TRUTH TELLING

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Truth telling (veracity) is a key factor in the relationship
between patients, their families and health professionals.

The Oxford dictionary defines truth as: a quality or state

of being true, genuine, loyal, faithful; in accordance with
fact or reality, exact, accurate.

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 TRUTH TELLING AND ETHICS
As a matter of both ethics and law, physicians have a duty to disclose to
patients information about their diagnoses, prognosis, and the risks and
benefits of any proposed therapies.
In making these disclosures, the ethical principle of beneficence suggests
that physicians should disclose information in a way that benefits and
does not harm patients.
Some commentators believe that in some cases physicians should
withhold certain information from patients because full disclosure would
be devastating to them. They believe this is required by the principle of
beneficence as well.
Furthermore, there are some cultural norms that counsel restraint in
disclosing medical information to patients in all cases. These non-
disclosures are ethically and legally problematic.

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 Do patients want to know the truth
about their condition?
Contrary to what many physicians have thought in the past, a
number of studies have demonstrated that patients do want
their physicians to tell them the truth about diagnosis,
prognosis, and therapy.
For instance, 90% of patients surveyed said they would want
to be told of a diagnosis of cancer or Alzheimer's disease.
Similarly, a number of studies of physician attitudes reveal
support for truthful disclosure.
For example, whereas in 1961 only 10% of physicians
surveyed believed it was correct to tell a patient of a fatal
cancer diagnosis, by 1979 97% felt that such disclosure was
correct.

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 How much do patients need to be
told?
In addition to fostering trust and demonstrating respect, giving patients
truthful information helps them to become informed participants in
important health care decision.
Thus, patients should be told all relevant aspects of their illness, including
the nature of the illness itself, expected outcomes with a reasonable range
of treatment alternatives, risks and benefits of treatment, and other
information deemed relevant to that patient's personal values and needs.
Treatment alternatives that are not medically indicated or appropriate
need not be revealed. Facts that are not important to the patients ability
to be an informed participant in decision making, such as results of
specific lab tests, need not be told to the patient.
Also, complete and truthful disclosure need not be brutal; appropriate
sensitivity to the patient's ability to digest complicated or bad news is
important.

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 What if the truth could be harmful?

There are many physicians who worry about the

harmful effects of disclosing too much
information to patients.
Assuming that such disclosure is done with
appropriate sensitivity and tact, there is little
empirical evidence to support such a fear.
If the physician has some compelling reason to
think that disclosure would create a real and
predictable harmful effect on the patient, it may
be justified to withhold truthful information.
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What if the patient's family asks me to
withhold the truth from the patient?
Often families will ask the physician to withhold a terminal or serious
diagnosis or prognosis from the patient. Usually, the family's motive is
laudable; they want to spare their loved one the potentially painful
experience of hearing difficult or painful facts.
These fears are usually unfounded, and a thoughtful discussion with
family members, for instance reassuring them that disclosure will be
done sensitively, will help allay these concerns.
In unusual situations, family members may reveal something about
the patient that causes the physician to worry that truthful disclosure
may create real and predictable harm, in which case withholding may
be appropriate. These occasions, however, are rare.

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 When is it justified for me to withhold
the truth from a patient?
There are two main situations in which it is justified to withhold the truth
from a patient. If the physicians has compelling evidence that disclosure
will cause real and predictable harm, truthful disclosure may be withheld.
Examples might include disclosure that would make a depressed patient
actively suicidal. This judgment, often referred to as the "therapeutic
privilege," is important but also subject to abuse. Hence it is important to
invoke this only in those instances when the harm seems very likely, not
merely hypothetical.
The second circumstance is if the patient him- or herself states an
informed preference not to be told the truth. Some patients might ask
that the physician instead consult family members, for instance. In these
cases, it is critical that the patient give thought to the implications of
abdicating their role in decision making. If they chose to make an informed
decision not to be informed, however, this preference should be
respected.

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 What about patients with different
specific religious or cultural beliefs??

Patient with certain religious belief or ethnic

or cultural backgrounds may have different views on
the appropriateness of truthful disclosure.

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 Is it justifiable to deceive a patient
with a placebo?
A placebo is any substance given to a patient with the knowledge
that it has no specific clinical effect, yet with the suggestion to the
patient that it will provide some benefit. The placebo effect is
powerful, in many cases providing measurable improvement in
symptoms in 20-30% of patients.
In general, the deceptive use of placebos is not ethically justifiable.
Specific exceptions should be rare and only considered if the
following conditions are present:

the condition is known to have a high placebo response rate

the alternatives are ineffective and/or risky
the patient has a strong need for some prescription

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 Case for Discussion : Keeping Secrets
from Patients
Dr. Michael Tenant has just read the lab
reports that confirm that 82-year-old Mrs.
Rose Schultheiss, who is currently
hospitalized, has severe heart and kidney
disease. In all likelihood, she has only a short
time left to live. As grave as her condition is,
she is conscious and lucid. She is extremely
frail and weak, but she does show an interest
in understanding what's wrong with her.
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 Case for Discussion(cont..)
Her daughter, Peggy, is at the hospital most of the time. The
two of them share a two-flat on the south side of the city.
Mrs. Schultheiss's son, who lives in Los Angeles, has come to
stay with his sister to help out. Because he is retired, he plans
to stay as long as necessary. Peter Schultheiss has, however,
cautioned Dr. Tenant against giving his mother any upsetting
information. He says I would rather see her slip away than to
see her worry about her condition. Dr. Tenant hopes to Mrs.
Schultheiss alone. He plans to ask her some indirect questions
and get a sense of how much she wants to know about her
medical condition. When he goes into her room, however,
Mrs. Schultheiss is asleep, and both Peggy and Peter are
there.

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 Case for Discussion(cont..)
Dr. Schultheiss motions the brother and sister into the hall
and explains that their mother has only a very short time left.
That's what I came to talk to her about. Oh, no," Peter says,
"you can't tell her anything like that. I know she would just
collapse if you told her that. Why can't we just say nothing?"
Dr. Tenant asks Peggy what she thinks. I think information
like that would hurt her, but I'm not sure. In that case,
Peter says, "the matter is settled. We cant tell her.

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 Case for Discussion(cont..)
What is the patient entitled to know about her diagnoses,
prognoses, and treatment options in this case?
Do the children present a compelling argument for overriding
the entitlement Mrs. Schultheiss has to information about her
medical condition?
If both the Schultheiss children remain opposed to their
mother being told she is very near death, should Dr. Tenant
honor their wishes? If so, what should he tell the dying
woman? If not, should Dr. Tenant mention to Mrs. Schultheiss
that her children wished the matter kept from here?

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