Truth-telling

in Medicine

Dra Frances Avilés

 Introduction
Should physicians not tell the truth to patients in
order to relieve their fears and anxieties?

Nottelling 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. In each context, the
questions are somewhat differently configured.
 Introduction

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.
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.

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 The Categorial Imperative doctrine

Immanuel Kant argued for truth and the strict rejection of

all lying - truth telling is a duty (imperative) which binds
unconditionally (categorical).
A lie is always evil because it harms human discourse and
the dignity of every human person.
Truth telling is always a duty, whether the other has the
right to know or whether innocent persons will be
severly harmed.

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 Conclusion

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?

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 Diversity
* After a survey of 800 seniors from four different ethnic
groups showed that Korean-American and Mexican-
American subjects were much less likely than their
European-American and African-American counterparts to
believe that a patient should be told the truth about the
diagnosis and prognosis of a terminal illness.
* European-American and African-American respondents
were more likely to view truth-telling as empowering,
enabling the patient to make choices.
* Korean-American and Mexican-American respondents
were more likely to see the truth-telling as cruel, and even
harmful, to the patients.

Further differences were noted in how the truth should be told and even in definitions of
what constitutes “truth” and “telling”.
Traditional approaches to truth

 NO general duty to disclose

 Truth as medicine; bad news can be harmful or fatal

 Subsumed under general duty of beneficence or “do no harm”

(nonmaleficence)

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Traditional approaches to truth
Objective, quantitative, scientific truth is abstract and
yet it is not alien to the clinical setting.
A clinical judgment is different from a laboratory
judgment, and the same is true of clinical and
abstract truth (clinical truth strives to address a
patient's inquiries without causing the patient
unnecessary harm).
Clinical/moral truth is contextual, circumstantial,
personal, engaged, and related both to
objective/abstract truth and to the clinical values of
beneficence and non-maleficence.
“Truth-dumping”
 Violation of beneficence-- usually perceived by patient as cruel and
uncaring

 Violation of autonomy?
 Does cruel disclosure make patient a better (freer) decision-maker?

 Does patient get a voice in how truth is told?

Truthful disclosure vs lying in a clinical context
Lying in a clinical context is wrong for many reasons
(patient is depressed and irrational and suicidal, is
overly pessimistic)
Doctors 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.
A SIX-STEP STRATEGY FOR
BREAKING BAD NEWS (SPIKES)

 STEP 1: S—SETTING UP the Interview

- Arrange for some privacy.
- Involve significant others.
- Sit down.
- Make connection with the patient.
- Manage time constraints and interruptions.
 A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.

 STEP 2: P—assessing the patient’s PERCEPTION

- You implement the axiom “before you tell, ask” - the
clinician uses open-ended questions to create a
reasonably accurate picture of how the patient perceives
the medical situation—what it is and whether it is serious
or not (e.g., “What have you been told about your medical
situation so far?)
A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.

 STEP 3: I—obtaining the patient’s

INVITATION
- While a majority of patients express a desire for full
information about their diagnosis, prognosis, and details
of their illness, some patients do not.
 A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.

 STEP 4: K—giving KNOWLEDGE and

Information to the patient
- Start at the level of comprehension and vocabulary of the
patient
- Try to use nontechnical words
- Avoid excessive bluntness
- Give information in small chunks and check periodically as
to the patient’s understanding
- When the prognosis is poor, avoid using phrases such as
“There is nothing more we can do for you.”
A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.

 STEP 5: E—addressing the patient’s

EMOTIONS with emphatic responses
- Patients’ emotional reactions may vary from
silence to disbelief, crying, denial, or anger.
- When patients get bad news their emotional
reaction is often an expression of shock,
isolation, and grief.
- In this situation the physician can offer support
and solidarity to the patient by making an
empathic response.
 A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.

 STEP 6: S—STRATEGY and SUMMARY

- Patients who have a clear plan for the future are less likely
to feel anxious and uncertain.
- Before discussing a treatment plan, it is important to ask
patients if they are ready at that time for such a
discussion.
 Reasonable Mix of Beneficence
and Respect for Autonomy

Robert Buckman, How to Break Bad News

(Baltimore, Johns Hopkins U. Press, 1992)
Truth Protocol (Buckman)
 Pick a good time and setting and assemble right
people
 Find out how much the patient already knows
 Find out how much the patient wants to know
 Share the information the patient seeks
 in sensitive manner

 in appropriate “chunks”

 Respond to patient’s feelings

 Planning and follow-through
Lessons from Buckman

 Effective truth-telling is heavy on listening and light on talking

 Most patients want to know more and can handle it; a few don’t want to
 Giving patient greater role in setting agenda is respectful of autonomy
and is also compassionate and caring
 When Can Paternalism Be
Justified?

Atul Gawande, “Whose Body Is It Anyway?”

