Assumption 1: The Literal Meaning of “Treat”

The authors’ initial assumption in their analysis of treatability statements is:

They analyze the following treatability statement as follows:

Below, we show that this initial assumption about the standard meaning of ‘treat’ ultimately leads to an erroneous conclusion about the mismatch between intended and received meaning. Six of the world’s most reliable English language dictionaries were consulted to ascertain whether the dictionary definition of the verb ‘treat’ entails the meaning of cure and/or restoration. All dictionaries were British English except two (Merriam-Webster and Oxford Advanced American Dictionary) and one British English dictionary (Cambridge) also provided an American-English definition.

All British English dictionaries, except for the Oxford Advanced Learner’s Dictionary, provide a definition of ‘treat’ that relates to curing or restoring (Table 1). Conversely, all American English definitions, except that in the Cambridge Dictionary, define ‘treat’ as simply giving medical care, with no reference to outcome or intention (Table 1). We see that the core meaning of ‘treat’ is generally broader in British English and narrower in American English.

Table 1. Definitions of ‘Treat’

The meanings of words change over time for a variety of reasons. The above cited divergence is evidence that ‘treat’ is undergoing what is known as semantic shift and, more specifically, sematic restriction, i.e., a reduction in the scope of its reference,^{Footnote 9} with the (primarily) American English version no longer extending to the intention to cure.

The authors note that there appears to be a mismatch in the meaning assigned to ‘treat’ between ICU HPs and oncologists. Oncologists, they contend, use it in a neutral manner to simply mean the provision of medical attention (with no reference to outcome or intention), while ICU HPs understand ‘treat’ to entail reference to a positive medical outcome (or at least the intention to achieve this). The authors then further extend the discordance between the core meanings of ‘treat’ claiming that, in fact, some HPs use it with an entirely different meaning, not noted in any of the dictionaries:

There is no linguistic evidence for this third alleged meaning, i.e., that ‘treat’ and its derivatives actually mean: to provide medical attention for a disease that is “certainly incurable”.

However, evidence of the fact that ‘treat’ and its derivatives are undergoing some change in meaning within the medical profession is the frequent use of numerous adjectives or adjectival phrases preceding the noun ‘treatment’ (e.g., active treatment, life-prolonging treatment, curative treatment). The use of such clarifying adjectives/adjectival phrases by HPs ensures that the intended purpose for which treatment is/will be provided cannot be misunderstood.

It might be argued that we have interpreted the treatability statements explored by our American colleagues with the broader standard meaning of ‘treat’, influenced by our own background in British and Australian English. This would surely have colored the current analysis with our understanding of such words and statements, one might suggest. We will revisit this point below.

Assumption 2 – Meaning of Treatability Statements Beyond their Literal Sentence Meaning

The second assumption made by the authors is predicated on Assumption 1, i.e.,

While it is true that we make sense of much of what we hear in conversation by relying on contextual factors (as well as additional factors such as prior knowledge, cultural and social facts, etc.) to understand the intent of seemingly unrelated conversational contributions, we believe that the authors have inadvertently added layers of interpretation as a result of their initial assumption about the surface meaning of ‘treat’ and its derivatives.

Based on at least some current definitions provided, patients are justified in understanding ‘treat’ as entailing some reference to a potential positive medical outcome and are therefore also justified in hoping for the best when hearing such treatability statements made in reference to serious and even life-limiting diseases. Further evidence that patients’ understanding of treatability statements does not relate to their inability to grasp the HPs’ intended meaning is offered by the authors themselves; some HPs use and understand the word ‘treat’ and its derivatives or synonymous phrases in exactly the same way as patients do, i.e. that these words and statements denote potential efficacy, impact, or intention to achieve some positive medical outcome. The authors’ recognition that some, presumably American, HPs understand the meaning of ‘treat’ to extend to the intention to cure adds further support to the fact that at least some Americans still use the broader meaning of treat (despite the narrower American English dictionary definition). This also supports the view that our own understanding and use of ‘treat’ and its derivatives has not led us to analyze treatability statements based solely on our understanding of ‘treat’.

In an attempt to justify the mismatch between HPs’ “intended” meaning of treatability statements and patients’ received meaning, the authors turn to Grice’s conversational implicature and claim:

Despite the broader and narrower meanings of ‘treat’, it is important to firmly note that ‘treat’ is not in any way a “technical term” with a meaning, intended or not, beyond the patient’s experience with medical terms, as suggested by the authors.

