Semantic and pragmatic peculiarities of verbs in informed consent templates for dental treatment

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Semantic and pragmatic peculiarities of verbs in informed consent templates for dental treatment

Kostenko V. G.

Ukrainian Medical Stomatological Academy

Solohor I. M.

Ukrainian Medical Stomatological Academy

Patient's voluntary informed consent for medical intervention has been known as an integral part of the modern system of moral, ethical and legal regulation of healthcare provision. The genre of informed consent for dental treatment reflects the stages over communication between the doctor and the patient, when sufficient comprehensible information regarding the nature and consequences of the proposed and alternative treatments is disclosed to patients.

The purpose of this study is to provide a semantic analysis of the verbs in the texts of informed consent templates for dental treatmentfrom communicative and pragmatic perspective. The focus on verbs is significant because they may belong to or take the shape of different grammatical categories, i.e. of their complexity in semantic, grammar, and syntactic features. A corpus of texts studied included 60 randomly selected original informed consent templates for dental treatment used in the USA healthcare settings authorized to provide oral and dental services. Nouns and verbs have been found as central word classes in the informed consent templates, moreover, the share of verbs is used to a much greater extent compared to other written texts of legal and academic discourses. The most frequent verbs according to findings obtained by employing Text Analyzer and Textalyzer online programs are central to the main themes in the texts studied; they serve as text-forming dominants in the organization of the information, its hierarchic representation that is especially relevant for the patients. The broad information potential of the verbs consists not only in their designating actions, processes, conditions characteristic of the information transfer between the addressers and addressees, but also in recurrence of actions, completeness, intensity, directness, the sequence of actions, therefore the verbs often appear as more meaningful elements in the sentences of the texts studied than nouns or nominative phrases. Semantically, the verbs in the texts analyzed are divided into five groups; the most prevalent verb types are the “mental” and “communication activity”, their greater use might be imposed by the communication purposes of the documents. There is no any specific pattern of the verb distribution throughout the texts. The most frequently used modal verbs are may (might) and can (could) expressing the epistemic modality, which mainly concerned with the degree of likelihood, the possibility of a proposition being true, given what is already known.

Key words: informed consent, genre, text, verb, semantics, pragmatics, modality. verb text informed consent

Костенко В. Г., Сологор І. М. СЕМАНТИКО-ПРАГМАТИЧНІ ОСОБЛИВОСТІ ДІЄСЛІВ У ФОРМАХ ПОІНФОРМОВАНОЇ ЗГОДИ НА СТОМАТОЛОГІЧНЕ ЛІКУВАННЯ

Добровільна поінформована згода пацієнта на медичне втручання є невіддільною частиною сучасної системи морального, етичного й правового регулювання надання медичної допомоги. Жанр поінформованої згоди на стоматологічне лікування зображує етапи спілкування лікаря та пацієнта, впродовж яких пацієнти мають отримати достатню та зрозумілу інформацію щодо характеру й наслідків запропонованого втручання чи відмови від нього, альтернативних методів лікування тощо.

Мета запропонованого дослідження - здійснити семантичний аналіз дієслів у текстах форм поінформованої згоди на стоматологічне лікування в комунікативно-прагматичному вимірі. Зосередженість на дієсловах зумовлена їхньою значною представленістю в текстах завдяки значному семантичному потенціалу, здатності утворювати різні граматичні форми й виконувати чимало синтаксичних функцій. Корпус досліджуваних текстів включав 60 форм поінформованої згоди на стоматологічне лікування, які використовуються в установах охорони здоров'я Сполучених Штатів Америки, уповноважених надавати стоматологічні послуги. Іменники й дієслова є основними лексико- граматичними класами слів, найбільш представленими в досліджуваних текстах. Було виявлено, що частка дієслів є значно більшою в порівнянні з іншими письмовими текстами юридичних і академічних дискурсів. Найуживаніші дієслова відповідно до результатів, отриманих з використанням онлайн- програм Text Analyzer і Textalyze, є центральними в основних темах, структурно виділених в окремі блоки в досліджуваних текстах; вони служать текстовими домінантами в організації інформації, її ієрархічному представленні. Широкий інформаційний потенціал дієслів втілюється не лише в позначенні дії, процесу, стану, характерних для ситуації обміну інформацією між агентом і клієнтом дискурсу, але і її завершеності, протяжності, інтенсивності, фазовості, спрямованості. Тому дієслова часто виступають як більш значущі елементи в реченнях досліджуваних текстів, ніж іменники чи номінативні словосполучення. Семантично дієслова можна розподілити на п'ять груп, водночас найпоширенішими типами є дієслова на позначення розумової та комунікаційної діяльності, що зумовлене комунікативною настановою документів. Не виявлено жодної конкретної закономірності розподілу дієслів у текстах. Найуживаніші модальні дієслова may (might) і can (could) вживаються для вираження епістемічної модальності, яка головним чином стосується ступеня ймовірності, можливості.

