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Effecting change through dialogue: Habermas' theory of communicative

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Med Health Care and Philos
DOI 10.1007/s11019-010-9260-5
SCIENTIFIC CONTRIBUTION
Effecting change through dialogue: Habermas’ theory
of communicative action as a tool in medical lifestyle interventions
Liv Tveit Walseth • Edvin Schei
 Springer Science+Business Media B.V. 2010
Abstract Adjustments of everyday life in order to pre-
vent disease or treat illness afflict partly unconscious
preferences and cultural expectations that are often difficult
to change. How should one, in medical contexts, talk with
patients about everyday life in ways that might penetrate
this blurred complexity, and help people find goals and
make decisions that are both compatible with a good life
and possible to accomplish? In this article we pursue the
question by discussing how Habermas’ theory of commu-
nicative action can be implemented in decision-making
processes in general practice. The theory of deliberative
decision-making offers practical guidelines for what to talk
about and how to do it. For a decision to be rooted in
patients’ everyday life it has to take into consideration the
patient’s practical circumstances, emotions and prefer-
ences, and what he or she perceives as ethically right
behaviour towards other people. The aim is a balanced
conversation, demonstrating respect, consistency and sin-
cerity, as well as offering information and clarifying
reasons. Verbalising reasons for one’s preferences may
increase awareness of values and norms, which can then be
reflected upon, producing decisions rooted in what the
patient perceives as good and right behaviour. The asym-
metry of medical encounters is both a resource and a
challenge, demanding patient-centred medical leadership,
characterised by empathy and ability to take the patient’s
perspective. The implementation and adjustments of
L. T. Walseth
Research Unit for General Practice, Uni Health, Bergen, Norway
L. T. Walseth (&)
E. Schei
Section for General Practice, Department of Public Health and
Primary Health Care, University of Bergen, Kalfarveien 31,
5020 Bergen, Norway
e-mail: liv@walseth.no
Habermas’ theory in general practice is illustrated by a case
story. Finally, applications of the theory are discussed.
Keywords Communication
Communicative action

Dialogue
Decision-making
General practice

Habermas
Lifestyle counselling
Lifeworld
First author’s prologue
Working as a general practitioner over many years, a
striking phenomenon aroused my curiosity; it seemed that
talking with patients about their everyday life over time
had a potential for effecting change in their lives. The
change could involve the relationship with a drug-addicted
son, getting courage to rise against injustice in marriage,
gaining strength to switch to a more fulfilling job or
achieve a healthier lifestyle. The patients shared their sto-
ries about everyday circumstances and commitments, joys
and sorrows, what made life worth living and the obstacles
to good living. These dialogues were characterized by
presence, closeness, humour, and common reflections
concerning what is perceived as a good life. I searched the
literature to find an explanation of what was going on. I
recognized the well-established significance of empathy, of
caring, of seeing and meeting the patient as a person, a
subject, not a medical object. Still, this did not fully
describe what happened. Reading Habermas’ theory of
communicative action made the pieces come together:
Decisions should spring from a respectful dialogue con-
cerning the patients’ commitments, feelings and practical
circumstances, sharing reflections concerning what is right,
what is good and what is practically feasible for the patient;
conversations where the world of everyday life is given a
language and reflected upon.
123

Introduction
Patient-centred medicine (PCM) has yielded crucial
contributions to medicine, and is widely used in education
of medical students. Starting with Balint’s seminal work in
the 1950s, PCM was further developed and formulated by
McWhinney (1981) and Stewart et al. (2003). A key ele-
ment in PCM is to acknowledge the medical importance of
clarifying the patient’s perspective, so that doctor and
patient may construct a shared understanding of the situa-
tion, a common ground. This is achieved, ideally, through a
good relationship and exploration of the patient’s biologi-
cal, psychological and social circumstances. According to
Stewart et al. (2003), this ‘‘process of finding a satisfactory
solution is not one of bargaining or negotiating but rather a
moving towards a meeting of minds or finding a common
ground’’. Despite the well established position of PCM, this
indistinct definition of the process towards a common
ground illustrates that PCM to some extent lacks pragmatic
tools for guiding real-life consultations, and is under-
theorised. Pursuing a practical perspective, Emanuel and
Emanuel (1992) and Charles et al. (1999) described dif-
ferent models for the doctor-patient relationship, including
shared decision-making. Mishler (1984) made a substantial
contribution to a pragmatic position when he analyzed the
doctor-patient relationship within the theoretically
well-grounded framework of Habermas’ theory of com-
municative action. Later on, several authors have elabo-
rated further on Habermas’ theory in a medical perspective
(Yassour-Borochowitz 2004; Stevenson and Scambler
2005; Robb and Greenhalgh 2006; Mikkelsen et al. 2008;
Barry et al. 2001). Yet a comprehensive set of theoretically
grounded, down-to-earth guidelines for the patient-centred
doctor remains to be established. The present article seeks
to further narrow the gap between sweeping ideals and the
pragmatic challenges of the doctor-patient encounter.
