Speech Acts in Chinese Doctor-Patient Arguments*

Yanjin Chen

Abstract. Different from the doctor-patient arguments in western society,the disagreements between doctors and patients in China partly come from the special types of speech acts in doctor-patient arguments.Firstly,this paper focuses on the large number of metaphorical words contained in Theory of Traditional Chinese Medicine (TCM).Secondly,the speech acts frequently used by Chinese patients are discussed,including indirect speech acts and metaphorizing speech acts.Thirdly,the fact that TCM doctors with professional medical knowledge may also use metaphorizing speech acts is illustrated,and the four main forms are clarified consequently.Finally,the differences between metaphorizing speech act and indirect speech act in the context of Chinese doctor-patient communication are pointed out.

1 Introduction

In the current western argumentation theory,the argumentative practices of doctor-patient in medical field have attracted more attention and gradually developed into a more mature branch of argumentation research.For example,there are some works discussing the institutional preconditions of argumentative practices followed by doctors ([20,7]),highlighting the role of effective argumentation for enhancing self-management abilities of elderly patients’ suffering from chronic diseases ([1]),illuminating the utility of argumentation in communication related to public health([8]),showing the reasonableness of doctor’s argument by authority([15,16]).Moreover,arguments if studied from the perspective of speech act,advice-giving is considered as the most important speech act in doctor-patient conversation,in addition to investigating the argumentative functions in the process of joint decision-making([21]).

Generally speaking,a common substantive starting point adopted by these studies is:as an institutional activity closely related to people’s life and health,the language of doctor-patient communication often avoids ambiguity and strives for accuracy.Based on the positive scientific language of modern western medicine,both doctors and patients use referential terms that can clearly refer to specific substances or phenomena as much as possible.However,the situation of doctor-patient communication in China does not seem to be so.A very typical phenomenon is that in the internal medicine consulting room,for the question of“how do you feel recently”given by doctors of western medicine,Chinese patients will answer with sentences such as “I’ve suffered fromshang-huo(上火) recently” or “I feel a littleshi-re(濕熱)”.

Obviously,both“shang-huo”and“shi-re”used by Chinese patients are not based on the naturalistic explanations such as“the fire is lit up”or“the body is wet and hot”.Therefore,these two words are not referential,but metaphorical.In fact,we can know from simple medical knowledge that these are traditional Chinese medicine terms which are obviously different from modern western medicine.Meanwhile,this kind of phenomena also mean that referential western medicine terms and non-referential traditional Chinese medicine terms are mixed used in doctor-patient communication.From the perspective of research of argumentative practices,the mixed use of these two kinds of medical terms will not only make Chinese doctors and patients face difficulties in meaning expression and meaning understanding in the process of communication,but also activate a variety of argumentative patterns based on different views of disease,diagnosis,treatment and life.

In view of this point,from the perspective of speech act,this paper will discuss the problem of mixed use of Chinese medical language and Western medical language in doctor-patient communication in China,especially clarify the characteristics of metaphorizing speech act based on traditional Chinese medicine theory,in order to provide a philosophical basis for revealing the generation mechanism of different opinions of doctor-patient communication in China.

2 Metaphorical Words Based on TCM Theory

The mixed-usage of Chinese medical language and western medical language shows that traditional Chinese medicine theory and modern western medicine(MWM)theory coexist in the doctor-patient communication in Chinese clinic.The MWM theory uses empirical scientific language and the phenomenon can be verified on experience level,while the TCM theory contains a large number of metaphorical words,and the expressed meaning is interpretative and not positivistic ([13],p.8).The typical terms such as sixyin(六淫),sevenqing(七情)of etiology,zheng-xie-sheng-fu(正邪勝負),shang-re-xia-han(上熱下寒)andbiao-han-li-re(表寒里熱)of pathogenesis,fourqiand fivewei(四氣五味)of pharmacology,andjun,cheng,zuo,shi(君,臣,佐,使)of formulaology all use metaphorical words([4,5]).

