy (van Eemeren, Garssen and Meuffels, 2009, pp. 176, 179, 187 & 189).
55
The reported score is for the evaluation of the “indirect” ad baculum (not the “physical” ad baculum).
In the indirect variant of this fallacy, the protagonist hints at the negative consequences for the antagonist
that the protagonist will make sure materialises if the antagonist does not accept his standpoint (A: “I am
of the opinion that women are not good drivers”, B: “Naturally, you’re entitled to your opinion, but have
you considered your own safety on the road? Of course, I can’t keep all these furious feminists behind the
wheel in check.”). In the present studies, only such ad baculum- fallacies were committed by the doctor (“Of
course, you’re perfectly entitled to continue smoking, but, in that case, it’d be wise to find another doctor”).
56
The reported score is for the evaluation of evasions of the burden of proof “by presenting the standpoint
as self-evident” (not by “personally guaranteeing the correctness of the standpoint” or “immunizing the
standpoint against criticism”). When presenting a standpoint as self-evident, the discussion party suggests
that there is no need for argumentation (A: “I think that habit of yours is bad for your development?”, B:
“How’s that?”, A: “There can be no two ways about it.”). In the present studies, only such evasions of the
burden of proof were committed (“You only have to take some rest, that speaks for itself ”).
95
A possible explanation for the difference between respondents aged 60 and over and respondents
under the age of 60 is that the more senior respondents may ascribe more authority to the doctor
and accept an authoritative approach by the doctor more than the younger respondents. Such a
difference would not be surprising since until the early 1970s, the doctor’s role in a consultation
was a paternalistic one rather than a patient centred one, so respondents aged 60 and over might
still expect (and accept) the doctor to be somewhat authoritative.
If the difference in reasonableness perception between respondents aged 60 and over
and respondents under the age of 60 is indeed due to their different expectations of a doctor’s
behaviour, this should be reflected in their evaluation of the fallacious control items. The more
senior respondents should also grant the doctor more leeway to commit a fallacy and should be
more prone to accept his support for the diagnosis or medical advice.
The data indeed show a significant difference between respondents aged 60 and over and
respondents under the age of 60 in their evaluation of the fallacies. With respect to the fallacies,
on average, the older respondents evaluated them with a score of 3.49 (.90) (in between “fairly
unreasonable” and “neither unreasonable, nor reasonable”) and the younger respondents with
2.33 (.65) (in between “unreasonable” and “fairly unreasonable”) (F(1, 276) = 47.22; p< .001; ES
= .15).57 These conclusions should, however, be drawn with the greatest care, because there were
only a very limited number of respondents aged 60 and over in the studies (N = 18). For this
reason, amongst others, a replication of the current studies was conducted. This replication is
discussed in chapter 7.
Apart from age, no extraneous variables seem to have been present in the studies. No
differences were found in the perceived reasonableness scores for the argument by authority
for respondents due to gender (t(282) = 1.24; p> .1), educational level (t(283) = -.31; p> .5)58,
medical education (t(284) = -.89; p> .1), or employment in the field of medicine (t(284) = -.52;
p> .5). These results were as expected and are in line with the research by van Eemeren, Garssen
and Meuffels (2009).
The results for the hypotheses concerning the higher order conditions were not as expected.
With the exception of a doctor’s indication of not having enough time (H4), it seems to be the
case that the tested consultative situations (the patient’s reference to an alternative source, the
severity of the patient’s health problem and the patient’s insufficient health literacy) do not
57
In their reasonableness perception of the sound control items, there was no significant difference
between respondents aged 60 and over and respondents under the age of 60 (F(1, 277) = 1.12; p> .05). Both
groups perceived sound arguments that were not authority arguments to be on average between “fairly
reasonable” and “very reasonable” (5.36 (.59) and 5.55 (.69), respectively).
58
Educational level did matter for perceived reasonableness of fallacious discussion contributions: higher
educated respondents perceived fallacies as significantly less reasonable than lower educated respondents
(t(275) = -1.595; p< .05). So, higher educated respondents seem to be more critical of the doctor’s fallacious
discussion contributions – even though their perception of reasonableness shows the same ordinal
pattern for a doctor’s discussion contribution in general as lower educated respondents. The more critical
evaluation of fallacies by higher educated respondents complies with the findings of van Eemeren, Garssen
and Meuffels (2009, pp. 81-82) in their study on the ad hominem fallacy and Wierda (forthcoming, chapter
6) in her study on authority in direct-to-consumer medical advertisements. Van Eemeren, Garssen and
Meuffels (2009, p. 82) found that managers of a Dutch bank “systematically judge each fallacy somewhat
more critically” than a group of high school student. Van Eemeren, Garssen and Meuffels explain that this
difference might by due to educational level and/or age. Age is not a factor in the research by Wierda. She
finds that the higher the educational level of the respondents, the lower they perceived the reasonableness
of direct-to-consumer advertisements.
96
substantially affect the respondents’ perception of reasonableness of the doctor’s argument by
authority. This lack of substantial influence indicates that the consultative situations do not affect
the fulfilment of the higher order conditions to the extent that it actually changes the perception
of reasonableness of a doctor’s discussion contributions.
In contrast, a doctor’s indication of not having enough time to fully discuss the patient’s
health problem noticeably affected the way in which respondents perceived the reasonableness
of the doctor’s discussion contributions. It can be concluded from the data that patients perceive
a doctor’s argument by authority as less reasonable when the doctor indicates that there is not
enough time available to conduct a discussion about the medical advice than when the doctor
does not indicate this. This was quite the opposite of what was hypothesised, resulting in the
rejection of H4 (Ordinary language users perceive a doctor’s argument by authority as more
reasonable when the doctor indicates that there is not enough time available to conduct a
discussion about the medical advice than when the doctor does not indicate this).
Just like the lower reasonableness scores for the sound argument by authority, the rejection
of H4, too, could be due to an evaluation from an institutional perspective, rather than an
argumentative one. Respondents may have judged the doctor’s mentioning of time limitations as
unprofessional (and perhaps unethical) from an institutional perspective; a doctor should have
enough time to discuss the health problem with the patient. Indeed, this explanation is supported
by the fact that the items in which a doctor advances sound argumentation, but also refers to
the limited consultation time are also evaluated as significantly less reasonable than the sound
arguments in which the doctor does not refer to time or required comprehension (respectively M
= 3.13; SD = .81versus M = 5.30; SD = .80; F’(1, 4) = 16,21; p< .05; ES = 36).
6.7 Conclusion
From the results obtained in the three empirical studies on the doctor’s argument by authority
discussed in this chapter, it can be concluded that, in general, ordinary language users do not
perceive a doctor’s sound argument by authority as equally reasonable as his sound use of other
argument schemes. In fact, they do not perceive this argument as reasonable in an absolute
sense. This is remarkable, because, from a pragma-dialectical perspective, there is no theoretical
reason to consider a doctor’s sound argument by authority as less reasonable than other sound
arguments. In line with what was expected, however, ordinary language users do perceive a
doctor’s sound arguments by authority to be more reasonable than his fallacious discussion
contributions. Indeed, the argument by authority is not judged as unreasonable in an absolute
sense (but as “neither reasonable, nor unreasonable”).
With respect to the specific situations in medical consultation that might affect the
argumentative discussion between a doctor and a patient, some other unexpected results were
also obtained: it appears to be the case that a patient’s reference to a contradicting source, a
doctor’s indication of the severity of the discussed health problem and a doctor’s indication of
the patient’s insufficient health literacy do not have a bearing on how ordinary language users
perceive the reasonableness of a doctor’s argument by authority. In contrast, a doctor’s indication
that there is not enough time available to conduct a discussion about the medical advice affects
this reasonableness perception: respondents in the studies perceived a doctor’s argument by
authority as less reasonable when the doctor indicates that there is not enough time available
to conduct a discussion about the medical advice than when the doctor does not indicate this.
97
A possible explanation for these unexpected results is that respondents evaluated the
reasonableness of a doctor’s argumentation from the perspective of its appropriateness in the
activity type of a medical consultation in addition to its argumentative content. To determine
whether this was indeed the case – or whether another alternative explanation should be provided
– a replication of the present studies was conducted in which respondents were additionally
asked to motivate their reasonableness evaluations. The results of this replication are presented
in the next chapter.
98
7 The respondents’ justification of their perception
of reasonableness
7.1 Reasons underlying perceived reasonableness
From the data discussed in the previous chapter, it can be concluded that patients do not
perceive a doctor’s argument by authority to be as reasonable as his other sound arguments
(such as referring to the patient’s symptoms in support of a diagnosis). As said before, this
was quite unexpected since in the experiments by van Eemeren, Garssen and Meuffels (2009)
respondents consistently evaluated sound arguments as reasonable. In contrast with these
previous experiments, the present data show that respondents evaluated the doctor’s argument
by authority as ‘neither reasonable, nor unreasonable’.
Why did respondents not perceive a doctor’s argument by authority to be as reasonable as
his other sound arguments? An important difference between the empirical studies presented
in chapter 6 and the experiments conducted by van Eemeren, Garssen and Meuffels (2009) is
that the dialogue fragments in the present studies were part of a specific communicative activity
type (medical consultation), whereas they were not explicitly part of such an activity type in the
research by van Eemeren, Garssen and Meuffels (2009).59 Thus, it could have been the case that the
argumentation in the present studies was not (just) evaluated from an ‘argumentative perspective’,
but (also) from an ‘institutional perspective’. As discussed in chapter 2, medical consultation is
a highly institutionalised practice with clear rules and conventions. The respondents might have
perceived the doctor to lose sight of these rules and conventions by advancing an argument by
authority.
To investigate whether patients indeed judge the reasonableness of the argument by
authority from an institutional perspective, a replication of the three studies discussed in chapter
6 was conducted. In this replication, respondents were asked to indicate to what extent they
perceive a doctor’s argumentation to be reasonable and, subsequently, to provide reasons for
their reasonableness judgements. The results of this replication are presented in this chapter.
First, the overall organisation of the replication is discussed (section 7.2), then the results are
provided (section 7.3).
7.2 Overall organisation of the replication
7.2.1 Set-up
In the replication, four out of the six hypotheses that were discussed in the previous chapter
were tested again: H1a (Ordinary language users perceive sound instances of a doctor’s argument
by authority as reasonable), H1b (Ordinary language users perceive sound instances of a doctor’s
argument by authority as more reasonable than a doctor’s fallacious discussion contributions), H4
(Ordinary language users perceive a doctor’s argument by authority as more reasonable when the
59
In the experiments concerning the argumentum ad hominem, van Eemeren, Garssen and Meuffels
(2009, pp. 60-62) make a distinction between three different discussion contexts: domestic discussions,
political debates and scientific discussions. However, these contexts do not refer to specific activity types
(with specific opportunities and constraints), but rather to discussion domains (without such specific
opportunities and constraints).
101
doctor indicates that there is not enough time available to conduct a discussion about the medical
advice than when the doctor does not indicate this) and H5 (Ordinary language users perceive a
doctor’s argument by authority as more reasonable when the doctor indicates that the patient is
insufficiently health literate to conduct a discussion about the patient’s health problem than when
the doctor does not indicate this). This time, as mentioned in the introduction, the respondents
were not only asked to indicate how reasonable they found the doctor’s discussion contribution
(indicating this on a 7-point Likert-scale), but also to explain why they gave this reasonableness
score (in their own words, in response to the question “Why did you choose this answer?”).
The decision was made to omit two hypotheses in this replication – H2 (Ordinary language
users perceive a doctor’s argument by authority as more reasonable when the patient refers to a
source that contradicts the (support of the) doctor’s medical advice than when the patient does
not do this) and H3 (Ordinary language users perceive a doctor’s argument by authority as more
reasonable when the doctor indicates that the patient’s health problem is not severe than when
the doctor does not indicate this). The design of the replication study included the requirement
for respondents to explain why they provided their reasonableness scores for a number of
evaluations; doing so, of course, takes more time than simply indicating a reasonableness score
on a scale. To mitigate the extra time required to provide these explanations, it was deemed
necessary to make a selection of four out of the six hypotheses to test in the replication.
The selection of the hypotheses (H1a, H1b, H4 and H5) was motivated as follows: H1a (about
the absolute perception of reasonableness of a doctor’s argument by authority) and H1b (about the
relative perception of reasonableness of this authority) are the main hypotheses of the previous
studies, and as such lay the foundation for a further examination of the influence of specific
consultative situations on the perceived reasonableness of a doctor’s argument by authority. H4
(about the effect of indicating that there is limited consultation time) and H5 (about the effect of
indicating that the patient is insufficiently health literate) were selected because they both concern
the fulfilment of the third order conditions for reasonably resolving a difference of opinion; they
deal with the external circumstances in which the discussion is conducted. These hypotheses
are primarily concerned with the effect of the professional tasks and role of a doctor, so these
circumstances may very well evoke a reasonableness evaluation from an institutional perspective.
It is less likely that a different reasonableness evaluation is evoked for the circumstances tested in
the hypotheses concerning the second order conditions (a patient’s reference to a contradicting
source and severity of his health problem) since they are about the discussants’ internal states
of mind. Therefore, the hypotheses concerning the second order conditions (H2 and H3) were
deemed to be the most suitable to omit from the replication.
To test the selected hypotheses, an almost identical set-up of the experiment was used as in
the previous studies (see section 6.4). Again, a repeated measurement design in combination with
a multiple message design was used in which respondents had to rate how reasonable they find a
doctor’s discussion contributions in short dialogue fragments. The replication set-up deviated from
the original studies in only four respects: first, respondents were additionally asked to justify the
reasonableness scores that they provided; second, the number of dialogue fragments was reduced
by 25%; third, fragments in which the doctor evades the burden of proof were replaced by dialogue
fragments in which the doctor commits a fallacy of authority, an argumentum ad verecundiam;
and, fourth, a greater number of respondents ages 60 or over were included in the sample. In what
follows, it will be explained why these changes were made.
With respect to the first change (additionally asking respondents for their reasons behind
the reasonableness scores that they provided), figure 7.1a shows what this amounts to: for half of
102
the dialogue fragments, respondents were asked to explain their answer. This was done to gain
insight into the underlying reasons that respondents have for their reasonableness judgments.
To ensure that respondents could fill out the questionnaire in 20 to 25 minutes, a request for
explanation was made for only half of the dialogue fragments.
Figure 7.1a Overview of the dialogue fragments in the replication questionnaire
a. 9 dialogue fragments in which the doctor advances a sound argument by authority

