Strategic manoeuvring with leading questions in medical consultations

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Strategic manoeuvring with

leading questions in medical

consultations

Master thesis submitted by

Matthijs Looij, 11782099, matthijslooij@gmail.com June 2019

University of Amsterdam Faculty of Humanities

RMA Argumentation, Rhetoric and Communication Supervisor: dr. A.F. Snoeck Henkemans

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Abstract

In this thesis, I explore how doctors can use leading questions to manoeuvre strategically in medical consultations. Doctors can use this type of questions to steer the patient into the direction of their own preference, which can be expected to happen, because the patient has the legal right to make the final decision during the consultation. In order to be able to analyse some examples of strategic manoeuvring with leading questions in medical consultations, I discuss the ideal model of shared decision making and the medical consultation as a communicative activity type with its own institutional constraints with respect to strategic manoeuvring, as well as two different types of leading questions (rhetorical questions and answer-suggesting questions) with their characteristics, felicity conditions and argumentative functions.

By analysing several examples, I will show that both rhetorical questions and answer-suggesting questions can be used to present standpoints in the confrontation stage, to propose starting points in the opening stage and to present arguments in the argumentation stage. Strategic manoeuvring with leading questions in medical consultations can be effective because it enables the doctor to present her own choice as the most obvious while at the same time making it seem as if the choice is completely up to the patient. When this is in fact not the case and the patient’s freedom is impeded, the doctor’s strategic manoeuvre derails.

Acknowledgements

There are several people that I would like to thank for their (indirect) contribution to this thesis. First and foremost, I am very grateful to my supervisor Francisca Snoeck Henkemans for her guidance during the process and her feedback on earlier versions of this thesis. Furthermore, I want to thank the members of the Department of Speech Communication, Argumentation Theory and Rhetoric for their comments and advice during the plenary meetings of the research internship. Last but not least, I would like to thank everyone that has supported me and by doing so indirectly contributed to this thesis.

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1. Introduction

In the extended pragma-dialectical argumentation theory, argumentation is analysed from both a dialectical and a rhetorical perspective. It is assumed that discussants try to reach the dialectical goal of resolving a difference of opinion in a reasonable way, while at the same time trying to reach the rhetorical goal of resolving the dispute in their own favour. Discussants can be expected to manoeuvre strategically between these two goals and, ideally, they are both reasonable and effective at the same time (van Eemeren & Houtlosser 2002, 2006; van Eemeren 2010). In strategic manoeuvring, three aspects are involved: discussants make a selection from the topical potential, they use certain presentational devices and they adapt their moves to audience demand (van Eemeren 2010: 93).

An example that is often used to explain the concept of strategic manoeuvring (see for instance van Eemeren 2010: 208 and van Eemeren & Snoeck Henkemans 2017: 141) is the following extract, taken from John le Carré’s novel A Perfect Spy:

(1) Do you love your old man? Well then…

This argument is used by a father who tries to prevent his little son from crying over his father’s heading off again after a short visit. In this extract, the father uses a rhetorical question to establish the premise ‘If you love your old man, you should not cry’ as a common starting point, which he turns into an argument by saying ‘Well then…’ As such, the rhetorical question in this extract is an example of strategic manoeuvring with presentational devices.

Snoeck Henkemans (2009) points out that rhetorical questions can be used strategically to put forward standpoints, to propose common starting points and to put forward arguments. Not only rhetorical questions can serve as a means to manoeuvre strategically; there are several types of leading questions1_{that can steer the other discussant into a certain direction}

and, thus, could be used to manoeuvre strategically.

Since argumentation can best be analysed in its institutional context (van Eemeren 2010), I want to assess the role that leading questions can play in strategic manoeuvring in a specific activity type: the medical consultation.2_{For medical consultations, the so-called model of}

shared decision-making is generally viewed as ideal (Stiggelbout et al. 2015: 1172). Generally speaking, according to this model, the doctor and the patient should work together to come to a treatment option that is in line with both parties’ preferences. Since those preferences do

1_{I use the term ‘leading questions’ to refer to all kind of questions that steer the other discussant into a certain}

direction, unlike Cross (1979) who uses the term for a very particular type of question, as will be discussed in chapter 3.

2_{Medical consultations have been described as a communicative activity type by Pilgram (2015) (see also chapter}

2). Other activity types in the medical domain are for instance health brochures (see van Poppel 2013) and medical advertisements (see Wierda 2015).

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not necessarily lead to the same outcome, a difference of opinion may arise.3_{Depending on}

the type of difference of opinion, one or both of the parties should advance argumentation in favour of their own treatment preference, and hence can be expected to manoeuvre strategically. Snoeck Henkemans & Mohammed (2012) have shown that strategic manoeuvring in medical consultations can take place within the limits of the ideal model of shared decision-making. In this thesis, I want to examine the role of leading questions in this process, with a focus on the doctor’s strategic manoeuvres. Therefore the research question of this thesis is: How can leading questions be used by the doctor to manoeuvre strategically in

medical consultations?

The reason to focus only on the doctor is twofold. First, according to the ideal model of shared decision-making, it is the patient’s legal right to make the ultimate decision. Nevertheless, the doctor could steer the patient into a certain direction, i.e. that of her preference. Second, the doctor acts as the discussion leader, which gives her the opportunity to steer the discussion.

There are a lot of guidelines for medical communication, which are not consistent in their advice concerning the use of leading questions in the shared decision-making process. According to the Calgary-Cambridge Guide, for example, the doctor should offer the patient suggestions and choices rather than directives, she should encourage the patient to contribute to the discussion and she should check if the patient accepts the plans (Silverman et al. 2005). How (i.e. by means of what discussion strategies) this should be accomplished remains unclear, but it can be expected that leading questions are not one of them. Gilligan et al. (2017) systematically reviewed 47 publications with communication advice for oncologists to come to a guideline, and stress that the doctor should promote the patient’s autonomy, she should make the patient aware of all treatment options and she should frame treatment options in the context of the patient’s goals and principles. Again, the role of leading questions is not explicitly mentioned, but it can be expected that they should not be used according to these authors. Whereas these guidelines remain rather general in their advice, Drossman (n.d.) explicitly mentions that doctors should not use leading questions.

According to the above mentioned guidelines, doctor’s should at least be careful using leading questions, because the patient’s freedom could easily be restricted, which would be in conflict with the ideal model of shared decision-making. Therefore, it is interesting to explore how leading questions can be used to manoeuvre strategically in medical consultations, i.e. how they are used to be as effective as possible and under which circumstances these strategic manoeuvres derail. Examining the role of leading questions in the specific activity type of the medical consultation is also interesting because each activity type has its own institutional constraints and the strategic potential of this type of questions has until now only been described in general (see for instance Snoeck Henkemans 2009).

