The four horsemen of clinical language

Conflicts, sadly, are a regular experience in medicine. Some of the most challenging occur in paediatrics, as families and team members each have strong obligations to protect children and deeply held beliefs about what is best for them. We suggest that there is a common language that clinical team members utilise when deep conflicts arise between teams and families in the (conscious or unconscious) hope that they will assert the clinical team as the ultimate decision-maker. We use this language, these linguistic tools, when we talk to families and to each other.1-3 We suggest that at least two additional examples operate in a similar manner: repeated questioning about what parents understand and concerns about resource scarcity. These concepts lack precision. More concerningly, they give the appearance of objectivity while obscuring underlying negative value judgements about the situation at hand. They cause harm: serving as a means to reinforce existing imbalances in power and deepen epistemic injustices. They short-cut decision-making, arrest discussion and minimise the perspectives, values and goals of families. This creates the expectation that only one choice (the clinician's choice) is correct, in the child's interests, compassionate or loving. The classical symbols of the four horsemen are seen as the harbingers of the end times, the apocalypse. The Greek word apokalypsis refers to a revelation or disclosure, an uncovering of what has been hidden. The conflict, strife and famine brought by the horsemen begin to reveal the hidden truth. With reference to this sense of unveiling, we identify futility, suffering, poor understanding and resource scarcity as the four horsemen of clinical language. ‘Futility’ is rhetorically powerful: if a treatment is futile then clinicians have no duty to perform it. However, the term is inherently imprecise and obfuscating. For example, when a clinical team member states a tracheostomy would be ‘futile’, they may mean that it would not work, perhaps because the patient is only 1 kg and there is not a tracheostomy small enough to accomplish the goal of providing a stable airway. However, they may also mean that a tracheostomy is ‘futile’ because the patient has Trisomy 18 and is expected to have a short lifespan, regardless of whether this intervention is undertaken. The second statement may appear initially to be a neutral clinical judgement similar to the first. However, it actually contains both an interpretation of emerging data about the lifespan of children with Trisomy 18 in the context of increasing clinical intervention and a value judgement about the degree of additional lifespan worth pursuing in the setting of other co-morbidities like profound neurodevelopmental impairment. Other clinicians may read the data differently. Families may or may not have a different sense of the worthiness of pursuing tracheostomy based on their own goals and values. A pronouncement that the tracheostomy is ‘futile’ truncates conversation, situates power with the clinical team and precludes consideration of subjective family goals and values in favour of a supposed objectivity. ‘Suffering’ is similarly problematic. Not because it is unreasonable to consider the patient's experience or quality of life when making critical decisions—these are extremely salient concerns. The problem is that ‘suffering’ is imprecise, observer-dependent and inherently subjective. For example, team members may suggest that a reason not to perform a tracheostomy for a child with Trisomy 18 is to prevent their ‘suffering’. But does the team member mean the pain associated with tracheostomy placement for any patient? The repeated hospital stays that might be expected for a technology dependent child in the long term? Or do they mean the emotional or existential suffering that they might envision themselves experiencing if they developed severe physical and cognitive impairments or complete dependence on others? If the child is intubated, what about the ‘suffering’ caused by breathing through an endotracheal tube? Suffering demands action to stop it. Clinician use of the word ‘suffering’, like ‘futility’, may side-step deliberation and deep consideration of each individual's particular observations, goals and values. ‘Suffering’ and ‘futility’ are not neutral descriptors. They may be deployed as ‘rhetorical manipulations’,1 or linguistic tools aimed to elicit a particular response, usually non-intervention. This is revealed in part by the fact that they are not deployed in most circumstances when they could be (Table 1). When the clinical team believes that ‘suffering’ is legitimate or reasonably balanced against a larger goal or benefit, we generally describe that as a situation of ‘pain’ or ‘discomfort’. For example, when we provide parents with information about a tracheostomy for choanal atresia, we do not say ‘the baby will suffer quite a bit as they recover’. We say ‘there may be some pain or discomfort’. In contrast, when we do not believe tracheostomy will serve the overall interests of the patient, we may say ‘we need to think about their suffering’ when describing the same treatment. We would add two additional linguistic tools to this small collection: ‘understanding’ and ‘resource scarcity’. ‘Understanding’, like ‘futility’, and ‘suffering’ is vague. It commonly takes the form of