Is It Ever Okay to Lie to Your Cancer Patient?

Liam Davenport

Disclosures

October 09, 2018

Have you ever outright lied to your patients with cancer, or been economical with the truth? Your instinct might be to say no, of course not, that you would never do such a thing.

But think about it for a minute. Lying per se is wrong, but in certain circumstances lying may be in the eye of the beholder.

For example, have you ever withheld information that you don't think a patient is ready to hear to protect them at a difficult time? Maybe you haven't told them about all the risks associated with a particular treatment because it might put them off having it. Or perhaps you've presented things in such a way that your patient makes the "right" choice.

Perhaps you've said you'd do something for your patient but didn't follow through on it. Or maybe a mistake was made but, with no harm done, you didn't disclose it.

Or have you lied on behalf of your patients to secure reimbursement for a costly procedure?

Do Doctors Lie?

If you have, you're not alone.

A survey by Everett and colleagues[1] of more than 630 residents from 22 specialties at Loma Linda University, in California, revealed that although the vast majority of physicians would disclose the truth about medical errors, a notable 10% would either not own up or would defer to another physician.[1]

Moreover, just 56% of respondents would reveal the truth about unanticipated events, rising to 75% if the error was serious enough to lead to a malpractice suit. Only 41%, however, would reveal a near miss if it had no impact on patient health.

Another survey, of nearly 1900 physicians from across the United States, indicated that around 90% thought that patients should be fully informed about the risks and benefits of interventions, and that confidential information should never be disclosed to unauthorized persons.[2]

However, fewer agreed that physicians should never tell a patient something that is not true, at just 83%, whereas only 66% believed that all significant medical errors should be disclosed to affected patients.

Perhaps more worryingly, 11% of physicians in the survey had told an adult patient or child's guardian something that was not true in the past year, and 20% had not fully disclosed a mistake to a patient because they were afraid of being sued.

Can Lying Benefit Patients?

However, there are forms of lying in a medical context that, it could be argued, are helpful to patients, at least in the short term.

One example is lying to third-party payers to manipulate the rules about reimbursement and offer treatments or tests to patients for which they might not otherwise qualify.

This "gaming" of the system has been condemned in some quarters as immoral and in violation of the physician's ethical code. It has also been described as potentially harmful to either patients themselves or to other patients, as well as a threat to the physician-patient relationship.[3,4]

However, some have praised the willingness of physicians to bend the rules on behalf of their patients, seeing them as "noble advocates" in a health insurance system that is commonly seen as burdensome and unfair.[3]

Tavaglione and Hurst[4] even argue that gaming the system "may sometimes be a physician's duty" and even "necessary from the viewpoint of the internal morality of medicine" in certain circumstances.

It is not surprising, then, that 47% of residents said they would deceive an insurance company if it resulted in additional patient benefit.[1]

Another survey of internists found that between 32% and 58% were willing to deceive a third-party payer to ensure patient access to a range of tests and procedures, including screening mammography.[5]

Daniel F. Chen, MD, an oncologist at Cambridge Health Alliance in Everett, Massachusetts, who is also affiliated with Harvard Medical School in Boston said that although he doesn't have personal experience of gaming the system on behalf of patients, "I don't doubt that it happens."

Although he has spent the majority of his career in the Veterans Affairs health system, where access to interventions and tests is less of an issue, he recently moved to a private insurance market and believes the issue of reimbursement manipulation is something "I fully expect to have to struggle with at some point."

Even now, he can see how the issue could arise. "When I have to deal with getting hospitalizations covered by insurers, there's a certain amount of bargaining and portrayal of things," he explained.

"Whether there's flat-out lying? Not yet! But given how dysfunctional our market is, I do think that to get a patient what they need sometimes might take that."

Chen did note, however, that it is not always clear-cut that gaming the system for a patient benefits them in the long run.

"There are a lot of physicians who overdo things that, in terms of practicing medicine, aren't necessarily guideline-based, and doing things out of overcaution may lead to unnecessary examples of that," he said.

Do Patients Need to Know Everything?

But when it comes to lying to, rather than for, patients, there are many situations that can be interpreted as lying.

A false statement is condemned as such, but what about nondisclosure or withholding of information? Is that a "lie," and always bad? Are there circumstances in which it could, in fact, be beneficial?

In a 2016 paper in the Journal of Medical Ethics, Cox and Fritz[6] write that forms of nondisclosure, such as not telling patients about resuscitation decisions, inadequately informing patients of a procedure's risks, and withholding information on medical errors, are seen as wrong.

However, other forms of nondisclosure are considered acceptable. Cox and Fritz give the example of a patient who has undergone successful angioplasty after a myocardial infarction but who is left with symptoms of congestive heart failure.

Doctor A tells the patient that the procedure was successful in unblocking the affected coronary artery but he is now suffering from "heart failure," which results in the patient becoming very anxious.

Doctor B tells the patient that the procedure was a success but that there is "a bit of fluid on the lungs, as the heart is not quite pumping strongly enough." The patient is content with the explanation and rates his illness severity as low.

Cox and Fritz argue that Doctor B's euphemistic explanation "is a form of secrecy, as it prevents [the patient] from appreciating the severity of the illness," and that secrecy is "not identical" to lying but there is a "tenuous border" between the two concepts.

In oncology, however, statements made to patients about their condition and prognosis can have a much greater impact than those given during cardiology consultations, and so the line between what and when to disclose information to patients is a little more blurred.

Indeed, Cox and Fritz recognize that the disclosure of information, particularly when the information is distressing, can have implications for the doctor-patient relationship.

