Halvor Nordby
Professor
Lillehammer University College
Faculty of Health and Social Research
halvor.nordby@hil.no

University of Oslo
Faculty of Medicine
Department of Health Management and Health Economy
halvor.nordby@medisin.uio.no

Abstract

1. Introduction

Lecturers, supervisors and other persons with teaching responsibilities in modern education programs are often involved in two forms of communication: face-to-face communication, in which the participants in a communicative process can observe each other and the wider context of communication, and interactive communication, in which communication happens through some interactive communication channel. Dialogues with students in traditional, physical classrooms are typical examples of the first kind of communication; supervision and discussions via internet-based programs like ‘Classfronter’ are typical examples of the second.
It is obvious that both face-to-face and interactive communication can involve fundamental challenges for communicators, but it is not so clear exactly how these challenges should be understood and related to each other. An important theoretical question is therefore this: To what extent are the communicative challenges involved in the two forms of communication similar, and to what extent are they essentially different?

A thorough analysis of all the potentially relevant aspects of this question would require a very comprehensive discussion. The obvious reason is that the question can be discussed from different perspectives, and that it is unreasonable, at least prima facie, to give one of these perspectives conceptual or epistemic priority (Davies 1998, Peacocke 1998). A better suggestion is that the similarities and differences between face-to-face communication and interactive communication can be elucidated in different ways, and that a variety of analyses can jointly contribute to a better, overall understanding of the nature of the two forms of communication.

My primary motivation for exploring the nature of face-to-face and interactive communication has been the need to understand communicative challenges that confront students in a national further education program for medical paramedics. As the person responsible for one of the courses in this program I have, from a pedagogical and theoretical point of view, attempted to analyze the various forms of interaction paramedics are involved in. I have, in particular, sought to address two questions: What are some of the fundamental problems of understanding paramedics confront when they encounter patients and other health personnel in face-to-face situations? How are these problems similar to, but also different from, the challenges they confront when they communicate interactively via radio or telephone with other health personnel such as nurses in acute medical communication centers?

The aim of this article is to address some important aspects of these questions on the basis of recent philosophical theories of speech acts and concept possession (Guttenplan 1996; Bechtel & Graham 1998). Within the theoretical framework I develop, I make a fundamental distinction between four communication conditions: firstly, speaker and audience (in a wide sense) need to share a common language that can be used to convey and understand a belief. Secondly, the audience must realize that the speaker has the intention of communicating this belief. Thirdly, speaker and audience must not associate beliefs and thoughts that are literally expressed in language with very different sets of other beliefs and thoughts. And finally, the experiences, motives and values that an audience ascribes to a speaker must not be radically different from the experiences, motives and values that a speaker intends to express.

I will argue that this philosophical framework is completely general but also particularistic. That is, the four conditions can be used to show how face-to-face and interactive communication involve some of the same fundamental communicative processes, but the conditions can also be used to illuminate crucial differences. This fact, I will argue, constitutes a plausible argument for using the conditions as a conceptual framework for analyzing empirical phenomena related to the two forms of communication. Moreover, the fact that the framework is suitable for understanding and explaining the two forms of communication constitutes an independent justification for the framework itself, as a genuine theory of communication.
In the last part of the article, I examine the question of how it is possible to avoid various forms of misunderstanding that occur when one or several of the four communication conditions are not met. This discussion is to a large extent based on ideas that have been central within modern philosophical hermeneutics (Bleicher 1980; Mueller-Vollmer 1986; Smith 1997). I focus particularly on Gadamer’s (1975) idea of the aim of understanding as a ‘fusion of horizons’ and argue that in order to avoid poor communication, it is imperative that speakers are aware of various intrinsic aspects of the cognitive and emotional perspectives audiences have. I conclude that this and other implications of the arguments I present should be of interest to anyone who wants to acquire a more philosophical understanding of the nature of face-to-face and interactive communication.

2. Background

’Nasjonal Paramedic Utdanning’ (http://paramedic.hil.no/) is a national further education course for health personnel working as paramedics in the national health services in Norway. The program consists of six courses, four of which focus mainly on issues directly related to medicine, one on legal issues and one on communication and ethics.

The need for focusing on communication in the program is obvious. In their daily work as paramedics the students are to a large extent involved in interpersonal relations where empathy, understanding and dialogue are important factors for securing successful interaction. With respect to the especially important relation between paramedics and patients, it is crucial that paramedics are able to understand adequately how patients experience and think about their states of disease, illness or sickness. Their choice of verbal and non-verbal behavior must be based on justified beliefs about the emotional and cognitive perspectives patients have on their condition of disease or illness (Enelow, Forde & Brummel-Smith 1996, Nordby 2004a; Nordby 2006).

A detailed analysis of the diversity of communicative contexts paramedics face in interaction with patients and other health personnel falls outside the scope of this article. The important point I will focus on is that paramedics are involved in two forms of communication that are essentially different from each other. Firstly, they are involved in many direct, face-to-face encounters with patients, relatives of patients and other health personnel - situations in which they are able to observe not only the persons they communicate with but also the wider context of communication. When communicators are able to observe each other in this way, the obvious consequence is that it is possible to use more than uttered words as interpretative clues. Interpretation can also be made on the basis of non-verbal behavior and other observable aspects of the communicative context (Nordby 2004b). The significance of this consequence is obvious. Normally, when we seek to understand other persons we rely on literal interpretation. As Burge (1979, p.88) observes, “literal interpretation is ceteris paribus preferred” in ordinary discourse. For instance, if a speaker says ‘It is raining’, audiences normally assume that the speaker, as long as he means to be sincere, expresses the belief that it is raining involving the concepts it, is and raining that are literally expressed by the words he utters.

