Truth-Telling

At the end of the session, participants will be able to:

  • Appreciate the ethical grounds oftruth-tellingin health care;
  • Recognize several degrees of truth-telling or ways of not telling the truth fully;
  • Understand the circumstances in health care where not telling patients the truth fully may be considered morally acceptable; and
  • Consider the implications of not telling the truth fully to certain third parties.

Introduction

The issue of truth telling in healthcare encompasses a wide range of practices that can be described as lying, withholding information, deception, and others.There was a time when clinicians routinelyused these practiceswith their patients, often claiming what is called a “therapeutic privilege” and believing patients did not want to know the truth about their conditions. Early codes of ethics for physicians almost never discussed the subject, and until 1980 the American Medical Association relied on the discretion of physicians in such matters.[1]But surveys have found that most patients want to know the truth about their conditions and other surveys indicate that physicians are now more likely to tell patients the truth. In 1979, 98 percent of physicians surveyed indicated that they would disclose a diagnosis of cancer to their patients, whereas in 1961 only about 12 percent said they would disclose such a diagnosis.[2]

Here, we will consider the ethical grounds of truth-telling in health care settings; deal with certain objections to disclosing the truth to patients that acknowledge several degrees of truth-telling or ways of not telling the truth fully to patients; and consider some very rare circumstances where not fully telling the truth to patients and other third parties may be considered morally justified.

Note that “not fully telling the truth” is not usually considered the same as outright lying. Indeed, in the Catholic moral tradition, following Augustine and Thomas Aquinas, intentionally lying is always considered morally wrong regardless of the circumstances, though not telling the truth fully may at times be justified.[3] Lying is also considered always wrong by certain moral philosophers, most notably Immanuel Kant. Lying is not advocated here; nevertheless, it is discussed so as to provoke reflection on one’s own practices and to acknowledge that there will be times that clinicians are tempted to lie to their patients or certain third parties. It is the intention of this essay to outline the meaning and definitions of the different degrees of truth telling, and, to illustrate that each degree entails various considerations and moral justifications for clinicians.

Some Preliminary Definitions

In health care, truth-telling “refers to [the] comprehensive, accurate and objective transmission of information, as well as to the way the professional fosters the patient’s or subject’s understanding.”[4]Note the two aspects to this definition that,time after time, complicate truthful communications in health care settings.The professional is responsible both to communicate the content of his or her communication truthfully and to do so in such a way as to account for how the communication is being received and perceived by the patient or patient’s surrogate. This dual aspect of truthful communication in health care will be explored more fully below.

Truth-tellingis also discussed in medical ethics under the termsveracity, honesty and disclosure, and is closely related to the notions of informed consent and confidentiality wheretruth-telling is generally assumed. The Introduction to Part Three of the Ethical and Religious Directives for Catholic Health Care Services (ERDs), on “The Professional-Patient Relationship,” discusses truth-telling as honesty and links it to mutual respect, trust and confidentiality as the basic moral requirements that are essential to the healing relationship between health care providers and patients. The close relationship between truth-telling and informed consent is also evident in two ERD directives (27 and 28) that discuss the requirements of informed consent. They are quoted in full here with the phrases that are important to our discussion italicized.[5]

27. Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatments and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.

28. Each person or the person’s surrogate should have access to medical and moral information and counseling so as to be able to form his or her conscience. The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.

The Ethical Grounds of Truth-Telling

Like informed consent and confidentiality, the obligation of truth-telling is ethically grounded in respect for personal autonomy or human dignity and the trust it engenders and helps sustain between clinicians and their patients. As we saw above in the ERDs, this trust is considered essential to establishing a healing relationship. Again, truth-telling in the health care context is bothabout the disclosure of relevant information by a health care professional andabout the professional assuming responsibility for how that information is perceived and processed by the patients receiving it. This responsibility, however, begs the question about what counts as truth in such situations.

