Chapter VI: speaking the truth.

AuthorFenigsen, Richard
PositionOther People's Lives: Reflections on Medicine, Ethics, and Euthanasia

"Falsehood is in itself bad and reprehensible," states Aristotle in The Nicomachean Ethics, "while the truth is a fine and praiseworthy thing." (55) He does not say why. There seem to be important reasons to respect and value the truth. We need some amount of truthful knowledge of the world to move around and perform our tasks (though we mostly achieve these goals with a mixture of truth, error, ignorance, emotional drive, and automatism, in varying proportions). We should respect the truth as the quest of everyone's mind. (56) And we should value it for its concordance with the state and course of the universe, its "beauty," as Einstein would have it.

But assuming that we sometimes know the truth, should we always tell it? Instances in which we shouldn't come to mind as soon as this question is posed. It may be a morally laudable and heroic act not to reveal the truth, as when a captive of the Gestapo refused under torture to name the members of an underground organization. Priests, lawyers, and doctors must not divulge what they have learned in the confessional or office. It is a bad employee who informs competitors of his firm's trade secrets. We do not approach a person to tell him we don't like his looks. Thus, we do not tell the truth if by doing so we would damage values which we place higher than veracity. In the language of W. D. Ross's philosophy, telling the truth may be our "prima facie duty," but not necessarily our "duty proper." (57)

Should We Tell The Patient That He Is Dying? (58)

The word Truth stands in the center of your emblem. But there is something more important than Truth: It is Life. (59) Rabbi Adin Steinsaltz

In the 1960-1970s the traditional doctor/patient relationship and method of informing patients about their medical condition came under assault. Philosophers, theologians, some patients, and the courts rose against medical deceit and asserted the patients' right to be correctly and fully informed of their diagnosis, prognosis, treatment alternatives, and/or imminent death. A doctor owed his patient the truth, they said, because, in the spirit of Kantian ethics, he should respect the patient as an autonomous rational being, (60) and provide him with truthful information needed to make rational decisions. The fiduciary relationship required that the patients' trust be rewarded with truthful information. (61) Patients were entitled to knowing the truth not so much because it concerned their own bodies, but because it concerned their own lives. (62) Not doctors, but patients and the courts should determine the extent of information patients received. (63) Dying persons needed to know the truth in order to settle family and money matters. (64) Informing the patient of his imminent death would induce him to renounce expensive treatments, thereby limiting the costs of health care and helping the national economy. (65)

There have been, and still are, strong arguments in favor of the traditional way of giving information, though it follows the principle of beneficence rather than autonomy Informing patients is part of medical practice and is, therefore, subject to the rule of doing no harm. Not only the tissues of a patient's body, but also his psyche, should be handled with care. Diagnoses are fallible and prognoses notoriously unreliable, thus, part of the information given to patients is bound to prove untrue: one more reason to restrain it. And the traditional medical rule of never taking away hope is based on the knowledge of wishes and reactions of patients who are gravely ill, i.e., the very group concerned.

Some people know they are dying. When a patient does not know that, that is, still believes he will live, I won't tell him he will soon die. For one thing, doctors can seldom predict that with certainty. But, most importantly, why should I kill his spirit while he is living? Why should I inflict such pain? I am a doctor and everything I do must be aimed at relieving suffering. I must have no other business. I should never do the opposite.

Important matters may be involved: the future of the family, decisions concerning money. But in my mind, medical considerations must prevail over all others. If I am not faithful to this principle, I have no business being a doctor.

I belong to the generation of physicians who used to be very cautious while talking to patients. Experience taught us that the more we talked, the worse were the misunderstandings: not because of the patients' lack of medical knowledge, but because of their anxiety. Hence the old clinical adage: "SAY ONLY WHAT IS ABSOLUTELY NECESSARY." It has been attributed to Hippocrates, but I could not find it in his writings. Whoever the author, I know the advice is sound.

We used to be very earnest and literal in observing the injunction "PRIMUM NON NOCERE," first of all, do...

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