Truth, Trust and Medicine

Jennifer Jackson

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781134666430
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

Truth, Trust and Medicine investigates trust and honesty in medicine. It looks at the doctor-patient relationship, raising questions which disturb notions of patients' autonomy and self-determination, such as withholding information and consent and covert surveillance in care units. It will be of interest to those working in medical ethics and applied philosophy, and a valuable resource for practitioners of medicine.

1 Truthfulness in medical and nursing practice

Truly, we are a truth crazed society

John Lantos, MD

A few years ago a hospital sister was suspended from her job and then given ‘a final formal warning’ for, on a consultant’s instruction, having added haloperidol (a tranquillising medication) to the tea of a 91 year old who was attending a day hospital for the elderly. The patient had resisted all efforts to persuade him to be admitted to hospital. The team felt that he was hypomanic and unsafe to return to his old people’s home without treatment. The consultant who had given the instruction to the sister was also upbraided: his medical director likened the action to having intercourse with a patient, ‘it may not harm the patient but it is equally wrong’ (Kellett 1996: 1250).¹

The disciplinary steps taken (by the chief nurse and the hospital unit general manager) were bizarre in themselves, but equally baffling, surely, must have been the moral judgements that were thought to justify them. Were the managers sticklers for openness? Not exactly, it seems: the consultant was actually rebuked for having subsequently told the patient and the patient’s nephew what had been done and why. The patient and the nephew were wholly satisfied with this explanation after the event. Not so, the management. Although the consultant was eventually found to be not guilty of professional misconduct, he was subsequently ordered ‘to stop releasing information of this type [that is, an account of his clinical actions and the reasons for them] to relatives or patients’ (White 1997: 299).

In the correspondence the report of this incident generated, doctors claimed that covert drug administration is quite common. In a questionnaire issued to a random sample of senior, middle grade and junior psychiatrists working in Heathlands Mental Health Trust, over a third of the doctors admitted to ‘either having participated in surreptitious prescribing or having been economical with the truth when giving information to patients’ (Valmana and Rutherford 1997: 300).

Of course, this is not the only setting in which doctors and nurses report that concealment, with or without deception, is routine practice. Parents and clinicians are said to collude in administering drugs surreptitiously to children (Griffith and Bell 1996: 1250). While many doctors and nurses admit to feeling particularly uncomfortable about lying, they may not feel so badly about other types of deception that do not involve outright lying, or that simply involve the withholding of information. Though, doubtless, they will agree that truthfulness is a duty, they may observe that this duty has to be balanced against other duties. It routinely and properly yields to other overriding concerns.

Maybe so. But how, then, are the different duties to be weighed up? Should the duty not to lie weigh more heavily than the duty not to deceive by other surreptitious tricks? By what measure or test are doctors or nurses to work out in this or that situation whether or not the duty not to lie, or the duty to be open, is properly overridden by some other duty? Is it possible at least to draw up guidelines on this matter? Will conscientious and experienced practitioners not need guidance? Are good intentions and common sense sufficient – sufficient to deal with the variety of challenges and predicaments that arise? Doctors and nurses can expect often to be faced with the questions what to tell, whether to tell, and how much to tell.

Should doctors inform their patients if Alzheimer’s is diagnosed even if the patients’ families want the information to be withheld? Should a nurse who discovers that she has accidentally given a wrong dose make a point of telling the patient that she has done so, even if the patient has suffered no ill effect in consequence? Should doctors always tell their patients if cost considerations prevent their being offered the best treatment for their condition? Is it ethically defensible to enter patients in a trial without telling them, provided that the treatment they receive in the trial is simply the standard treatment they would receive if they were not in the trial? Are there honest ways of using placebos on patients – as therapy? Is it unethical, in persuading an elderly patient to move into a nursing home, to withhold the information that no pets are allowed there, or to let the patient hold onto unrealistic hopes that the stay will be temporary? Is it unethical for the physiotherapist to persuade a patient to do exercises by giving unrealistic predictions (or by not correcting the patient’s own unrealistic expectations) about the extent of recovery that these will achieve?

The brother of a young woman who is critically ill with cystic fibrosis comes forward as a potential donor – offering part of his lung. He is tested and found to be an excellent match. You are now explaining to him in detail what the operation entails – including the risks and possible complications for him and for the recipient, his sister. It becomes clear to you that he is changing his mind and wants to back off. But he cannot bring himself to do so unless you are willing to conceal from his family the reason for not proceeding. He wants you to lie to his family about why the transplant cannot go ahead. If you tell them that he has been found not to be ‘medically suitable’ is that a lie? Is it any way a defensible deception? If you aim to deceive does it matter morally how you do this, whether with an outright lie or with an equivocation?

