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The Use of Maxims forCooperation in Chinese MedicalInterviewsJiang JinPublished online: 10 Dec 2009.

To cite this article: Jiang Jin (1999) The Use of Maxims for Cooperation inChinese Medical Interviews, Health Communication, 11:3, 215-222, DOI: 10.1207/S15327027HC110304

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The Use of Maxims for Cooperation inChinese Medical Interviews

Jiang JinEnglish Department

Suzhou Medical College

The discourse in doctor–patient interviews in China was analyzed to assess the wayLeech’s (1983) 4 maxims for cooperation play out in the medical context. Some viola-tions of the maxim of quantity were found. Violations of the maxim of quality werecommon for both doctors and patients. The maxim of relation and the maxim of man-ner were more closely followed. There was no evidence, however, that the violationof these maxims undermined the cooperativeness of doctor and patient. The medicalinterview may provide a context in which Leech’s maxims hold more in the generalthan in the particular.

Doctors and patients come together as strangers. Only through cooperation can bothkeep the conversation meaningful and complete their responsibilities and tasks ac-cording to their own roles. This is a process in which both abide by the “cooperativeprinciple.” Justas insocial conversation, thecooperativeprinciple indoctor–patientdiscoursecanbe realized through fourmaxims (Leech,1983).Usually, bothdoctorsand patients follow these four maxims voluntarily and willingly. Yet every rule hasits exception. When we analyze the nature and original intention of the speaker andtake the speaker’s mental condition into consideration, the violation of the maximsmaybecomeameans tobetterachievecooperation.Thisarticleexamines thatpossi-bility in doctor–patient interaction. I audio-recorded and observed more than 200complete conversations between doctors and patients in the clinics of six hospitalsaffiliated with the Suzhou Medical School in Suzhou, The People’s Republic ofChina.Selectedexamplesweretranslated intoEnglishforsociolinguisticanalysis.

THE MAXIM OF QUANTITY

The first maxim of Leech (1983) is that the amount of information should be appro-priate to the purpose of the conversation. For example, the opthamologist wants toknow about the patient’s eyes; the cardiologist wants to know about cardiovascularproblems (patient = P; doctor = D).

HEALTH COMMUNICATION, 11(3), 215–222Copyright © 1999, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Jiang Jin, English Department, Suzhou Medical College, 48Remin Road, Suzhou 215007, People’s Republic of China.

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P: Doctor, I have severe abdominal pain.D: When did it begin?P: After midnight last night. The pain woke me up, and became more and

more severe.D: How about your stool these days?P: It’s normal.D: What’s the location of the pain?P: I can’t make clear. Sometimes around the navel, but sometimes in the

whole abdomen. The pain causes nausea.D: Lie down here. (palpation) Pain?P: A little.D: Here?P: Pain …D: Here?P: Aiyao … very painful. I’m dying of pain.D: No operation on appendicitis before?P: No …

We can see that both the doctor and the patient follow the maxim of quantity. Theinformation is relevant to finding the problem.

P: I can’t pass stool out these two or three days.D: Constipation? For how many days?P: This is my old disease. I’ve suffered from it for 30 or 40 years now. I

take some medicines, ate some bananas, I felt better. I have poor appe-tite, feel bitter in mouth. I have stomachache and abdominal pain, and Ifeel bloated. I have headache when I meet cold wind, something jumphit in my head. I have bronchitis. I find blood strikes in sputum. I haverales in lung, I have pulmonary emphysema. There are some problemsin my heart. I am old. I have many diseases. Gastroptosis is an old dis-ease. Arthritis makes me feel difficult in walking. It’s not easy for meto go out to see doctor …

D: When did you begin to feel like this? I mean, you can’t pass stool?P: Eh, three days ago.D: Three days. Do you have abdominal pain?P: Yes, but not very …

Obviously, the patient’s complaints violate the maxim of quantity. This is com-mon with aged patients. In Western countries, old people try to prove themselveshealthy and useful to society, whereas in China many old people take others’ con-sideration as respect and attention. This old woman believes that the more shecomplains, the better she can help the doctor make the diagnosis, and the more at-tention she will be paid. However, she actually makes it harder for the doctor to

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make a differential diagnosis and treatment plan. Most doctors seem to tolerate pa-tients’ violations of the maxim of quantity. Doctors allow patients to say what theywant to say and encourage them by listening carefully. At the same time they arealso good at finding the main message for the topic of the next turn and for furtherexaminations as well as at inferring the conclusion. Patients want to tell doctors alltheir feelings and symptoms, whether they are real or imagined. This makes senseto patients as assisting diagnosis, not as being uncooperative.