Mishler (1984) stated that there is an ongoing struggle
between the voice of medicine and the voice of the life-
world in consultations. When the voice of medicine dom-
inates, the result is inhumane medicine and dissociation of
the patient from his or her context. Barry et al.’s (2001)
studies offered a more nuanced picture of this; the patient
does not necessarily suffer when the lifeworld was left out
of consultations, it depends on the theme and the particular
need of the patient. However, Barry showed that chroni-
cally ill patients seemed to suffer: They repeatedly started
to talk about the lifeworld, despite being consistently
ignored by the doctor. Why are lifeworld issues so
important to these patients, what keeps them struggling
against the doctor’s agenda? A reasonable interpretation is
that patients need to talk about how chronic illness affects
their lives, physically, mentally and socially. Illness entails
loss of mastery of daily life duties and activities, handicaps
123
L. T. Walseth, E. Schei
that necessitate new priorities and new ways of behaviour,
changes with complex existential implications. Chronically
ill people, and patients in need of lifestyle change in gen-
eral, are in need of ideas, motivation and courage to cope
creatively with everyday life.
Normally, behaviour emerges in a complex interplay of
reasons, reactions and goals, partly subconscious, where
personal preferences merge with immanent, perceived
expectations from the culture (Elsass 2003). Hence the
behaviour constituting a person’s ‘‘lifestyle’’ may seem
difficult or impossible to change. This raises the question:
How should physicians talk with patients about everyday
life in order to penetrate its blurred, subjective complexity,
to help them distinguish relevant concerns and make
workable decisions that may serve them well? The aim of
this article is to pursue this question. Building on Haber-
mas’ theory of communicative rationality, we focus not
only on ‘‘the voice of the lifeworld’’ emphasized by Mishler
and Barry, we also analyse the significance of different
aspects of the lifeworld and of the argumentation processes
(Habermas 1984). This represents an attempt to further
develop and apply Habermas’ theory in clinical work, with
an aim to produce practical guidelines for what to talk about
and how to talk about it, in ways that may empower patients
to reach good, practicable decisions rooted in medical facts
and the circumstances and resources of real life.
Habermas’ theory of communicative rationality
Habermas’ theory of communicative action builds on the
assumption of an ongoing struggle between different
rationalities (Habermas 1984). Society has to be regulated
by a result-oriented rationality inherent in laws, rules and
market. However, Habermas claims that in decisions con-
cerning human beings, a lifeworld perspective is essential.
Communicative rationality occurs when a statement or
decision is justified through reference either to factual
empirical conditions, or to a culturally accepted norm, or to
subjective emotions. Justification by means of norms and
emotions constitute the distinction between communicative
rationality and other forms of rationality, which generally
do not consider ‘‘rational’’ actions based mainly on social
consensus and personal preferences. It is probably impos-
sible to regulate a society if too much weight is put on a
lifeworld perspective, but priority to the system perspec-
tive, on the other hand, produces unfortunate consequences
since the relevant aspects of an individual’s situation can-
not be defined by any societal system. Well described by
Mishler (1984), this tension is highly present in consulta-
tions: the doctor and the patient are at the centre of a
dialectic between lifeworld and system world, with com-
municative rationality challenging instrumental rationality.
Effecting change through dialogue
Further, Habermas’ theory of communicative action is
based on the assumption that we reach a greater insight in
matters concerning ourselves and the world around us by
using language, presenting arguments, justifying state-
ments, asking and answering questions. His theory has
mainly been applied to political analysis at a societal level,
but Habermas uses individual examples as well, and argues
convincingly that communicative rationality is highly rel-
evant in matters concerning human relationships, ethics,
and personal decision-making. The theory of communica-
tive action offers a concrete outline of a procedure for how
to construct a conversation that observes the rules and
norms of communicative rationality. The procedure
describes what to talk about and outlines a framework for
how to talk about it. In the following, we elaborate on how
this can be employed in consultations.
What to talk about; the three dimensions
of the lifeworld
For communicative rationality to occur, decisions have to
be rooted in the participants’ lifeworld, a term derived from
Husserl. The lifeworld is the frame of a human being’s
lived life, a horizon of ‘‘taken-for-granted’’ knowledge,
norms and expectations. When people share the same
‘‘taken-for-granted’’ knowledge, cultures are shaped. A
common lifeworld functions as a link between the indi-
vidual and the social community he or she belongs to.
