Introduction
Patients normally assume their healthcare provider is telling them the truth about a diagnosis, the results of a test, or in recommending treatment options.
Historically, providers have not been as honest and revealing as patients probably assumed. Physicians sometimes felt patients couldn’t handle the truth. Decades ago, if a patient were diagnosed with terminal cancer the physician sometimes felt it was best if the patient wasn’t told. Better to let the patient enjoy their last few months happy rather than sad and depressed.
Attitudes have changed since then, at least in the United States, but the subject of truth-telling in healthcare is still controversial. Is it morally permissible for a provider to purposely withhold information from or otherwise deceive a patient?
What is Truth?
Many ethicists recommend providers never lie to patients. Their view is that providers should always tell patients the truth because that respects patient autonomy. This perspective is a good start, but unfortunately refraining from lying is not the whole story on truth and deception.
In the sense relevant here, a true statement is one that corresponds to reality, to the way the world really is. So a nurse telling a patient that his blood pressure is 120/70 is telling the truth if the patient’s blood pressure really is 120/70, assuming agreement about the time and context in which the statement applies.
Sometimes there are degrees of precision involved; no one charges a nurse with lying for saying “98.6” if in fact the thermometer reading would have been more accurately described as 98.59 degrees.
Uttering true statements does not guarantee lack of deception because, as explained below, it is possible to mislead or deceive someone even when telling true statements. This has long been recognized in the words of the famous admonition to “tell the truth, the whole truth, and nothing but the truth.”
What is Deception?
Deception can be thought of as intentionally misleading someone, or causing someone to come to a false belief. The plainest case of deception is outright lying. Someone can lie to you by uttering a false statement, knowing it to be a false statement, and yet representing it as true. (Uttering a false statement by mistake is not lying.)
Lying is deception, but there are other forms:
- Some people consider lies that don’t matter to be “white lies” or “fibbing.” So, for example, if you suddenly come across a long lost friend who really doesn’t look too good, you might still say to her that she “looks great.” Healthcare professionals probably utter their share of white lies trying to cheer patients up.
- “False suggestion” occurs when a person makes true statements but leaves out crucial information so that the hearer winds up believing something false. If a person asks you whether you were out late last night, if you tell them that the party you attended ended early they may think you are implying you were not out late and believe you came home early. Strictly speaking, what you said was true even if right after the party you then went to another friend’s house and stayed until 3 A.M.
- A “euphemism” is a vague, more comfortable term used in place of a more precise but less comfortable term. Calling a tumor “some tissue” or “a growth” may mislead someone into thinking the situation is less serious than it really is. Healthcare professionals sometimes use euphemisms to avoid shocking or unduly worrying patients.
- Exaggeration in the form of overstatement that is not recognized as such may be considered a form of deception.
- Deception can occur through intentionally withholding, hiding, covering up, or otherwise concealing the truth without making false statements. A child who intentionally throws away an exam with a bad score in order to keep it a secret from parents may mislead the parents into thinking the child is doing better at school than he or she really is. Over the years healthcare professionals have probably engaged in many cases of deception of patients when they thought it was for the good of the patient.
It should be pointed out that not every instance of withholding information is a case of deception, for example if withholding information is not done with the intent to mislead or cause false belief, and in fact does not do so. If you think about it, in a sense we withhold information constantly when we leave out irrelevant details, yet this is a harmless sense of “withholding.” If someone asks you where you were they do not expect a report of every step you took, just the important ones.
Using the above distinctions, we see that deception in healthcare can occur in a variety of ways. A provider can lie to a patient about the nature of a diagnosis or the risky nature of a procedure. Or, rather than lie, the provider can leave out important details and allow the patient to come to a false belief about a diagnosis or level of risk. Or, the provider can use a euphemism to describe a patient’s illness instead of a more frightening term: “growth” instead of “tumor,” for example. Or the provider can selectively refrain from telling the patient about some possible treatment options available in order to steer the patient toward a treatment preferred by the provider.
Such deceptions have undoubtedly occurred in healthcare. Probably in almost all such cases the providers believed they were acting for the patient’s benefit, not out of intent to harm the patient. The provider lied or left out important details out of concern for the patient’s mental state, or in order not to confuse the patient and risk having the patient select a treatment plan that in the opinion of the provider was not in the patient’s own best interests.
If we believe that providers have an obligation not to explicitly lie to patients, do we mean that they have obligations not to tell white lies, make false suggestions, use euphemisms or exaggerate, and intentionally withhold healthcare information?
Moral Obligation to Tell the Truth
Commonsense morality recognizes a moral obligation each of us has to tell the truth. The justification given for this may be that it is a basic moral principle, rule, or value. Some ethicists call for basic principles or values of lucidity, veracity, and honesty. Another line of reasoning is more “utilitarian”: truth-telling just works out best for everyone in the end (“honesty is the best policy”). Lying creates the need for more lies to cover one’s tracks, and the whole process winds up being a chain of falsehoods that eventually spirals out of control. As Mark Twain remarked, if you always tell the truth you don’t have to remember anything.
When commonsense morality holds we have a moral obligation to tell the truth it might mean something more than just the obligation not to intentionally utter falsehoods. It is probably broader, to the effect that we have a moral obligation not to intentionally mislead or deceive. If you create the same level of patient misapprehension through false suggestion as through lying, have you really been any more truthful by not lying?
