Gunjan Sharma
Devon, United Kingdom

“The arrow points only in the application that a living being makes of it.”
– Ludwig Wittgenstein¹

The language game

Language is a fascinating concept when viewed through a philosophical lens. Imagine if we no longer had a word for jealousy. Would that mean such a thing could no longer exist? Jealousy is an emotion that we experience within ourselves, yet without the word we would have difficulty in sharing this emotion with others. We would not know if such a feeling were normal or what it really meant.

One of the best known philosophers in this field is Ludwig Wittgenstein. In his work Philosophical Investigations, Wittgenstein suggests that the meaning of words and sentences do not lie in definitions but in their use or context. Wittgenstein called this the “language game” and the context in which it was played a “form of life.”² Communication in healthcare is a good example of this.

The language game in medicine

One of the most common presentations to the Emergency Department is pain.

“I have pain in my chest.”
“My arm hurts—I think I might have broken it.”
“My tummy is really sore—do you think I have kidney stones?”

In each of these sentences, the words “pain,” “sore,” and “hurt” take on a different meaning, and the language game is used to comprehend them. It is important to understand what pain means to the patient; does it mean they can no longer walk up the stairs to the bathroom? Does their headache stop them from studying for an exam? This illustrates the importance of context. The phrase “My arm hurts” might mean “I can’t write,” or “I need to cook for my family,” or “Please give me some painkillers.”

A problem occurs when the two separate cultures of patient and doctor meet, for this is when language games collide. A patient may have come to hospital because he is terrified he might have appendicitis like his brother did when he was ten, but “abdominal pain” in a doctor’s language is broader: could this be something acute? A perforation of the intestines or an obstruction blockage? Bleeding or infection?

We play this game because it works. If I say to a colleague, “This man has central chest pain, crushing in nature, and radiating to his jaw,” this has a different meaning from, “This man has central chest pain, described as burning with an acid taste in his mouth.” Both sentences use the words “chest pain” but the meaning is very different because of the context. I am speaking in a hospital setting and to a fellow clinician—not to my mother on the phone or to the flight attendant on a flight to Melbourne. But what if I were to use this language game with my patient?

The dangers of the language game

Wittgenstein describes words as tools in a toolbox.³ The correct tool needs to be used: a screwdriver is no use if one requires a hammer. Wittgenstein states there are rules in the language game just as there are rules in chess or Monopoly. These rules were made to ease the workings of the game; they do not reflect truths about the universe or the logic of our minds.⁴ For example, we have chosen to describe this color as red and that color as green so that when we use such words we are all referring to the same object. In a similar manner, we will have a concept for the word “pain” depending on the culture and society we grew up in. In the UK, pain is seen as an abnormal state of the body; it signals that something is wrong. We see pain as a mechanical process, like a phone screen that has become cracked. Thus, as with any machine that stops working, we go to the experts to get it fixed: doctors and nurses.

In Japan or South Korea, patients may present to their doctors with generalized somatic complaints with no clear cause: muscle aches, stomach aches, and weakness. Many of these patients are later diagnosed with depression or anxiety because in some Asian cultures the stigma of mental illness leads individuals to translate mental suffering into more “acceptable” physical symptoms.⁵ Others will turn not to their doctor but to the local temple or a guru; another example of a “life form.”⁶

Patient vs. doctor: Different forms of life

Things go wrong when language games clash. For example, the doctor may have ruled out all of the concerning diagnoses and feel more relaxed, but the patient, who still cannot eat and feels sick with diarrhea, might not. This may cause patients to feel ignored, stigmatized, and misunderstood. Healthcare professionals have tried to change the language game of pain to make things easier. Examples include the use of numerical pain scales, or observing physical signs of pain such as grimacing, a fast heart rate, and rapid breathing.⁷ This returns to the concept of pain being perceived as a mechanical process.

“But if I suppose that someone is in pain, then I am simply supposing that he has just the same as I have so often had.” — [..] [That]is as if I were to say: “You surely know what ‘It is 5 o’clock here’ means; so you also know what ‘It’s 5 o’clock on the sun’ means. It means simply that it is just the same there as it is here when it is 5 o’clock.”
– Wittgenstein⁸

This is a quote from Philosophical Investigations; the initial sentence is an argument, while the latter is Wittgenstein’s response. Wittgenstein is saying is that we cannot make the assumption that the pain felt by one person is the same pain experienced by someone else. Instead we must rely on things that can be observed: the language game. This includes our diverse vocabulary for pain (why do we need so many different words for pain?), but also non-verbal communication such as crying or lying in a fetal position. Of course, sometimes we get it wrong. We may not appreciate the amount of pain someone is in or its significance in their lives. Sometimes our language game prevents us from connecting with our patients.

Conclusion

Every one of us uses language but we rarely think about it. Once we start to look at the words and phrases we use, and the difficulties they can get us into, we begin to appreciate the barriers we have built for ourselves alongside the freedoms.

In medicine—a topic in which language is so vital—such reflections are crucial if we are to grow as healthcare professionals. When I ask my patients, “How are you today?” am I simply following the etiquette of society or opening a door for my patient to share their worries? When I tell the family, “The blood tests are not worrying,” do I mean they are all normal; or that they are not worrying in the context of the patient’s other problems; or that they are abnormal, but we as clinicians are not worried?

Such questions reveal not only our communication barriers but also the prejudices that we hold. Understanding the language game is important not just for philosophers; it is important for us all.

End notes

1. Ludwig Wittgenstein, Philosophical Investigations, ed. P. M. S. Hacker, J. Schulte, (West Sussex: Wiley-Blackwell, 2009), 132.
2. Ibid, 4.
3. Ibid, 6.
4. Ibid, 14.
5. Denise Arnault, Oksoo Kim, “Is there an Asian idiom of distress? Somatic Symptoms in Female Japanese and Korean Students,” Archives of Psychiatric Nursing 22, no. 1, (February 2008): 2-4.
6. Christoph Lauber, Wulf Rossler, “Stigma towards people with mental illness in developing countries in Asia,” International Review of Psychiatry 19, no. 2, (April 2007).
7. H. Breivik et al., “Assessment of Pain,” British Journal of Anaesthesia 101, no. 1, (16th May 2008): 18-23.
8. Wittgenstein, Philosophical Investigations, 111 (see n. 1)

Bibliography

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