It is generally considered that there are three types of metaphors in Chinese medicine language.The first type is orientation metaphor,e.g.,bothbiao-zheng(表證) andli-zheng(里證) are metaphorical words pointing at the spatial orientations like “exterior” and “interior”.The second type is entity metaphor,which includes the intangible concepts such as abstract and vague thoughts,feelings,psychologi-cal activities,events or states,all of which are regarded as concrete and tangible entities,which can be identified,described,interpreted or quantified.For example,the physical difference of two persons can be interpreted as the difference of two trees.The third type is structural metaphor,i.e.,some concepts with vague definitions and a fuzzy structure (or with no structure) are explained by other words which offer a proper definition and have a clear structure.For example,the relationship among fivezang-organs and sixfu-organs(五臟六腑)is interpreted by five elements includingshui(水),huo(火),mu(木),jin(金),andtu(土)([3,4]).

In TCM theory,the meaning of these metaphorical words is not equal to the meaning directly stated on physical level.Based on metaphorical cognition,one phenomenon(or mechanism)of interpretation of disease in TCM field is realized by describing another empirical phenomenon(or process)in nature([5]).For example,han(寒)is a high-frequency word in Chinese,whose literal meaning is“cold”.However,as a typical metaphorical word in the TCM theory,handoes not describe a certain natural climate state on physical level.As a matter of fact,it refers to certain physiological symptoms,or the relevant etiology/pathology.On the one hand,hanrefers to these symptoms,including severe chills?headache and body pain?no sweat?floating and tense pulse or coldness of body and limbs?no thirst or thirst for a hot drink?quietness with few words?copious and clear urine?loose stool?slow and sunken pulse.On the other hand,with respect to etiology and pathology,hanrefers to characteristics like coagulation and retardation.It is a pathogenic factor with contractile and tractive functions,which may destroy the dynamic balance betweenyin(陰)andyang(陽)of human body and impede circulation ofqi-xue(氣血),weaken the functions of fivezang-organs and sixfu-organs,and ultimately cause various diseases([24]).Therefore,in the Chinese context of medical consultation,identifying metaphorical words and interpreting their meaning are the key steps to implement the practical research of doctor-patient arguments.

3 Two Types of Speech Acts Used by Chinese Patients

Although most doctor-patient dialogues take the form of continuous questionanswer turns and there are rare distinctive argumentative activities,Chinese patients often use the following two kinds of speech acts to express their real opinions.

Firstly,Chinese patients use direct speech acts and further realize indirect speech acts.They often use closed alternative or tag questions,such as“Can I(not)+verb phrase (VP)?”.Here is a discourse of some Chinese patient recorded from a Firstclass Hospital at Grade 3 in Guangzhou:

Patient P1 asks doctor D:“Can I not be hospitalized?”? “Can I go back to one local hospital for getting an injection?”

This patient has used interrogative sentences to ask questions in order to seek information about her illness,but in fact she displays her psychological state which shows her unwillingness for hospitalization as suggested by the doctor D.By saying“I (don’t) want to+VP”,the patient wants to ask the doctor whether there is any possibility of an alternative prescription.The direct speech act of this patient is that of an enquiry,while the indirect speech act i.e.,request has more significance in this case,as it reflects the patient’s psychological state.

Such a manner used by Chinese patients is highly constrained by the sociocultural context.As these patients probably do not have faith in their doctors,they tend to adopt the role of arguers to express their doubts or objections.Meanwhile,these patients also adopt the role of communicators in the absence of medical resources and hence refrain from using directives such as command,order,request,or suggestion.They prefer to be polite and respectful to keep up with the social public standards and hence acknowledge the authority of their doctors.In Chinese,the usage of “Can I (not)+VP” of yes-or-no questions is generally understood as:the polite questioners have a negative tendency.On the one hand,Chinese patients question the doctors to clear their doubts in the hope of getting medical advice with respect to the feasibility of(not)implementing VP.On the other hand,the patients communicate in a discursive manner([10]),suggesting their own opinion which they are not sure of themselves.They consult the doctors in hope of getting an alternative treatment plan and indirectly express intention that “I (don’t) want to adopt this treatment plan”,anticipating that the doctor considers their request and hoping that he/she provides another option.

