Honesty in Medicine: should doctors tell the truth?
Dr. James F. Drane Profesor Emeritus University of Edinboro Pennsyvania
Introduction
Should physicians not tell the truth to patients in order to relieve their fears and anxieties? This
may seem simple but really it is a hard question. Not telling the truth may take many forms, has
many purposes, and leads to many different consequences. Questions about truth and untruth in
fact pervade all human communication. They are raised in families, clubs, work places, churches,
and certainly in the doctor/patient relationship. In each context, the questions are somewhat
differently configured.
Not telling the truth in the doctor-patient relationship requires special attention because patients
today, more than ever, experience serious harm if they are lied to. Not only is patient autonomy
undermined but patients who are not told the truth about an intervention experience a loss of
that all important trust which is required for healing. Honesty matters to patients. They need it
because they are ill, vulnerable, and burdened with pressing questions which require truthful
answers.
Honesty also matters to the doctor and other medical professionals. The loss of reputation for
honesty in medical practice means the end of medicine as a profession. Important as it is for
patients and doctors, however, honesty has been neither a major concern in medical ethics nor an
important value for doctors. It may be an exaggeration to say that honesty is neither taught in
medical school nor valued in medical culture, but it is not too much of an exaggeration.
Is concern for honesty and truth telling as absent or as threatened in other professions? Is honesty
a respected virtue among lawyers? The very question will appear ridiculous to most people. Is
truth any more respected by brokers, politicians, policemen? All these so called professionals are
publicly committed to do what is best for others and yet the others frequently are not told the
truth. Could doctors actually have fallen in with lawyers and brokers and politicians in
undermining the foundations of what we have known for centuries as the fiduciary role in a true
professional? If so, the loss to medicine is tragic because there is no comparison between the
consequences of lying in the doctor-patient relationship and the lying that goes on elsewhere.
Besides harming a patient's autonomy, patients themselves are harmed, and so are the doctors,
the medical profession, and the whole society which depends on humane and trustworthy
medicine.
Inattention to truth or violations of honesty by medical personnel is serious business. There is a lot
at stake as well for nurses, researchers and other health professionals. The truth issue is worth
thinking about by all health-care professionals. In some cases the harm from not telling the truth
may be less. Some degree of dishonesty may even be excusable sometimes in order to avoid more
serious patient harm. If there are reasons for not telling the truth, what are they? When could
incomplete disclosure be justified and under what circumstances? What exceptions, if any, exist to
the rule against lying? What kind of arguments support the answers to these questions? These are
the issues we will be trying to sort out.
Truthful disclosure vs lying in a clinical context
Subtleties about truth-telling are embedded in complex clinical contexts. The complexities of
modern medicine are such that honesty or truth, in the sense of simply telling another person
what one believes, is an oversimplification. There are limits to what a doctor or nurse can disclose.
Doctors and nurses have duties to others besides their patients; their professions, public health
law, science, to mention just a few.(1) They also have obligations created by institutional policies,
contractual arrangements, and their own family commitments. The many moral obligations a
nurse or physician may have to persons and groups other than to the patient complicates the
question of just how much a professional should disclose to his or her patients.(2)
Doctors and nurses in some cultures believe that it is not wrong to lie about a bad diagnosis or
prognosis. Certainly this is a difficult truth to tell but on balance, there are many benefits to telling
the truth and many reasons not to tell a lie. Tolstoy gave us a powerful message about the harms
which follow from lying to dying patients in The Death of Ivan Illich, and his insights came out of a
culture which assumed that lying was the right thing to do in such circumstances.
Listen-"This deception tortured him--their not wishing to admit what they all knew and what he
knew, but wanting to lie to him concerning his terrible condition, and wishing and forcimg him to
participate in that lie. Those lies--lies enacted over him on the eve of his death and destined to
degrade this awful, solemn act to the level of their visitings, their curtains, their sturgeon for
dinner--were a terrible agony for Ivan Ilych"(3)
Determining the appropriateness of less than full disclosure is one thing, but trying to justify a
blatant lie is another thing entirely. Lying and deception in the clinical context is just as bad as
continued aggressive interventions to the end. Both qualify as torture.
