Wednesday, November 14, 2012

Should Physicians Ever Lie?

Is it ever acceptable for a physician to lie to a patient?

So asks Theodore Dalrymple, in a meditation on whether physicians should always tell the truth to patients they believe to be terminally ill.

After reading Dalrymple and the excellent comments following his article, one can only conclude that the issue is too complex to warrant a simplistic solution.

Always telling the truth is just as much a moral mirage as always lying.

Dalrymple and several commentators note importantly that predictions about lifespan are just that: predictions. They are not facts.

As long as physicians are not executioners and are not God, they do not know how long you are going to live. If they tell you that you are going to die in six months they are claiming an authority that they do not have. They are not telling you the truth.

A physician can make an educated estimate based on similar cases, but an estimate, a likelihood or a probability is not a scientific fact. Too many physicians talk as though statistical probabilities are metaphysical certainties.

Dalrymple explains that his mother’s physician did not tell her what he considered to be the truth, on humane grounds:

My mother’s surgeon did not think my mother could bear the knowledge that she had an 80 percent chance of fatal recurrence of her cancer within a year, and she lived another nineteen years in ignorance of the fact (to say that it was blissful ignorance would be to put it too strongly).

We all believe that optimism promotes good mental and physical health. We understand that psychological factors can contribute to a patient’s recovery, even from a physical illness.

If a physician’s lie helps a patient to be optimistic about his illness, is it categorically wrong to shade the prognosis toward a better outcome than is statistically probable?

Of course, it matters how a physician words his opinion. A more experienced physician will introduce more nuances than will a younger one. The latter will tactlessly try to be straightforward and direct.

And then, most patients do not want to hear that they are going to die; they do not want to discuss it. They might be right to do so. It may be better for them to be optimistic. Perhaps it will improve their quality of life.

If patients do not want to know their prognosis, considerate physicians are obliged, out of respect, to spend more time discussing treatment options.

Dalrymple writes:

Research … suggests why patients may not hear, mark and inwardly digest what their oncologists say to them. On the whole oncologists do tell their mortally ill patients that they are dying; but, for very understandable reasons, they find the whole subject rather distasteful or embarrassing and move on to something else, namely what to do about it. 

As a rule, patients are far more optimistic about their chances for recovery or cure than the research would indicate. They believe in miracle cancer cures even when the latest treatment has only been shown to extend life for a few months.

Would they accept the treatment if they understood that treatment was going to make them extremely sick during those few months?

Here we are talking about risk/reward, not truth or falsehood.

Different physicians will express their opinions differently for different patients. The patients will hear what they want to hear, or better, will hear what serves their best interest. They will then make their own free choices.

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