**1. Introduction**

In healthcare, communication can be the difference between life and death. Communication happens in a variety of contexts from explaining infectious disease to the masses to messaging providers through online health portals—no matter its function, communication a modality for effective treatment.

Aside from communicating clearly and concisely when taking medical histories and explaining treatment options, studies have shown the importance of effective language [1]. Patient safety and quality of care may be enhanced or endangered, owing fault to whether or not communication is effectual [2]. The language used during clinical interactions may be correlated with health outcomes, for example, patients whose *L1*<sup>1</sup> is not the language of operation at the hospital in which they are receiving treatment have a higher chance of readmission [3].

A patient centered experience built through effective communication may build stronger patient-practitioner relationships, enhance decision making, and reduce patient uncertainty [4]. Clear communication is not only key to the effective exchange of health information, but it is also important when practicing clinical empathy [5]. In addition, adequate communication between patients and

<sup>1</sup> A patient's L1 is their first language or mother tongue.

practitioners promotes higher patient comprehension and therefore may yield higher treatment adherence [6].

Higher treatment adherence promotes patient satisfaction and increases the probability of better clinical outcomes [6]. As communication styles differ between cultural groups, it is important for practitioners to appreciate nuanced differences in communicative styles. As language influences cognition, including that of the patient, it is self-evident that healthcare communication should be interpreted as an influencing factor in patient care and thus be governed by bioethical praxis [7–12].

### **2. The** *lingua franca* **of bioethics**

Bioethics is founded on the ethical care of patients. With particular insights and influences from various philosophies, all theories of biomedical ethics try to arrive at the best way to honorably and justly treat patients [13]. Recent research suggests the study of bioethics would benefit from methodological study from all perspectives, whether bioscience or the humanities, as the patient in which it seeks to serve may be influenced by more worldviews than one [14].

Philosophers T. Beauchamp and J. Childress laid important framework for bioethical research and analysis [15]. This chapter uses, in brief, their work as a scaffold for bioethical standards that is further combined with communicative maxims. Beauchamp and Childress describe four principles for ethical medical practice including respect for autonomy, beneficence, nonmaleficence, and justice [15].

The principle of *beneficence* states that the clinician has a moral obligation to do all they can to benefit the patient. The principle of *nonmaleficence* declares that clinicians should ensure latent harm from treatments does not outweigh potential benefits, and that patients are not unnecessarily exposed to hurt. The principle of respect for *autonomy* articulates that the patient should always have a choice and play a role in their treatment. The principle of *justice* expresses that clinicians should always aim to do the most good for the most people and distribute resources fairly [15].

As language is the *de facto lingua franca* of bioethics—that is there would be no ability to express nor debate the virtuous versus the corrupt without language itself—it is axiomatic that communicative mores should be included in any sort of debate concerning itself with the benevolence of the patient. Notwithstanding how small or impartial the orthonym may appear in the context of the outpatient clinic, it is a communicative form within healthcare and therefore necessitates bioethical oversight.

Bioethics, to be properly applicable to that which is human, must concern itself with all things humanistic. That is, bioethics must not be so overtly preoccupied with stem-cell research, that it overlooks the outwardly mundane yet strikingly influential lexemes that affect the cognition and treatment of the everyday patient. The study of proper names in healthcare lends to the larger study of healthcare communication which has been proven unremittingly important to the patient. From increased patient satisfaction to higher treatment adherence, proper linguistic form in healthcare contexts is worth deeper evaluation.

#### **3. Communication in healthcare**

As language, ethics, and cognition are inherently intertwined [16], there is a need to study all forms of communicative value [including that of the orthonym] from various perspectives including bioethics [14]. Communication between clinics

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micro-level.

