Discuss the advantages of using Habermas’ theory of communicative action (see Walseth & Schei,

2011) as a way of taking a lifeworld-led approach to doctor-patient communication. Use examples

from research to illustrate your answer.

Habermas’ theory of communicative action is one of his best-known ideas in which individuals in
society seek to reach common understanding and to coordinate actions by reasoned argument,
consensus, and cooperation rather than strategic action strictly in pursuit of their own goals (Bolton,
2005).

Society has to be regulated by a result-oriented rationality inherent in laws, rules and market.
However, Habermas claims that in decisions concerning human beings, a lifeworld perspective is
essential. Communicative rationality occurs when a statement or decision is justified through
reference either to factual empirical conditions, or to a culturally accepted norm, or to subjective
emotions. Furthermore, Habermas’ theory of communicative action is based on the assumption that
we reach a greater insight in matters concerning ourselves and the world around us by using
language, presenting arguments, justifying statements, asking and answering questions. Habermas
argues convincingly that communicative rationality is highly relevant in matters concerning human
relationships, ethics, and personal decision-making. The theory of communicative action offers a
concrete outline of a procedure for how to construct a conversation that observes the rules and
norms of communicative rationality.

For communicative rationality to occur, decisions have to be rooted in the participants’ lifeworld, a
term derived from Husserl. The lifeworld is the frame of a human being’s lived life, a horizon of
‘‘taken-for-granted’’ knowledge, norms and expectations. When people share the same ‘‘taken-for-
granted’’ knowledge, cultures are shaped. A person is to be understood, not by ‘‘looking inside’’ (so
to speak), but by getting as full a view of their subjective lifeworld as possible. This is true whether
the person to be understood is myself* reflecting on my own lifeworld*or the person to be
understood is someone other than me.

A common lifeworld functions as a link between the individual and the social community he or she
belongs to. Habermas elaborates this further and describes three different dimensions of lifeworld—
the objective, the social and the subjective ‘‘worlds’’. The objective world contains knowledge that
can be judged ‘‘objectively’’. Empirically based medical knowledge belongs to this world. The doctor
presents how the situation is understood medically, and gives alternatives for further tests,
examinations and treatment. Further, the doctor should map the patient’s objective knowledge
about herself and her situation through concrete questions. The validity criterion for objective
conditions to serve as a basis for decisions is that they are factually true.

The social world concerns the way people relate to others, the rules and norms that govern social
interaction. Finding out about this social world is a way of taking a lifeworld led approach to doctor-
patient communication. While mapping the objective world and the daily schedule of a patient, the
doctor may get an initial picture of the patient’s important relationships. It may be relevant to
investigate the rules that govern behaviour in these relationships. What will happen if the patient
starts to act differently? What do the affected relationships mean for the patient? What does the
patient expect from the other persons and what do they expect from the patient? Are these
expectations realistic, and ethically appropriate? A conversation about such matters can disclose
unreasonable demands and unfortunate patterns. It can also become evident that certain health-
related decisions are not realistic due to the patients’ commitments.

An appropriate understanding of the social world in its uniqueness is often crucial for creating a
common understanding and reach proper decisions. This is crucial in doctor to patient
communication. The criterion of adequacy for decisions rooted in the social world is that they are
perceived as right by the patient. This is a major advantage of using the Habermas’ theory of
communicative action (see Walseth & Schei, 2011) as a way of taking a lifeworld-led approach to
doctor-patient communication.

The subjective world is made up of intentions, thoughts, emotions and wishes. The process of
clarification includes questions and reflections concerning what the patient perceives as good and
desirable, the premises for self-realization. The subjective world is partly revealed through a
persons’ mode of self- expression in dialogues. An objective fact about people is that they have
highly significant social and subjective worlds. These worlds contain knowledge about a patients’
situation, resources and obstacles, but have traditionally not been considered a core source of
medical insight. Investigating these fields involves touching upon sensitive themes, inviting patients
to talk about aspects of life that may be more or less automated, subconscious, or distorted by
shame and stereotypical adaptation to social conventions. This self-expression is an important
element in a lifeworld led approach to doctor-patient communication, and is a major advantage of
using this approach.