Sigmund Freud paid more attention to the subtleties of the doctor/patient relationship than
almost any other physician. He saw the damage which lying does to the doctor, to the therapeutic
relationship, and to the medical profession. Since we demand strict truthfulness from our patients,
we jeopardize our whole authority if we let ourselves be caught by them in a departure from the
truth.(4)
Lying in a clinical context is wrong for many reasons but less than full disclosure may be morally
justifiable. If a patient is depressed and irrational and suicidal, then caution is required lest full
disclosure contribute to grave harm. If a patient is overly pessimistic, disclosure of negative
possibilities may actually contribute to actualizing these very possibilities.
Now that so many medical interventions are available it is obviously wrong not to disclose the
truth to a patient when the motive is to justify continued intervention or in order to cover up for
one's own failures for your benefit, not the benefit of the patient. Doctors and nurses, however,
can do as much harm by cold and crude truth-telling as they can by cold and cruel withholding of
the truth. To tell the truth in the clinical context requires compassion, intelligence, sensitivity, and
a commitment to staying with the patient after the truth has been revealed.
If a patient is in a high-tech tertiary care facility, the problem of deciding just what to disclose is
compounded by the difficulty of deciding the right person to make the disclosure. A patient can be
attended by any number of professional staff members, each of whom has a professional code
and some sense of responsibility for telling the truth. Traditionally, the doctor alone was
responsible for all communication. Today, social workers and nurses also claim responsibility for
truthful communication with patients and families. Since all employees of a health care institution
are bound by institutional policies (including a Patient's Bill of Rights), coordination of truth-telling
is also more of a problem. One staff person who is not truthful is likely to be exposed by another.
Truth Telling and Patient Autonomy
A professional obligation to be truthful does not need linkage with patient autonomy to be
justified but in fact it is often so joined. Then, it tends to require what autonomists refer to as full
disclosure. For them, it is not sufficient to tell the truth, one has to tell the whole truth. Radical
advocates of patient autonomy tend to eliminate physician or nurse discretion and simply require
that "everything be revealed" because "only the patient can determine what is appropriate."
Other principles, like beneficence, non-maleficence, and confidentiality, may be given little
consideration or turned into subordinate obligations.
Autonomists who insist always on full disclosure usually set aside questions about uncertainties
which permeate the clinical context. But, medical diagnoses and follow-up therapeutic regimens
are rarely a matter of mathematical certainty. Psychiatric diagnoses for example, like diagnoses in
many other specialties, develop from hypotheses which are then tested out through continuing
symptom evaluation and carefully watched responses to therapeutic interventions. Does every
feasible hypothesis require disclosure to a patient? Is every bit of data about a disease or therapy
to be considered information to be disclosed?
Generally speaking, relative certainties and realistic uncertainties belong within honest disclosure
requirements because they qualify as information that a reasonable person needs to know in
order to make right health-care decisions. But reasonable persons do not want full disclosure even
if such were feasible. Telling the truth in a clinical context is an ethical obligation but determining
just what constitutes the truth remains a clinical judgment. Autonomy cannot be the only principle
involved. Truth telling has to be linked with beneficence and justice and protection of the
community.
Clinical Context and Clinical Judgement
We can see the clinical context's influence on truthful disclosure when we look at an emerging
new field like genetic medicine. What truth should be communicated to a patient who has just
undergone a diagnostic test which indicates a possibility that the patient will develop an incurable
disease? Should the simple facts be disclosed? How? When? By whom? To whom? After what kind
of broader patient assessment? What if the patient has a history of suicidal tendencies?
If a genetic test reveals predisposition to certain diseases, who interprets predisposition or
increased risk? What should be disclosed to a worrisome patient? If a genetic test indicates that a
certain disease at some point will be expressed, for which there is no cure or therapy, should the
eventual disease manifestation simply be disclosed? The patient may die from another cause
before the genetically potential disease appears. If genetic tests suggest that a woman age 40 has
a 20% chance of cancer which increases as she ages, when should the information be disclosed?
All these questions make one simple but important point; that disclosure of the truth in a clinical
context requires a clinical judgment and is not a matter of simply stating what is factually or
scientifically true or telling everything and letting the patient decide.