*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health*

manner, relevance, quality, and quantity according to its context [5, 19].

right or aversive and may already be heavily influential in medicine [21].

preted as potentially influencing the viewer's (patient's) cognition.

ought to be upheld to bioethical principles [30].

and communities must respect and abide by ethical institutions to do no harm [17]. Health communication, in order to ethically serve the patient, must be clear and concise, honest, and not sensationalize information; health communication should "adhere to the principles of beneficence, nonmaleficence, respect for personal

When it comes to language, British philosopher H. P. Grice, created a rubric for effectual discourse that this chapter argues should be used in conjunction with the principles of bioethics set forth by T. Beauchamp and J. Childress [15] in the context of healthcare communication. According to H.P. Grice, the language used in communication should include what is relevant and necessary given the environment of the discourse. More specifically effective communication should be appropriate in

Along with communication in general, proper names structure social spaces [20]. The ability to structure social spaces could be interpreted through association, the cognitive process of linking the abstract with the physical. This creates cultural narrative reinforced by language ideologies which are held in the collective consciousness of community members [20]. Concerning bioethics, the institutions within the collective consciousness of a culture are what determines what is morally

Relative to their cultures, orthonyms denote people, places, and things [20]. There is some evidence to suggest that descriptions alone cannot uniquely distinguish an object, place, or person, therefore requiring a proper noun to represent the physical object [20, 22–24]. However, time changes the meaning of language and the ethics of a community can change over time; proper nouns are context-

Within the analysis of proper nouns, social semiotics provides a framework for the context and the constituent parts [25]. Through the analysis of an orthonym, ideologies surrounding healthcare can be interpreted [26, 27]. The orthonym can also be interpreted as assigning roles to the creator verses the viewers [26, 28]. Throughout this chapter, time is spent on how the creators (most likely dentists) perceive themselves and viewers (patients) and how the discourse may be inter-

This creator-viewer relationship demonstrates the reflective influence communication and communicators have on each other [5, 29]. It is widely reported that communication plays a role in cognition, which in any event within healthcare

Before proceeding to the case study portion of this discussion on the intersection of communicative maxims and bioethical principles, this section will exemplify a case where the violation of communicative maxims ultimately leads to the undermining of biomedical ethics. The following anecdote illustrates a hypothetical patient experience at "Luxe Cosmetic Dentistry," and aims to begin this chapter's discussion on bioethical principles within healthcare communication at the

A patient is browsing listings of local dentists on the internet. Without a referral, they rely on things such as start ratings and the names of various clinics.

*DOI: http://dx.doi.org/10.5772/intechopen.93233*

autonomy, and justice" [17, 18].

**4. Onomastic analysis**

**5. A trip to the dentist**

dependent [22].

*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health DOI: http://dx.doi.org/10.5772/intechopen.93233*

and communities must respect and abide by ethical institutions to do no harm [17]. Health communication, in order to ethically serve the patient, must be clear and concise, honest, and not sensationalize information; health communication should "adhere to the principles of beneficence, nonmaleficence, respect for personal autonomy, and justice" [17, 18].

When it comes to language, British philosopher H. P. Grice, created a rubric for effectual discourse that this chapter argues should be used in conjunction with the principles of bioethics set forth by T. Beauchamp and J. Childress [15] in the context of healthcare communication. According to H.P. Grice, the language used in communication should include what is relevant and necessary given the environment of the discourse. More specifically effective communication should be appropriate in manner, relevance, quality, and quantity according to its context [5, 19].

Along with communication in general, proper names structure social spaces [20]. The ability to structure social spaces could be interpreted through association, the cognitive process of linking the abstract with the physical. This creates cultural narrative reinforced by language ideologies which are held in the collective consciousness of community members [20]. Concerning bioethics, the institutions within the collective consciousness of a culture are what determines what is morally right or aversive and may already be heavily influential in medicine [21].

#### **4. Onomastic analysis**

*Bioethics in Medicine and Society*

higher treatment adherence [6].

**2. The** *lingua franca* **of bioethics**

may be influenced by more worldviews than one [14].

form in healthcare contexts is worth deeper evaluation.

**3. Communication in healthcare**

practitioners promotes higher patient comprehension and therefore may yield

Higher treatment adherence promotes patient satisfaction and increases the probability of better clinical outcomes [6]. As communication styles differ between cultural groups, it is important for practitioners to appreciate nuanced differences in communicative styles. As language influences cognition, including that of the patient, it is self-evident that healthcare communication should be interpreted as an influencing factor in patient care and thus be governed by bioethical praxis [7–12].