Habermas elaborates this further and describes three dif-
ferent dimensions of lifeworld—the objective, the social
and the subjective ‘‘worlds’’. The term ‘‘objective’’ does
not claim absolute, objective truth; the process of reaching
understanding of all three worlds ‘‘takes place against a
background of culturally ingrained preunderstanding’’
(Habermas 1984 p.100). Below, Habermas’ dimensions of
lifeworld are further described. To illustrate, we use
examples relevant to a medical context. For the patient to
reach a good decision all three dimensions must be con-
sidered in the consultation, and their relevance judged.
1. The objective world contains knowledge that can be
judged ‘‘objectively’’. Empirically based medical
knowledge belongs to this world. The doctor presents
how the situation is understood medically, and gives
alternatives for further tests, examinations and treat-
ment. Further, the doctor should map the patient’s
objective knowledge about herself and her situation
through concrete questions. This may concern symp-
toms, family, working place and place of residence,
and the patients’ daily schedule. It may also be
relevant to ask for changes in the patient’s objective
world since before the illness. The validity criterion for
objective conditions to serve as a basis for decisions is
that they are factually true. There will at times be
different views as to what should be considered true.
This may be rooted in misunderstandings or cultural
differences. Within medicine there may also be
disagreement as to what is factually true, based on
different views of, for example, the relation between
body and mind, or the interpretation of statistical
information for individuals. The ‘‘objective’’ knowl-
edge of doctors may turn out to be erroneous and
misleading. Good conversations thus presuppose aca-
demic humility and acknowledgement of scientific
uncertainty, ignorance and fallibility.
The systematic quest for objective information about
illness, disease and treatment is a major point in medical
education. Systematic mapping of objective details of
patients’ everyday lives has not been considered equally
important. Yet these details are often crucial for diagnosis and
successful treatment plans. For a decision to be both medi-
cally sound and practically feasible it has to be anchored in
the objective world of the patient, as well as in medical facts.
An objective fact about people is that they have highly
significant social and subjective worlds. These worlds
contain knowledge about patients’ situation, resources and
obstacles, but have traditionally not been considered a core
source of medical insight. Investigating these fields
involves touching upon sensitive themes, inviting patients
to talk about aspects of life that may be more or less
automated, subconscious, or distorted by shame and ste-
reotypical adaptation to social conventions.
2. The social world concerns the way people relate to
others, the rules and norms that govern social interac-
tion. For example, in a society we may expect people
to be polite, to respect other persons’ views and
choices, and not to act in selfish ways. In subcultures
such as families and work groups, local rules may
develop. As an example it may be considered accept-
able to treat certain persons with disrespect. A wife
may be subjected to the rules of a violent husband, or a
daughter exhausted by repeatedly trying to satisfy
demanding old parents, obeying the tacit rule ‘‘we
always help our family’’. At work an employee may
silently succumb to unreasonable conditions, subjected
to the rule ‘‘the boss decides’’. Faced with new people
or new settings a newcomer tries to understand and
adapt to the tacit rules of that particular context.
While mapping the objective world and the daily sche-
dule of a patient, the doctor may get an initial picture of the
patient’s important relationships. It may be relevant to
investigate the rules that govern behaviour in these rela-
tionships. What will happen if the patient starts to act
differently? What do the affected relationships mean for
123

the patient? What does the patient expect from the other
persons and what do they expect from the patient? Are
these expectations realistic, and ethically appropriate? A
conversation about such matters can disclose unreasonable
demands and unfortunate patterns. It can also become
evident that certain health-related decisions are not realistic
due to the patients’ commitments.
An appropriate understanding of the social world in its
uniqueness is often crucial for creating a common under-
standing and reach proper decisions. The criterion of ade-
quacy for decisions rooted in the social world is that they
are perceived as right by the patient.
3. The subjective world is made up of intentions,
thoughts, emotions and wishes. The process of clari-
fication includes questions and reflections concerning
what the patient perceives as good and desirable, the
premises for self-realization. The subjective world is
partly revealed through a persons’ mode of self-
expression in dialogues, which may range from
truthful, open and trusting interaction to deception
and cynical manipulation. Truthfulness entails that
what we say and the way we say it truly express our
inner life. An utterance may be untruthful in different
ways; it may be a lie, a self-deception, or lip service.
Psychopathologies may also disturb truthfulness. Only
the speaker, in some cases with the help of therapy,
can decide whether the subjective world is expressed
truthfully. The degree of truthfulness may sometimes
be revealed by the success, or lack of such, when
decisions are put into action. Confidence and security
in the doctor-patient relationship is a premise for an
optimally truthful representation of the patient’s
subjective world. For medical decisions to be rooted
in the subjective world, the criterion is that the patient
perceives them as good, that is, congruent with his or
her intentions, emotions and wishes.