You explain to your patient that there is a waiting list for the heart bypass operation of 6–9 months. You do not mention that 70 per cent of patients on the waiting list die before their turn comes up. You also omit to mention that those who can afford to go private can have the operation done immediately. It is obvious to you that this patient cannot afford to go private. You give accurate figures regarding the relative risks of alternative treatments, one of which involves surgery. But you omit to mention that the risk of surgery in this hospital is significantly higher than the national figures you have quoted. If a patient, dying of cancer, wants to know what the dying may be like, are you obliged to give details of every possibility, however grim or unlikely? Do all patients, if competent (and otherwise, their relatives) have a (moral) right² to participate in the making of a decision not to resuscitate should they arrest?

You are seeking permission from parents to remove tissue from their deceased child to use for research purposes. You do not make it clear that ‘tissue’ as you and your medical colleagues understand the term includes eyes and organs. You do not spell this out fearing that if you did, consent might not be forthcoming.

The relative wants to know whether the patient was in pain when she died. You do not lie. You evade. You describe the pain relief that was offered and omit to say that it was ineffective. If a mother whose baby is dying waits by the cot meaning to hold her baby in her arms as it dies, but falls asleep at the critical moment, is a nurse remiss if she wakes the mother and hands her the baby allowing the mother to think the baby is still alive though the nurse realizes that it is not? A mother asks what will happen to the baby she has miscarried and the nurse replies that it will be cremated. She does not add that the body goes into a skip along with other miscarried or aborted foetuses and is tipped into an incinerator. Nor does she volunteer the information that a neighbouring health authority has a policy of cremating separately boxed miscarried foetuses.

These are mostly examples of withholding information or of incomplete disclosure where the intention to deceive may or may not be present. There are also situations where patients or their relatives are routinely and deliberately tricked. The doors into Alzheimers’ wards are deliberately designed so that the patients cannot work out how to open them. Pretences are adopted to trick patients out of their dependency on ventilators or drugs. Covert surveillance on relatives is used in paediatric wards where child abuse is suspected. If a patient dies suddenly, the relatives may be summoned with a lie or evasion to disguise the fact that the patient is already dead. Summoning relatives in this way may be the policy advocated to avoid what is considered worse: telling them the bad news over the telephone.

Deceptions in medical practice are not confined to doctors or nurses deceiving their patients: they may lie for them as well as to them. Is this always wrong? It is said that the first duty of doctors is to serve the best interests of their patients. What, then, if those interests are best served by lying on their behalf – to their insurers or employers or to a colleague?

Everyone can appreciate the prudential importance of being sparing with the lies one tells, in medicine, as in life generally. Lying is only useful where it is not suspected and if everyone lies, everyone suspects. That granted, is not truthfulness also something that can be overdone? If the reality in medical practice is that patients are often lied to, tricked with deceptions, and kept in the dark, is that necessarily a matter for surprise or condemnation? Are there not good and bad reasons for being untruthful or less than wholly truthful? Before condemning deceptive or secretive practices, we need to look into the situations in which they occur and the reasons why they are resorted to: these may or may not exonerate.

All the same, there does seem to be a rather blatant mismatch between what actually goes on in medical practice, the extent to which deceptions and secrecy occurs (naturally, one assumes that the extent is considerably wider than is admitted to) and the declarations and pronouncements on medical ethics which nowadays are so stridently in favour of truthfulness and openness. While there are many issues in contemporary medical ethics which are a source of continuing, often passionate, debate and controversy, one issue on which virtually everyone involved, professional associations of doctors and nurses, philosophers, patients’ groups (in the ‘Western’ world) agrees, is the enormous importance of truthfulness in medical and nursing practice. Many of the debates in medical ethics nowadays address new challenges which the health professions and society have never faced in the past. How truthful doctors should be with their patients is not a new issue. What is new is the current insistence among ethicists and others that good medical (and nursing) practice eschews deception and aspires to be open.

