Striking a Balance in Truth Telling
Michael McCabe
Issue 4, August 2001
The obligation of veracity is the obligation to tell the truth and not to lie or deceive others. Even though veracity is an essential part of the relationship between healthcare professionals and their patients, and an indispensable feature in establishing goals of care at the end of life, many codes of medical ethics frequently ignore rules of veracity and have little or nothing to say about deception and when or whether it is ever justified. The Hippocratic Oath, for example, does not mention this principle. [1] Ethicist, Sissela Bok, in her germinal book, "Lying; Moral Choice in Public and Private Life" suggests the reason why little is said about truth telling in codes of ethics is because, "reasons to lie occur to most people quite often. Not many stop to examine the choices confronting them; existing deceptive practices and competitive stresses can make it difficult not to conform. Guidance is hard to come by, and few are encouraged to consider such choices in schools and colleges or in their working life." [2] The principle of veracity and its allied virtue of truthfulness are expressions of the fundamental obligations contained in the primary principles of bioethics - respect for autonomy, justice, beneficence (to do the good) and non-maleficence (first do no harm).
Truth telling is a form of respect for the self as well as for others. This respect is commonly expressed through the principle of respect for autonomy, which forms the basis for rules of disclosure and consent. Unless a person is adequately informed, an act of consent cannot be an expression of autonomy. Informed consent depends on truthful communication.
From a bioethical perspective the duty of veracity is understood as flowing from the obligation of fidelity and promise keeping. When a patient-physician relationship is initiated, parties enter into a contract - the patient gains a special right to the truth from the physician, or healthcare professional, regarding diagnosis, procedures, prognosis, etc., while they, in turn, have a right to truthful disclosure from the patient. Lying, the act of "telling another person what one believes to be false in order to deceive that person", and inadequate or nondisclosure, fail to show respect for persons and their autonomy, violate implicit contracts, and also threaten relationships based on trust." [3] In the exploration of options and in the giving of truth, what is revealed, held back, or distorted, has a profound effect on the wellbeing of the patient. [4]
In aged care and in the care of the terminally ill a proper understanding of the obligation of veracity is essential if the goal of holistic care is to be achieved. Among other things this means a concentration on mere truth telling is inadequate. Knowing when to tell the truth is as important as knowing how to tell the truth. "Veracity refers to the comprehensiveness, accuracy, and objectivity with which information is handled, as well as the manner in which understanding is fostered in the relationship." [5]
The application of the principle of veracity requires the recognition of the "broad spectrum" nature of truth, and, equally, must seek to "meet" the patient at his or her point of need. The following are some principles which may assist both in meeting the needs of the patient at his or her point of need and also expand our understanding of the "broad spectrum" nature of truth.
- Explore all the options
A well-established obligation, and one that requires considerable energy in establishing goals of care at the end of life, is to disclose information on alternative options in treatment and care. In the care of the patient choices and possibilities abound regarding the exploration of options. It takes wisdom and skill to strike a balance between giving the patient adequate information and causing him or her unnecessary harm. While some patients are too sick to make the best choices for themselves, most can. This obligation applies just as much to the incompetent patient who has the right to have the options for holistic care explored with their family or caregiver.
- Truth telling is a process and must be initiated early.
To view care for the patient as a relationship based on respect and trust implies that the healthcare professional and patient must establish the process of truth telling early in the relationship. How such a process of dialogue begins and how it is maintained affects not only the mutual exploration of options but also the ending! An analysis of clinical cases, that have become full-blown ethics consults in healthcare institutions, frequently reveals a lack of adequate communication and truth telling between physician and patient. The process of truth telling can be disadvantaged by initially heightened expectations from both parties as well as by what has been said in the opening consultation. Because what has been heard by the patient can differ from what has been said, there is a need for reassurance and review to establish whether of not the patient has understood what has been said. It is helpful to remember that the way questions are framed can determine the answers and set the stage for later discussion.
- Rise above the family dynamic.
In establishing goals of care at the end of life, and in the care of the dying in particular, the ethical, psychosocial and spiritual elements of healthcare are interrelated. Nowhere is this more clearly seen than in the patient-family dynamic. Exploring all the options with the patient and his or her family may lead to significant conflict with family members, when the obligation to preserve confidentiality is in direct opposition with the duty of veracity. Conflict can also arise in a dysfunctional family where, even after due process and careful explanation, they are simply unable to give the dying family member emotional or practical support. Nevertheless, the sad reality of a dysfunctional family does not lessen the duty of veracity.
