Consent and truth telling
Lost in translation
A lady who does not speak English is receiving chemotherapy at the hospital. Her
family translate to her what the hospital staff say. The family learn that chemotherapy
has the side-effect of losing hair but knowing that this would upset the relative they
decide not to tell her. The patient has to sign a consent form for the treatment. In the
interests of the patient should you tell her the truth or follow the family’s good
intentions?
TUTOR NOTES
Consent, truth-telling, and confidentiality
Dilemma: Whether or not to participate in keeping the truth from a patient
Some possible areas for discussion include:
Consent
Meaning – free, full and informed
Purpose
Competence to give consent
Competent patient’s right to refuse even life-saving treatment
Proxy-decision-making
Ethical considerations
Criminal/civil liability considerations
Professional guidelines
Interpreters
Choice
Proficiency in language
Confidentiality
Enhanced responsibility on healthcare professionals
accuracy of message
errors
recognise difference between trained interpreter and untrained volunteer
potential conflicts of interest
patient’s best interests
Truth Telling
Is there a difference between being vague, being evasive, and lying?
What is ethically problematic with lying to patient?
What are the possible benefits?
What is in patient’s best interests?
Therapeutic privilege – withholding information out of concern that full disclosure may
be detrimental
Nature of information withheld
Complexities of modern medicine
complete honesty or ‘whole truth’ can be an oversimplification;
uncertainties permeate clinical situations;
diagnosis, prognosis, treatments - rarely matter of ‘mathematical certainty’;
limits to what a doctor or nurse can disclose with certainty;
duties to others besides patients;
consider appropriateness of less than full disclosure
Complete and partial disclosure
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difficult to justify a blatant lie - lying in a clinical context is wrong but less
than full disclosure may be morally justifiable? e.g. if a patient is depressed
and irrational and suicidal -caution required if full disclosure may contribute
to serious harm?
wrong not to disclose the truth to a patient when the motive is strong
paternalism, or in order to cover up for failures or mistakes, etc., or for selfinterest, or for interests of others?
generally speaking, relative certainties and realistic uncertainties should be
disclosed - information that a reasonable person needs to know in order to
make right health-care decisions
reasonable persons unlikely to want/expect full disclosure (even if such
were feasible)
Withholding information at request of patient
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withholding information from a patient does not always undermine veracity or
violate the truth principle - sometimes patients request that information be
withheld
 doctors sometimes asked to make decisions for patients without
communicating relevant information
 ordinarily, respecting such requests violates no major ethical principle: however, clinical judgement is always required because in some cases, even
a reluctant and intimidated patient who requests not to be informed, needs to
know some truths
 not knowing may create a serious danger to self or to others - if so, the
patient's request that information be withheld cannot be respected because it
violates the core principles of benefience and non-maleficence
Withholding information at request of family
 cultural, religious aspects
 certain traditional cultures see the patient not as an autonomous entity with
inviolable rights but as part of an extended family unit - family members rather
than the patient are given medical information - especially threatening information
like a fatal diagnosis
 ethics requires respect for cultural practices (closely related to respect for
individual patients) – N.B. cultures change, families are different, and some
cultural practices are ethically indefensible - clinical judgment may require that a
patient be included in the information cycle rather than cooperating with a cultural
practice which prefers communication only with the family
 who gets what information? - both family and patient can be kept informed and
general expectation that all will agree about options - what if do not agree? – best
interests judgement
 clinical judgment not only about patient competency but about what information
the patient can cope with and when the family should be involved/take charge
Confidentiality
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adult patients entitled to strict confidentiality - including spouse/family
relatives consulted about patient’s best interests only when commensurate with
duty of confidentiality and the patient’s wishes
if family members provide important medical information not known to the patient,
ordinarily they would be told that professional medical ethics requires that a
patient be given such information - however, as with other contextual variations,
great sensitivity and subtle clinical judgment is required
Ethical aspects
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Protect rights and interests of patients
Relationship between healthcare professional and patient:
Truthfulness is more than simply passing on accurate information -it expresses an
attitude towards another person that seeks to create open and mutually respectful
communication
Principles
o Respect for autonomy
 Veracity - truthfulness
 Faithfulness – faithful to patient’s best interests
o Non-maleficience duty to patient to ensure no harm is done
o Beneficience - act to benefit patient
o paternalism
o Justice
If strong advocate of patient autonomy
- tendency to eliminate any professional discretion
- require that ‘everything be revealed’ because ‘only the patient can
determine what is appropriate’
- other principles, like beneficence, non-maleficence, given little
consideration or become subordinate obligations
Autonomy cannot be the only principle involved - truth telling linked with beneficence and
justice and protection of the community, etc
Deontology: assumes that lying and deception are wrong in themselves and that healthcare
professionals, like everyone else, have a moral duty to tell the truth
Consequentialism: insists that the decision to tell or not to tell depends on the details of the
clinical situation and measure of best outcome for all involved
Virtues
integrity, honesty, veracity, courage, fortitude, respect for others, compassion, fairness,
self-control, prudence, etc.