3_{In cases in which the patient only casts doubt on the doctor’s standpoint to opt for a certain treatment option,}

the difference of opinion is non-mixed. When both parties argue for a certain treatment option, the dispute is mixed.

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7 To be able to answer the research question, I will first discuss the ideal model of shared decision-making and the medical consultation as a communicative activity type in chapter 2. In this chapter I will also discuss the institutional constraints on strategic manoeuvring in medical consultations. In chapter 3, I will discuss two types of leading questions by defining their characteristics and felicity conditions, as well as discussing their possible argumentative functions. In chapter 4, I will explore how these questions can be used by the doctor to manoeuvre strategically in medical consultations by analysing some prototypical examples. For every discussion stage, I will examine what the role of leading questions can be in that particular discussion stage and when the strategic manoeuvre derails. In chapter 5, I will summarise and discuss my findings.

2. Strategic manoeuvring in medical shared decision-making

2.1 Shared decision-making

For medical decision-making involving a doctor and a patient, the so-called model of shared decision-making (SDM) is nowadays generally viewed as the preferred model (Stiggelbout et al. 2015: 1172). Unlike older models for doctor-patient communication, such as the paternalistic model, in which the decision for the best medical treatment is entirely left to the doctor, and the informed decision-making model, in which the patient makes the treatment decision on her own, in SDM both parties try to come to a joint decision about the best medical treatment for the patient (Charles et al. 1997: 682-683). The process of shared decision-making is seen as particularly important in cases with no clinically superior option (Clayman et al. 2012: 367).

There is a lot of literature about shared decision-making, and its exact definition is still up for discussion. Makoul & Clayman (2006), for instance, provide a list of nine ‘essential elements’ (see also Clayman et al. 2012), whereas Stiggelbout et al. (2015) define SDM in the form of four steps that should be taken in the process.4_{There is nonetheless consensus about}

the most important characteristics that should at least be present: (1) both doctor and patient are involved in the decision-making about the treatment, (2) they share information with each other, (3) they present treatment preferences, and (4) they jointly agree on the final choice for the treatment (cf. Charles et al. 1999: 652).

According to the ideal model of SDM, both the doctor and the patient should be involved in the decision-making process, share information with each other and present their treatment preferences (characteristic 1-3). Both parties make an essential contribution to this process, because of the twofold ‘epistemic’ asymmetry between doctor and patient (Raymond 2014). On the one hand, there is a difference in biomedical expertise: the doctor is usually most knowledgeable when it comes to biomedical insights (Raymond 2014: 39; see

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also Charles et al. 1997, 1999).5_{On the other hand, there is a difference in expertise on the}

patient’s preferences: the patient is, obviously, most knowledgeable about her own personal preferences. These preferences could relate to medical decisions, for instance the preference for a certain treatment method, based on experiences, or to more practical decisions, for instance the distance to a hospital or the amount of time a certain treatment option will take (Raymond 2014: 39). According to the fourth characteristic formulated by Charles et al. (1999), the doctor and patient jointly agree on the final choice for a treatment option. Nevertheless, the ultimate right to make the decision about the treatment resides with the patient.6_{This difference in legal rights could be called a ‘deontic’ asymmetry (Lindström &}

Weatherall 2015). To make sure that all these steps (or characteristics) are taken care of, the doctor acts as discussion leader (Pilgram 2015: 22; Snoeck Henkemans & Wagemans 2019).

Following the shared decision-making model, in a medical consultation a doctor and a patient strive to reach a treatment decision that will not only improve the patient’s health, but that also meets both the doctor’s and the patient’s medical expectations and preferences regarding the available treatment options (Labrie 2012: 177). Since the expectations and preferences of both the doctor and the patient do not necessarily lead to the same conclusion, a difference of opinion could arise.7_{Consequently, both the doctor and the patient may have}

to advance argumentation in favour of their own preference (and, possibly, against the other party’s preference) and they can both be expected to manoeuvre strategically while arguing for the treatment option of their preference. In the next section, I will discuss the (institutional) limitations of strategic manoeuvring in medical consultations.

2.2 Strategic manoeuvring in medical consultations

To be able to analyse argumentation in its institutional context, van Eemeren (2010) introduced the concept of communicative activity types: culturally established communicative practices that have become more or less conventionalised and that are institutionalised to a certain degree. The medical consultation can be seen as an institutionalised communicative practice between a doctor and a patient: it only occurs in assigned places (such as hospitals) and is strongly regulated by institutions (Pilgram 2015: 20). The context of a medical consultation affects the way in which the doctor provides her argumentation (Pilgram 2009: 154).

In the extended pragma-dialectical theory, the combination of the following four preconditions is unique for every activity type: (1) the activity type’s initial situation, (2) its starting points, (3) the argumentative means available in the activity type, and (4) its possible

5_{As van Klaveren (2017) notices, it can be assumed that the average level of biomedical knowledge asymmetry}

have been reduced over the past decades, due to the fact that medical information can easily be accessed through the internet, which is often done prior to the consultation.

6_{In cases in which the doctor and patient both favour the same treatment option, the difference of opinion is}

resolved; in cases in which the doctor and patient disagree about the best treatment option, the dispute is settled by the patient’s ultimate decision.

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9 outcomes (van Eemeren 2010: 152-158). These preconditions are the empirical counterparts of the four stages of a critical discussion: the confrontation stage, opening stage, argumentation stage and concluding stage. In what follows, I will discuss the four preconditions of medical consultations as well as the possibilities for strategic manoeuvring in each discussion stage.

2.2.1 Confrontation stage and initial situation

The initial situation in a medical consultation is a lack of agreement between the doctor and the patient about the doctor’s advice, or the doctor assuming that the patient is hesitant to fully accept her advice (Pilgram 2015: 22).8_{In the first discussion stage, the confrontation}

stage, it becomes clear what the difference of opinion is about and what type of difference it is (van Eemeren & Grootendorst 2004: 60, 135). In line with the ideal model of SDM, the doctor is obliged to defend the standpoints that the different treatment options medically speaking are each an acceptable choice (Snoeck Henkemans & Wagemans 2019). Assuming that the patient does not yet have taken a standpoint, the difference of opinion is a non-mixed multiple one.9_{The doctor’s commitment to these standpoints results from her}

obligation to inform the patient about which medically acceptable treatments are possible (Snoeck Henkemans & Wagemans 2019).

