Collusion in the Clinic: Constructing Patients’ Moral Responsibility to Treat Cancer

Abstract

American healthcare involves expanding medical technologies and innovations in treatment to improve health outcomes and longevity. Social scientists have argued that this is explained by the moralization of health and cultural attitudes toward imperatives to treat, pointing to the U.S. healthcare system as one that rewards healthy behaviors and “curing” rather than “caring.” In this article, we analyze early-stage oncology encounters to understand how patients come to understand what constitutes oncology treatment at the outset of their treatment journey. In these visits (n = 23), we use conversation analysis to identify behaviors used across interactants to frame medically intensive treatment. Ultimately, we find that physicians, patients, and their families orient to patients having a moral responsibility to extend their lives as much as possible through aggressive treatment even when that entails unpleasant side effects, risks, or substantial time investments.

Health has become central to modern conceptions of morality. While in the past, morality hinged primarily on religious edicts (e.g., beliefs in God, avoiding “gluttony”), Katz (1997) argues that American culture has shifted toward a “secular morality,” in which individuals are increasingly held morally accountable for preserving their own health and the health of loved ones. Faced with a cancer diagnosis, protecting one’s own health is inexorably linked to improving prognoses.

However, a dilemma in modern cancer care concerns pitting this morality against the preferred health policy of patient-centered care, where patients’ treatment preferences (including whether and how to treat) are ultimately prioritized over physicians’ views on what the patient should do (Institute of Medicine (US) Committee on Care at the End of Life, 2001). Researchers have historically approached this dilemma through surveying and interviewing physicians and patients about their perspectives on treatment including hospice and chemotherapy. Notably, relatively little work has examined video-recorded oncology encounters where treatment decision making happens in real time. Exploring the structure of clinical communication is a research domain in its own right (Heritage & Maynard, 2006), with conversation analysis (CA) a dominant microanalytic approach that offers access to medical sensemaking and intersubjectivity through its focus on both the design and placement of talk and other components of social interaction (Heritage, 1984; Schutz, 1972).

Conversation analysts have found doctor–patient interactions play a critical role in shaping treatment outcomes across different phases of medical visits (Pino et al., 2016; Stivers & Tate, 2023; Tietbohl & White, 2022), particularly in light of recent structural changes to medicine and increasingly engaged patients (Timmermans, 2020; Timmermans & Oh, 2010). In this paper we turn this lens on treatment discussions in oncology. We focus on early-stage treatment discussions to better explain how patients come to understand what constitutes oncology treatment at the outset of their treatment journey.

Social scientists have argued that the expansion of medical technologies and treatment in healthcare (Nettleton, 2020) is an outgrowth of cultural imperatives to pursue longevity through treatment, pointing to the U.S. system as one that rewards “curing” over “caring” (Kaufman, 2015; Shim et al., 2008). Essentially, this prioritizes improving prognoses even if this conflicts with patient preferences. Tate (2022) examined how such imperatives emerged in oncologist–patient interactions in late stages of disease, finding that doctors prioritized life-extending interventions rather than treatments focused on quality of life. This, Tate argues, could contribute to what Mrig and Spencer (2018) term the hospice “underutilization paradox”: while patients report wanting care aimed at palliation in late disease stages (Arnold et al., 2015) and have favorable attitudes toward comfort care (Institute of Medicine, 2015), most patients nonetheless end up dying in institutions (Carr, 2019; Teno et al., 2013). This stands in direct contrast to the “good” death most Americans report wanting (Ariès, 1981; Cottrell & Duggleby, 2016; Institute of Medicine (US) Committee on Care at the End of Life, 1997).

This paper focuses on early-stage oncology encounters to explain how patients are socialized to the imperative to pursue life-extending treatment from the start of their cancer journey. Ultimately, we argue that from the beginning of cancer care, physicians, patients, and families orient to patients’ moral responsibilities to extend their lives (and thus delay death) through aggressive treatment even when that entails unpleasant side effects, risks, or substantial time investments. Our goal is not to challenge whether this is the choice patients want to make but to understand the kind of care practices that patients are socialized to expect.

Background

Treating health problems with biomedicine is central to American healthcare. Social scientists have largely explored this through biomedicalization, in which medicine expands its authority by integrating science and technoscientific innovations into maintaining health and managing illness (Clarke et al., 2003). Health and illness management, social scientists argue, have become individual, moral responsibilities, accomplished by self-surveillance, risk mitigation, biomedical goods, and self-help modalities (Clarke et al., 2003; Rose, 2007).

The increasing role of biomedicine in addressing health issues reflects the larger cultural trend of health moralization (Katz, 1997). Behaviors that put people at risk of worse health, such as cigarette smoking or food choice, are now subjected to moral scrutiny and thus ought to be avoided. Consistent with other definitions of morality, secular morality casts certain health behaviors as right versus wrong; as valued or not (Rozin, 1997). Those who engage in “healthy” behaviors are rewarded, while those who pursue “unhealthy” behaviors are sanctioned.