As a whole, a medical conversation advocating changes
in patient behaviour and lifestyle should seek to clarify the
patient’s practical circumstances on a detailed level, and to
reveal the patient’s core values and norms, that is, the often
unverbalized principles and goals that govern the patient’s
daily life. In practice, the three worlds will be heavily
intertwined. When decisions are made, three main ques-
tions need to be answered, representing the objective, the
social and the subjective world, respectively:
• What is practically feasible for the patient to do?
• What is right for the patient to do?
• What is good for the patient to do?
Focusing on these three questions provides the doctor with
relevant lifeworld knowledge. A common basis for further
123
L. T. Walseth, E. Schei
reflections and decisions is thus created. In this reflection,
cultural and religious differences between doctor and
patient may give rise to challenges. The doctor must take
care not to let her or his own normative views delimit the
decision-making process.
If the practical outcome of a decision is unsuccessful,
this should be an incitement to reinvestigate the premises
for the decision: Is the understanding of the objective world
true, that of the social world right, and that of the sub-
jective world truthful, or is the exploration of the three
worlds possibly unfinished? The three worlds and their
premises are described in Table 1.
How to talk; respectful dialogue and valid arguments
The procedural principles of the dialogue are in the fol-
lowing presented theoretically, in accordance with the
overall model, before we discuss adjustments to clinical
practice.
The participants in the dialogue should address each other
as equals, and avoid abuse of power. The participants should
not be restrained from contributing, and should be met with
respect concerning personal values and choices (Eekelaar
2006). An atmosphere of freedom in which to present
information and opinions is desirable (Skivenes 2002).
Sincerity is necessary. For issues to be clarified contradic-
tions must be avoided, words and expressions must be used
in a consistent way that can be understood by both parties
(Skivenes 2002). Respect and equality entail that partici-
pants act with integrity and authenticity, with a sincere wish
to help the other person to gain the necessary insight.
The participants’ points of view, opinions and knowl-
edge need to be clarified. Justifications must be offered for
what is said, and both must be permitted to ask for reasons.
This obligation to offer justifications is essential for the
conversation to reach a deeper understanding. Common
reasoning may help identify practical circumstances of
importance as well as values concerning right and wrong,
good and bad, and is a premise for capturing the three
dimensions of the lifeworld. The result may be a joint
understanding that the participants are closer to each other
than they may seem, or differences may be identified,
equally important when deciding on further action. The
clarification can give rise to a superior reflection and
weighing of values and norms. This can in turn reveal new
possibilities and may lead to a wish for new priorities. For
a positive, dynamic process to occur the participants must
have an open attitude and seek to understand the other and
be willing to change their own point of view when new
insight is obtained. Habermas describes this as being
moved by the uncoercing ‘‘force of the better argument’’
(Habermas 1984 p.12).
Effecting change through dialogue
Table 1 What to talk about?
Objective world
The patient’s practical circumstances including the daily
schedule before and after the illness. Medical knowledge.
What is practically feasible?
Is the description of the objective world true?
Adopting these guidelines for the argumentation process
increases opportunities to create insight, reach mutual
understanding and obtain a consensus supported by both
parties in a dialogue resting on ‘‘the binding force of good
reasons’’ (Habermas 1987 p. 215). The procedural
requirements are summed up in Table 2.
Adjustments to the patient-physician relationship
In practice there will be obstacles, and the ideal conver-
sation may never be achieved. The ideal may guide the
parties, though, by increased awareness of and conscious
adjustments to the goals and pitfalls of consultations.
In principle both parties in a dialogue are responsible for
upholding the communicative goals. However, this ideal
may be obstructed by numerous conditions on different
levels, which will only be briefly mentioned here by
pointing to common obstacles of medical consultations.
Seriously sick people may have transiently impaired cog-
nitive capacity (Cassell et al. 2001), and one may suppose
that patients in need of lifestyle changes, facing the pos-
sibility of serious sickness like heart diseases or diabetes,
also are in emotional states that can block rational com-
munication. Many patients are unfamiliar with argumen-
tative forms of talk, and are not used to being invited into
shared decision-making. Even in consultations with adult
autonomous patients with great argumentative skills, in the
most fortunate of settings, an implicit asymmetry exists
between doctor and patient. Illness, insecurity and worry
create vulnerability; patients are help-seekers. The doctor
Table 2 How to talk about it?
Equitability
Inclusion of relevant parties
Respect
Sincerity
Consistency
Information, opinions and reasons
Justification and reasoning
Reflection upon values and norms
Willingness to change one’s mind when convinced
Social world Subjective world
Relationships affected, including expectations, The patient’s emotions,
rules and social sanctions of behaviour. wishes and opinions.
What is right to do? What is good to do?
