Lies, Damned Lies, and Medical Ethics ~ by Jay

About six months after I finished residency, one of my patients told me she'd had an odd sensation in her arm. Her first child was about six months old; she was tired and overwhelmed, and she had these strange symptoms. I thought "oh, this is stress and fatigue", and then I checked her strength, and that arm was weaker. Hmm. So I sent her for an MRI, which in those days and that system took about three weeks, and the report arrived on my desk - multiple sclerosis. I remember sitting there staring at that piece of paper, crying, wondering how on earth I was going to break this news.  I called my father, who said "Well, do you have to tell her?"

It takes a lot to make me speechless, but that did it. He went on to say that the symptoms would probably resolve and might never recur, and there was nothing to do about it anyway (which in 1989 was unfortunately true) and would it really do her any good to know? I finally said "Dad, I HAVE to tell her. I can't lie". And he said well, do what you think is best, sweetheart.

About a year before Dad died, I asked him about that conversation. He looked at me, horrified. "Did I actually say that?" Yes, Daddy, you did. "Well, I was completely wrong". Yeah, I know that, and I can't figure out what you were thinking. "I don't know for sure, honey, but all I can imagine is that I wanted so badly to spare you the pain of telling her that I said the first thing that came into my mind. You're too good a doctor, though, to have listened to me".

I thought of my father last week when I read this, from Arthur Caplan, commenting on this study in the journal Health Affairs.  The study's authors summarize their findings:

...one-third of physicians did not completely agree with disclosing serious medical errors to patients, almost one-fifth did not completely agree that physicians should never tell a patient something untrue, and nearly two-fifths did not completely agree that they should disclose their financial relationships with drug and device companies to patients. Just over one-tenth said they had told patients something untrue in the previous year.

And Arthur Caplan, one of the leading bioethicists in the country, says "So what"? To be fair, he does not think we should lie about medical errors, but not because it's the right thing to do - because it's the safest thing to do.

It is inexcusable and not advisable to lie about an error. You may dodge a bullet on that one by having the patient not find out, but if it really affects their care, if they wind up harmed, if they wind up having to pay more and it comes out later that you didn't tell the truth or that there was an omission of the fact that an error occurred, you are going to get clobbered. I have seen it again and again in courtrooms. It may seem the easiest way out, to avoid telling the truth when an error takes place, but getting it out there and getting it over with early is the best protection in terms of malpractice associated with error.

Conflicts of interest? Well, you probably shouldn't lie, but patients don't care about that stuff, anyway.

You can simply offer the patient the opportunity to know that you see a lot of drug representatives or that you went out to dinner and learned about this drug, and they probably will say, "Doctor, I don't care. What do you think is the right thing for me to do?" Making the offer is a better way to deal with something that a lot of patients don't think is all that important.

Perhaps if we disclosed the impact that the dinner, the drug rep and the samples have on the costs of medication, the patients might care. Just - maybe.

And that business about being honest about prognosis and information?

It is not as clear that lying is always bad. Think about the use of a placebo. If you think that you can save a patient money and save them a lot of risk and side effects by giving them a placebo to see if it will calm their anxiety or help restore their sexual function, I am not sure that it is always wrong to prescribe a placebo. It is controversial, but I am not sure one is always wrong in trying to deal with a difficult or noncompliant patient, or one who has a bad, unhealthy lifestyle.

Gee, do you suppose that being lied to by doctors might make someone a difficult or non-compliant patient? Caplan goes on

Is it wrong to "up the ante" a little bit and scare the patient more than you might otherwise about the consequences that might follow from their bad behavior? I am not sure that that is wrong either. The goal is good, and by being a little bit on the far end of the truth about what could happen to them, I am not sure that it isn't worth it. With respect to the "rosy prognosis," if someone has cancer or Parkinson disease or Alzheimer disease, I'm not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics.

 So...the ends justify the means. Wonderful. I'm not always sure what patients want to hear, either, but there's this amazing, revolutionary thing I do: I ask them. And if they are feeling overwhelmed and don't want to talk any more, I stop - but I don't paint a "rosy" picture.

Look, I'm quite sure that most physicians who answered the prognosis question with "disagree somewhat" do know that it's wrong to lie to patients, and they find themselves withholding information or avoiding questions more often than flat-out speaking falsehoods. And I do understand that it's deeply, desperately hard to actually tell people they have Alzheimer's or cancer or diabetes. Docs are not trained to do this, and we have woefully little support to deal our own emotional responses to those encounters, let alone the emotions of our patients. But the answer to that isn't to condone lying, or collude in withholding - it's to learn to do this better, and to take care of ourselves so that we can take care of our patients. We must stand firm about this, because our ability to behave as professionals is under attack.

It's not enough that my colleagues - and at least one of our leading ethicists - shrug at lying; now we have politicians telling us we should lie to patients - specifically to women - in order to control their behavior. Legislators have been meddling in medical practice for years, since silly women can't be trusted to do what's best, and colluding, evil doctors can't be trusted to guide them because we're in it for the money (but drug companies and their representatives are, of course, beyond reproach, because they're in it for - what? the public good? I'm confused). Now that political meddling has reached a point that leaves me breathless with fury: we are told to violate one of the basic precepts of professionalism in order to prevent a woman from choosing a legal and medically indicated procedure. We will abrogate the trust of our patients, and set ourselves us as agents of the state, acting against the best wishes of women who are already desperate and who need us to live up to our values.

First, do no harm. We recite that in unison, faces shining and futures bright, as we hold our new diplomas in our hand at our medical school graduations. First, do no harm. Few things are as damaging to relationships as lying. I'm a doctor, dammit. That should mean something. That has to mean something. If it doesn't - if we accept the shrugs, and the "so what", and the imposition of state-sanctioned dishonesty, than we are not good enough doctors. We are not the doctors my father thought we should be, and we should be ashamed of ourselves.