Promises

discursive ethics is based on a special class of performance language—the promise; based on an article in the Journal of the American College of Dentists. (1 credit hour)

Learning Objectives

After completing the course, participants will be able to:

  • Define performance language and distinguish it from descriptive language
  • Identify the conditions of (a) qualified person, (b) proper circumstances, (c) appropriate language and gestures, and (d) altered status in performance langue and give examples of each
  • Make promises in conformance with sound performance language
  • Analyze and improve types of performance language in dental practice, such as diagnosis and informed consent

Please Review the Following Material:

Abstract
Sometimes language is used to describe things and sometimes it makes things happen. The four conditions required (person, context, words, and effect) for performance language are presented. It is argued that diagnosis is a performance and not a description and has traditionally been undervalued by dentists. Discursive ethics is based on a special class of performance language—the promise.

The dental profession has become increasingly concerned over the truthfulness of claims. Perhaps at no time in our history—and certainly not since the beginning of this century—have the practitioner and the public been subjected to such a variety of treatable diseases, so many products and processes, so much diversity in practice and payment patterns. More people then ever are making claims through more channels, and they seem to conflict with each other and what was said just a few months before. We have only begun to address the problems of truth claims.

Dentists and patients have to be concerned with another powerful group of statements that is not based on being true or false. These are words that do something. “You are under arrest,” “I would like you to join the professional team in my office,” “I now pronounce you husband and wife,” “I will sell my practice for $400,000,” “The insurance request is denied.”

Casey struck out in the bottom of the ninth. That is a fact, and anyone in Mudville who saw the game would say so. But what about that second, called strike? What was it when the ball just crossed the plate but before the umpire made his famous gesture? The answer is, as umpires everywhere will insist, it was nothing. The pitch is what the umpire says it is.

In just the same way, the verdict is what the jury declares; guests are made welcome on the date mentioned on the dinner invitation; dentists are competent to practice if the state board says they are; and patients have periodontal disease if the dentist diagnoses it. Sentences that describe conditions of the world and are subject to being true or false are called descriptive sentences. Sentences that do work, those that confer status, create relationships, or engender expectations are called performance language.

Rules for Doing Things with Words

There are four conditions that must be met in order to do things just by saying so. When any are missing, performance language miscarries or the situation becomes ambiguous. There is also a fifth condition, common to many performatives but not essential.

The Right Person. A parent or legal guardian can give informed consent for a minor or incapacitated patient. A state board can revoke a dentist’s license, and an insurance consultant can authorize payment on behalf of patients. But patients cannot revoke a license or authorize payment; a board cannot give informed consent or authorize payment; and the consultant cannot give consent for treatment or discipline a dentist. In very formal situations such as weddings or graduations, expected language often includes words to the effect “by the authority vested in me…”

The Right Circumstances. Dental licenses can only be disciplined or revoked following prescribed procedures conducted in a prescribed manner. None, to my knowledge, have been revoked in a bar or elevator in recent years. Sea captains are occasionally authorized to perform marriages, but only at sea. Conditions supporting doing things with words often extend to interpretation of the appropriateness of the circumstances, the mood of those present, and even the way something is said. A jury of twelve reasonable men and women is occasionally called on to decide whether a person was joking, coerced, or otherwise acting out of character when making a promise.

The Right Words. In order to accomplish something with words, the right person in the right circumstances has to use the right words. It is something like a magical incantation. The normal formula is “I verb object (where the object normally refers to another person or to something about another person). “I accept your offer to become a partner in the dental practice,” “I submit this treatment plan for preauthorization on behalf of the named patient,” “By my signature on this disclosure form I signify that there is no conflict of interest between the manuscript as submitted for publication and any commercial interest I may have in products or procedure described.” Sometimes performance language appears to evade this requirement by using professional jargon. An example might be “You have periodontal disease.” But it is always possible to restate a true performative into the conventional form, as in “By virtue of my training and license, I diagnose a treatable periodontal condition in your mouth.”