Is the description of the social world right? Is the description of the
subject world truthful?
has power through social and professional status, posses-
sion of medical knowledge, access to examinations and
treatment, and control of the amount of time available
(Ruyter et al. 2000). It is a constant challenge for medical
talk to balance the structural and symbolic inequalities
between people in general and between doctor and patient
in particular. As stated by Habermas (1997), encounters
with vulnerable individuals require an emphasis on mercy,
care and empathy. The doctor has an opportunity to soften
the asymmetry by striving to understand the patients’
perspective and act empathically. This requires the doctor
to search for knowledge of the patient’s wishes, concerns
and interests, and also to some degree allow her/himself to
appear as a person within the limits of professionalism. By
this, a foundation of trust may be created. Trust is a
necessity for the therapeutic alliance (Schei 2006), and
hence indispensable to a rational exploration of the situa-
tion. Professionalism entails that physicians use power
positively to strengthen the patient at different levels (Schei
2006). In complex situations the leader’s role cannot be
precisely defined in advance. Leadership can only emerge
as an improvised adaptation to the transforming processes
of the situation, in line with the Aristotelian notion of the
virtue phronesis, ‘‘practical wisdom’’. The ability to
improvise wisely towards unspecified ends requires expe-
rience, insight into practical and theoretical questions, and
an ability to adapt previous knowledge to new situations
(Barker 2001; Schei 2006). Such practical wisdom is an
essential aspect of the doctor’s role (Schei 2006; Hofman
2002), and a skill most doctors will be able to develop
through reflection over practice (Gulbrandsen and Forslin
1997).
Gaining insight into the unique and unexpected aspects
that inhere in every situation and every person is crucial for
wise leadership, and this is where Habermas’ theory of
communication connects with the Aristotelian notion of
phronesis, within the frame of clinical medicine. Awareness
of the need to gain knowledge about the particular situation
at hand, combined with general knowledge, is of great
importance when deciding what to do in complex situations.
As stated by Malterud (1995): ‘‘Perceiving the complex
patterns of particulars and integrating them into wholeness is
fundamental for …practical understanding’’. Taking a
leadership role implies taking responsibility for being a
123

moderator of the conversation, and a good conversation
partner. Through dialogue, relevant conscious and uncon-
scious reasons can be reflected upon, concerning both the
detailed everyday life level and more superior values. The
physician contributes to the reshaping of order and meaning
by facilitating patients’ reflection processes, aiming at a
practical understanding of oneself and the situation at hand
that may serve as a sustainable foundation for further action.
In consultations there is a need for explaining and clarifying
medical expressions, as well as social and cultural differ-
ences. More than in everyday conversation it may also be of
importance for the doctor to verbally express the perceived
understanding of and insight into the patients’ situation and
point of view. Additionally, the doctor can ask questions to
verify that the patient has understood the situation and
encourage the patient to express her or his insight. This
verbalizing of mutual understanding produces translucency,
clarifies the standpoints, reveals what is understood and
what is not understood, and counteracts the implicit hierar-
chy and subordination of helping relationships.
The doctor’s ability to communicate respect for differ-
ences in views and values is essential in maintaining an
alliance. When a patient does not spontaneously offer
arguments and does not show signs of fighting for her or his
interests, the physician may intervene by actively seeking
to clarify the patient’s reasons, opinions and arguments.
This will require care and discreetness. The doctor may
first ask for the patients’ objective circumstances and
everyday life routines. Seeking the reasons for the behav-
iour will reveal rules, commitments and preferences. Then
the doctor may invite the patient to reflect upon and weigh
the underlying priorities. Some values and norms are per-
haps withheld, others rejected, and new preferences may be
established. The practical circumstances, barriers and
options can be reflected upon. This constitutes the argu-
mentation process, which may result in a deeper under-
standing of the situation. A new foundation of consciously
chosen values, norms and practical options is created, upon
which decisions can be made, rooted in the patient’s
preferences, affiliations and contextual obligations. The
goal is to make a decision that appears right, good and
practical to the patient. The process is further illustrated in
the case story described below. The adjustments of
Table 3 Adjustments performed by the doctor
Leadership role
Empathy and care
The patient’s perspective
Translucency by explicit expressions
Ask for information, opinions and reasons
Reflection upon values and norms
123
L. T. Walseth, E. Schei
communication theory to the medical consultation are
summed up in Table 3.
A right decision?
One can never be quite sure whether a particular decision is
the optimal one. Habermas follows Kant’s universal prin-
ciple, that every human being should follow rules for
behaviour which can be universally valid, and that human
beings are never to be solely used as means to achieve
something, but have to be treated as goals in themselves.
This entails the necessity of seeing a problem from the
perspectives of all people involved. There is obviously
rarely perfect insight into practical matters and their con-
sequences. Such insight improves over time. Habermas has
a procedural understanding of rationality, and claims all
knowledge to be fallible. There are no guarantees that a
decision is correct, but the procedure, the line of action in
the conversation, can be characterized as right or wrong.