An example of this lifeworld-led approach to doctor-patient communication can be given from a

case story constructed about a 49-year-old female called Mary. She is 49 years old, married and has
two children. She experiences prolonged pain in hands and forearms and visits her GP. The pain has
been on and off for several years, with increasing intensity the last 6 months. Examination reveals
arthrosis of the thumbs and tendinitis of both forearms, and the GP offers her a sick leave, NSAIDS
and physiotherapy. Mary asks for a general check-up. She has lately felt more tired and is worried
that she has inherited a risk of heart-disease and diabetes from her parents. It turns out that she has
diabetes, mild hypertension, slightly elevated cholesterol, and is somewhat overweight. Mary is
given extensive information on diabetes and cardiovascular risk factors. The possible health
consequences and advisable lifestyle changes— more physical exercise and a change of diet—are
pointed out to her. Mary eagerly adopts the idea of lifestyle change, in order to avoid medication.
However, after a while it becomes clear that she is unable to carry out her plans. Mary becomes
increasingly discouraged and depressed.

The doctor realises that other strategies are needed to achieve her goals as the previous ones aren’t
working. He goes onto exploring Mary’s subjective lifeworld, by asking her about the rhythms of her
everyday life before and after she got sick, how she felt about her life before and after she became
ill, what the changes in her life mean to her, and in order to explore her social and subjective
lifeworld’s even deeper the doctor asks her about her family and how they are doing. By asking all
these the doctor was able to gain an understanding on Mary’s values and norms, and to explore
these values and norms deeper the doctor searches for reasons underlying Mary’s behaviour by
finding out things such as “what is the background for her priorities”, and “what values and norms
govern her behaviour”.

After speaking about everything, the doctor attempts to approach the situation from different
angles. By carefully reflecting upon and weighing her reasons and asking questions about alternative
solutions, the doctor helps her to gain awareness of the basis for her priorities. Her patterns seem to
contain some elements that may be destructive. Solutions such as feeling tired because of doing too
much housework are faced head on, by getting her husband to help with house hold chores and
getting her husband to change his eating habits. After gradually working on things, her former
feelings of depression and apathy gradually disappear. She then has the courage and energy to try
new things, and she applied for vocational training as she cannot return back to work. Her blood
pressure, weight and blood tests all show positive development.
In this case, the doctor focused on the three dimensions of the lifeworld and searched for reasons to
her behaviour which helped the doctor to discover what Mary considers to be good, right and
practically possible. By this, Mary’s values are made conscious, and a foundation for further
reflections is created, increasing her possibilities for control. By improving the patient’s ability to
judge and reflect on values and preferences, the consultation expands patient autonomy, beyond
simply letting the patient decide (Emanuel and Emanuel 1992).

This helped Mary make decisions that turned out to be good. Of major importance is the very
delicate use of power in a situation of trust and asymmetry; a less sensitive doctor may without
intent force his values on Mary and distort her development. The doctor in this case study did not
coerce Mary to any decision but created a conversation where she gained awareness of being in a
situation where execution of her decisions, and thereby fulfilment of her desires were dependant on
her husband.

The procedure produced a situation where Mary’s everyday life was discussed on a very detailed
level. Through this lifeworld mapping, the physician takes Mary seriously, conveys respect and
strengthens the physician- patient relationship. The doctor’s enduring interest and engagement in
seemingly trivial aspects of the patient’s life contributes to a powerful therapeutic alliance, which
has a strong empowering effect, clearly demonstrated in studies of psychotherapy effects (Wampold
2007). At the same time, a ‘‘practical understanding’’ of the situation is produced through a
reflection focusing on the particulars and the wholeness at the same time (Malterud 1995).

When challenged to help patients adjust to illness or change lifestyle, doctors need to take an active
interest in the patients’ everyday life, and seriously explore the conscious and unconscious
complexity that precedes, constitutes and results from behaviour. A medical dialogue based on
Habermas’ theory of communicative rationality represents a way of giving everyday life a language,
and a powerful access to non-oppressive processes of health- related change. Knowledge of the
theories reflected upon in this article may provide useful tools in medical practice. Medical success
will, however, always depend on the practitioner’s individual understanding of human life, and wise
judgment in deciding how to use this understanding
2. Describe the elements of the lifeworld. How can phenomenological research help us (i) to
understand lived experience of illness and (ii) to use that knowledge to develop lifeworld-led care?
Use examples from research to illustrate your answer.