CA research has shown that morality governs a host of dimensions of social interaction including in everyday conversation (Heritage & Raymond, 2005; Stivers et al., 2010, 2024). In healthcare, research has demonstrated multiple ways in which morality comes to bear, particularly in pediatrics (Heritage & Sefi, 1992; Prettner et al., 2024; Ranzani, 2024). One outgrowth of secular morality is evident in the theory of the treatment imperative. Kaufman et al. (2006) and Shim et al. (2008) put forth this theory to capture American healthcare’s default orientation to treating, even if that comes at a cost to quality of life. The authors describe the treatment imperative as embodying a momentum toward treatment that becomes “inescapable” at all stages of disease but can become particularly problematic in later stages, driving a desire by doctors and patients to pursue uncomfortable, costly, and sometimes ineffective treatment.

Kaufman (2015) argues that the treatment imperative is driven by the ever-evolving U.S. healthcare system, where medical innovation gives way to ethical imperatives for life-extending therapies. Once innovation gives way to new therapies effective in clinical trials, Medicare and private payers begin reimbursement for such services. These interventions then become the standard of care, leading patients to expect these and thus becoming what physicians must offer. An extension of society’s turn to secular morality, the treatment imperative is argued to be present across care contexts, though little work has examined actual practice in medical encounters through which it is interactionally constituted.

Prior work examining recommendations in late-stage oncology care has identified physician practices that reflect the theory of the treatment imperative, showing different ways oncologists prioritize invasive medical intervention (Tate, 2019, 2022). Other work exploring post-cancer treatment has found that patients construct treatment experiences in morally laden ways, shaped by cultural expectations to paint experiences of negative challenges as ones that were endured, survived, and required will-power (Staneva et al., 2018).

These behaviors are consequential to secular morality regarding care near the end of life because this pursuit of medical intervention can keep patients from the “good” death they desire (Carr, 2023; Steinhauser et al., 2000). While what constitutes a “good” death is subjective, most Americans report wanting to be prepared emotionally and financially, be free of pain, and maintain dignity (Steinhauser & Tulsky, 2015). Further, individuals consistently report wanting at-home deaths, surrounded by loved ones and quotidian comforts (Carr, 2019). Yet, trends in the medicalization of death underscore persistent challenges in attaining these goals, despite an increase in prevalence and acceptance of services designed to support deaths outside of a hospital setting (Koroukian et al., 2023; Patel et al., 2020). In one analysis, the National Cancer Institute finds approximately 25% of cancer patients over 65 died in a hospital setting and 29% were admitted to intensive care in the last month of life. Another national study finds approximately 40% of cancer patients eligible for hospice do not enroll before death (Cross et al., 2021). Others point to the fact that socioeconomic status can determine whether a “good” death is even achievable, finding that those in lower socioeconomic strata and those who are Black or Hispanic are less likely to attain “good” deaths (Carr, 2016; Carr & Luth, 2017).

While attitudes and behaviors that contribute to these trends have been studied in end-of-life contexts (Broom et al., 2014; Spencer et al., 2022; Tate, 2022), we know less about how they start in early disease stages. We show how doctors, patients, and families discussing cancer care early in treatment orient to pursuing treatment as a patient’s moral responsibility early in their cancer care journey. After describing our data and methods, we offer four types of evidence for this claim.

Data and Method

This analysis draws on a corpus of 90 video-recorded patient–oncologist encounters from three clinics, two gynecologic oncology clinics and one urologic oncology clinic, located at academic health systems in the western United States, collected between 2014 and 2017. All research activities were IRB-approved by the UCLA North General IRB, and participants provided written informed consent prior to enrollment. Five oncologists, identified from snowball sampling, first provided consent. Subsequently, 82 patients provided written informed consent using a convenience sampling method. For this project, we identified 51 recordings in which a patient received a treatment recommendation during a visit to an oncologist. We focus on the 23 cases in which patients are seeing the physician for new cancer treatment, suspected cancer, or pre-cancer consultations.

We relied on CA as our method (Sidnell & Stivers, 2012). CA is a microanalytic approach that identifies, turn by turn, the content and delivery of speech by interlocutors. CA involves four primary stages: collection building of a specific conversational practice, analysis of the design and sequential order of utterances in the practice, identification of patterns within the practice, and examining the interactional consequences of the practice (Tietbohl & White, 2022; Toerien, 2014). Aligned with this method, we focus on the practice of treatment and lifestyle recommendations and reviewed all visits looking for similarities and differences in how physicians, patients, and accompanying family members talked about such recommendations. Using ELAN, a software tool for annotating and coding video data (Wittenburg et al., 2006), we identified three main practices that physicians rely on to advocate for treatment as well as what patients and families rely on to respond to physicians. Following the identification of these practices, we used ELAN to code videos for each practice. In this paper, we report the conversation analytic findings of this study.

Results

In the early stages of cancer treatment, we argue that both physicians and patients/families talk about treatment as a moral responsibility. We offer several forms of evidence for this. First, physicians commonly recommend treatment using moral language. Second, physicians routinely presuppose patient compliance with life-extending treatment prior to securing patient agreement. Third, in the face of patient resistance or failure to assent to treatment, physicians rely on persuasion infused with moral language about patients’ responsibilities for accepting life-extending treatment. Finally, it is not only physicians who use moral language in advocating for life-extending treatment: Advocating for life-extending treatment; patients and their families collude with physicians in orienting to life-extending treatment as a moral responsibility through their own morally charged word choices and presuppositions of compliance. Taken together, our analyses support general conclusions about the salience of the treatment imperative in American healthcare.

Treatment Recommendation Design

A first form of evidence that there is an orientation in early care toward accepting life-extending treatment is that treatment is consistently recommended using moral language (20 of 23 cases). Four main types of language are consistently used across the cases (shown in Table 1). First, adjectives paint treatment as appropriate, reasonable, optimal, or beneficial.

