Discourse in different voices: reconciling N=1 and N=many

Social Science & Medicine 55 (2002) 1079–1087

Discourse in different voices: reconciling N ¼ 1 and N=many

Miles Littlea,*, Christopher F.C. Jordensa, Kim Paula, Emma-Jane Sayersa,Jane Ann Cruickshanka, Jantine Stegemanb, Kathleen Montgomeryc

aCentre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney NSW 2006, AustraliabDutch Health Council, The Hague, The Netherlands

cGary Anderson Graduate School of Management at University of California, Riverside, USA

Abstract

When groups are convened to discuss the making of policy, people are chosen to represent particular interests

because they have relevant experience. Different stakeholders, however, may use differing discourses, and particular

discourses may be privileged in particular contexts. This means that important contributions to the discussion may not

be reflected in final reports. Discursive incommensurability is particularly seen when individual, personal experience is

presented in meetings where quantification or ‘‘numbers talk’’ is privileged. While pooled personal experience may carry

some weight in such a context, individual anecdote does not.

The inclusion of ‘consumers’ in policy making groups may result in their dysempowerment. Their presence promises

that they will have influence, but their voices disappear from the final document. The promise of empowerment is not

realised. Dysempowerment may translate into empowerment with time, as it has done with feminism and the HIV/

AIDS lobby. In order to speed the process, we suggest some practical means whereby mixed discourses may be

generated and monitored. For constructive interchange, each party to the discourse needs to express the interests and

arguments relevant to the group he or she represents. Supporting this principle of representation are principles of

implicature and radical respect. Implicature is the act of implying what is relevant to others involved in the discourse.

Radical respect is a fundamental and foundational respect for others in their roles as representatives of stakeholders

with legitimate interests in the topic of the discourse. r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Health forums; Consumer representation; Stakeholders; Discourse incommensurability; Implicature

Introduction

This paper attempts to develop a theory of consumer

representation in health forums. We think that this is an

important topic because consumer representation has

become a basic tenet of policy formulation in many

areas of health. While there are useful guidelines for

consumer participation, there are still problems for

consumer representatives. Their role, status and power

are not clearly defined, and their ability to make

contributions depends very much on how the committee,

working party or forum is selected and chaired. We

develop an ‘ideal’ which is demanding and difficult to

achieve. We think this is important because it proposes a

standard against which reality can be measured, and

because it suggests ways in which the problems of

consumer representation in health can be defined and

perhaps ameliorated.

Methods and epistemological considerations

In this paper, we follow a line of working which we

have developed over the last five years (Little, Jordens,

Paul, Montgomery, & Philipson, 1998; Little, Jordens,

Paul, Sayers, & Sriskandarajah, 1999; Little, Jordens,

Paul, Sayers, & Sriskandarajah, 2000; Little, Paul,

*Corresponding author. Tel.: +61-2-9351-7794; fax: 61-2-

9351-4887.

E-mail address: [email protected],

[email protected] (M. Little).

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 2 6 4 - 7

Jordens, & Sayers, 2000; Little, Sayers, Paul, & Jordens,

2000a; Little, Sayers, Paul, & Jordens, 2000b; Little,

Jordens, Paul, & Sayers, 2001). It is a qualitative

methodology, a variant of Grounded Theory (Glaser

& Strauss, 1968; Strauss, 1987; Strauss & Corbin, 1990),

involving analyses of narratives given by participants in

a particular field of interest. Theories are generated and

revised until there is agreement that adequate explana-

tory power has been developed. Further testing follows

by further interviews, and by presentation of the work to

those with legitimate interests in the field. Reflexive

evaluation of the usefulness of the theory is based on

formal and informal assessment by participants in

seminars, workshops and meetings, and by Internet e-

mail correspondence responding to public broadcasts

that present research findings to a mass audience. This

feedback is systematically analysed for concordance or

discordance with the theory, using standard statistical

methods and software. The NUD*IST Vivo software

program is used for qualitative coding and analysis of

prolific e-mail correspondence. Most of our work so far

has concerned the existential and psycho-social pro-

blems of cancer survivors in remission.

The present project arises as a related issue, because

the work reported in the papers listed above needs to be

represented at various forums by former cancer sufferers

(‘consumers’). The difficulty that consumers have in

being heard in committees that develop policy which

affects them has prompted us to consider how to

theorise a ‘satisfactory’ environment and context in

which consumers might reliably affect policy develop-

ment. This paper presents the final theoretical phase of

development. We have started to test the theory at

workshops and seminars on cancer survival, and at a

new organisation we have started to coordinate infor-

mation, education and support services for cancer

survivors in remission.

