Transcript Truth-telling in Medicine

Truth-telling
in Medicine
Medical Humanities IV
Prof. Marija Definis-Gojanovic
2014-2015
Introduction
Should physicians not tell the truth to patients in
order to relieve their fears and anxieties?
Not telling the truth may take many forms, has many
purposes, and leads to many different
consequences.
Questions about truth and untruth in fact pervade all
human communication. In each context, the
questions are somewhat differently configured.
Introduction
Not telling the truth in the doctor-patient relationship
requires special attention because patients
today, more than ever, experience serious harm
if they are lied to.
Besides harming a patient's autonomy, patients
themselves are harmed, and so are the doctors,
the medical profession, and the whole society
which depends on humane and trustworthy
medicine.
Kant’s categorial imperative
doctrine
Kant argued for truth and the strict rejection of all lying truth telling is a duty (imperative) which binds
unconditionally (categorical).
A lie is always evil because it harms human discourse
and the dignity of every human person.
Truth telling is always a duty, whether the other has the
right to know or whether innocent persons will be
severly harmed.
Conclusion
Truth obviously is an essential moral good.
But, what if truth comes into conflict with other
essential moral goods like life itself, or
beneficence, or freedom?
Can a lie be justified if it saves a human life or a
community, or if another great evil is avoided?
Were Augustine and Kant right when they
admitted of no exceptions to the duty to tell the
truth?
Diversity
After a survey of 800 seniors from four different ethnic
groups showed that Korean-American and MexicanAmerican subjects were much less likely than their
European-American and African-American counterparts to
believe that a patient should be told the truth about the
diagnosis and prognosis of a terminal illness.
European-American and African-American respondents
were more likely to view truth-telling as empowering,
enabling the patient to make choices, while the KoreanAmerican and Mexican-American respondents were more
likely to see the truth-telling as cruel, and even harmful, to
the patients.
Further differences were noted in how the truth should be
told and even in definitions of what constitutes “truth” and
“telling”.
Traditional approaches to truth
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NO general duty to disclose
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Truth as medicine; bad news can be harmful or fatal
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Subsumed under general duty of beneficence or “do
no harm” (nonmaleficence)
Traditional approaches to truth
Objective, quantitative, scientific truth is abstract and
yet it is not alien to the clinical setting.
A clinical judgment is different from a laboratory
judgment, and the same is true of clinical and
abstract truth (clinical truth strives to address a
patient's inquiries without causing the patient
unnecessary harm).
Clinical/moral truth is contextual, circumstantial,
personal, engaged, and related both to
objective/abstract truth and to the clinical values of
beneficence and non-maleficence.
“Truth-dumping”
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Violation of beneficence-- usually perceived by
patient as cruel and uncaring
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Violation of autonomy?
– Does cruel disclosure make patient a better (freer)
decision-maker?
– Does patient get a voice in how truth is told?
Truthful disclosure vs lying in a clinical context
Lying in a clinical context is wrong for many reasons
(patient is depressed and irrational and suicidal, is
overly pessimistic)
Doctors can do as much harm by cold and crude truthtelling as they can by cold and cruel withholding of
the truth.
To tell the truth in the clinical context requires
compassion, intelligence, sensitivity, and a
commitment to staying with the patient after the truth
has been revealed.
A SIX-STEP STRATEGY FOR
BREAKING BAD NEWS (SPIKES)
STEP 1: S—SETTING UP the Interview
- Arrange for some privacy.
- Involve significant others.
- Sit down.
- Make connection with the patient.
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- Manage time constraints and interruptions.
A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.
STEP 2: P—assessing the patient’s PERCEPTION
- You implement the axiom “before you tell, ask” - the
clinician uses open-ended questions to create a
reasonably accurate picture of how the patient perceives
the medical situation—what it is and whether it is serious
or not (e.g., “What have you been told about your medical
situation so far?)
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A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.
STEP 3: I—obtaining the patient’s
INVITATION
- While a majority of patients express a desire for full
information about their diagnosis, prognosis, and details
of their illness, some patients do not.
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A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.
STEP 4: K—giving KNOWLEDGE and
Information to the patient
- Start at the level of comprehension and vocabulary of the
patient
- Try to use nontechnical words
- Avoid excessive bluntness
- Give information in small chunks and check periodically as
to the patient’s understanding
- When the prognosis is poor, avoid using phrases such as
“There is nothing more we can do for you.”
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A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.
STEP 5: E—addressing the patient’s
EMOTIONS with emphatic responses
- Patients’ emotional reactions may vary from
silence to disbelief, crying, denial, or anger.
- When patients get bad news their emotional
reaction is often an expression of shock,
isolation, and grief.
- In this situation the physician can offer support
and solidarity to the patient by making an
empathic response.
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A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
(SPIKES) – Cont.
STEP 6: S—STRATEGY and SUMMARY
- Patients who have a clear plan for the future are less likely
to feel anxious and uncertain.
- Before discussing a treatment plan, it is important to ask
patients if they are ready at that time for such a
discussion.
