Telling patients the truth

Andrew asked:

When, if ever, should a terminal patient’s right to be told the truth about their condition — that they are dying — be overridden?

Answer by Craig Skinner

I dont think a patient of sound mind who asks for the truth should be lied to.

As a medic, I would say medical ethics revolves around 4 principles:

  • beneficence (do good)
  • non-maleficence (do no harm)
  • autonomy (patient’s right to truth and to decide)
  • justice (fair sharing of limited resources)

Your question relates to autonomy. Relatives often say the patient shouldn’t know the truth because she couldn’t cope with it — she would give up, wouldn’t fight any more. So, they say,  autonomy clashes with doing no harm, the latter should prevail, I should lie. Whilst I always take account of relatives’ views, I am not bound by them, and I have never agreed with this view. It usually means it is the relative who cant cope, won’t know what to say if mum starts talking about death. And if we go along with it, the outcome is bad: the patient soon realizes she is dying anyway, but can’t talk about it because her family don’t want to, and so she is alone and isolated just when she most needs family support. So, I explain all this to the relative, and tell the patient the truth.

Two caveats.

First, a patient’s right to the truth doesn’t mean I have a right to ram the truth down her throat, as it were, when she doesn’t want to talk about it. I am guided by the patient’s wishes. So, having examined her and got back test results, I will start in nonspecific terms — there’s a shadow on your x-ray we need to investigate further, say. Then, “Is there anything you want to ask?”, and now we find out how much the patient wants to know, at this stage anyway. Some say no, that’s fine, lets get on with the tests, others ask if it could be cancer. And so it goes as we investigate further. If it turns out to be a fatal condition for which little can be done, I will say so if asked directly, otherwise will talk of treatment which may help for a time. If a patient has, or probably has, a very serious condition, but one which may be curable, and decides to bury her head in the sand, keep clear of doctors and hope for the best, then I will make sure she knows the serious position even though she did not ask me to spell things out.

Second caveat. Docs know only too well that they often get it wrong, so we must always consider very carefully before pronouncing an illness terminal or being too exact or sure about life expectancy. Second opinions may be a good idea.

I hope this is helpful to you.

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