The “lifeworld” view has emerged from the work of Husserl (1970). Husserl suggested that any
human view of the world without subjectivity has excluded its basic foundation from the beginning.
He articulates our world as textured, embodied and experienced by us and through us. A world of
colours, sparkling stars, memories, happiness, joy, anger and sadness. It is this “lifeworld” that when
health care becomes overly focused on decontextualized goals, victim blaming, and measuring
quality superficially can be neglected or even forgotten leaving us open to the risk of dehumanizing
research and practice.

Eight elements of “lifeworld” have been articulated, through building on Husserl's consideration of
what makes up the human experience of life (Boss, 1979; Heidegger, 1962; Merleau-Ponty, 1962).
These are selfhood, temporality, spatiality, intersubjectivity, embodiment, project, discourse and
mood. They will be considered here individually in relation to how phenomenological research can
help us to understand lived experience of illness and to use that knowledge to develop lifeworld-led
care.

Selfhood: As a fraction of the lifeworld, self-hood is a continual background meaning of our

thoughts, feelings, and behaviour. Selfhood asks what the situation means for social identity; the
person’s sense of agency, and their feeling of their own presence and voice in the situation. Identity
is undeniably part of sociality*our identity links us to others and is provided by interaction with
others.

Sociality/intersubjectivity: We are part of the world and are continuously interacting with it and
others in it. Our capacity for language extends our understanding and shared meanings in our world.
Through intersubjectivity, we locate ourselves meaningfully in our interpersonal world, who am I
close to, who am I worried about, who am I looking forward to seeing? What am I looking forward to
doing? Intersubjectivity also articulates how we are in relation to culture and tradition that impact
on how we view ourselves and others. Forms of intersubjectivity can humanize or dehumanize us
such as kindness or violence and can have a positive or negative impact on our well-being.
Embodiment: Being human, we live within our bodies and we experience the world through them in
a positive or negative way (Merleau-Ponty, 1962). Interestingly, embodiment has been articulated as
a key concept within an ecological perspective on public health (Lang & Rayne, 2001; McLaren &
Hawe, 2005; Rayner, 2009). Embodiment in public health and epidemiology is the means by which
humans biologically incorporate the physical and social environment in which they live throughout
their lives. An underpinning assumption of the term embodiment is that one's biology cannot be
understood without considering psychosocial and sociocultural aspects of individual development
and societies history (Krieger, 2001). If applying an anthropological perspective, embodiment is
relevant to the distinction between abnormalities in structure and function of organs (disease) and
the lived experience of sickness and the way in which sickness acquires social significance within
particular cultures and contexts. Embodiment pertains to how we experience the world that
includes our perceptions of our context and its possibilities or limits.
Temporality: all experience is lived through and has a temporal flow (Husserl 1991/1893– 1917;
Zahavi 2005). Temporality refers to time as it is experienced by us as humans. As we increasingly try
to fit our lives into the pressures of our “clock” time, the way that we experience time can become a
negative pressure rather than offering us a feeling of possibility. These feelings of possibility can
emerge through memories of the past and the potential offered by the rhythms of the seasons for
instance. The way we experience time can become oppressive and overly rigid and dominant which
has a negative impact on our well-being rather than offering us options and possibilities both for the
here and now and the future (Todres et al., 2006).
Spatiality: Spatiality refers to our environment as humans, our world and our experience of living in
that environment. It has been clear through all of the phases of public health action that the way we
interact with our environment and the nature of that environment have a positive or negative
impact on our well-being. Our own personal topography can impact on our health or health
behaviour for instance or put our personal safety at risk, just as it can also promote our well-being.
Our “space” can present us with opportunities for socialization and purpose, or natural images,
colours and textures, arts and sport for instance all of which have the potential to enhance our well-
being (Hemingway & Stevens, 2011). Or indeed it can limit our potential through offering no
opportunities for socialization and little access to the “natural” environment.

Project: How does the situation relate to the person’s ability to carry out the activities they are
committed to and which they regard as central to their life? (The emotions of regret and pride,
among others may relate to such pursuance of projects.) All the things and events of the lifeworld
may be related to the notion of project. For ‘‘project’’, we may also use the word ‘‘care’’ (Heidegger,
1962, pp. 238 􏰀 239), in the sense of having a personal concern for something. Phenomenologists
have from time to time emphasised the idea that it is the fact that people have cares or projects that
differentiates them from machines. We need to notice that this meaning of care is a bit different
from the sense we use it in ‘‘the caring professions’’, where it means ‘‘solicitude’’ for others;
thinking of them and noticing their needs and trying to fulfil them. This is a more restricted use of
the word.