The qualification ‘normally’ is important. Sometimes certain aspects of a situation constitute good reason for being skeptical about literal interpretation, as in the case of incongruent communication involving a definite mismatch between verbal and non-verbal behavior. By being sensitive to the potential importance of non-verbal interpretative clues, communicators can avoid incongruent communication and other forms of poor communication that can occur when there is a mismatch between what is strictly speaking said and what is more generally displayed (Eide & Eide 2004). In such cases of experienced inconsistency, attentive audiences use the wider context to form special non-literal and complex interpretations that do not correspond directly to the words that a speaker utters (Davidson 1984). Furthermore, it is a widespread view that there are no observable aspects of face-to-face communicative contexts that are irrelevant in principle for determining the non-literal meaning of verbal speech acts (Bezuidenhout 1997; Cappelen & Lepore 2005). Face-to-face interpretation is essentially holistic; interpreters’ beliefs about the meaning of speakers’ utterances are based on assumptions about of all sorts of observations and all sorts of assumptions about speakers’ social and cultural contexts.

Face-to-face communication has received most attention in the health care literature focusing on interaction between health personnel and patients, but interactive communication - here defined as communication that does not involve a face-to-face encounter - is often equally important for paramedics (Tjora 1997). When an ambulance is called out, it has received an interactive appeal from an Acute Medical Communication center (AMC - center) where emergency nurses who cooperate with ambulance coordinators have answered an emergency call (‘113’ in Norway). This interactive appeal has several elements, including a precise a description as possible of where the patient is, a categorization of the acuteness of the assignment according to a code, and an indication of the nature of the patient’s state of injury, illness or disease.¹

Furthermore, while patients are being transported there is often extensive interactive dialogue between paramedics and the AMC-center. The paramedics often provide information about the patient’s state of illness or disease, they sometimes ask for medical supervision, and they sometimes require further back-up assistance from other medical units. There are, in fact, a wide range of aspects related to patients’ conditions that are of potential significance in this interactive communication. From the perspectives of all the parties involved, the experienced success of the paramedic-patient interaction will often depend heavily on adequate interactive communication.

It should already now be emphasized that when I distinguish between face-to-face communication and interactive communication in this way, I do not mean to argue that the two types of communication involve communicative processes that are different in principle. On the contrary, I believe that the assumptions I make are consistent with the plausible view that communication is a contextual, interpretative process, and that the difference between face-to-face and interactive communication fundamentally is a difference of degree. The reason this is an important point to make is that some might infer from the above that I rely on unjustified assumptions about some underlying principled distinction, but this is not the case. All I am presupposing is that we have a reasonable clear idea of what the differences between face-to-face and interactive communication are.

More could be said about face-to-face and interactive communication and the particular ways in which paramedics are involved in these forms of communication, but this would fall outside the limits of this article. For my present argumentative purposes, it is sufficient to clarify the basic nature of two forms of communication. I assume, in particular, that I have made it clear that face-to-face communication and interactive communication must involve some different communicative challenges. In the following, I will first develop fundamental communication conditions that are relevant for understanding communication in general, and then use these conditions to shed light on relevant differences.

3. Philosophical perspective

In trying to understand some of the fundamental communicative challenges that paramedics confront in their daily work as health personnel, it has been important to make extensive observation studies in ambulances and AMC-centers. These studies have given me valuable knowledge of how the students in the further education course experience and try to solve problems of communication. At the same time it is important to remember that although observations of human behavior and interaction must necessarily provide the basis for deciding whether communication succeeds or fails in a given context, such observations alone cannot establish whether communication succeeds. Conclusions about the status of a communicative process must always be made on the basis of assumptions about the nature of communication. Traditionally, these assumptions have focused on how the ‘external’ - behavior and context – must match the ‘inner’ - the subjective and private (Davidson 1984, Bezuidenhout 1997; Cappelen & Lepore 2005). The traditional idea has been that a speaker has successfully communicated an ‘inner’ mental state S to an audience if, and only if, the audience understands that the speaker intends to use verbal or non-verbal actions to convey state S to him.

Of course, making such communicative assumptions is something we do more or less unconsciously all the time in ordinary discourse, and even if the aim is nothing more than to explicate our common everyday assumptions, we have in effect started to clarify a theory of communication. Indeed, the difference between common sense theories of communication and the philosophical perspective I will apply here is not meant to be one of principle. The aim is rather to locate assumptions that (a) appeal to our ordinary ideas and (b) can be used to understand the fundamental challenges that face-to-face and interactive communication involve.
The theoretical framework I will use in seeking to achieve this twofold aim is grounded in a modern tradition within cognitive science and philosophy of mind and language (Guttenplan 1996; Bechtel & Graham 1998). According to theories that fall within this tradition, verbal and non-verbal actions are conceived of as intentional language acts that express beliefs and thoughts. Beliefs and thoughts are in turn thought of as psychological attitudes to propositions involving mental concepts (Burge 1979; Peacocke 1992). For instance, the sentence ‘Water quenches thirst’ is normally used to express the belief that water quenches thirst involving the three concepts water, quenches and thirst. When a speaker associates these concepts with the sentence, communication of the concepts has succeeded if, and only if, the audience understands that the speaker intends to communicate a belief involving these concepts.
It should be emphasized that this does not mean that an audience must necessarily think that is it correct to understand a language act in the same way as a speaker. For communicative purposes, all that is required is that the belief that an audience thinks that a speaker intends to communicate really is the belief the speaker intends to communicate. Questions about the objective and normative status of the meaning of language acts are therefore not directly relevant for questions of communication; whether communication happens must be determined on the basis of considerations of how speaker and audience understand each other, not on the basis of considerations of how it is correct to understand a given language (Nordby 2006). ²

This point is of particular importance in discourse involving disputed concepts with unclear application conditions, like the basic health concepts disease, illness and sickness (Mechanic 1968; Nettleton 1995; Worhall & Worhall 2003). Health professionals sometimes encounter patients who do not understand these concepts in ways that correspond to influential conceptions within the health services, but if a paramedic tries to adopt a patient’s understanding for communicative purposes, exchange of concepts can happen even if the patient’s understanding is regarded as controversial or even incorrect.
A second and more philosophical point that should be made about the framework of communication that I will use, is that I do not mean to argue that it constitutes the only possible way of analyzing communication. Basically, what I am relying on is that the framework represents a fundamental and influential way of understanding human interaction. I presuppose, in particular, that the assumption that successful communication involves successful exchange of subjective states has an intuitive, immediate appeal that is grounded in our ordinary communicative practices. Of course, in everyday communication it is not common to think of exchange of thoughts and other subjective states as communicative processes, but the reason why the assumption is plausible is not that it aims to capture a process that we are consciously aware of in ordinary discourse. The reason is rather that as long as we conceive of communication as a rational activity, then we have to think of understanding and communication in cognitive terms: our understanding of the language we use, and the way we try to communicate our concepts to others, cannot be reduced to observable behaviour. As McDowell notes,

...to learn the meaning of a word is to acquire an understanding that obliges us subsequently – if we have occasion to deploy the concept in question – to judge and speak in certain determinate ways, on pain of failure to obey the dictates of the meaning we have grasped” (McDowell 1994, p. 160).

