Polite requests?

How physicians prompt patients to

sign consent forms

0. Introduction

A typical feature of polite action seems to be that a speaker expresses her/his opinion to

the listener, that s/he considers the needs of the other interlocutors (House 2005) and

that s/he follows certain rules of conduct in order to protect the interactional rights of

the other partner (Fraser 1980). In this sense, communication between a doctor and a

patient should be predestined as an example for polite action, since the Hippocratic

Oath focuses strongly on the well-being and the dignity of the patient. The maxims laid

down in the oath’s text are subject to constant modernization by the World Medical

Association, however, the goal of enhancing the patients’ well-being is still central to

the self-concept of physicians (cf. www.wma.net/e/policy/c8.htm). Contrary to this,

many publications on doctor-patient communication report on different kinds of

impolite or patronizing actions performed by physicians (cf. e.g. Borges 1986, Fisher

1984, Fisher & Dundas Todd 1986, West 1984, to name a few). For example, therapy

proposals that do not correspond to the patients views and perceptions of his/her illness

and life-style may lead to severe conflicts and thus be contradictory to the general

image of the harmonious and polite relations between the two parties (Rehbein 1994).

Such contradictions between institutional codes of conduct and self-concepts on the one

hand, and the communicative reality in institutions on the other, are well-known facts.

However, we doubt that some of the phenomena found in doctor–patient

communication can be grasped by the polite-impolite dichotomy established by Brown

& Levinson 1987. As recent work on politeness has pointed out, certain forms of

communication cannot be judged with regard to this dichotomy (Locher & Watts 2005,

1
Locher 2006). The appropriateness of speech actions does not necessarily depend on

whether or not they were realized in a polite manner. Rather, appropriateness seems to

depend on contextual factors. Similarly, indirect speech actions are not automatically

perceived as being polite (Blum-Kulka 1987).

Although recent discussions on the different definitions of politeness call for theoretical

elaboration (Spencer-Oatey 2007), this paper does not aim at providing new theoretical

insights or definitions of politeness. It is far more our aim to analyze the use of

linguistic phenomena that are usually associated with politeness and mitigation in order

to determine how they are linked to the achievement of institutional purposes. In this

context, we will focus our investigation on a certain speech action that has been

addressed ever since research has been carried out on politeness: the request. More

specifically, we will focus on requests in briefings for informed consent in diagnostic

and therapeutic settings. We are interested in the closing of the briefings, when doctors

ask their patients to sign consent forms. With this signature, the patient consents to the

treatment or the diagnostic procedure in a legally effective way. Obtaining the patients’

signature is therefore one important outcome of the briefing, if not the most important

(from the perspective of the medical institution).

Requests are generally perceived to be typical examples of face-threatening acts (FTA).

Thus, one assumes that they have to be mitigated in order to allow the speaker to

impose a need on the addressee (Brown & Levinson 1987: 68). Our data, however,

reveal that doctors use quite a range of different strategies to prompt the patient to sign

the form. Furthermore, in a significant number of cases the issue of signing the form is

in fact not addressed at all. We will discuss reasons for this and we will present a

typology of requests as they appear in our set of data. First, we will give a short

example taken from our data and a description of our corpus (section 1). Following that,

2
we will present a survey on different ways in which requests for a signature are carried

out (section 2). Thirdly, we will characterize the briefing for informed consent as a

specific type of institutional discourse with the act of signing the form as a constitutive

component and address the issue of the communicative dilemma attached to that.

Finally, we will conclude that doctors can contribute to patient autonomy by revealing

the institutional implications of the signature in briefings for informed consent.

1. How to request a signature from a patient – types

and tokens from our data

The study is based on a corpus of 28 briefings from different medical settings (mainly

diagnostic procedures in internal medicine and cancer therapy). The tape recordings

were carried out in German and Portuguese hospitals. Doctors and patients were either

native speakers of German or Portuguese, or Portuguese and Turkish immigrants living

in Germany. Some of the patients needed to be interpreted which was organized ad hoc

with help of bilingual staff members or relatives of the patients (Bührig & Meyer 2004).