It is not clear how absolute commonsense morality considers this moral obligation to be. For example, when presented with a case in which a person would have to lie to save someone from being murdered by a serial killer, many people believe it would be morally permissible and even morally obligatory to lie. Or suppose an undercover police officer on a drug case is asked point-blank by a drug dealer whether he is really a cop – does he have to say yes and get killed, leaving a family behind and blowing the whole operation? Can he instead lie or engage in false suggestion in order to save his life and to put the drug dealer in jail? Endless similar examples can be generated.
One way to interpret such situations is to say that we have a moral obligation to refrain from deception, but that this duty can be overridden, or trumped, by other moral obligations, such as an obligation to save someone’s life or prevent serious harm if it causes us no significant hardship. A different interpretation would hold that the obligation “not to deceive” is better described as an obligation “not to deceive unless it would save someone’s life” (or unless it would prevent significant harm, etc.). However it is phrased, many people believe that lying or otherwise deceiving is morally permissible in certain special situations.
Deception in Health Care
When a physician recommends a patient undergo a procedure or other medical intervention, it is commonly held the physician has a legal and moral obligation to explain the nature of the procedure, along with the anticipated benefits and possible risks, etc. in order to obtain informed consent from the patient. In presenting this information, does the physician or other healthcare professional (acting in a healthcare context) always have an obligation to avoid all deception?
Ordinarily physicians and other providers are considered to be bound by obligations to the patient of respect for patient autonomy, acting for the benefit of the patient, and refraining from anything that would harm the patient. Truth-telling or honesty is seen as a basic moral principle, rule, or value. Withholding information or otherwise deceiving the patient would seem to at least disrespect patient autonomy and potentially harm the patient. Respecting patient autonomy means allowing patients to make their own decisions about whether to have certain tests, procedures, treatments, or other interventions recommended by the healthcare provider. It means allowing patients to be in control of the course of their lives to the extent possible. But no one can be in control of their healthcare decisions and lives if the choices are being made on the basis of significantly incomplete information or outright deception. Then it becomes a sham choice.
A complete recounting to the patient of all possible diagnostic factors, alternative treatments and all their details, a highly technical explanation of the procedure, etc. would take an extraordinary amount of time, not to mention overwhelming to the patient. This would be simply impractical.
So it would seem something less would be more feasible. The physician may tell the patient only what he thinks the patient wants or needs to know, leaving out technical details and other irrelevant details that would have no bearing on the patient assessing risk and decide about the procedure. This might be seen as “withholding information” if it is recognized that anything less than telling absolutely everything possible is this kind of innocuous “withholding.” But on this view the physician must not withhold any significant information and must not deceive the patient.
On this view, then, the physician would have to truthfully disclose the diagnosis to the patient rather than trying to cover it up, lie about it, or minimize the severity. The physician would not be morally allowed to be unduly optimistic about the likelihood of success of possible therapeutic interventions either. The physician is not allowed to give false hope. This view certainly clashes with the older, paternalistic view of physician authority that would sanction lying to the patient about terminal cancer.
(The fact that medical decisions are often made in the midst of uncertainty, dealing with probabilities, does not preclude physicians being truthful. They should be truthful about the lack of certainty without frightening patients. Some critics, however, would charge that physicians often neglect to be fully candid with patients about the uncertainty.)
An opposing perspective, or a commonly recognized exception to the “full relevant disclosure” view above, is that there are situations in which the physician may withhold significant information or deceive the patient. Suggested situations include when revealing information would cause significantly more harm to the patient than benefit (legally this is sometimes called “therapeutic exception”), when the patient is unable to consent to treatment because incompetent or incapacitated and emergency treatment is required (“emergency exception”), when the patient has previously expressed the desire to the physician that he or she does not want to know the truth if it is bad because it would be too upsetting or frightening (legally, “therapeutic waiver”), and if the patient is a child with a serious illness. Not all legal jurisdictions accept the legal versions of the above situations.
A situation in which the patient may be harmed by information would be a case in which a patient became so despondent upon hearing bad news that he or she became severely depressed and suicidal. This might be considered a harm to the patient. On the other hand, the risk of this needs to be balanced against the harm of not knowing that might occur for other patients. A patient with a terminal illness might like to know this in order to prepare for death by dealing with finances and spending time with family and friends. Keeping the patient in the dark would preclude this. There is some evidence that most patients want to know the truth, even if it hurts.
A child with a serious illness presents a special case. Children can understand only a limited amount, and decision-making rests with the parents, so they are the ones who need to know. However, many parents who have lost a child to a terminal disease think it desirable to have talked to the child rather than trying to hide it.
Some thinkers believe that the focus on patient autonomy and telling the truth to patients is an American emphasis not shared by other cultures. Some other cultures believe that in a case of terminal illness the family should be told and then they should decide whether to tell the patient. Others believe this is an overly simplistic view of non-American cultures and the basic moral principle should still apply, including the principle of respect for autonomy, because patients the world over might rather know then be kept in ignorance.
In the United States, in recent decades, there has been a change in what is considered the ideal model for the relationship between healthcare providers and patients. Paternalistic models have been replaced by models in which more emphasis is placed on respecting patient freedom and sharing decision making.
Controversy still exists, however, about which non-paternalistic model is best and how far providers should involve themselves in influencing the patient’s values, goals, and decisions.
