Friday, 8 November 2013

Geoff Mckay - Truth Telling

Definition:  Truth-telling, or veracity, can be defined as the avoidance of lying, deception, misrepresentation, and non-disclosure in interactions with patients or relevant to patient care.

Seems simple – why is it a big deal?

Being honest with patients about their diagnoses is a relatively new addition to the ethics of health care. Until recently, doctors often avoided telling patients the full extent of serious diagnoses, particularly when there were limited treatment options. In addition, in some cultures, it is customary to hide a serious diagnosis from the patient for fear that he or she will lose hope or become demoralized by the information.

Truth-telling also involves being forthright about medical errors. Many ethicists argue that the primary physician and observing members of a medical team all have an obligation to report errors not only to oversight committees but directly to the affected patient. This is not always easy to do - particularly when the mistakes harm patients and their families, when it is not obvious that telling the patient will improve the situation, and when the stakes for admitting errors are high. However, physicians have an obligation to report errors and to support colleagues who do so. Only then is it possible to recognize errors when they occur and to develop systems for avoiding the problems in the future.

Why is it so essential to avoid misrepresentation and nondisclosure of information?

Prima facie wrong: lying is viewed as an inherent wrong—something that we naturally consider unethical.

Barrier to Patient Autonomy and Informed Consent: it is inappropriate for a doctor to lie because it precludes the patient from making an informed decision and providing informed consent, thereby trampling over the patient’s autonomy.  If the doctor provides improper or insufficient information, the patient will not possess adequate information to make the most personally meaningful decision.            

Destroys patients trust: If the doctor lies to the patient and the patient later finds out about the betrayal, the patient will be less likely to trust the physician in the future.  This destroys the foundation of an effective patient-physician relationship, in which the patient trusts the doctor to provide appropriate information regarding diagnosis, prognosis, and treatment.  Accordingly, if one patient tells another patient about his/her experiences with mistrust, then this may lead to a slippery slope in which other patients may subsequently mistrust their physicians, leading to countless shaky patient-physician relationships.

Most patients want to know: According to one survey, 94% of patients said they “would want to know everything” about their medical condition, “even if unfavorable.”  Even more patients wanted to know about a diagnosis of cancer.  Therefore, it is inaccurate for doctors to think that their patients want to be spared the bad news.

Lying is impractical: One lie will naturally lead to another, creating a web of deceit.  Furthermore, other members of the healthcare team may notify the patient at some point during the course of illness, leading to the patient’s resentment at not having received the information directly from the physician in the first place.

What happens if a family member declares that the patient should not receive any information about the diagnosis, perhaps due to cultural reasons?

Although a family member may wish to uphold the cultural values of protecting the patient from bad news, the doctor must ensure that these wishes also reflect those of the patient.  Therefore, the doctor must explicitly ask the patient how he/she wishes to receive the information, if at all.  It is important to confirm the family member’s request with the patient in order to uphold patient autonomy—after all, there may be some cases in which the patient still chooses to receive the information, regardless of the family member’s request.

Are there any exceptions to truth-telling?

One exception involves the patient who directly tells the physician that he/she does not want to receive any information regarding his/her diagnosis.  In this case, it is ethical to withhold information because the patient does not wish to receive it, thereby upholding patient autonomy, or free will to decide.  One must never assume that the patient prefers nondisclosure, but rather one must ascertain these wishes through direct conversation with the patient.  This can be achieved by asking the patient how he/she wishes to receive the information before the test results even arrive, thereby allowing both the patient and physician to plan the logistics of breaking possible bad news ahead of time.

Another exception involves a mentally unstable patient who may put himself/herself in harms way after receiving the bad news.  In this example, a doctor may be justified in delaying the disclosure of information until after the patient’s mental health improves and/or the patient possesses appropriate psychiatric backup.

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