New York hospitals have just altered an institutional ethic policy on truthful disclosure about H.I.V.
status to a new mother. Previously H.I.V. testing and disclosure of test information required
patient permission. Now both are automatic. The shift reflects a re-evaluation of the risks and
benefits associated with H.I.V. testing and the possibility of altering the course of the disease in
adults who know the truth about their status. Now truth, in the sense of reporting known factual
information, is considered a public health responsibility and more important than a patient's right
to control or to individual autonomy. This is another example of a changing medical context and
delicate clinical judgment about disclosure of truth.
The concept of clinical context can extend over to the financial dimensions of medical practice.
Lawyers, driven by self interests, have permeated the clinical context with the fear of malpractice
suits and this situation makes revealing mistakes and errors imprudent or even self destructive.
Ideally, truthful disclosure of physician or hospital errors to patients would be recommened and
would likely strengthen the trust between doctor and patient, but this is rarely the case in today's
clinical context.(5) Here a conflict may exist between prudence and truthful disclosure and no
simple rule, like tell everything, will resolve the conflict.
Justifying Less Than Full Disclosure
Withholding information from a patient does not always undermine veracity or violate the truth
principle. Sometimes patients request that information be withheld. Doctors sometimes are asked
to make decisions for patients without communicating relevant information. Ordinarily, respecting
such requests violates no major ethical principle: neither autonomy, nor truth, nor beneficence.
But 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, and if so, the patient's request that information be withheld
cannot be respected because it violates the core principles of benefience and nonmaleficence.
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. Medical ethics requires
respect for cultural practices because these are closely related to respect for individual patients.
And yet, cultures change, and 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 painful isolation and communication
only with the family.
Sometimes, a particular family member may be the designated decision-maker for an incompetent
patient who later regains competency. Then who gets what information? Ordinarily both family
and patient can be kept informed and will agree about options, but not always. Again, the clinician
has to make a judgment not only about patient competency but about what information the
patient can handle and when the family should take charge. If family members give a doctor or
nurse 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.
The Dying Patient
No one could pretend to speak for every patient in every context but generally speaking, patients
want to know the truth about their condition and doctors are unlikely to be correct when they
judge this not to be the case. Some patients who are given a cancer diagnosis and a prognosis of
death may use denial for a while and the bad news may have to be repeated, but the use of denial
as a coping device does not mean that patients would prefer to be lied to or that truth is not
important to them. Patients need the truth even when it tells them about their death. To live
without confronting the inevitability of death is not to live in anything approaching a rational or
moral way. It is wrong to assume that patients prefer irrationality and moral superficiality. A death
notice is a shock and a pain and yet patients can derive benefit from being told the truth even
about their own death.
Without the disclosure of truth in a dying situation, patients are likely to be subjected to
aggressive treatments which will turn their dying into a painful, expensive and dehumanizing
process. It is just this kind of situation which has contributed to increasing support for the
euthanasia movement. Patients rightfully are afraid that they will not be told the truth about their
medical condition and therefore will die only after futile interventions, protracted suffering, and
dehumanizing isolation. On the other hand, the benefits of being told the truth may be
substantial; for example, improved pain management, even improved responses to therapy, etc.
But harm too may come from telling the truth about death. Harm may be rare, but still it must be
guarded against. The doctor who tells a dreadful truth must do so at a certain time, and in a
certain way. The communication of truth always involves a clinical judgment. Truth telling in every
clinical context must be sensitive and take into consideration the patient's personality and clinical
history. Generally speaking, however, in case of doubt it is better to tell a patient the truth.
In complex clinical contexts, it may be difficult to draw the line between truthful disclosure and a
violation of truth. Reasons could certainly be advanced to justify not telling a certain patient the
whole truth. Outright lies, on the other hand, rarely are excusable. Something less than full and
complete truth is almost inevitable. The good clinician is not just good at medicine and a decent
person; he or she is also good at judging just what the principle of truth telling requires in a
particular clinical context.