(5 of which with a request for explanation)
argumentation (6 of which with a request for explanation)
c. 3 dialogue fragments in which the doctor commits an ad verecundiam fallacy
d. 4 dialogue fragments in which the doctor commits an ad baculum fallacy
(2 of which a with request for explanation)
Figure 7.1b Overview of the consultative situations tested in the dialogue fragments in which
the doctor advances an argument by authority
a. 3 dialogue fragments in which the doctor indicates that there is not enough time
b. 3 dialogue fragments in which the doctor indicates that the patient is insufficiently health literate
c. 3 dialogue fragments of the ‘neutral’ situation, in which the doctor neither indicates that there is
not enough time nor that the patient is insufficiently health literate (1 of which with a request for
explanation)
The second deviation from the three studies discussed in chapter 6 is that, for reasons of
feasibility, the questionnaire consisted of a quarter less dialogue fragments than in each of the
three previous studies (36 items instead of 48). In twelve of these fragments, the doctor advances
an argument by authority, three quarters of which are sound, and in a fourth of these dialogues
the doctor commits an ad verecundiam fallacy. In the other fragments, the doctor either advances
sound argumentation or commits a fallacy in which he does not make use of the argument
scheme of authority argumentation.
Figure 7.1b specifies how the consultative situations are distributed over the dialogue
fragments in which the doctor advances an argument by authority. In three dialogue fragments,
the doctor indicates that there is not enough time available to extensively discuss the patient’s
health problem. In three dialogue fragments, he indicates that the patient is insufficiently health
literate to conduct a detailed discussion. There are also three dialogue fragments in which the
doctor does not indicate anything regarding time constraints or health literacy (this will be
considered the ‘neutral’ situation).
103
7.2.2 Materials
For the replication study, a random selection of the dialogue fragments from study 3 (the study
testing H4 and H5) was used. A slight change was, however, made in the fallacious control items
(the third deviation from the studies discussed in chapter 6): the dialogue fragments in which
the doctor evades the burden of proof were replaced by dialogue fragments in which the doctor
commits an argumentum ad verecundiam, the fallacious use of an authority argument (see, for a
discussion of this fallacy, chapter 5). This was done in order to determine whether respondents
merely evaluate the fact that the doctor uses the argument scheme of authority argumentation
(regardless of whether this is done in a sound or fallacious manner), or whether they evaluate the
way in which a doctor uses this argument scheme (soundly or fallaciously).
In the three studies discussed in chapter 6, the ad verecundiam fallacy was deliberately not
included. The reason for this exclusion was that in the argumentative activity type of medical
consultation, such a fallacy by a doctor in medical consultation would mean that the discussion
topic has to change from the patient’s health problem to something that falls outside the realm
of medicine. After all, the doctor can be regarded as an expert on medical issues, so even topics
that are only remotely related to medicine can be interpreted as issues about which the doctor
can soundly refer to his authority, or in other words, issues about which he possesses existing
ethos. Because dialogue fragments can easily be interpreted as dealing with issues about which
the doctor has existing ethos, constructing ad verecundiam fragments means that the topic of
the dialogue fragments needs to be changed as much as possible to non-medical issues. Such
a change might, however, render the dialogue unnatural and could thereby jeopardise the
ecological validity of the research.
Nonetheless, to control for the argument scheme in the tested sound and fallacious items,
ad verecundiam fallacies were included in the replication study. To make the dialogue fragments
that include an ad verecundiam as natural as possible, they were about topics that are related
to health, but about which GPs in general cannot be assumed to possess specific knowledge or
expertise.60 The topics were selected for their ordinariness in everyday conversation so that they
do not seem to be peculiar in a medical consultation. Figure 7.2 illustrates what such a dialogue
fragment in which the doctor commits an ad verecundiam fallacy looks like.
Figure 7.2 Example of a control item in which the doctor commits an ad verecundiam fallacy
For the last couple of months, a patient has been suffering from extreme tiredness. The doctor
advises him to exercise a bit more, after which the patient indicates that he could go to the gym next
to his office.
1. Doctor: You could better go to a smaller gym, the one you’re talking about is humongous.
2. Patient: Is that really better?
3. Doctor: Yes, you could take it from me as a doctor that smaller gyms are really better.
60
Concretely, the discussion topics in the ad verecundiam items were: the choice for a particular gym (see,
for this fragment, figure 7.2), the quality of organically grown food and the whitening of a discoloured tooth.
104
Similar to the dialogue fragments in which the doctor discusses the patient’s health problem, the
item starts out with information about the patient’s health problem and about what has happened
before the fragment occurs (the patient suffers from extreme tiredness and the doctor advises
him to exercise more). The dialogue that follows proceeds in the same manner as the other items:
the doctor gives advice in turn 1, the patient expresses doubt about this advice in turn 2 and the
doctor advances an argument by authority in turn 3.
Yet, in turn 1 of the ad verecundiam dialogue fragments, the doctor does not provide
medical advice, but advice about a non-medical issue (in figure 7.2, advice about which gym to
choose). Since there is no reason to ascribe authority to the doctor on such a non-medical issue,
referring to his authority on this matter can, from a pragma-dialectical perspective, be regarded
as hindering the reasonable resolution of the difference of opinion at hand; it does not fulfil
the general credibility condition for authority argumentation (“The protagonist may not regard
a standpoint as conclusively defended if the defence takes place by an appeal to his authority
that does not really warrant the standpoint in support of which an argument by authority is
advanced” see section 5.1.1).61 This means that the doctor’s contribution in turn 3 of the dialogue
fragment (“Yes, you could take it from me as a doctor that smaller gyms are generally better”) is
fallacious: it amounts to an argumentum ad verecundiam.
The dialogues in which a doctor commits an ad verecundiam fallacy replaced the control
dialogues in which he commits the fallacy of evading the burden of proof from the previous
studies. These burden of proof items were replaced because they provided the least clear contrast
with sound argumentation: on average, respondents perceived them to be in between “fairly
unreasonable” and “neither unreasonable, nor reasonable” (with an average score of 3.38
(.83)), while they judged the other fallacies to be in between “fairly unreasonable” and “very
unreasonable” (with scores between 1.98 (.86) and 2.26 (.94), see also table 6.4).
To determine how reasonable respondents perceived the doctor’s discussion contribution
to be, the same 7-point Likert scale was used as in the studies presented in chapter 6. This time,
the additional question “Why did you choose this answer?” 62 was printed below the scale, with
sufficient space to provide an answer (see figure 7.3).
61
It should be noted that the general credibility condition for an argument by authority is referred to here,
rather than the specific credibility condition for a doctor’s argument by authority in medical consultation.
The reason for referring to this general condition is that the specific conditions were specified for a
discussion in which the doctor’s standpoint amounts to treatment advice (see section 5.1.2). In the ad
verecundiam dialogues, this is not the case: the arguments in these dialogues are fallacious precisely because
the standpoint is about a non-medical issue. The specific soundness conditions can therefore not be used.
This is, however, not to say that the general soundness conditions cannot be used either. In fact, the general
credibility condition explains why the instances of the argumentum ad verecundiam in the replication are
fallacious.
62
The original in Dutch reads: “Waarom heeft u voor dit antwoord gekozen?”.
105
Figure 7.3 Reasonableness scale and additional question for explanation in the replication study
If you were the patient in the conversation above, how reasonable would you find the doctor’s last
contribution to this conversation?
very unreasonable fairly neither fairly reasonable very

unreasonable unreasonable unreasonable, reasonable reasonable
nor reasonable
O O O O O O O
Why did you choose this answer?

………………………………………………………………………………………………………
……………………………………………………………………………………………………….
………………………………………………………………………………………………………
……………………………………………………………………………………………………….
To avoid order effects, three versions of the questionnaire were made, in which the order of
the dialogue fragments varied. In each version of the questionnaire two dialogue fragments
with subsequent questions about the reasons that respondents had for choosing their answer
were followed by three dialogue fragments without such subsequent questions. This alternating
presentation of fragments with and without open-ended questions was done to make sure that
the dialogue fragments and their possible accompanying open-ended questions fitted on the
same page.
7.2.3 Respondents
A total of 94 (Dutch) respondents took part in the replication study. Inhabitants of beach houses
along the coast of Zeeland were asked to fill out questionnaires. These holiday house inhabitants
were selected to ensure that enough respondents aged 60 or over were included in the sample.
In the previous studies, it seemed to be the case that these older respondents were more lenient
in their evaluation of a doctor’s argument by authority than younger ones, but not enough older
respondents were included in the sample to generalise with confidence over the population.63
In the present replication, approximately one-third of the 94 respondents was aged 60 or
over (amounting to the fourth deviation from the studies discussed in chapter 6). This larger
number of older respondents enables a clearer distinction between the evaluations by older and
younger respondents than in the studies that are replicated. However, this larger number also
constitutes an overrepresentation of the respondents aged 60 or over in the sample (c2(1) = 31.8;
p< .001).64 In the analysis of the replication data, it was therefore also checked to see whether the
overall reasonableness evaluations of the doctor’s argument by authority differ significantly from
those evaluations in the replicated studies if the scores by the respondents aged 60 or over are
not included in the sample (as will be discussed in the section 7.3.1, there was no such significant
63
There was a significant difference between the number of respondents aged 60 or over in studies 1-3
(6.1%) and the number of people aged 60 or over in the Dutch population (12.8%, based on statistics for the
year 2013 provided by the CBS, 2014a) (c2(1) = 11.9; p< .001).
64
Significance was determined under the assumption that 12.8% of the current Dutch population are aged
60 or over based on the CBS (2014a) statistics for the year 2013.
106
difference). Overall, the respondents were between 15 and 81 years old, with an average age of
53 (SD = 14.03).
The respondents from the beach houses also better reflected the educational levels in the
population than the respondents in the studies presented in chapter 6. In these earlier studies,
most respondents were higher educated: 73.3% versus 24.8% lower educated respondents.65 This
meant that respondents were significantly better educated than the general population (c2(1)
= 298.4; p< .001).66 In the present replication, about half of the respondents (48.9%) was lower
educated and half higher educated (47.9%)67, which is still better educated than the general
Dutch population (c2(1) =19.04; p< .001), but more representative overall of the educational
levels in the population than in the previous studies (contrast c2(1) = 19.04 with c2(1) = 298.4,
respectively).
As in the studies presented in chapter 6, a minority of the respondents in the replication
study is (or has been) enrolled in a medical study programme (18.3%) and a minority works
in the medical sector (14.9%). Furthermore, again slightly more respondents were female than
male (54.3% versus 45.7%). This time, it took the respondents 20 to 40 minutes to complete the
questionnaire, depending on how extensively they answered the open questions.
7.2.4 Instruction
At the start of the questionnaires, a similar page with instructions was provided as in the
three studies discussed in chapter 6. Again, the respondents received information about the
dialogue fragments; they were told that these fragments were excerpts of hypothetical medical
consultations and that the respondents had to evaluate the reasonableness of the doctor’s last
contribution to the dialogues. To avoid S-bias, it was left implicit that the fragments consisted of
argumentative discussions. As in the previous study, it was explained that people’s conception of
reasonableness might differ and that it is therefore being researched in the present study.
The only change that was made to the instructions in the previous questionnaire was
that in the questionnaires used in the replication, the open question about the reasons that the
respondents have for providing their answer was introduced. Respondents were told that for
half of the dialogue fragments, such a question would follow so that they could provide a brief
explanation as to why they scored the reasonableness of the discussion contribution the way they
did.
65
As mentioned earlier, respondents are considered to be ‘higher educated’ if their highest educational
level consists of: university education (wo), pre-university education (vwo) or higher vocational education
(hbo). They are consider to be ‘lower educated’ if their highest educational level is: intermediate vocational
education (mbo), higher general secondary education (havo), lower vocational professional education
(vmbo) or primary school (basisschool). Respondents that did not complete these educational programmes
were categorised as ‘other’.
66
Significance was determined under the assumption that 28.3% of the population is higher educated.
These percentages are based on the educational levels of the Dutch population in 2013 (CBS, 2014b).
67
The missing 3.2% is due to the fact that two respondents indicated that their highest completed
educational level was not listed in the provided options – the options were: primary school (basisschool),
lower vocational professional education (vmbo), higher general secondary education (havo), pre-university
education (vwo), intermediate vocational education (mbo), higher vocational education (hbo), and
university education (wo) – and one respondent did not provide any information about his educational
level.
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7.3 Results
7.3.1 Consistency with the replicated studies

In order to examine the reasons that respondents gave for their evaluation of the reasonableness
of a doctor’s argument by authority, it should first be determined whether the results in the
replication are comparable to those in the previous studies. From the average reasonableness
scores depicted in table 7.1, it appears that these results are similar: just as in the previous studies,
on average, the sound argumentation that is not authority argumentation is received the highest
score (M = 5.52; SD = .67), the fallacious discussion contributions are the lowest (M = 2.45; SD =
1.04) and the argument by authority falls in between these scores (M = 4.29; SD = 1.17).
Table 7.1 The average reasonableness scores for a doctor’s argument by authority, other
sound argumentation and fallacious contributions in the replication and study 1-3
Discussion contribution by the doctor Replication Study 1-3
(combined)
Argument by authority 4.29 3.99
(1.17) (.99)
Sound argumentation 5.52 5.54
(excluding authority argumentation) (.67) (.68)
Fallacious contributions 2.45 2.40
(excluding the argumentum ad verecundiam) (1.04) (.72)
The doctor’s argument by authority did receive a substantially higher reasonableness score in the
replication than in the previous studies (see table 7.1; t(379) = .15; p< .05; ES = .02). This higher
score amounts to an evaluation of in between “neither reasonable, nor unreasonable” and “fairly
reasonable” (M = 4.29; SD = 1.17), rather than the almost exact score of “neither reasonable,
nor unreasonable” in the previous studies (M = 3.99; SD = .99). In fact, the replication score is
significantly higher than the “neither reasonable, nor unreasonable”-point of 4 on the Likert-
scale (t(90) = 2.39; p< .05; Cohen’s d = .25). So, compared to the previous studies, the respondents
in this replication were more generous in their evaluation of this argument. This was expected
because of the increased number of respondents that are aged 60 or over in the replication; 6.1%
(N = 18) of the respondents in the previous studies (N = 295) was aged 60 or over, while 33.0%
(N = 31) fell in this age category in the replication (N = 94). Indeed, when removing the older
respondents’ reasonableness scores from the sample (resulting in N = 63), the reasonableness
score for a doctor’s argument by authority no longer differs significantly from “neither reasonable,
nor unreasonable” (t(58) = 1.05; p> .05). So, the obtained scores for the doctor’s argument by
authority are more or less comparable to those in the three studies discussed in chapter 6, and
the deviations that did occur are easily explainable.
In terms of general hypothesis H1a (Ordinary language users perceive sound instances of a
doctor’s argument by authority as reasonable), the somewhat higher score in the replication for
the argument by authority than in the previous studies does not mean that H1a can be accepted:
even when taking into account all respondents – regardless of their age – in the replication, the
average reasonableness score (M = 4.29; SD = 1.17) is still significantly lower than the “fairly
reasonable”-point of 5 (t(90) = -5.77; p< .000; Cohen’s d = -.61). In the previous studies, H1a was
rejected also, so this replication result was not surprising.
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Like the studies discussed in chapter 6, the respondents in the replication also provided a
similar evaluation of the doctor’s argument by authority when this argument is contrasted with
the doctor’s other discussion contributions. In study 3 of the previous studies, for example,
respondents perceived the argument by authority as significantly less reasonable than other
sound arguments (respectively M = 3.66; SD = .88 versus M = 5.47; SD = .71; F’(1,22) = 16.50;
p< .001; ES = .27). 68 In the replication, respondents also perceived the argument by authority as
significantly less reasonable than other sound arguments (F’(1, 21) = 34.16; p< .001; ES = .39).
Additionally, the respondents in the replication perceived these authority arguments to be more
reasonable than the fallacious discussion contributions by the doctor (F’(1, 18) = 4.02; p = .06; ES
= .09).69 This is again comparable to the results in the previous studies. In study 3, for instance,
respondents also judged the argument by authority to be more reasonable than the fallacious
contributions (respectively M = 3.66; SD = .88 versus M = 2.39; SD = .86; F’(1,23) = 4.08; p =
.055; ES = .09).
When analysing the replication results for the doctor’s argument by authority in the
different consultative situations, again, a similar pattern can be discerned as in the previous
studies. As depicted in table 7.2, the average reasonableness scores that the respondents provided
for this argument by a doctor in different consultative situations (M = 4.29; SD = 1.17 in the
‘neutral’ situation, M = 2.62; SD = 1.12 in a situation in which the doctor indicates that there is
not enough time and M = 3.35; SD = 1.23 in a situation in which the doctor indicates that the
patient is insufficiently health literate) are similar to those in the previous studies (respectively M
= 3.99; SD = .99, M = 2.56; SD = .94 and M = 3.64; SD = 1.06).
Table 7.2 The average reasonableness scores for the consultative conditions in which a
doctor advances an argument by authority in the replication and study 1-370
Consultative situation Replication Studies 1-3
(combined)
Neutral situation 4.29 3.99
(1.17) (.99)
Not enough time (H4) 2.62 2.56
(1.12) (.94)
Insufficiently health literate (H5) 3.35 3.64
(1.23) (1.06)
Indeed, respondents also perceived a doctor’s argument by authority as significantly less

reasonable when the doctor indicated that there is not enough time. In the studies presented
in chapter 6, such a difference was established: if a doctor advanced an argument by authority
68
In fact, the results in the replication are also comparable to the other two studies (see chapter 6), but, for
the sake of clarity, only the results of study 3 are included: this study specifically addresses the hypotheses
about the consultative situations affecting the fulfilment of the third order conditions.
69
Although this latter score is not significant, there is a trend towards a higher reasonableness evaluation
of the argument by authority than of the fallacious contributions, which presumably becomes significant if
the experiment’s power were to be increased.
70
More precisely, for the score listed for the “neutral situation”, the average score is based on all three
studies; for “not enough time” (H4), the average is based on studies 1 and 3 (H4 was not tested in study 2);
and for “insufficiently health literate” (H5), the average is based on studies 2 and 3 (H5 was not tested in
study 1).
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in a consultative situation in which he indicated that there is not enough time, the respondents
perceived this argument as less reasonable than when he did not indicate such a lack of time
(respectively M = 2.56; SD = .94 and M = 3.99; SD = .99; F’(1,6) = 12.45; p< .05; ES = .26). A
similar difference can be observed in the present replication (F’(1, 4) = 10.63; p< .05; ES = .35).
Furthermore, respondents’ judgements of reasonableness in the replication did not
depend on whether the doctor referred to the patient’s insufficient health literacy (F’(1, 4) =
3.90; p> .05). This was also the case in the studies that were replicated: no significant difference
between the perceived reasonableness of the doctor’s argument by authority was found in the
replicated studies between the consultative situation in which the doctor indicates that the
patient is insufficiently health literate and such a situation in which the doctor does not indicate
this (respectively M = 3.64; SD = 1.06 and M = 3.99; SD = .99; F’(1, 6) = 1.35; p> .05).
Since the replication results are in essence equivalent to the results in the three studies in
chapter 6, it can now be determined what reasons respondents provided for their reasonableness
judgments. Determining this provides insights into the considerations that ordinary language
users had when deciding whether to accept a doctor’s argument by authority in a medical
consultation.
7.3.2 Explanatory responses
7.3.2.1 A taxonomy for classifying the respondents’ justifications

To determine what reasons the respondents had (or claimed to have) for providing their
evaluations of the reasonableness of a doctor’s argument by authority (and his other discussion
contributions), the responses to the question “Why did you choose this answer?” were analysed.
As illustrated in figure 7.4, these answers varied from “Very curt answer”, to “You also have to do
something about your health yourself and not always ask for medication”. In order to investigate
whether the respondents’ reasonableness evaluations were based on the argumentative merits of
the doctor’s discussion contributions or on other considerations, the answers had to be coded.
For the coding of the answers, a taxonomy for classifying the respondents’ justifications
was, first, constructed based on the extended pragma-dialectical theory. Based on this theory,
the category ‘argumentative merits’ was included, which comprises all explanatory answers in
which the respondents explained their judgment of reasonableness by referring to the general
or specific soundness conditions discussed in chapter 5 (“Doctor knows nothing about gyms
in general”). Additionally, to determine to what extent the activity type affects the evaluation of
argumentation in medical consultation, the category ‘institutional considerations’ was added.
Answers in which reference is made to the institutional role and professional tasks of a doctor in
medical consultation belong to this category (“A GP sometimes has to take extra time”).
Second, based on earlier empirical research by van Eemeren, Garssen and Meuffels (2009)
on the argumentum ad hominem, the category of ‘politeness’ was added. This category consists of
explanatory answers in which respondents refer to certain standards of social interaction (“Very
curt answer”). Van Eemeren, Garssen and Meuffels (2009) ruled out politeness considerations as
a significant contributor to the evaluation of ad hominem fallacies by comparing these fallacies
in different kinds of discussions. Adding this response category to the present taxonomy allows
for the same procedure in the present replication.
Last, a random selection of approximately one third of the explanatory answers in the
replication was analysed to test the suitability of the taxonomy and to determine whether other
110
categories apply that had not yet been included. Based on this analysis, the category ‘no answer
/ illegible answer / incomprehensible answer’ was added. To make the taxonomy exhaustive, the
category ‘Other answers’ was introduced. The answers in this category varied from references
to personal experiences (“I had the same and I only had to take rest”) to just repeating the
reasonableness judgment (“Because it’s reasonable”).
This resulted in the following taxonomy:
0 No answer / illegible answer / incomprehensible answer

