Mack Lipkin, "On Telling Patients the Truth"
from Newsweek, 4 June 1979, p. 13.
Reprinted in Intervention and Reflection: Basic Issues in Medical Ethics. 5th ed. ed. Ronald Munson (Belmont; Wadsworth 1996). pp 288-290. (notes omitted)
Should a doctor always tell his patients the truth? In recent years there has been an extraordinary increase in public discussion of the ethical problems involved in this question. But little has been heard from physicians themselves. I believe that gaps in understanding the complex interactions between doctors and patients have led many laymen astray in this debate.
It is easy to make an attractive case for always telling patients the truth. But as L. J. Henderson, the great Harvard physiologist-philosopher of decades ago, commented:
To speak of telling the truth, the whole truth and nothing but the truth to a patient is absurd. Like absurdity in mathematics, it is absurd simply because it is impossible.... The notion that the truth, the whole truth, and nothing but the truth can be conveyed to the patient is a good specimen of that class of fallacies called by Whitehead "the fallacy of misplaced concreteness." It results from neglecting factors that cannot be excluded from the concrete situation and that are of an order of magnitude and relevancy that make it imperative to consider them. Of course, another fallacy is also often involved, the belief that diagnosis and prognosis are more certain than they are. But that is another question.
Words, especially medical terms, inevitably carry different implications for different people. When these words are said in the presence of anxiety-laden illness, there is a strong tendency to hear selectively and with emphases not intended by the doctor. Thus, what the doctor means to convey is obscured.
Indeed, thoughtful physicians know that transmittal of accurate information to patients is often impossible. Patients rarely know how the body functions in health and disease, but instead have inaccurate ideas of what is going on; this hampers the attempts to "tell the truth."
Take cancer, for example. Patients seldom know that while some cancers are rapidly fatal, others never amount to much; some have a cure rate of 99 percent, others less than 1 percent; a cancer may grow rapidly for months and then stop growing for years; may remain localized for years or spread all over the body almost from the beginning; some can be arrested for long periods of time, others not. Thus, one patient thinks of cancer as curable, the next thinks it means certain death.
How many patients understand that "heart trouble" may refer to literally hundreds of different abnormalities ranging in severity from the trivial to the instantly fatal? How many know that the term "arthritis" may refer to dozens of different types of joint involvement? "Arthritis" may raise a vision of the appalling disease that made Aunt Eulalee a helpless invalid until her death years later; the next patient remembers Grandpa grumbling about the damned arthritis as he got up from his chair. Unfortunately but understandably, most people's ideas about the implications of medical terms are based on what they have heard about a few cases.
The news of serious illness drives some patients to irrational and destructive behavior; others handle it sensibly. A distinguished philosopher forestalled my telling him about his cancer by saying, "I want to know the truth. The only thing I couldn't take and wouldn't want to know about is cancer." For two years he had watched his mother die slowly of a painful form of cancer. Several of my physician patients have indicated they would not want to know if they had a fatal illness.
Most patients should be told "the truth" to the extent that they can comprehend it. Indeed, most doctors, like most other people, are uncomfortable with lies. Good physicians, aware that some may be badly damaged by being told more than they want or need to know, can usually ascertain the patient's preference and needs.
Discussions about lying often center about the use of placebos. In medical usage, a "placebo" is a treatment that has no specific physical or chemical action on the condition being treated, but is given to affect symptoms by a psychologic mechanism, rather than a purely physical one. Ethicists believe that placebos necessarily involve a partial or complete deception by the doctor, since the patient is allowed to believe that the treatment has a specific effect. They seem unaware that placebos, far from being inert (except in the rigid pharmacological sense), are among the most powerful agents known to medicine.
Placebos are a form of suggestion, which is a direct or indirect presentation of an idea, followed by an uncritical, i.e., not thought-out, acceptance. Those who have studied suggestion or looked at medical history know its almost unbelievable potency; it is involved to a greater or lesser extent in the treatment of every conscious patient. It can induce or remove almost any kind of feeling or thought. It can strengthen the weak or paralyze the strong; transform sleeping, feeding, or sexual patterns; remove or induce a vast array of symptoms; mimic or abolish the effect of very powerful drugs. It can alter the function of most organs. It can cause illness or a great sense of well-being. It can kill. In fact, doctors often add a measure of suggestion when they prescribe even potent medications for those who also need psychologic support. Like all potent agents, its proper use requires judgment based on experience and skill.
Communication between physician and the apprehensive and often confused patient is delicate and uncertain. Honesty should be evaluated not only in terms of a slavish devotion to language often misinterpreted by the patient, but also in terms of intent. The crucial question is whether the deception was intended to benefit the patient or the doctor.
Physicians, like most people, hope to see good results and are disappointed when patients do poorly. Their reputations and their livelihood depend on doing effective work; purely selfish reasons would dictate they do their best for their patients. Most important, all good physicians have a deep sense of responsibility toward those who have entrusted their welfare to them.
As I have explained, it is usually a practical impossibility to tell patients "the whole truth." Moreover, often enough, the ethics of the situation, the true moral responsibility, may demand that the naked facts not be revealed. The now popular complaint that doctors are too authoritarian is misguided more often than not. Some patients who insist on exercising their right to know may be doing themselves a disservice.
Judgment is often difficult and uncertain. Simplistic assertions about telling the truth may not be helpful to patients or physicians in times of trouble.