There may also be times when a family forbids the healthcare team to say anything at all to their family member when there is a poor prognosis. In their view the communication of such information to their family member equates to removing the patient's sense of hope. When the truth telling process is hindered, by these or similar dynamics, it can be difficult for the healthcare professional to maintain integrity. In striving to rise above the patient/family dynamic, it is helpful for the healthcare professional to recall that the end of life becomes a point of focus for the family and their narrative. Even the most trusted healer only sees a snapshot of that particular narrative. This fact is frequently born out in ethical case review when previously undisclosed information can be introduced to the healthcare team.
- Tell the truth with sensitivity
While the truth may be "brutal" the telling of it should not be. An indispensable factor in veracity, is telling the truth sensitively, as Emily Dickinson beautifully expresses in her poem:
Tell all the Truth but tell it slant
Success in Circuit lies
Too bright for our infirm Delight
The Truth's superb surprise
As Lightning to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind
Physician Brian Pollard argues that, while deception "should play no part in the doctor's dealings" with the terminally ill, this "is not the same as always telling the full truth or telling the truth in an insensitive way." Individuals vary in their needs. That is why truth telling must meet the patient's need at that particular time and according to his or her circumstances. Facts that are irrelevant for this particular patient may be withheld. "For some, this will be the full truth, if that is what is asked for, while for another, it may be a graded offering of truth which never approaches full disclosure, if that would not be welcome. The cue as to how far one should go will usually be obtained from the patient, if the signs are looked for, as one feels the way gently ahead." [6]
- Begin with cues from the patient.
The wonderful medieval maxim, "that which is received is received according to the mind [or mode] of the receiver", reinforces the need for the healthcare professional to begin with cues from the patient. Allowing them to talk and express their concerns helps to nurture a relationship of trust in which the truth can be expressed. In giving relevant information to a patient there is a need to repeat and to reassure in order to enhance the possibilities of understanding. Here the family or caregiver can help. Obviously, the constraints of time and caseload are realities for the healthcare professional and it is not always possible to develop a conversation with the patient at every visit. Nevertheless, the short-term time gains of ignorance are far outweighed by the long-term benefits of knowledge.
- Recognize the "truth-telling" windows.
Just as a skilled clinician is able to recognise a therapeutic "window of opportunity", in providing care for a critically ill patient, so a wise healthcare professional is able to recognise the window of opportunity in communicating truthfully with the patient. Most competent patients give significant opportunities for this to occur over time. For example, when a patient makes a comment such as, 'I'm scared', or 'I'm afraid', or 'I'm worried about my family', etc. These moments can become moments of breakthrough in the establishing and communication of effective goals of care for the patient at the end of life. As with the administration of effective palliative care, the communication of truth must be "titrated" proportionately, according to emotional and intellectual capability of patient and his or her family/caregiver. If the relationship of trust has not been adequately nurtured then the ability to recognise the "truth telling" window will be diminished.
- People can cope with knowledge.
To commit the dying patient to a world of silence, for whatever reason, is to compound his or her suffering. In Leo Tolstoy's classic, The Death of Ivan Ilych, Ivan Ilych laments the loneliness he feels in having knowledge that he is unable to share. "The deception tortured him – their not wishing to admit what they all knew and what he knew, but wanting to lie to him concerning his terrible condition, and wishing and forcing him to participate in that lie. Those lies – lies enacted over him on the eve of his death and destined to degrade this awful, solemn act to the level of their visitings, their curtains, their sturgeon for dinner – were a terrible agony for Ivan Ilych."
- Truth telling is influenced by cultural and institutional values.
Closely related to the family dynamic are cultural and institutional values, which also influence the process of truth telling. For example, the cultural value that "anything is possible" does not always provide fertile ground for coming to terms with the reality of limits and the ultimate reality of mortality and death. Similarly, a strong emphasis on curative treatment to the detriment of palliative or holistic care can limit the opportunities for healing and truth telling.
Truth telling is qualitatively different from other aspects of the patient healthcare professional relationship. Truth telling can rarely, if ever, be achieved in professional isolation. Neither can it be established in fleeting encounters with patient and family. It must be cultivated and supported by the healthcare institution whose role is to nurture a moral culture of listening and compassion through the promotion of values that enhance truth telling.
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[1] Tom Beauchamp and James Childress, Principles of Biomedical Ethics, New York: Oxford University Press, 1989: 307.
[2] Sissela Bok, Lying; Moral Choice in Public and Private Life, New York: Vintage Books. 1978:xviii.
[3] Beauchamp and Childress, 308-309.
[4] Sissela Bok, 234-240.
[5] Beauchamp and Childress, 310.
[6] Brian Pollard, Euthanasia: Should We Kill the Dying? Bedford: Mount Series Print, 1989:11-12.
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Rev Michael McCabe PhD
Director
The Nathaniel Centre
©
2001