Striving for a good procedure then becomes central
(Eriksen 2001). Habermas’ theory can promote a uniform
procedure for the dialogue, and serve as a template to be
used over and over again as new elements emerge, until a
good result is achieved. As such, this procedure improves
the quality of the consultation and its outcome. In complex
clinical relationships where new arguments and knowledge
are revealed over time, there may be a need to repeat the
procedure over several consultations until a realistic deci-
sion anchored in the patient’s core values and context is
reached.
Communicative rationality in practice, a case story
To show how the procedure outlined above can be practi-
cally implemented, a case story constructed from the
authors’ medical experience is presented. The story is fle-
shed out to illustrate the importance of detail, time and
trust, describing a patient’s increasing ability to make
independent decisions over a prolonged period of interac-
tion with her GP, in which the core elements of the theory
of communicative action are applied.
Mary is 49 years old, married, has two children and
works as a cleaner. She experiences prolonged pain in
hands and forearms, and visits her general practitioner,
whom she knows fairly well. The pain has been on and off
for several years, with increasing intensity the last
6 months. Examination reveals arthrosis of the thumbs and
tendinitis of both forearms, and the GP offers her a sick
leave, NSAIDS and physiotherapy. Mary asks for a general
check-up. She has lately felt more tired, and is worried that
she has inherited a risk of heart-disease and diabetes from
her parents. It turns out that she has moderate diabetes type
2, mild hypertension, slightly elevated cholesterol, and is
Effecting change through dialogue
somewhat overweight, with a body mass index of 30. She
does not smoke. Mary is given extensive information on
diabetes and cardiovascular risk factors. The possible
health consequences and advisable lifestyle changes—
more physical exercise and a change of diet—are pointed
out to her. Mary eagerly adopts the idea of lifestyle change,
in order to avoid medication. However, after a while it
becomes clear that she is unable to carry out her plans.
Mary becomes increasingly discouraged and depressed.
The negative changes in Mary’s quality of life are rec-
ognized by the doctor, and he realizes that other strategies
are needed to help her achieve her goals. Her diabetes must
now be treated with medications, and the issues of weight,
hypertension and cholesterol are given more attention. The
doctor attaches great importance to creating a good atmo-
sphere for further conversation. He is aware that he may
need to talk with Mary about very personal and sensitive
matters, and emphasises a careful approach. He expresses
understanding of the difficulties of carrying out lifestyle
changes, and shows that he is interested in reflecting with
Mary on the barriers to change. They agree on further
consultations that will solely focus on the necessary life-
style changes.
The doctor makes sure that Mary has understood the
medical information, and then invites her to talk about the
rhythms of her everyday life before and after she became
sick, exploring her objective world as a starting point.
Mary used to get up at 5 every morning to go to work. On
returning home she was tired and needed a nap. Afterwards
she did some housework and made dinner, although this
became increasingly difficult because of the pain in hands
and arms. After dinner she helped her children with their
homework and drove them to leisure activities. Finally in
the evening she was tired and had little energy. She wat-
ched TV with her husband and shared a good meal with
him. Once a week she participated in a weaving course.
The family otherwise lived a quiet life. Now, on sick leave,
Mary gets up at 7.30 with the children before they go to
school. As the pain in her hands has become more man-
ageable, she gets around the house work by doing a bit
every day, resting every now and then. With reduced pain
she sleeps more, and has more energy since she does not
work. She had to quit the weaving course due to the pain in
her hands.
To further explore Mary’s subjective life world, the
doctor asks how she felt about her life before and after she
became ill. Mary says she had a good life, even if it was
somewhat strenuous and she often felt tired. She now has
more physical energy, but has a feeling of emptiness and
experiences a certain degree of apathy, which results in
difficulties with initiating new activities. She finds it hard
to handle the increasingly obvious fact that she will not be
able to return to her job, and she cannot imagine starting in
a new one. She feels bad about her role as a patient, and
increasingly despises herself for not being able to carry
through the necessary lifestyle changes.
To further explore Mary’s values the doctor asks what
the changes in her life means to her; what were important
to her earlier, and how has the change affected these top-
ics? It turns out that her workplace was of great importance
to her social life, and, additionally, it gave her a feeling of
not solely existing for her family. The weaving course had
the same effect. She has now lost her social arenas, where
she to a greater extent was seen as a person.
The doctor asks how the family is doing. By this, the
social and subjective worlds are explored even further.
Mary describes the relationship with her husband as good,
although she does feel that she has too much of the
responsibility for housework and children. Her husband is
tired after work and contributes very little to housework
and follow-up of the children. In the evenings they relax
together, sharing good food. Her husband wants to continue
as usual, and finds her new food suggestions of no interest.
Mary worries that if she carries out the changes, an
important part of their relationship will disappear. Because
of her family commitments she has not had the energy to
exercise much.