McDowell’s claim is illuminating, not only because it is reasonable in itself, but also because McDowell ascribes it to the later Wittgenstein. In contrast to the tradition that McDowell’s interpretation of Wittgenstein is framed within, Wittgenstein is sometimes described as a modified behaviorist. According to this behaviorist interpretation, communication is essentially an observable activity within ‘language-games’, an activity that can be fully explained by referring to how we conform to language rules in different contexts (Kripke 1982).

Whether or not it is (contrary to what McDowell thinks) correct to ascribe some kind of behaviorist ‘third person’ perspective to Wittgenstein, is an important question of exegesis, but it would fall outside the scope of this article to address it. For the purposes here it is more important to think of behaviorism as a genuine source of challenge to cognitive analyses of communication. Independently of what Wittgenstein writes, some might argue that all versions of behaviorism are not obviously false, and that I have not showed why the cognitive framework of communication I have adopted here is more plausible than all these versions.

Is important to say something briefly about this objection, first and foremost because the choice of framework has substantial different practical consequences. Consider as an example a patient who utters the sentence ‘I am in pain’ and a paramedic who comes to assistance. A behaviorist will typically think of this as a complete communicative process and claim that further explanations that refer to ‘underlying’ subjective states and audiences’ mental interpretations of these states are irrelevant, superfluous or ‘quasi’ explanations that fall outside the realm of proper psychological explanations. ³

There are in my opinion two main problems with this view. Firstly, and as indicated above, if McDowell is correct, then it is possible to think that the way we understand words and communicate meaning is derived from our use of language, and at the same time think that explanations of underlying mental phenomena are important. According to McDowell, what Wittgenstein is opposed to is not mental explanations per se, but a certain way of conceiving of the relation between ‘private’ subjective states and observable actions. It is only if one starts out with a classical Cartesian first-person perspective that one is easily led to think that this dualism involves overwhelmingly difficult epistemic and metaphysical obstacles (Burge 1979; Nordby 2004c). The problem with behaviorism as a response to the Cartesian tradition is that the position inherits the same dualistic way of thinking. The only difference is that behaviorism starts from the other end - from the ‘outside’ - and then claims that it is only this perspective that we have ‘real’ epistemic access to. Behaviorism is a general doctrine that is grounded in a positivistic idea of what counts as elements in scientific explanations of communication.

Secondly, objections to the scientific status of cognitive analyses of communication often seem to rest on the idea that there is only one ‘proper’ level of psychological explanation. However, there is no good reason for holding that this is so. It is true that it is possible, on one level, to explain communication from a third-person perspective. And from this perspective it is correct to say that communication has succeeded if an audience manifests appropriate behavior as a response to actions performed by a speaker. But accepting that this is correct is compatible with holding that there is more to say about underlying mental processes from other perspectives.

Consider again the above example of a patient who utters ‘I am in pain’ and a paramedic who comes to assistance. How are we to understand this as a communicative process? We find it overwhelmingly natural to assume that the patient really is in pain (as long as he is sincere), that his utterance expresses his experience of being in pain, and that he intends the paramedic to understand that he is in pain (as long as his utterance is not merely an expression of pain) and so on. It is equally natural to assume that the reason the paramedic comes to assistance is that he thinks that the patient is in pain. This idea about the patient’s state of illness is derived from the fact that the patient used the sentence he used, and probably other interpretative clues like signs of pain. In short, the paramedic forms a belief about the patient’s state of mind on the basis of observable properties of the context. Again, this does not depend on a special Cartesian picture of the mental, or on the idea that interpretation is a conscious process. It is simply a natural way of widening a more narrow third-person explanation of what communication involves.

Hopefully, this defense of the plausibility of the cognitive framework has indicated why it has a strong appeal, and why proponents of other approaches therefore face formidable challenges. Obviously, much more could be said about communication as a fundamental philosophical concept, but that would fall outside the aim here as long as my main focus is the application of the framework within health care. In the next section I will argue that theories of speech acts and concept possession can potentially shed theoretically interesting light on face-to-face and interactive communication, and that they can be used to analyze crucial differences within a completely general framework. I have explained how the framework focuses in a comprehensive way on verbal and non-verbal speech acts, but I have also indicated how it implies that an observable context can play a crucial role in interpretation. In the following I will first focus on the issue of general significance and then discuss the idea of an observable context in more detail.

4. Communication conditions

Clarifying how communication can succeed or fail is equivalent to clarifying communication conditions – conditions that must be met in order for successful communication to happen. In order to understand communicative challenges within the framework I have outlined, I will make a fundamental distinction between four conditions. The first is that communication requires a common language:

Here I use the expression ‘speaker’ in a wide sense to mean someone who has a belief, thought or other concept-involving psychological attitude that he wishes to communicate to an audience (one or several persons). Since audiences are unable to grasp speakers’ thoughts and beliefs directly, these subjective states have to be expressed in language acts that can be seen, heard or observed and interpreted in other ways. As emphasized above, this can be all sorts of intentional behavior, but for the sake of clarity I will in the following primarily focus on verbal speech acts. Thus, in order for an audience to be able to understand that a speaker expresses a given belief, it is necessary that the speaker and the audience understand the sentence that the speaker uses in a sufficiently similar way, so that they associate the same concepts with the words that the speaker uses (Cappelen & Lepore 2005).
The qualification ‘sufficiently similar’ is important. When I claim that speaker and audience must have a common language, I do not mean that they have to understand this language in the same way in the sense that they use it in exactly the same ‘language games’ (Wittgenstein 1953). It is sufficient that their understanding is so similar that that they associate the words that are used with the same concepts (Burge 1979; Peacocke 1992; Guttenplan 1996).
This, in effect, presupposes that the conditions for the sharing of concepts are weaker than the conditions for sameness of understanding. It is obvious that communicators must have some similar understanding of a word in order to associate the same concept with it – the understanding that the audience has must to some extent approximate the speaker’s understanding.⁴ But this leaves open what a sufficiently similar understanding is, and exactly what the threshold condition for shared concepts is has been a disputed issue (for a discussion of this, see Nordby 2004c).