Table 1.

Moral Language in Treatment Recommendations.

Adjective	“It would be very reasonable to ...” “The science tells me this would be the best choice.” “I think that the right thing to do: . . .”
Verb	“I would strongly recommend...” “This thankfully is not a fire drill but we want to get it done for you as quickly as possible.” “I would not wait months to start chemotherapy, usually we should start it within ideally within four weeks.”
Adverb	“We just want to shave off the part that’s abnormal out here and spare as much cervix as possible.” “If that MRI looks bad we’re gonna have to move quickly.” “I really wantchu tuh start some sort of treatment in the next two tuh three weeks.”
Account	“Even if it’s not a problem, it’s big enough it has to come out.” “We should at least consider doing radiation to prevent this cancer from coming back.”

Second, verb choices convey the physician’s position that the treatment should, needs to, or must happen. Moreover, this can be framed as what the patient needs or should do or what the physician wants, encourages, or recommends. These recommendations can be further upgraded or downgraded through adverbs like very, still, strongly, probably, a lot, or absolutely. Finally, accounts for treatment recommendations can be built into the recommendation turn, and in these cases, they also push patients to comply with treatment.

We illustrate how moral language practices come together in advocating for life-extending treatment in (1) where the physician recommends chemotherapy for early-stage fallopian cancer—the first mention of treatment in this visit following an examination of an incision:

(1) 209
01 DOC: .hhh now moving forward? I still think
02 we do need to:::.h do: chemotherapy.=and
03 the reason I say that is th- i- a fallopian
04 tube cancer there is a much higher risk of
05 this: .hhh potentially coming back compared
06 to a uterine cancer.
07 (.)
08 DOC: Now the fact that it’s an early fallopian
09 tube cancer is excellent and that’s really
10 really good news .hh and I think if
11 we do the chemotherapy? (.) .hh u:m I think
12 you’re gonna have a good chance of this staying
13 away for a long long time en
14 hopefully if not forever.
15 (0.2)
16 DOC: Okay,=
17 PAT: =.pthhh well- okay so I had a couple of- (0.6)
18 question[s er,
19 DOC: [Mhm,
20 PAT: (0.4) thoughts. .hh um:. ...

Within the core recommendation, “I still think we do need to:::.h do: chemotherapy” (lines 1–2), treatment is framed with the verb “need,” orienting to an obligation to treat. This is emphasized with the auxiliary verb “do” (Raymond, 2017), indicating contrast between no longer thinking chemotherapy is needed and continuing to think it is needed.

Other elements across lines 2–14 underscore the patient’s moral responsibility to do chemotherapy. First, the physician accounts for his recommendation with the relatively high risk of cancer recurrence, while chemotherapy gives the patient “a good chance of this staying away for a long long time en hopefully if not forever” (lines 12–14). The patient is thus presented with a treatment option specifically framed as improving the odds of keeping this cancer at bay. Doing so is portrayed as “good” while cancer recurring is a “risk.”

There is no doubt that many physicians and patients feel that cancer recurrence or growth is bad while its elimination or slowing is good. Our goal here is not to judge these belief systems but to understand how the moral aspects of treatment are interactionally cultivated because this sets up a normative culture of treating cancer. Thus, our first claim is that from the early stages of cancer care, the decision to pursue life-extending treatment is cast as the morally correct one. In (1), chemotherapy is presented as a choice insofar as the physician frames the recommendation as what he thinks should be done (Stivers et al., 2018). However, the choice is between taking steps that increase the risk of cancer returning (devalued) or decrease that risk (valued), making the patient’s decision a moral one.

In this section, we saw that in cancer care, recommendations for life-extending treatment are treated not simply as choices but choices with moral implications. Physicians orient to maximizing longevity and minimizing risk as elements that patients should value. While recommendations generally preserve a patient’s inherent right to decide treatment, the language used makes clear that there is an optimal path, suggesting that patients can decide against that at their own peril, evidence for secular morality at work in early cancer treatment.

Presupposing Compliance With Life-Extending Treatments

Presuppositions are assumptions built into an assertion or question (Levinson, 1983; Lyons, 1977). For instance, Who questions presuppose that a person is known and can be identified. In these data, presuppositions can range from presupposing that life-extending treatment will happen to presupposing what treatment will happen. Together, this constitutes a second way that physicians orient to patients’ life-extending treatment as a moral responsibility—part of a secular morality orientation to preserving health. Medically intensive treatment is presupposed as happening in 15 of the 23 cases in these data. Table 2 shows a subset of the data categorized into the three main ways that physicians rely on presupposition to convey patients’ moral responsibility to pursue treatment. First, in these data, physicians consistently presuppose treatment through “pronouncements” (i.e., recommendations that assume compliance such as I’m going to start you on X (Stivers et al., 2018)). In previous work, pronouncements were identified as recommendations that imply that treatment has been decided (whether or not that is actually the case). Here, pronouncements are used after a recommendation but before clear acceptance. In these cases, physicians announce plans to start treatment, schedule surgery, or decide the number of chemotherapy rounds.

Table 2.

Presuppositions of Treatment Compliance.