1 Answer based on the argumentative merits of the doctor’s contribution
2 Answer motivated by institutional considerations about the doctor’s role
3 Answer motivated by politeness considerations concerning the doctor’s contribution
4 Other answers
Figure 7.4 provides examples of the explanatory answers that respondents gave in the present
replication and illustrates how they were coded. Specifically, answers in which the respondents
referred to the quality of the explanation or argumentation (“Logical explanation”), or in
which they provided a counterargument to the doctor’s contribution (“Doctor knows nothing
about…”) were coded as a 1 (argumentative merits). Answers in which the respondents referred
to the professional tasks of the doctor (“A GP sometimes has to take extra time”) or the rights of
the patient (“Patient has right to information”) were coded as a 2 (institutional considerations).
Answers in which the respondents referred to the impolite character of the doctor’s discussion
contribution (“Because the doctor can formulate this in a friendlier manner”) were coded as a
3 (politeness considerations). All other answers – such as answers that deal with e.g. the medical
procedure (“First only a urine-test, later perhaps blood when unclear”) and answers that e.g.
concern the patient in the dialogue fragment (“You also have to do something about your health
yourself and not always ask for medication”) – were coded as a 4 (other).
In case the respondents provided more than one reason for their reasonableness evaluation
and one of these reasons was based on the argumentative merits of the doctor’s contribution,
the answer was coded as a 1 (argumentative merits); in all other cases in which two or more
coding categories applied, the answer was coded as a 4 (other). This was done to ensure that all
evaluations based on the argumentative quality of the doctor’s contributions were taken into
account.
Figure 7.4 Examples of answers to the question “Why did you choose this answer?”
in the replication (original Dutch answers in grey)
1 Argumentative merits
a. Logical explanation.
Logische uitleg.
b. Doctor knows nothing about gyms in general.
Arts weet niets van sportscholen algemeen.
c. It is explained what a negative effect atarax has but not what side effect zyrtec has. Too brief.
Er wordt uitgelegd wat een negatief effect atarax heeft maar niet wat zyrtec voor bijwerking heeft.
Te summier.
111
2 Institutional considerations
a. A GP sometimes has to take extra time.
Een huisarts moet soms extra tijd nemen.
b. Patient has right to information.
Patiënt heeft recht op informatie.
c. That should be discussible in this day and age!!! For sure!!
Dat moet in deze tijd bespreekbaar zijn!!! Zeker weten!!
3 Politeness considerations
a. Rude.
Onbeschoft.
b. Very curt answer.
Erg bot antwoord.
c. Because the doctor can formulate this in a friendlier manner.
Omdat de arts dit vriendelijker kan verwoorden.
4 Other
a. Small effort to prescribe medication.
Kleine moeite om medicijn voor te schrijven.
b. You also have to do something about your health yourself and not always ask for medication.
Je moet ook zelf iets aan je gezondheid doen en niet altijd medicijnen vragen.
c. First only a urine-test, later perhaps blood when unclear.
Eerst alleen urinetest, later evt. bloed bij onduidelijkheid.
To check for reliability of the coding, a colleague at the University of Amsterdam who also
researches authority argumentation in the medical field from a pragma-dialectical perspective
was asked to code one-third of the answers as well. Excluding the answers coded as a 0 (no
answer / illegible answer / incomprehensible answer), this resulted in 71.49% identical codings,
indicating sufficient coding reliability – including the answers coded as 0, this amounts to an
overlap of 77.46% (K = .58).
7.3.2.2 Classifying the respondents’ justifications

Based on the coded answers to the open evaluation questions, it can now be investigated whether
the unexpected results in the previous studies are indeed due to the fact that respondents (also)
provided an evaluation of reasonableness from an institutional perspective, rather than (or
in addition to) one based solely on argumentative merits. As depicted in table 7.3a, it is clear
that this is the case for the evaluation of a doctor’s argument by authority in a consultation in
which there is not enough time to discuss the patient’s health problem (H4). Most frequently,
respondents motivated their evaluation of reasonableness of the doctor’s argument by authority
in this particular consultative situation by means of institutional considerations (“As a doctor,
you still have to try to explain. It has to be understandable to the patient too”).
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Table 7.3a The most frequently occurring response categories for the evaluation of a doctor’s
sound argument by authority
Consultative situation Mode
Neutral situation Argumentative merits
Not enough time (H4) Institutional considerations
Insufficiently health literate (H5) Argumentative merits
Table 7.3b The frequencies (in percentages) with which the response categories occurred
for the evaluation of a doctor’s sound argument by authority (excluding the
‘no answer/ illegible answer/ incomprehensible answer’ category)
Consultative situation Argumentative Politeness Institutional Other

merits considerations considerations
Neutral situation 52.2 4.3 15.9 27.5
(K = 69) (K = 36) (K = 3) (K = 11) (K = 19)
Not enough time (H4) 35.8 5.4 41.9 16.9
(K = 148) (K = 53) (K = 8) (K = 62) (K = 25)
Insufficiently health literate (H5) 36.1 2.7 33.3 27.9
(K = 147) (K = 53) (K = 4) (K = 49) (K = 41)
A closer look at the exact frequencies with which the different types of explanatory responses
were given (table 7.3b) reveals that in 41.9% of the coded evaluations of the dialogue fragments
in which a doctor advances an argument by authority when there is not enough time, the
respondents motivated their evaluation by referring to institutional considerations. In contrast,
in the fragments in which a doctor advances such an argument in a ‘neutral’ situation (that
is, without mentioning lack of time or health literacy issues), the respondents only referred to
institutional considerations in 15.9% of their answers – they predominantly (for 52.2%) evaluated
the doctor’s argument by authority in this neutral situation based on its argumentative merits
(“What is his opinion based on?”). These percentages show that the respondents motivated
their reasonableness evaluations significantly differently when a doctor argued by authority
in dialogue fragments in which he indicates that there is not enough time than in a neutral
consultation (c2(4) = 15.2; p< .005; C = .26). This significant difference is predominantly due to
the difference in the number of times an evaluation of a doctor’s argument by authority is based
on institutional considerations (it contributed an amount of 9.4 to the total c2 (= 15.2)).
As further shown in table 7.3a, if the argument by authority is provided in fragments in
which the doctor refers to the patient’s insufficient health literacy, respondents mostly evaluated
this argument based on its argumentative merits (“Further examination of the swollen ankle
might be necessary. The doctor doesn’t explain clearly why it’s thrombosis”). Yet, table 7.3b shows
that the amount of evaluations in which respondents refer to institutional considerations is also
substantial: in one third of the cases in which the doctor indicated the patient’s lack of health
literacy, the respondents based their answer on institutional considerations (“As a doctor, you still
have to try to explain. It should be understandable to the patient too”). Again, this is in contrast
with the explanations based on these considerations when the doctor advances an argument
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by authority in a neutral situation (33.3% versus 15.9%, respectively). As a consequence,
respondents motivated their evaluation of reasonableness of the doctor’s argument by authority
in a consultation in which the doctor indicates that the patient is insufficiently health literate
somewhat differently from such an argument in a neutral consultation. This difference turns out
to be marginally significant (c2(4) = 8.56; .1 > p >.05; C = .20). More importantly, the difference in
evaluations is, here too, predominantly due to evaluations based on institutional considerations
(this difference contributed an amount of 5.15 to the total c2 (= 8.56)).
To check whether the control items were evaluated based on their argumentative merits,
the explanatory responses for the sound arguments in which the doctor did not use authority
argumentation and for the fallacies also need to be examined. Table 7.4a shows which explanations
respondents most frequently provided for their evaluation of the doctor’s contribution in these
items. The respondents evaluated the doctor’s sound control argumentation, direct ad hominem
and ad verecundiam predominantly (respectively 72.9%, 30.8% and 75.3%, see table 7.4b) based
on their argumentative merits (“Doctors are no gym specialists”).
Table 7.4a The most frequently occurring response categories for the evaluation of the
doctor’s discussion contributions in the control items (excluding the ‘no answer/
illegible answer/ incomprehensible answer’ category)
Control item Mode
Sound argument (excl. authority argumentation) Argumentative merits
Ad baculum Argumentative merits
Ad hominem (direct) Argumentative merits
Ad verecundiam Argumentative merits
Declaring the standpoint taboo Institutional considerations
For the argumentum ad baculum, the respondents most frequently failed to provide any answer
at all: in 45 cases (23.9% of the total of 188 responses for the fragments in which the doctor
committed an ad baculum fallacy), no explanation was provided – as opposed to the 44 cases
(23.4% of the total of 188 responses for the ad baculum fragments) in which the respondents
provided an explanation based on argumentative merits (“Second part [of the doctor’s
contribution is] threatening, blackmailing”). Disregarding the evaluations with no explanation,
however, the reasonableness of the ad baculum fragments was most often evaluated from
an argumentative perspective (30.8% of the total of 143 ad baculum fragments for which an
explanation was given, see table 7.4b).
The most frequently occurring response category in the evaluations of the dialogue
fragments in which a doctor declares a standpoint taboo deviates from that of the other
control items: as depicted in table 7.4b, respondents explained 62.0% of their evaluations of
the reasonableness of this fallacy based on institutional considerations (“Every doctor should
reasonably be willing to have a conversation about euthanasia”). This significantly differs from
their explanations of the other control items (both sound control and fallacious) (c2(4) = 152.2;
p< .001; C = .38); the evaluations based on institutional considerations contribute an amount of
112.7 to the total c2 (= 152.2)).
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Table 7.4b The frequencies (in percentages) with which the response categories occurred
for the evaluation of the doctor’s discussion contributions in the control items
(excluding the ‘no answer / illegible answer / incomprehensible answer’ category)
Control item Argumentative Politeness Institutional Other
merits considerations considerations
Sound argumentation 72.9 0.7 6.8 19.6
(excl. authority argumentation) (K = 301) (K = 3) (K = 28) (K = 81)
(K = 413)
Ad baculum 30.8 15.4 30.1 23.8

(K = 143) (K = 44) (K = 22) (K = 43) (K = 34)
Ad hominem (direct) 26.5 21.9 25.8 25.8

(K = 151) (K = 40) (K = 33) (K = 39) (K = 39)
Ad verecundiam 75.3 0 9.6 15.1

(K = 73) (K = 55) (K = 7) (K = 11)
Declaring the standpoint taboo 21.3 0.7 62.0 16.0

(K = 150) (K = 32) (K = 1) (K = 93) (K = 24)
There is also a difference between the reasons that the respondents gave for evaluating the
doctor’s sound arguments by authority and their fallacious counterparts as committed by the
doctor. Comparing the explanatory responses for authority arguments in a ‘neutral’ situation
(i.e., without lack of time or health literacy issues mentioned by the doctor, see table 7.3b) with
those for the ad verecundiam fallacies (see table 7.4b) shows a significant difference (c2(4) =
9.7; p< .05; C = .25), which is mostly due to the fact that the ad verecundiam fallacies were
more frequently evaluated based on their argumentative merits (“Do you [the doctor] also have
knowledge of gyms?”) and the sound arguments by authority were more frequently evaluated
based on institutional considerations (“‘Trust me’ [as said by the doctor in the dialogue
fragment] is not taking the patient seriously”). The evaluations of the ad verecundiam fallacy
committed by the doctor based on argumentative merits and the sound arguments by authority
based on institutional considerations, in fact, contribute to an amount of 6.0 of the total c2 (=
9.7)). Although this difference is found between sound authority arguments and fallacious ones,
it cannot be observed between the explanatory responses for the sound control items and the ad
verecundiam fallacies (c2 = 2.0; p> .05). The next section discusses what these results (and the
results that were previously discussed) mean.
7.4 Discussion
The results discussed in the previous sections of this chapter show that respondents indeed
evaluate the reasonableness of a doctor’s argument by authority from an institutional perspective
in addition to an argumentative one. To what extent has this evaluation from an institutional
perspective influenced the testing of the hypotheses in the previous three studies?
With respect to the general hypotheses, H1a (Ordinary language users perceive sound
instances of a doctor’s argument by authority as reasonable) and H1b (Ordinary language
users perceive sound instances of a doctor’s argument by authority as more reasonable than a
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doctor’s fallacious discussion contributions), the influence of institutional considerations in
the respondents’ evaluations of reasonableness is not substantial. The explanatory answers to
questions about the evaluation of a doctor’s argument by authority in a ‘neutral’ consultative
situation are relevant for these hypotheses. They show that respondents predominantly provide
evaluations of reasonableness from an argumentative perspective and not from an institutional
one (with a score of 38.3% on an evaluation based on ‘argumentative merits’ versus a score of
11.7% on ‘institutional considerations’, see table 7.3b).
Contrasting the influence of the perspective from which respondents evaluated the
doctor’s argument by authority with the influence of the perspective when the respondents
evaluated other sound arguments nonetheless reveals a remarkable difference. Evaluations of
a doctor’s other sound arguments are to a much larger extent provided from an argumentative
perspective (56.1% of the other sound arguments as opposed to the 38.3% of the arguments by
authority, see table 7.4b). At the same time, the influence of the institutional perspective on the
respondents’ evaluations of these other sound arguments is negligible: only 1.3% (contrast this
with the score of 11.7% for the argument by authority). These results shed more light on the
result concerning H1a in the previous studies. Based on the three previous studies presented in
the previous chapter, it was concluded that this hypotheses had to be rejected: ordinary language
users did not perceive sound instances of a doctor’s argument by authority as reasonable. Now,
a plausible explanation can be provided for this result: it was because of the greater influence
of institutional considerations on the evaluation of a doctor’s argument by authority that this
hypothesis needed to be rejected.
The replication results also provide a possible explanation for the surprising results about
the hypotheses concerning the third order conditions. From the studies in the previous chapter, it
appeared that H4 had to be rejected: ordinary language users did not perceive a doctor’s argument
by authority as more reasonable when the doctor indicates that there is not enough time available
In fact, an opposite effect was obtained (an indication of a lack of time resulted in a significantly
lower reasonableness score). The present replication shows that an explanation for this result is
that when the doctor indicates a lack of time to discuss the patient’s health problem, respondents
based their reasonableness evaluations of the doctor’s argument by authority substantially
more on institutional considerations than when the doctor does not indicate this (respectively
33.0% versus 11.7%, see table 7.3b). This does not mean that the respondents in the replication
were completely unconcerned about the argumentative merits of the doctor’s argument by
authority (still 28.2% of their evaluations were based on the argumentative merits of the doctor’s
contribution), but it does mean that the institutional perspective became more prominent in
their reasonableness evaluations – resulting in lower reasonableness scores.
For the independent variable tested in H5, the doctor’s indication of the patient’s
insufficient health literacy, a similar explanation can be provided based on the results of this
replication. As discussed in chapter 6, H5 had to be rejected: ordinary language users do not
perceive a doctor’s argument by authority as more reasonable when the doctor indicates that the
patient is insufficiently health literate to conduct a discussion about the patient’s health problem
than when the doctor does not indicate this; there was no discernible effect of this indication on
the reasonableness scores provided by the respondents. The explanatory responses in the present
replication show that, in a similar vein as for the fragments in which the doctor indicates a lack
of time, when he indicates that the patient is insufficiently health literate, the evaluations of the
doctor’s argument by authority are somewhat more influenced by institutional considerations
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than the evaluations given when the doctor does not indicate this (respectively 26.1% versus
11.7%, see table 7.3b). Again, the respondents still base some of their evaluations of the
argument by authority on its argumentative merits (28.2%), but the institutional considerations
become more influential. So, an explanation for the rejection of H4 is that respondents evaluate
the reasonableness of the doctor’s argument by authority from an institutional perspective in
addition to an argumentative one.
7.5 Conclusion
The results of the present replication demonstrate that the reasonableness of a doctor’s argument
by authority is predominantly evaluated from an argumentative perspective in cases in which
the doctor does not indicate that there is insufficient time to conduct a discussion about the
patient’s health problem or that the patient is insufficiently health literate to participate in such
a discussion. In such a ‘neutral’ consultative situation, institutional considerations do play a part
in the reasonableness evaluation, but not a substantial one. However, if the doctor indicates that
there is a lack of time or that the patient is insufficiently health literate, institutional considerations
become more important in the reasonableness evaluation of the doctor’s discussion contributions.
These results can explain the unexpected results in the three empirical studies that were
discussed in chapter 6. The results show that patients do not perceive sound instances of a
doctor’s argument by authority as reasonable, because institutional considerations affect their
reasonableness evaluation of a doctor’s argument by authority to a greater extent than they affect
their reasonableness evaluations of his other sound argumentation. Additionally, based on these
results, it can be concluded that respondents regarded the doctor’s argument by authority as less
reasonable if he indicates that there is a lack of time for discussion in the consultation or that the
patient is insufficiently health literacy, because, when indicating this, the doctor is seen as failing
to adequately fulfil his institutional role or tasks.
Now that it has been established that institutional considerations in medical consultation
affect the reasonableness evaluation of a doctor’s argument by authority, the following chapter
examines what this means for the effectiveness of the argument by authority in medical
consultation. Is the effectiveness of the doctor’s argument by authority determined by its
evaluation on argumentative grounds or do institutional considerations (also) come into play?
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8 The perception of effectiveness of a doctor’s
argument by authority
8.1 Examining the perception of effectiveness
In the empirical studies that were discussed in chapters 6 and 7, it was investigated whether
ordinary language users perceive a doctor’s sound argument by authority to be reasonable
within the communicative activity type of medical consultation. Establishing the perception of
reasonableness of a strategic manoeuvre (such as a doctor’s argument by authority) constitutes the
first step in clarifying the relation between reasonableness from a pragma-dialectical theoretical
perspective (i.e., pragma-dialectical conception of reasonableness) and effectiveness. According
to the pragma-dialectical theory, the aim of a protagonist who advances argumentation that is
pragma-dialectically reasonable is to convince the antagonist of his standpoint (van Eemeren
& Grootendorst, 1984, pp. 63-68). To be effective in making his standpoint acceptable, the
antagonist needs to regard the protagonist’s argumentation as reasonable.
In the empirical studies on the perception of reasonableness of a doctor’s argument
by authority discussed in the previous two chapters, it was established that the perception of
ordinary language users of the reasonableness of this argument is not completely in line with
the normative evaluation of the reasonableness of this argument from a pragma-dialectical
perspective. Sound instantiations of a doctor’s argument by authority are recognised as
reasonable within a pragma-dialectical analysis, but were evaluated by the ordinary arguers as
neither reasonable nor unreasonable.
The extent to which discussion contributions are perceived to be reasonable can be expected
to influence how effective these contributions will be (Meuffels, 2006, p. 21). Consequently,
the question arises as to what extent the doctor’s argument by authority is effective in medical
consultation in the eyes of ordinary language users. Answering this question is important both
from an argumentation theoretical and a practical, medical perspective. From an argumentation
theoretical perspective, the answer would clarify the extent to which the soundness of a strategic
manoeuvre is associated with its effectiveness. From a practical medical perspective, answering
this question would clarify whether it is advisable for a doctor to advance an argument by
authority in medical consultation, and, if so, under which conditions.
The results of an empirical study on the effectiveness of a doctor’s argument by authority in
medical consultation are presented in this chapter. First, the relationship between reasonableness
and effectiveness is discussed (section 8.2). After this, he overall organisation of the empirical
study is explained (section 8.3), which is followed by a presentation of the results (section 8.4)
and a discussion of what these results show about the relationship between the pragma-dialectical
conception of reasonableness and effectiveness (section 8.5). Subsequently, possible reasons for
the obtained results are examined (section 8.6).
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8.2 The relation between reasonableness from a pragma-dialectical perspective
and effectiveness
As discussed in chapter 4, in the pragma-dialectical theory, argumentation is regarded as a