Doctors’ violations of this maxim are in the opposite direction. Patients com-plain that doctors give too little information for them to know the nature of theirdiseases and treatment procedures. What the doctors reveal is “tolerance and guid-ance,” whereas patients want “cooperation and understanding.” This appears to bea special feature of doctor–patient communication.

THE MAXIM OF QUALITY

The second maxim, that of quality, says that no untrue statement should be utteredpurposefully. Both people in the conversation should be sincere and honest, speaktrue feelings and opinions, and tell their real purpose in the process of seeking andsolving problems. Both hope to hear the truth as well.

Doctors often violate this maxim. They want patients’ cooperation in the treat-ment and encourage patients to have confidence in their health and future lives.The violation of this maxim is consistent with medical ethics in traditional Chinesemedical practice.

P: Doctor, what on earth I have? What is my disease?D: It’s not so easy to explain everything clearly in a short time.P: Do I have to get a big operation?D: No big operation, but you have to stay in the hospital for a period of

time for drip injection with some special medicines. You can becomebetter gradually.

P: They say that I have got “blood cancer”?D: There is no such a term. Who told you that? Don’t think too much.

Don’t think too bad. …P: But doctor, please, please tell me how many days I can live? If my dis-

ease can’t be treated, I don’t want to stay in hospital. Let me go home. Idon’t have enough money. I don’t want to spend all my money for thedisease. I am old. They must live on. It’s no use throwing money in thisway. …

D: Listen to me please. We try our best to treat you. This is the admissioncard. Ask your son to prepare. I’ll come to see you in the ward tomor-row morning.

P: Doctor. …

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D: (to her son) Go downstairs over there. Get everything ready. Nursewill arrange when you are in section 12. See you tomorrow morning.

The patient was diagnosed with malignant lymphoma and was eager to know thenature of her disease. The doctor tried not to confirm the patient’s suspicion be-cause he knew that the patient came from an area with little education and mentaltolerance. The only thing in the patient’s mind was her responsibility to her family,a traditional value of Chinese women. The doctor felt sympathetic but didn’t tell thetruth because he wanted her to have the treatment. The doctor admitted her to thehospital and discussed the treatment plan with her son.

This isatraditionalwayofacting inChinesehospitals.Fewdoctorstell thetruthtothe patients at diagnosis. They would rather say something such as “There seems tobesomeproblems in the film,but furtherexaminationsareneeded”or “Wecanoper-ate on it, don’t worry too much.” No doctor would tell the patient how many days heorshecan livebut insteadwouldsay “The functionofmedicinedoesn’tworkso fast;youwillbebettergradually”or “You looknotsobadtoday.”Doctorswilldiscuss thetruth with the relatives of the patient. In the pathology department, doctors are oftenrequiredby the relativesof thepatients towrite twodifferent reports.Onereports thereal condition of the patient to the physician or surgeon, whereas the other keeps thepatient in the dark about the illness and makes the patient accept the treatment.

D: Did you spend your night outside about 10 days ago?P: No. Just at home. I helped my wife with housework.D: No?! Then what about your wife?P: No. Surely no. We believe each other.D: But I don’t think that your wife can believe you.P: I didn’t do anything. …D: You’d better with me. The problem is advancing. It’s no good for you.

It’s no good for your family. You must take proper medicine in propertime.

P: I don’t understand.D: Well, I’ll keep secret for you. I must give you medicine only after I

make correct diagnosis. Only when you tell me the truth can I makemedical decision. If not treated in time, the disease will do great harmto you and your wife. Early treatment is important. You are already alittle late. Understand?