New Yorker, Oct. 4, 1999
 “Weak” Paternalism

 Patient lacks important dimensions of capacity to make autonomous

decisions
 Child

 Dementia

 Mentally ill

 Generally easier to justify

“Strong” Paternalism

 Patient appears to have full capacities for autonomous decision-making

 Provider nevertheless feels that decision is mistaken and will cause
great harm
 Usually seen as much harder to justify-- threat to respect for autonomy
Schneider (cont.)
 The people who wish not to choose often have very rational reasons for
this preference
 Weakness and fatigue

 Lack of knowledge or understanding

 Awareness of problems in own thinking process

 Avoidance of guilt
Truth Telling and Patient Autonomy
Autonomists - full disclosure (it is not sufficient to tell the
truth, one has to tell the whole truth; 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.
Truth Telling and Patient Autonomy
But, 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?

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.
The Dying Patient
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.
The Dying Patient
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.
Usually the Questions

 “When to tell?”
 “How much to tell?”
 “What exact words to use?”
 “Whom should be there with the patient?”
 “What comes next?”
 Do patients want to know the truth
about their condition?

Contrary to what many physicians have thought in the

past, a number of studies have demonstrated that
patients do want their physicians to tell them the truth
about diagnosis, prognosis, and therapy. For
instance, 90% of patients surveyed said they would
want to be told of a diagnosis of cancer or
Alzheimer's disease.
 How much do patients need to be
told?

Patients should be told all relevant aspects of their

illness, including the nature of the illness itself,
expected outcomes with a reasonable range of
treatment alternatives, risks and benefits of
treatment, and other information deemed relevant to
that patient's personal values and needs.
 What if the truth could be harmful?

Assuming that such disclosure is done with appropriate

sensitivity and tact, there is little empirical evidence to
support such a fear. If the physician has some
compelling reason to think that disclosure would
create a real and predictable harmful effect on the
patient, it may be justified to withhold truthful
information.
 What if the patient's family asks me
to withhold the truth from the
patient?

Usually, the family's motive is laudable; they want to

spare their loved one the potentially painful
experience of hearing difficult or painful facts. These
fears are usually unfounded, and a thoughtful
discussion with family members, for instance
reassuring them that disclosure will be done
sensitively, will help allay these concerns.
 When is it justified for me to withhold
the truth from a patient?

If the physicians has compelling evidence that

disclosure will cause real and predictable harm,
truthful disclosure may be withheld ("therapeutic
privilege“) is important but also subject to abuse.

The second circumstance is if the patient him- or herself

states an informed preference not to be told the truth.
 What about patients with different
specific religious or cultural beliefs?

Those patients may have different views on the

appropriateness of truthful disclosure.

A culturally sensitive dialogue about the patient's role in

decision making should take place.
 Is it justifiable to deceive a patient
with a placebo?

In general, the deceptive use of placebos is not ethically

justifiable.
Specific exceptions :
- the condition is known to have a high placebo
response rate
- the alternatives are ineffective and/or risky
- the patient has a strong need for some prescription
Truth in the History of Medical Ethics

The historical medical codes 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.
“Tell the truth as long as it helps rather than harms the patient."
Truth in the History of Medical Ethics
The doctor's principal moral obligation was to
help and not to harm the patient.
Today, things have changed. Beneficence and
non-malifience remain basic medical ethical
principles, but truth is also a medical ethical
principle.
Today, Bacon's comment that "knowledge is
power but honesty is authority," is particularly
applicable to doctors.
Truth in the History of Medical Ethics
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, "Principles of
Medical Ethics" of the American Medical
Association, "Patient's Bill of Right" ...
Applied ETHICS
Operative Principles

 Beneficence: actions or practices are right insofar as they

produce good consequences.
 Expressed negatively as Nonmaleficence: Do No Harm).
 Autonomy: actions or practices are right insofar as they
involve respecting the autonomous choices of individuals.
 Justice: The principle that actions or practices are right
insofar as they treat people in similar situations equally.
Case 3: Beneficence and Paternalism

 Mr. Lawson, a longtime patient of Dr. McMasters, has lived with Type II diabetes for
more than a decade. Each year, during his eye exam, Mr. Lawson refuses dilation, part
of the recommended standard of care for patients with diabetes. This year, Dr.
McMasters observed signs of diabetic retinopathy during his standard examination.
Though McMasters explained the possible implications of this observation to Mr.
Lawson, the patient still steadfastly refused dilation. Dr. McMasters considers it his duty
to follow the recommended care standards, and is considering refusing to prescribe
vision correction for Mr. Lawson unless he consents to the dilation and examination.
Beneficence as a Moral Perspective

 Beneficence has an important historical role in medical ethics

as the core of the Hippocratic Oath.
 The focus of the principle of Beneficence is on the
consequences of the actions of the practitioner for the health
and welfare of the patient.
 The weight in the decision-making process is thus placed on
the judgment of the practitioner.
Problems with Beneficence

 The principle of Beneficence, while relatively non-

controversial, is not as straightforward as it first appears.
 There are important questions that need to be resolved before
a practitioner can be confident that they are acting
beneficently.
 Subjective vs. Objective Estimates of Benefits
 Medical vs. Other Personal Benefits

 Conflicting Goals within the Medical Sphere

Beneficence and Paternalism

 Paternalism: action taken to benefit a person against her will.

