“The arrow points only in the application that a living being makes of it.”
– Wittgenstein (1)
This article was originally posted in the Hektoen International Journal:
https://hekint.org/2019/03/18/the-language-game-of-medicine/?highlight=gunjan%20sharma
Language is a vital part of society. Its importance lies not just in its use as a communication tool but its ability to bring us closer to each other. With the power of words I can share the joys and pleasures which reside within my mind. I can release my anger and frustration or the fragility of my heart. I can reveal my background and my status in society. In healthcare we take language even further; we use it to step inside other people’s vulnerabilities.
Language is a fascinating concept when viewed through a philosophical lens. Imagine if we no longer had a word for jealousy. Would that mean such a thing could no longer exist? The commonsense answer would be no – for jealousy is an emotion which we feel inside ourselves. Yet without the word we would have great difficulty in sharing this emotion with others. We wouldn’t know if feeling such a thing were normal, or where it came from or what it meant.
One of the best known philosophers in this field is Ludwig Wittgenstein. In his later work, Philosophical Investigations, Wittgenstein suggests that the meaning of a word is not its definition or the object it refers to; to define a chair you cannot merely point to one. The meaning of a word is how it is used i.e. the context but also the culture, the society and the experiences of the people within such spheres. Wittgenstein called this the ‘language game’ and the context in which it was played as a ‘form of life’ (2). But this doesn’t just apply to words, it also applies to sentences. Healthcare is a perfect example of when language games come together and when the rules are not followed.
One of the most common presentations to the Emergency Department is pain.
‘I have pain in my chest.’
‘My arm hurts – I think I might have broken it.’
‘My tummy is really sore – do you think I have kidney stones?’
In each of these sentences the word ‘pain’ or ‘sore’ takes on a different meaning. I cannot know exactly what these people mean when they are in pain. I cannot feel that pain with them. So, I must use the language game. It is important for me to understand what pain means to the patient; does it mean they can no longer walk up the stairs to their bathroom? Does their headache stop them from studying for their exam? Or perhaps they have had this pain before and ended up vomiting – something they do not want to go through again.
This illustrates the importance of context when it comes to the meaning of words and sentences. The phrase ‘My arm hurts – I think I might have broken it’ might mean ‘I can’t write and I have an essay due in’ or ‘I need to cook for my whole family’ or ‘please give me some painkillers to get rid of it.’
The problem occurs when patients meet doctors, for this is when language games collide. You see, we have our own language game. You may have come in because your abdomen feels like it is about to burst and you’re terrified you might have appendicitis like your brother did when he was ten but ‘abdominal pain’ in my language means: rule out the nasties – perforation of the intestines? A blockage somewhere? Cancer? Bleeding? Infection?
And we play this game because it works. If I go to my colleague and say ‘this guy has come in with central chest pain, crushing in nature and radiating to his jaw’ this has a completely different meaning to ‘this guy has come in with central chest pain, described as burning with an acid taste in his mouth.’ In both sentences I have used the words ‘chest pain’ but the meaning I have communicated is very different because of the context; firstly that I am speaking in a hospital setting and secondly I am speaking to another clinician – not to my mother on the phone or the flight attendant on my flight to Melbourne.
But what if I were to use this language game with my patient? Wittgenstein describes words as tools in a toolbox (3). The correct tool needs to be chosen depending on the context. A screwdriver is no use if one needs a hammer. Wittgenstein makes it clear that there are rules as there are in any game and these are rules made simply to ease the workings of the game (4). For example, we have chosen to describe this colour as red and that colour as green so that we are all working from the same foundations. In the same way we will have our own concept of the word ‘pain’ depending on the culture and society we have grown up in. In the UK, pain is seen as an abnormal state of the body; it signals that something is wrong. We see pain as a mechanical process like a phone that has had its screen cracked. And as with any mechanism that has gone wrong, we go to the experts to get it fixed; the doctors and nurses.