Ключові слова: поінформована згода, жанр, текст, дієслово, семантика, прагматика, модальність.

Background

At present professional discourses and special texts are being closely scrutinized by scholars representing social sciences as sociology, philosophy, psychology, linguistics and pedagogy because of their impact on large-scale communication, professional training and daily living. Despite the plurality of health definitions reflecting the variety of contexts in which health has been elaborated, all modern concepts of health recognize it as a maximum capacity for self-realization and self-fulfilment [20, p. 432], and healthcare has become an influential sector in the global economy. Consequently, medical discourse in the broadest sense is of profound social significance.

All types of medical records and text documents are of great clinical and legal importance; their key mission is to facilitate in providing the high-quality medical care. Informed consent documents are among central to the consent process in clinical practice. Through the doctrine of informed consent there are six functions to be achieved:

“1)protection of individual autonomy;

2) protection of the patient's status as a human being;

3) avoidance of fraud or duress;

4) encouragement for doctors to carefully consider their decisions;

5) encouragement of rational decision-making by the patient;

6) involvement of the public in medicine” [19, p. 80].

In the Western countries these documents are fundamental for patient-doctor alliance and also serves as a legal contract and, upon the patient's signature, it becomes a binding document that links patient and physician throughout their medical and contractual interaction. By signing the inform consent, the patient is agreeing to be treated, to share information between providers, as well as acknowledging different practices such as appointment, privacy policies, and payment. As M. Pilegaard posits, these forms are “an element in bureaucracy, helping the doctor treat the patient and presumably protecting the doctor from potential lawsuits” [17, p. 86].

Prototypical situation of informed consent giving / obtaining envisions the verbal exchange between doctor and patient, when the doctor discloses the information regarding treatment, associated risks and benefits, possible alternatives etc. in an objective manner, the patient understands the information given or ask the question to clarify it, and the healthcare personnel make the efforts to ensure the patients' understanding and then the patient acts voluntarily making decision to consent or refuse the treatment. The language peculiarities of this recurrent specific communicative situation make up prototypical texts always relative to a certain genre [12, p. 73]. We can presume the communicative value of informed consent templates is dependent on how much of useful information from the viewpoint of the patient they contain and how easily are understood.

Although there is a voluminous body of literature elucidating historical, philosophical, ethical, and legal facets of informed consent forms, as well as its readability and comprehension, surprisingly little attention has been paid to in-depth study of their generic peculiarities and linguistic characteristics, which underlay the precise understanding of the documents. There have been a few reports of national and international researchers devoted to the above issues [2; 4; 17; 22]. The purpose of this study is to provide a semantic analysis of the verbs in the texts of informed consent templates for dental treatment from communicative and pragmatic perspective. The focus on verbs is significant because they may belong to or take the shape of different grammatical categories, i.e. of their complexity in semantic, grammar, and syntactic features.

Materials and methodology

For the purpose of this study, we compiled a corpus of 60 original informed consent templates (ICT) for dental treatment used in the USA healthcare settings authorized to provide oral and dental services (New York City Metropolitan Hospital Center, Alliance for Dental Care PLLC (Rochester, NH)), and those given by medical insurance companies (Dentists Benefits Insurance Company (DBIC), MedPro Group). The templates were searched for using Google search engine and downloaded from internet sources Open Dental Software, American Dental Association dental records reference, Delta Dental Incorporation.