‘Consumer representation’

‘Consumer representation’ in health discourse is well-

established. In Australia, the Consumers’ Health Forum

of Australia has produced a thoughtful and helpful

guide for consumer representatives (Consumers’ Health

Forum of Australia, 1999). It begins by explaining the

role and importance of consumer representatives on

committees.

A consumer representative is a committee member

who voices the consumer perspective and takes part

in the decision making process on behalf of

consumers. This person is usually nominated by,

and is accountable to, an organisation of consu-

mers. (p. 3)yThe consumer representative plays

an important role on any committee. Due to a

greater public recognition of the need for consumer

representative involvement in decision making

processes, there is greater public confidence in those

committees which have a consumer representative

(p. 4).

The document explains that consumers are there to

represent other consumers, and that they should

repeatedly remind themselves of this representative role.

Eight basic consumer rights are listed: rights to

satisfaction of basic needs, to safety, to be informed,

to choose, to be heard, to redress, to consumer

education, and to a healthy environment (p. 4).

Consumer representatives are repeatedly advised to

understand the purpose, aims and limitations of the

committee, to insist on clarification and translation from

jargon or technical language, to report to and consult

the organisation they represent, to prepare themselves

by reading background material, to read minutes and

have them corrected and clarified. Instructions are given

on setting goals and behaving assertively at meetings

(pp. 14–15).

The functions of the Chairperson and Secretary or

Secretariat are explained (p. 11). The document speci-

fies some common problems, and offers solutions (pp.

17–20): it deals with incomplete, late or over-lengthy

agenda papers; decisions requested before consultation

can be arranged with the consumer organisation; doubt

about evidence; adversarial confrontation; agreements

that are forgotten or never implemented. It examines

briefly but informatively confidentiality, conflict of

interest, and the sense of isolation that may affect

consumer representatives on committees dominated by

professionals.

The booklet advises consumer representatives how to

achieve the greatest impact on their committees. It

stresses impression management, preparation for meet-

ings, coalition-forming, regular reporting to the spon-

soring or nominating agency, preserving identity as a

consumer, and careful listening to the voices of others

(pp 23–29).

This is helpful advice, and the publication clearly

signals that consumer representation affects health

discourse. The tone of the publication is generally

positive and optimistic, suggesting that consumers have

the ability to help in the shaping of policy. One

consumer representative, for example, is quoted as

saying (p. 31):

I found out after the committee had finished its work

that one doctor thought the best thing about the

committee was having a consumer representative on

it.

There is, however, another side to committee func-

tioning, which we believe needs further examination. On

M. Little et al. / Social Science & Medicine 55 (2002) 1079–10871080

p. 18, a consumer representative is quoted as saying:

I found decisions had been made the night before at a

dinner to which I had not been invited. Now I get

invited to dinner, but find decisions are made over

port and cigars after (to which I am not invited).

It is this sense of exclusion from health discourse that

we address in this paper.

The dynamics of health discourse

When we come to represent ourselves or others in

discourse or conversation, our experience counts be-

cause it accredits us to speak with some authority. In

formal contexts, where ‘important’ issues are to be

discussed, our relevant experience is one criterion for

our inclusion in the discussion. It is, however, also a

potential restraint. The nature of our experience informs

what we may say, but it also limits our legitimacy and

power.

Let us illustrate this insight. A peak Cancer Organisa-

tion convenes a group of people to discuss and define

‘quality in cancer care’. The chosen committee is chaired

by an ‘eminent Professor of Oncology’, four ‘distin-

guished physicians’, a health manager, an epidemiolo-

gist, a bioethicist and a health economist are chosen,

along with a ‘consumer representative’. The consumer

representative is, of course, someone who has had

cancer. This person’s experience of cancer and of its

treatment should be essential to any discussion of

‘quality care’. Knowing what it is like to receive the

diagnosis of cancer and the traumatic treatments that

follow is surely important to any decision the committee

might make.