Sissela Bok (1978) connects the change of attitude with the emergence of the notion of informed consent.³ She and others also connect this change of attitude with the modern post-Kantian emphasis on the duty to show respect to patients by allowing them to make autonomous choices. Thus, for example, Sheila McLean declares that the ‘fundamental characteristic’ of showing respect is ‘the honest provision of information which permits the patient to make a self-determining decision about the personal benefits attached to surgery’(1989: 81–2). This connecting of showing respect owed to patients with recognizing and supporting their ‘autonomy,’ their right to make their own choices in the light of their own personal values and ‘life-plans’ is echoed approvingly throughout the literature on medical ethics. Respect for autonomy, declares the BMA’s practical guide to doctors, Medical Ethics Today, ‘has become the core principle of modern medicine’ (1993: 321). Attention to this principle is hailed as an advance over the less enlightened paternalist attitudes which prevailed in medical and nursing practice until recent times. Tom Beauchamp and James Childress remark: ‘By contrast to this traditional disregard of veracity, virtues of candour and truthfulness are among the most widely praised character-traits of health professionals in biomedical ethics’(1994: 395).

Until quite recently, truthfulness has not featured in medical or nursing codes. It does not seem to have been any significant part of the Hippocratic tradition – unlike confidentiality, which has always been seen as a strict duty owed by doctors to their patients. But nowadays it gets explicit attention. The General Medical Council issues a card to all medical students in the UK stating the essential duties of a doctor. These include: ‘be honest and trustworthy’, ‘give patients information in a way they can understand’ and ‘respect the rights of patients to be fully involved in decisions about their care’. The 1983 version of the International Code of Medical Ethics produced by the World Medical Association includes the statement: ‘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’.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting issued an Advisory Document on ‘Exercising Accountability’ (UKCC 1989). It has a whole section on ‘Consent and Truth’ which includes the following:

If it is to be believed that, on occasions, practitioners will withhold information from their patients the damage to public trust and confidence in the profession, on which the introduction to the Code of Professional Conduct places great emphasis, will be enormous.

So much for what is said. What actually happens may be rather different. Third year medical students at University College London are given practice through role-play in handling difficult patients.

Judging by the scenarios I witnessed, the strongest reaction in students faced with a difficult patient was to obfuscate, and even lie. They protested that the doctors training them routinely lie to patients. ‘My consultant never even tells the patients they have got cancer, let alone telling them that they are going to die’ said one.

The Sunday Times 30 April 1995

If there is a mismatch between what does happen and what it is said should happen in regard to truthfulness, which is it that needs fixing? Is it the declarations that are unsound, simplistic – maybe, because they are put about by ethicists who do not understand the realities of clinical practice and how patients’ needs are best served? (Thurston Brewin blames what he calls ‘fundamentalist ethics’ for the unsound rhetoric which advocates an overly rigid tactless and insensitive insistence on telling ‘the truth’) (1993: 161–3). Or, is it bad practice that needs fixing – maybe because clinicians too casually assume that truthfulness is impossible – that other duties must often prevail? Or, are practice and pronouncements not all that far apart since the pronouncements, on closer inspection, are vaguely worded or hedged about with qualifications which allow practitioners ample scope for tailoring the extent to which they are truthful to the particular demands of the situations they encounter? Brewin claims that actual practice has not changed all that much: good doctors and nurses understand the need to convey information always with tact and sensitivity (1996: ix).

How important are honest communication and openness in medical practice? Why do they matter? Do they matter equally and for the same reasons? Are they just as important in medical practice as in life generally? And how important is that? How ‘situationist’ should doctors and nurses be about telling lies, condoning lies, deceptive tricks and ploys, withholding information or keeping secrets? How should the need to speak the truth and the need to be open be accommodated with the other needs that doctors and nurses are duty-bound to serve?

Should doctors heed truthfulness in one way if they are working under adverse conditions, for example, under a totalitarian regime which does not respect the basic rights of all people within its borders, and in another way if they are working within a stable democratic and liberal society? Thus, Christine Korsgaard (1996) argues that under non-ideal conditions truthfulness may have to be seen as a goal rather than as a constraint. The mountaineer ascending Everest who passed without stopping, a climber who had collapsed, said in self-defence: ‘You cannot afford morality at 8000 metres’. Are there corresponding circumstances in which doctors cannot afford truthfulness – even as a goal?

If, as is so often claimed, patients can only trust those who are truthful and open with them, how did doctors and nurses manage to win their trust formerly in the days when truthfulness and openness were not seen to be requisite to good practice? Why is it that nowadays, notwithstanding the preaching, trust seems if anything more precarious, not less?