Moral Arguments About Truth and Lying
Classical Catholic natural law tradition, beginning with Augustine(6) and continuing with
Aquinas(7) and beyond, considered every instance of lying to be a sin. Lying, in this tradition,
subverts the nature of speech and therefore violates the divine purpose in creating us as speaking
animals. Circumstance, intention, and consequences may mitigate its gravity but could never
change the inherent evil of untruthful speech. If the intention was right and serious harm to others
was avoided, then the objective evil would be much less, but lying was never a good act. This
Catholic moral teaching, however, was modified by confessors who were forced to decide whether
individual penitents in particular contexts had committed a sin or not. Confessors and Casuists
introduced mental reservation as a way of denying the intrinsic evil of every lie.
At the end of the 18th century Kant(8) argued for truth and the strict rejection of all lying. In Kant's
categorial imperative doctrine, truth telling is a duty (imperative) which binds unconditionally
(categorical). A lie is always evil for Kant because it harms human discourse and the dignity of
every human person. Kant did away with mitigating circumstances, intentions and consequences.
Truth telling is always a duty, whether the other has the right to know or whether innocent
persons will be severly harmed.
In Natural Law theory, truth has an objective foundation in the very structure of human nature.
Even in Kant, an assumption exists that lying violates an objective moral standard. In both the
Catholic and the Kantian tradition, truth telling is a condito sine qua non for individual human
integrity. Habitual violations of veracity robs the liar of any sense of who he or she is. Truth telling
is necessary in order to become a decent person and even to know oneself.
Truth telling is even more obviously necessary in order to sustain human relations. Human beings
are essentially relational, and without truthfulness human relations are impossible. Without
honesty, intimacy and marriage dissolve. Without intimacy and marriage, communities cannot
exist, small or large, civil or economic. Without honesty and trust, human beings are condemned
to an alienating isolation. What is the case for human beings, generally speaking, is even more true
for doctors who are by definition in relationships with their patients.
Truth obviously is an essential moral good. But, what if truth comes into conflict with other
essential moral goods like life itself, or beneficence, or freedom? Can a lie be justified if it saves a
human life or a community, or if another great evil is avoided? Were Augustine and Kant right
when they admitted of no exceptions to the duty to tell the truth, or were the Confessor and
Casuists right when they insisted on considering consequences, intention and circumstances, and
when they considered some lies to be of little or no moral import? Historically a doctor's
benevolent lie told to a sick and worried patient was considered the least evil act of all. In fact,
Casuists and Confessors considered benevolent lying to patients to be a good act.
Trying to decide what to say in medical relationships or in clinical contexts is often side-tracked by
phony arguments. One such argument claims that there is no moral responsibility to tell the truth
because truth in a clinical context is impossible. This argument focuses on the enormous
complexity of grasping and then communicating concrete medical truth in its full sense. This
argument, understood in abstraction, is respectable, and yet in its application it turns out to be
fallacious.
We may recognize and readily admit epistomological complexity as well as an inevitable human
failure to achieve "the whole truth". But these recognitions do not make truth telling impossible
and do not cancel out or even reduce the moral obligation to be truthful. The doctor who pauses
thoughtfully before responding to a sick, anxious, and vulnerable patient's questions is faced with
a clinical moral issue rather than a philosophical perplexity. The truth issue here is not that of
inevitably limited human cognition trying to grasp the full complexity of a particular person's
disease. Rather, it is the question of what to disclose of known information in order to make sure
that the disclosure helps the patient or in order to keep the truth which is known from doing a
vulnerable patient more harm than good.
This same idea can be expressed in different ways. Rather than speaking about epistomological vs.
moral truth, we can speak of abstract vs. contextual truth. Objective, quantitative, scientific truth
is abstract and yet it is not alien to the clinical setting. Relational, contextual, clinical truth always
points toward the incorporation or application of what is objective and abstract. But the two are
not synonymous or reducible one to the other. A clinical judgment is different from a laboratory
judgment, and the same is true of clinical and abstract truth(9). The clinical truth strives to address
a patient's inquiries without causing the patient unnecessary harm. It cannot ignore objectivity,
but is not reducible to it(10). Clinical/moral truth is contextual, circumstantial, personal, engaged,
and related both to objective/abstract truth and to the clinical values of beneficence and nonmaleficence.
Besides making the distinction between epistomological and clinical truth, one needs also to look
at the consequences which follow from rejecting this distinction and collapsing one into the other.