Discourse: Is the language we use to describe the situation. What sorts of terms are employed to
describe the situation * educational, social, commercial, ethical, etc.and thence to live? It has been
considered by many that, since a great deal of philosophical emphasis has been given to language in
the last century it is the ‘‘house of being’’ (Heidegger);

Mood: Mood is intimate to how we are as human beings and is both impacted upon and impacts
upon ones spatial, temporal, intersubjective and embodied horizons and our ability to realize
potential. Anxiety reveals a very different experience of the world than joy and sorrow do. Mood is a
potent messenger of the meaning of our situation (Todres et al., 2006) and as such will influence and
be influenced by our physical and mental well-being and is influenced by the other dimensions
mentioned.

In phenomenological psychological research, then, we may address a particular experience in terms

of its meaning for the self. How does the lifeworld speak to us of social identity, our sense of agency,
and a person’s feeling of their own presence and voice in the situation? (For example, powerlessness
might be a feature of the psychological situation for the individual.) We can use this research to
understand

The phenomenology of personhood of the other is challenged in some distressing circumstances

such as the later stages of Alzheimer’s disease (Ashworth & Ashworth 2003). In addressing the
lifeworld in the context of a phenomenological psychological study of a particular phenomenon, we
ought always to concern ourselves with the relevance of others and of relations with other people.
How are others implicated in an experience, and does the situation affect relations with others?
2. Describe the elements of the lifeworld. How can phenomenological research help us (i) to
understand lived experience of illness and (ii) to use that knowledge to develop lifeworld-led care?
Use examples from research to illustrate your answer.

Phenomenological research into the elements of the lifeworld which have just been mentioned have
helped us to understand that when dealing with individuals with illness, we are not dealing with
simple systems.

As human beings, we are complex as are our groups, tribes or communities. Within this complexity
lie our strengths and through them we express our unique human qualities and our desire to both
experience the here and now and influence the future. We need to work with and through this
complexity to understand what it is we need to flourish. In order for the promotion of “well-being”
to become the dominant discourse within our “sickness” and “sickness causation” focused actions,
we need to come to a shared definition that may be context specific, however should be specific
enough to build policy and practice upon. Todres et al. (2006) when discussing the core perspectives
of lifeworld led care mentioned “grounding” that is an understanding of others‘ experiences of living
through and within complex circumstances that can help us to understand our adaptive systems.
Our well-being is densely connected with many systems as we move through our lives such as
community, culture and state to name but a few. Our lived experience of these systems is equally as
important as outcome-based quantitative evaluation. Indeed, if these experiences were valued
equally, then the design of our health and other state systems could be guided by the real
experience of the end user. This could give our public health efforts the potential to be supported or
driven by real “actors” as assets within any given context as we can all share an understanding of
what we are trying to achieve. As human beings, we can intuitively share the experiences of others
that help to motivate us to participate and share in the efforts or actions needed to promote well-
being through using a narrative that makes sense to us.

The need to rebalance our mindset

The elements of the “lifeworld” expose the potentially de-humanizing impact of a public health
approach that focuses solely on “experts” giving advice to those who need “fixing”. It is clear that to
deal with the complexities of the human condition and experience, we urgently need to learn from
and with others to find a vision for the future. Less of a focus on “labels” and “experts” and more of
a focus on ‘listening”. Indeed, focusing on “expert advice” may never increase our well-being
freedoms as it does not enable us to find our own way forward. Therefore, it seems to be important
to focus on listening to the patients to develop lifeworld led care and to understand the lived
experiences of illness.