The chairperson is careful to ask each committee

member to speak on important issues. The voices of the

clinicians dominate the discourse. They have extensive

professional experience, and good command of the

relevant medical literature. The economist, manager

and epidemiologist have little trouble being heard,

because they have command of issues of finance and

distribution of disease burden. The ethicist is heard

because he talks in general principles, and is seen to

provide some measure of risk management against

the law and public condemnation. Furthermore, the

voice of the ethicist is ‘enshrined’ because the bioethics

movement has gradually permeated the discourse of

health since the late 1940s, accompanied by the voice of

the law (Beauchamp & Childress, 1964; Beauchamp &

Walters, 1994; Dix, Errington, Nicholson, & Powe,

1996; Breen, Plueckhahn, & Cordner, 1997; Campbell,

Charlesworth, Gillett, & Jones, 1997; Kerridge, Lowe, &

McPhee, 1998). The ethicist will also have an interest

in seeing that the processes by which policy is

developed are fair and equitable. Yet every comment

that the consumer makes about personal experience

seems out of place against the statistical, pooled

experiences or the general principles which the others

use. The consumer’s discourse is, in a sense, incommen-

surable with the discourse of the others (Little, 1998;

Fenton & Charsley, 2000). When the final report is

made, all too often the consumer voice is nowhere to be

found.

Dysempowerment

This is perhaps an oversimplification of a complex

process. Yet it represents the personal experience of two

of us (E-JS and JAC) on more than one occasion. The

result is the dysempowerment of the consumers. The

concept of dysempowerment was introduced to the

management literature by Kane and Montgomery

(1998) to describe the process that unfolds when an

individual perceives a lack of respect for his or her

dignity and voice in an organization, but it is equally

appropriate in the policy arena. We can say that

dysempowerment (rather than disempowerment) occurs

when there is cognitive acceptance of a principle, but

moral ambiguity toward it. Our example of the peak

Cancer Organisation explains this concept. The con-

sumer representative is included in the policy discussion

because the consumer movement is developing, and it is

politically expedient to recognise its force. But con-

servative bodies and systems either remain skeptical

about including new forces in well-established processes

and domains, or do not know how to incorporate them

into their deliberations. It has taken many years to

accept the voice of the ethicist as one that counts, for

example. To include a consumer in a policy making

committee is (usually unwittingly) to signal a recognition

of the discourse of individual experience. But that

discourse, because of its particularity, does not sit

comfortably with the numerical and generalisable

discourse of the others at the table, whose standing is

more clearly defined by tradition and habit. The

‘language games’ (Wittgenstein, 1991, pp. 2e–172e) are

incommensurable (Ramberg, 1989; Fenton & Charsley,

2000). The membership of the committee is heavily

weighted in favour of those who use statistics, numbers

and generalisations. The empowerment offered to the

consumer is therefore not realised.

This rather hollow offer of power is dysempowerment.

Its adverse psychological effects on the dysempowered

individual within an organisation, described by Kane

and Montgomery (1998), include feelings of humiliation,

anger, indignation and hostility. Consequently, institu-

tions, or in this case policy committees, suffer from

impairments in trust, commitment, motivation, coopera-

tion and innovation (Kane & Montgomery, 1998).

M. Little et al. / Social Science & Medicine 55 (2002) 1079–1087 1081

Stakeholders and discourse incommensurability

The concept of stakeholders helps us to understand

why some individuals and groups at the table are more

likely to experience dysempowerment than are others

because their voices are not respected. Stakeholding is

an ambiguous term. It is sometimes used pejoratively to

mean ‘vested interest’, usually an interest in main-

taining dominance in some context. We use it here

in the benign sense used by Mitchell and colleagues

(Mitchell, Agle, & Wood, 1997) to express a party’s

interest held in an issue or entity, which may result

in the party’s loss of something valued. For example,

the stakeholder’s potential loss could be of financial

value, or it could be of human value (e.g., reputation,

health, life). Various stakeholders are identified by their

salience vis-a-vis the relevant issue or entity, which is

determined by three parametersFpower, legitimacy and

urgency.

Let us examine how this works in practice. If we

return to our example of the peak Cancer Organisation

and its discussion of ‘quality in cancer care’, we can see

how the various stakeholders are identified and why

some may be at greater risk of dysempowerment.

Medical members of the committee are stakeholders

because the conditions of their practice are under review;

that is, their reputations and their livelihoods are at

stake. They have legitimacy and power, because of their

knowledge, expertise and membership of the therapeutic

community, and because there is general agreement that

their activities are central to cancer management. They

may also have a degree of urgency if they are aware of

dangerous shortfalls in availability or standards of care.

