The Ethics of Truth Tellingand Hope

Alex ChamberlainCoordinator of Clinical EthicsSt. Luke’s Regional Medical Center

What Would You Do?

• A mother says, “My seventeen year old isn’t ready to hear that he needs a heart transplant. Please keep this a secret for now, and tell him he’s going to get stronger.”

• A patient with terminal cancer requests, “My wife has dementia. If she asks you if I will be all right, please tell her I am going to be fine.”

• A physician says, “This patient is drug seeking. Let’s give him a gradually reduced amount of active medication and then confront him about his use of pain meds. Track his pain scale responses as the day goes on, would you?”

Falsehood Definitions

• Lying: one person intentionally misleading another either through concealment or falsification.

• Deceit: misrepresentation, evasiveness, exaggeration, manipulation.

• Patronization: overly simplified explanations because the patient needs to have information “dumbed down.”

Tension between Utilitarianversus

Deontological Ethics

Seek the good, the best consequences for the most people, do a caring calculation of

outcomes.OR

Do what is right, do your duty, stick to what has proven to be the moral thing over the

ages.

Catholic Tradition

The Catholic natural law tradition, from Augustine onward, considered every instance of lying to be a sin. Lying, in this tradition, subverts the nature of speech and therefore violates the divine purpose in creating us as speaking animals.

Immanuel KantThis 18th century philosopher echoed Catholic moral tradition while strengthening the moral responsibility to not lie. Kant considered truth telling a duty that was imperative and never justified by mitigating circumstances. There was a categorical requirement to always tell the truth regardless of anticipated consequences.

I deny the lawfulness of telling a lie to a sick man for fear of alarming him. You have no business with consequences; you are to tell the truth. Besides, you are not sure what effects your telling him that he is in danger may have.

Samuel Johnson 1709-1784

I cannot tell a lie, but my biographers may have done so

Utilitarian justifications for lying

• 1803 ,Dr Percival, Great Britain, “To a patient who makes inquiries which, if faithfully answered, might prove fatal to him, it would a gross and unfeeling wrong to reveal the truth.”

• 1927, Dr. Joseph Collins, “The longer I practice medicine the more I am convinced that every physician should cultivate lying as a fine art. But there are many varieties of lying.”

Do No Harm

• What if telling the truth to a patient will harm that person?

• When would it be beneficial to withhold the truth from a patient?

Hope, Deception, and Fortune Telling

• Ambrose in the 16th Century wrote, “Always give the patient hope, even when death seems at hand.”

• In the mid-19th Century the AMA’s code of ethics included the admonition that physicians had a “sacred duty” to “avoid all things which have a tendency to discourage the patient and depress his spirits.”

Placebos Have Their Place

We can agree to a deception

Genetic testing…a new wrinkle in truth

• What do we tell a patient whose genetic information demonstrates increased chances of developing a devastating disease?

• What if the disease is incurable, with no helpful therapy on the horizon? Who would want to know that?

• If a person has a 20% chance of contracting a disease from age forty onward, with the odds of it manifesting itself increasing with age, when should the patient be told?

But, Hope of….what?

CureMiraculous recoveryHealingNot being abandonedPain eliminatedPain managedMore timeBetter QOLPeaceful death

The heart asks pleasure first, And then, escape from pain; And then, those little anodynes That deaden suffering,And then, to go to sleep; And then, if it should beThe will of its Inquisitor,The liberty to die.

-Emily Dickinson

While we talk with great facility about the dangers of taking away the patient’s hope, I am not sure that we really have that power to do so except in very rare instances.

-Howard Brody, MD, PhD

Hope and Meaning

Hope is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out. –Vaclav Havel

The Hospital Culture

Has a tremendous risk of engendering deception, half truths, and outright lying…

and a reluctance to acknowledge pain, suffering, dismay, despair, or doubt.

Everybody Lies?

Liar, Liar…• I’ve just left the office-be there in five minutes• This won’t hurt a bit• The doctor will call you right back• You may feel a little discomfort• I am sure he will be fine

…well, at least a chaplain wouldn’t lie when a patient is being coded in the ER…right?

Have you ever lied to a healthcare provider?

(Don’t lie now!)

Do you want a doctor who is “brutally honest” or one who is reassuringly vague?

Patient Self-Deception

• I am less injured, ill, disabled than they think I am.

• I have the good fortune, or good judgment, to be under the care of superior physicians in an excellent hospital.

• When a doctor speaks vaguely, I will gladly put a positive spin on it. I have a “treatable lesion” not a nearly unbeatable diagnosis of cancer.

Provider Self-Deception

• Each patient is a statistic of one• Each patient is unique, so we can’t be sure

that a given treatment might not work in this person

• Every treatment is truly experimental• I remember reading about a case…

Patient Collusion

• “Give it to me straight” versus “Let’s avoid any unpleasantries”

• Is there a wink and a nod between patients and physicians?

• If a patient winces as bad news is shared, will the doctor then “back off”?

Probability versus Possibility

• Patients tend to focus upon possibilities

• Healthcare providers work out of probabilities

Maybe they don’t want to hear it

• Some Native Americans, Japanese, Hispanic and other family groups “protect” the patient from a diagnosis or prognosis.• How do we honor an obligation to tell the truth and seek informed consent while also being culturally sensitive?

Truth telling as a process

• Why tell the truth? (compassion, information sharing, embracing the values surrounding honesty, getting it over with)

• What is the truth? (a diagnosis, an emotion, likelihood of a certain outcome, a prognosis with or without treatment, a fact…or an opinion?)

• How tell the truth? (reluctantly, boldly, over time)

Patient Centered Truth Telling We live in the much appreciated age of tailored or

personalized cancer treatments to best match the makeup of our patients. Most times, such tailoring is considered in the context of medication dosing, but communicating cancer diagnoses and prognoses to patients and their families is no less a treatment than medication titration.

How they want the disease treated and how they want the truth treated are not vastly different.

-Pamela Hinds, RN, PhD

Uncertainty as a Component of Truth

• Uncertainty can be normalized• Acknowledge their emotional dissatisfaction with

not knowing• Concede that this lack of sureness makes it difficult

for them to plan with any certainty• Demonstrate appropriate humility regarding the

limitations of our knowledge• Uncertainty can plant hope…it can nurture positive

thinking about a variety of futures. We can avoid presumption about worst case scenarios

What helps increase trust and openness

• Model tolerance for uncertainty• Look at truth telling as a process rather than

an event• Discuss with a patient the amount and detail

of information to be discussed, asking how they would like such to be handled

What Would You Do?

• A mother says, “My seventeen year old isn’t ready to hear that he needs a heart transplant. Please keep this a secret for now, and tell him he’s going to get stronger.”

• A patient with terminal cancer requests, “My wife has dementia. If she asks you if I will be all right, please tell her I am going to be fine.”

• A physician says, “This patient is drug seeking. Let’s give him a gradually reduced amount of active medication and then confront him about his use of pain meds. Track his pain scale responses as the day goes on, would you?”