However, most patients in German hospitals who needed an interpreter were also able

to follow the conversation in German, as they usually had at least some command of

their host countries’ language. Therefore, interpreter-mediated and direct interaction

sometimes occurred side by side within the same conversation. In the following, we will

describe two types of requests that we identified in our data: (1) the ‘compulsory’-type,

where the signature, without dwelling on details, is handled as an objective institutional

necessity, and the consent of the patient is partly taken for granted; and (2) the ‘appeal’-

type, where the doctor asks the patient to sign the form and explicitly refers to features

of the institutional constellation by using pronouns, modal verbs, and other mitigating

3
devices such as German verba dicendi and/ or performative verbs, used in constructions

such as ich möchte Sie bitten ‘I would like to ask you to’. Despite the obvious

differences between these two types, however, the doctors’ aim of obtaining consent

from the patients shines through in all cases.

1.1 The ‘compulsory’-type request

The following example (1) is taken from a recording carried out in German without any

participation of an interpreter (ID: D-61). The physician is a young male doctor for

internal medicine. The patient is a male Italian migrant in his forties who came to the

hospital with stomach pain. The procedures for which the consent of the patient is

required are a gastroscopy and an examination of the pancreas. The talk goes on for

about three minutes. The physician tries to explain the procedures, but the patient claims

right from the beginning that he doesn’t need any explanations. In broken German he

confirms that he trusts the doctor and that the only thing he wants is anaesthesia during

the examination. Finally, he confirms that it is “okay” and that the doctor should carry

out the procedures (Maken! ‘Do!’). Example 1 follows on from these utterances.

Example 1

Doctor: (1) • • • Gut. ((holt hörbar Luft))

‘Fine.’ ((inhales audibly))
(2) Okay.
‘Okay.’
(3) Ich hab Ihnen hier diese Bögen mitgebracht.
‘I have brought these forms here for you.’
(4) Ich hab selbst schon unterschrieben, dass • wir das eben •
besprechen, nech?
‘I already signed, that we discussed that, right?’
Patient: (5) Hm.
Doctor: (6) Und Ihre Einwilligung wäre dann...
‘And your consent would then need to be...’

4
Patient: (7) Wo is das?
‘Where is it?’
(8) Hier unter.
‘Down here.’
Doctor: …hier zu unterschreiben.
‘...signed here.’

The doctor initiates the closing of the briefing after the patient has orally confirmed that

he agrees with the proposed method. The transition to the act of signing is organized by

the two discourse markers in (1) and (2). Then the doctor introduces the consent forms

(“I brought these forms here for you“) and states that he himself has already signed the

forms in utterance (4). In utterance (6) the doctor uses an impersonal

conjunctive/conditional construction (Konjunktiv II) in order to request the patient’s

signature: “And your consent would then need to be signed here.” In this construction,

the patient is not directly addressed. It is only the possessive pronoun in Ihre

Einwilligung ‘your consent’ that helps the addressee to infer who has to sign the form.

The impersonal construction wäre zu unterschreiben (‘would need to be signed’) serves

to express an obligation (Zifonun et al. 1997). Interestingly, the patient doesn’t wait for

the request to be completed but already asks where to place his signature before the

doctor has actually finished his request (utterances 7 and 8).

Example 1 clearly shows that patients do not always need an explicit request to carry

out the act of signing the form. In contrast, experienced patients already know that there

are often certain legal procedures to be conducted towards the end of the briefing.

Furthermore, patient and doctor in this case are both positive about the planned

procedure, and, consequently, they treat the signature as a bureaucratic or formal act

that is not worth talking about. Nevertheless, the doctor uses a mitigated construction.

5
This indicates that he treats the request as a delicate topic that requires a specific

communicative embedding.

In the second example (example 2), a female doctor for internal medicine talks to a

Portuguese worker who has lived in Germany for 18 years but doesn’t speak German

very well (ID: P-27). A nurse who has Portuguese as her first language serves as an

interpreter for him. The conversation is a briefing for a broncoscopy. After explaining

the procedure and pointing out possible risks and side effects, the doctor asks whether

the patient has any questions. The patient negates and responds (in German): Was soll

ich fragen? (‘what should I ask?’). The doctor then asks whether the patient has

understood everything. His response is Ungefähr, ja. (‘Yes, more or less’). Example 2

directly follows on from this statement made by the patient.