The manager is also a stakeholder, because responsible

handling of the health services budgets may protect the

health care system from financial losses. She has

legitimacy and power because she determines how

money will be distributed for services. She may also

have a degree of urgency if there are shortfalls in

essential services.

The epidemiologist and economist are stakeholders

because their professional standing depends on their

ability to influence policy, which in turn depends on the

authority with which they present their data. They have

legitimacy and power because they have knowledge of

statistics and costs that reflect levels of need and

capacity to meet that need, and this knowledge is

necessary to validate the activities of the committee.

Usually, they have relatively little urgency, since they do

not stand to lose directly from the outcomes of the

discussions. The ethicist is a stakeholder to assure that

the moral integrity of the system is not lost during

debates about resource allocation, justice, beneficence,

autonomy and so on. He or she has a legitimacy

conferred by agreement and convention, and by a

contemporary acknowledgment that moral issues are

part of risk management and of public perception of

acceptable processes. It has taken time for the ethicist to

have an accepted place at the table. An ethicist possesses

little power, except as the reference point for moral

issues. He or she will generally carry little sense of

urgency. An ethicist uses moral reasoning, which is

generalised but not numerically based.

The consumer is a stakeholder because he or she faces

the risk of loss of health or even life through the disease

experience. He or she has a generalised legitimacy

conferred by a contemporary determination to acknowl-

edge consumerism as a force in health, and a specific

legitimacy because of the first-hand experience with the

systems that the others work in or study, and knows

something of strengths and weaknesses that the others

may not appreciate. The consumer also has urgency

because the health system is set up to deal with the

experience of illness. The consumer, however, has little

power.

The physicians, the manager, the economist and the

epidemiologist share commonalities in the way they

speak. All use numerical data of one kind or another,

and all can speak in terms of pooled personal experience

or of secondary experience gained from studying the

work of others. The physicians can speak of case series

they have read, of their own personal experience, or of

the experience their clinics have had with the treatment

of a particular cancer. While physicians deal with

individuals who are ill, they will not speak in this forum

about individuals, because their credibility is under-

pinned by their use of statistical data. Similarly, the

epidemiologist and the economist speak through numer-

ical data. They do not aim to convince others by appeal

to individual suffering, nor to anecdotes of bad manage-

ment.

Both physicians and managers also speak in another

way. They draw on their overall experience of many

situations, but set it against a recognised body of their

disciplinary knowledge. The clinicians speak of their

‘experience of many such cases’. Managers explain how

they use past experiences to approach current problems.

Both set this personal experience against the specialised

knowledge that they have mastered in order to become

recognised as professional clinicians or managers. This

epistemological standpoint of pooled experience in-

formed by background knowledge may be similar in

principle between clinicians and managers, but is likely

to cause tensions because basic values are interpreted

differently. Managers must make limited budgets stretch

to provide essential services, and reality is determined by

knowing that the budget will stretch no further. For

clinicians, there are patients to be treated, and reality is

determined by the demands for services.

The ethicist uses ‘moral-talk’, commenting on specific

issues by reference to ethical principles. He may refer to

specific cases for precedent or comparison, but does not


use statistics to make or justify a case. He may also

speculate on the moral responses that ‘the community’

may have to particular decisions. This way of speaking

has become acceptable after many years because health

care accepts the need to remember its own grounding in

moral values.

The consumer speaks from a different base. Included

because he or she has actually experienced cancer and its

treatment, the consumer speaks of that experience. The

talk that results is statistically defined as n ¼ 1:Although the consumer’s presence on the committee is

meant to empower his or her talk, it usually fails to do

so because n ¼ 1-talk is incommensurable with

n=many-talk. No one really knows what to do with

n ¼ 1-talk, which seems too personal, too idiosyncraticto include in the final report. It is easy to dismiss n ¼ 1-talk that is critical of treating-systems on the grounds

that ‘‘this is an isolated response’’, which ‘‘does not fit

with my extensive experience’’. We can say, in short,

that different parties to this discourse represent different

‘discourse communities’, and that there are dangers to

fruitful communication from potential incommensur-

ability.

If, on the other hand, the committee were to have

been set up by a cancer support organisation, and were

to be dominated by people who had experienced cancer

and its treatment, the mode of discourse would be

quite different. Personal experience would then be

privileged, and scientific, statistical data helpful only in

supporting arguments for more or better services.