I will not presuppose any specific view on this issue here, but I will rely on the widespread idea that it is unnecessary that communicators use a word in exactly the same way in order to associate the same concept with it. The main reason why this idea is reasonable is this: We very seldom use language in exactly the same ways; there are normally differences due to our respective social and cultural contexts. So if we needed an identical understanding in order to share concepts, we would, in fact, seldom be able to exchange beliefs and thoughts involving the same concepts. Furthermore, laypersons should not need complete expert competence regarding the application conditions of a term in order to express the same concept as persons who have expert competence (Putnam 1981; Pessin & Goldberg 1996). If that were the case, laypersons within a given area of discourse would be unable to communicate with experts (consider again the area of health care and the relation between patients and medical doctors). This is a counterintuitive consequence, and it constitutes a good reason for being skeptical about the view that a platform of shared concepts requires an identical understanding.

The second communication condition I wish to focus on is more straightforward:

The idea is as follows: A speaker might express a belief, used a language that the speaker and the audience have a sufficiently similar understanding of and think it has reached the consciousness of the audience. It can nevertheless happen that the audience fails to realize that the speaker intends to communicate this belief. The reason for this may be lack of attention, problems of interpretation due to a chaotic situation, or an impaired capacity for rational reasoning (a patient might be in a state of shock or under the influence of drugs). But the problem may also be of a more technological nature, e.g. computers that do not work so that audiences are unable to use them as interactive communication tools.

It is important to bear in mind that in order for a misunderstanding of this kind to occur, the speaker must be unaware of the communicative problems. The speaker must genuinely believe that he has the attention of the audience, that there is no significant communicative ‘noise’ or disruption; otherwise he would not be sincerely attempting to communicate a belief. An example can be used to illustrate the point:

Paramedics encounter a patient who has taken a large amount of paracetamol. Relatives have called 113, and the patient himself, in a confused and agitated state, makes it clear that he does not want to be taken to hospital. In order to persuade the patient that treatment in hospital is necessary, the paramedics try to inform the patient about the physiological effects of paracetamol and they tell him that large doses of paracetamol can lead to serious irreversible damage to the liver. They hope that this information will lead the patient to change his mind, but this does not happen. Consequently, the paramedics decide that there is little use in trying to persuade the patient, and they begin to consider more complicated strategies for securing necessary transport and treatment.

In this situation it was evident that the paramedics assumed that the information about the negative health effects of large doses of paracetamol had reached the consciousness of the patient. However, it soon became evident that this had not happened. When the patient calmed down and his relatives told him what the paramedics had said, the patient realized the gravity of the situation and made it clear that he wanted to go to the hospital after all. In the first place, because of his confused state and the stressful encounter with the paramedics, the patient did not form the belief that the paramedics intended to communicate and thought that it was important to communicate.

If we manage to avoid the two forms of misunderstands that occur when conditions (i) or (ii) are not met, does this mean that communication has succeeded? Not necessarily. Even if speaker and audience have a platform of shared concepts, and even if the speaker has the attention of the audience so that the message that he intends to communicate actually reaches the consciousness of the audience, it might still happen that the audience associates this message with beliefs and thoughts that are very different from the set of beliefs and thoughts that the speaker associates with the message. This third form of misunderstanding corresponds to a third communication condition:

(iii) The wider set of beliefs and thoughts that an audience associates with a belief that is directly expressed in language must not be radically different from the wider set of beliefs and thoughts that the speaker associates with this belief.

As Davidson (1987, p.449) notes, interpretation always “rests on vague assumptions about what is and what is not shared” by speaker and audience, and problems typically arise when assumptions about what is shared beliefs turn out to be incorrect. Of course, if communicators’ perspectives are so radically different that they influence the semantic interpretation of the language that a speaker uses, then the misunderstanding that arises is a misunderstanding of the first kind (i). In such cases speaker and audience do not even have a common language. A misunderstanding of the third kind requires that the message that is literally expressed by language is understood, that the communicators have a sufficiently similar understanding of the words that are used in the sense explained above. The problem that can still arise is that the beliefs that surround this message are radically different. An example can illustrate the point:

An AMC-nurse tells a patient who has called 113 that ‘The ambulance is on its way’. The patient forms the belief that the ambulance is on its way, but he then forms a further belief - the belief that the ambulance will arrive very soon within the next few minutes. The patient expresses disappointment when the ambulance arrives after 30 minutes.

In this case communication of the belief that the ambulance is on its way has succeeded. The AMC-nurse has the attention of the patient, and they both associate the concepts the, ambulance, is, on, its and way with the sentence ‘The ambulance is on its way’. The problem is that communication has failed in the wider sense that the AMC-nurse does not associate the belief that the ambulance is on its way with the belief that the ambulance will arrive within a few minutes.⁵ The patient, however, forms this association. He grasps the content of the message that the nurse expresses literally in words, but he then forms further associations that are radically different from the way the nurse intends this message to be understood.

The qualification ‘radically different’ is important here. Two persons never associate the beliefs and thoughts they form with other beliefs and thoughts in exactly the same way; there will always be some different associations as long as interpretation is shaped by social and cultural context (Burge 1979; Davidson 1984; Smith 1997). The important point is that there are many cases in which the associations that are formed are so different that poor communication occurs. From the perspectives of speakers, it is the beliefs that it is most important to communicate that are ordinarily expressed literally in words; that is why communication of these beliefs is normally straightforward. It is when speaker and audience understand what is not strictly speaking said in significantly different ways, that a misunderstanding of the third kind (iii) occurs.