The mismatch between preaching and practice ranges beyond what is said or not said to patients (or for them). There is a mismatch, for example, between the official declarations which totally repudiate dishonest practices in research and publication – the use of fraudulent data, plagiarism, redundant publication, and actual practice.⁴ The fact that there are charlatans and rogues in medicine as in every other profession comes as no surprise. Yet we should not too hastily assume that every type of deception is dishonest or otherwise ethically indefensible. Even the most vigorous enthusiasts for truthfulness and for openness with patients will concede that there are some occasions where deceiving a patient is justified. Should they be equally ‘pragmatic’ about recourse to fraudulent data in scientific research? If not, why not?

Is it always dishonest to pledge to act one way when you intend to act otherwise? Is it a dishonest pretence to ‘respect’ Jehovah’s Witness patients’ refusal of blood up until they lose consciousness and then proceed to transfuse them as emergency cases? Is it dishonest pretence to circumvent statutory regulations that restrict legal access to abortion, signing patients as needing abortion on ‘social’ grounds when they do not? Is such a ruse not dishonest if nobody is fooled, if it is an open secret that this has become the conventional way round a tough law?

Is it dishonest of doctors to invite pregnant mothers to undergo prenatal screening without making it crystal clear to them that if they test positive, they will be offered an abortion? One hears that women have sometimes been invited to undergo such screening as if it were a way of helping the baby – ‘making sure it is doing well’. Should it not be made clear if the only help for the baby that might be forthcoming is being ‘helped’ to die?

Peter Singer (1995) complains of the mismatch between doctors’ continuing firm insistence on the sanctity of human life alongside their adoption of a new definition of death that enables them to harvest vital organs from the living. Singer claims that this ‘convenient fiction’ that the brain dead are dead is a dishonest pretence.

There are thus a host of practices in medicine and nursing which compromise truthfulness (or may seem to), some of which many practitioners may defend as sometimes necessary and not unethical, others of which may be defended by some and denounced by others. Needless to say, there are also instances where the truth is compromised unjustifiably but understandably – where there are mitigating considerations.

Being truthful can be difficult for two quite different reasons:

1. it may be difficult because though it is obvious what being truthful requires, acting accordingly is costly (to oneself, to others)
2. it may be difficult because in a particular context what truthfulness allows or requires is not at all clear

It is only the latter sort of difficulty that I want to explore in this book. Hence we will not be concerned with obvious skulduggery or venial lapses but with compromises with the truth that might seriously be defended: for example, on the grounds that these are necessary in the line of duty. In order to framework our reflections on truthfulness in clinical contexts we will need to explore more generally the nature of truthfulness: what it involves and why it matters.

Even if the general account of truthfulness that follows is sound, we cannot expect to be able to extrapolate guidelines directly from it in a way that will make truthfulness thereafter a problem free zone in clinical contexts. That would be a ridiculous ambition. My aim here is more modest: to shed some important light on truthfulness that will help those who encounter or anticipate such problems in their clinical roles to think them through more critically. Of course, much of the difficulty in applied ethics comes at the point where one moves from the more general enduring truths to the applications in particular fields, such as those explored in the study of health care ethics. But that is no excuse for not attempting to work towards a shared understanding of what are defensible and indefensible practices and policies. In working out their own guidelines doctors and nurses need to have one eye on the more general underlying issues: in this case, of what truthfulness involves and why it matters.

Before we proceed to analyse its nature, let us take a closer look at some of the pronouncements on the subject in medical and nursing ethics and at some of the history behind the current emphasis on these notions.

2 Noble lies and therapeutic tricks

If the appearance of doing something be necessary to keep alive the hope and spirits of the patient, it should be of the most innocent character. One of the most successful physicians I have ever known, has assured me, that he used more bread pills, drops of coloured water, and powders...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Preface
• Acknowledgements
• 1 Truthfulness in medical and nursing practice
• 2 Noble lies and therapeutic tricks
• 3 Why truthfulness matters
• 4 What truthfulness requires
• 5 The teaching we need to preserve truthfulness
• 6 Doctors and nurses as ‘caring pragmatists’
• 7 Deceptions and concealments in medical and nursing practice
• 8 Dishonesty in medical research
• 9 Can doctors and nurses be ‘too honest’?
• 10 Truth and trust
• Notes
• Bibliography