If you go to Japan or South Korea you will find many patients presenting to their doctors with generalised somatic complaints with no clear cause such as muscle aches, stomach aches, nausea etc, who are later diagnosed with Depression or Anxiety (5). In many Asian cultures the stigma of mental illness leads to many patients translating mental suffering into more ‘acceptable’ physical symptoms (6). Once again we return to a ‘life form’ of the language game.
When this goes wrong in healthcare is when our language games clash. I may have ruled out all the horrible and concerning diagnoses and no longer be worried about your abdominal pain but you sure are. You can no longer eat, you constantly feel sick and this diarrhoea has made you bed bound! When this mismatch continues is when patients begin to feel frustrated, misunderstood and stigmatised.
Healthcare professionals have tried to change the language game of pain to make it easier for ourselves. Examples include ‘on a scale of one to ten how bad is your pain?’ or physical signs of pain such as grimacing, a fast heart rate or rapid breathing (7). Here returns the concept of pain being seen as a mechanical process of the body.
“But if I suppose that someone is in pain, then I am simply supposing that he has just the same as I have so often had.” — That gets us no further. It is as if I were to say: “You surely know what ‘It is 5 o’clock here’ means; so you also know what ‘It’s 5 o’clock on the sun’ means. It means simply that it is just the same there as it is here when it is 5 o’clock.” — The explanation by means of identity does not work here.
– Wittgenstein (8)
This is a quote from Wittgenstein taken from the Philosophical Investigations. The initial sentence is an example of someone arguing against him while the latter is Wittgenstein’s response. If only this quote were taught to medical students.
In essence what Wittgenstein is saying here is that I cannot make the assumption that the pain that I feel is exactly the same pain as you feel. How could we ever know? What I must rely on are the things I can observe; the language game. This can include the broad vocabulary for pain which we have developed (which suggests the importance of such a concept in our culture) but also non-verbal communication such as crying, screaming or lying in a fetal position. But because of the lack of bridges between my mind and yours, we do sometimes get it wrong. We don’t appreciate the amount of pain our patients are in, or its significance in their lives. Sometimes our language game stops us from connecting with our patients.
When I first started my job in the Emergency Department I was often left confused with the things people came in with. Of course I don’t expect everyone to have gone through medical school but I’m pretty sure my mother wouldn’t come to A&E with a papercut or tummy pain for which she hadn’t first tried some painkillers. But once I began to talk to my patients and enter into their language game, to see the meaning of pain in their context, I began to understand. I began to see that sinusitis to some meant a brain tumour. Diarrhoea and vomiting meant possible cancer. A fracture meant weeks of disability. Rather than learn this from medical textbooks though, bizarrely I learnt this from Wittgenstein.
The late physicist Stephen Hawking once made a controversial statement:
“Philosophy is dead” (9)
I respectfully disagree. Every one of us uses language, most without a second thought. But once we start looking at the words we use, the ways we use them and the difficulties they can get us into we begin to appreciate the barriers that we have built for ourselves alongside the freedoms.
In Medicine – a topic in which language is so vital – such reflections are crucial if we are to grow as healthcare professionals. When I ask my patients “How are you today?” am I simply following the etiquette of society or opening a door for my patient to share their worries? When I tell the family ‘the blood tests are not worrying’ do I mean they are all normal or that they are not worrying in the context of the patient’s other problems; or that they are abnormal but we as clinicians are not worried so you shouldn’t be either?
Such questions are important to discuss for they reveal not only the lack of clinical information which we share with our patients but also the prejudices we ourselves hold as healthcare professionals towards patients and their families. Being aware of the language game and how it operates is important not just for Philosophy but for Medicine as well.
You detail some sound statements.
Very good blog post. I definitely love this website. Stick with it!
I’m amazed, I have to admit. Rarely do I encounter a blog that’s both educative and interesting, and without a doubt, you’ve hit the nail on the head. The problem is something too few folks are speaking intelligently about. I am very happy that I stumbled across this in my search for something regarding this.