Part One: In Defense of Medicine
Chapter VI. Speaking the Truth
"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)
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 no harm; and it has always been obvious to us that suffering could be inflicted and harm done not only with ill-performed procedures, or ill-judged prescriptions, but also with imprudent words. And we tried not to frighten, depress, or traumatize the patients by choice of words, tone of voice, facial expression, or body language. When it was necessary to break bad news, we would also point out some good aspect of the situation, a chance of improvement, or something that could be done, even if it was the hope that a lesser complaint could be relieved: "THE PATIENT MAY LOSE HIS LIFE, BUT NEVER HOPE." This old clinical proverb is not cynical. It reminds us of our ultimate powerlessness; and that we should be supportive to the very end.
The traditional way of informing patients had its shortcomings. Not only the bioethicists but also some medical practitioners voiced criticism. These doctors argued that while most patients in declining health avidly accepted words of promise and hope, others became critical and ultimately distrusted the doctor. Further, unbearable tension and falsity could be created between the family members who knew, and the hopelessly ill person, who did not. Some doctors also admitted that there might be a mixed motivation behind the policy of not informing the patient of his demise. Doctors who pursue such a policy in order to protect the patient soon discover that it is also protecting themselves. It allows the doctor to avoid the painful difficulty of speaking to the patient on the subject of his death and facing him afterwards.
The debate might have led to an improved manner of informing the patients, (66) but was solved in the least appropriate way, by court rulings.
The Lethal Avalanche. Whatever the weaknesses of the traditional way of informing patients, it did promote doctors' good qualities: caution and gentleness.
The information revolution produced the opposite effect. The intellectual mediocrities and the emotionally unstable individuals in the medical profession started to assail the patients and the families with cruel, thoughtless, and often erroneous information. The court rulings that only "material" information should be disclosed, (67) and that patients had the right to waive information, (68) have been sweepingly disregarded. There has been no reckoning with the obvious fact that patients belonging to certain ethnic and cultural groups did not want and could not tolerate medical death sentences.
The new manner of informing the patients has quickly spread throughout English-speaking countries and is even making inroads in Central Europe and the Mediterranean. In Holland, prof. Jongkees, the long-time editor of The Netherlands Journal of Medicine, published an article warning against the medical explosion of verbal cruelty. (69) In one of the cases he cited, the patient recovering after a serious operation received a special visit from a doctor in whose opinion the surgeon in charge had not provided the patient with sufficient information. He explained to the patient that his condition was much worse than he thought, and, in fact, hopeless. "A couple of days later the patient died of a massive myocardial infarction," wrote Jongkees; and added: "I don't want to say that this was directly caused by that truth-loving doctor's words." (70)
I had just twice defibrillated a young woman with a myocardial infarction, and no sooner had she opened her eyes than a nurse hastened to tell her: "Madam, in the last few minutes you died twice." I know a young woman who went to her family physician because of a low-abdominal pain and immediately heard from him that "this could be cancer." Two weeks later this was determined not to be cancer, but the patient had not slept one night in the meantime, and had already bid farewell to her friends, and to life. People diagnosed with cancer not only must hear about the metastases that have been found, but also about those which might appear in the future: in the spine, the heart, the brain! With good reason Jongkees queried the real motive of "speaking the truth": honesty or sadism? (71)
He forgot to mention stupidity. When someone in my family was diagnosed with multiple myeloma (a bone marrow malignancy), professor B at a hospital in Geneva limited himself to stating, "Vous etes incurable," but the associate professor, Dr. S, said to the patient: "Oh, how I pity you! You'll be dying in infernal pain." The horrible pains somehow failed to appear, but after receiving that information the patient attempted suicide twice.
And what if the "truth" the patient has been told proves untrue? In a university hospital in Holland, I witnessed a conversation between a young doctor and a female patient who, despite the implantation of two prosthetic heart valves, wasn't doing well, and moreover, had a complication of anesthesia: a tracheal narrowing due to intubation. Weeping, the patient told the doctor that she would not be able to withstand another procedure as painful as the one that day (an attempt to widen the trachea). "Oh yes you will,"...