While some scholars argue that the doctor should not put forward a standpoint on which of the possible treatments is the most suitable, others argue that doctors are allowed to indicate which treatment option they prefer (Snoeck Henkemans & Wagemans 2019). Based on the second view, a doctor can manoeuvre strategically by establishing a definition of the difference of opinion that is optimal for herself (cf. van Eemeren 2010: 45). She can do so by formulating her standpoint as effectively as possible, that is, in such a way that it could be defended best. In the view according to which doctors are not allowed to argue for the treatment option of their preference, there is not much space for strategic manoeuvring: the doctor is only allowed to present the different treatment options (i.e. to defend the standpoint that all available treatment options are, medically speaking, an acceptable choice). Every attempt by the doctor to present one of the treatment options as a better choice would, in this view, be regarded as a derailment of strategic manoeuvring.

2.2.2 Opening stage and starting points

In the opening stage, the starting points for the discussion are established (van Eemeren & Grootendorst 2004: 60, 137). There are two types of starting points: procedural and material

8_{Besides the doctor’s advice for a treatment option, the difference of opinion can also be about her diagnosis or}

prognosis (Pilgram 2015: 22). In this thesis I focus on discussions about treatment options, so consultations about diagnoses will not be discussed in this section.

9_{According to Snoeck Henkemans & Wagemans (2019) there are multiple standpoints in this situation (1. T}₁_{is an}

acceptable choice; 2. T2 is an acceptable choice, etc.). Instead, one could say that this is one standpoint (1. T1-Tn are

all acceptable choices). The latter would make it a single (instead of a multiple) difference of opinion. Snoeck Henkemans & Wagemans did not choose this option, because the acceptability of all treatment options (T1-Tn)

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starting points. Procedural starting points concern the procedure of the discussion (i.e. the discussion rules and the division of the burden of proof), while material starting points consist of propositions that the discussants may use in their argumentation (van Eemeren & Grootendorst 2004: 60). The doctor acting as the discussion leader is an example of a procedural starting point (Pilgram 2015: 22).

Another procedural starting point is the division of the burden of proof. This division depends on the type of difference of opinion: in a non-mixed difference of opinion, only one party carries the burden of proof: the party that put forward a standpoint (in this activity type that will generally be the doctor); in a mixed difference of opinion, both parties carry the burden of proof for their own standpoint (Snoeck Henkemans & Wagemans 2019). Yet another procedural starting point is the patient’s right to make an ultimate decision for the treatment option of her preference, as well as all the other characteristics of SDM (such as both parties’ involvement in the SDM process and them sharing information with each other).10

When it comes to the material starting points, it is generally speaking the doctor who determines the starting points with respect to medical facts, whereas the patient determines those starting points concerning her own preferences and values (Pilgram 2015: 23; Snoeck Henkemans & Wagemans 2019).

A doctor can manoeuvre strategically in the opening stage by establishing the procedural and material starting points that are optimal for herself (cf. van Eemeren 2010: 45). Although the procedural starting points are to a high degree institutionalised by the ideal model of shared decision-making, there are possibilities for strategic manoeuvring in proposing material starting points in such a way that they are most likely to be accepted by the other party.

2.2.3 Argumentation stage and argumentative means

The aim of the argumentation stage is to test the acceptability of a standpoint by an exchange of arguments and criticism (van Eemeren & Grootendorst 2004: 61). In the process of SDM, the aim of this exchange is to make a choice between the different treatment options (Snoeck Henkemans & Wagemans 2019). As their argumentative means, the doctor and patient can advance argumentation based on the established material starting points, i.e. the doctor’s medical expertise and the patient’s personal preferences and values (Pilgram 2015: 23). The material starting points form the basis for decision criteria on the basis of which the treatment can be chosen. In the process of SDM, these decision criteria are related to the consequences of carrying out various treatments (Snoeck Henkemans & Wagemans 2019).

According to Snoeck Henkemans & Wagemans (2019), the argumentation in medical consultation generally follows this prototypical pattern:

10_{Pilgram (2015: 22) furthermore mentions the legal requirement of informed consent (which is more or less the}

same as the patient’s right to make an ultimate decision, which is also a part of the SDM model) and explicitly incurred codes of ethics (such as the Hippocratic Oath) as examples of procedural starting points.

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11 1 Treatment option T1 is the best choice from the medically acceptable treatment

options T1-Tn

1.1 Of the medically acceptable options, treatment option T1 is most in agreement with

the patient’s preferences

1.1’ The treatment option that is most in agreement with the patient’s preferences is the best choice from the medically acceptable treatment options T1-Tn

A doctor can manoeuvre strategically in the argumentation stage by establishing argumentation that constitutes an optimal defence of the standpoint at issue, or by raising critical doubts that constitute an optimal attack on the standpoint(s) and the argumentation by the patient (if any) (cf. van Eemeren 2010: 45). In other words, a doctor should choose and formulate arguments that are expected to be the most convincing to the patient.

2.2.4 Concluding stage and possible outcomes

The aim of the concluding stage is to establish the outcome of the discussion (van Eemeren & Grootendorst 2004: 61-62, 154). The discussion outcome could be agreement between the doctor and patient about the best treatment option (Pilgram 2015: 24). In these cases the difference of opinion is resolved. Since it is the patient’s legal right to make the ultimate decision, it could also be the case that she decides to opt for a different treatment than the one that was recommended by the doctor (Snoeck Henkemans & Wagemans 2019). In these cases the dispute is settled. Pilgram (2015: 24) points out that it is in principle not possible to go back to the initial situation: they cannot start the discussion again from scratch (which would be possible in, for instance, informal discussions). Nevertheless, the doctor and patient could start a new consultation once new material starting points enter the discussion (such as new results from laboratory tests or alternative treatment options).

In general, a discussant can manoeuvre strategically in the concluding stage by establishing the results of the critical procedure in the way that is optimal for her as a way of maintaining her standpoint (cf. van Eemeren 2010: 45). Since the ultimate right to make a final decision resides with the patient, there is not much room for strategic manoeuvring for the doctor in the concluding stage.

2.2.5 General strategies to manoeuvre strategically in SDM

Snoeck Henkemans & Mohammed (2012) discuss three strategies that a doctor could use in shared medical decision-making to manoeuvre strategically. They argue that strategic manoeuvring within the boundaries of the ideal model of SDM is possible, although derailments might occur.