Example 2

Doctor: Gut. ((lacht kurz)) Dann können Sie einmal hier unterschreiben.
‘Fine. ((short laughter)) Then you can sign here once.’

The discourse marker Gut ‘fine’ evaluates the fact that the patient understood the doctor

‘more or less’. The temporal deictic dann ‘then’ is used here as a causal connective in

the sense of ‘as a consequence’. The modal verb können ‘can’ characterizes the

signature merely as within the range of possible actions of the patient. There is neither

any reference to the institutional implications of the signature, nor to other possible

actions (for example, not to sign the form). The doctor simply treats the act of signing

as the logical and self-evident follow-up action that has to be carried out by the patient

after being informed about the proposed medical procedure. By signing the form, the

patient treats it in the same manner.

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As illustrated in examples (1) and (2), when adopting the ‘compulsory’-type request, the

doctor treats the signature as unavoidable and makes no reference to legal aspects or to

the importance of the signature within the institutional workflow. Furthermore, in most

instances of the ‘compulsory’-type request, consent is simply presupposed by the

doctor. Other modal verbs used in combination with this type of request are müssen

‘must’ (‘you must sign here’) or brauchen ‘to need’ (‘I need your signature’).

1.2 The ‘appeal’-type request

German and Portuguese provide performative verbs for the speech action of ‘asking

someone for something’. The transitive verbs bitten (Ger.) and pedir (Port.) make a

difference when used in requests since they force the speaker to explicitly name the

agent and the addressee of the speech action. Therefore, the linguistic format of the

request highlights the fact that the doctor actually asks the patient to sign the form. In

example 3, an elderly Portuguese migrant is being prepared for surgery on his hip joint

(ID: P-17). A female nurse who has Portuguese as her native language serves as an

interpreter for him. During the briefing concerning the surgery, an anaesthetist rushes

into the room and insists on briefing the patient on the forthcoming anaesthesia even

though the briefing on the surgery has not yet finished. The surgeon agrees, and the

briefing on the anaesthesia takes place in the usual format. After asking several

questions referring to the physical condition of the patient and explaining the course of

the medical procedure, the anaesthetist makes the request for the patient’s signature (see

example 3).

Example 3

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Doctor: Dann würde ich ihn nämlich bitten, • • zu unterschreiben,
((Kugelschreiber klickt)) dass wir bei ihm eine Vollnarkose machen
dürfen.
‘Then I would ask him to sign ((pen clicks)) that we are allowed to carry
out a general anaesthesia on him.’

The so-called ‘würde’-conjunctive (würde…bitten ‘would like to ask him’, Konjunktiv

II) in German is a kind of irrealis mood that transfers the actual request into a

hypothetical sphere, meaning that a possible refusal is licensed or admitted. Hence, the

Konjunktiv II can be associated with politeness (cf. e.g. Zifonun et alii 1997: 1753). By

using the performative verb bitten and the Konjunktiv II, the doctor characterizes the

constellation between herself and the patient in a different manner in comparison to the

examples 1 and 2. The involvement of the institutional actors (‘we’) and the patient is

enunciated, and a possible refusal is at least implicitly admitted. Furthermore, the doctor

uses the modal verb dürfen ‘to be allowed to do something’ in the subordinated clause,

which clearly indicates that the actions are constrained by norms or regulations. Thus,

the ‘appeal’-type request in briefings for informed consent is characterized by the fact

that important features of the constellation between doctor and patient are spoken out

and a possible refusal is implicated.

The ‘appeal’-type request leaves more space for the patient’s decision. Nevertheless, it

may also come along with the implicit or explicit expectation that the patient will

consent to the proposed treatment. In example 4, a female Portuguese doctor for internal

medicine talks to a female cancer patient about an upcoming chemotherapy. The talk

(ID: P-92) lasts approx. 14 minutes. It takes place in a huge public hospital in the

northern part of Portugal. The hospital is frequented mainly by people living in the

surrounding villages. The doctor starts the consultation by asking whether the patient is

already aware of the results of a biopsy that had been carried out on her. The patient

8
negates, and so the doctor informs her about the fact that a malign carcinoma has been

found and that a special treatment is required. She briefly describes the diagnosis and

recapitulates the preceding diagnostic steps. Then she asks the patient to read the

consent form and to sign it (see example 4). The patient quickly browses through the

text, but doesn’t understand it very well. Therefore, the doctor provides detailed

information on how the chemotherapy will be performed. Finally, at the end of the

conversation, the patient signs the form. Thus, the request is presented not at the end of

the talk, but more or less in the middle, and is not followed immediately by the act of

signing.