P: Ehr … , let me think it over. About two weeks ago, I …

This is a example of violation of the maxim of quality on the part of the patient. Theurologist had diagnosed the patient’s disease, but he needed definite informationabout the symptoms. The patient realized that his disease had something to do withthe violation of social ethics and was afraid of its effects on his family, his job, hissocial relationships, and his own reputation. Thus, he tried to mislead the doctor.

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The urologist saw through the patient’s lie but didn’t reveal it. He only tried his bestto explain, guide, urge, educate, and persuade.

Generally speaking, in doctor–patient discourse, the doctor’s violation of themaxim of quality is for the benefit of the patient’s health. Patients’ violations areeither to hide breaking social ethics or to relieve relatives of worry.

Doctors’ violations of the maxim of quality are losing their special function of“benevolent deception,” especially with patients with high education. The “trick”is too commonly used. Hence, some patients doubt the doctor’s diagnosis and seekalternative explanation through other channels. It is better for doctors to tell thetruth and earn patients’ trust and cooperation. As people learn more about healthprotection and medicine in China, doctors should gradually reduce the violation ofthe maxim of quality and increase truthful explanation to get patients’ cooperation.This will require changes in current medical ethics.

THE MAXIM OF RELATION

The third maxim, the maxim of relation, means that whatever the speaker saysshould be relevant to the main topic and to what the former speaker has said. Yetseemingly irrelevant questions may be relevant in this setting. The question “Doyou drink beer?” seems to have nothing to do with the illness but is important to therecognition of the disease gout. The question “Where do you work?” suggests thatthe patient’s illness may have something to do with the job.

Ambiguous questions can also yield relevant answers. The following are an-swers to “How are you?”:

1. I don’t feel well. I feel a little numb in the back of my head and my righthand.

2. My eyes become more and more dim. Everything looks double even veryclose in the distance.

3. I have finished with my medicine. My headache is not so severe.4. My tinnitus becomes less. I don’t hear big noise since this Monday.5. There is a little itching throughout the skin. No lump on the skin.6. My heart jumps a little faster.7. I feel much better. I can sleep well during the night. I don’t feel very tired

when I do some housework.8. I went to climb Mount Ti last week.9. I begin to go to work. They changed a new light task for me. I don’t feel tired

during the work. The company management takes care of me.10. The mass seems larger. I can touch it myself.

These answers give a general idea about what kinds of patients are in which clinicsfor what. Some answers (e.g., Number 8) seem to have nothing to do with medicalexamination and treatment. But in this setting, it means “I have recovered very well

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after the last operation and I am now strong enough to go out seeing and climbingmountains.”

Usually, verbal and nonverbal expressions in doctor–patient discourse are allrelevant to the setting and the topic. This differs from social talk. A cough duringsocial conversation may signal impatience or the attempt to interrupt, but in medi-cal conversation, it may reveal bronchitis, a cold, smoking, or lung problems. Asneeze may be seen as disrespectful in social talk, whereas in the consultation itwill be taken as a sign of a cold or rhinitis. A belch may be heard as a noise or inter-ruption in ordinary conversation, whereas in doctor–patient conversation it may bea clue about dietary habits or digestion.

Body language of both doctor and patient are also relevant. Proper dress or uni-forms worn by doctors and nurses indicate treatment and health improvement. In achildren’s hospital, nurse uniforms are pink in autumn and winter and light greenin spring and summer to show warmth, life, courage, and hope. An old woman inan outpatient department wanted to see a doctor with “white hair” because she re-lated white hair with experience. So in the setting of the hospital, doctors andnurses pay special attention to their appearance and behavior. Careless expressionsmight be regarded as hints about illness by some sensitive patients.

THE MAXIM OF MANNER

The maxim of manner says that the language should be clear. Clarity, simplicity,conciseness, and orderliness help prevent misunderstanding. Doctors follow thismaxim by telling patients their illness conditions and drug effects using simple ex-planations and vivid metaphors to make complicated medical terms easy to under-stand. If there is a violation of this maxim, it is because the patient’s illness makes ithard for doctors to express their feelings clearly.

D: How about your pain?P: There is pain in my feet also in my waist. Foot pain connects my waist

pain.D: You just said it the wrong way. The main problem is in your waist.