The first strategy is presenting the recommendation in such a way that the patient seems to participate in the decision making process about the best treatment (Snoeck Henkemans & Mohammed 2012: 25). If this is in fact not the case, strategic manoeuvres like this are derailed, since they are in conflict with the ideal model of SDM (according to which both the doctor and the patient should participate in the decision-making process).

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The second strategy is presenting the available treatment options in such a way that the treatment preferred by the doctor seems to be the most reasonable option, for instance by presenting it as the standard treatment (Snoeck Henkemans & Mohammed 2012: 26). If the doctor neglects the patient’s wishes, she fails to act in accordance with the ideal model of SDM, according to which the patient’s treatment preferences should be taken into account.

The third strategy is presenting the recommendation in such a way that it looks as if the decision is completely up to the patient (Snoeck Henkemans & Mohammed 2012: 27). If the decision is, in fact, not made by the patient, the strategic manoeuvre derails, because it is the patient’s legal right to make an ultimate decision.

In principle, the doctor could use these strategies in various discussion stages; they are not limited to one specific discussion stage. Furthermore, it needs to be noticed that these strategies are quite general: there are several possibilities to apply these strategies.

Before examining the role of leading questions in strategic manoeuvring in medical consultations, I will first define two different types of leading questions in the next chapter.

3. Questions in argumentative discourse

3.1 Introduction

In pragma-dialectics, argumentation is defined as:

A verbal, social, and rational activity aimed at convincing a reasonable critic of the acceptability of a standpoint by putting forward a constellation of propositions justifying or refuting propositions expressed in the standpoint (van Eemeren & Grootendorst 2004: 1).

According to van Eemeren & Grootendorst (1984), argumentation is a complex speech act, consisting of more than one elementary illocution, that belongs, in principle, to the Searlean category of the assertives.

Although argumentation is thus prototypically put forward by means of assertives (i.e. statements), questions can also play an important role in argumentative discourse. Critical questions, for example, serve as a means to evaluate the soundness of the argument scheme that is used (see for instance Garssen 1997; van Eemeren, Houtlosser & Snoeck Henkemans 2007; van Eemeren & Snoeck Henkemans 2017). Other research on questions in argumentation focuses, among other things, on the general characteristics and the reconstruction of question-answer sequences in a critical discussion (van Eemeren et al. 1993; Polcar 2007), or the specific evaluation of questions in argumentative discourse (Walton 1989). The role of specific types of questions in argumentation has also gained attention, for instance by Slot (1993), Ilie (1994) and Snoeck Henkemans (2009) who examined rhetorical

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13 questions, and Taraman (2010) who discussed the strategic function of premise-eliciting questions.

In this thesis, I am interested in the role of leading questions in doctor-patient consultations. In the next section, I will discuss two different types of leading questions and their function in argumentative discourse.

3.2 Two types of leading questions and their argumentative functions

Based on the literature about specific types of questions in argumentative discourse as mentioned above, and on the types of questions I found in the excerpts, I distinguish two types of leading questions: rhetorical questions and answer-suggesting questions. In this section, I will discuss these two types by discussing the characteristics and the felicity conditions of each type. To get a better understanding of these types and to see how they differ from informative (‘real’) questions, I will first discuss real questions.

3.2.1 Informative (‘real’) questions

According to Searle (1969), questions belong to the category of the directives: their aim is to get the hearer to provide an answer. The felicity conditions for informative (‘real’) questions are as follows (Searle 1969: 66)11_:

Propositional content condition

Any proposition or propositional function.

Preparatory conditions

1. S does not know ‘the answer’, i.e., does not know if the proposition is true, or,

in the case of the propositional function, does not know the information needed to complete the proposition truly.12

2. It is not obvious to both S and H that H will provide the information at that

time without being asked.

Sincerity condition

S wants the information.

Essential condition

Counts as an attempt to elicit this information from H.

Although informative questions can play an important role in doctor-patient consultations (e.g. in determining what the precise problem is), according to van Eemeren & Grootendorst

11_{In the felicity conditions, S stands for speaker and H stands for hearer.}

12_{Searle (1969) makes a distinction between ‘real questions’ and ‘exam questions’. The difference between the two}

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(2004), they do not play a role in the process of resolving a difference of opinion (see also Taraman 2010, who provides a nice summary of the different speech acts that play a role in the resolving process). Consequently, all questions with an argumentative function must be another type of question, for instance an indirect speech act such as a rhetorical question. An indirect speech act is ‘one in which one illocutionary act is performed indirectly by way of performing another’ (Searle 1979: 60). Indirect speech acts have a primary and a secondary illocutionary act: the primary illocutionary act is performed by way of the secondary illocutionary act.

3.2.2 Rhetorical questions

Since argumentation is prototypically put forward by means of assertives (cf. van Eemeren & Grootendorst 1984), rhetorical questions can be expected to be a strategic means to put forward a standpoint or to advance argumentation indirectly (cf. Houtlosser 1995: 313): the secondary illocutionary act is a question (directive), but the primary illocutionary act is a statement (assertive). Ilie (1994: 45-46) defines rhetorical questions by providing a list of five ‘distinctive features’. First, there is a discrepancy between the interrogative form of the rhetorical question and its communicative function as a statement. Second, there is a polarity shift between the rhetorical question and its implied answer: an affirmative rhetorical question usually implies a negative answer and vice versa (Ilie 1994: 51-52). Third, the answer to the rhetorical question is implicit and exclusive. As an indirect speech act, a rhetorical question does not convey its message explicitly. Its message derives from its one and only implied answer that excludes all other answers. The addressee has to infer this specific answer (Ilie 1994: 53). Fourth, the speaker is committed to the implicit answer. Unlike in the case of ‘real’ questions, the speaker does not want the hearer to answer the question, but she wants to make the hearer aware of the answer she regards as the only possible one. Since she excludes all other answers, she is also committed to the implied answer (Ilie 1994: 56). Fifth, rhetorical questions are multifunctional: they can fulfil more discursive functions at the same time, e.g. giving information, being ironical or expressing an opinion (Ilie 1994: 59-60). Slot (1993) distinguishes four functions of a rhetorical question: its evasive function, its persuasive function, its function of drawing attention and its aesthetic function.

This characterisation can be illustrated by means of the following example13_:

(2) D: You really should stop smoking. Or do you want to get lung cancer?

The question posed by the doctor (in italics) is a rhetorical question. The answer is no, obviously; there is no need for the patient to really answer the question. Instead, the doctor in fact states that the patient does not want to get lung cancer, so she definitely should stop smoking. All characteristics proposed by Ilie (1994) are present: there is only one possible

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15 answer (‘no’), all other answers are excluded, there is a polarity shift between the affirmative question and the negative answer, the communicative function of the question is a statement and, thus, the doctor cannot deny her commitment to the implicit answer.