The Right Effect. The intent of using words to do something is always to transform someone. “You are fired, out, married, guilty, exonerated, in arrears, etc.” These statements have the effect of changing the status of the person referred to. Sometimes performance language changes both the speaker and the listener. “Because of certain circumstances, I find it necessary to discharge you as a patient” or “I agree to the conditions of the memorandum of understanding for hospital privileges” change both the person speaking and the person to whom the speech is addressed.

Ceremony and Symbols. The four requirements just listed pretty much define what is necessary for doing things with words. There is, however, a fifth element that is often present and, because it is so special, is distinctly associated with performance language. Very formal and high language is often used to call attention to the fact that something is being done rather then merely being described. Special locations are reserved (such as the Temple for Mormon marriages) or special costumes are worn (judges’ robes or academic regalia). Often gifts are exchanged as a visual sign of an anticipated transformation (such as wedding rings or buying a round of drinks after a business deal is concluded). The show and ceremony are not essential to doing things with words, but they are a way of drawing attention to the fact that words are being used here in a special way.

Diagnosis
A case can be made that diagnosis is an undervalued service in dentistry and that it is undervalued because of the mistaken belief that it is merely description.

There is one universal kind of action statement that requires no approval or authority from anyone else. That is a statement that is binding on the person who makes it for some future action—a promise.

The alternative presented here is that diagnosis is the essential foundation for all professional work and that diagnosis is performance language. Diagnosis meets all of the necessary conditions. Only certain individuals are qualified to do it, it takes place in specific circumstances, a formal language is used, and it significantly alters the person to whom the diagnosis is addressed. A hygienist or assistant can see white spots on enamel and accurately record pocket depths, but neither has the training nor the authority by a license to diagnose. The diagnosis is made in a dental setting and is based on traditionally recognized tests and examination procedures. The diagnosis follows a formula of the dentist naming a condition present in the patient, normally using professional nomenclature. But most importantly, a dental diagnosis alters the person who is diagnosed. It is something more than accurately describing the signs and symptoms; it is creating a treatable condition. Regardless of how well a dentist performs a therapeutic intervention, he or she is open to malpractice action or censure if the therapy is not based on an accurate diagnosis. From an insurance point of view, patients are ineligible to receive reimbursement under the conditions of their prepaid benefits unless an appropriate diagnosis has been made.

Because diagnosis has often been confused with description (words that tell about things) instead of being performance language (words that do things), there is a tendency to devalue it compared to the physical interventions of doing things to patients. The same confusion is less likely to occur among physicians. They normally bill patients a fee commensurate with the value added by the diagnosis and then allow follow-up by nurses and technicians who provide services at a lesser fee, presumably because these add less value. Those dentists who advertised discounted or even free diagnosis raise some concern about the worth of their diagnoses and undermine the value of diagnosis generally throughout the profession. There is a significant difference between a dentist’s diagnosis and a free estimate for getting one’s roof repaired.

The story had been told before but bears repeating in this context. An old gentlemen ran the power plant in a small New England community for years until his retirement. Several months into the watch of his replacement the plant failed and the town was in darkness for hours. Nothing the new man did revived the system. In desperation he phoned the fellow who had kept the plant in operation for so many years and the old guy promptly restored the power simply by kicking one of the pieces of equipment. He provided a bill to the city fathers of $408. When questioned about the high cost of such an easy solution, the old-timer itemized his work as follows: “Kicking $8; knowing where to kick $400.”

Promises
Philosophers such as J. L. Austin have proposed various classifications and analyses of performance language. There is one category of words that do things that merits special attention. These are promises. The first criterion for performance language is that a person of special status must be authorized to make the statement that causes an action. There is one universal kind of action statement that requires no approval or authority from anyone else. That is a statement that is binding on the person who makes it for some future action—a promise. Each of us is qualified (subject to certain exclusions for age, competence, and capacity to perform) to create relationships with others that commit us to predictable behavior in the future. Almost any circumstance is appropriate and the formal language (“I promise you …”) applies. In the case of promises, performance language alters both the person to whom spoken and the person doing the speaking. It creates a relationship among them.

Sentences that do work, those that confer status, create relationships, or engender expectations are called performance language.

