Is it ever acceptable to lie to
A 10 year-old boy has end stage kidney disease and
needs a transplant. Among twelve family members an uncle is the only match.
This man changes his mind and decides he does not want to be a donor. What
will you tell the parents when they ask if a match has been found?
An elderly Korean woman has terminal pancreatic cancer.
She wants to know about her condition, but her family members adamantly
feel that for cultural reasons only they should know her diagnosis and prognosis.
A woman with a frail psyche has lymphoma. Complex
chemotherapy will probably cure her but carries small but substantial risks
for permanent lung or heart damage. If she knows these risks she will likely
decline the treatment and succumb to the disease. Will you explain these
small risks to her?
Truth telling is itself a virtue and the lynchpin
of all relationships, especially the therapeutic one between patient and
physician. The foundation of trust, it is usually in the best interests
of patients. Empiric studies show that patients invariably want to know
the truth about their medical conditions.
It is also axiomatic in medicine that, whatever else
they may or may not be able to do, physicians first must do no harm to the
What if truth is harmful? In other words, is it ever
ethical to deceive or lie to a patient for the greater good of not doing
Consider the cases above. Being truthful in each
case is one option, but what would be the consequences? Lying to the family
of the boy with kidney failure would obviate the harm of disrupted family
relations, especially since the uncle will not be a donor anyway. Similarly,
telling the truth to the Korean patient would be very insensitive to the
family's cultural values. Family alliance will be crucial in later care
of this patient and it would not be a good strategy to alienate them now
or ever. The physician could defer all such inquires to the family. The
risks of chemotherapy are relatively small for the woman with lymphoma so
the physician might deceive the patient with a biased explanation of the
The point here is that truth telling is not always
straight-forward and must often be weighed against its possible harm.
Medical mistakes are common but not always important.
Significant errors leading to morbidity, such as leaving a sponge in the
abdomen after surgery, must be disclosed to patients. Should physicians
also disclose less important mistakes, such a single inconsequential medication
Is it acceptable for physicians to modify medical
information on insurance forms so companies would be more likely to reimburse
patients? Outright erroneous information is fraud, but there are ways of
gaming the system short of this.
Patients also have an obligation to tell the truth.
Still, they deceive physicians for a variety of reasons: to hide conditions
from insurance companies or their employers, to obtain narcotics for sale
or personal addiction.
Physicians have a basic obligation to be truthful
to patients while being sensitive to cultural and emotional factors. The
onus is on the physician to justify deception or lying. Regardless of its
merits, if the lie is ultimately uncovered, trust is sacrificed and the
patient-physician relationship will likely perish. This is a contingency
the physician must accept with his decision.
- Gallagher, T., Waterman, A., Eben, A., et.al.,
Patient and physician attitudes regarding disclosure of medical
errors, Journal of the American Medical Association,
289 (8), 2003, p. 1001-1007. This article shows that patients want and
expect full disclosure of errors and it stresses the importance of emotional
support for the patient by physicians in this context.
- The, A.,Hak, T., Koeter, G., et.al.,
Collusion in doctor-patient communication about imminent death: an ethnographic
study, British Medical Journal, USA, 1, 2001, p. 42-46.
This piece gives an interesting slant to truth telling wherein physician
bias and patient filters in the emotionally charged context of imminent
death precludes truth being communicated or received.
Capacity and Informed Consent:
How do physicians know patients are making the right health care decisions?
When they cannot decide, who does it for them?
A 45 yr old man has an acute bowel obstruction and
needs emergency surgery. After an altercation with an admissions clerk over
his insurance he leaves the hospital against medical advice.
An 85 year-old woman with several chronic but stable
diseases declared in an advanced directive that she did not want any artificial
life support mechanisms to be kept alive if her medical condition deteriorated.
Now she is semi-comatose from drug induced kidney failure. A short course
of dialysis will likely reverse her kidney problem and return her to her
baseline health. However, the family wishes her directives be honored and
she be allowed to die.