Pronouncement	“An’ I’m gonna start it [chemotherapy] next week or the week after.” “You won’t be here, so it’s [the surgery’s] gotta be the 12th or 13th.” “It doesn’t look that scary to me on ultrasound. Now I could be wrong and that’s why we’re gonna do the surgery.”
Future process	“Once we start lowering your testosterone levels your libido is not going to come back.” “It’s [the scan] probably accurate but no guarantee, so while we are there why not take a few samples of tissue.” “I’ll send Kevin in to talk to you and we can try to book up a chemo date for you.”
Future decision points	“Options would be to exci:se thee area, and just remove it with a little scalpel, Another option would be to treat it with a laser.” “If there is a cancer we’ll go ahead and take the uterus out.” “Doctor Hamlin has to decide whether he wants to treat you for this first or second.”

A second way physicians consistently rely on presuppositions to convey a patient’s moral responsibility is by presupposing future treatment processes. For instance, when a treatment recommendation involves lowering testosterone, the physician goes on to say “Once we start lowering your testosterone levels.” This presupposes that the patient will comply with the recommendation. Alternatively, when the recommendation is for chemotherapy, a presupposition of starting chemotherapy is conveyed with “I’ll send Kevin in . . . and we can try to book up a chemo date,” where again the physician presupposes compliance as a prerequisite to scheduling.

A third way physicians use treatment presuppositions to convey patients’ moral responsibility is by presupposing treatment involving future decision points. In some cases, treatment is generally presupposed, but another option remains undecided. For instance, when a physician states “Doctor Hamlin has to decide whether he wants to treat you for this first or second,” it presupposes that some type of treatment is occurring but puts the decision point in the physician’s (not the patient’s) domain (i.e., which treatment is done first). In other cases, treatment is presupposed through first indicating a contingency (e.g., if there is cancer; if it has spread; if there are negative margins in the surgery) and then communicating which treatment would occur if that contingency materializes.

These and other presupposition types in the data communicate bias toward medically intensive, life-extending interventions because they assume treatment pursuit. This directly embodies one key facet of the treatment imperative, an “almost inexorable momentum” toward medical intervention (Shim et al., 2008). Intuitively, patients who demonstrate willingness to treat facilitate physicians presuming treatment. Further, if treatment is likely to yield good prognoses, physicians may be more likely to communicate a moral responsibility by presupposing treatment.

In (2), a female patient visits a gynecologic oncologist following a visit with another oncologist, who found cancer in her uterus after first finding it on her lung:

(2a) 301
01 DOC: It’s normally the size of my fist.
02 PAT: Mhm.
03 DOC: Yours is the size of a volleyball, ((widens hands))
04 It’s this big. (0.2) So I’m sure it’s probably
05 coming from there to the lungs.
06 (.)
07 En that’s why [you shou-
08 PAT: [.hhh it has always been that-
09 like that way.
10 DOC: Now it may have developed a focus of cancer that’s
11 spread to the lungs, ((points to chest))
12 (0.4)
13 DOC: So (.) y- see Doctor Hamlin and see if he agrees
14 with me, (.) We should take out the uterus
15 and the cervix?
16 .hh the tubes and the ovaries? .hhh through an
17 incision that’ll come down like this ((points
18 downward)) Fix your hernia at the same time, (0.2)
19 Why not. (.) Fix it at the same time.=.hh and then
20 look around everywhere else and do biopsies,.hh and
21 see if it’s anywhere else. (.) At the same time.
22 PAT: .pthh where else for example.

This oncologist describes the nature of her cancer: a uterus normally the size of a fist “is the size of a volleyball” (line 3) which spread to the lungs. Following the patient’s counter that her uterus “has always been that- like that way” (lines 8–9), the physician reaffirms the cancer likely originated in the uterus (lines 10–11). The physician initially recommends they “should take out the uterus and the cervix? .hh the tubes and the ovaries.” In describing the details of the procedure, the physician shifts from recommending in a suggestion format “we should” (Stivers et al., 2018) to one that presupposes a future process, “through an incision that’ll come down” (lines 16–17) and uses grammar to invoke a moral responsibility to add on a hernia procedure through minimizing, “Why not. (.) Fix it at the same time” (line 19). Despite two response-mobilizing upward intonations (Stivers & Rossano, 2010), the patient does not take up the recommendation. Instead, she resists, requesting more details (lines 8–9). After more description, the patient continues resisting:

(2b) 301 ((1.5 minutes later))
73 PAT: .pthhh u- uh:. you have done many of surgeries like
74 that.
75 DOC: Yeah.
76 PAT: Making a man from a woman.
77 DOC: I’ve done that too.

She questions the physician’s experience using a declarative question (lines 73–74) which the physician responds to simply (line 75), but then she uses an extreme case formulation (Pomerantz, 1986) to frame the surgical removal of her female organs as “making a man from a woman” (line 76). The physician says he has done gender altering surgery (line 77), but in framing it as “that too,” he differentiates this surgery (removing her uterus, tubes, and ovaries) from a gender transition surgery, orienting to her label as extreme.

In the next 15 lines (data not shown), the patient equates the cancer surgery with making her into a man and asks if she will receive hormones to prevent her from growing facial hair. The doctor in (2c) counters that death can be delayed with chemotherapy (line 94):

(2c) 301
93 DOC: Surgery will not cure you.=The chemotherapy has a
94 chance to: delay the: .hh cause of death.
95 (0.2)
96 DOC: But it won’t cure you either probably. (0.2) But it
97 may delay it coming back quickly.
98 PAT: ((Nods))
99 DOC: So you’ll have to discuss that part with Doctor
100 Hamlin. I think he’ll want me to take this out, .hhh
101 the question is when.

