Transcript Telling Patients the Truth: A Case Study in Ethical Decision Making

Telling Patients the Truth: A
Case Study in Ethical Decision
Making
Robert Scott Stewart, Ph.D.
Professor of Philosophy
Cape Breton University
[email protected]
Clinical Ethics Consultation
 At
CBDHA, a request for a clinical ethics
consultation is sent to the Ethics Committee,
currently chaired by Frances Butler.
 Such requests can come from patients, health care
workers, patients, or families.
A Method for Making Clinical Ethical
Decisions
Michael MacDonald, UBC
http://www.ethics.ubc.ca/upload/Framework2.pdf
 Fair consultation process
 Collect relevant facts and determine what ethical values
are in play
 See who will be affected by your decision, and how
 Determining options and subjecting them to ethical tests
 Make a decision

Consultation Process & Collecting the
Facts
 Hearing
from everyone
 Representative sample on the committee
 Who will be affected by the decision and how
 Literature Search
Values
 Principlism
and Normative Ethical Theory
 Autonomy
 Non-Maleficence
 Beneficence
 Justice
 Kindness

as a Virtue
Thomasma. (1994). “Telling Patients the Truth: A Clinical Ethics Exploration,” Cambridge Quarterly of Health
Care Ethics 3: 375-382
Autonomy and Respect for Persons
Immanuel Kant and the special nature of human beings
 Models of patient-physician relationship: the movement
away from paternalism (Emanuel and Emanuel. (1992). “Four models of the physician-patient

relationship,” JAMA 267 (16): 2212-2226
In 1961, only 10% of physicians believed it was correct to
tell a patient they suffered from a fatal cancer diagnosis.
By 1979, 97% of physicians believed disclosure was
correct.
 Patients agree: In 1998, 90% said they would want to be
told of a diagnoses of cancer or Alzheimer’s (Braddock. (1998). “Truth

Telling and Withholding Information,” Ethics in Medicine)
Autonomy and Respect for Persons
 The
Consumer or Informative Model of the
Patient-Physician Relationship
 Patients provided more control over their health
care.
 To make their own decisions, patients must be
given ‘adequate/appropriate/full’ information
 Informed consent – avoiding battery
Non-Maleficence and Beneficence:
Utility
 Measuring
costs and benefits: avoiding harms and
improving benefits
 Non-maleficence historically used as a basis for
withholding truth
 E.g., Mark Lipkin in 1979: (1) Patients don’t have
requisite knowledge to be told “the whole truth.”
 (2) placebo effect (Mark Lipkin. (1979). “On Telling Patients the Truth,” Newsweek 13).
Response to Lipkin
The responsibility of health care workers to communicate
effectively
 Respect for persons
 “Most treatments for serious diseases require the full
cooperation of the patient” (Cullen and Klein. (2000).”Respect for patients, physicians,

and the truth,” In R. Munson, ed., Intervention and Reflection. (2004), 155-163)
Patient’s good in some situations may mean planning for
their death.
 Telling patient the truth is the “default” position, which
can be overridden only in special circumstances.

“Offering the Truth”

“A patient’s knowledge of diagnosis and prognosis is not
all-or-nothing. It exists on a continuum, anchored at one
end by the purely theoretical ‘absolute ignorance’ and at
the other by the unattainable ‘total enlightenment’. Actual
patients are to be found along this continuum that vary in
response to external factors (verbal information, nonverbal clues, etc.) as well as internal dynamics such as
denials.” (B. Freedman. (1993). “Offering Truth,” Archives of Internal Medicine 153 (3) 572-576)
“Offering the Truth”
Begin by finding out what the patient knows (or suspects).
 “It is important to hear from the patient himself or herself,
so that [the health care team] can confirm what he or she
knows or clear up any misunderstanding that may have
arisen” (Freedman, 1993, 575).
 Follow this by a series of steps toward full disclosure.
 Be aware that some patients will NOT want to know and
want the physician to make their decisions. This is okay.

Justice
 Justice
has both a substantive and procedural side.
Substantive views of justice vary depending upon
one’s political theory (Marxism, capitalism,
socialism, etc.). In Canada, universal health care,
so whatever policies we establish have to be
available to all.
 Procedural theory of justice: ‘Treat equals equally’
 Ethics of Justice vs Ethics of Care & Virtue Ethics
Kindness
 Virtue
Theory: Building Virtuous Character
 Kindness and Friendship as Virtues
 Trust and Honesty as ingredients of kindness and
friendship
Concluding Remarks
 Telling
competent patients the truth is the default
position. I.e., one has to provide an outstanding
reason to withhold the truth from patients.
 This policy can be defended on grounds of
Autonomy/Respect for Persons; Utility/NonMaleficence/Beneficence; Justice; and
Kindness/Virtue.
 Truth can be told in a process called “offering the
truth.”