Since rhetorical questions are indirect assertions, the felicity conditions for the elementary speech act are the same as those of assertions (Searle 1969: 66):

Any proposition.

1. S has evidence for the truth of the proposition.

2. It is not obvious to both S and H that H knows (does not need to be reminded

of, etc.) the proposition.

S believes that the proposition is true.

Counts as an undertaking to the effect that the proposition represents an actual state of affairs.

Ainsworth-Vaughn (1994: 210) argues that doctors can use rhetorical questions in consultations to strategically mitigate their authority and to indirectly put forward criticism or commands. Although the use of rhetorical questions that she describes is not (necessarily) argumentative14_{, rhetorical questions can also have a persuasive function, and can thus be}

used to manoeuvre strategically. According to van Eemeren, Houtlosser & Snoeck Henkemans (2007: 94), asking a rhetorical question is a quite common means of proposing a premise as a starting point in the discussion. Rhetorical questions that are used to propose a common starting point often include adverbs and expressions like ‘then’, ‘now’ and ‘just’, and tag-questions such as ‘is it?’ and ‘isn’t it?’. Besides its function as a means to propose common starting points, rhetorical questions can also be used to put forward a standpoint or argumentation (Houtlosser 1995: 313; Snoeck Henkemans 2009: 15).

When rhetorical questions are used in argumentative discourse, the felicity conditions are a bit different than described above. When a rhetorical question is used to present a standpoint, the speech act counts as an undertaking to make H aware of S’s standpoint; when it is used to present an argument, the speech act counts as an attempt to convince H of

14_{Ainsworth-Vaughn (1994: 199-200) provides examples like ‘Why don’t you hop aboard?’ and ‘Why don’t I plan}

on seeing you the day you come in for your second chemo, which will be in about four weeks?’ that are indirect commands in which the doctor uses her structural power over the patient.

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the truth (or acceptability) of S’s standpoint.15_{When a rhetorical question is used to propose}

a common starting point, it functions as a premise-eliciting question (cf. Taraman 2010).16

Since in this case the rhetorical question functions as a proposal (belonging to the Searlean category of the commissives), the felicity conditions are different, and could be formulated as follows (Taraman 2010: 12-13):

The question’s propositional content is relevant to the defence of the protagonist’s standpoint.

1. H has not yet explicitly agreed (or disagreed) to the proposition.

2. S believes that H is willing to make his agreement (or non-agreement)

explicit.

S wants H to explicitly agree (or disagree) on the proposition.

Counts as an attempt to elicit agreement (or non-agreement) to a proposition from the other party which can subsequently be used as a common starting point.

According to Slot (1993: 133), rhetorical questions are persuasive ploys that are aiming at winning the difference of opinion, rather than resolving it. Whereas Slot (1993) seems to argue that strategic manoeuvring with a rhetorical question is likely to derail, Snoeck Henkemans (2009) takes a more moderate position. She argues that a rhetorical question ‘can be a useful means of realising important dialectical and rhetorical objectives in […] a discussion’ (Snoeck Henkemans 2009: 20). Nevertheless, strategic manoeuvring with rhetorical questions can derail when a discussion rule is violated.

3.2.3 Answer-suggesting questions

Another type of leading questions are what I call ‘answer-suggesting questions’. These questions are a very specific type of what Cross (1979) calls ‘leading questions’. The answer elicited by a leading question is normally expected to confirm the questioner’s assumptions about facts or data that are expected to be known by both the questioner and the answerer

15_{The second preparatory condition would then be: It is not obvious to both S and H that H has already accepted}

S’s standpoint.

16_{The term ‘premise-eliciting questions’ refers to all kind of questions that are used to propose a premise as a}

common starting point in the discussion (see Taraman 2010 for an extensive description of premise-eliciting questions).

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17 (Ilie 1994: 55). Cross (1979: 226) defines a leading question as ‘one which either (a) suggests the answer desired, or (b) assumes the existence of disputed facts as to which the witness is to testify’. This definition and the examples Cross uses make clear that he is merely interested in the legal context and that the type of questions he refers to with leading questions are more or less the same as what in argumentation theory is known as the fallacy of many questions. That is not what I mean with answer-suggesting questions, so although there are some similarities, Cross’ leading questions and my answer-suggesting questions are not quite the same.

As the name suggests, answer-suggesting questions lead the hearer to a particular answer that is strongly suggested by the speaker. The speaker is committed to this preferred answer, which she thinks is the only ‘correct’ one. This is what answer-suggesting questions have in common with rhetorical questions. But unlike rhetorical questions, answer-suggesting questions need to be answered by the hearer (which they have in common with real questions). Since answer-suggesting questions require an answer from the hearer, a very specific answer that is suggested by the speaker, they belong to the Searlean category of directives.

The following example illustrates this characterisation:

(3) D: You are coughing all day. Do you really not want to stop smoking?

The doctor’s question (in italics) is an example of an answer-suggesting question. It is clear that the doctor suggests that the patient should want to stop smoking. Unlike in the case of a rhetorical question, the doctor wants the patient to answer the question. In principle, the patient could provide a reason why she does not want to stop smoking, but it is clear that this is not the preferred answer to the doctor’s question.

Based on the above description of answer-suggesting questions, the felicity conditions can be formulated as follows17_:

Any proposition.

1. S has reasons to believe that answer A is the one and only right answer to the

question.

2. It is not obvious to both S and H that H will provide the information at that

time without being asked.

S believes that A is the one and only right answer to the question.

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18

Counts as an attempt to get H to answer the question with A.

An answer-suggesting question can, in principle, have any propositional content, as is reflected in the propositional content condition. Asking the answer-suggesting question counts as an attempt by de speaker to get the hearer to answer the question with the specific answer A that is preferred and strongly suggested by the speaker (essential condition). The propositional content condition and the essential condition together are called the identity conditions of the speech act and specify the conditions under which a question can be identified as an answer-suggesting question (cf. van Eemeren & Grootendorst 1984: 39-42). The circumstances under which the performance of the answer-suggesting question would be correct are reflected in the correctness conditions: the preparatory conditions and the sincerity condition. According to the first preparatory condition, the speaker should have some kind of reason to believe that answer A is the one and only right answer to the question. This condition is based on the first preparatory condition of rhetorical questions. According to the second preparatory condition, it is not obvious that the hearer would provide the information (i.e. answer A) anyway, otherwise asking the question would be pointless. The sincerity condition states that the speaker really believes that answer A is the only right answer to the question; therefore the speaker is committed to this answer.