There is a bone hurt when you were working. Then the pain reflects toyour leg. Well, in a simple way, when something electric line, no lightcan be turned on but when one electric bulb is broken. There will be noeffect on the lights or the line. Understand?

P: At first one foot painful, but now two feet painful.D: Legs, not feet. Mw … somewhat in the center. Do you have the history

of trauma?P: History of trauma? What do you mean by trauma?D: Have you ever been crushed or hit by something heavy or hard, and frac-

ture or sprain? Oh, well, I mean broken bone or twist or something?

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P: Bones were not broken, but I often fell or hit by something hard. I wayyoung at that time and didn’t I mind at all. Went back to work after oneor two day’s rest in bed.

D: Do you do heavy work in construction site now?P: No. Operation?D: But the prognosis is not so good if doing operation now.P: Prognosis?D: I mean the result after operation is not so good.P: But finally I have to be operated on?D: Yes. But it’s better to do operation when the pain of your bone is more

severe than the pain due to the operation.P: Then the result will be better?D: Yes. What about some injections for a couple of weeks?P: OK. …

In this part of conversation, the patient had a protrusion of an intervertebral disc andan operation was necessary but not urgent. The doctor and the patient joined in themedical decision making. They discussed the illness condition and possible com-mon opinion. During the conversation, both tried to explain everything clearly withsimple explanations and vivid metaphors.

P: (Showing the doctor a bottle of medicine) Doctor, the more I take themedicine, the worse my stomach problem becomes. My stomachproblem can’t be treated any more?

D: (Studying the instruction on the bottle) You’ve taken the wrong medi-cine. Your stomach is afraid of cold food. The main components of themedicine are cold plants. How can you use the medicine?

P: I watch television advertisement, and I … .D: Well, just like you want to go to Nanjing, but you get on the train to

Shanghai. The faster the train, the faster you leave Nanjing. You mustgo to see doctor for medicine. You can’t take medicine according toadvertisement. Don’t worry. How do you feel about your stomach?

P: Mm …P: I asked for sick leave a month ago and I’ve been at home since.D: Never go out?P: Seldom.D: Do you have auditory hallucination?P: What is auditory hallucination?D: Eh … , I mean, do you hear somebody talking while alone at home?P: Yes. I often hear someone talking about me. They are gossiping.D: Do you know who they are? Is their voice loud?P: Men and women. In the upper right of my head. My head is splitting

with these noises.

MAXIMS FOR COOPERATION 221

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D: Now think it over. Did you think of it or hear it?P: I heard it.D: Anyone around you in your house when you heard the noise?P: Nobody at my home except for myself. Everyone went to work. Eh … ,

yes? I couldn’t see anyone then. How can … ? How can I hear thenoise? The noise is so loud that almost make my head explode. No onewill be little others behind with such a loud voice. What’s the matter?Why?

D: You have given a very good explanation. This is auditory hallucina-tion. We shall try to solve that problem.

The doctor’s questions followed the maxim of quantity, but the patient asked forclarification because he didn’t understand the termauditory hallucination.Thedoctor took this opportunity to induce the patient’s own explanation of the problem.

CONCLUSION

The first three maxims are concerned with what to say whereas the fourth is con-cerned with how to say it. The application of the four maxims in doctor–patient dis-course implements the cooperative principle. If followed they can improve doctors’communication skill (what to say and how to say it) and make the clinical processmore satisfactory to patients.

Yet contrary to Leech’s argument, occasional violations in the medical contextseem to produce a higher level of cooperation. This is different from the result ofpurposeful violations in social talk. However, every rule has its exception. The co-operation principle is not a rule to control ordinary conversations but rather a lawobserved in research on social talk.

The study of the use of maxims for cooperation in Chinese medical interviewshas interdisciplinary usefulness. The observations in this study inform medicalcommunication as well as disciplines such as linguistics, psychology, anthropol-ogy, and medical ethics.

China is developing rapidly and peoples’ value conceptions are changing rap-idly. With the progress of the society, the improvement of living standards, the de-velopment of the national economy, and the raising of the educational level, newstudies will be needed to modify what has been concluded here. More and moreexceptions are likely to be found in future studies.

REFERENCE

Leech, G. N. (1983).Principles of pragmatics.London: Longman.

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