 Strong: taking such an action even though the person is mentally competent.
 Weak: taking such an action when a person is known or suspected to be
incompetent.
 Hippocratic ethics are often taken to justify both forms of
paternalism. This is one of the reasons many contemporary
medical ethicists are moving away from the Hippocratic
perspective toward perspectives the emphasize respect,
autonomy, truth-telling, and fidelity.
Case 4: Autonomy and Informed Consent

 Dr. Joan Paulsen had a problem. Her good friend Marcia had brought in her elderly
mother for an eye exam during which Dr. Paulsen found advanced diabetic retinopathy
in the periphery of both eyes. Typically, she would immediately report these findings to
the patient, prepared to discuss the diagnosis and treatment options, but Marcia had
told her that her mother’s emotional and mental states were very fragile. In light of this
Marcia had requested that any negative information about her mother’s ocular health
be withheld from her, and instead reported to Marcia. In her conversation with Marcia’s
mother, Joan had not noticed any sign of fragility. Now she wondered how to proceed.
Autonomy as a Moral Perspective

 Autonomy is a moral perspective that frequently conflicts with

beneficence, and thus with the Hippocratic perspective.
 The beneficence perspective gives a great deal of prominence
to the consequences of actions. Autonomy, on the other hand,
places the emphasis on the claims that a patient has on a
practitioner.
 These claims can be articulated as rights the patient has
relative to the practitioner or as the duties the practitioner has
to the patient.
The Conflict: Informed Consent

 “Informed Consent” refers to obligations a practitioner has to provide her

patient with all relevant information about her health and treatment
options.
 This obligation allows the patient to make appropriate decisions about their care.
 The Beneficence perspective can provide some justification of informed
consent, but only to the extent that the consent benefits the patient.
 The Autonomy perspective, on the other hand, requires that all
meaningful information be disclosed to the patient, even when it is
believed that the disclosure may be harmful.
Standards for Disclosure

 Fully informing a patient is frequently, if not always,

impossible. The general obligation is to provide adequate
information.
 How can a practitioner determine when they’ve met their
obligation?
 The Professional Standard: what would similarly situated colleagues
do?
 The Reasonable Person Standard: what information would a
reasonable person want?
 The Subjective Standard: what information fits the life plans and
interests of the individual?
Justice and Resource Allocation

 Faced with declining insurance reimbursements and increasing practice

costs, Dr. Ball fears that she may be forced to discontinue her
participation in the statewide insurance program for the economically
disadvantaged and uninsurable. Though one of her original motivations
to become an optometrist was her conviction that providing quality care
to underserved populations was the right thing to do, the economic
implications of this choice seemed increasingly dire. What was more
important, maintaining her principled commitment to the less fortunate,
or pursuing her own fortune?
Justice as a Moral Perspective

 Justice is another moral perspective that seems to conflict

with implications of the principle of beneficence. Most
obviously, beneficence seems to lack a notion of moral
community.
 The autonomy perspective seems to fare little better.
 The perspective of justice corrects this inattention to the
broader social implications of health care by raising the
question of the duties medical professionals have to third
parties.
The Problem of Scarcity

 Scarcity of medical resources is an obvious concern of the justice

perspective in medical ethics. One form of scarcity is that of access to
care.
 Despite the amazing amount of money spent each day on health care in
this country (~3.5 billion dollars/day), significant numbers of our citizens
lack even basic insurance coverage. In 2000, 14% of the U.S. population
was completely without coverage.
 At the same time, practitioners are increasingly pinched by the insurance
industry (public and private), and by rising costs, exacerbating access
scarcity.
Justice in Allocation

 The justice perspective requires practitioners to balance their obligations

to themselves and their patients against their obligations to those who
lack the means of access to appropriate care.
 Clearly, there are limits to this balancing act. practitioners may lack the
means to accurately calculate the balanced benefits. There are also
problems posed by the conflicts between the obligations of justice and
those that flow from their patients.
 In response, some people have argued that practitioners should be
exempt from considerations of justice, but that seems too extreme.
Balancing Values and Principles

 Despite the conflicts between the various perspectives we’ve

considered, each of them has their place in an individual practitioner’s
attempts to embody the values outlined in the AOA code.
 An important part of being a responsible optometric professional is
reflecting on the different implications these principles have for the
values you should embody.
 Ultimately, it is the individual practitioner’s responsibility to reflectively
negotiate the conflicts between principles and across values.