The patient continues actively resisting. Even facing sustained resistance, the physician responds proposing that the patient talk with another oncologist. However, this still presupposes some treatment when he says “I think he’ll want me to take this out, .hhh the question is when.” Next, the patient asks about her prognosis. The doctor responds that although it is unlikely to be curative, treatment could prolong life, presenting treatment as a moral choice (lines 93–97). Pursuing medical intervention is presupposed by again setting up a decision point, in which some sort of treatment is happening, but “the question is when” the surgery happens relative to chemotherapy (line 101). Treatment presuppositions demonstrate a patient’s moral responsibility to treat because treatment is framed as happening, even without prior acceptance. This case additionally demonstrates a moral responsibility to treat because treatment continues to be presumed despite active resistance and poor prognosis. This illuminates how medical intervention, even in such an environment, becomes inescapable.

Persuasion to Secure Patient Buy-In

Once physicians recommend treatment, primary care patients typically either accept or resist (Stivers, 2005; Stivers et al., 2018). This is also the case in oncology (Tate, 2019). Resistance may take the form of demurring—passive resistance—or it may take the form of question asking, challenging the recommendation, or outright refusing it—active resistance (Stivers, 2005; Toerien, 2021). Physicians who do not readily receive clear acceptance of a recommendation commonly work to forestall active resistance with persuasion, while those who encounter resistance use persuasion to work to transform resistance into acceptance (Stivers & Timmermans, 2020, 2021). While persuasion is not routinely part of treatment recommendations, in these data, persuasion is exceedingly common (19 out of 23 cases). Persuasion is exclusively used to secure agreement to life-extending treatment (see Table 3). First, physicians incentivize patient buy-in when they make assertions about treatment efficacy. Here, physicians in these data consistently focus on recommended treatment as “helpful”; that it “works,” “reduces risk,” or is “standard of care.” This conveys to patients that they should agree and want the treatment. Note that this type of persuasion sets aside (even temporarily) any side effects or downsides to treatment. Second, they incentivize buy-in and guard against resistance when minimizing the imposition of complying with recommendations. They do this by addressing how little time treatment takes; the quickness of recovery; minimal side effects of treatment; or treatment’s low intrusiveness such as removing as little of the cervix as possible. While it is not always possible to paint difficult treatment as minimal, physicians may still contrast the time it takes to treat with the potential payoff—a longer life.

Table 3.

Forms of Persuasion.

Efficacy	“Because it does reduce your risk of getting an ovary cancer.” “That reduces the lifetime risk of ovarian cancer from twenty five percent to four percent.” “Which means that radiation and chemotherapy is likely to work!^”
Minimality	“But the chemotherapy for prostate cancer is significantly easier.” “But in general people are back to their regular lives (0.2) in two weeks no doubt.” “In general we like to do these leep procedures because we save more cervix.”
Risks	“Because we’ve talked about this before and I worry that if we don’t do treatment we may not get a chance to cure you.” “I would say that if- if you do not have chemotherapy your chance of recurrence is extremely high.” “It’s painless, radiation is painless so it doesn’t hurt you.”

Third, physicians in these data work to disincentivize resistance by describing risks of non-compliance. Here, physicians focus on patient risks (e.g., genetic or physical risk factors), cancer risks (e.g., ovarian vs. breast), or stage risks (e.g., whether it has metastasized). In all cases, physicians invoke risks in ways that convey patients should neither want nor knowingly take risks with their health. Recall that in secular morality, preserving health is moral. Thus, taking on risks that could result in a worse health outcome is not moral. Through persuasion, physicians convey patients have a moral responsibility to undergo treatment and delay death because treatment is generally efficacious, is worth the imposition on them, and that not doing so carries risks that they should not, as good patients, be prepared to bear.

In (6), the physician relies on efficacy, describing risks, and minimizing imposition:

(6a) (patient from (1))) 209
131 PAT: Yiknow I’m not completely opposed to doing the- (.)
132 the: urn:. (0.2)
133 DAU: Ch[emotherap-
134 PAT: [.h chemotherapy?
135 DOC: Mmhm,
136 PAT: I’m tending toward not doing it.
137 DOC: Mm:. (.) .tchhh eh=
138 PAT: Becau::se_ Well: (0.8) I- I guess I’m tending toward
139 (it) because like ya know I’m looking at this lady and
140 she- had cancer an’ she had chemo then £she had
141 cancer again.£ Ya know_ different place.
142 DOC: I know:.
143 PAT: But uh:m (0.6)
144 DOC: Everybody’s different, an: this- it’s [r-
145 PAT: [An’
146 it just seems like it- An’ you said
147 eighteen weeks, that seems like uh lo::ng,
148 DOC: .hhh
149 PAT: uh lo:ng,
150 DOC: Ya kn(h)o(h)w I think you hafta put init- in
151 context, i- Ultimately?, th- thuh beauty of
152 free will? (.) You’re gonna make [whatever decision=
153 PAT: [No no. I know.
154 DOC: =you want. My goal here is to inform you.
155 DOC: Uh;m I would say: that if- if you do not
156 you do not have chemotherapy your chance of
157 recurrence is=i- is extremely high.
158 PAT: °(Okay?)°