If, in clinical practice, doctors operate under the assumption that truth is impossible and therefore
of no concern, patients will be blatantly lied to for whatever reason. Lies will be used to benefit
the doctor, the hospital, the HMO, the insurance company, the doctor's specialist friends, the free
market labs in which the doctor is invested, etc. No difference would exist between
communication with a competent and an incompetent doctor. Many different parties would stand
to gain from considering truth to be impossible. The only parties who would not gain are patients.
If patients are ravaged as a result of collapsing the moral into the epistomological, then reasons
exist for rejecting the proposition that "truth is impossible."
Truth in the History of Medical Ethics
The historical medical codes addressed issues like not doing harm, not taking life, not engaging in
sexual acts, not revealing secrets, but said little or nothing about telling the truth and avoiding lies.
The value of not doing harm was so strong that lying in order to avoid harm was considered
acceptable, a twisted form of medical virtue. Because communicating the truth about disease is
difficult, many physicians simply discounted or ignored the moral problem of truthfulness in the
doctor-patient relationship. The importance of not doing harm in effect relegated truth telling to
the category of "everything else being equal, tell the truth" or "tell the truth as long as it helps
rather than harms the patient."
Because of the historical centrality of non-maleficence, and because telling the truth about fatal or
even serious diagnoses was assumed to cause harm to the patient, physicians traditionally did not
tell the truth to patients. Many moral philosophers referred to physician discourse with patients as
an exception to the obligation to tell the truth. The doctor's principal moral obligation was to help
and not to harm the patient and consequently, whatever the doctor said to the patient was judged
by its effect on these core duties.
Today, things have changed. Beneficence and non-malifience remain basic medical ethical
principles, but truth is also a medical ethical principle. The importance of truth telling in the clinical
context derives from taking more seriously the patient's perspective in medical ethics. The
historical justifications of lying to patients articulate the perspective of the liar, not that of a
person being lied to. In most cases people are hurt when they are deliberately deceived. This is
especially true of patients. This may not have been so historically, but it is definitely true today.
Today, Bacon's comment that "knowledge is power but honesty is authority," is particularly
applicable to doctors. In the end, lies in the doctor/patient relationship hurt patients, doctors, the
medical profession, and the whole society which depends upon a medical system in which patients
can trust a doctor's authority.
The historical absence of a truth requirement in medical ethics has much to do with the moral
assumptions of ancient cultures. Paternalism in our culture is a bad word, a "disvalue," something
to be avoided. In earlier cultures it was an ideal to treat other persons as a father treats a child.
Paternalism was something virtuous; the opposite was to treat the other as a slave. In early Greek
culture, the good doctor or the good ruler treated the patient or the citizen as a son or daughter
rather than a slave. He did what was best for the "child" but without ever asking for his or her
consent. With no involvement in treatment decisions, making known the truth to a patient was
less important. Because patients today can and must consent to whatever is done to them,
truthful disclosure of relevant information is a legal and ethical duty.
Modern medical ethical codes reflect this shift in the importance of veracity. The code of the
American Nurses Association states: "Clients have a moral right..to be given accurate information."
It urges nurses to avoid false claims and deception. Even the "Principles of Medical Ethics" of the
American Medical Association, in 1980, included a reference to honesty. "A physician shall deal
honestly with patients and colleagues and strive to expose those physicians deficient in character
or competence, or who engage in fraud or deception." This first official reference to veracity in
physician codes remains a very abstract one, and is more concerned with failures of honesty
among colleagues than with truth telling to patients.
The American College of Physicians however did refer to the physician's obligation to honesty in
the doctor/patient relationships in its ethics manual. It focused on the obligation to provide
truthful information to patients in order to contribute to an acceptable doctor/patient
relationship. Similar references and recommendations have been included in sub-specialty medical
codes (orthopedics', surgeons', psychiatrists', obstetricians' and gynecologists').
The link between patient autonomy and veracity is characteristic of modern medical ethics and is
most evident in the American Hospital Association's "Patient's Bill of Right" (1972). The
requirement of honesty is clearly linked today with the patient's new legal right to give informed
and free consent or refusal of treatment. Patient power in the doctor/patient relationship is the
distinguishing element of modern medical ethics. In requiring adequate information for decision
making, modern medical ethics broke with the paternalistic tradition. Traditionally the doctor did
not tell the truth lest the patient be harmed. Now, not to harm the patient requires in most
instances that patients be truthfully informed and then invited to participate in clinical decision
making.