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Truth Protocol (Buckman)
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Pick a good time and setting and assemble right
people
Find out how much the patient already knows
Find out how much the patient wants to know
Share the information the patient seeks
– in sensitive manner
– in appropriate “chunks”
Respond to patient’s feelings
Planning and follow-through
Lessons from Buckman
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Effective truth-telling is heavy on listening and light
on talking
Most patients want to know more and can handle it; a
few don’t want to
Giving patient greater role in setting agenda is
respectful of autonomy and is also compassionate
and caring
When Can Paternalism Be
Justified?
Atul Gawande, “Whose Body Is It
Anyway?” New Yorker, Oct. 4,
1999
“Weak” Paternalism
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Patient lacks important dimensions of capacity to
make autonomous decisions
– Child
– Dementia
– Mentally ill
Generally easier to justify
“Strong” Paternalism
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Patient appears to have full capacities for
autonomous decision-making
Provider nevertheless feels that decision is mistaken
and will cause great harm
Usually seen as much harder to justify-- threat to
respect for autonomy
Schneider (cont.)
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The people who wish not to choose often have very
rational reasons for this preference
– Weakness and fatigue
– Lack of knowledge or understanding
– Awareness of problems in own thinking process
– Avoidance of guilt
Truth Telling and Patient Autonomy
Autonomists - full disclosure (it is not sufficient to tell the
truth, one has to tell the whole truth; simply require
that "everything be revealed" because "only the
patient can determine what is appropriate."
Other principles, like beneficence, non-maleficence, and
confidentiality, may be given little consideration or
turned into subordinate obligations.
Truth Telling and Patient Autonomy
But, does every feasible hypothesis require disclosure
to a patient? Is every bit of data about a disease or
therapy to be considered information to be disclosed?
Telling the truth in a clinical context is an ethical
obligation but determining just what constitutes the
truth remains a clinical judgment. Autonomy cannot
be the only principle involved.
The Dying Patient
Some patients who are given a cancer diagnosis and a
prognosis of death may use denial for a while and the
bad news may have to be repeated, but the use of
denial as a coping device does not mean that
patients would prefer to be lied to or that truth is not
important to them.
Patients need the truth even when it tells them about
their death.
The Dying Patient
The doctor who tells a dreadful truth must do so at a
certain time, and in a certain way.
The communication of truth always involves a clinical
judgment.
Truth telling in every clinical context must be sensitive
and take into consideration the patient's personality
and clinical history.
Usually the Questions
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“When to tell?”
“How much to tell?”
“What exact words to use?”
“Whom should be there with the
patient?”
“What comes next?”
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Do patients want to know the truth
about their condition?
Contrary to what many physicians have thought in the
past, a number of studies have demonstrated that
patients do want their physicians to tell them the truth
about diagnosis, prognosis, and therapy. For
instance, 90% of patients surveyed said they would
want to be told of a diagnosis of cancer or
Alzheimer's disease.
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How much do patients need to be
told?
Patients should be told all relevant aspects of their
illness, including the nature of the illness itself,
expected outcomes with a reasonable range of
treatment alternatives, risks and benefits of
treatment, and other information deemed relevant to
that patient's personal values and needs.
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What if the truth could be harmful?
Assuming that such disclosure is done with appropriate
sensitivity and tact, there is little empirical evidence to
support such a fear. If the physician has some
compelling reason to think that disclosure would
create a real and predictable harmful effect on the
patient, it may be justified to withhold truthful
information.
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What if the patient's family asks me
to withhold the truth from the
patient?
Usually, the family's motive is laudable; they want to
spare their loved one the potentially painful
experience of hearing difficult or painful facts. These
fears are usually unfounded, and a thoughtful
discussion with family members, for instance
reassuring them that disclosure will be done
sensitively, will help allay these concerns.
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When is it justified for me to withhold
the truth from a patient?
If the physicians has compelling evidence that
disclosure will cause real and predictable harm,
truthful disclosure may be withheld ("therapeutic
privilege“) is important but also subject to abuse.
The second circumstance is if the patient him- or herself
states an informed preference not to be told the truth.
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What about patients with different
specific religious or cultural beliefs?
Those patients may have different views on the
appropriateness of truthful disclosure.
A culturally sensitive dialogue about the patient's role in
decision making should take place.
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Is it justifiable to deceive a patient
with a placebo?
In general, the deceptive use of placebos is not ethically
justifiable.
Specific exceptions :
- the condition is known to have a high placebo
response rate
- the alternatives are ineffective and/or risky
- the patient has a strong need for some prescription
Truth in the History of Medical
Ethics
The historical medical codes said little or
nothing about telling the truth and avoiding
lies. The value of not doing harm was so
strong that lying in order to avoid harm was
considered acceptable.
“Tell the truth as long as it helps rather than
harms the patient."
Truth in the History of Medical Ethics
The doctor's principal moral obligation was to
help and not to harm the patient.
Today, things have changed. Beneficence and
non-malifience remain basic medical ethical
principles, but truth is also a medical ethical
principle.
Today, Bacon's comment that "knowledge is
power but honesty is authority," is particularly
applicable to doctors.
Truth in the History of Medical Ethics
Because patients today can and must consent
to whatever is done to them, truthful
disclosure of relevant information is a legal
and ethical duty.
Modern medical ethical codes reflect this shift in
the importance of veracity: The code of the
American Nurses Association, "Principles of
Medical Ethics" of the American Medical
Association, "Patient's Bill of Right" ...