Bioethics is founded on the ethical care of patients. With particular insights and influences from various philosophies, all theories of biomedical ethics try to arrive at the best way to honorably and justly treat patients [13]. Recent research suggests the study of bioethics would benefit from methodological study from all perspectives, whether bioscience or the humanities, as the patient in which it seeks to serve

Philosophers T. Beauchamp and J. Childress laid important framework for bioethical research and analysis [15]. This chapter uses, in brief, their work as a scaffold for bioethical standards that is further combined with communicative maxims. Beauchamp and Childress describe four principles for ethical medical practice including respect for autonomy, beneficence, nonmaleficence, and justice [15]. The principle of *beneficence* states that the clinician has a moral obligation to do all they can to benefit the patient. The principle of *nonmaleficence* declares that clinicians should ensure latent harm from treatments does not outweigh potential benefits, and that patients are not unnecessarily exposed to hurt. The principle of respect for *autonomy* articulates that the patient should always have a choice and play a role in their treatment. The principle of *justice* expresses that clinicians should always aim to do the most good for the most people and distribute resources

As language is the *de facto lingua franca* of bioethics—that is there would be no ability to express nor debate the virtuous versus the corrupt without language itself—it is axiomatic that communicative mores should be included in any sort of debate concerning itself with the benevolence of the patient. Notwithstanding how small or impartial the orthonym may appear in the context of the outpatient clinic, it is a communicative form within healthcare and therefore necessitates bioethical

Bioethics, to be properly applicable to that which is human, must concern itself with all things humanistic. That is, bioethics must not be so overtly preoccupied with stem-cell research, that it overlooks the outwardly mundane yet strikingly influential lexemes that affect the cognition and treatment of the everyday patient. The study of proper names in healthcare lends to the larger study of healthcare communication which has been proven unremittingly important to the patient. From increased patient satisfaction to higher treatment adherence, proper linguistic

As language, ethics, and cognition are inherently intertwined [16], there is a need to study all forms of communicative value [including that of the orthonym] from various perspectives including bioethics [14]. Communication between clinics

**118**

fairly [15].

oversight.

Relative to their cultures, orthonyms denote people, places, and things [20]. There is some evidence to suggest that descriptions alone cannot uniquely distinguish an object, place, or person, therefore requiring a proper noun to represent the physical object [20, 22–24]. However, time changes the meaning of language and the ethics of a community can change over time; proper nouns are contextdependent [22].

Within the analysis of proper nouns, social semiotics provides a framework for the context and the constituent parts [25]. Through the analysis of an orthonym, ideologies surrounding healthcare can be interpreted [26, 27]. The orthonym can also be interpreted as assigning roles to the creator verses the viewers [26, 28]. Throughout this chapter, time is spent on how the creators (most likely dentists) perceive themselves and viewers (patients) and how the discourse may be interpreted as potentially influencing the viewer's (patient's) cognition.

This creator-viewer relationship demonstrates the reflective influence communication and communicators have on each other [5, 29]. It is widely reported that communication plays a role in cognition, which in any event within healthcare ought to be upheld to bioethical principles [30].

#### **5. A trip to the dentist**

Before proceeding to the case study portion of this discussion on the intersection of communicative maxims and bioethical principles, this section will exemplify a case where the violation of communicative maxims ultimately leads to the undermining of biomedical ethics. The following anecdote illustrates a hypothetical patient experience at "Luxe Cosmetic Dentistry," and aims to begin this chapter's discussion on bioethical principles within healthcare communication at the micro-level.