‘Intentional Ambiguity’ in Treatability Statements

We would like to offer an alternative explanation for why such treatability statements are used in circumstances where no cure or amelioration for the disease is possible. In a 2007 systematic review focusing on HPs’ truth-telling practices when discussing prognoses with patients with advanced life-limiting illnesses (many of which focused on cancer), it was found that many HPs develop strategies of avoidance or withholding of prognostic information even though they acknowledged the benefits of open and honest disclosure to patients and their families.^{Footnote 10}

Hancock and colleagues identified several reasons why HPs do not always disclose information in an open and transparent manner or are reluctant to do so.^{Footnote 11} These included HPs’:

1. 1.) perceived lack of training in prognostication

2. 2.) uncertainty about estimating illness trajectory

3. 3.) stress relating to dealing with family members, the patient’s emotions, depressing their patients, and about controlling their own emotions during discussions as well as the HPs’ own attitudes toward death

4. 4.) limited time to attend to the patient’s emotional needs

5. 5.) feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment

6. 6.) fear of a negative impact on the patient, and

7. 7.) requests from family members to withhold information

We would like to propose that, where life-limiting conditions are concerned, HPs are aware of the hope that patients derive from treatability statements, so they sometimes consciously or unconsciously use treatability statements to create ‘Intentional Ambiguity’. This is a term we have coined to describe the use of treatability statements for incurable conditions which address HPs’ need to satisfy important obligations, both as a professional and a feeling human being. First, by uttering “This is a treatable condition” to patients with terminal cancer, for example, the HP feels that s/he does not strip patients of all hope; the patient and their family are not crushed by the deafening fact that medicine cannot fix all and that time may be short. Second, the HP does not ignore his/her obligation to be ‘truthful’ to patients and their families; s/he will indeed be providing a medical intervention targeted at the disease. Third, the intentional ambiguity created by such treatability statements helps defer the need to confront items listed in 3-6 above, i.e., the messy patient, family, and HP emotions that come to the fore in the face of death. While such intentional ambiguity may function as a shield against deep emotional discomfort, it is, in the end, damaging to patients and their families, and perhaps even HPs.

Cooperative Principle (CP) and Intentional Ambiguity

Grice’s work aimed to elucidate how it is possible for speakers to know how to generate implicit meaning and assume that the listener will understand their intended meaning despite the intended meaning being unrelated to the actual words spoken. In addition, his focus was also necessarily on how listeners understand the speaker’s intention despite the use of implicit language. Grice’s focus was therefore on the logic of conversations which could account for the gap that often exists between what is said and what is meant. Grice called this additional meaning (i.e., the intended meaning) conversational implicature. Underlying Grice’s CP is the notion that rationality is central to human action and language as a system, and the CP expresses a general principle governing how people interact communicatively with one another (see Davies^{Footnote 12} for an interesting analysis).

Batten and colleagues offer an example of seemingly unrelated conversational exchanges which nevertheless cohere as a result of the listener making sense of the speaker’s intended meaning.^{Footnote 15} Below, we further clarify how it is possible for us to both convey and understand implicit meaning when the surface meaning seems unrelated.

Four Conversational Maxims are associated with the CP. When communicating, both the speaker and the listener assume that these ‘rules’ are, in broad terms, being observed, i.e., that we

1. 1.) give enough, but not too much, information (Maxim of Quantity),

2. 2.) only convey things we believe to be true and based on evidence (Maxim of Quality),

3. 3.) provide information relevant to the discussion (Maxim of Relation), and that we

4. 4.) convey information clearly so that there is no confusion & that we do not engage in long-winded explanations (Maxim of Manner).

Grice clarifies that we exploit these maxims to generate conversational implicature by deliberately flouting a maxim. When a maxim is flouted (e.g., the response to the listener’s question seems completely unrelated) the listener seeks to find the intended meaning which coheres with, and furthers the exchange, precisely because the underlying assumption is that rationality underlies the exchange and that the CP is being observed. If not flouting these maxims for communicative effect, observing the maxims is the default assumption.

When we want to opt out from the operation of a maxim, we usually signal this to the listener. For example, we use phrases such as “This may or may not be the case but…”—this signals that we are unsure about the veracity of the statement and by stating it in advance, we will not be violating the Maxim of Quality (and hence cannot be labelled a liar or rumor monger).