It is evident that the Chinese patients adopt request as an indirect and primary speech act whereasenquiryas a direct and secondary speech act.Accordingly to the Theory of Indirect Speech Act([19]),it can be known that:(1)the propositional condition for patients’speech acts of“Can I(not)+VP”is that the expected situation of“(not)to+VP”does not occur at the time of questioning?(2)the illocutionary point of these speech acts is to request doctors to confirm the possibility of“(not)adopting the previous treatment plan”?(3)the direction of fit between words and world of these speech acts is to make the final treatment plan suitable for the situation of“(not)+VP”.

Secondly,Chinese patients embed metaphorizing speech acts([11])1In language communication,speakers use metaphors to express their discourse meaning,implement certain speech acts,and directly or indirectly complete some relevant speech act force.into direct speech acts.While describing symptoms,they often use both direct speech acts and metaphorizing speech acts,viz.,embedding metaphors into assertive sentences.The metaphorizing speech acts used by Chinese patients usually include the following indicators:shang-huo(上火),re-qi(熱氣),han(寒),re(熱),shi(濕),xu(虛),andtiao-li(調(diào)理).For example,Chinese patients usually express these complaints:“I have felt somewhatre-qirecently”? “Am I toohan?”? “Maybe my body is a bit ofxu.”From the perspective of cognition,it can be concluded that Chinese patients often use metaphorizing speech acts unconsciously,i.e.,these patients do not realize that they are just interpreting their symptoms,rather than providing an accuratedescription.2In this situation,TCM doctors often believe that this is likely to result in a distorted explanation of their patients,so it is necessary to make a refutation.But obviously,when using indirect speech acts,Chinese patients can clearly realize that they are trying to express some implied meanings,so as to achieve the corresponding perlocutions.

4 Metaphorizing Speech Acts Adopted by Chinese Doctors

Through a secondary analysis based on the existing database(2012-2015)which is provided by the Project of Logical and Cognitive Mechanisms and Computer Simulation in the Cross-Cultural Interaction in Sun Yat-sen University,I also notice a very significant communication phenomenon.Not only Chinese patients use metaphorizing speech acts,but also Chinese doctors with higher medical professional level use this type of speech acts.It is mainly reflected in the following four aspects:

4.1 Clarification of TCM terms

TCM doctors use differentiating strategy ([14]) to point out that “Concept A of TCM is not the concept B of MWM”,so as to point out the differences between these two theories of medicine.For example,one TCM doctor clarifies that“l(fā)iver”in MWM and“gan”in TCM are not the same concept.From the perspective of TCM,“Ganis the mu in the East”.The concept ofganbelongs to one of the fivezangorgans(i.e.,gan,xin,pi,feiandshen)in Zang Xiang Theory(also known as Visceral Manifestation Theory),andganis a metaphorical concept established onmu.In other words,according to the characteristics ofmuof five elements,the physiological characteristics and pathological changes ofgancan be explained,and the characteristics ofmuare growing,rising,comfortable and unlimited.According to the similarity of these two concepts,the TCM theory holds that“Ganlikes the unlimited state and hates the depressed state”([2]).

It should be noted that the so-called“gan”in Chinese medicine is different from“l(fā)iver” in western medicine.This metaphorical term of TCM does not refer to an organ entity,but the functional system ofgan.Similarly,according to the MWM Theory,lungs are a part of the respiratory system,and large intestine is a part of the digestive system.However,in the TCM Theory,lungs and large intestine share the same properties and functions,and both belong to the functional system offei([26]).Therefore,when a doctor from the perspective of TCM emphasizes that “Concept A of TCM is not concept B of MWM”,he/she factually refers to the metaphorical concept,i.e.,A refers to a certain functional system (e.g.,the functional system ofgan),which is different from the object denoted by the substantive concept B(e.g.,gan-organ).