Stories of experience would then define failings in the

treating-systems, and suggest ways to achieve improve-

ments. The realities of funding and scarce resources

would come later, as would the positioning of needs

and perceptions within the context of evidence-based

medicine.

The context, in short, determines what kind of

experience will be privileged in talk, or which discourse

community will rule the discourse. The selection of the

membership and the chair are thus all-important, and

depend on who initiates the discourse. At one end of the

scale, scientific meetings exclude anecdote and accounts

of individual experiences. At the other end, say at a

cancer support group meeting, individual experience is

privileged, and statistical data seem out of place. In the

middle, pooled personal experience is assigned variable

weight, because it is seen to be ‘expert opinion’. Expert

opinion can help the talk at either extreme, but may be

regarded with suspicion by both because it represents

‘authority’ which may be based in perceptions of power,

rather than episteme (the knowledge-base), phronesis

(the practical wisdom involved in applying knowledge)

or techne (the technical skills required). Evidence-based

medicine accords less respect to expert opinion than

it does to any form of clinical trial (Moynihan, 1998,

p. 12).

Moving beyond incommensurability

Dysempowerment and discourse incommensurability

are probably inevitable stages of a developing discourse.

Ramberg writes of the hermeneutic process of discourse

change (Ramberg, 1989, p. 140):

The occurrence of incommensurability is actually an

essential part of this hermeneutic process. For

incommensurability is precisely a signal of conflict

of prejudgements and preconceptions. And it is only

through conflict, through disruption, that it is

possible to become conscious of these prejudices as

such. We remain unaware of our basic assumptions

until faced with someone who does not share them..

As the discourse gathers social momentum, it becomes

expedient to recognise it within established discourses, at

least by acknowledging its presence. The ‘token con-

sumer’ allows the Cancer Organisation to declare its

awareness of a new and perhaps important element, but

the power apparently given is actually withheld. If the

new discourse gathers power, mechanisms will be

created whereby its voice is heard, and there is true

empowerment. Cancer support groups, feminism

(Gatens, 1989), bioethics (Beauchamp & Childress,

1989; Beauchamp & Walters, 1994) and HIV/AIDS

(Ariss & Dowsett, 1997) all provide examples of this

process whereby discourses have gathered power and

social impact. A good example of the way in which

individual voices can be heard in policy documents is

provided by Bringing them Home, in which the

Australian Report of the National Inquiry into the

Separation of Aboriginal and Torres Strait Islander

Children from Their Families is set against the individual

stories which illustrate the policy statements (National

Inquiry into the Separation of Aboriginal and Torres

Straits Islanders from Their Families, 1997). The impact

of that report on many people in Australia suggests that

dysempowerment need not be permanent.

In the kind of health discourse that we are discussing,

the same thing can happen. The Consumers’ Health

Forum of Australia (1999) provides an example on p.

31, when it cites a consumer representative as saying:

On my committee they completely under-estimated

me because I was the consumer representative but I

set myself a task and just kept hammering away.

Now we have monitoring guidelines which makes

products safer and better for consumers.

Ramberg supports this evolutionary argument in his

work on incommensurability of discourses (Ramberg,

1989), which uses concepts put forward by Davidson

(Davidson, 1980; Davidson, 1984). He writes (pp. 130–

132):


Incommensurability, as a communication break-

down, can be understood as a breakdown of

linguistic conventions, caused by changes in use that

are too abrupt to be absorbed smoothly, or changes

that a particular set of conventions are too rigid to

accommodatey. [I]ncommensurability is a diachro-

nic relation, not a synchronic one; it is not a relation

between structures, but a symptom of structural

changey[I]ncommensurability in discourse can only

begin to occur once we think we have begun to agree

on linguistic conventions, but in actuality remain

confused as to what language we are using.

Ramberg expresses the hope that incommensurability

of discourses can be cured, and that ‘a concrete

diagnosis is the first step towards a resolution’ (Ram-

berg, 1989, p. 133). This legitimation of discourses

implies the fusing of ‘horizons of understanding’ as

Gadamer describes (Gadamer, 1993, pp. 302–307).

Dysempowerment may be cured by a hermeneutic

process of curing incommensurability. One must be

understood and believed before one can be empowered.