This qualitative study was based on the framework proposed by C. K. Ogden and I. A. Richards [10; 15; 18] - the conceptual theory, where there is a triangular relationship between reference, thought and symbol (the semiotic triangle). This method was selected because it brings out the inter-relationship between the lexical items and the entities in the real world. The methodology of the study also included discourse analysis for studying language in relation to its social context (“the analysis of language as it is used to enact activities, perspectives, and identities” [9, p. 4]; the analysisofgeneric structure was done by identifying and naming the main themes in the documents; part- of-speech tagging; semantic analysis dealing with the meaning of words and sentences, these words and sentences refers to the elements in the world; online programs Text Analyzer (https://www.online- utility.org) and Textalyser (http://textalyser.net/) were used for identifying word frequency.

Results and discussion

The ICTs are designed for various kinds of oral and dental treatment or procedures ranging from somewhat cosmetic like tooth whitening to invasive or surgical including Informed Consent for Composite Restoration, Informed Consent for Tooth Extraction, Informed Consent for Orthodontic Treatment, Informed Consent for Periodontal Treatment, Informed Consent for Crown and Bridge Prosthetics, Informed Consent for Bone Grafting etc. Though the documents are varying from setting to setting and are to serve for various dental procedures, they are highly stereotyped and recognized by set of themes usually presented in an order that is typical for this genre.

Textually, the ICTs are organized according to the goals of the communication over the informed consent process and cover themes essential for patients in making right decision, for example, the formulation of the oral or dental problem and treatment propose, the brief description of treatment procedure or its essence, the possible risks and risks of not receiving the treatment, the alternatives and some others. The ITC themes are mainly represented in ten possible structural sections or “generic moves” [8, p.10]:

1. Current health status /Diagnosis; 2. Recommended Treatment / Treatment plan / Work To Be Done;

3. Risks of The Recommended Treatment / Possible Side Effects and Complications /Possible Outcomes;

4. Benefits of The Recommended Treatment;

5. Changes in Treatment Plan; 6. Alternative Treatments / Other Treatment Choices; 7. Risks and Benefits of Alternative Treatments; 8. Possible Outcomes of No-Treatment; 9. Drugs and Medication (medication history, medication before, during, or after the procedure); 10. Consent/Acknowledgement. It should be stressed that ordering of information was not always consistent between documents.

The situation of information exchange between the doctor and patient during the process of obtaining / giving voluntary informed consent can be described in terms of a mutually responsive collaborative dialogic conversation, and the authors of the ICTs attempt to convey the subject matter of the dialogue appropriately for both parties and to reflect key situational aspects first of all through the thorough selection of lexis and grammar.

Though the content area of informed consent templates is highly context-specific and relates to medicine predominantly, the lexical layer of the texts studied is represented mainly by common language vocabulary (72%) mixed with special and technical vocabulary of professional languages of medicine, dentistry (21%) and law (7%). Semi-technical language was also found, such as “allergic reactions”, “concomitant drug use”, “nerve exposure” etc., which, while not involving technical terminology, is based on assumptions regarding readers' familiarity with particular terms. The identification and quantification of word classes (parts of speech) in the ICTs have shown that nouns make up 28% of the total number of words both content and functional, verbs used in either a finite or non-finite way constitute 18.8%, and adjectives, which share is 8.7%. The English sentence is typically characterized by a dispersal of verbal elements over various parts of the predicate, such that it is often difficult to assemble verbs and verbal phrases from the texts [11, p. 97].

The morphological distribution of lexis points out the complexity and a multitude of aspects covering the reference situation of decision making. Nouns and verbs have been found as central word classes in the ICTs. Though nouns and nominal groups are considered as far prevalent in written texts [1; 3; 7; 8], the share of verbs is used to a much greater extent in the ICTs compared to other written texts of legal and academic discourses [1; 3; 5]. The most frequent verbs according to findings obtained by Text Analyzer and Textalyzer online programs, e.g. understand, recommended, advise, consent, cause, prevent are central to the main themes in the texts studied; they serve as text-forming dominants in the organization of the information, its hierarchic representation that is especially relevant for the patients.