Is communication ensured if we manage to avoid the three forms of misunderstanding that correspond to communication conditions (i)-(iii)? We might think so, but this is because we sometimes tend to forget that communication is not always a rational activity. In addition to beliefs and thoughts that are true or false, there are many other subjective states that are important in human interaction. The fourth and final communication condition is meant to capture the fact that we sometimes communicate psychological states that are essentially different from beliefs and thought that are true or false:

By ‘values, emotions and other non-conceptual subjective states’ I mean states that cannot be ascribed as beliefs or thoughts that involve concepts. When we think about communication we often tend to focus on such states, on attitudes we ascribe by saying things like ‘S believes that p’ or ‘S thinks that p’ where ‘p’ is a concept-involving proposition. For instance, when I say ‘S believes that snow is white’, I ascribe to S the attitude of believing in a proposition involving the three concepts snow, is and white (which is true if snow is white and otherwise false). It is easy to forget that we sometimes intend to communicate psychological states that are not attitudes to propositions. Personal values are not attitudes to propositions, it makes no grammatical sense to say ‘S values that p’ and replace for ‘p’ propositions that are true or false depending on how the world is. Personal values are rather attitudes to ‘forms of living’ (Wittgenstein 1953; Johnston 1989); to the ways we wish to live our lives and the activities we like to participate in (Dancy 1996). The same applies to emotions and other personal experiences. The way I feel a certain pain, or the way I have a visual impression of a computer in front of me, cannot be directly experienced by another person. I can attempt to report and communicate my experience by using a sentence that I think is true or false (‘I am in pain’, ‘I have the impression of seeing a computer in front of me’), but this sentence is not identical to the state I talk about and have privileged first-person access to. The state is a pure subjective experience, not a belief or thought about something (Rosenthal 1991).
Understood in this way, the significance of (iv) becomes similar to that of (iii). We often try to communicate our personal values and experiences to other persons, but sometimes our audiences ascribe to us states that are different from those we intend to communicate. For instance, a patient who uses emotional vocabulary like ‘I am in pain’ will normally be interpreted as expressing a state with a certain qualitative ‘pain’ content. If this interpretation is wrong - if the pain that the paramedic thinks that the patient feels is very different from the qualitative nature of the pain the patient feels – then a misunderstanding of the fourth kind has occurred.

Values that are attitudes to forms of life or activities are subject to the same problems of interpretation. In discourse between persons from different social or cultural contexts the values that are ascribed may be different from the values that the communicators have. It is reasonable to assume that this sometimes occurs in paramedic-patient interaction. A patient who is perceived as a person who appreciates that the paramedics are acting in a certain way might in fact be a patient who endorses an alternative course of action. Typical cases include interaction between elderly people and younger paramedics who have a more ‘modern’ way of life. In one case observed by the author of this paper, a paramedic consequently addressed an elderly patient by his first name, even though it was fairly evident that the patient would have appreciated an alternative course of action (e.g. he introduced himself using his surname).

This last communication condition (iv) might seem to inflate the philosophical framework of speech acts and concepts, but this is not the case. On the contrary, since the first three conditions focus entirely on concept-involving beliefs and thoughts, it is possible to formulate a fourth condition that captures the remaining ‘subjective’ and qualitative dimension of human communication. The philosophical framework I have outlined leaves room for this further condition precisely because it makes a sharp distinction between concept-involving and non-concept-involving subjective states.

5. Implications: interactive and face-to-face communication

I am not going to argue that the four conditions I have presented represent the only possible way of analyzing communication. Holding that they are reasonable is consistent with holding that there are other conditions that are important as well. In fact, I do not even mean to provide a direct argument for the view that the conditions offer a plausible analysis of how poor communication can occur. What I primarily wish to focus on is their explanatory power, particularly the way they can be used to shed light on the similarities and differences between face-to-face and interactive communication.
If we start with the first condition (i), i.e. having a common language, how is this condition relevant for understanding the nature of the two forms of communication? The basic distinction to be made in connection with (i) is that between what a word means and what a speaker means. An utterance heard on the phone or a sentence read on a computer screen means something – it has a semantic content. But when an audience is confronted with a speaker the immediate question for the audience is as follows: What is the mental state – belief, thought or value - that the speaker has and intends to communicate?
This difference of focus corresponds to two different ways of conceiving of a speech act. The activity that is performed interactively is a pure language act; the social context of the act is not part of the meaning of the act. From the perspective of an audience, the aim is to understand the proposition expressed by the language shared by the speaker and the audience. The focus must be explicitly or implicitly on meaning, and the relevant interpretative activities correspond to the scope of philosophy of language – to philosophical questions about the meaning of language.

Face-to-face communication, on the other hand, is a social activity that essentially belongs within pragmatics and philosophy of mind. The question that confronts face-to-face communicators is this: What is the belief that the speaker in this context uses language to express? This is not a semantic question about the meaning of the words per se, but a question about the psychological nature of the relevant mental states of the speaker.
Even though the interpretative activities involved in the two forms of communication in this way correspond to different philosophical disciplines, it is important to recognize that the activities are similar in the sense that they both involve literal interpretation. That is, we normally assume that words that are used literally express the concepts communicated. We assume, for instance, that the word ‘dog’ in interactive communication means dog, just as we assume that a speaker who uses the word ‘dog’ expresses a belief involving the concept dog. In this sense there is an important similarity between face-to-face and interactive communication, and the requirement that communicators need to have a common language can be used to understand challenges related to concept communication within both forms of communication.

At the same time it is important to bear in mind that there are sometimes good reasons for not accepting literal interpretations, and in such cases the differences between face-to-face and interaction communication become more significant. In order to show why this is so it is important to distinguish three kinds of expressions. The first is what might be considered words with vague or unclear application conditions. Many words that are used in everyday discourse do not have precise definitions, and the meaning explanations speakers give often differ even though they are members of the same linguistic community (Burge 1979; 1986).⁶ Three of the most disputed words in the area of health care are ‘disease’, ‘illness’ and ‘sickness’ (Lupton 1994; Radley 1994; Worhall and Worhall 2001), but the point is of course general. There are countless vague or abstract words that communicators tend to understand in significantly different ways.