Example 4

Doctor: Pronto, e eu queria que agora lesse isto ((1s)) e que depois assinasse que
concordava.
‘Okay, and I would like you now to read this and to sign afterwards that
you agree.’

In this request, the doctor uses an imperfect form (queria) of the verb querer ‘to want

something’ in combination with a subordinated clause in which the desired actions of

the patient are described (‘to read everything and to sign that you agree’). The imperfect

form (imperfeito) is normally used to describe actions and events that happened in the

past. In colloquial Portuguese, however, it is frequently used in place of the conditional

(condicional I) to express a wish or to be polite. Thus, the use of the imperfeito of

querer is a typical way of weakening the illocutive force of requests (queria um café ‘I

would like to have a coffee’). In the given syntactic construction, the verbs ler ‘to read’,

assinar ‘to sign’, and concordar ‘to agree’ in the subordinated clause are obligatory

marked for the conjunctive. Furthermore, they follow the imperfect mood of the matrix

9
verb querer. Thus, despite the explicit expectation that the patient consents (‘sign that

you agree’), the request still has an ‘appealing’ character.

In the examples 1-4 we presented several ways in which doctors prompt patients to sign

consent forms. Furthermore, we identified two types of requests: namely ‘compulsory’

and ‘appeal’ requests. Our criteria for distinguishing the two types were basically mood

and modality, the use of performative verbs, the degree of explicitness by which the

doctor reveals that s/he expects the patient to consent, and the implicit or explicit

concession of refusal. Thus, a typical compulsory request would be a situation in which

the doctor does not even allude to a possible refusal, takes the consent for granted,

speaks in the indicative mood and makes use of modal verbs like brauchen ‘to need’ or

müssen ‘to have to’. However, the examples also show that our distinction is not always

clear-cut. For example, the conjunctive mood is used in ‘appeal’-type requests, but also

in ‘compulsory’-type requests, and even if doctors use a lot of mitigating devices, as

(shown) in example 4, they may (nevertheless) explicitly expect the patient to consent.

The distinction is, in other words, a matter of degree. In our data we didn’t find any case

in which a doctor adopts an impartial stance with regard to the decision to be made by

the patient.

2 ‘Compulsory’-type and ‘appeal’-type requests: a comparison

In 28 briefings for informed consent, we found nine cases of ‘compulsory’ requests,

seven requests were of the ‘appeal’ type, and twelve cases in which the issue of signing

the form was not addressed at all (see table 1).

‘Compulsory’-type requests ‘Appeal’-type requests No request

9 7 12

10
 Table 1: Request types and tokens (n=28)

In five cases we were able to reconstruct from the data the reasons for the signing of the

form not being addressed. In two cases, patients had already signed the form, while in a

further three cases the doctor explicitly asks the patient to read the consent form first

and sign later or on the following day, after reading the form. In the seven remaining

cases there is no indication of why the issue of signing the form is not addressed. This

doesn’t automatically mean that the patients in these briefings didn’t consent to the

proposed treatment. In contrast, it could mean that the issue of signing the form literally

goes without saying for the respective participants, i.e. it is not worth talking about.

However, as we neither have evidence from the transcriptions nor from other sources,

we cannot make any claim about that.

The distribution of ‘compulsory’- and ‘appeal’-type requests is almost equal but, as the

data set is relatively small, one should not draw any premature conclusions from the

quantities. Rather, the different patterns and combinations of mood and modality show

the range of possibilities. In general, ‘compulsory’-type requests are characterized by

the use of indicative mood and several modal verbs which indicate obligation (‘it needs

to be’, ‘you must’) or possibility (‘can be signed’). The ‘appeal’-type requests, however,

rely on different types of the irrealis (such as the German Konjunktiv II or the

Portuguese Imperfeito) and performative verbs of ‘asking someone to do something’

(‘would like you to sign’) (see table 2).