We met this patient in (1) where the physician recommended chemotherapy for her early-stage fallopian cancer. The patient responds first with resistance—she would like to find out the results of genetic testing before deciding—and subsequently displays stronger resistance shown in (6a) where she says, “I’m tending toward not doing it” (i.e., chemotherapy) (line 6). She then invokes someone she knows who had chemotherapy and then got another type of cancer before adding that the duration of chemotherapy is a further disincentive. The physician responds first by asserting that it is ultimately the patient’s choice (lines 150–152), and his role is to inform (line 154). However, as he works to address her concerns, he moves into persuasion which is morally laden. First, he states that the risk is “extremely high” (line 157) if she does not have chemotherapy. Then, following a question by the patient’s daughter and the physician’s response, the physician continues with a second persuasive turn that again invokes risk, arguing microscopic cancer cells can “grow” and “recur.”

After an exchange about the likelihood of this happening (lines 169–172), the physician moves to indicate the efficacy of chemotherapy for destroying any microscopic cells, recasting doing the treatment not as risky but as “the much safer side of valor” (line 179):

(6b) 209
168 DOC: Uhm thuh reason is that this cancer .hh without
169 chemotherapy: there’s likely microscopic cells
170 the naked eye cannot see, .hh and there’s a
171 chance those microscopic cells will become active
172 at some point, (.) en: grow an- and recur.=
173 DAU: =a[nd we don’t want that.
174 PAT: [Even though you took it- you don’t think
175 it was: like [u:m:.
176 DOC: [I don’t think it had spread but-
177 but .hh we always assume there’s microscopic cells
178 there.=we have to assume. (.) u:m so: that’s
179 the much safer side of valor? .hh uh:m if it
180 were me I would do the- I would without a doubt
181 in my mind do the chemotherapy?
182 DOC .hh I’m gonna play devil’s advocate here and
183 say eighteen weeks of your lif:e (.) one day
184 a week i:s much less than:, dying from a
185 recurrence in >three or four< years.

He then invokes personal pressure: “I would without a doubt in my mind do the chemotherapy?” (lines 180–181). Note, too, this reinvokes his earlier statement about the efficacy of the treatment in (1) (lines 10–14). Contesting the patient’s earlier account for resisting on the grounds of duration, he minimizes the imposition of the treatment’s “eighteen weeks” by arguing that “eighteen weeks of your lif:e (.) one day a week i:s much less than: dying from a recurrence in > three or four < years” (lines 183–185). The patient is thus treated as behaving irrationally and immorally if she does not pursue chemotherapy treatment.

In (6a–b), the physician’s use of persuasion works to counteract patient resistance to his recommended course of treatment. However, persuasion is also regularly used when buy-in is at risk despite a lack of resistance. Taken together, we see in this section that physicians rely on persuasion strategies to convey that complying with recommendations is a moral responsibility. When patients resist, as in (1), physicians do not simply accept that. Instead, as in line 7, the physician conveys disapproval by neither affiliating nor accepting the resistance. Rather his response is “Mm:” followed by a hesitation, then an inbreath and another vocal hesitation. That the patient hears this as contesting her resistance is clear as she next offers multiple accounts for her resistance, as discussed above. In (6), the physician orients to the patient as having a right to make the choice and to the fact that complying with the recommendation is the correct choice given efficacy, risks, and minimal impositions.

Patients’ and Families’ Orientations to Patients’ Moral Responsibility to Follow Treatment

So far, we have focused on how physicians orient to treating cancer and extending life as a patient’s moral responsibility. We showed that physicians recommend treatment in ways that orient to patients having choices but also that complying with recommendations is better, safer, or reasonable, and not complying is risky, unwise, or dangerous. They presuppose acceptance of treatment recommendations prior to that having been made clear—a second way that patients are brought onto the treatment train. Finally, if patients are resistant or even not fully accepting, physicians rely on persuasive strategies that accentuate the efficacy of the recommended treatment, the minimal imposition of the recommendations, and the risks that would be involved in non-compliance. All these strategies make clear that “good” cancer patients follow recommendations.

However, it is not only physicians who orient to patients as having a moral obligation to accept life-extending treatment. Patients, too, orient to having an obligation to do whatever it takes to maximize their longevity including accepting any hardships of treatment. Patients commonly resist aggressive treatment initially (e.g., in (6) or see Tate and Spencer (2023)), but when they do, as discussed here, this is treated as problematic. Moreover, patients are usually brought around to acceptance through persuasion. Once brought around, we see many of the same orientations to a moral responsibility to treat by patients as by physicians. It is in this way that we argue that patients are colluding with physicians in orienting to patients as having an ongoing moral responsibility to treat cancer.