Truthful communication of information in health care requires a judgment that can be negotiated between the professional and the patient about what counts as relevantor material information to the patient’s decision-making process. A discussion of “relevant information” addresses one of the objections that is sometimes made by clinicians for not fully disclosingthe truth,namely, that patients cannot possibly understand all the technical information that clinicians process for them in making their judgments and that it is therefore permissible to compromise the truth when communicating with patients. Indeed, communicating the truth fully is sometimes thought not to be possible. But patients do not usually require the truth about their condition to be communicated as fully and as technically as the health care professional might understand it. Patients need information that is relevant or material to their own need to understand their situations and to participate in their health care decisions.

For our purposes, relevant or material information includes the kind of information that would normally satisfy the informed consent process for clinical settings. As we saw above with the ERDs, such information includes the nature of a patient’s illness or injury, expected outcomes given a range of possible treatment options, the risks and benefits of the recommended treatment, and other information that patients may request based on anassessment of their own needs and values (for subjects in research settings, not discussed here, the bar is set higher). Again, patients need this information if they are to participate appropriately in clinical decision-making for themselves, and this information can and should be conveyed sensitively and in ways patients or their surrogates can understand and process, both intellectually and emotionally.[6]

Nevertheless, and also like informed consent and confidentiality, truth-telling is not considered absolute by most secular ethicists. The obligation to tell the truth can and sometimes does conflict with the obligation to protect patients or third parties from possible harms associated with the truth, and clinicians may at times feel they are forced to choose between telling the full truth or something less. We will consider such situations below, but for now it is enough to emphasize that those possible harms must be evaluated in each case, and the presumption should always be to tell the truth in the relevant sense discussed above.In any event, when clinicians believe they should tell less than the full truth, it doesn’t necessarily mean they should lie. There are several degrees of truth-telling short of outright lying that should be considered and that may be justified.

Degrees of Truth-Telling

Beauchamp and Childress distinguish between the full disclosure of relevant information, staged-disclosure, under-disclosure, nondisclosure, deception and lying. The distinction between these terms is not always clear (for instance, under-disclosure today with the intention of full disclosure tomorrow could also be an example of staged-disclosure), but since these practices are used in health care settings the reader should at least be aware of them.Generally,the further one travels down this list of options, the harder it is to justify one’s actions. However, Beauchamp and Childress argue that deception and even lying can sometimes be justified.[7] In such cases, it is assumed that the clinicians’ motives and intentions are good, that is, that they are acting in their patients’ interests and not in their own.Here, we are concerned with those times when clinicians believe they might have to tell patients less than the full truth or even to deceive or lie to them for the patients’ own good. (If clinicians give evidence that they are disclosing less than the full truth to patients in order to advance their own interests—say, to save time in a busy day at the expense of their patients’ understanding, this is not considered for the patients’ own good). Please see the case at the end of this essay as an example.

For clinicians, staged-disclosure involves telling patients the relevant truth over time, but in measured doses so they can have the emotional space to process it. This option may be considered for patients who have a dire prognosis and are giving evidence that they are not able to process all the information the clinician wants to impart to them at a given time. Under-disclosure involves telling patients the truth, but perhaps not as fully as it might be told under different circumstances. This option may be considered for patients who are fearful about their diagnosis or prognosis and may be cognitively or emotionally impaired in ways that limit their ability to understand their condition fully. Nondisclosure involves not offering information to which patients are normally entitled, but perhaps for which they are not asking, at least at the present time. This option should be considered only after negotiating with the patients about what they wish to know. With the patient’s agreement, clinicians may disclose this information to family members or other surrogates rather than the patient.

Deception and lying are closely related, but there are ways of deceiving patients that need not be understood as lies. Patients can be deceived by concealment (that is, nondisclosure without their permission), evasion, the withholding of relevant information, speaking the truth in ways that are intended to obfuscate or confuse or lead the patient to believe something that is not true, and, interestingly, by deliberately overwhelming them with the truth (sometimes called truth-dumping).For example, exaggerating one’s experience with certain surgeries or rates of success with a certain surgery may mislead the patients about information that may be relevant to their selecting a surgeon, and it is morally wrong even if the deception is intended to relieve their normal stress.