A patient is browsing listings of local dentists on the internet. Without a referral, they rely on things such as start ratings and the names of various clinics. The patient stumbles upon "Luxe Cosmetic Dentistry." What comes to mind when reading the name "Luxe Cosmetic Dentistry?" The patient's mind may bring up images of beautiful teeth, linen clothed, perfectly tanned people on a sand beach, living the life of luxury—an image straight out of The Condé Nast Traveler. And that would be the purpose! Names are chosen specifically to draw on the human mind's ability to draw from memories, feelings, and associations. This orthonym, or proper noun, relies on the patient's idea of luxuriousness to paint an image of the dental clinic the patient will find. This patient, upon reading the name of this dental clinic, and imagining how pleasant of an experience a visit might be, decides to book an appointment. But when the patient arrives, this is what they find (**Figure 1**).

When the patient enters the waiting room, they are shocked, even angry. This is nothing like what they were expecting. Based on the patient's framework about what a dental clinic titled "Luxe Cosmetic Dentistry" should look like, the patient experiences a state of dissonance. The patient decides to continue with the appointment, but the patient's care may be at risk. When patients feel uncomfortable, they may be less likely to communicate properly with practitioners about their health. In this case, the patient just wants to get the appointment over with.

If the language used properly reflected its referent, the dental clinic may have more accurately looked like the following (**Figure 2**). If this were the case, the language would have clearly communicated, set patient expectations, and set the tone for the appointment—all before the patient started speaking with the doctor. Thus, in this analogy, the language of the orthonym has directly affected the patient's experience, and may go on to have a negative impact on patient care. And in such a case, this form of healthcare communication has violated bioethical principles.

By violating the aforementioned communicative maxims the principles of bioethics were also violated. As insignificant as the name of an outpatient clinic may seem, it is clear that this type of communication within a healthcare context could influence patient care and ought to be guided by bioethical principles. In this anecdote one example of a violation was presented, this chapter will examine the multiple way in which orthonyms can uphold or violate bioethical principles.

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**6. Methodology**

*Cosmetic Dentistry" [32].*

**Figure 2.**

the United States Census [34].

*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health*

Healthcare communication is most considerably studied on a larger scale. To add more breadth to the field of health communication research it was desired that a previously unstudied form of communication was selected. To aid in the ease of application of various principles, communicative values with succinctness were also

*Perhaps something more along the lines of what a patient might expect from a dental clinic titled "Luxe* 

Using Google's map apparatus, clinics in Chicago were searched. The names of 50 dental clinics were recorded with attempt to select equal portions of dental offices on Chicago's North, West, and South sides. Each of the clinics on the list was assigned a number [1-50]. Using the Random Number Service's random integer generator, 10 numbers were selected from integers 1–50 [33]. These 10 numbers and

The medical dental clinics selected are not intended to represent a complete sampling but to offer localized analysis. The City of Chicago is composed of distinct neighborhoods, each with specific socio-economic characteristics; various neighborhoods were selected to offer diversity to the study. Socioeconomic data of the various neighborhoods were gathered from The Statistical Atlas which sources from

The data was then analyzed in the context of the aforementioned four bioethical principles and the four communicative maxims to assess ethical compliance and communicative value. The above rubrics (**Tables 1** and **2**), which offer concise applications of the theories of Grice [19], Beauchamp and Childress [15], Parli [20],

Along with broad-reaching analysis of orthonyms specifically and healthcare communication in general, this analysis will offer focused insight. In Illinois, where this research has been conducted, there are specific guidelines that dental practices must follow when representing themselves through the orthonym. These laws are a

preferred. The proper noun was selected as it met both criteria.

the dental clinics they represent were designated for the analysis.

and Webber [22], and others were created to aid this case study.

*DOI: http://dx.doi.org/10.5772/intechopen.93233*

**Figure 1.** *Probably not the dental clinic the patient was expecting [31].*

*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health DOI: http://dx.doi.org/10.5772/intechopen.93233*

#### **Figure 2.**

*Bioethics in Medicine and Society*

find (**Figure 1**).