complex speech act by which a discussion party aims to convince another party of the (un)
acceptability of a particular standpoint. The communicative effect of this complex speech act is
that the other party understands the argumentation. To successfully generate the interactional
effect of convincing, the other party also needs to accept that the argumentation contributes to
the acceptability of the standpoint in question – or demonstrates the unacceptability of it (van
Eemeren & Grootendorst, 1984, pp. 65-66).71
More precisely, accepting that the argumentation contributes to the acceptability or
demonstrates the unacceptability of a standpoint constitutes its inherent interactional effect: it is
the effect that this argumentation immediately has on the argumentative discussion. Any further
effects that a discussion contribution might generate (a change in the antagonist’s beliefs, feelings,
behaviour) are considered as consecutive interactional effects (van Eemeren & Grootendorst,
1984, p. 24; see also section 4.2.1). When discussing the ‘effectiveness’ of the doctor’s argument by
authority in the present study, the inherent interactional effectiveness of this argument is meant,
which is to say: the extent to which the doctor’s argument by authority adds to the acceptability
of his advice or judgement.
According to the pragma-dialectical theory, in principle, the reasonableness of a discussion
contribution can be expected to induce effectiveness (van Eemeren & Grootendorst, 1984, p.
68). The preliminary steps required to empirically establish the relationship between pragma-
dialectical conception of reasonableness and effectiveness have already been taken: it has been
shown that ordinary language users concur with the pragma-dialectical rules for a critical
discussion in their evaluation of the reasonableness of discussion contributions, that they expect
other discussion parties to adhere to the critical discussion rules, and that those who do not
adhere to these rules should be held accountable for being unreasonable (van Eemeren, Garssen
& Meuffels, 2012, pp. 50-51).
These empirical findings function as preliminary steps for effectiveness research from a
pragma-dialectical perspective. First, if ordinary language users had not complied with the rules
for a critical discussion in their reasonableness evaluations or had not expected others to do so,
there is no reason to believe that they will link the effectiveness of a discussion contribution to
its pragma-dialectical conception of reasonableness. Second, if ordinary language users had not
deemed other discussion parties to be accountable when they fail to adhere to the rules for a
critical discussion, there is no reason to believe that they expect reasonable manoeuvres to be
more effective than fallacious ones. So, although these studies have not directly demonstrated
that there is a relationship between reasonableness from a pragma-dialectical perspective and
effectiveness, they warrant the belief that such a relationship exists.
To test whether the pragma-dialectical conception of reasonableness of a discussion
contribution induces its effectiveness, an additional factor needs to be taken into account: the
71
In addition to the term the ‘effectiveness’ of argumentation, the term ‘persuasiveness’ can also be used.
In line with van Eemeren (2010, p. 39) and van Eemeren, Garssen and Meuffels (2012, pp. 51-52), only the
term ‘effectiveness’ is used in this study. The reason is that ‘effectiveness’ can be applied to every discussion
contribution – not just to argumentative moves in the argumentation stage like ‘persuasiveness’. Besides,
when using the term ‘persuasiveness’, social and cognitive psychological connotations also come into play,
which are not relevant for the present study.
120
extent to which the discussion contribution is perceived as reasonable. Without ordinary language
users perceiving pragma-dialectically reasonable discussion contributions as reasonable,
the pragma-dialectical conception of reasonableness would be of little concern for the actual
effectiveness of a discussion contribution. Van Eemeren and Grootendorst (1984, p. 68) indeed
state “Whether the perlocutionary effect that the listener is convinced of the acceptability or
unacceptability of the expressed opinion to which the argumentation relates actually occurs,
depends on various factors, one of which is the listener’s assessment of the soundness of the
argumentation schema being used in the argumentation”.
Meuffels (2006, p. 21) demonstrates empirically that there appears to be a strong correlation
between the perceived reasonableness and the perceived convincingness of discussion contributions.
In his quantitative study on the ad hominem fallacy, he not only shows that discussion contributions
that violate the pragma-dialectical freedom rule are perceived as less reasonable than contributions
that observe this rule, but also that the perceived reasonableness of discussion contributions
correlates strongly with their effectiveness. More precisely, Meuffels demonstrates that discussion
contributions that are perceived as reasonable are also perceived as convincing. In contrast,
contributions that are perceived as unreasonable are perceived as less convincing than those that
are perceived as reasonable. Indeed, when regarding ‘perceived reasonableness’ as a covariate –
so, acting as though sound and fallacious discussion contributions statistically received the same
reasonableness scores – the differences in convincingness between the sound and fallacious
discussion contributions are cancelled out. This indicates that there is a causal relation between
perceived reasonableness and convincingness. These findings are in line with O’Keefe’s (2005,
p. 220) more general observation that “normatively-good argumentative practices commonly
engender persuasive success” – and O’Keefe (2005, p. 216) remarks that these ‘normatively good
argumentative practices’ are accommodated by the pragma-dialectical theory.
Of course, it will not depend on the pragma-dialectical conception of reasonableness alone
whether a particular discussion contribution is effective. As discussed in chapter 4, according
to the extended pragma-dialectical theory, a discussion party will try to make his discussion
contributions more effective by selecting advantageously from the topical potential, by adapting
to audience demand and by using expedient presentational devices (van Eemeren, 2010, pp. 93-
128). If done successfully, manoeuvring strategically will increase the effectiveness of a discussion
contribution.
For a discussion party’s strategic manoeuvre to be successful, the communicative activity
type in which the party performs this manoeuvre must be taken into account: a particular
manoeuvre that works in one activity type may not necessarily work in another. For example,
a doctor might convincingly argue by authority (“It is best to take antihistamines; trust me, I’ve
studied this”) in medical consultation, while such an argument might not be convincing in a
discussion with a colleague (“Well, I’ve studied that too, but I don’t think antihistamines are
needed here”). This is because each communicative activity type is unique in the opportunities it
offers and the constraints it places on the parties’ strategic manoeuvring. So, when examining the
effectiveness of a doctor’s argument by authority, the specific characteristics of the communicative
activity type of medical consultation should be taken into consideration (see, for a discussion of
these characteristics, chapter 3).
In sum, it is to be expected that the pragma-dialectical conception of reasonableness
of a discussion contribution induces its effectiveness provided that the contribution is indeed
perceived as reasonable by the other party. In empirical studies aiming to test the effectiveness
of a discussion contribution, the characteristics of the particular communicative activity type in
121
which this contribution is made need to be taken into account. Based on these considerations, the
hypotheses concerning the effectiveness of a doctor’s argument by authority will be formulated
in the next section.
8.3 Overall organisation of the experiment
8.3.1 Hypotheses
As discussed in the previous section, it can be expected that a discussion contribution will be
perceived as effective if it is perceived as reasonable, and that it will be perceived as ineffective if
it is perceived as unreasonable. The studies from chapters 6 and 7 show that ordinary language
users generally find sound instances of a doctor’s argument by authority as neither reasonable, nor
unreasonable; they perceived these instances to be almost exactly halfway on the reasonableness
scale used in these studies (see figures 6.7 and 7.3). It can consequently be hypothesised that sound
instances of the doctor’s argument by authority will also be appraised as halfway between adding
“very much” and “not at all” to the acceptability of the doctor’s standpoint.72 It can therefore be
hypothesised that (H1a) ordinary language users perceive sound instances of a doctor’s argument
by authority as only moderately effective.
The reasonableness studies presented in the previous two chapters provide the basis for
hypotheses about the relative effectiveness of the argument by authority. First of all, these studies
show that ordinary language users consistently perceive a doctor’s sound argument by authority
as less reasonable than sound argumentation in which the doctor does not make use of the
argument scheme of authority argumentation. It can therefore be expected that (H1b) ordinary
language users perceive sound instances of a doctor’s argument by authority as less effective than
a doctor’s other sound arguments. Second, the reasonableness studies from the previous two
chapters show that ordinary language users consistently perceive a doctor’s sound argument by
authority as more reasonable than his fallacious discussion contributions. Based on this result,
it can be hypothesised that (H1c) ordinary language users perceive sound instances of a doctor’s
argument by authority as more effective than a doctor’s fallacious discussion contributions.
So far, the formulated hypotheses pertain to medical consultations in which the consultative
situation is ‘neutral’: the doctor and patient do not make any additional discussion contributions
that might influence the effectiveness of the argument by authority (such as a doctor’s statement
about the severity of the health problem, or the patient’s reference to a source that contradicts the
doctor’s medical advice). In practice a doctor and patient can, of course, make such additional
contributions in the consultation. The reasonableness studies discussed in chapters 6 and 7 have
demonstrated that such additional contributions could, under certain circumstances, influence
ordinary language users’ perception of reasonableness of a doctor’s argument by authority: it was
shown that the perception of reasonableness of this argument is negatively affected if a doctor
indicates that there is not enough time available to conduct a discussion about the medical advice
in addition to advancing an argument by authority. However, not all consultative situations that
were investigated affect the perceived reasonableness of a doctor’s argument by authority: a
patient’s reference to a contradicting source, a doctor’s indication that the health problem in
question is severe or that the patient is insufficiently health literate do not significantly influence
how reasonable ordinary language users perceive the doctor’s argument by authority to be.
72
‘Moderately effective’, thus, amounts to a score of ‘4’ on a 7-point effectiveness scale.
122
To test whether ordinary language users appraise the effectiveness of the doctor’s argument by
authority in line with their perception of the reasonableness of this argument, the following
hypotheses were formulated. First, (H2) ordinary language users perceive a doctor’s argument
by authority as less effective when the doctor indicates that there is not enough time available
Second, (H3) ordinary language users perceive a doctor’s argument by authority as equally
effective when the doctor indicates that the patient is insufficiently health literate to conduct a
discussion about the patient’s health problem as when the doctor does not indicate this.
Only these two hypotheses (H2 and H3) about the consultative situations (insufficient time
and insufficient health literacy) were formulated. Testing more than two hypotheses in a repeated
measurement design combined with a multiple message design would require too extensive a
questionnaire or the division of the study into several smaller studies. Not using these designs
is not advisable either, since their omission would hamper the internal validity of the research
and give rise to the so-called language-as-a-fixed-effect fallacy (see, on this fallacy, Clark, 1973;
Meuffels & van den Bergh, 2006a; 2006b).
The reason for specifically formulating hypotheses about the consultative situation in which
the doctor indicates that there is not enough time (H2) or that the patient is insufficiently health
literate (H3) is that by testing these hypotheses, it can be established, on the one hand, whether
consultative situations that influence ordinary language users’ perception of reasonableness also
influence their perception of effectiveness and, on the other hand, whether consultative situations
that do not influence their perception of reasonableness neither influence their perception of
effectiveness. So, this study enables rather straightforward inferences to be drawn about whether
the consultative situation has any bearing on the effectiveness of the doctor’s argument by
authority and, if so, whether this effect depends on the soundness of the argument (not just on
the consultative situation).
To test whether consultative situations that affect ordinary language users’ perception of
reasonableness of a doctor’s argument by authority also relate to their effectiveness perception,
only the consultative situation in which the doctor indicates that there is insufficient time (H2)
can be used. After all, this is the only situation that appeared to affect ordinary language users’
perception of reasonableness in the studies, which was discussed in chapters 6 and 7.
To test whether consultative situations that do not affect the perception of reasonableness
of the doctor’s argument by authority neither relate to perceived effectiveness, the consultative
situation was selected in which the doctor indicates that the patient is insufficiently health literate
to fully discuss the medical advice about or diagnosis of the health problem (H3). The reason for
this selection is that from the reasonableness studies presented in the previous two chapters, it
appears that this consultative situation does not significantly affect the perceived reasonableness
of a doctor’s argument by authority, and that when the doctor indicates that the patient is
insufficiently health literate, his argument by authority is predominantly evaluated based on its
argumentative merits (rather than on institutional considerations, on politeness consideration,
or on other grounds). So, it can be expected that respondents in the present study will evaluate
the effectiveness of the doctor’s argument by authority based on its argumentative merits.
For the sake of clarity, an overview of the hypotheses on the effectiveness of the doctor’s
argument by authority is provided in figure 8.1. H1a-1c constitute the main hypotheses and H2-3
are the hypotheses concerning the possible influence of consultative situations on the argument’s
effectiveness.
123
Figure 8.1 Overview of the hypotheses pertaining to the effectiveness of a doctor’s argument
by authority
H1a Ordinary language users perceive sound instances of a doctor’s argument by authority as moderately
effective.
H1b Ordinary language users perceive sound instances of a doctor’s argument by authority as less effective
than a doctor’s other sound arguments
H1c Ordinary language users perceive sound instances of a doctor’s argument by authority as more
effective than a doctor’s fallacious discussion contributions.
H2 Ordinary language users perceive a doctor’s argument by authority as less effective when the doctor
indicates that there is not enough time available to conduct a discussion about the medical advice
than when the doctor does not indicate this.
H3 Ordinary language users perceive a doctor’s argument by authority as equally effective when the
doctor indicates that the patient is insufficiently health literate to conduct a discussion about the
patient’s health problem as when the doctor does not indicate this.
8.3.2 Set-up
To test the hypotheses that were discussed in the previous section, an almost identical experimental
set-up was used as in the reasonableness studies from chapters 6 and 7. In the present study too
the argument by authority was tested by means of hypothetical dialogue fragments of medical
consultations in which a doctor acts as the protagonist of a diagnosis, medical advice or a
prognosis in a non-mixed difference of opinion with a patient. The doctor in these fragments
advances a sound argument or commits a fallacy in response to the patient’s doubt or hesitance
to accept his advice or judgment. Again, the respondents had to evaluate the dialogue fragments
by means of a pencil-and-paper test. As in the reasonableness studies presented in chapters 6
and 7, a repeated measurement design in combination with a multiple message design was used.
In the present study, the consultative situations in which the dialogue fragments are placed
vary systematically as in the earlier studies. As in study 3 (chapter 6) and the replication study
(chapter 7), the doctor in the dialogue fragments indicates that there is not enough time, that the
patient is insufficiently health literate, or refrains from indicating anything about consultation
time or health literacy (the ‘neutral’ situation’). Using these consultative situations enables the
testing of H2 (Ordinary language users perceive a doctor’s argument by authority as less effective
when the doctor indicates that there is not enough time available to conduct a discussion about
the medical advice than when the doctor does not indicate this) and H3 (Ordinary language users
perceive a doctor’s argument by authority as equally effective when the doctor indicates that the
as when the doctor does not indicate this).
The present study differs from the reasonableness studies from chapters 6 and 7 in two
respects. First and foremost, the dependent variable of the present study is different. In the
present study, it is not the extent to which patients perceive a doctor’s argument by authority
to be reasonable that is measured, but the extent to which they perceive this argument to be
inherently interactionally effective – i.e., the extent to which it adds to the acceptability of the
standpoint.
124
The second difference is that the number of tested dialogue fragments differs from that of the
reasonableness studies that were discussed in chapters 6 and 7: the present study consisted of
slightly fewer fragments than the reasonableness studies from chapter 6, and more fragments
than the replication study from chapter 7 (42 dialogue fragments were included in the present
study instead of the 48 fragments in the reasonableness studies from chapter 6 and the 36
fragments in the replication study from chapter 7). This is because for the present study, the same
dialogue fragments were used as in the replication study from chapter 7, but more fragments
were included because the respondents in the present study did not have to answer any open
questions as they did in the replication study from chapter 7. Therefore, they could answer more
questions in the available time.
The above explains why more dialogue fragments were used in the present study than
in the replication study from chapter 7, but not why the number of dialogue fragments in the
present study is somewhat fewer than that in the reasonableness studies from chapter 6 (42 as
opposed to 48 dialogue fragments). The reason for this lower number of fragments is that the
present study includes fragments in which the doctor commits an ad verecundiam fallacy, which
were not included in the reasonableness studies from chapter 6. These ad verecundiam fragments
are incorporated to check whether the respondents distinguish between sound arguments by
authority and fallacious ones in their effectiveness appraisal. The potential risk of including
ad verecundiam fallacies is that it becomes too obvious that the research is about authority
argumentation. To avoid giving away the purpose of the research in this way, the number of ad
verecundiam fragments was kept to only a quarter of all authority arguments – and all authority
arguments together, in turn, make up only about a quarter of all dialogue fragments. Therefore,
the total number of dialogue fragments in the questionnaires used in the effectiveness study was
slightly less than in the reasonableness studies from chapter 6.
Figure 8.2a provides an overview of the dialogue fragments that were used in the
questionnaires of the current effectiveness study. As shown in this figure, half of the questionnaire’s
fragments are sound and half are fallacious. About one in five is a dialogue of interest: a fragment
in which the doctor advances a sound argument by authority. All other items functioned as
control items and, at the same time, as distractors. These items are used as benchmarks for the
interpretation of the results and hide the exact purpose of the experiment.
As in the reasonableness studies from chapters 6 and 7, the consultative situations are
equally distributed over the sound argument by authority fragments (see figure 8.2b). These
situations are randomly assigned to the control items: sometimes, the doctor indicates that there
is limited time available to discuss the issue in the control item, sometimes he indicates that the
patient is insufficiently health literate, and sometimes he does not indicate anything at all about
consultation time or health literacy.
125
Figure 8.2a Overview of the dialogue fragments in the questionnaires
a. 9 dialogue fragments in which the doctor advances a sound argument by authority

argumentation
c. 3 dialogue fragments in which the doctor commits an ad verecundiam fallacy
d. 6 dialogue fragments in which the doctor commits an ad baculum fallacy
Figure 8.2b Overview of the consultative situations tested in the dialogue fragments in which
the doctor advances a sound argument by authority
a. 3 dialogue fragments in which the doctor indicates that there is not enough time
b. 3 dialogue fragments in which the doctor indicates that the patient is insufficiently health literate
c. 3 dialogue fragments of the ‘neutral’ situation, in which the doctor does not indicate anything about
time or the patient’s health literacy
8.3.3 Measuring effectiveness

