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Case example
Twenty-two-year-old Annie was brought by friends to the ED of a small Virginia hospital. She fell while horseback riding, was kicked by her horse, and lay in a field for several hours. Despite initial IV therapy, her blood pressure remains very low, and an abdominal tap reveals that she is bleeding very rapidly into her abdomen.
Though she is in shock, Annie remains awake and alert. She asks Dr. Smith, the emergency physician caring for her, “Is it a serious injury? Will I live?”
Dr. Smith responds, “Everything will work out, Annie. It may be a little rough for a bit, but it will work out.”
“Are you sure?” she asks. “Please, tell me honestly.”
Dr. Smith is very concerned about Annie’s unstable condition, and he is unsure how she will do. What should he say to her?1
Past and present
In twenty-first-century Anglo-American societies, truthfulness is widely acknowledged as a central professional responsibility of physicians. Professional standards regarding truthfulness have, however, undergone significant change over the past century, and what constitutes truthful communication is still a matter of some controversy. Other cultures, moreover, endorse somewhat different approaches to communication between physicians and patients. This chapter will examine the meaning and justification of truthfulness in the therapeutic relationship.
In an article published in 1903, physician Richard Cabot states the “rule for truth-speaking” he was taught as a Harvard medical student: “When you are thinking of telling a lie, ask yourself whether it is simply and solely for the patient’s benefit that you are going to tell it. If you are sure that you are acting for his good and not for your own profit, you can go ahead with a clear conscience.”2 As this rule illustrates, the medical profession of that era condemned self-serving lies, but approved lies told for the benefit of patients. Notice that the rule authorizes the physician to judge whether truthful or deceptive information will do more good for the patient, and to base his or her disclosure on that judgment.
This rule Cabot cites appears to have persisted well into the twentieth century. In a survey of 200 Chicago physicians published by Oken in 1961, almost 90 percent of the respondents reported that they generally withheld information about a cancer diagnosis from their patients.3 These physicians cited various reasons for withholding this information, including a belief that the patients would not want to know and a desire to maintain the patients’ hope for recovery and their cooperation with treatment.
Professional standards and practices regarding information disclosure changed rapidly during the last third of the twentieth century. This period witnessed growing acceptance of a duty to obtain informed consent to treatment that was first articulated in American case law in 1957 (see Chapter 8, “Informed consent”). This duty required physicians to inform the patient about his or her condition and its recognized treatment options as a necessary condition of obtaining a valid informed consent. Informed consent was one cornerstone of a patient rights movement that rejected traditional attitudes of deference to physician “orders” and demanded a more active role for patients.4
Revisions made by the AMA to its “Principles of Medical Ethics” during this period reflect growing recognition of a professional duty of truthfulness. The version of this document adopted in 1957 makes no mention of honesty or truthfulness.5 A revision of the document adopted in 1980 includes, as its second principle, “A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception” (emphasis added).6 The wording of this principle is strengthened in the current version of the “Principles,” adopted in 2001: “A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities” (emphasis added).7 The American College of Physicians (the US medical professional association of specialists in internal medicine) devotes an entire section to the topic of “Disclosure” in the 2005 fifth edition of its “Ethics Manual.” That section includes an assertion that “Information should be disclosed whenever it is considered material to the patient’s understanding of his or her situation, possible treatments, and probable outcomes. This information often includes the costs and burdens of treatment, the experience of the proposed clinician, the nature of the illness, and potential treatments.”8
Do these changes in official statements of professional ethics regarding disclosure reflect a corresponding change in physician practice? One study offers impressive evidence that such a change in practice did occur. In 1977, Novack and colleagues administered a questionnaire to physicians in Rochester, New York, about their practice regarding disclosure of a cancer diagnosis; the questionnaire was almost identical to the one used by Oken in the 1961 study described above.9 Ninety-eight percent of the 278 respondents in this latter study reported that their general policy is to disclose a cancer diagnosis to the patient, an almost complete reversal of the predominant practice reported sixteen years earlier.
The case for truthfulness
Are there compelling moral reasons for the shift in professional standards and practice regarding truthfulness described in the preceding section? If so, what are those reasons? I will argue that a persuasive moral case for truthfulness can be made by appealing to bioethical principles of respect for autonomy, nonmaleficence, and beneficence.
Respect for autonomy
Patients seek health care for many reasons, including, to be sure, treatment and prevention of illness and relief of pain and suffering. Another important reason for seeking care, for most patients, is a desire to understand their health condition. To achieve that understanding, patients typically want to know whether they have a particular disease, what are their treatment options, and what is the likely outcome of the disease, both with and without treatment. To fulfill patients’ desires to understand their health condition, physicians must provide truthful and relevant information about diagnosis, treatment, and prognosis. Without such information, patients cannot make meaningful choices about what treatment to accept. Thus, truthful communication respects patients’ basic rights to know about their health condition and to make treatment choices based on that knowledge.10 In contrast, a physician’s decision to withhold significant medical information or to deceive a patient about his or her health condition is likely to be viewed as a sign of disrespect, a judgment that the patient lacks moral worth and therefore has no claim on important information about him or herself and no right to make important health choices based on that information.
Nonmaleficence
As described in Chapter 3, the principle of nonmaleficence has its origins in the ancient medical pledge to “do no harm,” and is best understood today as a commitment to refrain from actions that are likely to cause more harm than benefit. To apply this principle to the topic of truthfulness, therefore, we must address the question whether a practice of truthfulness is likely to cause more harm than benefit, or vice-versa. The prevailing early twentieth-century view described by Richard Cabot emphasized the harmful effects of truthful disclosure, especially of bad news, in provoking anxiety and depression, and so recommended against disclosure. To test this view, Cabot undertook an “experimental” practice of truthful disclosure, and he reports his conclusion in dramatic fashion: “It has been, on the whole, the most interesting and surprising experiment that I have ever tried. The astounding innocuousness of the truth when all reason and all experience would lead one to believe that it must do harm, has surprised me even more than the remarkable tolerance of febrile patients for alcohol” (italics in original).11 If Cabot’s experience is representative of the consequences of truthful communication in other health care contexts, most patients and their loved ones are resilient enough to accept and deal with the truth about their health, even when the news is bad.
Truthful disclosure may sometimes cause harm, but so, obviously, may a practice of deception. As Cabot also points out, if a patient discovers a physician’s attempt to deceive him or her, that patient is likely to mistrust everything the physician says, causing irreparable damage to their therapeutic relationship. Failure to disclose important health information may also cause harm. If, for example, a patient is not informed that his or her illness is terminal, the patient may not attend to important business or relationship matters before death, and those lost opportunities may result in major financial or emotional harm.
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