One of Stephen Covey’s seven habits of highly effective people is putting first things first. Covey defines discipline as keeping the promises we make to ourselves. It is obvious that promising has the capacity to change people. One of these capacities is to create trust. This is an essential condition for human interaction—the ability to go about our own business on the assumption that others will do theirs consistently and as promised. Without such trust, life would be brutish, superstitious, and primitive. Consider the simple act of signing one’s name on a piece of paper at the end of a pleasant dinner (normally without reading anything more then the total charge) and then several weeks later signing a check to the credit card company that covers, among other things, the cost of the dinner. The check is a warrant authorizing another, unknown person to adjust your assets. All of these transactions are based on promises, and in a society that keeps such promises, life is richer and more fulfilling. Contrast this with the barter arrangement between strangers in primitive societies or with the failure of the Russian economy and its tax and banking systems.

Descriptions are subject to being tight or wrong and can be verified by reference to the facts. If a pocket depth reading is charted as four millimeters, this description can be verified or repudiated by re-measuring. The same sort of truth test does not apply to performance language, such as diagnosis. Two professionals can agree on the descriptive language that supports the diagnosis and still disagree on the diagnosis. Although performance language is subject to disagreement, there are elaborate mechanisms that govern how disputes are resolved. Normally this involves appeal to other professionals who are qualified to make their own performance language statements. A marriage, for example, is not dissolved by people agreeing that they no longer love each other. Only certain bodies are recognized as having authority to overturn performance language announcements such as revoking a dental license or disputing a diagnosis in a malpractice suit. If disputes over performance language could be resolved by appeal to the facts, lawyers would be an unnecessary class of professionals.

A case can be mode that diagnosis is on undervalued service in dentistry and that it is undervalued because of the mistaken belief that it is merely description.

There is a school of ethics, known as discursive ethics, that places promises in a central role. In fact, a discursive ethicist would say that beneficence is a promise to do one’s best to benefit others; nonmaleficence is a promise to avoid harm (either intentionally or unintentionally through performing work one is not qualified to undertake); veracity is a promise not to mislead others; etc. None of these are principles in the abstract sense—all of them are actions performed with words that have the effect of changing the particular person who makes the promises and those who receive the promises.

For a discursive ethicist, veracity and autonomy has special meaning. For one such as Jurgen Habermas, veracity—freedom from misleading others is more than an ethical principle; it is a precondition for any ethical relationship. No promise is meaningful without a presumption that those involved will refrain from being misleading. Autonomy also has a special meaning in discursive ethics. To be valid, all promises must be freely given and un-coerced. This means the promisor must be informed and have the opportunity to promise or refrain from promising as they see fit. The opposite of autonomy is paternalism. This is the position of withholding information, attempting to decide for others what is in their best interests, coercing or limiting the options of others, and in general denying them the right to make reciprocal promises. Discursive ethicists are very keen on informed consent. In the extreme view, it might be said that without informed consent the ability to create a mutually satisfactory relationship through promises—all of the other ethical principles are substantially diluted.

Each of us is qualified…to create relationships with others that commit us to predictable behavior in the future.

With respect to making promises and other uses of performance language, dentists are in powerful positions. Their training gives them wide expertise and freedom of choice; they are recognized by society generally and by law specifically as having authority to do things with words, such as make diagnoses, that no one else can do. This power gives them unusual influence in creating the kind of world they would like to live in.

As a rule dentists prefer a world that is orderly and trusting. They give the benefit of the doubt to patients and their professional colleagues. Occasionally they are disappointed by a bad actor, but for the most part they persist in making promises along high, ethical grounds and expecting that others will do the same. Dental malpractice is confined to a fraction of practicing dentists, but it is more damaging than its numbers would indicate. A dentist who mistreats patients or defrauds an insurance company is guilty of a transgression against the patients or the company and of a significant offense against the profession and the community at large. Not only has a promise to be competent or truthful been broken, but the whole fabric of trust—a community based on mutual promises—has been eroded.

Reference

Chambers DW. Promises. Journal of the American College of Dentists, 2000, 67, 51-54.

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