4.2 Criteria integration between TCM and MWM

TCM doctors at the time of diagnosis integrate the criteria of TCM and MWM,i.e.,they try to explain the functional disorder ofzang-organ in the TCM framework by using various parameters for examining certain organs of the MWM theory.The following text provided by a TCM doctor is a discussion on the integrated use of diagnostic criteria taken from TCM and MWM:

The experimental parameters of syndromes in five zang-organs are non-specific.Each syndrome type ofzang-organs involves the changes of multiple systems and multiple parameters.The essence of eachzangorgan almost involves the physiological and pathological phenomena of multiple systems,multiple organs and multiple parameters,which are related to neuroendocrine,immunization,circulation,sensation,blood,and so forth.…There are some overlap among the neuroendocrine systems,immune systems and other systems ofzang-organs.The functional interactions of fivezang-organs are generated through the structural connections within a singular system.Meanwhile,through the transmission of common transmitters,hormones,cytokines and other signal molecules among different systems,the various systems and organ cells of human body are mutually regulated and integrated at multiple levels.And all the physiological and pathological phenomena of human body are the results of macro-integration based on micro dynamic changes([27]).

TCM doctors who adopt an integrated approach by considering various criteria from TCM and MWM believe that the function of a certainzang-organ of TCM system usually involves many organs as per the modern anatomical physiology of the west,and the symptoms associated with a certainzang-organ also indicate functional as well as structural changes in multiple organs and organ systems.So,it is not necessary that a certainzang-organ syndrome as per the TCM system bears relationship with an abnormal parameter as per the MWM system,and a single parameter of MWM system cannot thoroughly reflect the syndrome characteristics of a certainzang-organ.For example,the liver examination parameter such as “transaminase”cannot thoroughly reflect the syndromes of functional system of gan(ibid.).

4.3 Diagnosis of disease

In Chinese clinics,the“disease”discussed by doctors of Chinese medicine mainly refers to the syndromes of fivezang-organs and six fu-organs.For explaining the occurrence and development mechanism of diseases,Chinese medicine language makes use of many structural metaphors originated from war,as shown in Table 1([23]).As in a war,there are two parties,i.e.,an attacking party and a defending party.Similarly,with respect to a particular disease,there exists a fighting process betweenzhengqi(正氣) andxie-qi(邪氣) in human body (which may involve multiple pathogenic factors or physiological functions,such asqi-xueandjin-ye).

Table 1 .Disease:Metaphorical Concepts based on War

The TCM doctors provide explanations on diseases by using war metaphors and believe that the human body resists pathogens(e.g.,xie-qi)as in a war like situation,when they enter the body.Like in a contest betweenzheng-qiandxie-qi,there would be a fall of energies and shortage of materials and hence an individual will feel uncomfortable and painful.Ifzheng-qiis able to resist the invasion ofxie-qi,then the human body will recover?otherwise,it will lead to death.

4.4 Interpretation of etiology and pathology in TCM theory

TCM doctors use war metaphors to explain the etiology and pathology of diseases for e.g.“battle betweenzhengandxie”,“xiewins andzhengretreats.”The main reason is that the TCM theory proposes to establish a human life system based on the functional model and insubstantial relations,but not the anatomical prototypes and material entities.Meanwhile,TCM theory follows the Chinese philosophical tradition of“Yuan-qiTheory”(元氣論)and“Harmony between Man and Nature”(天人合一),and adopts an integrated approach for interpreting life.The explanation with respect to etiology and pathology based on TCM theory mainly involves the causes and mechanisms of occurrence of diseases and their development.The above explanation is based on the Theory of Yin-Yang and Five Elements(陰陽五行理論)and Theory of Jing-Qi (精氣學(xué)說),Foundation Theory of Zang-Fu Organs,Theory of Meridians and Theory of Qi-Xue and Jin-Ye (臟腑經(jīng)絡(luò)及氣血津液理論).Accordingly,the TCM doctors explore the pathogenic factors,illustrate pathological changes and material basis of the occurrence and development of diseases and their relationship with varied pathogens,so as to reveal the mechanism of occurrence,development,evolution and outcome of disease([23,26]).

The TCM doctors who use such a method for interpretation think thatzhengqi(i.e.,the disease-resistant ability)andxie-qi(i.e.,the external pathogenic factors)are the major aspects pertaining to diseases.Zheng-qi includes many physiological substances(e.g.,qi,xue,jingandye)with relevant functions for maintenance of human life,whilexie-qiincludes six-yin(i.e.,feng,han,shu,shi,zaoandhuo) and epidemic pathogens.In the process of disease development,ifzheng-qiis sufficient andxie-qiis weak,thenzheng-qiwill cause retardation ofxie-qiand hence the disease will be quickly controlled,and the body will be able to recover soon? ifzheng-qiis insufficient andxie-qiis abundant,thenxie-qiwill invade into thezang-organs and fu-organs,thus leading to worsening of the disease and poor prognosis,or may even lead to death?if bothzheng-qiandxie-qiare strong,then disease will be more acute with severe pathological reactions?if bothzheng-qiandxie-qiare weak,then it is easy to mitigate the pathological reaction,and the body will enter a weak state of chronic disease([23]).