Nevertheless, while deceiving patients for their own good or to avoid certain harms is paternalistic, in certain rare cases it may be justified. For example, when a patient is known to be pathologically fearful about his or her prognosis and is threatening suicide, non-disclosure may be considered.Deception with the intent to mislead is, like lying, not advocated here. If clinicians believe that some of the forms of deception listed above may be justified in a specific case to prevent immediate and serious harm,they should be mindful that frequent use of deceptive practices can be corrosive to the doctor-patient relationship and cause the profession to beperceivedas a group of deceivers.

Lying to patients differs from the forms of deception just discussed in that it involves telling them a statement that is intended to deceive them, even though, again, the clinician’s larger or overriding intention is good, that is, to protect the patient from some possibleharm by using the deceptive statement.[8] Again, lying is not advocated here, and in the Catholic moral tradition lying even with a good intention is never considered morally justified. Nevertheless, in very rare circumstances clinicians may believe they are morally justifiedin lying to protect their patients. Beauchamp and Childress illustrate (but do not try to justify)a therapeutic lieby discussing a case of a 90year-old patient who had become very fearful over a period of years that he would develop cancer, and it was known that this possibility had very negative associations for him (shame, pain, and certain death). When he was diagnosed with a squamous cell carcinoma, which could be completely cured with a short course of radiation therapy and without hospitalization, his physician told him it was not cancer when the patient asked him about it tearfully.[9]

Placebos are sometimes categorized as a form of lying. Similar to the discussion on deception, when they are used to prevent immediate and severe harm, their use may be justified. Whenever the use of a placebo is being contemplated in a therapeutic context for, say, an abnormally stressful response to information (again, the research context is not considered here), clinicians should examine their reasons even if the placebo is intended to present a harm; subsequent discovery of the placebo by the patient carries with it the potential to undercut the doctor-patient trust. For example, clinicians might assert that “this pill will do no harm” (assuming this can be said with confidence) and if the patient fails to ask for further clarification, say no more. If the patient presses the clinician in such cases, the clinician will have to take the time to explain him- or herself more fully, refer the patient for counseling, or, failing everything else, decide to use a therapeutic deception.

Degrees of Truth-Telling with Third Parties

Clinicians may also believe they have reasons to be less than truthful with others besides their patients.Sometimes, for example, they may know about or suspect malpractice on the part of a colleague or that a colleague is impaired when practicing, and they will need to disclose this information to the proper administrators in order to protect others, even those who are not their own patients.Nondisclosure increases the risk of harm to others and undermines the essential trust between clinicians and their patients. Nondisclosure also threatens to harm the medical profession as a whole.

Physicians in particular may also be tempted to distort the truth with third party payers for the sake of their patients. They may do so because there is a stigma associated with their patients’ diagnoses or because they want to be sure their patients’ diagnoses will be covered by their health insurance. This is sometimes discussed in the medical ethics literature as “gaming the system.” A survey in 1999 indicated that 50% of the physicians surveyed would exaggerate the severity of their patients’ conditions to get them adequate coverage, and other studies indicated that this practice is more likely to be considered for more serious conditions.[10]

While this practice seems justified to many physicians, in fact it reduces the resources available for others who may be more deserving or needy. It thus raises questions of social justice, as well as questions of professionalism. Clinicians may also be breaking their contracts with payers. Moreover, though we do not discuss it here, it raises questions of fraud for which clinicians may be criminally liable. As health care gets more expensive and more people are un- or underinsured, this practice may increase, but it is wrong and should be resisted. Instead, physicians should advocate for their patients to receive the coverage they need and to which they are entitled.

Finally, clinicians may have reason to withhold or distort the truth with third parties involved with their patients in order to protect the rights of their patients. Geneticists, for example, may discover a genetic disease in their patients with potentially harmful implications for members of the patients’ families. Should they disclose such information to the family members if, for some reason, their patients ask them not to do so? Generally, based on the special relationships between clinicians and their patients, clinicians have greater responsibilities for the well-being of their patients than the third parties associated with their patients. Nevertheless, the patients themselves mayhave interests in the well-being of these third parties, and sorting our whether and how much to disclose, and to whom, can be complicated. In such cases, clinicians should not hesitate to seek confidential advice from their professional societies, their colleagues, and their organization’s ethics committee. (See also a discussion of when to breach patient confidentiality to protect third parties in the Confidentiality module.)