In the questionnaires of the effectiveness study, each dialogue fragment was followed by the
question: “To what extent does the doctor’s last contribution add to the acceptability of his advice
/ judgement?”73 The respondents were not asked to rate the effectiveness of this contribution
directly, but rather the extent to which the contribution adds to the doctor’s advice or judgement,
to make sure that they would appraise the inherent interactional effect of the doctor’s discussion
contributions (and not, for example, its consecutive effectiveness). As depicted in figure 8.3,
the words “doctor’s last contribution” were printed in bold type to clearly indicate the last
contribution in the dialogue fragment (which was also printed in bold type).
Figure 8.3 The question that was asked after each dialogue fragment
To what extent does the doctor’s last contribution add to the acceptability of his advice / judgement?
not at all not a little little nor much somewhat a lot very much
O O O O O O O
The respondents had to answer this question on a 7-point Likert scale, ranging from the doctor’s
discussion contribution does “not at all” contribute to his advice or judgement, to it contributes
“very much” to his advice or judgement.74 The following three criteria were used in developing
this scale: the scale should enable an adequate rating of the inherent interactional effectiveness of
a doctor’s discussion contributions, it should be clear to the respondents what the answer options
73
The original question in Dutch reads: “In hoeverre draagt de laatste bijdrage van de huisarts bij aan de
aanvaardbaarheid van zijn advies / oordeel?”.
74
The original categories in Dutch read: (1) “totaal niet”, (2) “niet”, (3) “weinig”, (4) “weinig noch veel”, (5)
“tamelijk veel”, (6) “veel” and (7) “ontzettend veel”.
126
denote, and these answer options should enable a comparison with the reasonableness scores
in the studies from chapters 6 and 7. Two pragma-dialecticians with extensive experience of
quantitative empirical research critically reviewed the development of this scale on these criteria
in three rounds of revisions.
The scale depicted in figure 8.3 is the result of this development procedure. In combination
with the description of inherent interactional effectiveness in the question that precedes it, the
scale adequately measures the dependent variable without becoming too technical. Additionally,
the choice for a 7-point scale enables a comparison with the reasonableness scores on the
(7-point) scale used in the studies from chapters 6 and 7.
It was ensured that the dialogue fragment and its accompanying question and scale were
printed on the same page in the questionnaires. To avoid order effects, three versions of the
questionnaire were made in which the order of the dialogue fragments varied at random.
8.3.4 Respondents
A total of 103 (Dutch) respondents completed the effectiveness questionnaires. They were asked
to partake in the study on two July days in parks in Amsterdam.75 Parks were used as the location
of the experiments as there would be many people about with time on their hands and who
presumably did not have any background in argumentation theory. Respondents were recruited
on two separate days.
Respondents were aged from 17 to 80 years old, with an average age of 30 (SD = 12.7).
Somewhat more women (56.3%) than men participated. The vast majority of the respondents
was higher educated (82.5%).76 A number of respondents had received education in the medical
sciences (18.4%), a minority worked in the medical sector (9.7%). It took the respondents 15 to
20 minutes to fill out the questionnaire.
8.3.5 Instruction
The first page of the questionnaires consisted of instructions to the respondents. Respondents
were told that they were about to read 42 fictitious dialogue fragments, each dealing with a health
problem about which the patient consults the doctor.
To avoid S-bias, the respondents were not informed about the purpose of the study. It was
instead emphasised that, depending on the specific consultative situation, people might differ in
their appraisal of the extent to which a doctor’s dialogue contribution adds to the acceptability
of a medical advice or judgement and that, hence, the question “To what extent does the doctor’s
last contribution add to the acceptability of his advice / judgement?” is asked after each dialogue
fragment. Respondents were kindly requested to answer this question by choosing only one
answer option on the scale depicted in figure 8.3.
To reassure the respondents that they were capable of filling out the questionnaire, it was
pointed out that answering the questions does not require any specific medical expertise and
75
Respondents were recruited in the Westerpark and Park Frankendael. These parks were chosen as they
are not the biggest tourist hotspots (and so the chance of asking non-Dutch people was kept to a minimum)
and they are in different areas of Amsterdam (to avoid asking people twice).
76
As in the reasonableness studies reported on in chapters 6 and 7, respondents were considered to be
‘higher educated’ if their highest educational level consists of: university education (wo), pre-university
education (vwo) or higher vocational education (hbo). They were considered to be ‘lower educated’ if their
highest educational level is: intermediate vocational education (mbo), higher general secondary education
(havo), lower vocational professional education (vmbo) or primary school (basisschool).
127
that it is only about their own opinion. They were also told that their data would be dealt with
anonymously. To encourage respondents to answer the questions honestly, it was stressed that
there are no right or wrong answers.
8.4 Results
Now that it has been explained how the experiment on the effectiveness of a doctor’s argument
by authority was conducted, the results of this experiment can be reported.
With respect to general hypothesis H1a (Ordinary language users perceive sound instances
of a doctor’s argument by authority as moderately effective), the respondents evaluated the
effectiveness of a doctor’s sound argument by authority with an average score of 3.44 (1.09) (see
table 8.1). This score translates into an evaluation that the argument adds between “little” and
“little nor much” to the acceptability of the advice or judgement of the doctor. A one sample
t-test shows that this effectiveness score differs significantly (t(99) = -5.61, p < .001; Cohen’s d =
-.51) from a score of 4 (“little nor much”). This means that, assuming that a doctor’s “moderately
effective” argument is regarded as an argument that contributes “little nor much” to his advice or
judgement, H1a has to be rejected: in an absolute sense, a doctor’s argument by authority added
less than moderately to the acceptability of his advice or judgements.77
Table 8.1 The average effectiveness scores for a doctor’s sound argument by authority,
other sound argumentation and fallacious contributions
Discussion contribution by the doctor Mean

Argument by authority 3.44
(1.09)
Other sound argumentation 5.27
(excluding authority argumentation) (.68)
Fallacious contributions 2.19
(.76)
How does the extent to which a doctor’s argument by authority is perceived as effective compare
to the perceived effectiveness of other sound argumentation? The results concerning general
hypothesis 1b (Ordinary language users perceive sound instances of a doctor’s argument by
authority as less effective than a doctor’s other sound arguments) provide an answer to this
question. As shown in table 8.1, in general, respondents regard a doctor’s sound argumentation
in which he does not make use of the argument scheme of authority argumentation to add
between “somewhat” and “a lot” to the doctor’s advice or judgement: respondents gave it an
77
It should be noted that the respondents’ evaluation of the doctor’s argument by authority also
significantly differs (t(99) = 4.00, p < .001; Cohen’s d = .40) from contributing “little” (a score of 3) to the
doctor’s advice or judgement. This might be considered a reason to accept H1a. However, the argument by
authority received an average reasonableness score of 3.99 (.99) in the studies presented in chapter 6 and of
4.29 (1.17) in the replication study present in chapter 7, and H1a in the effectiveness study is based on these
reasonableness scores. Consequently, “moderately effective” in H1a is likewise interpreted as corresponding
to a score of 4 – meaning that H1a should be rejected.
128
average effectiveness score of 5.27 (.68). This is a significantly higher effectiveness score than a
doctor’s argument by authority generally received (F’(1, 5) = 25.09; p < .005; ES = .41). So, H1b
can be accepted: ordinary language users indeed perceive sound instances of a doctor’s argument
by authority as less effective than a doctor’s other sound arguments.
The lower effectiveness evaluation for the doctor’s argument by authority than for his other
sound arguments does not mean that a doctor’s argument by authority is on par with his fallacious
discussion contributions. On average, respondents considered a doctor’s fallacious contributions
to add between “not” and “a little” to his advice or judgement (a score of 2.19 (.76); see table 8.1).
This score is significantly lower than that which the respondents gave a doctor’s argument by
authority (F’(1, 5) = 14.32; p < .05; ES = .22). H1c can, therefore, be accepted: ordinary language
users indeed perceive sound instances of a doctor’s argument by authority as more effective than
a doctor’s fallacious discussion contributions.
Even though no specific hypothesis was formulated about the difference in effectiveness
between a doctor’s sound argument by authority and an ad verecundiam fallacy committed by
the doctor, it was checked whether there is such a difference. With an average effectiveness score
of 2.78 (1.02), respondents in the study regarded the doctor’s ad verecundiams to be less effective
than his sound arguments by authority (3.44 (1.09)). Yet, this difference turns out not to be
significant (F’(1, 5) = 2.29; p > .05)).
This result appears to have been due to a failed manipulation of only one ad verecundiam
fragment: while the ad verecundiams in the other two fragments were, on average, appraised
as contributing between “not” to “a little” (amounting to an average score of 2.39 (1.07)) to the
acceptability of the doctor’s standpoint, this particular ad verecundiam was regarded to contribute
between “a little” and “little nor much” (an average score of 3.57 (1.54)) to the standpoint’s
acceptability.
A closer look at the dialogue fragments shows that the more positively appraised ad
verecundiam concerns a patient’s discoloured tooth. More specifically, in the dialogue fragment,
the doctor argues that the patient might consider bleaching his discoloured tooth with carbamide
peroxide gel 10%, because “based on my experience as a GP, I know that this works just fine”. The
other two ad verecundiam fragments were about the choice for a small gym over a large one, and
the superior taste of organic food.
The discussion topics of the dialogue fragments in which the doctor commits the
argumentum ad verecundiam fallacies might shed light on the reason why the ad verecundiam
in the consultation about the discoloured tooth was considered more effective than the other
instantiations of this fallacy. Although a doctor is, strictly speaking, not qualified to treat the
patient’s dental problems in his professional capacity, he should be able to refer a patient to a
dentist when necessary. Therefore, respondents might have assumed the doctor to possess
sufficient authority on dental problems to consider the doctor’s argumentation in this fragment
to be sound.
Because the dialogue fragment about the patient’s decoloured tooth therefore does not
seem to adequately test the effectiveness of the ad verecundiam fallacy. It was checked whether
the difference between a doctor’s sound arguments by authority and ad verecundiam fallacies
by the doctor was significant without the inclusion of the discoloured tooth dialogue fragment.
Indeed, the difference in effectiveness between the sound instantiations of the argument by
authority and the other ad verecundiam fallacies then turns out to be significant (F’(1, 4) = 19.75;
p < .05; ES = .19).
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The confirmation of H1c (Ordinary language users perceive sound instances of a doctor’s argument
by authority as more effective than a doctor’s fallacious discussion contributions) together with
the confirmation of H1b (Ordinary language users perceive sound instances of a doctor’s argument
by authority as less effective than a doctor’s other sound arguments), means that language users’
perception of the effectiveness of the doctor’s argument by authority correlates positively with
their perception of the reasonableness of this argument. In other words, if the doctor’s argument
by authority is perceived as reasonable, then it will also be perceived as effective. If this argument
is perceived as unreasonable, it will also be perceived as ineffective.
So far, the consultative situations in which a doctor advances the argument by authority
have not been taken into account. To test H2 and H3, taking these situations into account is
necessary. To test H2 (Ordinary language users perceive a doctor’s argument by authority as less
effective when the doctor indicates that there is not enough time available to conduct a discussion
about the medical advice than when the doctor does not indicate this), requires consideration
of the effectiveness scores for the doctor’s argument by authority in a consultation in which he
indicates that there is not enough time available.
As depicted in table 8.2, on average, respondents evaluated the effectiveness of the argument
by authority when the doctor indicates that there is not enough time with a score of 2.51 (.80),
which translates to the argument adding “not” to “a little” to the doctor’s advice or judgement.
This score is significantly lower than that for a doctor’s argument by authority in a ‘neutral’
situation (that is, without the doctor’s indication of a lack of time or the patient’s insufficient
health literacy; F’(1, 5) = 8.71; p < .05; ES = .16). Consequentially, H2 has to be accepted.
Table 8.2 The average effectiveness scores for the different consultative conditions
in which a doctor advances an argument by authority
Discussion contribution by the doctor Mean

Neutral situation 3.44
(1.09)
Not enough time (H2) 2.51
(.80)
Insufficiently health literate (H3) 2.76
(1.05)
Similarly, the doctor’s indication that the patient is insufficiently health literate negatively affects
the effectiveness scores that respondents provided for the doctor’s argument by authority. On
average, this argument received a score of 2.76 (1.05) when the doctor referred to the patient’s
lack of health literacy – as opposed to a score of 3.44 (1.09) when he did not refer to the patient’s
health literacy (see table 8.2). The difference between the evaluations of a doctor’s argument
by authority with and without a doctor’s indication of the patient’s insufficient health literacy
is significant (F’(1, 6) = 8.50; p< .05; ES = .11). This means that H3 (Ordinary language users
perceive a doctor’s argument by authority as equally effective when the doctor indicates that the
as when the doctor does not indicate this) has to be rejected.
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8.5 The empirical relation between perception of reasonableness and effectiveness
The results of the present effectiveness study and the previous reasonableness studies (chapters
6 and 7) agree with each other on the relative evaluation of the doctor’s argument by authority
and on the evaluation of this argument when a doctor indicates that there is limited time. For
both of these evaluations, ordinary language users’ perception of effectiveness of the argument by
authority correlates as expected to their perception of reasonableness of this argument.
The absolute effectiveness of a doctor’s argument by authority and its effectiveness when
the doctor indicates that the patient is insufficiently health literate, however, do not correspond
to ordinary language users’ perception of reasonableness. As shown in table 8.3, while language
users perceived a doctor’s argument by authority as “neither unreasonable, nor reasonable”
when he does not refer to time limitations or the patient’s health literacy, they did not perceive
this argument as adding “little nor much” to the doctor’s medical advice or judgement; instead,
they evaluated its effectiveness more negatively. Compared to the reasonableness outcomes in
chapters 6 and 7, a more negative effectiveness evaluation was also given to the argument by
authority in the consultative situation when a doctor indicates that the patient is insufficiently
health literate than when he does not do so (see table 8.3).
Table 8.3 Overview of the average reasonableness and effectiveness scores for the
consultative conditions in which a doctor advances an argument by authority
in the different studies
Study Neutral situation Not enough time Insufficiently health

literate
Reasonableness evaluation 3.99 2.56 3.64
in studies 1-3 (Ch.6) (.99) (.94) (1.06)
Reasonableness evaluation 4.29 2.62 3.35
in replication (Ch.7) (1.17) (1.12) (1.23)
Effectiveness evaluation 3.44 2.51 2.76
in present study (1.09) (.80) (1.05)
Table 8.4 Overview of the average reasonableness and effectiveness scores for control items
in the different studies
Study Other sound argumentation Fallacious contributions