5 Differences between Metaphorizing Speech Act and Indirect Speech Act

One of the prominent features of metaphorizing speech acts is that the utterance meaning (UM) of these speech acts cannot be directly interpreted according to the sentence meaning(SM).Consider a typical diagnosis in database:

For some uncomfortable symptoms of patientP1,who is diagnosed as suffering from“jaundice”as per TCM and the etiological explanation provided is that the patient is“invaded byshi-xie”,on the condition that the patientP1shows invasion byshi-re.This diagnosis obviously differs from the diagnosis carried as per MWM.The diagnosis for the patientP1’s disease according to MWM is “hepatitis B”,and the etiological explanation is that the patient is“infected with hepatitis B virus.”This explanation is based on the detection of hepatitis B virus surface antigen and e-antigen inP1’s blood.The details have been illustrated in Table 2 ([5]).In essence,“shire”from the perspective of TCM theory is borrowed from daily language,i.e.,it is a metaphorical concept,which uses the humid and hot climate state in nature to describe the condition of human body.Andshi-xie(established on the property ofshi-re)is one of the six pathogenic factors,which are also represented by metaphorical concepts.However,the diagnosis and the etiological explanation from the perspective of MWM theory is significantly dependent on the observable test data for e.g.,parameters of surface antigen or e-antigen.

Table 2 .Disease Diagnosis and Etiological Interpretation of certain Discomfort Symptoms

The basis of the disease diagnosis and its etiological explanation as per the TCM theory are the key symptoms,which are associated with the disease and pathological changes caused by the following factors for e.g.,states ofqistagnation,xuestasis,food stagnation,yindeficiency andqideficiency.The purpose of TCM theory is not to find an initial cause of the disease in a causal chain,but to identify the properties of the disease or the diseased condition as a result of complex reactions within the human body.While on the contrary,the“Law of Causality”in the theory of MWM can be explained by the concept of“mechanism”in reference to biological neurology and molecular biology.The mechanism takes into account entities and activities responsible for generation of certain changes in the human body.Only when one entity is in a derivative activity,can it be called“cause”.For example,the antibiotic penicillin is used for treating pneumonia and the disease disappears because of it.The purpose of diagnosis of a disease as per MWM is to locate specific organs,which are associated with the symptoms from biological and anatomical perspective([12,27]).

From the perspective of perlocutionary effect,the metaphorizing speech acts used by TCM doctors enable the patients know the complex state of dysfunctions of the multiple systems,and they expect doctors to issue prescriptions for tiao-li that can increase the disease-resistant ability or adaptive ability of the human body.The concept oftiao-lirefers to recuperating body constitution.According to the TCM theory,“body constitution”is characterized by certain features like relative stability and dynamic changeability.If there is any kind of disequilibrium in the state,e.g.,qi-deficiency oryin-deficiency,then the human body starts to show certain functional disorders,finally leading to a diseased state.Through regulation of proper balance in the body constitution and enabling efficient overall function,the therapeutic purpose of TCM can be achieved as a result.In such a situation,the Chinese patients are neither aware of the material basis or chemical composition of disease,nor reveal whether or not they accept doctors’ prescription by confirming whether some chemical property of drug is consistent with that of disease([25]).

It should be noted that metaphorical speech acts differ from indirect speech acts.([19]) Neither of them conveys information regarding discourse of the disease,but rather indicate one speaker’s UM through SM.For instance,when a TCM doctor uses a metaphorizing speech act and says to his patient having jaundice,“You are veryshi-re”,he indirectly refers to the increased metabolic activity(hyperactivity)which means that the reaction ofzang-fuorgans is enhanced? and there is a state of disequilibrium in functioning ofyinandyang,thus resulting in symptoms such as fever,red face,red eyes,dry mouth,dysphoria,and yellow coating on the tongue.When a Chinese patient asks her TCM doctor if she cannot take antihypertensive drugs,she wants to indirectly express UM,i.e.,make a request that “please do not prescribe those drugs”.So,let us analyze the differences between these two speech acts.

