January 1980 I/5
TELLING THE TRUTH TO PATIENTS
"What to tell the patient" has been considered one of the more difficult and delicate ethical questions for health care professionals. In the not too distant past, some physicians and other health care professionals thought that the less patients knew about their condition, the better would be the chances of recovery. Some health care professionals would even withhold information of impending death, fearing that such knowledge might lead a person to despair. Due to an awakened moral sense on the part of health care professionals and a sharper realization that patients have legal and moral rights that must be respected, today there is a much greater tendency to be open and honest with the truth concerning their condition, the purpose of the treatment to be given, and the prognosis of the treatment. "The Patient's Bill of Rights" of the American Hospital Association (1972) states:"The patient has the right to obtain from the physician complete current information concerning diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand."
Clearly, the information concerning serious sickness or impending death is to be furnished even if the individual does not ask for it. Legal precedent as well as moral concern prompts this realization. Hence, physicians and other health care professionals may not defend their lack of communication by pleading that the patient did not wish to know and did not ask questions. In some hospitals, a patients' representative helps patients understand their situation, especially when surgery is anticipated. Whenever possible, the leader of the health care team, the physician, should be involved in explaining the situation to the patient.
Though health care professionals usually respect the rights of patients insofar as providing the proper information is concerned, difficult situations often arise and health care professionals hesitate to tell patients their true condition. For example, patients with serious cases of cancer might become despondent, morose, and even suicidal if they know their true situation. With this in mind, "The Patient's Bill of Rights" states:
"When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person in his behalf."
Though it is well intentioned, this statement is unsatisfactory and incomplete. It seems to indicate that when health care professionals feel that harm might result if the patient knows the truth, they fulfill their obligation by telling some friend or member of the family about the patient's condition and the prognosis. But the statement does not indicate what the member of the family or the friend is supposed to do once the information has been communicated. In order to ensure proper respect for the patient then, another dimension of the situation must be explored.
Even though the medical personnel might fear untoward results if patients are informed of their true condition, it does not mean that patients should never be told the true facts. Indeed, health care professionals should remember in these cases the words of Dr. Eric Cassell, "The depression in patients that commonly occurs after the diagnosis of a fatal disease seems to stem in part from the conspiracy of silence. The physician can be a great help by simply making it clear to the patient that he is available for open and direct communication."(l) Interviews with people who are seriously ill or with dying patients reveal that they do not wish to be kept continually in doubt about their condition; on the other hand, they do not want it revealed to them in an abrupt or brutal manner. According to Dr. Howard Brody,
"A decision to reveal a grave prognosis, which may be 'ethical' in itself, may become 'unethical' if the physician tells the patient bluntly and then withdraws, without offering any emotional support to help the patient resolve his feelings. In fact, the assurance that the physician plans to see it through along with the patient, and that he will always make himself available to offer any comfort possible, may be more important than the bad news itself. In many of the 'sour cases' that are offered as justification for withholding the truth, it may well be the absence of this transmission of compassion, rather than the telling of the truth, that produced the unfortunate result."(2)
Because physicians are not always able to convey information concerning serious illness or impending death in a fitting manner, a person who is trained in the dynamics of accepting sickness and death is useful in the present-day hospital setting. Crisis counseling of this nature is not an arcane art, but on the other hand, one must be prepared competently in order to perform it well. Well-meaning but untrained people can do more harm than good when trying to help in crisis situations.
In summary, it is clear that because of our increased knowledge of psychology and greater regard for the subjective process that accompanies sickness and dying, the ethical question in regard to truth telling has changed. The question should not be "should we tell?' but rather, "How do we share this with the patient?"
Kevin O'Rourke, OP
1. The Healer's Art, Lippincott, New York, 1976, p.197.
2. Ethical Decisions in Medicine, Little Brown, Boston, 1976, p.40.
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