If today a physician decides, in light of clinical considerations, to conceal the truth, he or she must
bear the burden of proof. A doctor must be able to defend this decision before other professional
persons involved in the patient's care. And some member or members of the patient's moral
community must be given the truth. If physicians habitually lie, or conceal truth from patients,
they cannot be excused based on a clinical context or a discrete clinical judgement.
Truth and True Professionals
If providing truthful information to a patient is a matter of judgment, mistakes are bound to be
made. If the information itself is limited and the amount to be disclosed must be determined by
the context of each case, then inevitably there will be inadequacies and failures. It is one thing to
fail, to make a mistake, to miscalculate what should have been said. It is quite another thing, to set
out to lie. It is even worse to adopt a pattern of deception. Failure is one thing, becoming a liar is
quite different, something incompatible with being a professional.
For a true professional, striving to become an honest person is important. We have seen the
strong stand of Immanuel Kant on this issue. Now listen to the person against whom Kant was
most often pitted against and with whom he most often disagreed, John Stuart Mill. In the
following quote, he is talking about the feeling of truthfulness or veracity. He said that his feeling
is
"one of the most useful, and the enfeeblement of that feeling one of the must hurtful, things to
which our conduct can be instrumental; and (..) any, even unintentional, deviation from truth does
that much toward weakening the truth-worthiness of human assertion, which is not only the
principal of all present social well-being but the insufficiency of which does more than any one
thing that can be named to keep back civilization, virtue, everything on which human happiness on
the largest scale depends.."(11)
For Mill, if someone as much as diminishes reliance on another persons' truthfulness, he or she is
that person's enemy. Why? Because to lose the trust of others is to lose one's own integrity. A
doctor can do even greater harm because not being honest damages the climate of trust within
the profession. Then, it is not an individual's integrity, but a whole profession's integrity that is
lost. If patients are habitually lied to or misinformed or deceived, then the context of medical
practice is polluted. The whole profesion is discredited.
A recent American movie, Liar Liar, attempted to make a comedy out of the all-pervasiveness of
lying in the legal profession. The film makers seemed most interested in creating laughter but in
the process made a not at all funny commentary on how lying and deceit have become pervasive
among lawyers. Without lying, the main character could not function in the court system. His
lawyer colleagues were repugnant characters. The comic star of the movie saved his life and his
marriage and his moral integrity by discovering the importantce of being truthful. Consequently,
he had to seek a different type of work. The image of the legal profession portrayed in this film
was sickening. We cannot let this happen to doctors and medical researchers.
Something similar must not happen to doctors and the medical profession. Now, more than ever,
patients have to be able to trust their doctors and to be able to rely on the truth of what they are
told. Since truthfulness and veracity are such critical medical virtues, doctors have to work to
develop the virtue of truthfulness. This is not an easy task.
To become a truthful person we have to struggle first to know the truth. Then we have to struggle
with personal prejudices which can distort any information we gather. We have to try to be
objective. We have to work to correct a corrupting tendency to confuse one side of a story or one
perspective of an event with the whole truth. And, finally, we have to recognize that selfaggrandizement corrupts the capacity to know the truth and to communicate anything except
pathological, narcissistic interests. Truth for an egoist is reduced to what promotes his ego. The
egoist cannot see the truth and therefore cannot tell it. The only thing which can be
communicated is his or her own aggrandized self.
Knowing the truth and telling the truth is difficult enough without shadowing weak human
capacities for virtues with narcissistic pathological shades. If we are self-deceived we cannot hope
to avoid deception in what we disclose. Not to address pathological character distortions is to
make lies inevitable. The classical medical ethical codes were preoccupied with a good physician's
personal character traits--rightfully so.
Conclusion
This paper argues for truth in the doctor/patient relationship but not for flat-footed or insensitive
communication. The presumption is always for truth and against lying. But the arguments support
the need to make humane clinical judgments about what is told, when, how, and how much.