The patient stumbles upon "Luxe Cosmetic Dentistry." What comes to mind when reading the name "Luxe Cosmetic Dentistry?" The patient's mind may bring up images of beautiful teeth, linen clothed, perfectly tanned people on a sand beach, living the life of luxury—an image straight out of The Condé Nast Traveler. And that would be the purpose! Names are chosen specifically to draw on the human mind's ability to draw from memories, feelings, and associations. This orthonym, or proper noun, relies on the patient's idea of luxuriousness to paint an image of the dental clinic the patient will find. This patient, upon reading the name of this dental clinic, and imagining how pleasant of an experience a visit might be, decides to book an appointment. But when the patient arrives, this is what they

When the patient enters the waiting room, they are shocked, even angry. This is nothing like what they were expecting. Based on the patient's framework about what a dental clinic titled "Luxe Cosmetic Dentistry" should look like, the patient experiences a state of dissonance. The patient decides to continue with the appointment, but the patient's care may be at risk. When patients feel uncomfortable, they may be less likely to communicate properly with practitioners about their health. In

If the language used properly reflected its referent, the dental clinic may have more accurately looked like the following (**Figure 2**). If this were the case, the language would have clearly communicated, set patient expectations, and set the tone for the appointment—all before the patient started speaking with the doctor. Thus, in this analogy, the language of the orthonym has directly affected the patient's experience, and may go on to have a negative impact on patient care. And in such a case, this form of healthcare communication has violated bioethical principles. By violating the aforementioned communicative maxims the principles of bioethics were also violated. As insignificant as the name of an outpatient clinic may seem, it is clear that this type of communication within a healthcare context could influence patient care and ought to be guided by bioethical principles. In this anecdote one example of a violation was presented, this chapter will examine the multiple way in which orthonyms can uphold or violate bioethical principles.

this case, the patient just wants to get the appointment over with.

**120**

**Figure 1.**

*Probably not the dental clinic the patient was expecting [31].*

*Perhaps something more along the lines of what a patient might expect from a dental clinic titled "Luxe Cosmetic Dentistry" [32].*

### **6. Methodology**

Healthcare communication is most considerably studied on a larger scale. To add more breadth to the field of health communication research it was desired that a previously unstudied form of communication was selected. To aid in the ease of application of various principles, communicative values with succinctness were also preferred. The proper noun was selected as it met both criteria.

Using Google's map apparatus, clinics in Chicago were searched. The names of 50 dental clinics were recorded with attempt to select equal portions of dental offices on Chicago's North, West, and South sides. Each of the clinics on the list was assigned a number [1-50]. Using the Random Number Service's random integer generator, 10 numbers were selected from integers 1–50 [33]. These 10 numbers and the dental clinics they represent were designated for the analysis.

The medical dental clinics selected are not intended to represent a complete sampling but to offer localized analysis. The City of Chicago is composed of distinct neighborhoods, each with specific socio-economic characteristics; various neighborhoods were selected to offer diversity to the study. Socioeconomic data of the various neighborhoods were gathered from The Statistical Atlas which sources from the United States Census [34].

The data was then analyzed in the context of the aforementioned four bioethical principles and the four communicative maxims to assess ethical compliance and communicative value. The above rubrics (**Tables 1** and **2**), which offer concise applications of the theories of Grice [19], Beauchamp and Childress [15], Parli [20], and Webber [22], and others were created to aid this case study.

Along with broad-reaching analysis of orthonyms specifically and healthcare communication in general, this analysis will offer focused insight. In Illinois, where this research has been conducted, there are specific guidelines that dental practices must follow when representing themselves through the orthonym. These laws are a

preventative measure should outpatient dental clinics attempt to misrepresent their practice with potential consequences on patient health.

The Illinois Dental Practice Act [37] states that dental clinics may not include titles or specialties in their orthonym that they are not certified to perform, use words that misrepresent or cause the patient to misinterpret services provided in order to gain more patients, practice under a false name, allow another uncertified individual or clinic to practice under their name, and must include disclaimers when appropriate*.* 2

In addition to regional regulations limiting the naming of dental clinics, the American Dental Association sets national regulations for dentists [38]. These standards (**Table 3**), as influenced by bioethical principles, state that an orthonym that is misleading in any way is considered to be unethical.3


#### **Table 1.**

*A brief guide for onomastic analysis and discussion.*


*ethical standards within healthcare communication?*

#### **Table 2.**

*A rubric for analysis of communicative value and bioethical compliance within healthcare communication.*

#### **ADA Principles of Ethics & Code of Professional Conduct [Revised 2018]**

#### *5.G. Name of Practice*

Since the name under which a dentist conducts his or her practice may be a factor in the selection process of the patient, the use of a trade name or an assumed name that is false or misleading in any material respect is unethical. Use of the name of a dentist no longer actively associated with the practice may be continued for a period not to exceed 1 year.