Motive(s) for lying important – e,g,
- to reduce fear; anxiety; stress
- to prevent harm
- to enhance well-being
- to protect privacy / preserve confidentiality
- to help others
- to remove patient choice
- to protect interests of others
Professional aspects
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Professional guidance
o GMC; BMA; RPSGB; NHS/DoH
must be competent to communicate well (well-meaning but untrained
people can do harm when trying to help in difficult/sensitive situations)
telling the truth in the clinical context requires compassion, intelligence,
sensitivity, and a commitment to the patient after the truth has been
revealed
care not to undermine trust and confidence
multidisciplinary team - number of professions, each of whom has a
professional code and some sense of responsibility for telling the truth
traditionally, the doctor is responsible for all communication with
patients and families (today, nurses, etc. also claim responsibility for
truthful communication with patients and families as ‘patient
advocates’)
Legal aspects
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common law consent to treatment
absolute right to not be treated against will
competence and decision-making
no-one can give or withhold consent to medical treatment on behalf of
another adult
duty of candour?
therapeutic privilege
material/significant risks – level of risk warranting disclosure
not developed full doctrine of ‘informed consent’ requiring patients to
be given full information
legal status of ‘consent forms’
competence
o understanding/believing/weighing up information
o freely given
criminal/civil liability
Summary points
Telling the truth – demonstrates respect for person; enables informed decisions
(self-determination); social contract; establishes trust and confidence
Telling the truth in a clinical context is an ethical obligation but determining just
what constitutes the ‘truth’ is a matter of clinical judgment;
Issue of deciding just what to disclose may be compounded by the difficulty of
deciding the right person to make the disclosure
Co-ordination of truth-telling raises potential difficulties – one person who is not
truthful is likely to be exposed by another
ETHICAL DECISION-MAKING
Is the question an ethical one?
Legal and professional issues but the also ethical issues: Avoiding harm, Doing good,
Confidentiality, Truth telling, Faithfulness
Step 1 – Gather relevant information
Step 2 – Identify type of ethical problem
 rights and best interests of patient
 withholding information
Step 3 – Analyse problem
 principles of autonomy, non-maleficence; beneficence; faithfulness; veracity
Step 4 – explore options/solutions
 deontological approach – weighing of conflicting principles/conflict of duties –
which course of action best respects duties and rights?
 utilitarian approach – consider all potential consequences (to all parties involved)
– what benefits and harms will each course of action produce and which will lead
to best overall consequences?
 virtues approach – which course of action develops moral virtues?
 alternative courses of action, e.g.
do not tell patient ↪ sufficiently informed to provide valid consent appropriate? ↪
consequences of disclosure (therapeutic privilege) ↪ patient autonomy undermined ↪
loss of trust? ↪ patient response when side-effects become apparent/informed by
another, etc.? ↪ honesty also matters to doctors and other healthcare professionals↪
loss of reputation for honesty - end of a profession?
incomplete disclosure ↪ what is appropriate to withhold?
complete disclosure ↪ patient fully informed ↪ patient confidence in efficacy of
treatment? ↪ fulfil patients’ need for honesty when ill, vulnerable, and burdened with
pressing questions which require truthful answers ↪ appropriate person(s) to tell
patient specific information (who; when; what)? ↪ how do you know information has
been accurately imparted?
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N.B. frequently, there are no definitive right answers, only answers that are more
or less reasonable, more or less defensible: two people may come to an opposite
decision using the same information - it depends on how important each
consideration is to each person and also the degree to which an individual takes a
“deontologist“ or a “consequentialist” approach.
Step 5 – make decision
Step 6 – assess and reflect
Discussion review/links
Pharmacist responsibilities and accountability
Consent to medical treatment
Patient preferences
Surrogate-decision making
Health/sickness role - cross-cultural aspects
- language; geographical; religious; family structure; relationships
- role of family in disclosure; consent; decision-making (hierarchy of decisionmaking); conflict resolution
Ethics and role of interpreters