Mood Modality

‘Compulsory’-type requests Indicative ‘need to’, ‘must’, ‘can’

‘Appeal’-type requests Irrealis ‘would like to’

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Table 2: Request types, mood, and modality

The discussed data differ with regard to the degree and the manner in which they

explicitly name the involved actors and their attitudes towards the act of signing. In

example 1 an impersonal construction is used, whereas in example 2 the doctor

verbalizes the act of signing as an act that the patient can decide on. The examples 3 and

4 differ from the former in that they name the doctor as someone who requires the

patient’s signature (example 3), or who wishes to have it (example 4). Together with the

varying usage of mood and modality such differences allow us to distinguish between

the two types of request (‘compulsory’ and ‘appeal’). By investigating the construction

types, the morphological features and the modal verbs used, the differences between the

two types can be described in more detail. Furthermore, we will draw on action theory

in order to show in which aspects the two types converge, despite their grammatical

differences.

In action theory, actions and events are generally perceived as processes which happen

in stages. In linguistics, this perception of actions has been mainly adopted by Austin

(1954) and Rehbein (1977). From this perspective, an action is divided into ‚prehistory‘

(motivation and planning), ‚history‘ (carrying out) and ‚posthistory‘ (results,

consequences) (cf. Rehbein 1977).

The signing of the form in informed consent is an action that in most cases hasn’t yet

been carried out at the moment the briefing takes place. Not the main voice of the

conversation (the doctor) is the signatory, but the patient – which is why the request is

needed. By using modal verbs, performatives and specific moods, however, all requests

refer to the prehistory of the act of signing the form, but they do so in different ways.

While the irrealis mood allows speakers to treat an action as if it is fictitious and its

becoming reality is dependent on certain conditions, modal verbs such as ‘can’ or

12
‘must’ refer to the motivations and planning processes. In combination with

performatives or forms of address, modal verbs allude differently to the involved actors

(doctor and patient). While the modal können ‘can’ in combination with the pronoun of

address Sie ‘you’ focuses on the patient (example 2), the performatives bitten and pedir

locate the prehistory of signing in the action space of the doctor: obtaining the signature

is his or her need (or wish). Thus, the two types of requests differ with respect to the

characterization of the involvement and the motivations of the actors. They converge,

however, in that they, in one way or the other, all maintain a certain distance to the

history of the requested action (the ‘carrying out’-stage). Even the most directive use, as

shown in example 1 (‘need to be signed’), still mitigates the request via the irreal

Konjunktiv II-mood (wäre zu unterschreiben). In this context, on should note that the

use of the indicative would have been grammatical (ist zu unterschreiben ‘is to be

signed’).

Although distance from the ‘carrying out’-stage of the requested action is probably a

common feature of mitigated (or polite) requests in general, the routinized mitigation

via mood and modality points towards a communicative dilemma associated with the

discourse type of informed consent, which will be discussed in the following section 3.

3 The communicative dilemma of informed consent

While it is generally presupposed that doctors work solely for the well-being of the

patient, the act of signing presupposes that this might not always be the case. The legal

regulation of medical interventions became necessary due to the fact that the „benign

order of everyday life“ (Maynard 2003) can only be regarded as an ideal conception: in

reality, doctors sometimes make mistakes and medical procedures may have unwanted

effects. Thus, by signing the form, the patient becomes involved in the decision-making

and, although only partly, even shares responsibility with the doctor for the whole range

13
of possible outcomes of the medical procedure, both positive or negative. This

contradicts the general assumption of the trustful relation between doctor and patient, in

which potential mistakes and negative side-effects are simply not taken into

consideration.

The normative concept of informed consent implies that the patient is fully informed

about an upcoming medical procedure, including potential complications, benefits, and

alternative treatments (Kaufert, O’Neil & Koolage 1991). From this perspective, the

purpose of informing the patient is to enhance the patient’s autonomy and to guarantee

his/her self-determination of the forthcoming medical procedures. Terms like

‘autonomy’ and ‘self-determination’ clearly indicate that the concept of ‘informed

consent’ is strongly determined by legal norms and ethical considerations, rather than

medical ones.