Firstly,the degree of separation between SM and UM is different.The UM of metaphorizing speech acts is completely separated from SM,but there is still a connection between SM and UM in indirect speech acts.([19],p.123)For the metaphorizing speech act used by the above TCM doctor,UM at the level of human body is completely separated from SM at the level of natural weather.However,for the indirect speech act used by that patient,there is still a connection between the SM(i.e.,directly expressed in interrogative form)and the UM,which is indirectly expressed as an imperative sentence.

Secondly,the separation results between SM and UM of these two speech acts are different.In metaphorizing speech acts,the meaning of UM is totally different from that of SM.For the metaphorizing speech acts used by TCM doctors(e.g.,“You are veryshi-re”),there is only UM,but not SM on the level of natural climate.The reason is that there is obvious conflict between SM and the doctor-patient communication in context of TCM clinic.However,there is still a connection between UM and SM in indirect speech acts.For the question about prescription of antihypertensive drugs mentioned above,suppose the TCM doctor answers“Yes”.As a direct speech act,this answer means that there is the possibility of not prescribing antihypertensive drugs.But in the context of medical consultation,this answer is not only a direct response about his ability,but also expressing an acceptance of patient’s imperative speech act,which means“I can make a prescription without using antihypertensive drugs”.Thus,there is still a correlation between the separated UM and the original SM.

According to the viewpoints of Searle ([17,18,19]),when implementing an indirect speech act,one speaker means not only what he says,but also more than that.For the utterance that“Can I(not)+VP”,the meaning of this sentence includes two aspects:(1) the SM which is expressed by the direct speech act ofenquiry? (2) the UM which is implied by the indirect speech act ofrequest.Apparently,the patient’s purpose of saying such a sentence is to ask doctor(not)to VP(e.g.,not to prescribe antihypertensive drugs),rather than enquiring if he has this ability.In other words,the illocutionary acts of this sentence can be interpreted from two aspects:one is a direct speech act,and the other is an indirect speech act.The two acts appear together,but the illocutionary force of this sentence mainly lies in the indirect speech act.Therefore,the direct speech act is only asecondary illocutionary act,and the indirect speech act which implies UM is theprimary illocutionary act.Meanwhile,the realization of indirect speech act depends on the use of direct speech act.

Thirdly,the semantic ranges of UM and SM involved by these two speech acts are different.The metaphorizing speech acts involve two different semantic fields,while the indirect speech acts are carried out within the same semantic range([22]).As one of the most important criteria for identifying metaphor is that the tenor and the vehicle should belong to different fields respectively,and the essence of metaphor is that“understanding and experiencing one kind of thing in terms of another”([9]).Therefore,metaphorizing speech acts connect two different semantic fields through similarity.In context of TCM consultation,the semantic field of UM in metaphorical speech acts (e.g.,han) is based on the explanation of physical symptoms,etiology and pathology as per TCM theory,rather than on empirical description of natural phenomena.

6 Conclusion

This paper reveals the important argumentative characteristics of Chinese doctorpatient communication from the perspective of speech act.As an important institutional activity related to personal quality of life and health,doctor-patient dialogue is not entirely composed of explicit direct speech acts.On the one hand,ordinary patients not only implement indirect speech acts according to the politeness principle,but also often use metaphorizing speech acts to state their state of illness.On the other hand,Chinese doctors with professional medical knowledge (mainly the doctors of Chinese medicine) also use a large number of metaphorizing speech acts based on TCM theory in the process of referring to an organ,describing a symptom or explaining the relevant etiology and pathogenesis.The mixed use of these two speech acts and direct speech acts not only restricts the meaning-understanding and intentionexpressing of Chinese doctors and patients,but also further leads to the emergence and intensification of differences of opinion between the two sides.Furthermore,I will take the perspective of Generalized Argumentation([6])and discuss the doctorpatient argumentative patterns in future studies.