Like rhetorical questions, answer-suggesting questions can be used to put forward standpoints, to propose starting points and to put forward argumentation. As is the case with rhetorical questions, when answer-suggesting questions are used in argumentative discourse, the felicity conditions are slightly different. When it is used to present a standpoint, an answer-suggesting question also counts as an undertaking to make H aware of S’s standpoint (i.e. answer A). When it is used to present an argument, the speech act counts as an attempt to convince H of the truth (or acceptability) of S’s standpoint (essential condition), and to the preparatory conditions should be added that it is not obvious to both S and H that H has already accepted S’s standpoint. When an answer-suggesting question is used to propose a starting point, it functions as a premise-eliciting question and the felicity conditions are the same as for rhetorical questions that are used as premise-eliciting questions (see above).

3.3 Analysing leading questions in argumentative discourse

The two types of leading questions that are discussed in the previous section could occur in medical consultations. Before analysing some examples of strategic manoeuvring with leading questions by a doctor, I will briefly discuss some potential difficulties with the analysis, based on the above descriptions.

Firstly, the distinction between the two categories can in practice sometimes be unclear. Although there is, in theory, a distinction between rhetorical question and answer-suggesting questions, in practice it might occur that this distinction is not always so clear. It could, for instance, be the case that the patient answers the rhetorical question because she

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19 did not interpret it as a rhetorical question. As an analyst, it is not possible to know the doctor’s intention (i.e. to know if the question was meant rhetorically or not), so based on the transcripts the question could then also be analysed as an answer-suggesting question: the patient simply answered the question with the ‘right’, suggested answer. It is, in other words, a thin line between rhetorical and answer-suggesting questions.

Moreover, it is possible that these questions occur in combination with each other and are in fact strategic because they are used together. An example is the strategy for confrontation that is discussed by Bleiberg & Churchill (1975): a confronter (here: the doctor) asks two closed (yes/no) questions followed by a rhetorical question that contradicts the confronted’s (the patient’s) original statement. This strategy can be illustrated by means of the following example, taken from Bleiberg & Churchill (1975: 274):

(4) P: I don’t want my parents to have anything to do with my life. D: You live at home?

P: Yes.

D: They pay your bills? P: Yes.

D: How could they not have anything to do with your life?

This example begins with the patient making a declarative statement. The doctor tries to show that this statement is false by pointing at facts that contradict it: by asking two premise-eliciting questions18_{, the doctor elicits two concessions from the patient. Based on these}

concessions (that have become starting points in the discussion), the doctor asks the rhetorical question how they could not have anything to do with the patient’s life, which is in fact a way of formulating his standpoint strategically.

These ‘difficulties’ are not necessarily problematic for the analysis. In this thesis, I want to show how doctors can use leading questions to strategically steer the patient into a certain direction. Whether that is a rhetorical question or an answer-suggesting question is of minor importance, since they are both types of leading questions. In the analysis, I will determine as precisely as possible what type of leading question is used, but if it is uncertain what the exact type of question is, I will still use it as an example of strategic manoeuvring with a leading question.

18_{In principle, all types of questions can be used as premise-eliciting questions. In section 3.2, I explained how}

rhetorical questions and answer-suggesting questions can function as premise-eliciting questions; this example shows that informative questions can be used as premise-eliciting questions as well.

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20

4. Strategic manoeuvring with leading questions in medical

consultations

In this chapter, I will discuss several examples of strategic manoeuvring with the two types of leading questions as discussed in chapter 3. In chapter 2, I discussed the doctor’s possibilities for strategic manoeuvring in each stage of the discussion. Consequently, the analysis follows this structure: I will analyse several examples of strategic manoeuvring with leading questions in the confrontation stage (section 4.1), opening stage (section 4.2) and argumentation stage (4.3).

The excerpts analysed in this chapter are taken from earlier publications on medical communication. For every excerpt, I will specify where it was originally published.19_{I will}

present background information as far as available in the original publication and relevant for the analysis of the strategic manoeuvring.20

4.1 Confrontation stage: strategically presenting standpoints

The doctor’s rhetorical aim in the confrontation stage is to establish a definition of the difference of opinion that is optimal for herself, i.e. to formulate her standpoint in such a way that it is most convincing. Both rhetorical questions and answer-suggesting questions could be used to do so. In excerpt 1, the doctor uses an answer-suggesting question to manoeuvre strategically.

Excerpt 121

1 D: Look, you already had two abortions, at seventeen.

2 P: I know this.

3 D: Well!?!!

4 P: But the next time I become pregnant, I’m gonna keep it.

19_{I did not make any changes in the excerpts with respect to the content. Line numbers were added to transcripts}

in which they were not present yet. For reasons of consistency, in some of the excerpts conversation analytical symbols or indications that were not relevant for the analysis were removed.

20_{It has to be noticed that most of the examples discussed in this chapter are about lifestyle changes and, strictly}

speaking, shared decision-making is about situations in which there are treatment options that are medically speaking equivalent, which is not the case in most of these lifestyle discussion (e.g. stopping smoking or not stopping smoking are not medically equivalent, obviously). Nevertheless, most of the essential characteristics of shared decision-making are present in these consultations: the doctor and the patient have to share information and their preferences, they will discuss several options and they will try to come to an outcome that is acceptable for both parties, although the patient makes the final decision whether or not to follow the doctor’s advice. Still, in this type of medical consultations, doctors can be a bit ‘harsh’ compared to medical shared decision-making in the strict sense.

21_{This excerpt is taken from Fisher & Todd (1983: 178); line numbers added by me. In this consultation, the doctor}

is a man and the patient is, obviously, a woman. According to Fisher & Todd (1983: 178), the doctor wants to ‘discourage reproductive carelessness’. Although it is not clear from this excerpt, it could be expected that the doctor’s main aim in this consultation would be to convince the patient to use contraceptives.

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21

5 D: Yeah, but I mean at seventeen and being single,

6 do you want to be pregnant?