Empirical studies of briefings for informed consent reveal that there is a discrepancy

between the normative concept and the actual performance of the participants. In

particular, referring to potential risks depends on the doctor’s understanding of which

information is appropriate for a specific patient in a given institutional context (Meyer

2005). Moreover, an important medical reason for a briefing seems to be the preparation

of the patient for future action. This action (the diagnostic or therapeutic procedure) is

in many cases a standard routine for employees of the hospital, but unfamiliar to the

patient (Meyer 2004).

As has already been shown in earlier studies, briefings are characterized by a repetitive

and somewhat generic or standardized course of action. They usually consist of the

ANNOUNCEMENT of the procedure, which is expanded by DESCRIPTIONS, ELUCIDATIONS

or EXPLANATIONS of its various aspects (Biel 1983, Mann 1984, Krafft 1987, Meyer

2004). After announcing and describing the procedure, doctors should refer to potential

14
complications, which does not happen in all cases. If complications are mentioned,

doctors usually also add information about the frequency and seriousness of the

respective complications. The final and pivotal step is the closure of the briefing and the

signing of the consent form. The patient’s consent has to be documented in written form

in order to prove that an authorization has been given before the treatment has been

carried out.

The prototypical course of the briefing for informed consent (ANNOUNCING,

DESCRIBING, POINTING OUT risks to the patient, and prompting the patient to sign the

form) encloses both legal and medical requirements. The patient’s ‘consent’, thus, refers

to different communicative outcomes: the fulfillment of legal norms and, at the same

time, the establishment of a common ground with respect to future cooperation (see

Fig.1).

Legal purpose:
the patient gives consent in spite of his or her
knowledge of medical risks

Phase I Phase II
Announcing Describing Pointing out risks Signing the form

Medical purpose:
establishing a common
ground for future
cooperation

Fig. 1: Integration of legal and medical purposes in briefings for informed consent

(adapted from Meyer 2004)

The medical procedure is part of a larger, all-embracing plan for medical action. The

patient’s decision-making potentially jeopardizes the plan at this stage. Should a patient

reject a proposed treatment or method, the medical staff has to restart the whole process

of planning and checking for an alternative treatment. Therefore, we may conclude that

15
doctors do not necessarily adopt an impartial stance regarding the patient’s decision-

making. In contrast, the purpose of briefings seems to be that the patient consents to the

planned diagnostic or therapeutic procedure, although he or she has been informed

about the potential complications that the respective procedure might entail. This is

further supported by the fact that in our data doctors often characterize complications as

‘infrequent’ and ‘non-serious’ (Meyer 2005). The relevance of a potential negative

outcome is downplayed in order to ensure the patient’s affirmative decision. This is

referred to as the communicative dilemma of informed consent: doctors require the

patient’s signature in order to carry out a procedure that may affect the well-being of the

patient. The patient has to consent to a treatment that, potentially, may harm her/him.

4 Conclusion
To our knowledge, Robillard, White & Maretzki 1983 were the first to suggest that

doctors tend to “trivialize” the act of signing in informed consent as mere paperwork. In

our study we looked at how this is actually exercised in authentic briefings for informed

consent, and which linguistic means are used in this context. In our view, the specific

use of verbal moods and modal verbs is neither simply a result of an asymmetry of

power or an attempt to impose a treatment on the patient, nor is it a reflection of a more

general communicative rule. Rather, we would argue that the types of requests we found

in our data are borne out of the dilemma between medical and legal purposes of

informed consent. Doctors have developed different verbal routines to cope with this

dilemma, some of which are more direct or imperative, and others which are less so.

However, all these routines come along with the expectation that the patient consents to

the treatment and signs the form. Although it is highly unlikely that doctors will

completely give up this expectation, a more patient-oriented closing of briefings for

informed consent would be desirable. By revealing the institutional implications of the

16
signature, instead of trivializing and concealing them, doctors could contribute to the

ideal of patient autonomy and shared decision-making.

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