Time and social pressures may cure dysempowerment,

but at the expense of time wasted and good will

dissipated. More importantly, unchecked dysempower-

ment impairs the ability of the dysempowered party (as

well as the performance of the group) to move toward

creative solutions, that require trust, commitment, and

cooperation of all involved (Kane & Montgomery,

1998). Thus, a therapy for dysempowerment, or a

preventive measure to stop it occurring might save both

time and good will, as well as contribute to more

valuable outcomes. It would be difficult to say unequi-

vocally what this therapy or prophylactic might look

like, but it is possible to state some characteristics of the

process. One set of suggestions about procedures and

processes that might help consumers has been provided

by the Consumers’ Health Forum of Australia (1999).

What follows is an attempt to develop some simple

principles that might guide all participants in a mixed

health discourse.

The principle of representation

First of all, it would be a process for generating mixed

discourses in which the voices from the domains of

numeration, pooled experience and individual experi-

ence would be heard. The various rules for conducting

discourse (Grice, 1989; Alexy, 1990; Searle, 1995;

Devlin, 1997; Devlin & Rosenberg, 1997) do not really

deal with this issue, because they focus on such things as

perspicuity, sincerity, courtesy, respect for context and

consistency. In short, they lay down procedural rules,

without dealing specifically with incommensurability of

different discourses. Rules may be stringently enforced,

but voices that are not legitimated will still disappear

from the conclusions of the discourse. Ways must be

found to legitimate equally voices from the three

domains. This will often mean that whoever runs the

meeting must constantly remind those who speak of the

purpose of the discourse. At the same time, each party to

the discourse needs to observe a principle of representa-

tion. Policy is meant to apply to groups of people, in

order to provide some predictability for individuals

within the group. Individuals taking part in focussed

discourses are there to represent the interests of people

like themselves. While individual experience may be

helpful, this principle of representation is important,

because it applies equally to each participant. The voice

of individual experience is more likely to be heard when

it speaks on behalf of others who have had similar

experience.

Therapy begins, therefore, by a move from the

specificity of rules and guidelines to the more general

domain of values and principles. If the meeting is there

to discuss ‘quality in cancer care’, the parameters of care

are not confined to survival, mortality, morbidity, costs

and benefits, which express the rules of those who use

n=many-talk. While these measures are important, the

values that sustain health services have their source in a

common agreement that human life is important in both

quantity and quality. The nature of the experience of

those who undergo the process of care is essential to any

assessment of the quality of that care. That insight can

come only from narratives of individual experience

(n ¼ 1-talk), and somehow these narratives must be

allowed to contribute to the proceedings of the

committee. Qualitative research, with its emphasis on

individual narrative, and its capacity to crystallise and

illuminate categories of experience from its examination

of many narratives, offers one means of bridging the gap

between n=many- and n=1-talk.

The principle of implicature

There is, therefore, a responsibility for those who take

part to ensure that what they say is relevant to the

problem or problems at hand. This responsibility applies

to all participants, just as much to those who recount

their personal experience as to those who deal in

statistics and pooled experience. What might sustain

and illuminate the processes by which this might be

achieved is a principle of implicature like that of Grice

(1989). In the sense used here, implicature is the act of

implication, of implying a consequence or consequences

by the making of a statement. As Grice points out,

implication shifts with context. Someone who says ‘‘The

doctors were very cruel’’ to his wife when he comes out

of hospital after treatment for cancer may be appealing

for sympathy, confirming his wife’s longstanding suspi-

cion about the medical profession, or presaging a formal

complaint. The same statement, made in the context of a


meeting on ‘quality in cancer care’, might mean that

doctors can make the process of cancer treatment both

painful and frightening, and that the medical profession

needs to do something about this perceived failing.

This suggests that contributors to mixed discourses

should think about the implications of what they choose

to say for all the other participants, and what message

they want to convey on behalf of others whom they

represent. Statements of personal experience which have

no relevance to the context of the discourse should be

excluded from the discourse. Before speaking, each

person needs to ask herself ‘‘What will this statement

imply (if anything) for other stakeholders, both those

that I represent and those whose diverse interests bring

them to this meeting?’’ Participants in focused discourse

that is meant to produce policy are there to represent the

interests of others. They have been chosen because their

experience is considered to be relevant to the theme of

the discourse.