#### **Table 3.**

*Excerpt from the American Dental Association's document on ethical standards.*

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*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health*

Each section will anecdotally analyze clinic names used in this case study.

offered [ex: salon]

In this case study, the analysis of ten medical dental clinic names will be categorized in units for ease of reading. The units include explanations of orthonyms that: (a) list medical credential, (b) describe the ideal patient, (c) focus on the patient experience, (d) refer to health outcomes and (e) appeal to patient identity (**Table 4**).

> Orthonyms in this category contain lexical entries that position the clinic or dentist as qualified to operate [ex: D.M.D. or D.D.S.]

> Orthonyms in this category contain lexical entries that describe the

Orthonyms in this category contain lexical entries that describe services

Orthonyms in this category contain lexical entries that refer to patient

Orthonyms in this category contain lexical entries that build patient

type of patient they seek to treat [ex: pediatric]

health outcomes [ex: perfect smile]

rapport through identity [ex: ownership]

Medical credential is important—it is what determines whether or not someone should be operating on a patient. Whether the proper name uses the word 'doctor' or lists dental degrees such as D.D.S. or D.M.D., or specialties such as periodontics or maxillofacial surgery, these orthonyms are communicating with the patient that the dentist they are seeing is indeed qualified to be practicing dentistry. Due to their

nature, the misuse of lexemes in this category would be highly unethical.

*Dr. Joseph Watson, DDS.* This orthonym is simple and direct. It is made up of the doctor's name followed by their medical credential. The words used in the orthonym are obvious in their meanings and do not require the patient's analysis. This language conforms to discursive maxims in that it uses only what is necessary to convey only what information is essential. This dental clinic is located in the South Shore Neighborhood of Chicago on Chicago's Southside, and is 2.8% White, 1.8% Hispanic, 93.3% Black, 0.4% Asian, 1.3% Mixed, and 0.4% other. The median

This orthonym states medical credential and education level twice. This may be a reinforcement to the patient that the dentist is an expert and qualified to do their job by using "Dr." and "DDS" in the clinic's name. This may also be interpreted as the dentist positioning themselves as of greater education level perhaps serving to increase the gap between the patient and the practitioner. This orthonym adheres to both communicative maxims and bioethical principles: It communicates well and

*Dr. Louis C Rutland III.* This orthonym takes a similar form as the previous. It is short and direct and does not require interpretation. The words used in this orthonym are orthonyms on their own combined with a marker of education level. This orthonym is short and gives only the necessary information in accordance with discursive maxims [19]. Dr. Rutland's office is located in the East Chatham

*DOI: http://dx.doi.org/10.5772/intechopen.93233*

**Communicative purpose Description**

**7.1 Orthonyms that list medical credential**

*This table shows the major categories of orthonyms in the region of data collection.*

household income in this neighborhood is \$27,900.

does not appear to cause harm.

**7. Data and analysis**

Orthonyms that list medical

Orthonyms that describe the

Orthonyms that focus on the patient experience

Orthonyms that refer to health

*Regional trends in dental clinic names.*

Orthonyms that appeal to patient identity

credential

ideal patient

outcomes

**Table 4.**

<sup>2</sup> The full version of the *Illinois Dental Practice Act* can be found at www.ilga.gov.

<sup>3</sup> The full version of the American Dental Association's *Principles of Ethics & Code of Professional Conduct (2018)* can be found at www.ada.org.

*Biomedical Ethics and Communicative Maxims: Case Studies in Outpatient Health DOI: http://dx.doi.org/10.5772/intechopen.93233*
