March 15, 2004

 

Respect for Persons and Telling the Truth

 

 

            In a perfect world, people would not be weakened by the knowledge that they have a fatal illness.  They could live their last days as fruitfully as the nature of their disease allowed.  However, many people are emotionally and mentally wrecked by news of the probability of their untimely deaths. Some people believe they would be so distraught if they received such information that the remaining days of their lives would be of little value.  Considering the emotional devastation the news would bring, these people claim that they would “prefer not to know.”

            A good physician has the responsibility of promoting the health and longevity of his patients.   Mark Lipkin argues that this responsibility sometimes requires withholding information from the patient.  Most patients cannot even understand their doctor’s explanation of their condition, he argues, much less handle the reality of a terminal disease.  For the sake of keeping the patient’s anxiety to a minimum, it is morally right to keep information from him or her.  After all, the doctor does not know what the outcome of the patient’s disease will be, and often the patient never asks.  Even when a patient insists on knowing, Lipkin argues there are cases where the patient may be doing himself a disservice, especially since the "whole truth" is beyond the grasp of the average patient.

            Lipkin's assertions about patients' ability to understand their conditions and of the average patient to handle the information in a sensible way is not only wrong and disrespectful, as Susan Cullen and Margaret Klein claim, but it is also insulting.  Cullen and Klein correctly argue that a physician's "default position" should be to tell patients the truth.  Human beings are rational agents—we can make choices.  Because this is what makes us special among living things, actions which limit our ability to make choices are morally wrong.

A person with basic mental abilities can certainly comprehend the "layman's" version of what his condition is, and it is part of a physician's responsibility to translate the medical information into simple, but nonetheless true, terms.  A patient may not have the education or experience to understand the complexities of the pancreas, but most patients can understand medical judgments about a condition's severity and a doctor's explanation about the time-frame for its unfortunate, probable outcome.  Even in cases where mental abilities are hindered, most people still have the ability to understand the important, basic facts about their conditions.  Mild to moderately mentally retarded adults, for example, are, in general, not deceived into thinking that they are no different from other people who are not mentally retarded.  Their condition can explained to them in terms that they can understand so that they can understand the limitations of their abilities, not to mention the great potential they still possess.  Deception intended to benefit the patient is wrong except in rare cases.

            Cullen and Klein point out three critical questions concerning the issue of truth telling in medicine.

First, “What if the patient doesn't want to know about his disease or the state of his health?”  Cullen and Klein concede that it is a patient’s right to have certain truths about his condition withheld, if he makes an explicit request.  However, blatant lies are still morally wrong.  A doctor can meet a patient’s request to be kept ignorant by not informing him, but deceiving him with a false diagnosis is something altogether different, and still wrong. 

In cases where the patient does not say how much he wants to know, or if the patient is only suggestive about not wanting to know certain facts, it is the physician’s responsibility to tell him a “wholly true” account of his condition.  Full disclosure remains the default position, as the patient’s decisions about how to proceed with his life may be dramatically altered by the knowledge of his or her failing health.  Though Cullen and Klein claim later in their article that it is a physician’s responsibility to “find out about how much his patient wants to know”, it is more intuitive that judging what the patient really wants to know is not the duty of the doctor, and usually something he is unable to do with certainty, as they claim earlier on.

Even in some cases where a patient explicitly states that he wants to remain ignorant of his diagnosis, the physician’s responsibility is to tell the truth, as certain diagnoses not only affect the patient but others with whom he or she may come into contact.  A patient with a contagious disease like HIV may not want to know his or her serostatus, but even if the news of the infection would be more devastating than it would to the average patient, having the knowledge that he or she is HIV positive may prevent the patient from engaging in behaviors that will infect others.  Of course, the patient may disregard the health and well-being of others, and engage in those behaviors anyway.  But the doctor, by telling the truth, will have fulfilled his moral obligation to the public at large.  Similarly, providing a patient with information about a genetic disease gives him or her the ability to make decisions relevant to the well-being of others, including partners in creating children and the yet-to-be created children themselves.

  The second critical question is, “What if a physician is unable to tell a patient the truth?”  Cullen and Klein correctly state that this is not the difficult issue of truth-telling, as the real issue is about telling the truth when it is known.  There is nothing morally wrong with a physician acknowledging his limitations, if he is limited by his area of expertise or if his knowledge is limited in the way that the whole of medical knowledge is.  In cases where a more precise expertise is available and needed, the doctor can refer the patient to an appropriate specialist. 

            As previously stated, most patients do not have the medical training to know the “whole truth”.  However, Cullen and Klein distinguish between the “whole truth” and what is “wholly true”.  A doctor is not justified in deceiving his patient simply because he cannot tell his patient the “whole truth”.  Most patients can understand the nature and seriousness of their conditions, and can make decisions based on an understandable explanation of the risks and benefits of available treatments.  In order for patients to make these decisions based on the information the doctor provides, the patient must trust the doctor.  Trust is undermined any time a doctor withholds or lies, in which case the patient has been disrespected, and will likely face a detriment to his health that outweighs any real benefit that “false hope” would provide in his recovery.

            The third critical question is, “Don't physicians sometimes have a duty to lie to their patients?”  Cullen and Klein appeal to the lack of empirical data for their claim that it is easy to overestimate the actual benefit of deception in the patient’s regaining of his or her health.  Just as “false hope” is given too much weight in deciding whether or not to lie to a patient, the benefit of having knowledge about one’s condition is underestimated.  Serious medical conditions require the patient’s full attention to and participation in a proper treatment regimen.  Furthermore, respect for the patient’s autonomy requires that the patient know the facts about the state of his or her health, so as to plan for a future in which he or she will most likely have less time. 

            Out of respect for the patient, physicians should not deceive their patients.  Just as false information about the need for a procedure hinders the patient’s ability to make proper choices about his life, so does false information that makes a patient believe his or her prognosis is better than it actually is.  The principle of respect for persons is crucial to a patient’s autonomy and the public’s trust in the medical community.

 

 

© 2004 chadofborg@yahoo.com

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