Commentary — September 2014
Tex Med. 2014;110(9):7.
By Edwin T. Melendez-Murphy, MD
Medical ethics statements on lying are ambiguous. An American Medical Association policy on the patient-physician relationship states, "The relationship between patient and physician is based on trust and gives rise to physicians' ethical obligations to place patients' welfare above their own self-interest and above obligations to other groups, and to advocate for their patients' welfare." The statement doesn't address lies specifically. Logically, trust cannot exist if the patient discovers a lie.
The amount of truth a physician provides is often referred to as therapeutic privilege. An honest discussion of the use of this privilege ensures a therapeutic relationship among patients and physicians that extends to the health care system and society.
A study titled "Survey Shows That At Least Some Physicians Are Not Always Open or Honest With Patients" published in 2012 in Health Affairs shows lies are commonplace among physicians.
I heard a story on the radio about a nursing home in Germany that had a problem with wandering Alzheimer's patients. When patients disappeared, the police had to collect and return them. The home's unique solution to the problem involved developing a ruse to trick patients who tried to wander.
The nursing home built a fake bus stop right outside. A remarkable thing happened: The patients who wandered were found sitting at the bus stop. The staff would coax them back into the home without the stress of having to restrain them or call the police.
Analyzing the ethics of lying in this story requires balancing the core ethical tenants of autonomy and beneficence. The patients at the nursing home lacked total autonomy. Returning them by force caused them severe stress that, if avoided, could be considered beneficence. In this case, beneficence outweighed autonomy, justifying the lie.
Patient-physician communication scenarios like this arise throughout physicians' careers. Often, the decision to tell the truth comes naturally. Sometimes, it's not so cut and dry.
As an intern, I lied to a patient receiving a cardiac catheterization. The cardiologist had already read the results and told me the patient wasn't likely to live longer than three months. When I met the patient, he asked me what the catheterization showed. It was my understanding the cardiologist would discuss the results, but I was the first physician to speak to the patient after his procedure.
I told the patient I was not fully aware of the results and said the cardiologist would discuss his findings.
I have told this story to others, and they usually question whether I had lied to the patient. They say I simply delayed the communication of information. I understand that argument, but I see value in calling what I did lying. Acknowledging my lie forced me to look for an ethical justification for my actions.
I justified my lie with the knowledge the cardiologist would speak with the patient and share the diagnosis. I believe if I had divulged the prognosis I would not have had the medical knowledge to accurately answer all of the patient's questions.
The decision to tell the complete truth will come easy to most physicians. But lies are sometimes necessary. The need to lie in more ambiguous cases will be a constant dilemma for medical professionals.
Edwin T. Melendez-Murphy, MD, is in The University of Texas Southwestern Medical School's Austin Family Medicine Residency Program. Before that, he served as a naval flight surgeon.