(excluding authority argumentation)
Reasonableness evaluation 5.54 2.40
in studies 1-3 (Ch.6) (.68) (.72)
Reasonableness evaluation 5.52 2.45
in replication (Ch.7) (.67) (1.04)
Effectiveness evaluation 5.27 2.19
in present study (.68) (.76)
It seems to be the case that ordinary language users make the step from perceived reasonableness
to effectiveness, in general, very critically. Not only does table 8.3 show that the doctor’s argument
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by authority received lower effectiveness scores than perceived reasonableness scores in every
consultative situation, but that the same pattern also emerges for the doctor’s other discussion
contributions. As shown in table 8.4, the doctor’s other sound argumentation and his fallacious
contributions also scored lower on effectiveness than on perceived reasonableness.
A more negative evaluation of the effectiveness of the doctor’s discussion contributions
than was expected based on their reasonableness scores indeed explains why H1b-c (about the
relative effectiveness of the doctor’s argument by authority) and H2 (about the effectiveness of this
argument when the doctor indicates that there is limited time for discussion) were confirmed,
while H1a (about the absolute effectiveness of the doctor’s argument by authority) and H3 (about
the effectiveness of this argument when the doctor indicates that the patient is insufficiently
health literate) had to be rejected.
The hypotheses concerning the relative effectiveness of a doctor’s argument by authority
(H1b-c) could be confirmed precisely because it is about relative effectiveness: even though the
effectiveness scores for the doctor’s argument by authority are lower than perceived reasonableness
scores, the argument’s effectiveness still compares to the effectiveness of other sound and
fallacious discussion contributions in the same way as it does on perceived reasonableness.
The hypothesis about the effectiveness of the doctor’s argument by authority when the
doctor indicates that there is not enough time for further discussion (H2) could be confirmed
because it was already expected that ordinary language users perceive this argument as less
effective when a doctor indicates that there is limited time than when he does not. So, a more
negative evaluation of the effectiveness of a doctor’s argument by authority than of its perceived
reasonableness only leads to a clearer confirmation of this hypothesis.
In contrast, the hypothesis about the absolute effectiveness of the doctor’s argument by
authority (H1a) had to be rejected precisely because this hypothesis is about absolute effectiveness:
the lower effectiveness scores than were expected based on the perceived reasonableness scores
necessarily lead to the rejection of H1a; ordinary language users perceive sound instances of a
doctor’s argument by authority as less than moderately effective.
The rejection of the hypothesis about the effectiveness of the doctor’s argument by
authority when he indicates that the patient is insufficiently health literate (H3) might also be
explained by the more negative evaluation of its effectiveness than was expected based on its
perceived reasonableness. In the reasonableness studies from chapters 6 and 7, the respondents
perceived the argument by authority in this consultative circumstance as less reasonable than in
a ‘neutral’ situation (see table 8.3), but this difference was not significant – neither in the studies
from chapter 6 (F’(1, 6) = 1.35; p > .05), nor in the replication from chapter 7 (F’(1, 4) = 3.90; p >
.05). The more negative effectiveness appraisal might, nonetheless, have lowered the effectiveness
score for the doctor’s argument by authority when he indicates that the patient is insufficiently
health literate more than it lowered the score for this argument when the doctor does not indicate
this, resulting in a significant difference between these consultative situations (F’(1, 6) = 8.50; p
< .05; ES = .11). A possible explanation for this more negative appraisal is discussed in the next
section.
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8.6 Discussion
Assuming that, as suggested in the previous section, ordinary language users indeed appraise the
effectiveness of the doctor’s discussion contributions more negatively than they perceive these
contributions to be reasonable, what could be the reason for this? An answer to this question can
be given by taking into account that, with his discussion contributions, the doctor manoeuvres
strategically in the communicative activity type of medical consultation.
As discussed in section 8.2, next to the pragma-dialectical conception of reasonableness of
a discussion contribution, contextual factors can also be expected to influence the effectiveness
of the contributions. Based on the extended pragma-dialectical theory, it is, for instance, likely
that the extent to which a discussion party successfully manoeuvres strategically influences
effectiveness. Whether a party’s strategic manoeuvre is successful depends, among other
things, on the communicative activity type in which he performs this manoeuvre. Thus, the
effectiveness of the doctor’s contributions in the questionnaires depends, among other things, on
the characteristics of the activity type of medical consultation.
Because medical consultation is characteristically about a patient’s health problem that
is potentially very serious, the outcome of an argumentative discussion in the consultation is
of great importance for the patient. This could be a reason why the discussion contributions in
the effectiveness study were appraised more negatively than in the reasonableness studies from
chapters 6 and 7. The reasoning behind the effectiveness appraisal would be then that although
the doctor’s sound discussion contributions are generally perceived as reasonable, the issue
under discussion is potentially of such importance that it requires more than these contributions
to make ordinary language users fully accept the doctor’s medical advice or judgment.
The importance of the discussion outcome can explain the rejection of H1a (Ordinary
language users perceive sound instances of a doctor’s argument by authority as moderately
effective), but not that of H3 (Ordinary language users perceive a doctor’s argument by authority
as equally effective when the doctor indicates that the patient is insufficiently health literate to
conduct a discussion about the patient’s health problem as when the doctor does not indicate
this). To understand why the hypothesis about the doctor’s indication of the patient’s insufficient
health literacy is rejected, the characteristics of the activity type of medical consultation can also
provide an indication.
As already discussed in chapters 2 and 5, a doctor is legally bound to obtain the patient’s
informed consent before prescribing a particular treatment. This obligation consists of two parts:
the informed-part (which requires the doctor to fully inform the patient about what the advised
treatment amounts to, the risks and consequences of this treatment, alternative treatment
options and the patient’s prospects when undergoing this treatment) and the consent-part
(which requires the doctor to obtain the patient’s agreement with the advised treatment before
prescribing this treatment). A doctor’s indication that the patient is insufficiently health literate
to fully discuss his health problem might be regarded as going against the informed-part of this
requirement. The respondents may have expected the doctor to provide further information
until the patient reaches a sufficient understanding. Not doing so may be seen as unreasonable.
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8.7 Conclusion
The results of the present study on the effectiveness of a doctor’s argument by authority in medical
consultation show that the effectiveness of this argument depends on how reasonable ordinary
language users perceive it to be. The results suggest that this effectiveness also depends on the
characteristics of the communicative activity type of medical consultation.
First of all, it can be concluded that the effectiveness of a doctor’s argument by authority
depends on ordinary language users’ perception of the reasonableness of it, as the study shows that
the relative effectiveness of a doctor’s argument by authority in medical consultation corresponds
to their perception of reasonableness of this argument. Likewise, the study demonstrates that
there is a positive correlation between perceived reasonableness and perceived effectiveness of
the argument by authority when the doctor indicates that there is not enough time to discuss the
medical advice or judgement.
For the effectiveness of the doctor’s argument by authority in an absolute sense and in
the consultative situation in which the doctor indicates that the patient is insufficiently health
literate, an additional factor seems to come into play: the extent to which the doctor takes into
account the characteristics of the communicative activity type of medical consultation in his
discussion contributions. The fact that, in contrast to what was hypothesised, the study shows
that ordinary language users perceive sound instances of a doctor’s argument by authority as less
than moderately effective can be explained by the typical characteristic of medical consultation
that the discussion outcome is of the utmost importance to the patient. The unpredicted negative
effectiveness appraisal of the argument by authority when the doctor indicates that the patient
is insufficiently health literate could be due to the fact that through indicating that the patient
is insufficiently health literate, the doctor might appear to fail to fulfil the legal requirement of
informed consent.
Based on the results of this effectiveness study, the hitherto predominantly assumed
relation between pragma-dialectical conception of reasonableness and effectiveness of a
discussion contribution can be substantiated. The present study shows that effectiveness indeed
positively correlates with reasonableness from a pragma-dialectical perspective. In line with the
extended pragma-dialectical theory, the study furthermore suggests that the extent to which the
pragma-dialectical conception of reasonableness correlates with effectiveness depends on the
degree to which the discussion party takes into account the characteristics of the communicative
activity type in his discussion contribution.
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9 Conclusion
9.1 Main findings
The aim of this study was to determine under which conditions a doctor’s argument by authority
constitutes a reasonable and effective strategic manoeuvre in medical consultation. Establishing
these conditions is important from both an argumentation theoretical and a medical perspective.
From an argumentation theoretical perspective, this study clarifies the relationship between
pragma-dialectical reasonableness and effectiveness of the particular strategic manoeuvre of
arguing by authority in the particular communicative activity type of medical consultation.
The relationship between pragma-dialectical reasonableness and effectiveness has not, so far,
been fully examined empirically, let alone in the context of a particular activity type. From a
medical perspective, this study shows if and under what specific conditions it is useful for a
doctor to argue by authority in medical consultation. Given patients’ increased access to medical
information and the emphasis on shared decision-making in medical practice, this study may
provide valuable insight into the extent to which a doctor can reasonably and effectively argue by
referring to his medical authority.
To establish the conditions under which a doctor’s argument by authority constitutes a
reasonable and effective strategic manoeuvre in medical consultation, a number of questions
had to be answered. First, which characteristics of medical consultation affect the strategic
manoeuvring in the consultation? Second, in which ways can a doctor manoeuvre strategically
with an argument by authority in medical consultation? Third, what conditions should a doctor’s
argument by authority meet for this argument to reasonably contribute to the resolution of a
dispute? Fourth, what conditions should a doctor’s argument by authority meet for this argument
to be perceived as reasonable by the patient in practice? And fifth, what conditions should a
doctor’s argument by authority meet for this argument to effectively contribute to the acceptability
of his diagnosis, prognosis and/or advice in medical practice? These questions were answered in
the present study by analytically and subsequently empirically investigating a doctor’s argument
by authority in medical consultation from a pragma-dialectical perspective.
In the first part of this study, the analytical part, it was argued that medical consultation
can be characterised as a communicative activity type in which argumentation can play an
important role (chapter 2). This communicative activity type places four institutional constraints
on the argumentative discourse.
First, the confrontational trigger of the argumentative discourse determines how a
discussion arises. In medical consultation, this trigger typically amounts to a lack or assumed
lack of agreement between a doctor and patient about (part of) the doctor’s diagnosis, prognosis,
and/or advice concerning a health problem of the patient.
Second, the discussion contributions by the doctor and patient are affected by the starting
points that are generally in place in a consultation. The starting points in the consultation consist
of explicit rules (such as the legal requirement of informed consent), implicit rules (such as
the doctor acting as discussion leader), explicitly established concessions (such as information
obtained by the doctor’s verbal inquiry into the health of the patient) and implicitly established
concessions (such as information obtained by the doctor’s physical examination of the patient).
Third, the available argumentative means that are characteristic of medical consultation
determine how a doctor and patient can resolve their difference of opinion on the merits. In a
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medical consultation, argumentation is typically based on the interpretation of concessions in
terms of medical facts and evidence, and the discussion characteristically takes place by means
of cooperative conversational exchanges.
Fourth, the consultation’s possible discussion outcomes influence the resolution process.
These outcomes can amount to explicit agreement on the diagnosis, prognosis and/or medical
advice (including refraining from treatment or referrals to a specialist).
These institutional constraints need to be taken into account in the analysis of a doctor’s
strategic manoeuvring in medical consultation: they explain why it could be advantageous for
a doctor to opt for a particular discussion contribution in a particular way in a discussion with
the patient. A doctor’s argument by authority was analysed as a strategic manoeuvre based on
precisely these institutional constraints.
For this analysis, an analytical distinction between four different ways in which a doctor’s
authority can affect the discussion outcome was introduced (chapter 3). This distinction was
proposed between a discussion party’s existing ethos, his acquired ethos, the argument from
authority and the argument by authority. Although these four authority variants are likely to
interact in practice, each of them has its own particular strategic advantages, which is the main
reason why it is useful to distinguish them analytically.
‘Existing ethos’ refers to the discussion party’s authority that is already in place at the start
of the argumentative discussion, ‘acquired ethos’ to the party’s constructed authority during the
discussion, the ‘argument from authority’ to an authority argument in which the discussion
party refers to an external source as an authority on the issue under discussion – that is, to a
source that is not the protagonist – and the ‘argument by authority’ to an authority argument in
which the discussion party refers to himself as an authority on the issue under discussion. In an
argument by authority, the standpoint ‘X is acceptable’ is thus supported by the premises (1.1)
‘the protagonist is of the opinion that X’ and (1.1’) ‘the opinion of the protagonist indicates that
X is acceptable’.
For a doctor in medical consultation, the strategic advantages of arguing by authority arise
from the fact that he can present the medical authority that the patient already ascribes to him as
an indication of the acceptability of the standpoint (chapter 4). The patient can be said to ascribe
authority over his health problem to the doctor by virtue of requesting a medical consultation:
the patient does not exactly know what is the matter with him, how serious his health problem
is, and/or what to do about it, and requests a consultation with the doctor because he thinks the
doctor knows about these matters. By advancing an argument by authority, the doctor confirms
that he indeed possesses this medical authority (his existing ethos). This makes a doctor’s
argument by authority potentially very effective in medical consultation.
Moreover, by advancing an argument by authority, a doctor could avoid an extensive,
detailed and technical discussion about the patient’s health problem. This is potentially
advantageous given the limited consultation time and the asymmetry in knowledge and expertise
between the doctor and patient that are characteristically in place in medical consultation.
Even though a doctor’s argument by authority is a strategic manoeuvre in medical
consultation, it does not always constitute a reasonable discussion contribution (for instance,
when a doctor refers to authority that he does not actually possess). From a pragma-dialectical
perspective, an argument by authority is reasonable if the doctor fulfils the various specific
soundness conditions that apply to this argument in medical consultation.
The specific soundness conditions that a doctor’s argument by authority should meet
for this argument to contribute to the reasonable resolution of the difference of opinion were
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established in the last chapter of the analytical part of this study (chapter 5). In this chapter, the
soundness conditions for the argument by authority in general were determined. These general
soundness conditions were subsequently precisized and specified for the communicative activity
type of medical consultation, thereby making them specific soundness conditions. Four specific
soundness conditions have been proposed in the present study for the particular discussion
situation in which a doctor advances an argument by authority in support of treatment advice.
First, the specific burden of proof condition needs to be fulfilled: “The doctor who advances
an argument by authority in support of treatment advice is obliged to continue the defence of
this advice if the patient has not consented to the treatment subsequent to the doctor’s argument
by authority”. This specific condition is a specification of the general soundness condition that
can be said to apply to the argument by authority based on the pragma-dialectical burden of
proof rule (rule 2). The legal requirement of informed consent was used for specifying this general
soundness condition. The consent-part of this legal requirement requires the doctor to obtain
the patient’s agreement with the advised treatment before prescribing this treatment. This part of
the requirement consequently means that the doctor should continue the defence of his medical
advice after advancing an argument by authority if the patient has not yet consented to the advice.
Second, the requirement of informed consent was also used to specify the relevance
condition: “The doctor may not parade his own qualities in order to avoid advancing
argumentation that indicates that the advised treatment is beneficial and to be preferred over
relevant alternative treatments or non-treatment”. The informed-part of the requirement of
informed consent clarifies when a doctor violates the pragma-dialectical relevance rule (rule 4)
by parading his own qualities, since this part of the requirement sets out which topics a doctor
should address in a discussion about treatment advice (namely, what the advised treatment
amounts to, the risks and consequences of this treatment, alternative treatment options and the
patient’s prospects when undergoing this treatment).
Third, based on the characteristic starting point of medical consultation that the patient
requests a consultation with the doctor precisely because of the doctor’s knowledge and expertise
in the field of medicine, the condition under which the pragma-dialectical argument scheme
rule (rule 8) is violated in a treatment discussion was specified. By requesting a consultation,
patients ascribe authority to the doctor that is genuine and relevant to their health problem. So,
in principle, the doctor can reasonably refer to this authority in argumentation about treatment
advice. However, given certain circumstances, a patient might become less convinced of the
doctor’s authority during a consultation (for instance, because the doctor prescribes a different
treatment than the patient expected). In such situations, the doctor can no longer reasonably
refer to his medical authority. This is laid out in the credibility condition: “The doctor may not
regard his treatment advice as conclusively defended by an argument by authority if the patient
has indicated doubt about the genuineness or relevance of the doctor’s authority on the treatment
advice during the medical consultation”.
Fourth, to adhere to the pragma-dialectical argument scheme rule (rule 8), a protagonist
who advances an argument by authority must also correctly cite any opinions in that argument
that he stated prior to conducting the argumentative discussion. If a protagonist misrepresents
his earlier opinion (for instance, when exaggerating or simply forgetting what he had exactly
said), this opinion cannot be regarded as a reasonable indication of the acceptability of the
standpoint. This general condition also applies to a doctor’s argument by authority in a treatment
discussion. It was therefore precisized for a doctor in medical consultation, resulting in the
specific appropriateness condition: “A doctor who cites (an) opinion(s) that he expressed before
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participating in the argumentative discussion in medical consultation should do so correctly at
a point where this is relevant”.
With the precisations and specifications of the soundness conditions for a doctor’s
argument by authority, the aim of this study has already been partly fulfilled: it was determined
under which conditions a doctor’s argument by authority constitutes a reasonable strategic
manoeuvre in medical consultation. Whether and under which conditions ordinary language
users perceive a doctor’s argument by authority as a reasonable and an effective strategic
manoeuvre was investigated in the empirical part of the study (chapter 6-8).
To find out whether a doctor’s argument by authority is effective in getting a diagnosis, prognosis
and/or medical advice accepted by ordinary language users, it was first empirically investigated
whether ordinary language users perceive a doctor’s sound arguments by authority to be
reasonable (chapter 6). The reason for first empirically investigating this issue was that ordinary
language users’ appraisal of the effectiveness of a doctor’s argument by authority can only be
positively influenced by pragma-dialectical soundness if ordinary language users evaluate the
reasonableness of this argument in accordance with the specific soundness conditions for it.
By means of three independent empirical studies, the perception of ordinary language
users of the reasonableness of a doctor’s (pragma-dialectically sound) argument by authority
was examined in various consultative situations. These studies showed that language users did
not perceive a doctor’s sound argument by authority as equally reasonable as his sound use of
other argument schemes, or as equally unreasonable as his fallacious discussion contributions.
In fact, they neither perceived this argument as reasonable, nor as unreasonable in an absolute
sense. This result was quite unexpected: viewed from a pragma-dialectical perspective, there is
no reason to evaluate a doctor’s sound argument by authority as less reasonable than other sound
arguments. So far, empirical studies in the past have consistently shown that arguments that
are sound from a pragma-dialectical perspective are also perceived as reasonable by ordinary
language users, who also judge discussion contributions that are considered to be fallacious from
a pragma-dialectical perspective as unreasonable.
With respect to the consultative situations in which a doctor advances an argument by
authority, it also appeared from the present empirical studies that the respondents’ perception
of reasonableness of a doctor’s argument by authority is not affected by a patient’s reference to a
contradicting source, a doctor’s indication of the severity of the discussed health problem, or his
suggestion that the patient is insufficiently health literate. In contrast, a doctor’s indication that
there is not enough time available to conduct a discussion about the medical advice negatively
influences this perception of reasonableness.
These last outcomes clearly contradict the expectations in this study about the consultative
situations in which the argument by authority was advanced: based on the pragma-dialectical
higher order conditions, it was expected that a patient’s reference to a contradicting source (H2),
a doctor’s indication that the patient’s health problem is not severe (H3), his indication that there
is not enough time (H4) and his indication that the patient is insufficiently health literate (H5)
would each contribute positively to ordinary language users’ perceptions of reasonableness of a
doctor’s argument by authority.
To explain these unexpected results, a replication of the studies was conducted in which
respondents were not just asked about the extent to which they perceived the doctor’s argument
by authority to be reasonable, but also why they perceived the argument’s reasonableness in this
way (chapter 7). The replication clearly showed that ordinary language users perceived sound
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instances of a doctor’s argument by authority as “neither reasonable, nor unreasonable” because
of institutional considerations influencing their evaluation.
In this replication study, respondents predominantly perceived the doctor’s argument by
authority as less reasonable when he indicated a lack of consultation time or the insufficient health
literacy of the patient. Interestingly, the respondents regarded these two situations as indications
of the doctor not adequately fulfilling his institutional role or tasks in medical consultation, and
not therefore as unreasonable in a purely argumentative sense. Thus, the empirical results of the
replication demonstrate that not only pragma-dialectical reasonableness, but also the exigencies
of the specific communicative activity type in which discussion contributions are made contribute
to the reasonableness perception of argumentative discourse in practice.
Based on these insights, the perceived effectiveness of a doctor’s argument by authority
was investigated (chapter 8). To what extent do ordinary language users perceive the argument by
authority to be effective? The empirical study on effectiveness that was conducted to answer this
question indicates that the perceived effectiveness of a doctor’s argument by authority correlates
strongly with its perceived reasonableness. In line with the reasonableness perception in the
empirical studies presented in chapters 6 and 7, respondents perceived the doctor’s argument
by authority as more effective than a doctor’s fallacious discussion contributions and as less
effective than his other sound arguments. Moreover, when the doctor indicates that there is a
lack of time, the respondents’ effectiveness perception of his argument by authority echoed their
reasonableness perception: ordinary language users perceived a doctor’s argument by authority
as less effective when the doctor indicates that there is not enough time than when he does not
indicate this.
Surprisingly, the obtained effectiveness results also showed that although the respondents’
effectiveness appraisals of a doctor’s argument by authority follow their reasonableness
perceptions, the effectiveness scores that respondents provided were more negative in an absolute
sense. On average, respondents found a doctor’s arguments by authority less than moderately
effective, while they appraised these arguments as moderately reasonable (‘neither reasonable,
nor unreasonable’). Also, when the doctor indicates that the patient is insufficiently health
literate, the effectiveness of his argument by authority is significantly lower than was expected
based on the obtained results in the perceived reasonableness studies.
9.2 Implications
What are the implications of the findings of this study? From an argumentation theoretical
perspective, the present study provides clarification of the relation between pragma-dialectical
reasonableness and the effectiveness of discussion contributions. More specifically, it shows a
strong positive correlation between the perceived reasonableness of a discussion contribution
and its perceived effectiveness, while it also demonstrates that the perception of reasonableness
of a pragma-dialectically sound discussion contribution can be strongly affected by institutional
considerations.
According to the pragma-dialectical theory, whether a discussion party is convinced of the
acceptability of a standpoint is likely to depend on various factors, such as the discussion party’s
assessment of the soundness of the argument scheme used in the argumentation. Although this
idea is theoretically viable, it has, so far, not been substantiated empirically. The present study
provides empirical support for this relation between the convincingness and soundness: it shows
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that perceived effectiveness of a doctor’s argument by authority indeed clearly correlates with
ordinary language users’ assessment of the soundness of this argument.
At the same time, the present study shows that conclusions about the relation between the
pragma-dialectical reasonableness of discussion contributions and their effectiveness should be
drawn with great care. Ordinary language users’ perception of the reasonableness of a discussion
contribution is not always solely, or primarily, influenced by the discussion contribution’s
reasonableness from a pragma-dialectical perspective. Institutional considerations that arise
from the communicative activity type may strongly influence ordinary language users’ perception
of the reasonableness of a discussion contribution just as much. The present study showed that
ordinary language users most frequently arrived at their perception of the reasonableness of a
doctor’s argument by authority based on institutional considerations in medical consultation.
The findings of the present study also have important implications for health commu
nication: the empirical studies on the doctor’s argument by authority show that a doctor should
only cautiously advance this argument. Although a doctor’s argument by authority can contribute
in a sound manner to a discussion in medical consultation, on average, ordinary language users
did not find this argument as reasonable and as effective as other sound arguments. In fact, in the
study respondents generally did not regard this argument to constitute a reasonable or effective
discussion contribution in an absolute sense. At the same time, the study showed that ordinary
language users consistently regarded sound discussion contributions to be more reasonable and
more effective than fallacious contributions, also in the case of a doctor’s argument by authority.
This consistent result underlines the importance of sound argumentation in medical consultation.
The lower perception of the reasonableness and the effectiveness of a doctor’s argument
by authority, and the higher evaluation of sound discussion contributions than fallacious
contributions throughout the studies, are in line with the logic of the current patient-centred
approach towards doctor-patient communication. Since the 1970s, the doctor in medical
consultation has become less and less paternalistic, and acts more and more as the patient’s guide
or partner, meaning that contemporary medical consultations are described as more patient-
centred. Doctors are stimulated to engage patients in treatment discussions, as evidenced by
legal regulations, policies and protocols on shared decision making. To some degree, a doctor’s
argument by authority goes against a patient-centred approach: the argument by authority might
be perceived as too paternalistic, even if a doctor still provides an indication of the acceptability
of the diagnosis, prognosis and/or treatment advice by means of it. At the same time, the fact
that ordinary language users consistently perceived fallacious discussion contributions as
unreasonable in an absolute sense and as less reasonable than sound discussion contributions
in medical consultation is in accordance with the starting points of a patient-centred approach
to discussions in the consultation. This perception of reasonableness indicates that ordinary
language users recognise and do not appreciate a doctor’s attempt to hinder or frustrate the
reasonable resolution of their difference of opinion.
142
Summary
The general objective of this study is to establish the conditions under which a doctor’s argument by
authority may constitute a reasonable and effective strategic manoeuvre in medical consultation.
In such a consultation, it is the doctor’s task to diagnose the patient’s health problem, to provide
the patient with a prognosis of this problem and/or to advise him about which treatment to
undergo.
Despite having requested the consultation with the doctor, in some cases the patient might
not immediately or fully agree with the doctor’s medical judgments and/or advice. In other cases,
the doctor may simply assume that the patient is hesitant to accept his judgements and/or advice
(for example, because the patient does not react as expected). To remove (assumed) hesitance,
doubt or opposition, the doctor can advance argumentation in support of his judgments. From
the perspective of the pragma-dialectical argumentation theory, which is used as the theoretical
basis for this study, the doctor and patient can then be said to conduct an argumentative
discussion.
One of the argumentative means that is available to the doctor in an argumentative
discussion in medical consultation is to argue by authority. The patient ascribes knowledge and
expertise to the doctor about his health problem, so the doctor could refer to this knowledge or
expertise as a sign of the acceptability of his diagnosis, prognosis and/or advice. In other words,
the doctor could argue that his medical judgment is acceptable, because, as a doctor, he is of the
opinion that this judgment is acceptable.
Even though a doctor’s argument by authority could be quite convincing precisely because
the patient already ascribes medical authority to the doctor, the doctor can also be perceived
as overly paternalistic by advancing such an argument; he could be seen as using the argument
by authority as a means of shutting down the discussion. Since medical consultation has
moved from the paternalistic model of the past to a more inclusive, patient-centred approach,
it is important to establish the conditions under which a doctor’s argument by authority may
constitute a reasonable and effective strategic manoeuvre in a present day medical consultation.
From an argumentation theoretical point of view, establishing these conditions clarifies the
relationship between the reasonableness of a particular strategic manoeuvre and the effectiveness
of this manoeuvre in a particular institutionalised context. To establish the conditions under
which a doctor’s argument by authority may constitutes a reasonable and effective strategic
manoeuvre in medical consultation, this study is divided into an analytical part (chapter 2-5)
and an empirical part (chapter 6-8). In the analytical part, the conditions under which a doctor’s
argument by authority can be regarded as reasonable are established. In the empirical part,
the conditions under which a doctor’s argument by authority can be perceived as effective are
established.
Before the reasonableness conditions could be examined in the analytical part, however, first,
two preliminary questions had to be answered: (1) Which characteristics of medical consultation
affect the strategic manoeuvring in the consultation? (2) In which ways can a doctor manoeuvre
strategically with an argument by authority in medical consultation? The answers to these
questions provide the starting points for this study: they clarify how the context of a medical
consultation can affect argumentative discussions and what a doctor’s argument by authority
exactly amounts to in such discussions.
145
To analyse the characteristics of medical consultation that affect the strategic manoeuvring
in the consultation (the first preliminary question), in chapter 2, medical consultation is
characterised as a communicative activity type in which argumentation can play an important
role. The confrontational trigger, starting points, argumentative means and possible outcomes of
the communicative activity type of medical consultation are examined to gain insight into the
opportunities and constraints for strategic manoeuvring in the consultation.
Based on the characterisation of medical consultation as a communicative activity type,
an analysis of a doctor’s argument by authority as a strategic manoeuvre in medical consultation
is provided in chapter 4. Before this analysis could be conducted, however, the argument by
authority is defined in chapter 3. In chapter 3, a four-fold analytical distinction is proposed
between authority variants that affect the discussion outcome, of which the argument by
authority is one. The other variants are: a discussion party’s existing ethos, his acquired ethos and
the argument from authority. Authority variants are likely to interact, but, since each of them has
particular strategic advantages, it is useful to distinguish them analytically.
The argument by authority that is advanced by a doctor in medical consultation is further
analysed in chapter 4 to establish in which ways a doctor can manoeuvre strategically with an
argument by authority in medical consultation (the second preliminary question). According
to the extended pragma-dialectical theory, in argumentative discourse, discussion parties
aim to resolve their difference of opinion on the merits (their dialectical goal). The parties
simultaneously strive to get their point of view accepted (their rhetorical goal). Balancing these
goals leads to strategic manoeuvring.
In medical consultation, advancing an argument by authority can be a useful means
for a doctor to balance these goals. The argument by authority is a potentially advantageous
selection from the topical potential consisting of all other (variants of) argument schemes. A
doctor can take into account the expectations, preferences and wishes of the patient by advancing
this argument, thereby adapting to audience demand. At the same time, doctor’s argument by
authority can be regarded as a presentational device to present argumentation in a communicative
and interactionally functional way.
Despite the fact that a doctor’s argument by authority can be analysed as a strategic
manoeuvre, it does not always constitute a reasonable discussion contribution. In chapter 5,
the last chapter of the analytical part of this study, it is established under which conditions a
doctor’s argument by authority constitutes a reasonable discussion contribution in medical
consultation. From a pragma-dialectical perspective, an argument is reasonable if it fulfils the
specific soundness conditions that apply to it. For a doctor’s argument by authority, the following
specific soundness conditions can be said to apply: the burden of proof condition, the relevance
condition, the credibility condition and the appropriateness condition.
By establishing the specific soundness conditions for a doctor’s argument by authority, the
main objective of this study is already partly fulfilled: it is determined under which conditions
a doctor’s argument by authority constitutes a reasonable strategic manoeuvre in medical
consultation. Under which conditions ordinary language users may perceive a doctor’s argument
by authority as an effective strategic manoeuvre is investigated in the empirical part of the study
(chapter 6-8).
To examine the conditions under which a doctor’s argument by authority is effective in getting a
diagnosis, prognosis and/or medical advice accepted, it is first empirically investigated whether
ordinary language users perceive a doctor’s sound arguments by authority to be reasonable. The
146
reason for first empirically investigating this issue is that it enables establishing whether there is
a positive correlation between ordinary language users’ appraisal of the effectiveness of a doctor’s
argument by authority and the argument’s soundness from a pragma-dialectical point of view.
By means of three independent empirical studies, presented in chapter 6, ordinary language
users’ perception of the reasonableness of a doctor’s (pragma-dialectically sound) argument by
authority is examined in various consultative situations. These studies show that language users
did not perceive a doctor’s sound argument by authority as equally reasonable as his sound use
of other argument schemes, or as equally unreasonable as his fallacious discussion contributions.
In fact, they neither perceived this argument as reasonable, nor as unreasonable in an absolute
sense. This result was quite unexpected: viewed from a pragma-dialectical perspective, there is
no reason to evaluate a doctor’s sound argument by authority as less reasonable than other sound
arguments, and results of earlier empirical research did not suggest a deviation in evaluation
either.
To explain this unexpected result, a replication of the studies was conducted in which
respondents were not only asked about the extent to which they perceived the doctor’s argument
by authority to be reasonable, but also why they perceived the argument’s reasonableness in this
way. The outcomes of this replication study are presented in chapter 7. These outcomes clearly
show that ordinary language users perceived sound instances of a doctor’s argument by authority
as “neither reasonable, nor unreasonable” because of institutional considerations influencing their
evaluation.
Based on this insight, the perceived effectiveness of a doctor’s argument by authority is
investigated. To what extent does ordinary language users’ perception of the effectiveness of the
argument by authority correspond with their perception of the reasonableness of this argument?
The empirical effectiveness study, presented in chapter 8, indicates that there is a strong positive
correlation between perceived effectiveness of a doctor’s argument by authority and its perceived
reasonableness. Surprisingly, the obtained results also show that although the respondents’
effectiveness appraisals of a doctor’s argument by authority follow their reasonableness
perceptions, the effectiveness scores that respondents provided were more negative in an absolute
sense. These results suggest that the effectiveness of a doctor’s argument by authority does not
only depend on the perception of its reasonableness, but also on the communicative activity type
of medical consultation.
147
Samenvatting
Het doel van deze studie is het vaststellen van de voorwaarden waaronder een argument
met autoriteit van een arts in medische consultatie als een redelijke en effectieve strategische
manoeuvre beschouwd mag worden. In een consultatie is het de taak van de arts om een
diagnose te stellen, een prognose te geven en/of een voorstel te doen voor de behandeling van
het gezondheidsprobleem van de patiënt.
Hoewel de patiënt het consult aanvraagt, is hij het niet altijd meteen volledig eens met de
medische oordelen van de arts. Soms veronderstelt de arts ook simpelweg dat de patiënt twijfelt
aan zijn oordelen (bijvoorbeeld omdat de patiënt anders reageert dan verwacht). Om dergelijke
(veronderstelde) twijfel of oppositie weg te nemen, kan de arts argumentatie aandragen. Vanuit
de pragma-dialectische argumentatietheorie, die in deze studie het theoretisch kader vormt, kan
het gesprek tussen de arts en de patiënt dan worden gereconstrueerd als een argumentatieve
discussie.
Een van de argumentatieve middelen die de arts in een argumentatieve discussie in
medische consultatie tot zijn beschikking heeft, is het aandragen van een argument met autoriteit.
Door de consultatie aan te vragen, maakt de patiënt duidelijk dat hij de arts medische kennis
toeschrijft. De arts kan tijdens de consultatie ter ondersteuning van zijn diagnose, prognose en/
of advies naar deze kennis en expertise verwijzen. Hij betoogt dan in feite dat zijn medische
oordeel aanvaardbaar is, omdat hij als arts van mening is dat het aanvaardbaar is.
Juist omdat de patiënt al medische kennis en expertise aan de arts toeschrijft, kan een
argument met autoriteit van de arts bijzonder overtuigend zijn. Het gevaar is echter dat de arts
zich door dit argument te gebruiken te paternalistisch opstelt; met het argument met autoriteit
kan zijn oordelen immers ook aan de patiënt opdringen. Omdat een patiëntgerichte houding
van de arts sinds de jaren zeventig steeds meer de voorkeur geniet, is het van belang om vast te
stellen onder welke voorwaarden een argument met autoriteit van de arts in de huidige medische
consultaties een redelijke en effectieve strategische manoeuvre kan vormen. Het vaststellen van
deze voorwaarden vanuit argumentatietheoretisch oogpunt maakt ook duidelijk wat in een
specifieke institutionele context het precieze verband is tussen de redelijkheid van een bepaalde
strategische manoeuvre en de effectiviteit van deze manoeuvre.
Om de voorwaarden vast te stellen waaronder het argument met autoriteit van de arts
als redelijk en effectief beschouwd mag worden, is zowel analytisch als empirisch onderzoek
uitgevoerd. Het analytische gedeelte van de studie (hoofdstuk 2-5) heeft betrekking op de
redelijkheidsvoorwaarden, het empirische gedeelte (hoofdstuk 6-8) op de effectiviteits
voorwaarden.
Voordat in het analytische gedeelte van de studie de redelijkheidsvoorwaarden kunnen worden

