J Med Ethics: first published as 10.1136/jme.8.3.115 on 1 September 1982. Downloaded from V, Journal ofmedical ethics, I982, 8, II5-II6

Editorial On telling dying patients the truth

Dr Lawrence Goldie, who speciaiises in psychotherapy The third argument against truth telling is that for dying and severely ill patients, provides in this issue patients do not wish to be told the truth when they have a persuasive case for honesty with such patients. The a fatal illness and not much longer to live. It is perhaps honesty he advocates involves painstaking and sensi- worth briefly considering each of these arguments. tive commitment, not five minutes ofblunt speaking in Primum non nocere is certainly a vital principle of a busy outpatient clinic (he gives a horrifying example medical ethics but its priority or absoluteness and its ofincompetent truth telling); it is an honesty which the exact meaning may both be questioned. Clearly the patient has sought in the course of psychotherapeuti- principle can not entail that anything which causes cally orientated discussion; it is an honesty which harm to a patient must be avoided: operations for includes continuing support; and it is an honesty example cause some harm and certain life-prolonging which, believes Dr Goldie, reduces unnecessary suffer- and potentially curative cancer treatments may cause ing and helps patients to survive it when it is inevitable. severely harmful side-effects. The principle must be Such views, from a doctor who spends much of his understood to mean that the doctor should strive to ensure a professional life actually talking at length and in depth that his interventions achieve positive balancecopyright. with patients who are dying deserve very serious con- of benefit over harm. Yet even this principle cannot be sideration. Yet they probably represent a small minor- given absolute priority otherwise the doctor's safest ity ofmedical opinion on thNs issue. More commonly - course would always be to leave well alone, thereby in practice if not in print - doctors tend to deceive ensuring that he was not ever causing more harm than patients with fatal diseases (especially cancer) about good (this assertion admittedly ignores the philosophi- both diagnosis and prognosis. cal problem of whether or not one can cause things to Three arguments defending such deception are happen by inaction). If, as seems essential, primum non often heard. The first is that the doctor's primary nocere is understood in this modified way then it can http://jme.bmj.com/ moral obligation is not to harm his, or her, patient not justify deceiving patients unless (a) the failure to (primum non nocere) and that this obligation over-rides deceive would result in an overall excess of harm over the requirement not to deceive: fatally ill patients benefit and (b) the net avoidance of harm achieved by already have enough problems oftheir own without the deceit outweighed any other relevant moral principles. doctor harming them further by telling them that they It is indisputable that most people suffer anguish have cancer and will probably soon die from it. when they learn that they have a fatal disease which is The second argument against truth telling is that the likely to kill them. Far less obvious is that such infor- doctor can never be sure of the diagnosis or prognosis mation causes more harm than good, for against the on September 29, 2021 by guest. Protected and in any case patients have not been trained to under- anguish must be set such benefits as: relief of uncer- stand the truth even if they are told it: patients have tainty (many such people already suspect that some- insufficient comprehension of the intricacies of thing is seriously wrong); the possibility of informed medicine; of the enormous variety of conditions reflection and discussion about the likely course of encompassed by the word 'cancer'; of the range of events; the opportunity to take stock, mend bridges, possible outcomes; of the pros and cons of various make farewells, arrange affairs and even help family treatments, and thus, even if one wants to, it is usually and friends to come to terms with their loved one's impossible successfully to communicate the truth. An impending death; the avoidance ofthe extensive web of American physician combined these two arguments deceit in which an initially limited medical (or family) long ago when he wrote: 'it is meaningless to speak of decision to deceive often results - deceit which may telling the truth, the whole truth and nothing but the supplant a lifetime's mutual trust; and finally the truth to a patient. It is meaningless because it is impos- amelioration of the process ofdying which honest pre- sible . . . far older than the precept "the whole truth paration for death may achieve. Apart from Dr and nothing but the truth" is another that originates Goldie's own examples of the benefits of honesty in within our profession, that has always been the guide of terminal disease a vivid example is provided in a recent the best physicians and ifI may venture a prophecy will JME Case conference (2) (see also this issue's Case always remain so:"so far as possible do no har... ." (i). conference). Thus even on mere harm-benefit II6 Editorial J Med Ethics: first published as 10.1136/jme.8.3.115 on 1 September 1982. Downloaded from calculations there is good reason to doubt that deceit will hand almost go per cent of American doctors generally generally be of overall benefit to the dying patient. For withheld the truth about cancer diagnoses from their non-utilitarians such calculations are in any case not patients (8). Although these surveys are now distinctly sufficient; the maximising of overall good is only one of elderly they at least cast substantial doubt upon the claim many moral principles