The principle of radical respect

But each party to the discourse also has a duty to

listen and a duty to hear. Scientists need to learn to hear

the messages that emerge from accounts of individual

experience, and consumers to fit the messages of science

and pooled experience to individual experience. Listen-

ing and hearing imply that each party respect the other,

if not in person then at least in role. This is a radical

respect, radical in the sense of being fundamental and

foundational to the relationship between the parties.

Without it, listening and hearing will at best be

incomplete, and the opportunity for improvement may

be squandered. Radical respect requires engagement

with the arguments and reasoning of others. Radical

respect thus inhibits dysengagement, in which a false

engagement conceals negative judgements, such as

contempt and unwillingness to accept another’s con-

tribution to a discourse.

Focused discourse, designed to generate policy, then

becomes an exercise in accountability. Each participant

might be called upon to give an account of his motive for

being there. Is the motive consistent with the kind of

outcome that the discourse might work toward? Or are

there other and conflicting interests which will influence

and perhaps corrupt the process? Whoever runs the

meeting is accountable for the process whereby the

meeting is run. Is everyone given the chance to be heard,

and is each voice guaranteed due weight, always

provided that the implications of what is said are

germane to the object of discourse? Are the destructive

potentials of adversarial confrontations kept under

control? Or are debating victories taking the place of

legitimate argument and constructive discussion? Is the

problematic of the discourse kept always in mind, or does

the discourse stray into irrelevance? Are the implications

of each thing that is said relevant to all stakeholders, or

do some statements and claims fall short of the

generality which helps to frame policy?

This implies that everyone who takes part in a mixed

discourse must bear some responsibility for making the

discourse work. Gray reminds us that collaborations

evolve dynamically, and that power shifts during

processes of transaction (Gray, 1985). No one pretends

that resolving conflict is easy (Arrow et al., 1995). Some

claim that it is impossible (Hammond, 1996), others that

it is undesirable in free, liberal societies (Berlin,

1991(1950)). It is scarcely surprising that political

differences, financial interests and personal investments

of time and reputation should make some kinds of

discourse especially difficult and unlikely of resolution.

But the kind of discourse with which we began this

paper should be manageable in ways which achieve at

least some definition of agreed problems, and some

measures to resolve them, or at least to understand them

better. When such discourse fails to satisfy the aspira-

tions and needs of legitimate stakeholders, it does so

commonly because of incommensurability of different

discourses, and this is not an insurmountable problem.

We thus theorise that discourses in which people have

common interests in securing a ‘good’ outcome need to

work within a principle of representation, supported by

principles of implicature and radical respect. The

principle of representation imposes a duty to speak

and listen as representative of those with similar

experience. The principle of implicature requires that

we consider the implications for relevant others of each

statement or claim made. The principle of radical respect

requires that the discourses of those included in the

discourse should be heard, and translated if necessary

into a meaning which reaches to all parties to the

discourse.

What we propose arises from qualitative research

which proceeds reflexivelyFthat is, by repeatedly

testing its theories against the responses of consumers.

We suggest that the results of research of this kind could

become an effective means by which consumers could

change opinions and policies. The success of evidence-

based medicine (EBM) in challenging expert opinion

suggests that evidence and research can achieve change.

What is needed now is a broadening of the kind of

evidence privileged by current models of EBM to include

the evidence of good qualitative research.

We recognise that our theory represents an ideal

which may never be attainable because of power

imbalances between participants on committees; because

some people are more articulate than others; and

because some may fear that certain outcomes may not

be in their own group’s interests, and may therefore seek

to manipulate the process or play a ‘‘spoiling game’’ by

sabotaging prospects of agreement. Nevertheless, we

believe it is helpful to set out what might be necessary


for effective consumer participation, because mixed

discourses are generally convened under conditions of

good will, and the consumer movement is growing in

importance in most Western countries. Defining the

ideal at least allows us to see the reality more clearly.

Acknowledgements

This work has been supported by Grants from the

Andrew Thyne Reid Trust; Mrs Caroline Simpson; the

Faculty of Medicine, University of Sydney; the Royal

Australasian College of Surgeons; and Strathfield

Private Hospital. Kathleen Montgomery has spent two

periods of sabbatical leave at the Centre for Values,

Ethics and the Law in Medicine, University of Sydney,

funded by the University of California, Riverside.

Tineke Stegeman’s sabbatical leave at the Centre for

Values, Ethics and the Law in Medicine has been funded

by the Dutch Health Council.

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