A 28 year-old man sustains severe multiple trauma
in a car accident. He is a Jehovah's Witness and refuses to receive transfusions,
even though surgery for his wounds will not be possible without replacing
Capacity generally means a person's ability to do
certain things correctly and responsibly. In medicine it refers to a patient's
ability to make his health care decisions. This entails understanding relevant
information, deliberating and making a judgment about the information and
arriving at a decision consistent with previously held values. Physicians
have the responsibility clearly to communicate this information and to guide
patient deliberation. They must also determine if patients have capacity.
If there is clearly diminished mental status wherein understanding and deliberation
are not possible, or if a decison is inconsistent with conventional wisdom
or a patient's previously held values, someone else, a surrogate, must be
enlisted for help with decison making.
Informed consent entails the optimal information,
effectively communicated to a patient that will allow a proper decision.
What is optimal is case specific. Generally, the higher the complexity and/or
risk of the proposed treatment or test, the more information and time allotment
for deliberation must be given. For example, informed consent for an elective
skin biopsy would be considerably less than for a prolonged multi-drug cancer
For the physician, the elements of informed consent
include explaining the nature and purpose of the treatment (or test), the
risks involved, the chance of success, the alternative treatments and their
relative merits, and the likely outcome if no treatment is given. He must
also ascertain if capacity is present and that no coercion has occurred.
The patient must hear and understand the information, weigh the alternatives,
risks and consequences and make a free decision.
Providing all these elements were met, the Jehovah's
Witness patient's decision would have to be respected, even though it is
antithetical to most health care providers. They might attempt surgery with
alternative fluids but the man would likely die in the operating room.
When capacity is lacking a surrogate must help with
decision-making. Who this would be legally follows a hierarchy: a court
appointee; a medical power of attorney stated in an advanced directive;
the spouse; the majority of adult children; then parents and siblings. Knowledge
of the patient as a person, specific portions of an advanced directive or
verbal statements, and reasonable assessment of best interests, with input
from the physician, are all factored into the decisions.
The woman with kidney failure obviously lacks capacity
and her surrogates are aware of her wishes through her advanced directives.
If the medical problem were chronic irreversible kidney disease there would
be no question what to do. Here the dilemma for the doctor is that she has
a relatively simple reversible problem that still needs high tech artificial
life support. He might try to persuade the family to allow a brief trial
on dialysis to confirm that the patient would recover to baseline. In other
words, it would be in the patient's best interests to return to her stable
baseline state with a short time on dialysis, whereas it would not be right
to do dialysis for irreversible renal failure.
Sometimes physicians are prevented from giving all
relevant information by so-called "gag rules". Managed care organizations
may prohibit doctors from advising patients of treatment options that are
more expense than those covered by the organization. Some religiously run
hospitals or clinics prevent the discussion of sterilization, contraception
Fear, depression and anxiety, particularly in emergency
or life threatening situations, can cloud comprehension, judgment and decision
making. Here it is often difficult for physicians to ascertain capacity.
The first case represents this. The man may have been very fearful of surgery
and used the excuse of the argument with the administrator to leave the
hospital. The right strategy for his physicians would be to address the
fears, possibly provide more information, and convince him voluntarily to
stay for surgery.
The courts regard children incompetent to make health
care decisions until they are 18. Most older children have some capacity
to make their own decisions and their input should be sought when appropriate.
Exceptions wherein children are deemed competent are in cases of pregnancy,
contraception, and sexually transmitted disease and with emancipated minors
i.e. being married or living independent of parents.
Informed consent can be ignored in emergencies where
capacity is lacking and a surrogate cannot be located, when a patient waives
the right, and with certain government waivers, as with preschool vaccinations
and newborn genetic testing.
Physicians are responsible for assessing capacity
and effectively delivering optimal information for patients to make proper
health care decisions. If capacity is lacking for whatever reason surrogate
decisions must be made consistent with previously known patient wishes or
what is perceived as his best interest. In emergencies, when capacity is
lacking it is usually imperative to treat the patient until either capacity
is restored or reliable surrogate decisions can be obtained.
- Drane, J., Competency and giving informed
consent, Journal of the American Medical Association,
252 (7), 1984, p 925-927. This is a practical bedside guide for assessing
- Brody, H., Transparency: informed consent
in primary care, Hastings Center Report, Sept/Oct
1989, p. 5-9. This article emphasizes the role of openness in a doctor's
thought process for enhancing patient understanding and subsequent decision-making.