The fact that we commonly use vague words has an important consequence: different conceptions of what words mean are normally easier to detect face-to-face than interactively. There are at least three reasons why this is the case. Firstly, face-to-face communication more often than interactive communication involves substantial dialogue over time in which communicators realize that they do not have a similar understanding. Furthermore, when differences emerge and receive attention, audiences who are interested in communicating tend to adjust their conceptions of what speakers mean. Secondly, it is sometimes evident from the body language or verbal behavior of a person that he does not share the understanding of another person. If a doctor tells a patient who is feeling ill that it has not been establish that he has a disease, and if the patient thinks that the doctor has a very narrow, rigid understanding of ‘disease’, the patient’s body language may manifest incongruent communication: even though the patient says that he accepts the doctor’s opinion, the patient’s body language or other aspects of the communicative context indicate that he disagree. Thirdly, in face-to-face communication speakers have time, and it is often natural, to explicate in some detail how they understand words they conceive of as controversial. In particular, speakers often provide direct or indirect meaning explanations of words they think the audience has an incomplete understanding of.

Again, these points must be understood as prima facie principles that do not cover all cases. For instance, speakers regularly provide meaning explanations in interactive communication, consider an explanation of what an ‘essay’ is that a teacher distributes to his students via the internet. And face-to-face communication does not always involve extensive rational dialogue and proper explanations of theoretical or technical terms that are conceived to be important, as the above ‘paracetamol case’ clearly illustrates. However, it is surely the rule and not the exception that it is easier to detect and influence different conceptions of what a word means in face-to-face communication than in interactive communication.

This also applies to a second kind of words that can be termed ‘qualitative words’. Qualitative words are words that refer to private, individual experiences, or subjective states that have a significant personal element. Typical examples are words that denote states like pain, nausea or dizziness, but the category, as I understand it here, also includes emotional vocabulary like ‘love’, ‘compassion’ and ‘empathy’ that are used to communicate states that do not so clearly refer to determinate conscious experiences. The important point is that these words also have a subjective, private dimension that it can be difficult to detect in communication.

Communicative challenges related to the use of qualitative words are to a large extent similar to the challenges related to unclear words, but qualitative words have an additional dimension: an audience has by definition only indirect access to a speaker’s first-person experiences, but it is these experiences that constitute the reference and thereby the individual meaning of qualitative words. Qualitative words report these experiences, but they can only function as interpretative clues to the underlying nature of the experiences. This does not necessarily mean that the experiences are completely hidden from an audience; there are few modern traditions in philosophy of mind that hold that emotional states are fully independent from behavior (Rosenthal 1991; Davies 1995; Guttenplan 1996). The important point is that there must be some independence; there are not many theorists today who accept the extreme and classical behaviorist doctrine that experiences are identical to behavior (Ryle 1949). And if we accept the modern, more modest view that experiences are partly displayed in behavior, then it is reasonable to assume that communication of qualitative words more often succeeds in face-to face communication than in interactive communication. Normally, facial expressions or other forms of observable body language constitute part of the content of the experiences that a speaker intends to communicate.
The third category of words that deserve attention is technical or theoretical words. In face-to-face encounters it is sometimes sufficient to watch a person’s eyes in order to discern whether theoretical vocabulary represents meaningless sounds or not. Furthermore, in face-to-face interaction it is possible to use various forms of body language as specialized communicative tools. A good example is the non-verbal dialogue in AMC centers between nurses and ambulance coordinators. While talking to patients on the phone, they are able to observe each other and use body language – language that patients do not observe – as part of the basis for deciding what to do. An ambulance coordinator might for instance hold up two fingers to suggest to the nurse that the ambulance should be called out under ‘code 2’. If the nurse nods while the patient is on the line, the ambulance coordinator normally proceeds to call up an ambulance under ‘code 2’.

There is also a further aspect of the communication of technical words that is essentially different from the communication of unclear words and experiences. The fact that technical words have a standard, normative meaning means that it is possible to make a principled distinction between experts who have a complete, correct understanding and laypeople who have an incomplete understanding. Within recent philosophy of mind, it has been a widespread view that if a layperson is willing to defer to an expert’s correct understanding of a word, then he possesses the same concept as the expert even though he does not have a complete understanding. Burge expresses this view in an illuminating way when he writes that

…wherever the subject has attained a certain competence in large relevant parts of his language and has assumed a certain general commitment or responsibility to the communal conventions governing the language’s symbols, the expressions the subject uses take on a certain inertia in determining attributions of mental content to him. (Burge 1979, p. 114)

It is only when a person with an incomplete understanding is unwilling to defer to the normative meaning of a word that he should be understood as someone who has chosen to associate the word with his own individual concept that does not correspond to the correct, normative understanding. Deference-willingness is in this sense a precommunicative attitude: laypeople need to have this attitude in the first place in order to be able to possess the same concepts as experts who possess and fully understand the correct, standard concept.

The fact that this point is valid only when the expert-layperson distinction applies has an important implication: from the perspective of a speaker who has a competent understanding, it is often easier to secure a platform of shared concepts by using words with precise application conditions than by using unclear, everyday words that do not have standard, normative definitions. The reason is that audiences normally think they are entitled to understand the latter words in special, idiosyncratic ways if there is no profession that knows what the correct understanding is (Helman 1984; Lupton 1994). More generally, communicators tend to think that they are justified in understanding and using unclear or vague expressions in accordance with how they have learned them in their particular social and cultural contexts, even though they know that other speakers sometimes use them in other ways in other contexts. In such cases the idea of deference-willingness does not apply: Communicators from different contexts will stand face to face and be unwilling to revise their understanding.⁷ But when one of the parties is perceived as being an expert on the application of a word within a given area – e.g. the way students often think of their teachers - the non-expert will normally defer and thereby possess the same concept as the expert.

If one seeks to apply this theory of deference-willingness, the strategy will obviously work only if it is possible to give the audience a sufficient understanding and if the audience is really willing to defer. The latter condition is particularly important. Even if there are standard application conditions for a term, this does not help if the audience thinks of the speaker as a strict authority and consequently does not defer to his explanations. From the perspective of a speaker with a competent understanding who faces an audience who does not have a complete understanding, it is therefore necessary to create a situation where the audience feels comfortable deferring to the normative meaning in order to secure a platform of shared concepts. Furthermore, it is reasonable to assume that this aim is easier to achieve face-to-face than interactively. Often a simple smile, a friendly gesture or other form of body language is sufficient for creating an atmosphere in which audiences think of speakers not only as experts, but as sympathetic experts. In this deep philosophical sense, it is easier to secure communication of concepts in face-to-face relations than in interactive relations.

