Journal of medical ethics 1995; 21: 77-81 J Med Ethics: first published as 10.1136/jme.21.2.77 on 1 April 1995. Downloaded from The use of deception in nursing Kevin Teasdale and Gerry Kent Sheffield University Abstract deception is another issue altogether. Deception is Arguments about the morality ofthe use ofdeception in much harder to justify and certainly rarely patient care have been conducted largely in an empirical acknowledged in public. Instead, many professionals vacuum, with few data about the situations in which prefer to use euphemisms such as 'information man- deception occurs. Do stafffrequently deceive their patients agement' to describe times when they give inac- and, ifso, under what conditions? Can the consequences curate information or withhold accurate information ofdeception always beforeseen? Whatjustifications do in order to mislead. staff use to explain their behaviour? The small-scale study It is sometimes argued that such situations should reported here on the uses ofdeception by nurses when not be described as cases of deception, since the attempting to reassure patients provides information on whole truth about a patient's situation can never be these questions. The results suggest that deception can known or fully communicated; therefore one can have deleterious effects on trust and increase the emotional never know whether or not the information which distance between patients and staff one gives is accurate or not. However, Bok (7) has copyright. pointed out that although we can never know the Recent articles in this journal (1-3) have discussed whole truth we still have the option of trying to some of the issues relating to deception in clinical convey the truth as we understand it. She argues that encounters. Jackson (1,3) has argued that while lying anything less is a form of deception, stating that: is almost always morally indefensible, deception can 'The moral question of whether you are lying or not be justified when it does not endanger the trust is not settled by establishing the truth or falsity of between a health professional and patient. Bakhurst what you say. In order to settle this question we must http://jme.bmj.com/ (2), on the other hand, contends that lying and know whether you intend your statement to mislead' deception are often morally equivalent, because they (8). Independent support for this viewpoint comes infringe a patient's right to autonomy. from studies in the philosophy of language which Hoffmaster (4) has argued that normative ethics suggest that communication is best described as an provide a poor model for understanding the inferential process in which one person uses everyday ethical decisions made by clinicians since language and non-verbal signs to try to induce they do not provide a contextual understanding of another person to infer the intended meaning (9). on September 26, 2021 by guest. Protected action. In practice, doctors and nurses often override Thus the key to deception depends less upon the the rule of veracity in the interests of individual precise coded form ofwords or other signs employed patients in particular situations. Frohock (5) than upon the intentions of the communicator. concludes, on the basis of an analysis of treatment Empirical studies have indicated that deception is decisions in neonatal intensive care units, that the used to promote what is perceived as better care for language of harm (the principle of non-maleficence) the patient, sometimes through reassurance (for fits the reality of clinical practice more closely than example, maintenance of hope for the future) and the language of individual rights. sometimes because of organisational needs (for It seems likely that non-disclosure is widespread example, time considerations or concern that a in patient care. Doctors and nurses frequently see it patient would become difficult to manage). In a as part of their professional responsibility to 'titrate' small-scale survey by Schrock (10) of the deceptions the amount ofinformation they give to patients. This used by student nurses, 60 per cent of the deceptive can be justified on empirical grounds since some situations were attributed to doctors' orders or ward patients are distressed if they receive more policy, 20 per cent were carried out in order to information than they desire (6), but the use of promote better patient management (since the nurses feared that if patients knew the truth they would be unwilling to comply with treatment) and Key words the remainder of deceptions were carried out in Ethics; deception; nursing; reassurance. order to withhold information about patients' 78 The use ofdeception in nursing J Med Ethics: first published as 10.1136/jme.21.2.77 on 1 April 1995. Downloaded from illnesses or drug treatments or because truthful psychiatric specialties were asked to complete a explanations would have taken too long. critical incident sheet (21) and 55 qualified nurses In a study of midwifery practice, Kirkham (11) working in the same specialties were given a semi- observed frequent use of evasive answers to mothers' structured interview. Although no personal details of questions, amounting in many cases to deception. the staff given the critical incident sheets were Mothers were allowed very little choice or autonomy collected for reasons of anonymity, there were 12 during labour, and deceptive strategies were used to male and 39 female nurses in the interview sample, maintain medical and midwifery control over the situ- with an average 16 years of nursing experience. ation. Bond (12) reported similar uses of deception in a cancer ward where the 'social order ofthe ward' was PROCEDURES considered to require non-disclosure of diagnosis. The critical incident sheets asked the staff to McIntosh (13), identified widespread use of describe situations when they (a) nursed a patient deception by all members of the health care team who was anxious, worried or distressed, (b) tried to working on a cancer ward. The team was consistent help the patient become calmer, more secure or in its belief that disclosure of diagnosis would assured, and (c) were able to find out or observe the destroy patients' hopes of recovery and make their effects on the patient oftheir intervention. The semi- management difficult. McIntosh found that in many structured interviews with the nurses and patients instances the patients themselves knew their true covered the same areas but in more depth. Of the diagnosis, but supported the non-disclosure policy 272 nursing staff approached, 251 (93 per cent) of ward staff. Glaser and Strauss (14) noted that agreed to describe such incidents. The two authors nurses caring for patients with cancer were independently assessed the questionnaires and frequently hampered in their communication with transcripts of interviews for the presence of patients by uncertainty over what patients already deception or lying. The first author identified 13 knew about diagnosis or treatment and by what they incidents in which nurses used deception in their were allowed to disclose. Melia (15) in the UK attempts to alleviate patients' concerns, while the found that student nurses faced similar problems, second identified 12 incidents. Full agreement was describing this as 'nursing in the dark'. found for ten incidents, which form the data-base forcopyright. Although these studies indicate that deception is results described below. sometimes used in an attempt to manage situations, there are few indications of its 'success' or its effects on the professional-patient relationship. However, Results detection rates in real life may be high (16) and the pressures on those using deception increase when the DESCRIPTIONS OF INCIDENTS http://jme.bmj.com/ message is an important one and when there are The 251 nurses indicated that they used a variety of considerable adverse consequences of detection (17). interventions when attempting to help a patients In these circumstances, which are typical of clinical to be calmer, more rested or secure. As shown in settings, social skills are more likely to break down Table 1, the most common was the use of prediction and the likelihood of discovery to increase (18). The (in which staff provided information about what was emotional costs of collusion in a deception may be to happen to the patients), followed by emotional considerable (19) and the need for teamwork in support (touching, providing time to listen), giving maintaining deception increases the risk of discovery the patient some control over events, direct action on September 26, 2021 by guest. Protected (19). For all these reasons, the use of deception in (making some change in their care procedures) and health care is a relatively high-risk strategy. distraction. Although deception was not given a The aim of the present study is to provide further category in this analysis, most instances involving empirical data on the use of deception in clinical deception fell under the prediction and distraction settings. In a study on the use of reassurance in categories. nursing (20), nurses were asked to describe situations in which they sought to alleviate patients' anxiety or distress. Those situations in which staff reported the use of deception form the database for this report. An Table 1 analysis of these situations helps to develop a better Percentages of types of intervention understanding of the processes involved when nurses used by nurses when attempting to actively attempt to mislead a patient. reassure patients Prediction 41-2 Methods Emotional support 29-1 Patient control 17.9 SUBJECTS Direct action 7.7 Ninety-one student and 126 qualified nurses Distraction 4-0 working in medical, surgical, community and Kevin Teasdale, Gerry Kent 79 J Med Ethics: first published as 10.1136/jme.21.2.77 on 1 April 1995. Downloaded from While the study collected incidents concerning distress, and taking steps to minimise or avoid it.