On occasion, speakers violate the maxims intentionally or unintentionally. The violation of maxims can lead to concerns about the reliability of the speaker, as well as impressions about their character, which, in the clinical context particularly, can be detrimental given the obligations we feel HPs have toward their patients and their families. For example, when the HP gives less information than required for a patient to fully understand the prognosis, the patient would be justified in feeling let down and concerned that critical information is being withheld. In previous work, we have shown that major communicative and emotional issues arise when the maxims are violated in the clinical context.^{Footnote 16} Here we would like to draw on Grice’s Cooperative Principle and the associated maxims to illustrate why intentional ambiguity is particularly damaging.

• • the speaker (HP) indicates that there is treatment (narrow meaning) for a terminal cancer

• • the patient interprets this statement, with its core broader meaning in mind, to mean that there is at least some hope that the disease may be successfully controlled (or even perhaps eradicated!)

• • the HP does not clarify that there is no medical intervention that will fully or partially restore the patient’s health because the ambiguity that has been created with ‘there is treatment’ serves other useful purposes, as outlined above

• • when it comes to light that there is no possibility for the extension of life, the patient and family may feel that at least three conversational maxims have been violated:

  1. ○ the maxim of quality—the HP’s statement was either not truthful or was not based on evidence—Can I ever trust him again? Does he even know what he is doing?

  2. ○ the maxim of quantity—the HP did not provide enough information to convey an accurate understanding of the gravity of the situation—How could he leave me in the dark like that? How am I supposed to cope with all this and make important decisions?

  3. ○ the maxim of manner—the HP allowed a cloud of ambiguity to hang in the air even though there was evidence the patient remained hopeful—Why didn’t he just tell it as it is? How could he show such little regard for me when I am dying?

• • the violation of these maxims in the clinical context leads to powerful emotions of anger and sadness as we have shown in analyses in the pediatric context.^{Footnote 17,Footnote 18}

In Table 2 below we focus on Batten and colleagues’ case to further illustrate how the treatability statements with their broad and narrow meanings are understood, and how intentional ambiguity arises in some contexts.^{Footnote 19} We also offer some suggestions for alternative wording which could have been used to help avoid ambiguity.

Table 2. Understanding how and where Intentional Ambiguity is created and ways to improve communication

Excerpt from Batten and colleagues’ case to provide context (to be considered in conjunction with Table 2): “Given Ms. P’s age and medical comorbidities, the ICU team wonders if she will survive this acute episode of sepsis. And even if she does survive, they predict she will return to the hospital with another decompensation. According to the oncologist, multiple forms of treatment for her breast cancer may be available if Ms. P stabilizes and survives to discharge, including further hormonal therapy, chemotherapy, or palliative radiation for symptomatic masses. However, her oncologist wonders if her poor functional status might mean that these treatments will have a poor benefit-burden ratio. To discuss these matters, the ICU team and the consulting oncologist hold a conference with the patient’s daughter.”

We contend that intentional ambiguity is ultimately very damaging; partially satisfying the maxim of quality, and temporarily shielding the HP and patient and family, from the immediate discomfort and anguish that transparency would have caused are not robust enough justifications for such ambiguous treatability statements. Despite the individual and cultural differences in the informational needs of people with life-limiting conditions, there is significant evidence that patients and families want and benefit from truthful but sensitively-conveyed information,^{Footnote 20,Footnote 21} and that they find relief in having greater control of their difficult circumstances as a result of open discussions.^{Footnote 22} Research has also shown that HPs’ concerns about the negative impact of truthful prognostic information on patients and families are unfounded.^{Footnote 23}

The changing meaning of ‘treat’ and its derivatives, both transatlantic and contextual, as we have shown above, also highlights the real challenges posed when doctors are communicating with families from different cultural contexts, or when they themselves come from a different culture. This is a point we have not focused on here, but which merits brief mention. In such contexts, navigating and negotiating the explicit surface meaning is challenging enough, let alone the implicit intended meaning in challenging communicative exchanges.

Particularly around end of life, communication is fraught with potential for misunderstanding for all involved, and particularly so for some groups of patients and their families. This is one of the reasons why health professionals need to work hard to be explicit and unambiguous in their communication. Observing basic communicative expectations in the clinical context is paramount, as important decisions must be made based on the information exchange with HPs; if patients are to be shown respect and supported in processing and accepting devastating prognoses, HPs must refrain from what we have termed intentional ambiguity, and/or be made aware of the standard broader and locally or situationally narrower meanings of ‘treat’. Anything less than open and transparent communication of prognostic information not only impacts on patients and their families in a devastating way but also ultimately undermines the broader relationship of trust between communities and healthcare professionals.