Truth telling and Lying: Is Deception Ever “Good” in Healthcare?

1. Truth telling and Lying: Is Deception Ever “Good” in Healthcare?

2. The Purposes • Will explore the questions posed by truth-telling in medical ethics. • Will explore the principles, distinctions and cases clinicians discern in complex patient cases.

3. Autonomy and the Birth of Bioethics • Henry K. Beecher, "Ethics and Clinical Research", New England Journal of Medicine, 247 (1966): 1354-1360. • Maurice Pappworth, Human Guinea Pigs. (London: Routledge & Kegan Paul, 1976).

4. With more careful examination our perception reveals itself to look more like this.

5. More Recent Evidence of “Lenses” • Studies have shown that not only were clinicians’ willingness to withdraw life support influenced by personal characteristics such as age, religion and clinical experience, but personal preferences also impacted when they chose to withdraw life support. • Studies have shown that some clinicians will misperceive their patients preferences and substitute their own preferences for those of the their patient. (Schneiderman, Journal of Clinical Ethics, 1993) • Recent NIH Study on the accuracy of surrogates decisions, proxies were accurate 68% of the time, but off the mark in almost one out of every three cases.

6. Defining “A Lie” A Lie is… “an intentionally deceptive message in the form of a statement”.

8. Why is Lying Bad? • It diminishes trust among human beings. • Makes the possibility of human community more difficult.

9. Distinctions: Even “Little White Lies”? • Flattery: “you look lovely” • Gratitude: “that's just what I wanted” • Bargaining: “my best price is $500” • Generalisation: “it always rains in Seattle” • Unpredictable situations: “it won't rain today” • False excuses: “he's in a meeting”

10. Reasons for Lying • Protection • Avoid harm • Maintain Confidentiality

11. Mr. Smith Mr. Smith is 75 years of age, fragile but alert and competent. He is a multi-year survivor of cancer and, after a few months of feeling poorly, just completed diagnostic tests that showed the cancer has returned and is beyond curable treatment. The current oncologist has not cared for Mr. Smith previously. She informed Mr. Smith’s only child, Chris, and was stunned by the response:

12. Mr. Smith (con’t) Do not tell him the cancer has returned. Please refer him back to his family physician. He and I agree that the news will destroy him; in fact, the doctor kept his own mother’s diagnosis of cancer from her as long as he could in order to strengthen her will to live and not destroy hope. We plan to tell my father that the symptoms are due to something else that is treatable. The oncologist does not hide diagnostic information from her patients, but conveys the truth with sensitivity and accompanying support. The other clinical staff participating in Mr. Smith’s care feel in conflict because they believe “he has a right to know.”

13. Guidance of the ERDs “Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.” (Ethical and Religious Directives #27).

14. Lies told in teaching religion Lies which hurt someone and help nobody Lies which hurt someone but benefit someone else Lies told for the pleasure of deceiving someone Lies told to please others in conversation Lies which hurt nobody and benefit someone Lies which hurt nobody and benefit someone by keeping open the possibility of their repentance Lies which hurt nobody and protect a person from physical 'defilement. St. Augustine’s Hierarchy of “Lying”

15. Malicious lies: lies told to do harm Malicious lies are mortal sins 'Jocose lies': lies told in fun These are pardonable 'Officious' or helpful lies These are pardonable Thomas Aquinas on Types of Lying

16. Sissela Bok’s “Test” for Lying… • Are there some truthful alternatives to using a lie to deal with the particular problem? • What moral justifications are there for telling this lie - and what counter-arguments can be raised against those justifications? • What would a public jury of reasonable persons say about this lie?

17. Diversity: Does the Principle Hold? After a survey of 800 seniors from four different ethnic groups showed that Korean-American and Mexican-American subjects were much less likely than their European-American and African-American counterparts to believe that a patient should be told the truth about the diagnosis and prognosis of a terminal illness, we undertook an ethnographic study to look more deeply at attitudes and experiences of these respondents. European-American and African-American respondents were more likely to view truth-telling as empowering, enabling the patient to make choices, while the Korean-American and Mexican-American respondents were more likely to see the truth-telling as cruel, and even harmful, to the patients. Further differences were noted in how the truth should be told and even in definitions of what constitutes “truth” and “telling”. Blackhall LJ, Frank G, Murphy S, Michel V.  Bioethics in a different tongue: the case of truth-telling.  Journal of Urban Health.  2001 Mar;78(1):59-71

18. Mrs. Lee An 80-year-old Asian widow is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her oldest son approaches the physician and asks that the patient not be told, stating that in their culture the elderly are protected from such distressing news. In mainland China, tuberculosis was considered fatal and to tell her would be like giving her "a death sentence." Should you respect the son’s approach?

19. Narrative Ethics

20. A Key Paradigm Shift From diagnosis and treatment of disease ….to understanding how illness integrates into my life story.

21. The Explanatory Model Arthur Kleinman, Ph.D. • Culturally sensitive approach to asking about a health problem • What do you fear most about your illness? • What are the chief problems your sickness has caused you? • Anyone else with the same problem? • What have you done so far to treat your illness: What treatments do you think you should receive? What important results do you hope to receive from the treatment? • Who else can help you?

22. The LEARN ModelBerlin and Fowkes Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment

23. Four Phases for Addressing Conflict

24. “Hope is not the expectation that things will turn out well; it is the belief that there is meaning no matter how things turn out.” Vaclav Haval

25. The Purposes • Will explore the questions posed by truth-telling in medical ethics. • Will explore the principles, distinctions and cases clinicians discern in complex patient situations.