In this excerpt, the doctor asks the patient if she wants to be pregnant (line 6). He uses an answer-suggesting question: it is clear that the doctor does not think it is a good idea for her to get pregnant (again). He provides three arguments for his standpoint: she is seventeen, she is single and she already had two abortions so apparently she did not want to be pregnant before. The argumentation structure could be reconstructed as follows:

1 You should not want to be pregnant 1.1a You are seventeen

1.1b You are single

(1.1c) (You did not want to be pregnant before) (1.1c).1 You already had two abortions

Based on the arguments provided by the doctor, it is clear what his standpoint is. Nevertheless, he wants the patient to answer his question: she needs to take a stand as well. By using an answer-suggesting question, the doctor makes it look as if he gives the patient a choice and the decision is completely up to her, although he clearly steers her into the direction of his own standpoint: the preferred answer to his question is ‘no’. By doing so, the doctor presents the option of not getting pregnant again as the preferred option. When the doctor would have put forward his standpoint directly by means of an assertion (‘You should not want to be pregnant’), it would be clear that not getting pregnant is the preferred option, but he could not make it seem as if the choice is completely up to the patient. When the doctor would have opted for a real, informative question to present his standpoint, instead of a leading question22_{, it would be clear that the choice is completely up to the}

patient, but it would not be clear what the doctor’s preferred option would be. As such, a leading question is a strategic means to both ends.

The doctor provides three arguments to defend his standpoint23_{, that are quite strong: the}

patient is very young, she is single (and has thus no-one to help her to take care for a child) and she already had two abortions (so apparently she did not want to be pregnant before). By doing so, the doctor manoeuvres strategically within the boundaries of reasonableness. Although it is a leading question, an answer-suggesting question like this still needs to be answered by the patient. She could, in principle answer that she does want to get pregnant

22_{The form of the question itself does not make it a leading question in this excerpt (a real informative question}

would have the same form); the combination of the question with the provided arguments makes clear that this is an answer-suggesting question.

23_{This could also be a sub standpoint, backing up the main standpoint ‘You should use contraceptives’. Whether}

or not this is the case does not really matter for the analysis: the doctor’s strategic manoeuvring would be within the boundaries of reasonableness either way.

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22

again (which she already hints at in line 4). The final choice to get pregnant or not is up to the patient, which is in line with the ideal model of shared decision making.

In excerpt 2, the doctor’s standpoint is presented by means of a rhetorical question. Excerpt 224

1 D: What, what do… what other kinds of exercise do you do?

2 P: Naturally we bicycle.

(12 lines omitted in which D and P discuss several types of P’s exercising)

15 P: Bicycle in the summer.

16 D: Every day or what?

17 P: Two, three times a week.

18 D: Yes for how long?

19 (short pause)

20 P: About an hour.

21 D: Yes.

22 (short pause)

23 P: Approximately five kilometres.

24 D: What prevents you from doing this every day?

25 P: Nothing does.

26 (short pause)

27 D: No.

28 P: Nothing.

29 D: Couldn't you do this every day?

30 P: We could easily do that.

In this excerpt, the doctor uses a confrontation strategy that looks like the one described by Bleiberg & Churchill (1975). The doctor asks the patient about his exercise habits (line 16, 18), followed by the question what prevents him from exercising every day (line 24). This last question could be regarded as an answer-suggesting question: it is clear that the doctor thinks that nothing is preventing him from doing so, which is indeed the patient’s answer.25

Based on this concession, the doctor asks the (rhetorical) question whether the patient could not do this every day (line 29). By means of this rhetorical question, the doctor presents indirectly the standpoint that the patient should exercise every day. The argumentation structure can be reconstructed as follows:

1 You should exercise every day

1.1a You exercise two or three times a week

1.1b Nothing prevents you from doing this every day

24_{This excerpt is taken from Guassora et al. (2015); original line numbers. In this consultation, the patient is male,}

the doctor’s sex is unknown.

25_{To be more precise: this is an answer-suggesting question that is used as a premise-eliciting question. I will}

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23 One could doubt whether the doctor’s question in line 29 is indeed a rhetorical question, or rather an answer-suggesting question. It is clear that the doctor thinks that the patient could exercise every day, which is reasonable based on the patient’s concessions. The question fits in the pattern of the confrontation strategy described by Bleiberg & Churchill, and it meets most of Ilie’s criteria: there is a discrepancy between its form as a question and its function as a statement (at least it could be interpreted this way), there is a polarity shift between the question (negatively) and its implied answer (affirmatively), there is only one ‘right’ answer and the speaker is committed to this implied answer. The last two characteristics also hold for answer-suggesting questions and since the patient really answers the question, it could also be analysed as an answer-suggesting question. Anyway, it is clear that the doctor’s question in line 29 is a leading question that is used to steer the patient into the direction of the doctor’s standpoint that he should exercise every day.

By using a rhetorical question, the doctor manoeuvres strategically, because she makes it seem as if exercising every day is the most obvious choice. Compared to the answer-suggesting question in excerpt 1, the suggestion that the doctor’s choice is the most obvious is even stronger in this example. The doctor can make such a strong suggestion because of the concessions elicited from the patient. Furthermore, the doctor manoeuvres strategically by formulating her standpoint as a question rather than as a statement, because it seems as if the patient came up with this conclusion himself (although he was clearly steered into this direction by the doctor).

It needs to be noticed that the strategic formulation of the standpoint in this excerpt does not stand on its own: the combination of the rhetorical question with the previous questions aimed at eliciting concessions is a strategic move. By eliciting these concessions from the patient, the doctor leads him to the inevitable conclusion that he should exercise every day.

The doctor strategically presents ‘exercising every day’ as the preferred option. From this excerpt it does not become clear what kind of problem should be solved (e.g. obesity, muscle and joint pain, et cetera). Therefore it is hard to evaluate the soundness of the doctor’s argumentation. If these are the only arguments provided by the doctor, the strategic manoeuvre could be derailed: exercising more often just because you can is not a good reason; there has to be another reason why the patient should exercise every day (i.e. that this will help him solving his problem, e.g. to lose weight). In light of the ideal model of shared decision making, this strategic manoeuvre might also be problematic: it does not become clear whether there were other options besides exercising every day (e.g. changing his diet), and if so, whether the doctor discussed these options. On the other hand, it could be the case that the doctor and the patient already decided together (e.g. in an earlier consultation) that exercising is important for the patient’s health. In short, to be able to give a good evaluation one would need more information.

In excerpt 2, there could be discussion about whether the standpoint is presented by means of a rhetorical question or an answer-suggesting question. A clearer example of a standpoint that is presented by means of a rhetorical question can be found in example 4, repeated below as excerpt 3, which will only be analysed briefly.