The need to rebalance our orientation

The lifeworld-led approach seeks to explore the lived experience, and inter-subjectivity of human life
through its elements. As human beings, we have evolved to find shared meanings, values, beliefs
and aspirations; however, the notion of experts who find causes and fix our problems in our western
societies has become the dominant paradigm. This means our shared language and understanding of
our issues and our potential to solve problems has become marginalized and undervalued, thus
limiting our well-being freedoms (Sen, 2002). Exploring lived experience and the intersubjectivity of
human life can help us understand the lived experience of illness and help develop lifeworld led
care.
Innovate to feed our future
The elements temporality, spatiality, intersubjectivity, embodiment and mood suggest that to
flourish, we need to better understand our part in what is happening to us and to others. We need
to focus not just on the causes of our loss of well-being but crucially on what it means to us as
human beings to be well (Easterlin, 1980). It would appear that if one looks closely at income
inequality research, the most likely explanation is that it is what individuals are able to “be” and “do”
at each level of their social hierarchy that produces the gradient in ill health rather than the simple
fact of their being in possession of different amounts of income (Sen, 2002). How we experience our
world as humans impacts on our physical and mental well-being, these experiences are subjective;
however, we need to understand the elements of our subjective experiences in order to promote
well-being. Inevitably, otherwise we will focus on gross economic measures or disease as they are
easily measurable.
Lifeworld-led care: Is it relevant for well-being and the 5th wave of public health action?

http://eprints.bournemouth.ac.uk/17449/3/lifeworld_led_care_and_the_5th_wave_of_public_health.pdf

Effecting change through dialogue: Habermas’ theory

of communicative action as a tool in medical lifestyle interventions

https://link.springer.com/content/pdf/10.1007%2Fs11019-010-9260-5.pdf

Case study of Mary

A conceptual framework for public health: NICE’s emerging approach

https://ac.els-cdn.com/S0033350608002795/1-s2.0-S0033350608002795-main.pdf?_tid=81e3c3e8-84bd-4e1e-
acc7-e23bb7a7c60b&acdnat=1522968703_b417124759c549b1a4645eb703v489f3b

The lifeworld is the locus of experience: social, psychological and physical. It is that social and emotional space which all of us
uniquely inhabit. It is the world of the everyday; the world of the immediate experience and the aspects of life that we take for
granted. It is where life is at its most meaningful and its most painful. The lifeworld is also about the physical space which we
inhabit. It is where the social meets the biological. Lifeworlds are the point at which stressors are moderated, mediated or exacer-
bated. It is the point where insults are parried or where they have their noxious effects. It is the point where vulnerabilities translate
stressors into physical and emotional damage. It is where immu- nities – biological, physical or psychological – work their protective
powers. Social disadvantage is characterized by the inability or lesser ability to control the lifeworld. Social advantage is charac-
terized by the ability to make control of the lifeworld sustainable.

HABERMAS’S THEORY OF COMMUNICATIVE ACTION AND THE THEORY OF SOCIAL CAPITAL

https://pdfs.semanticscholar.org/4d37/90471aaf0ea2280aa701651ec97ba920934d.pdf
Communicative action is individual action designed to promote common understanding in a group and
to promote cooperation, as opposed to "strategic action" designed simply to achieve one's personal
goals (Habermas 1984, especially pp. 85-101, 284-8).

The lifeworld – enriching qualitative evidence

https://www.tandfonline.com/doi/pdf/10.1080/14780887.2015.1076917?needAccess=true

Peter D. Ashworth

Seeing oneself as a carer in the activity of caring: Attending to the lifeworld of a person with
Alzheimer's disease

https://www.tandfonline.com/doi/pdf/10.1080/17482620600967786?needAccess=true

Peter D. Ashworth

Lifeworld-led healthcare is more than patient-led care: an existential view of well-being

Karin Dahlberg Les Todres Kathleen Galvin

https://link.springer.com/content/pdf/10.1007%2Fs11019-008-9174-7.pdf

Lifeworld-led healthcare: revisiting a humanising philosophy that integrates emerging trends

Les Todres, Kathleen Galvin, and Karin Dahlberg

https://link.springer.com/content/pdf/10.1007%2Fs11019-006-9012-8.pdf

Hidden geographies: the changing lifeworld’s of women with multiple sclerosis

Isabel Dyck

https://ac.els-cdn.com/0277953694E00916/1-s2.0-0277953694E00916-main.pdf?_tid=14fb03d7-
7c9b-4a5b-9b54-110ca28c709c&acdnat=1523139305_e5c7ccd924963c2a1843e99a1dd7bbcb

HIDDEN GEOGRAPHIES: THE CHANGING LIFEWORLDS