questions or statements such as ‘Do they really understand what life will be like?’ or ‘I am worried that they don't get it’. Expressed concerns about ‘understanding’ appear facially neutral but may reveal our deeply held values and biases. It is rare to hear a team member express concern that a new parent does not ‘understand’ what they are facing when they prepare to bring home their healthy newborn. Despite this, most new parents will say that they had absolutely no understanding of what they were doing or how difficult it would be. On the other hand, it is common to hear clinical teams express worry that a family does not ‘understand’ what they are facing when they are considering taking home a medically fragile child with a tracheostomy. Repeated questions about family ‘understanding’ or continual, undesired attempts at education are linguistic moves that serve to delay proceeding with a family's decision. Persistent concerns about ‘understanding’ raise the bar for what families can choose and maintains the status quo. For example, we need not move forward with tracheostomy in the setting of Trisomy 18 if the family does not ‘understand’. Invoking this language reinforces that it is the clinical team who get to decide when to proceed and when enough information is enough. At the bedside or in the breakroom, repeatedly expressed concerns about ‘resource scarcity’ operate in much the same way. For example, questions about ‘who is paying for this?’ or concerns about ‘bed space’, ‘staffing’ or ‘cost’ commonly arise in times of deep disagreement. Such concerns are similarly imprecise and obscure personal values. Clinical teams regularly recommend expensive and resource intense therapies even in the setting of uncertain benefit and risk of harm. But resource concerns are rarely expressed when there is agreement that the therapies or recipients of the therapies are ‘legitimate’ in some way (regardless of the data). We almost never hear questions about ‘who is paying for’ a novel airway reconstruction that is exciting to the team or questions about why patients receiving such therapies are ‘taking up bed space’ despite the experimental nature of the procedures. When clinicians lack this enthusiasm, redirecting the focus to the preservation of systemic resources serves to emphasise a hierarchy of importance. In this hierarchy, the patient's ongoing care plan or proposed treatment is not sufficiently valuable for the allocation of limited resources. Emphasis on perceived scarcity hides this value judgement behind supposed limits that are outside of the team's control. Futility, suffering, understanding and resource scarcity—while all carrying important considerations—are deeply fraught concepts.4 Our assertion is not that these are invalid—indeed some therapies are futile, patients do suffer at times, in some circumstances families do not understand and oftentimes resources are scare. Rather, we argue that they are commonly utilised by clinical teams in times of conflict to veil their own value judgements and assertions. Clinical teams apply these terms as if they are objective and in doing so, assert their power over patients and families to decide. The identification of a treatment plan as ‘futile’ serves to delegitimise it as a valid option (whether it is truly ineffective or more likely, a complex assessment of risk, benefit and goal). Over-emphasis on the potential for suffering places an intensified negative pressure on families to avoid certain types of care pathways. This inappropriately elevates the team as the exclusive advocates for the child. Repeatedly questioning a family's understanding raises the threshold to move forward with a parent's choice and forces maintenance of the current state. Finally, concerns about resource scarcity prevent discussion or disagreement about a treatment on its own merits, and instead relocates the conflict outside of the team's—and the family's—control. These tools are thus deployed (usually unconsciously) by clinical teams to leverage power to direct care and conceal subjective value judgements and biases behind veils of supposed objectivity, expertise, experience, credentials and impersonal systems. We identify futility, suffering, poor understanding and resource scarcity as the four horsemen of clinical language. As these terms are elevated, clinical teams should pause. They do not carry the supposed objectivity they are employed to convey. Their usage instead points to a revelation of real points of contention, disagreement and competing values between families and clinical teams that should be considered on their own terms. The language that we use in clinical settings is powerful. We should use that power to elevate family perspectives, address epistemic injustice, highlight differences in goals and values, make recommendations and explain clearly why. Attention to the four horsemen of clinical language directs our attention to critical moments of care, where identification of instances of conflicting values and judgements unveils opportunity for deeper exploration, honest conversation and clarification of perspectives. Jennifer Cobelli Kett: Conceptualization; writing – original draft; writing – review and editing. Luke Mosley: Conceptualization; writing – original draft; writing – review and editing. Aaron Wightman: Conceptualization; writing – original draft; writing – review and editing.