6. Further implications

So far I have focused on implications of the first communication condition (i), but as emphasized above, meeting (i) can only be a necessary condition for meeting the three further conditions (ii)-(iv). When I claim that two persons must understand a language in the same way, what I mean is that they must understand it in the same way in general. Obviously, when a speaker does not have the attention of an audience, speaker and audience do not understand the language act that is performed in the same way there and then. What the second communication condition (ii) was meant to capture is the idea that in order for the communication of a belief to succeed, the attention of the audience is needed in addition to a shared platform of concepts.
Is (ii) a condition that is relevant in both face-to-face and interactive communication in the way (i) is? It is since speakers always need the attention of their audience in order to be able to communicate beliefs and thoughts. The differences between the two forms of communication do not matter; (ii) represents a fundamental communicative aim both in face-to-face and in interactive communication.

At the same time there is an obvious difference between face-to-face and interactive communication: it is much easier to secure the attention of an audience in the former than in the latter. After all, speakers are normally able to see whether they have the attention of their audience, and it is also easier for them to understand how to proceed in order to secure attention. Again, this does not apply without exception. Audiences might ostensibly understand and internalize what a speaker says but nevertheless make it clear later that they have not formed the beliefs that speakers intend to communicate. Causes can be states of shock or stress but also, less dramatically, lack of genuine attention or problems of concentration.

It is equally evident that the third communication condition that focused on associate misunderstandings applies in both face-to-face and interactive communication. Both forms of communication can involve audiences who associate a message with beliefs and thoughts that are radically different from the beliefs and thoughts that a speaker has. Whether or not the communicators observe each other is not crucial for this. An audience who hears a speaker over the phone might ascribe to the speaker beliefs that the speaker does not have, even though the audience understands what is literally expressed by the sentence in question, as the above ‘The ambulance is on its way’ case clearly illustrated. But this case could also be redescribed to show how a similar misunderstanding could occur face-to-face. Imagine for instance a doctor who tells a patient who has been hospitalized for some time that ‘Your condition has really improved’. The patient takes this to mean that the doctor thinks that he will be able to leave the hospital within a few days, he becomes frustrated when this turn out to not happen, and we might even imagine that he tells relatives that the doctor gave him false expectations. The problem, we may assume, is that doctor does not associate the belief that the patient’s condition has improved with the belief that the patient should be sent home within a few days. He does not mean to commit himself to this or any other specific interpretation of ‘improved condition’.⁸

Even though these two cases clearly show that associate misunderstandings can occur both in face-to-face and interactive interaction, they also suggest an argument for the view that they more often occur in the former than the latter. When doctors in situations like the above utter sentences like ‘Your condition has really improved’, it is not unusual for patients to ask ‘Does this mean that I will be able to go home soon?’ if they are concerned about this. There is typically more of an atmosphere of dialogue and conversation in face-to-face communication, and this often causes audiences to clarify their own perspectives and make inquires about the speaker’s beliefs. In fact, communicators’ overall communicative aim is often to clarify their own perspectives and the perspectives of the persons they are talking to. Associate misunderstandings typically occur when the situation is hectic, or when there is for some other reason poor dialogue about different aspects of the issue of discourse. In interactive communication, the problem is often that it takes a lot of time to clarify one’s own perspective extensively.

The same point applies in connection with the last communication condition (iv), which focused on incorrect ascriptions of experiences and values, but now communicators face an additional challenge that makes observation even more significant. On the phone or via radio a person’s subjective states can only be presented as descriptions or single words that express these states. Everything depends on the interpretation that the audience makes; the language that is heard on the phone or seen on the screen is the only interpretative clue. An observable communicative context, on the other hand, will often provide vital clues to the nature of an underlying experience. An adequate understanding of a pain state will normally be easier to achieve in face-to-face encounters because a person’s body language tends to reveal intrinsic aspects of the state.

As long as a person’s immediate surroundings provide important clues to his social and cultural background a similar point applies when values are communicated. Our personal values, the activities we like to participate in and the complex ways we wish to live our lives, are first and foremost accessible by observations of how we actually choose to live our lives in the contexts we are in. In this sense similarities and differences in values are often easier to detect face-to-face than interactively, and incorrect attributions of values do not occur so easily.

There is a further even more fundamental difference between the fourth and the first three communication conditions. The first three focus on conditions for communication of concept-involving prepositional attitudes like beliefs and thoughts. This means that they are subject to the aim of understanding as a ‘fusion of horizon’, the idea that fundamental understanding is a matter of speaker and audience sharing subjective states involving the same concepts. (Gadamer 1975, 1994; Mueller-Vollmer 1986; Green 2000). A speaker and an audience who share many of the same beliefs have cognitive horizons that are much more similar than communicators who do not have many of the same beliefs. From the perspective of a speaker, the practical implications of this idea that a fusion of horizons should be regarded as an aim of understanding can be formulated as three action-guiding questions: corresponding to the first communication condition (i), does the audience have an understanding of the language I use that is sufficiently similar to my own understanding? Corresponding to the second condition (ii), do I have the genuine attention of the audience? And corresponding to the third (iii), is it reasonable to think that the audience will associate the belief that I express literally in language with other beliefs that are radically different from the beliefs I have?

It is important to recognize that since the fourth condition does not focus on conceptual states a similar question related to the idea of a shared horizon cannot be formulated. An experiential state like pain does not involve concepts that can be shared with another person. Of course, if a person reports ‘I am in pain’, and if an interpreter takes this to mean that the person is in pain, then they share the concept pain. But as emphasized above, this is not the same as sharing the state of pain. Similarly with values; a speaker might appreciate living his life in a certain way and attempt to communicate this value to an audience by using a particular sentence. The audience might associate this sentence with the same concepts as the speaker, but this does not mean that they share the same value. In order to understand what the underlying value is, the audience needs to take a further step and identify the value state that lies beneath the surface of language. A misunderstanding of the fourth kind occurs when this attempt fails. The question a speaker needs to ask in order to prevent misunderstandings of this kind is therefore this: Have I correctly understood the values of my audience, and is there a chance that I will be ascribed values that I do not have?