Unlike the language of most written texts of legal or academic discourses, for which nominalization and nominal groups are considered as a universal means for denoting new knowledge, concepts, and ideas, thereby creating more complex expressions and providing higher information density, the language of ICT texts seems as less artificial and more dynamic due to employing more verbs and verbal forms. The dynamism of the documents studied is primarily predetermined by the multiplicity of aspects underlying the communicative situation of engaging patients in “meaningful discourse in an effort to optimize patient understanding of diagnoses and treatments, including their rationale, risks, benefits, goals, and alternative treatment options” [19, p. 81]. And verbs in this context appear as an important constituent of the conceptual map for activities that occur over the reference situation. The broad information potential of the verbs consists not only in their designating actions, processes, conditions characteristic of the information transfer between the addressers and addressees, but also in recurrence of actions, completeness, intensity, directness, the sequence of actions, therefore the verbs often appear as more meaningful elements in the sentences of the texts studied than nouns or nominative phrases:

In order to gain greater tooth length, some bone will be removed around the tooth or teeth to be lengthened as well as the adjacent teeth and any bone irregularities may be reshaped [28]. I have been educated and informed regarding the root canal treatment for which I am giving my consent and I understand the risks that are involved in performing this procedure [24]. <...> Dr.

will then open the tooth to make access into the pulp or nerve chamber of the tooth, and that this may require Dr.to drill through crowns, bridges, fillings, or tooth structure [37].

Semantically, the verbs of ICTs can be distributed into 5 main domains as follows:

Causative verbs denoting injuries / impacts, which might result from untreated conditions, accidental iatrogenic traumas during the procedure, or occur as side effects of treatment or medication (to destroy, to infect, to affect, to break, to deform, to fracture, to damage, to traumatize, to crack). For example: An infection that might affect the new bone graft and need treatment [27]. Any of the root canal instruments may break inside my tooth [37].

Verbs describing the course of diseases or conditions, their treatment, their development or progression (to progress, to develop, to compromise, to worsen, to go far, to advance (diseases, conditions). For example: I run the risk of developing a severe infection, and losing the tooth [31]. I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the joint [35].

Verbs involving communication activities since the primary purpose of the documents is to provide sufficient specific information for a reasonable patient in making the decision (to explain, to tell, to advise, to inform, to clarify, to discuss, to notify). For example: I have told the dentist and/or his/her staff about any pertinent medical conditions I have, allergies (especially to medications) or medications I am taking [32]. The nature of root canal therapy has been explained to me and I have had a chance to have all of my questions answered [30]. I must notify your office if this or other concerns arise [34].

Mental verbs signalling the type of mental operations that patients are expected to perform over the comprehension of the facts and circumstances relating to the dental treatment proposed: to understand, to know, to realize, to acknowledge, to conclude, to infer. For example: We understand that dentistry is a stressful and worrying event [29]. I understand that depending on my diagnosis, alternatives to extraction may exist which involve other disciplines in dentistry [35].

Verbs of volition as a subtype of mental verbs mainly represented by willingness verbs denoting acts of making a conscious choice or decision (to wish, to agree, to authorize, to assume, to permit, to reject, to consent, to attest). For example: I voluntarily assume any and all known possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved [28]. In light of the above, I hereby authorize Dr. to proceed with the root canal therapy [37]. As H. Verplaetse emphasizes, “the notion of volition is essential to human experience and hence to human communication” [21, p. 152], and in the ICTs the role of volition verbs is exclusively important since they express the patient's authorization allowing a dentist to execute the proposed treatment.

The most common verb types are the “mental” and “communication activity”, and their greater use in the ICTs analysed might be imposed by the communication purposes of the documents. There is no any specific pattern of the verb distribution throughout the texts: the mental verbs are scattered through all the sections of the ICTs; the verbs denoting injuries / impacts are typically concentrated in the sections of Risks of The Recommended Treatment / Possible Side Effects and Complications, Risks and Benefits of Alternative Treatments, and Possible Outcomes of No-Treatment; the verbs of volition are predominantly concentrate in the final section, Consent / Acknowledgement, as they are to demonstrate and confirm that patient is free in his / her decision from “coercion and from unfair persuasions and inducements” [6, p. 637].

Having mentioned of volition, we should stress that it occupies an important place on the semantic map of modality. Modality, schematically taken to signal “the speaker's attitude toward the proposition” [14, p. 1344] refers to a broad and complex semantic category placed at the intersection of logic, pragmatics, grammar, syntax. There are three types of modality that can be distinguished in the modal system of English. Thus, according to G. von Wright, there have been called epistemic, deontic, and dynamic [23, p. 24]. Epistemic modality expresses solely the speaker's attitude to the status of the proposition, deontic modality directs that the event / action is controlled by circumstances external to the subject of the sentence, while with the dynamic modality the control is internal to the subject [16, p. 7]. Applying this classification, we have analysed the modal verbs employed in the ICTS.