To explore even deeper Mary’s values and norms, the
doctor now searches for the reasons underlying Mary’s
behaviour. What is the background for her priorities? What
values and norms govern her behaviour? Why does she do
the practical things which occupy her everyday life? She
expresses that she truly appreciates her family. She wants
to be there for her children, and she wants to keep a good
relationship to her husband without nagging and quarrel-
ling. In order to keep a peaceful home she has avoided
talking with him about the obvious unfairness in the
sharing of daily chores. Her core values thus include fol-
low-up of the children, a peaceful home, and an unstrained
relationship with her husband. Her subjective need to rest is
necessary for her to manage the pursuit of these values. She
also appreciates good food, and sees the meals as highlights
of family life.
Now the doctor attempts to approach the situation from
different angles. By carefully reflecting upon and weighing
her reasons and asking questions about alternative solu-
tions, the doctor helps her to gain awareness of the basis for
her priorities. Her patterns seem to contain some elements
that may be destructive. She is afraid of bringing up con-
flicts, her focus on food may be a cover for dissatisfaction,
and she gives other people high priority, at her own
expense. In the conversation a considerable frustration over
her husband’s passivity emerges, she sees that it reduces
her opportunities to take care of her own health and well-
being. She realizes that she misses values such as good
health, equal division of home chores, a richer relationship
123

with her husband, and a richer social life. She has gained
the insight that her priorities maintain unfairness and
consolidate a situation where she is not able to realise her
real values and needs. This is reinforced by loss of social
arenas,—job and weaving course.
The options for change in Mary’s’ life involve her
husband to a great extent. The doctor invites them both to a
consultation. This way the husband reaches a greater
understanding of the situation, and he expresses a will-
ingness to change with respect to food habits, and to share
the household chores more fairly. However, after some
time there are practically no changes. Mary becomes
increasingly frustrated. She persuades her husband to visit
a family counselling office. After some consultations
changes start to slowly occur. They hire a house cleaner,
and share the follow-up of the children. For Mary this frees
energy and time. She gathers courage and calls on an
earlier colleague, and the two of them agree to go for a
walk twice a week. She also registers for a language
course. Mary gradually introduces changes in their food
habits. After some months they re-establish contact with
previous friends. The family gradually discovers that they
have a richer relationship which motivates them to keep up
the positive changes. Mary realises more of her life values,
and becomes more satisfied. Her blood pressure, weight
and blood tests all show positive development. It becomes
clear that her health does not allow her to keep working as
a cleaner. However, her former feelings of depression and
apathy have gradually disappeared. She has courage and
energy to try new things, and she applies for vocational
retraining.
In this case, the ‘‘awakening’’ created by the dialogue
helped Mary make decisions that turned out to be good. Of
course, there are situations where the level of complexity
or the strength of emotions blocks a rational dialogue like
this. Of major importance is the very delicate use of power
in a situation of trust and asymmetry; a less sensitive doctor
may without intent force his values on Mary and distort her
development.
Discussion
Being aware of values is crucial to motivating oneself and
taking control of one’s life (Kieffer 1984). In the case
story, focusing on the three dimensions of the lifeworld and
searching for reasons for behaviour helps the doctor to
discover what Mary considers to be good, right and prac-
tically possible. By this, Mary’s values are made conscious,
and a foundation for further reflections is created,
increasing her possibilities for control. By improving the
patient’s ability to judge and reflect on values and prefer-
ences, the consultation expands patient autonomy, beyond
123
L. T. Walseth, E. Schei
simply letting the patient decide (Emanuel and Emanuel
1992). Mary’s abortive attempt at change visualises how
decisions concerning complex matters may be well-inten-
tioned but constructed on a fragile foundation of superficial
(self-)insight. In addition to the autonomy of self-deter-
mination she also needed the freedom created by insight
into valuable alternatives and awareness of the moral
obligations she wanted to pursue, developed through
reflection. The doctor did not coerce Mary to any decision,
but created a conversation where she gained awareness of
being in a situation where execution of her decisions, and
thereby fulfilment of her desires, were dependent on her
husband. Hence, it was clarified that an important aspect of
autonomy was not available (Sandman 2004). In Mary’s
situation, the lack of independence, necessary for full
autonomy, was rooted in injustice. Clarifying this
empowered her to fight for her rights. In other examples,
the dependence on other people may be inevitable, yet
important to clarify.
The procedure produced a situation where Mary’s
everyday life was discussed on a very detailed level.
Through this lifeworld mapping, the physician takes Mary
seriously, conveys respect and strengthens the physician-
patient relationship. The doctor’s enduring interest and
engagement in seemingly trivial aspects of the patient’s life
contributes to a powerful therapeutic alliance, which has a
strong empowering effect, clearly demonstrated in studies
of psychotherapy effects (Wampold 2007). At the same
time, a ‘‘practical understanding’’ of the situation is pro-
duced through a reflection focusing on the particulars and
the wholeness at the same time (Malterud 1995).
