COMMENTARY

Lying to Patients: No Huge Ethical Failure, Says Bioethicist

Arthur L. Caplan, PhD

Disclosures

February 10, 2012

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I am Art Caplan, and I am at the University of Pennsylvania in the Department of Medical Ethics and Health Policy. Today I would like to talk to you about a pretty thorny subject and one that is fascinating because it is so ethically rich: Should doctors ever lie to their patients?

The trigger for this discussion is a study that just came out that found that doctors do lie. In fact, the study found that 20% of more than 2000 doctors surveyed admitted that they had not told patients the truth when an error had taken place. They found out that more than 10% hadn't discussed financial conflicts of interest, and 15% said they gave a rosier picture about prognosis and risk and benefit with respect to a disease.

There has been a good deal of interest in this survey, and the public and some media reports are saying that this is shocking. We expect our physicians to always be truthful; this survey apparently shows that there is a considerable amount of lying going on, withholding of the truth, and not being forthright. What's wrong? Is there a huge ethical failure going on out there among doctors and medical practitioners?

The answer is no. It is inexcusable and not advisable to lie about an error. You may dodge a bullet on that one by having the patient not find out, but if it really affects their care, if they wind up harmed, if they wind up having to pay more and it comes out later that you didn't tell the truth or that there was an omission of the fact that an error occurred, you are going to get clobbered. I have seen it again and again in courtrooms. It may seem the easiest way out, to avoid telling the truth when an error takes place, but getting it out there and getting it over with early is the best protection in terms of malpractice associated with error. It isn't lying.

With respect to financial conflict of interest, patients have a right to know about it, and it should be brought up. But a lot of patients don't care, so you can get around that very quickly. You don't have to lie or withhold information. You can simply offer the patient the opportunity to know that you see a lot of drug representatives or that you went out to dinner and learned about this drug, and they probably will say, "Doctor, I don't care. What do you think is the right thing for me to do?" Making the offer is a better way to deal with something that a lot of patients don't think is all that important.

What about that circumstance in which a better prognosis is offered than is really the case for the patient? That circumstance, and a couple of other topics, are real ethical gray zones. It is not as clear that lying is always bad. Think about the use of a placebo. If you think that you can save a patient money and save them a lot of risk and side effects by giving them a placebo to see if it will calm their anxiety or help restore their sexual function, I am not sure that it is always wrong to prescribe a placebo. It is controversial, but I am not sure one is always wrong in trying to deal with a difficult or noncompliant patient, or one who has a bad, unhealthy lifestyle.

Is it wrong to "up the ante" a little bit and scare the patient more than you might otherwise about the consequences that might follow from their bad behavior? I am not sure that that is wrong either. The goal is good, and by being a little bit on the far end of the truth about what could happen to them, I am not sure that it isn't worth it. With respect to the "rosy prognosis," if someone has cancer or Parkinson disease or Alzheimer disease, I'm not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics.

You might say that telling the truth is a noble thing to do, an important thing to do, and it is the way that we are going to keep patients trusting the doctor. At the same time, however, truth is not an event; it is a process. The survey may have failed to capture that insight. Telling the truth is important, but letting it come across in a humane way, letting it come across sometimes in "dribs and drabs" so that the patient can absorb it and not be psychologically devastated or emotionally harmed, is the right thing to do.

So, don't lie about mistakes, don't lie about conflict of interest, and be forthright when things go wrong. When there is a reason not to be trusted, let the patient decide how they want to manage that. Truth is a better policy. In some other areas, the truth, although it ought to come out eventually, is probably something that is more of a tool to be worked with in trying to help patients than it is an absolute necessity all of the time.

I am Art Caplan at the University of Pennsylvania. Thanks for watching.

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