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24

Excerpt 326

1 P: I don’t want my parents to have anything to do with my life.

2 D: You live at home?

3 P: Yes.

4 D: They pay your bills?

5 P: Yes.

6 D: How could they not have anything to do with your life?

Although the discussion in this excerpt is not about a (treatment) option, it is nonetheless a nice example of a rhetorical question that is used to present a standpoint in medical communication (line 6). The doctor’s argumentation could be reconstructed as follows: 1 It is impossible for your parents not to have anything to do with your life 1.1a You live at home

1.1b They pay your bills

As discussed in section 3.3, the doctor uses two premise-eliciting questions to elicit concessions (i.e. starting points), that he turns into arguments when he presents his standpoint in the form of a rhetorical question. Based on the patient’s concessions in line 3 and 5, the doctor’s conclusion in line 6 is in fact inevitable: by using a rhetorical question, the doctor makes it seem obvious that it is impossible for the patient’s parents not to have anything to do with her life.

4.2 Opening stage: strategically proposing starting points

The doctor’s rhetorical aim in the opening stage is to establish the starting points that are optimal for herself, i.e. to propose starting points that serve her own defence best and to formulate them in such a way that they are most likely to be accepted by the patient. Both rhetorical questions and answer-suggesting questions can be used to propose starting points (and as such function as premise-eliciting questions). As soon as a premise is accepted as a common starting point, it can be used as an argument in the discussion.27_{In excerpt 4 a}

starting point is proposed by means of a rhetorical question.

26_{This excerpt is taken from Bleiberg & Churchill (1975: 274). Line numbers added by me. Female patient and}

male doctor. This conversation takes place in a therapeutic setting.

27_{The opening stage is only about the propositional content of the material starting points, not about their}

justificatory force. In other words, when a discussant accepts a premise as a common starting point, she only accepts its content and not necessarily its justificatory force for the other party’s standpoint.

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25 Excerpt 428

1 D: Are you smoking again?

2 P: Yes.

3 D: How many?

4 P: Only five.

5 D: That’s hardly worth it isn’t it?

6 P: I know… But… When you’ve got the young ‘un running around…

7 D: It helps with the stress?

8 P: It’s that or take it out on her.

9 D: Yes, that’s true.

In this excerpt, the doctor wants to elicit a concession from the patient: smoking five cigarettes is hardly worth it (line 5). He proposes this premise as a common starting point by means of a rhetorical question. By doing so the doctor manoeuvres strategically. According to Snoeck Henkemans (2009: 17), rhetorical questions that are used to propose starting points are somewhat like “offers you can’t refuse”: the doctor makes it seem as if the acceptance of the proposed starting point is taken for granted, in other words, as if it is obvious that the doctor is right and that the patient will accept this premise as a common starting point. The strategic potential becomes most clear when it is compared to alternative formulations. The doctor’s rhetorical question is (rhetorically speaking) more convincing than a real question (‘Do you think that smoking five cigarettes is worth it?’), because in the case of the rhetorical question, the acceptance is already assumed. Dialectically speaking, a rhetorical question seems to be more reasonable than an assertion (‘That is not worth it’), because the form of a question gives the patient more space to disagree (cf. Snoeck Henkemans 2009: 19). In other words, using a rhetorical question to propose a starting point is strategic because the doctor makes it seem as if it is obvious that the premise should be accepted and, at the same time, the doctor can make it look like the choice whether or not to accept the premise is up to the patient.

According to Snoeck Henkemans (2009: 22), strategic manoeuvring with rhetorical questions may derail ‘if the arguer ascribes unwarranted commitments to the opponent and tries to prevent this opponent from putting forward criticisms, either with respect to the propositional content or to the justificatory force of the argument’. That is not the case in this excerpt. After accepting the premise as a starting point in line 6 (‘I know’), the patient criticises its justificatory force by pointing at a reason why she still smokes: it helps her to relax and that is what she needs because of her young child.29_{Oddly enough, the doctor}

28_{This excerpt is taken from Pilnick & Coleman (2006: 2505). Line numbers added by me. Female patient and male}

doctor. The patient has come to the doctor for injectable contraception. During the consultation, her smoking habits are discussed (see excerpt). After the doctor’s agreement in line 9, smoking is not further discussed.

29_{In fact, the propositional content could also be criticised: why would smoking only five cigarettes a day hardly}

be worth it? One could argue that smoking only five cigarettes still helps to relax and that it is less damaging than smoking (for example) ten to fifteen cigarettes a day. Nevertheless, the patient accepts the propositional content instead of criticizing it.

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26

seems to agree with the patient (line 9). After his agreement, smoking is not further discussed. The doctor giving up his standpoint this easily could be explained by the fact that smoking is not the main reason for this consultation, and it is possible that the doctor does not want to spend too much time on discussing it. The doctor’s strategic manoeuvre to propose the starting point by means of a rhetorical question was only partly successful: the patient indeed accepted his proposal, but it did not help him to convince the patient to accept his (implicit) standpoint that she should stop smoking.

In excerpt 4, the patient does not really answer the question, but simply agrees with its propositional content (‘I know’), which makes clear that the patient perceives the doctor’s question as rhetorical. On the contrary, in excerpt 5, the patient does answer the doctor’s question.

Excerpt 530

1 D: Do you smoke?

2 P: Yes.

3 D: How much do you smoke?

4 P: From about ten to fifteen a day.

5 D: So that’s quite a bit of money isn’t it?

6 P: Yes.

7 (both D and P laugh)

(30 lines omitted in which D and P discuss what would be the best way of stopping smoking)

It is not completely clear whether the doctor’s premise-eliciting question in line 5 is a rhetorical question or an answer-suggesting question. Both could be the case: there are a lot of similarities with the premise-eliciting question in excerpt 4, but we do not know the doctor’s intention and the patient apparently did not perceive it as a rhetorical question. Anyway, this premise-eliciting question is an example of a leading question, because the doctor clearly steers the patient into the direction of an affirmative answer. The patient indeed gives the preferred answer (line 6). The doctor’s phrasing of the proposed starting point is strategic for the same reason as discussed above: the doctor makes it look like it is taken for granted that the patient will agree on the acceptance of the starting point: he makes it seem as if it is obvious that smoking ten to fifteen cigarettes a day costs a lot of money. It could be assumed that few to no people would criticise the propositional content of the premise (most people would agree that smoking that many cigarettes costs a lot of money). On the contrary, its justificatory force could easily be criticised: one could argue that smoking is worth spending a lot of money on. The doctor’s leading question is mainly strategic because he makes it seem as if the justificatory force of the premise is also obvious. The patient seems not only to accept the propositional content of the premise, but also its

30_{This excerpt it taken from Pilnick & Coleman (2010: 66). Line numbers added by me. Female patient and male}

doctor. The consultation is about oral contraceptive pills; smoking as well as the patient’s overweight are also discussed.

Strategic manoeuvring with leading questions in medical consultations