which may be relevant. Others that most patients do not wish to know the truth. include those various principles which may con- One possible explanation for the discrepancy be- veniently be subsumed under the concept ofrespect for tween what doctors believe about patients' wishes and the individual person. The moral principles that one what patients say they wish is the one suggested by Dr should tell the truth, honour one's promises and con- Goldie, and supported by another study (9), that doc- tracts, and keep faith with others, are all examples of tors find death, and especially the prospect oftheir own respect for persons. Another is the principle of auton- death, particularly disturbing. Certainly, talking hon- omy which recognises the individual's right to deter- estly with patients about their death is disturbing, a mine his own preferences, make his own moral profoundly moving experience, and perhaps one ofthe decisions and generally determine his own course of more difficult tasks with which a doctor may be faced. action at least in so far as it does not conflict with the Nonetheless if it was recognised more generally to be autonomy of others. Such principles might lead the an important and legitimate aspect ofhis role then ways non-utilitarian to avoid deceptions and respect a of ameliorating his disturbance, including appropriate patient's autonomy even in cases where he did foresee training, good support and a reasonable distribution of that this would result in overall harm to the patient. this type ofwork-load, could doubtless be devised with The second argument is that doctors are unable to the assistance of those experienced in such work. tell patients the truth because patients are unable to The foregoing arguments do not, it should be understand it and in any case doctors can never them- emphasised, support indiscriminate, let alone casual, selves know it to be the truth, for their diagnoses and curt or unsupporting, truth telling to all dying especially their prognoses are often wrong (most doc- patients. Rather they are arguments which reject any tors have dramatic stories to illustrate this). This blanket generalisation in this complex area. They do argument involves a fundamental confusion between however indicate that a concern for the autonomy of the moral issues of truth telling or truthfulness and the patient requires a sincere effort to be made tocopyright. deceit on the one hand and the logical, semantic and discover what his, or her, wishes really are, and then to epistemological issues besetting the concept of truth give those wishes very considerable weight. They sug- itself on the other. While these latter issues are of gest that the basic moral norms of truth telling and central importance in philosophy they have almost fidelity cannot lightly be over-ridden; and they suggest nothing to do with the question ofwhat to do with such that when assessing overall harm and benefit, more knowledge of the truth as one does have. Here the complex assessment is required than a mere considera- crucial moral issue concerns the doctor's intention; tion of the patient's.immediate distress on being told does he intend to transmit to the patient information he the truth. Finally they suggest that strategies need to http://jme.bmj.com/ has reason to believe to be true, does he intend to be developed to help medical staff deal with their own withhold it, or does he intend to lie to or otherwise distress when confronted by such problems. deceive the patient? Discussions about the concept of truth, about how we can know the truth, especially where information is probabilistic, and about different References degrees of understanding of what is known or justifi- (i) Henderson L. Physician and patient as a social system. ably believed to be true, are all but a smokescreen New Englandjournal ofmedicine 1935; 2I2: 8I9-823. which does nothing (in the ordinary case) to resolve the (2) Higgs R. ed. Truth at the last - a case of obstructed on September 29, 2021 by guest. Protected dilemmas of truthfulness and deceit. Those with death?Journal ofmedical ethics I982; 8: 48-50. residual doubts should imagine, as Bok in her (3) Bok S. Lying - moral choice in public and private life. Sissela Hassocks, Sussex: The Harvester Press, i978: 227. excellent discussion of lying suggests, what their (4) Veatch R. Death, dyingand the biologicalrevolution. New response would be to a used-car dealer who used such Haven and London: Yale University Press, 1976: arguments to justify his deceit (3). 229-238. Finally, there is the argument that patients do not (5) Aitken-Swan J, Easson E C. Reactions ofcancer patients wish to be told the truth about their fatal condition. on being told their diagnoses. British medical journal This is an important argument for it implicitly recog- 1959; (i): 779-783. nises that doctors ought to be responsive to their (6) McIntosh J. Patients' awareness and desire for informa- patients' wishes - it recognises implicitly the autonomy tion about diagnosed but undisclosed malignant disease. of patients. If it could be shown Lancet 1976; 7: 300-303. that all patients did (7) Kelly W D, Friesen S R. Do cancer patients want to be indeed wish not to be told the truth about their fatal told? Surgery I950; 27: 822-826. diseases this would be an important argument at least (8) Oken D. What to tell cancer patients. Journal of the for withholding the truth. However several surveys (4, American Medical Association i96i; 175: II220-iI28. 5, 6, 7) have shown that a large majority, generally (9) Feifel H, Hanson S, Jones, R et al. Physicians consider over 8o per cent, of patients and the general public say death. Proceedings ofthe American Psychological Associa- that they would like to be told the truth. On the other tion Convention I967: 201-202.