For instance, consider (7). The patient is in her 30s with ovarian cancer. Ovarian cancer is notoriously difficult to treat and rarely caught in an early stage, and this patient is no exception. She is receiving what the physician admits is a “tough” regimen (line 1):

(7a) 116
01 DOC: So: the cisplatinum is tough I mean we
02 kinda: [talked about this
03 PAT: [Yeah.
04 DOC: before this is a tough regimen but .hhh
05 (.) you’re: young and and this is the bes:t
06 [this is the best we have so: (.) >I don’t=
07 PAT: [yeah,
08 DOC: =wanna skimp<.
09 PAT: Right.=Well and I can tell: (0.2) .hhhhhh
10 I’m starting to read about other people’s
11 treatments with um:. like I read that book

Critically, the physician does not orient to the “tough” regimen as problematic or as a reasonable cause for resistance. Rather, she frames it as tough “but” defensible and appropriate because “You’re: young and and this is the bes:t . . . we have so: (.) >I don’t wanna skimp<” (lines 5–6/8). After line 11, the physician picks up on the book the patient is referring to and discusses some things that are different with that patient’s treatment. The patient then returns to discussing how she is informing herself through reading. In (7b), she states that she understands “we are treating this like super aggressively: like from what I’ve been readi:ng” (lines 61–63):

(7b) 116
60 PAT: [Yeah .hh um:. so: (.) yeah I guess I’m just-
61 I’m starting to get a better feeling that we
62 are treating this like super aggressively:
63 l[ike from what I’ve been readi:ng en .hh en=
64 DOC: [Yes.
65 PAT: =she said that too like she went for a second
66 opinion at USB? .hh and their treatment (.)
67 wasn’t as aggressive it was- as what she
68 was getting here so .hh I’m fine with that
69 eheh yi(h)know tr(h)eat it as a(h)ggressively
70 as you need to now I’ll be as sick as
71 I need to now. .hh and we’ll get it
72 [(.) outta: the way. [.hhh
73 DOC: [°Right°. [That’s-
74 our goal. That’s w- our hope,

However, rather than this or how sick the cisplatinum treatment made her as grounds for resisting treatment, she goes on to say that she is appreciative of this aggressiveness. She says, “I’m fine with that eheh yi(h)know tr(h)eat it as aggressively as you need to now I’ll be as sick as I need to now .hh and we’ll get it (.) outta: the way.” Importantly, with this statement, she shows that her own suffering is something she believes she should endure. The laugh particles orient to this stance of self-inflicted suffering as delicate (Jefferson, 1984). However, she nonetheless treats this as both necessary and as part of a shared goal of extending her life; the treatment is “now” and it will be “outta” the way the rest of her life.

Patients who are going along with treatment presuppose that treatment is going to happen. For instance, by asking her physician, “This treatment you: you prefer to the hysterectomy?”, the patient presupposes her compliance with treatment. We also see morality infused in their word choices such as what they “need” to do (shown in 6b). As a final illustration, a patient is talking about treatment and says “I don’t know if I’m g’na get sick again (every) time I do it but I hafta do what I(h) go(h)tta do(h),” again orienting to her own obligation to persist with treatment in the face of hardship.

Even family members collude in the need to persist in treatment. Although most visits involve patients on their own, some include family members (e.g., spouse and child). In (6a) (for which the recommendation was shown in (1a)), the patient brings her sister and adult daughter to the visit. After the patient resists chemotherapy and the physician’s first persuasive work to overcome this, her daughter supports the physician’s position when she requests confirmation that the physician would recommend the same treatment if it were for his mother (6c):

(6c) 209 ((positioned just before 1c))
166 DAU: So if she was your raother_ you would t- recommend it.
167 DOC: Oh without uh doubt. Without uh doubt.

In this way, the daughter shows her orientation to the relevance of complying with the treatment recommendation. Moreover, the daughter supports the physician slightly later when he says that if left untreated the microscopic cells could grow and recur. He implies that this is problematic but does not explicitly assess this as such. She draws this implication out when she says “And we don’t want that” (line 173 in 1c), suggesting that the patient should avoid this problem by treating her cancer.

In this section, we argued that it is not only physicians who orient to patients as having a moral responsibility to treat their cancer but also patients and families. All these individuals are found to invoke morality through their choice of words (e.g., verbs, adjectives, and accounts) and presuppositions.

Discussion

Cancer treatment presents challenges for both patients and clinicians—its invasive nature, treatment complexity, and uncertain prognosis create a complex landscape. Patients face decisions, ranging from potentially life-altering choices to more routine considerations. Underlying many of these decisions is the sobering reality that cancer treatments often involve prolonged treatments laden with side effects, but that the disease can be fatal if left untreated. How then do patients and doctors discuss pursuing treatment in the early stages of care aimed at prolonging life while also honoring patient autonomy?

This article examined physician, patient, and family member behavior to show that all actors orient to patients as having a moral responsibility to pursue longevity through treatment. The first part of our analysis showed that physicians orient to this morality through language used to recommend treatment. This language promotes treatment acceptance by setting up its pursuit as a morally laden and thus clear choice in favor of treatment. Physicians also orient to patients’ moral responsibility to accept life-extending treatment by presupposing their agreement to prior recommendations. Finally, physicians orient to patients’ moral responsibility to undergo treatment through persuasion that emphasizes treatment efficacy, its low imposition, and the risks of not treating.

In the latter part of our analysis, we turned to patients and families, showing that they collude with physicians in orienting to patients as having a moral responsibility to treat. Patients demonstrate their orientations through stated commitments to enduring the difficulties of life-extending therapies for a future benefit. Moreover, patients, like physicians, presuppose that treatment will happen and impart moral language in talking about pursuing treatment. We additionally illustrated how even family members orient to patients’ responsibilities to adhere to medically intensive treatment by supporting physicians’ positions in favor of treatment even in the face of patient resistance and by framing risks of not treating as in conflict with desired outcomes.