In times of rapid change, such as ours, values and norms
have a floating character, with individual freedom forcing
upon people a responsibility for setting their own stan-
dards. This increases the need for an expanded under-
standing of patient autonomy through deliberative dialogue
(Komesaroff 1995; Emanuel and Emanuel 1992).
However, doctors often find such consultations difficult,
possibly because they differ in structure, goals and proce-
dures from the classical medical interview (Emanuel and
Emanuel 1992). Habermas’ theory, with the accommoda-
tions presented above, seems to serve as a fruitful practical
approach in these consultations.
Processes of communicative rationality create binding,
justified decisions (Habermas 1997), where the persons
involved are committed to themselves and their conversa-
tion partner. Structuring action around choices based on
communicative rationality touches upon issues of identity
and self-understanding. Through dialogue, Mary gains
insight into the foundations of her own actions. Reflecting
on such insight holds a potential for self-development, for
Mary accomplished through a shift from adherence to
unconscious, unfortunate patterns to consciously chosen
Effecting change through dialogue
values congruent with good living. For this shift to be
possible, deep trust is necessary, allowing open, non-
defensive reflection. Trust rests on the pillars of respect and
truthfulness, decisive elements in Habermas’s theory.
Verbal language is not necessarily the decisive factor in
human communication. In a consultation, body language,
office design, the patient’s stress level and the circum-
stances before and after the consultation are matters that
influence the outcome. For a doctor-patient dialogue to
generate fruitful linguistic reflections, a basis of trust-
engendering behaviour and an obliging atmosphere are
needed, in which new thoughts and behavioural patterns
may be developed through trial and error.
Tight time schedules are a returning problem in medical
practice, and an obstacle to good communication. How-
ever, change happens gradually, and as the case of Mary
makes clear, repeated consultations over time are well
suited for general practice and for processes of change.
With this approach the doctor gives the subject priority, he
acknowledges Mary’s difficulties and he takes seriously the
medical importance of achieving lasting change.
Communicative rationality presupposes, and helps rea-
lise, a patient-centred approach to medical practice. We
argue that Habermas’ theory offers theoretical arguments
and practical guidelines that may facilitate the implemen-
tation of PCM in everyday medical practice by expanding
existing models (Stewart et al. 2003; McWhinney and
Freeman 2009). In PCM, the creation of a common ground
through mutual understanding is crucial. The argumenta-
tion process described by Habermas offers an explicit
approach that may create a solid and deep-reaching com-
mon ground, less clearly described in the existing literature
on PCM.
In general practice consultations, as in everyday life, a
number of factors disturb the possibilities for an ideal
dialogue. Human relations and behaviour are unpredict-
able. In practice, well-intentioned statements may produce
unexpected interpretations and reactions. However, want-
ing to be originators of good and right actions, human
beings have but one option: to do our best, accept fallibility
and try again. According to Pellizzoni (2001), Habermas’
communication theory may function as an ideal that gives
ideas and goals to strive for. Theories can, however, rarely
be transferred from science as uncomplicated instructions
to practitioners (Danermark 2002); they can only provide
descriptions of mechanisms. This paper presents some of
the mechanisms of ideal communication, mechanisms that
produce asymmetry in the doctor-patient relationship,
mechanisms counteracting this asymmetry, and mecha-
nisms with a potential for turning asymmetry into a med-
ical asset. In a practical situation, the doctor has to take into
consideration the particular patient in her or his particular
circumstances at that particular time. This requires the
doctor to struggle with the task of personal development
towards wisdom as a leader, through focusing on ‘‘self-
reflection, relational skills and empathic understanding’’
(Schei 2006). Combining the power of wise leadership and
the potential impact of Habermas’ theory may increase the
likelihood of creating processes that promote strength and
healing for patients.
Conclusion
When challenged to help patients adjust to illness or
change lifestyle, doctors need to take an active interest in
the patients’ everyday life, and seriously explore the con-
scious and unconscious complexity that precedes, consti-
tutes and results from behaviour. A medical dialogue based
on Habermas’ theory of communicative rationality repre-
sents a way of giving everyday life a language, and a
powerful access to non-oppressive processes of health-
related change. Knowledge of the theories reflected upon in
this article may provide useful tools in medical practice.
Medical success will, however, always depend on the
practitioner’s individual understanding of human life, and
wise judgment in deciding how to use this understanding.
Acknowledgments Thanks to Marit Skivenes, HEMIL-Centre,
University of Bergen, Norway, for helpful commentaries. Thanks to
‘‘Fund for research in General Practice, the Norwegian Medical
Association’’, for funding the study.
Conflicts of interest statement None.
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