This question about values should be sharply distinguished from the question of whether a person expresses a true or false subjective state. A belief is subject to rational discussion about truth and falsity; if someone thinks that a person has a false belief, he can rationally try to show the person that the proposition he believes in is false. Since values are attitudes to activities and not propositions, they are not subject to similar questions about objectivity. If someone wants to influence or change another person’s values, the only rational way of doing so is to go beneath them, to locate possible beliefs and thoughts they are grounded in. For instance, I appreciate drinking a lot of coffee. This is an everyday personal value I have, but I would not have it if I formed the belief that drinking a lot of coffee is very unhealthy. So, if a person I consider to be a medical expert explained to me that me my activity is very unhealthy, then I would probably form this belief, and I would no longer have my value.

It is therefore sometimes possible to change a person’s values by identifying unjustified beliefs that support them. The problem arises only if we think that a person’s values are equivalent to beliefs and thoughts and consequently attempts to show the person that his values are not ‘objectively correct’. A person who is subject to such a criticism will typically feel that we are encroaching on a private sphere that we are not entitled to enter; the person has already an implicit grasp of the nature of personal values as subjective states that we have an individual right to form.

A further discussion of this issue would fall outside the scope of this article, but I think it has been important to make it clear exactly why successful communication presupposes that communicators, implicitly or explicitly, are able to distinguish beliefs and thoughts from personal values. A fundamental identification of a person’s values is often crucial for successful communication, regardless whether or not we want to change these values.

7. Conclusion

By using examples from paramedic-patient interaction within a theoretical framework from philosophy of mind and language, I have tried to explain how the idea of communication conditions can be used to analyze communication. In doing so I have made a distinction between four fundamental conditions. The first focuses on the idea of a shared language, the second on communicative attention, the third on the way we associate beliefs with other beliefs, and the fourth on subjective states like experiences and values that do not have a conceptual, propositional content.

I have argued that these four conditions constitute fundamental communicative aims both face-to-face and in interactive communication. At the same time they suggest different strategies for how these aims should be achieved within the two realms of communication. The fact that the four conditions cover both forms of communication constitutes a fundamental justification for adopting these strategies in face-to-face and interactive interaction. This does not mean that the conditions imply that it is easier to secure successful face-to-face communication than it is to secure interactive communication. Obviously, it is natural to assume that it is often easier to achieve the former than the latter (but there are some obvious exceptions), but the question of whether this really is so remains a further question. My aim has been to develop a plausible framework for addressing this and other normative questions related to face-to-face and interactive communication.

In addition to this instrumental justification for applying the communication conditions, .I think it is important to recognize a further argument. It is sometimes held that an instrumental justification of a theory must be essentially incomplete, since it is possible for an instrumental theory to be false (Dennett 1978). But in this context I do not think this is a genuine possibility. Philosophical theories of communication are after all meant to capture ordinary discourse - it is standardly assumed that whether they do or not is what makes them true or false - so in this case the fact that the conditions match our communicative practices constitutes a good reason for holding that they are true. Too often philosophical theories of communication are developed in isolation from areas of application, even though it is claimed that they are grounded in common sense. What I have tried to show is that the four communication conditions are really grounded in ordinary communicative practices.

Finally, I would like to make it clear that it has not been possible to discuss in detail the practical consequences of the analyses I have made within the limits of this article. The aim has been to develop and clarify some fundamental philosophical distinctions and to point out some reasonable implications of these distinctions. However, more empirical research is necessary to explore these implications further. What I have offered is a framework for doing such research, but this is a framework that in itself should be modified and developed further on the basis of such research.

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¹ An important motivation for providing information about the patient’s condition is that the paramedics can prepare themselves mentally and in practical terms for the situation that awaits them.

² It is in general a sound methodological principle that issues of understanding and communication are not subject to questions about normativity in the way questions of truth and knowledge are.

³ I am grateful to an anonymous referee for this journal for pointing out that this objection needs to be addressed.

⁴ As emphasized above, this can be an understanding that the audience thinks is correct in general but also an understanding that is employed for communicative purposes. The important point is that the understanding that the audience employs must approximate the speaker’s understanding.

⁵ When the condition of a patient is perceived as not being acute the ambulance is not required to adopt ‘code one’ which is the code for acute situations, and it might take some time before it arrives (but outside central areas it might take some time even if the code is ‘code one’).

⁶ A meaning explanation is here understood as the explanation a speaker would give if he was asked to explain what a word applies to. Meaning explanations are very seldom conceived of as complete descriptions of what a word means; we do not consider them as sentences that capture the whole meaning of the term we are asked to explain. They are rather statements that capture central aspects of a word’s meaning. Compare, for instance, the explanation ‘The word ‘dog’ applies to a group of mammals with four legs’ with the explanation ‘ The word ‘dog’ applies to an animal my grandmother has’. Only the first statement is normally conceived of as a meaning explanation.

⁷ Consider again a doctor who tells a patient that he has not been able to locate any underlying disease. The patient, we might suppose, thinks that he must have a disease, and thinks that the doctor has a very narrow understanding of ‘disease’. An important part of the reason why such an attitude is widespread is that the patient thinks that he is entitled to use ‘disease’ in the way he has learned the word in his special social and cultural context. This point generalizes to countless words with non-standard application conditions.

⁸ This kind of misunderstanding is sometimes displayed in newspapers, under headlines like
‘The doctor gave me six months to live’. One should be skeptical about the idea that doctors very often state predictions in such a bold way. In fact, what has often been stated is something much weaker (‘There is a significant possibility that…’), but patients often associate these statements with stronger claims. This is a general phenomenon that most professionals involved in interaction with various forms of clients or patients should be aware of: we tend to forget qualifications like ‘significant possibility’ after a while, and we think of claims that have been made as much stronger than what they in reality were.