The most frequently used modal verbs according to the findings obtained by the Text Analyzer and Textalyser, are may (might) and can (could). They express the epistemic modality, which mainly concerned with the degree of likelihood, the possibility of a proposition being true, given what is already known: “it refers to the conclusions drawn from actual evidence about the range of possibilities for what is the case in reality” [13, p. 80]. For example: Complications of therapy may include infection, dry socket, loss of fillings, injury to other teeth or soft tissues, jaw fracture, sinus exposure [32]. The doctor has advised me that I might have deficient alveolar ridge for future implant or bridge placement [33]. I agree not to fly in an airplane, helicopter or do any skydiving where sinus pressure changes occur. This can compromise grating and affect success rates and have a higher risk of infection [27].

Modal verb may is mainly used to emphasize caution, uncertainty, can is also used to express possibility or likelihood, or to attenuate the categoricity of some statements, and thus, to avoid directive tone in providing facts and arguments to facilitate decision making.

Modal verbs should, need, have to, and must are used to designate the obligation or necessity, and predominantly refer to deontic necessity, expressing what is required, or what someone is obliged to do: Every female must inform the anaesthesiologist and dentist if she could be or is pregnant [29]. Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile [32].

As modal verbs have been reported to account for 15% of verb use in academic texts [5, p. 111], the share of the modal verbs in the ICTs has been found out as somewhat higher, and makes up 22% of all the verbs and verbal forms employed. The value and the frequency of the modal verbs in the texts analyzed are stipulated by the reference situation of the decision-making.

Conclusion

As the situation of informed consent obtaining / giving can be described as mutually responsive collaborative dialogic conversation, thus, the language of informed consent templates has been found as more dynamic due to employing more verbs and verbal forms. The dynamism of the documents studied is primarily predetermined by the multiplicity of aspects underlying the communicative situation of engaging patients in the discourse of decision making. And verbs in this context appear not only as more meaningful elements in the sentences than nouns or nominative phrases, but as an important constituent of the conceptual map for activities that occur over the reference situation. In order to achieve pragmatic goals and to avoid creating a minefield of difficulties for patients, the authors try to use the most pragmatically appropriate vocabulary for conveying the most objective, complete, and accurate information, as the decision on human health and life largely depends on these qualitative characteristics. Among the values of verbs is their ability to help modulate the message via modal auxiliaries. The results of such analysis can contribute to creating the descriptive frameworks of the genre of informed consent for dental treatment or clinical research and can be used in educational settings to assist medical students in the interpretation and production of genre-specific texts.

The results of such analysis can contribute to creating the descriptive frameworks of the genre of informed consent for dental treatment or clinical research and can be used in educational settings to assist medical students in the interpretation and production of genre-specific texts.

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31. Informed Consent for Endodontic Treatment. URL: https://www.endoexperience.com/filecabinet/ Consent%20Forms%20and%20Printouts/Consent%20Form%20Examples/informed%20consent%20double%20 04-20-02.pdf.

32. Informed Concent for General Dental Procedure. Abington Dental Associates. URL: https://www.abingtondental.com/wp-content/uploads/2018/08/Informed-Consent-for-General-Dental-Procedures.pdf.

33. Informed Consent & Information for Ridge Preservation Surgery. URL: https://www.alldentalcare.com/ wp-content/uploads/updatedridgepresconsentform.pdf.

34. General dentistry informed consent form. URL: https://www.bhdentists.com/wp-content/uploads/2017/01/ BDG-Informed-Consent-Forms.pdf.

35. Patient Consent to Begin Orthodontic Treatment. URL: https://www.tdicinsuranentsce.com/Portals/0/ Region-D/pdfs/forms/ Orthodontic-informed-consent.pdf.

36. Patient Information / Informed Consent Form for Dental Treatment. URL: https:// www.dentalclinicmanual.com > documents.

37. Root canal treatment and informed consent. URL: http://theparkfamilydental.com/onlineforms/forms/ ROOTCANALTREATMENTANDINFORMEDCONSENT.pdf.

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