This article extends prior research in three main ways. First, it contributes new knowledge to extant literature about the moralization of health and treatment imperatives (Kaufman, 2015, p. 201; Rozin, 1997; Shim et al., 2006, 2008; Spencer et al., 2022). Second, it enhances what is known about oncology care (Staneva et al., 2018; Tate, 2019, 2022) by adding conversation analytic work on video recordings of medical visits. Third, it builds on existing work on the medicalization of death (Carr, 2023; Steinhauser et al., 2000) through examining how early cancer care behaviors may hold implications for utilization trends in late-stage cancer care.

We document multiple language-based practices through which physicians pressure patients to accept this kind of treatment while simultaneously not offering a no-treatment or palliative care option in any of these early care visits. We propose that because physicians begin care with a clear orientation to longevity and the morality of life-extending treatment, patients are socialized to this expectation. Thus, if in each oncology visit, physicians provide only life-extending treatment options, patients hear this as what they should do. However, it also carries the implication that when a physician brings up palliative care or non-treatment at a much later visit, this means that life-extending treatment is no longer an option. As the system is now, this is likely exactly how physicians mean it. Palliative care and hospice are brought up (and utilized) only late in cancer care.

There are alternative communication options, such as inviting patients to discuss treatment possibilities or considering not treating their cancer, but this carries different risks. Bringing up a no-treatment approach suggests to patients that physicians view this as a reasonable approach when it may go against standard of care. For a patient with an aggressive metastasized ovarian cancer, for instance, the chances of chemotherapy and radiation providing a long life are slim with survival rates of 30% five years after treatment, even if the patient is under 40. However, treating this cancer with chemotherapy and radiation is the only treatment that offers a chance at longer term survival. Is it more appropriate to propose that not treating is an option to a patient like this from the beginning if it increases the odds that she will not treat and therefore lose that slim chance of longer survival? Or, is it more appropriate to persuade her to try for that chance, even if this means hardship during treatment and the possibility of a limited increase in lifespan?

A related dilemma is for patients with highly treatable cancers: if physicians bring up non-treatment or palliative care option early, patients might be more likely not to pursue treatment which could lead to shorter lifespans given that the cancer is potentially curable with treatment. Is there a moral obligation to push patients toward life-extending treatment or to give patients the option of not treating from the beginning?

Our work does not answer these thorny ethical questions, but we have argued that when physicians frame all treatments as moral obligations, patients could be socialized to a moral default of accepting medically intensive treatments regardless of their own preferences. While they are routinely told that it is their “choice,” the moral language of treatment conveys that they should accept. Physicians are trained (and may well believe) that any chance at extending a patient’s life is the right thing to do. We do not mean to delegitimize that training and belief system. Rather, we aim to document how this shapes treatment discussions and to consider the implications of these practices.

Our work also involves the addition of novel methodological approaches to measure treatment pursuit. Prior work examined the emergence of the treatment imperative through retrospective accounts and ethnographies among older patients seeking life-extending treatment for life-limiting chronic illnesses (Kaufman, 2015; Kaufman et al., 2006; Shim et al., 2008) and palliative care patients (Spencer et al., 2022). Little work has explored the moment-to-moment construction of imperatives to treat through video recording and analysis of doctor–patient interactions. The CA approach affords an additional angle through which we can understand these treatment imperatives, namely, identifying the interactional behaviors manifesting treatment imperatives and examining the context in which these behaviors come up, how they are talked about, how they are responded to, and the actors involved. In this work, we see that the treatment imperative emerges from multiple actors in the exam room in patterned ways. While doctors recommend and advocate for treatment with moral language that imparts an imperative to treat, patients and families also use moral language to frame obligations to treat. Tate (2022) was among the first to use CA to explore how imperatives to treat emerged in late-stage oncology visits. We extended this work by examining where these behaviors originate in early-stage oncology visits. Specifically, through this microanalytic method, we can ground issues of a moral imperative to treat in specific ways that physicians, patients, and family members talk including how treatment is recommended and accepted (or resisted), presupposed, or through persuasive language.

This collusion between physicians, patients, and families to treat cancer may affect end-of-life care. Specifically, there is an ongoing puzzle in existing literature: Americans consistently report that a good death means dying in relative comfort at home with loved ones. Yet, there are well-studied trends in overutilization and overtreatment in late life (Institute of Medicine, 2015). These interventions come at the expense of quality-of-life concerns and have been shown to contribute to the underutilization of hospice (Mrig & Spencer, 2018) which would make the type of death Americans say they want possible. These forms of care tend to be used for short periods at the end of life despite research documenting their ability to enhance quality of care. Our work offers insight into why there may be this underutilization in the case of cancer. Specifically, physicians do not bring up hospice and palliative care in early cancer treatment consultations. Thus, when they are brought up, it is as a last resort, after all life-extending treatments have been tried. Future work should also explore mid-care visits, but it seems likely that hospice and palliative care is simply not put on the table until late in cancer care, and for this reason, few patients use it before that point.

The pursuit of life-extending cancer treatment throughout a patient’s disease journey is a reasonable choice for patients. However, we cannot currently reconcile Americans’ desires for a death at home without pain and with family with the current reality that many cancer patients are still not receiving this sort of death. If this is truly what patients want, it is likely that the only way for this to happen more often among cancer patients is for physicians to bring up palliative care and hospice options earlier in cancer care so that patients are less frequently facing in-patient care at the end of life.