onderzocht moeten er twee voorbereidende vragen worden beantwoord: (1) Welke kenmerken
van medische consultatie beïnvloeden het strategische manoeuvreren in de consultatie? (2)
Op welke wijzen kan een arts in een medische consultatie strategisch manoeuvreren met een
argument met autoriteit? De antwoorden op deze vragen vormen de uitgangspunten van deze
studie: ze verduidelijken hoe de context van een medische consultatie een argumentatieve
discussie kan beïnvloeden en hoe een argument met autoriteit precies bijdraagt aan een dergelijke
discussie.
Om de kenmerken van medische consultatie in kaart te brengen (de eerste voorbereidende
vraag), is medische consultatie in hoofdstuk 2 geanalyseerd als een communicatief actietype
149
waarin argumentatie een belangrijke rol kan spelen. De initiële situatie, uitgangspunten, argumen
tatieve middelen en mogelijke uitkomsten van het communicatieve actietype van medische
consultatie zijn bij elkaar gezet om inzicht te krijgen in de mogelijkheden en beperkingen bij
strategisch manoeuvreren in een consultatie.
Op basis van deze argumentatieve karakterisering is in hoofdstuk 4 een analyse gegeven
van het argument met autoriteit van de arts als strategische manoeuvre in medische consultatie.
Voorafgaand aan deze analyse is in hoofdstuk 3 het argument met autoriteit echter eerst
gedefinieerd. Daarbij wordt er een analytisch onderscheid gemaakt tussen vier verschillende
autoriteitsvarianten die de uitkomst van een discussie kunnen beïnvloeden, waarvan het argument
met autoriteit er een is. De andere varianten zijn: het bestaande ethos van een discussiepartij, zijn
in de communicatie verworven ethos en het argument van autoriteit. Deze autoriteitsvarianten
zullen in de praktijk interacteren, maar omdat elke variant unieke strategische voordelen heeft, is
het nuttig om ze analytisch van elkaar te onderscheiden.
Een verdere analyse van het argument met autoriteit van een arts is gepresenteerd
in hoofdstuk 4, om zo te bepalen op welke wijzen een arts met dit argument strategisch kan
manoeuvreren (de tweede voorbereidende vraag). In de pragma-dialectische zienswijze streven
discussiepartijen er niet alleen naar om hun verschil van mening op een redelijke wijze op te
lossen (hun dialectische doel), maar ook om daarbij hun eigen standpunt aanvaard te krijgen
(hun retorische doel). Hun streven om de balans te bewaren tussen deze twee doelen leidt tot
strategisch manoeuvreren.
Het argument met autoriteit kan voor een arts in medische consultatie een handig
middel zijn om zowel zijn dialectische doel als zijn retorische doel te bereiken. De keuze voor
dit argument vormt een mogelijk gunstige selectie uit het topisch potentieel dat bestaat uit alle
(varianten van) argumentatieschema’s. De arts kan met het argument met autoriteit tevens
inspelen op de verwachtingen, voorkeuren en wensen van de patiënt, wat kan worden gezien als
een aanpassing aan het auditorium. Tegelijkertijd kan het argument met autoriteit in medische
consultatie een communicatief en interactioneel functioneel presentatiemiddel vormen.
Het feit dat het gebruik van het argument met autoriteit in een medische consultatie
geanalyseerd kan worden als een strategische manoeuvre betekent niet dat het ook altijd een
redelijke discussiebijdrage vormt. In hoofdstuk 5, het laatste hoofdstuk van het analytische
gedeelte van deze studie, zijn de voorwaarden vastgesteld voor het redelijk gebruik van een
argument met autoriteit door de arts in medische consultatie. Vanuit pragma-dialectisch
perspectief is een argument redelijk als het de specifieke deugdelijkheidsvoorwaarden vervult
die voor dit argument gelden. Voor een argument met autoriteit van de arts betekent dit dat het
aan de volgende voorwaarden moet voldoen: de bewijslastvoorwaarde, de relevantievoorwaarde,
de geloofwaardigheidsvoorwaarde en de geschiktheidsvoorwaarde.
Met het vaststellen van de specifieke deugdelijkheidsvoorwaarden voor een argument
met autoriteit van de arts is het doel van deze studie al gedeeltelijk bereikt: de voorwaarden
zijn vastgesteld waaronder een argument met autoriteit van een arts in medische consultatie
als een redelijke strategische manoeuvre beschouwd mag worden. Onder welke voorwaarden
gewone taalgebruikers dit argument als een effectieve strategische manoeuvre beschouwen, is
onderzocht in het empirische gedeelte van deze studie (hoofdstuk 6-8).
Om de voorwaarden te bestuderen waaronder het argument met autoriteit van een arts een effec
tief middel vormt in het aannemelijk maken van een diagnose, prognose en/of medisch advies,
is eerst empirisch onderzocht of gewone taalgebruikers een deugdelijk argument met autoriteit
150
van de arts ook als een redelijk discussiebijdrage zien. De reden om dit eerst te onderzoeken, is
dat dan vervolgens een eventuele positieve correlatie tussen de effectiviteitsbeoordeling van het
argument met autoriteit door gewone taalgebruikers en de pragma-dialectische deugdelijkheid
van dit argument kan worden vastgesteld.
Aan de hand van drie onafhankelijke empirische studies is de gepercipieerde redelijkheid
van het (pragma-dialectisch deugdelijke) argument met autoriteit van een arts in medische
consultatie getoetst in verschillende consultatieve situaties. Deze studies zijn besproken in
hoofdstuk 6. Uit de studies blijkt dat gewone taalgebruikers het deugdelijke argument met
autoriteit van de arts niet als even redelijk beschouwen als deugdelijke andere argumentatie van
de arts, maar ook niet als even onredelijk als zijn drogredelijke bijdragen. Gewone taalgebruikers
beschouwen dit argument noch als redelijk, noch als onredelijk in absolute zin. Dit resultaat
was onverwacht, want er is vanuit pragma-dialectisch oogpunt geen reden om een verschil in
redelijkheidsbeoordeling te verwachten tussen een deugdelijk argument met autoriteit en andere
deugdelijke argumenten en ook eerder empirisch onderzoek geeft geen aanleiding om zo’n
verschil te verwachten.
Om dit onverwachte resultaat te kunnen verklaren, is een replicatieonderzoek uitgevoerd.
In dit replicatieonderzoek is de respondenten niet alleen gevraagd hoe redelijk ze het argument
met autoriteit van de arts vonden, maar ook wat de reden voor hun redelijkheidsoordeel was. De
resultaten van dit replicatieonderzoek, die te vinden zijn in hoofdstuk 7, tonen duidelijk aan dat
gewone taalgebruikers het deugdelijke argument met autoriteit van de arts ‘noch redelijk, noch
onredelijk’ vinden omdat ze institutionele overwegingen meenemen in hun beoordeling.
Op basis van dit empirisch inzicht is de beoordeling van de gepercipieerde effectiviteit van
het argument met autoriteit van de arts onderzocht. In hoeverre komt het effectiviteitsoordeel
van gewone taalgebruikers over het argument met autoriteit van de arts overeen met hun
redelijkheidsoordeel? Uit het empirische onderzoek dat is besproken in hoofdstuk 8 blijkt
dat er een sterk positieve correlatie is tussen de gepercipieerde effectiviteit van het argument
met autoriteit van de arts en de gepercipieerde redelijkheid van dit argument. Verrassend
was dat deze resultaten ook laten zien dat, hoewel de effectiviteits- en redelijkheidsoordelen
sterk overeenkomen, de effectiviteitsoordelen in absolute zin gemiddeld lager uitpakken dan
de redelijkheidsoordelen. Deze resultaten duiden erop dat de effectiviteit van een argument
met autoriteit van de arts niet alleen afhankelijk is van de gepercipieerde redelijkheid van dit
argument, maar ook van het communicatieve actietype van medische consultatie.
151
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Index of names
Appelbaum, P.S. 63 Hamblin, C.L. 62
Aristotle 31, 33 Have, P. ten 20, 23, 48
Heath, C. 20
Bal, B.S. 21 Helmes, A.W. 31
Balint, M. 51 Hymes, D. 19
Barth, E.M. 62, 75
Bengel, J. 31 Isocrates 31
Bensing, J.M. 22-23, 48
Berg, M. van den 78 Jackson, S. 81
Bergh, H. van den 81, 123 Jenicek M. 20
Blanchard, C.G. 52 Jong, J. de 52, 75
Boegl, K. 20
Bowen, D.J. 31 Hitchcock, D.L. 20
Brabers, A. 53, 75 Houtlosser, P. 13, 19-20
Brown, J.B. 20
Brown, P. 50 Krabbe, E.C.W. 62, 75
Kroneman, M. 78
Cardol, M. 78
Cicero 41 Labrie, N. 20, 76
Clark, H.H. 81, 123 Lester, D. 82
Levinson, S.C. 19, 50
Deveugele, M. 20, 78 Lidz, C.W. 63
Dingwall, R. 30
Meisel, A. 63
Edelstein, L. 32 Meuffels, B. 73-74, 81, 83,
Edwards, A. 13 89-91, 94-96, 101,
Eemeren, F.H. van 11, 13-16, 19-20, 22, 110, 119-121, 123
34-35, 38-39, 45-48, 50, Mohammed, D. 19
53-54, 59-61, 63, 73-75, Müller-Engelmann, M. 77
78, 83, 89-91, 94-96, Murphy, E.A. 20
101, 110, 119-121 Murtagh, M. 52
Elwyn, G. 13, 76
Naess, A. 63
Finkers, H. 59
O’Keefe, D. 121
Garssen, B. 34-35, 38. 47-48, 73-74, Orne, M.T. 82
83, 89-91, 94-96, 101,
110, 120 Patel, V.L. 20
Goodnight, G.T. 22-23, 63 Pilgram, R. 63
Goodwin, J. 11 Pilnick, A. 30
Grice, H.P. 53, 57, 76 Poppel, L. van 47
Groot, W. 78
Grootendorst, R. 11, 14-16, 22, 34-35, 38, Quintilian 31
45-48, 59-60, 89, 119-121
159
Reitsma-van Rooijen, M. 52, 75
Robinson, J.D. 23, 48
Rubinelli, S. 21, 63
Ryan, B.L. 20
Say, R. 52
Scanlon, L. 31
Schellens, P.J. 34, 60
Schulz, P.J. 20-21, 63
Searle, J.R. 35
Snoeck Henkemans, A.F. 47
Stewart, D.E. 77
Stewart, M. 20
Suziedelyte, A. 52, 75
Thomson, R. 52
Tindale, C.W. 31
Tuckett, D. 21
Walton, D. 11, 31, 36,