Perhaps the best way to sum up the argument is to quote a sensitive and humane physician on
this topic: Dr. Cicely Saunders, the founder of the Hospice movement.
Every patient needs an explanation of his illness that will be understandable and convincing to him
if he is to cooperate in his treatment or be relieved of the burden of unknown fears. This is true
whether it is a question of giving a diagnosis in a hopeful situation or of confirming a poor
prognosis.
The fact that a patient does not ask does not mean that he has no questions. One visit or talk is
rarely enough. It is only by waiting and listening that we can gain an idea of what we should be
saying. Silences and gaps are often more revealing than words as we try to learn what a patient is
facing as he travels along the constantly changing journey of his illness and his thoughts about it.
(..)So much of the communication will be without words or given indirectly. This is true of all real
meetings with people but especially true with those who are facing, knowingly or not, difficult or
threatening situations. It is also particularly true of the very ill.
The main argument against a policy of deliberate, invariable denial of unpleasant facts is that it
makes such communication extremely difficult, if not impossible. Once the possibility of talking
frankly with a patient has been admitted, it does not mean that this will always take place, but the
whole atmosphere is changed. We are then free to wait quietly for clues from each patient, seeing
them as individuals from whom we can expect intelligence, courage, and individual decisions. They
will feel secure enough to give us these clues when they wish(12).
Finally, to tell the truth is not to deny hope. Hope and truth and even friendship and love are all
part of an ethics of caring to the end.
NOTES
Sometimes the patient cannot be told about truths or strong hypothetical suppositions
associated with public health requirements.
Military physicians, for example, are often compormised in truth telling because of their military
obligations. The same is true of doctors and researchers working for an industry or the
government, or a managed care facility.
Leo Tolstoy. The Death of Ivan Ilych. Quote from Bok, Sissela Lying: Moral Choice in Public and
Private Life, Pantheon Books, NY. 1978. p.220.
Sigmund Freud, Collected Papers. Cited from Lying: Moral Choice in Public and Private Life.
Pantheon Books, NY. 1978, p.221.
If finances in the clinical context complicate truth telling for healthcare professionals, imagine
the truth telling problems created by today's healthcare industry. Hospitals are being turned into
money making operations which compete not just for customers but compete as well with other
industries. Can patients cound on truth telling in the advertisement of HMO's, insurance
companies, and pharamceutical firms? Increasingly, patients as well as doctors need truthful
communications of information, but what they get is most often a manipulative message. Is it
reasonable to expect either free-market capitalism or its agents to be truthful? Is continuing to
insist on truth in medical care naive? Instead of counting on truth from for-profit health care
administrators, patients now have to adopt the practice of caveat emptor?
Augustine, "On Lying," Treatises on Varies Subjects, in Fathers of the Church, Deferrariced R.J.
Catholic University of American Press, NY 1942, v.14, ch.14.
Aquinas, Summa Theological, Secunda Secunda, questions 110, art2.
Kant, The Doctrine of Virtue, N.Y.: Harper and Roe, 1964, pp. 92-96.
In a clinical setting, telling the truth has to do with a particular patient, who has a particular
illness, and a particular history. It would be an error to think that telling the truth in this setting is
something totally different from telling the truth in an academic journal focused on scientific
research. They are not totally different, but obviously they are different. The different settings
create different realities and different standards for judging what is really honest and ethically
required.
The department of finance in a for-profit hospital and the bedside context of a patient in the same
hospital are related but different. Hospitals cannot survive if economic realities are left
unattended. Economics is related to clinical realities but the two are not the same or reducible one
to the other. What is good for the economic bottom line may not be good in a particular doctorpatient relationship. Many realities intersect and influence one another but cannot be collapsed or
reduced to one another. There is a personal, existential dimension in a hands-on doctor-patient
relationship which is absent from the mathematical manipulations bottom line data in economics.
It would be an unexcusable error to reduce care for the sick to economics. One has to be warm
and engaged, the other has to be cold and abstract.
Mill, John Stuard. (1861). 1961. Utilitarianism In The Philosophy of J.S. Mill, Marshall Cohen, e.
New York:The Modern Library, p.349.
Cicely M.S. Sanders, "Telling Patients," in Reiser, Dyck, and Curran, Ethics in Medicine, pp. 238240