59-60, 62
Wierda, R.M. 96
Woods, J. 11, 59-60
Zandbelt, L.C. 22
Zee, J. van der 78
160
Index of subjects
Acquired ethos 32-34
Activity type (see communicative activity type)
Antagonist 23
Appropriateness condition 62, 65-66
Arete 33
Argument by authority 36-39
Argument from authority 34-36
Argument scheme 34-35
Aspects of strategic manoeuvring 45-54
Asymmetry 30-31, 47, 51, 53, 75, 79
Audience demand 50-52
Authority argumentation 34-35
Burden of proof 35-36

Burden of proof condition 60, 62-64, 66
Canterbury v. Spence 22, 64

Causal argumentation 47-48
Classical rhetoric 31
Communicative activity type 19-21
Communicatively functional 53-54
Comparison argumentation 47-48
Consultation time 78-79
Consultative situation 74-80, 82-83, 85-86, 93, 102-103,
109-110, 112-113, 123-126, 130-132
Contradicting source 75-77, 85-86, 93
Council Directive 93/16/EEC 29-30
Credibility condition 60-62, 65-66
Critical discussion 14
Declaration of Geneva 22, 32, 64

Dialectical aim 13, 19, 45
Discussion rules (see rules for a critical discussion)
Educational level 90, 107, 127

Effectiveness 45-46
Ethos 31-34
Eunoia 33
Existing ethos 29-32
Explanatory responses 110-112
161
Fallacy
Argumentum ad baculum 82-83, 87-88, 95, 103, 114-115, 126
Argumentum ad hominem 82-83, 88, 95, 103, 114-115, 126
Argumentum ad misericordiam 84
Argumentum ad verecundiam 59-60, 69-70, 82, 102-105, 114-115,
125-126, 129
Declaring the standpoint taboo 82-83, 88, 94-95, 103, 114-115, 126
Evading the burden of proof 40-41, 82, 105,
Goodwill (see eunoia)
Health literacy 79-81

Hesitance 11, 88
Higher order conditions 74-75
Second order conditions 75-78
Third order conditions 78-80
Hippocratic Oath 22, 32, 64
Informed consent 14, 22, 24, 63-64

Institutional considerations 110-117, 141-142
Interactional effect 45-46, 120
Interactionally functional 53-54
Jargon 53-54
Justificatory force 36, 49
Liability 21
Maxim of quantity 53-54, 76

Medical consultation 20
Paternalism 13, 22
Patient-centeredness 22, 51-52
Perception of effectiveness 122, 126-127
Perception of reasonableness 73, 89-90
Perlocutionary effect (see interactional effect)
Phronesis 33
Physical examination 20, 23-24
Politeness considerations 50, 110-113. 115
Practical wisdom (see phronesis)
Precisation 63
162
Preconditions for strategic manoeuvring 21-24
Argumentative means 23-24
Initial situation 21-22, 24
Possible outcomes 22, 24
Staring points 22-24
Presentational devices 53-54
Protagonist 22-23
Reasonableness 13, 15, 59-60

Referral 11, 20, 65
Relevance condition 62-66
Responsibility condition 35
Rhetorical aim 13, 19, 45
Rules for a critical discussion 14, 60, 74, 120
Argument scheme rule 60, 139
Burden of proof rule 14, 60, 139
Relevance rule 60, 139
Second opinion 24
Self-diagnosis 75-76
Severity of the health problem 77-79
Shared decision making 13, 77
Soundness conditions 14-15, 59-69
General soundness conditions 60-62
Specific soundness conditions 63-66
Speech act 35, 45-46, 120
Status 31-32
Strategic manoeuvring 13-14, 19-21, 39, 45-57
Symptomatic argumentation 35, 38, 47
Taxonomy for classifying respondents’ justifications 110-112

Time constraints 78-79
Topical potential 46-50
Variants of authority 29, 39

Verbal inquiry 24
Virtue (see arete)
WGBO 13-14, 22, 63-64
163
In medical consultation, a doctor can appeal to
his medical knowledge or expertise as a sign of
the acceptability of his diagnosis, prognosis and/
or advice (“It’s best to take these loratadine tablets,
because I have seen them work really well against
hay fever”). This could be quite convincing, as
the patient typically requests a medical consul
tation because he does not know exactly what
his health problem amounts to, how serious this
problem is and/or what to do about it, while he
does expect the doctor to be able to determine
these matters. Yet, in some cases, an argument by
authority from a doctor can be too paternalistic
and does not allow for further discussion about
the doctor’s medical judgment or advice. In this
study, it is investigated under which conditions a
doctor’s argument by authority may constitute a
reasonable and effective strategic manoeuvre in
medical consultation.
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A doctor’s argument by authority: An analytical and empirical study of strategic manoeuvring in

Printing: Ridderprint, Ridderkerk, the Netherlands

© Roosmaryn Pilgram, 2015. All rights reserved.

ter verkrijging van de graad van doctor

Promotor: Prof. dr. F.H. van Eemeren, Universiteit van Amsterdam

Copromotor: Dr. H.L.M. Meuffels, Universiteit van Amsterdam

Overige leden: Prof. dr. T. van Haaften, Universiteit Leiden

Faculteit der Geesteswetenschappen

2 Argumentation in medical consultation 19

3 Authority in argumentative discourse 29

4 A doctor’s argument by authority as a strategic manoeuvre 45

6 The perception of reasonableness of a doctor’s argument by authority 73

7 The respondents’ justification of their perception of reasonableness 101

Index of names 159

Index of subjects 161

1.1 A doctor’s argument by authority

1.2 A pragma-dialectical approach

To determine the conditions under which a doctor’s argument by authority constitutes a

1.3 Aims and methods

2.1 Characterising medical consultation from an argumentation perspective

To examine when a doctor’s argument by authority constitutes a reasonable and effective

2.2 Communicative activity types

To properly analyse and evaluate argumentative discourse in medical consultation, it needs to

2.3 Medical consultation as a communicative activity type

Communication is an important part of medical consultation: adequate doctor-patient

2.4 Preconditions for strategic manoeuvring in medical consultation

Figure 2.1 Argumentative characteristics of medical consultation

Medical (assumed) lack of explicit rules (e.g., argumentation based agreement

By analysing medical consultation as a communicative activity type, the characteristics of the

3.1 An analytical distinction between variants of authority

3.2 Existing ethos

1 D: It could be the case that it had been a fracture.

Isocrates (Oration XV278) notably emphasises the importance of a speaker’s character:

3.3 Acquired ethos

3.4 Argument from authority

3.5 Argument by authority

Instead of referring to an external source in an authority argument, a discussion party can

1 P: And then I wanted to ask something else right away.

Figure 3.3 Reconstruction of the doctor’s argument by authority in case 3.4

(a) Example of an argument from authority

(b) Example of an argument by authority

The argument in which a discussion party refers to his own authority to

4.1 An integrated pragma-dialectical approach

4.2 The strategic aspects of a doctor’s argument by authority

Based on the characterisation of the communicative activity type of medical consultation

4.2.1 Topical potential: The choice for an argument by authority as a variant of

4.2.2 Audience demand: The argument by authority in response to a patient’s hesitance

4.2.3 Presentational devices: The argument by authority as a means to simplify

4.3 Interaction of the three strategic aspects of a doctor’s argument by authority

Figure 4.1 Reconstruction of the doctor’s argument by authority and subordinative

1 There is no need to be concerned about the infant’s diet.

A doctor can manoeuvre strategically in medical consultation by means of advancing an

5.1 The reasonableness of a doctor’s argument by authority

Accepting a standpoint based on authority argumentation can be perfectly reasonable. A

5.1.1 General soundness conditions for the argument by authority

Figure 5.1 General soundness conditions for an argument by authority

5.2 A doctor’s argument by authority evaluated in practice

Figure 5.3 Reconstruction of the doctor’s argument by authority in case 5

1 We have to take an x-ray of your ankle.

6.1 Factors affecting ordinary language users’ perception of reasonableness

6.3 Contextual factors that affect the perception of reasonableness

6.3.1 Higher order conditions

Figure 4.1 Reconstruction of the doctor’s argument by authority and subordinative

Walton, D. 11, 31, 36,

Educational level 90, 107, 127