They note, for example, that some physicians are concerned that "giving patients too much technical information may not just be unhelpful, but unethical," and that the "neutral truth," in which patients are given all the medical details, may be tantamount to doctors "delegating, not sharing," their responsibilities.

Giving Cancer Information in Stages

For oncologists, who often have long-term relationships with patients, a frequent question is when and how to reveal information piece by piece, so as not to overwhelm and frighten a patient, and to help guide them toward making the most rational management choices, especially at the beginning of their journey.

"In a fragmented system, that isn't always the case, but I do think about that a lot: how I can let the process unfold, and the pacing of revealing information," Chen said.

Chen continued, "I think especially up front, when patients first encounter the diagnosis, they're traumatized in a sense, and what they're able to absorb in one sitting in a very sensitive period is limited for a lot of people."

"So, through time, I am measured and think about the long game in terms of communicating how much is appropriate or even, practically speaking, realistic to have somebody absorb in one meeting, and what can be sort of saved till later to discuss," he said. "That can be a hard question, but you have to kind of read the room."

Rebecca S. Dresser, MS, JD, a professor of law at Washington University in St Louis, Missouri, and an expert in biomedical ethics, who is also a cancer survivor, agreed that staging information to cancer patients can be appropriate.

"In general, doctors should tell the truth but not be brutal about it. So I think that, in some situations, it's too much to hear it all at once, especially if it's breaking bad news," she said.

She pointed to the SPIKES six-step protocol for delivering bad news, which has been applied to oncology,[7] noting that one of the steps is "to ask the patient how much information they are ready for."

Dresser believes, however, that there are limitations to this approach.

"Obviously, these are delicate things, and when you say, well, it's okay to withhold information to protect the patient, you don't want that to become a loophole," she emphasized. "Breaking bad news is not something that anyone enjoys, and so any reason for not having to do it will be attractive.

"I think a good doctor knows how to be sensitive about this and tell the truth, but do it in a sensitive way."

Andrew G. Shuman, MD, a head and neck surgical oncologist at the University of Michigan Medical School, Ann Arbor, Michigan, goes further, however.

For him, it's not a question of staging information delivery, but rather providing enough context so that patients can better understand the information they are given.

"I think it's important to provide more information when patients are concerned or even not necessarily accepting what a physician is saying. In general, those are reasons and times to provide more information and contextualize it appropriately, rather than provide less," he said.

Does Information-Sharing Help or Hinder Decision-Making?

The issue nevertheless remains that a low-risk cancer patient who is frightened and overwhelmed may choose to opt for a more radical intervention at an early stage in their cancer journey rather than go for recommended conservative management.

Schuman said, "Some patients who are sophisticated will be able to engage in a formal, full conversation and discussion of that, whereas others might not."

"But still, even for the most sophisticated patient, coming out with a diagnosis of cancer, in and of itself, can be terrifying and may commit them to a treatment course that is not necessarily consistent with what the data would suggest is necessary," he continued.

Chen pointed out that a lot of the discussion of cancer in the popular press is focused solely on the efficacy of a particular drug, radiation therapy, or surgery, "but in addition to that, I think it's as important to communicate about not only what something can do but also the limits of what it can do."

He added, "I think that gets a lot of short shrift when, especially early on in the diagnosis, the patient is scared, but the physician is scared too."

"The physician wants obviously to be able to offer something and to be able to treat an illness, but, especially with many different kinds of cancer, the treatments have their second edge to them," Chen stated.

Chen also treats geriatric cancer patients, in whom anticancer treatments themselves can be "devastating." With these patients, speaking about issues other than simply "kill the tumor, kill the tumor" is even more important, he explained.

Can 'Cancer' Itself Be a Lie?

In the grayer areas of physician-patient communication, there is an even more fundamental question: Do doctors and patients understand language in the same way?

For example, the word "cancer" means different things in different contexts, and may not always convey the same information.

Some have even argued that the term itself should be replaced in circumstances where the prognosis of a condition is far better than the label "cancer" would traditionally imply.

A recent study by Nickel and colleagues[8] examined this very issue in papillary thyroid cancer (PTC), having noted that, as small PTCs are commonly overdiagnosed and overtreated, less invasive options should be considered for low-risk patients.[8]

They devised a study in which 550 men and women without a history of thyroid cancer were presented with three hypothetical scenarios in which PTC was described as "papillary thyroid cancer," a "papillary lesion," or "abnormal cells."

The participants reported significantly higher anxiety levels and were twice as likely to choose total thyroidectomy when the term "papillary thyroid cancer" was used to describe the condition than when the term "papillary lesion" or "abnormal cells" was used.

"The words we use don't necessarily have the same connotations to different people in terms of their implications for prognosis as well as for treatment," said Schuman, who also wrote an editorial accompanying the paper.[9]

"The issue of language is an important one, and I think what's important to recognize is that in order to communicate effectively and in order to ensure that patients and physicians are truly on the same page, the words that we use need to be understood in a similar way," he said.

He emphasized, however, that "what that doesn't mean is that changing words is an excuse for deliberate deception, because that's truly not what we're aiming for, but rather making sure that there is a true common language, if you will, in terms of the implications of what is being said.... [T]he diagnosis of a cancer is something that is rife with cultural and social implications that are distinct but just as important as the clinical implications."

Little White Lies

In an article published last year in JAMA, Chen[10] described an incident with a Vietnam veteran in his late 50s who was battling advanced esophageal cancer and had never received his long-promised surgery. He was living alone and with little support, had run out of sick leave, had fallen behind on his bills, and was on the verge of homelessness.

At the end of a difficult consultation, during which the patient was trying to deliver his story to the palliative care team between bouts of dry heaves, Chen and his colleagues decided to come back when the patient was less nauseous.

"No, no, let's talk now," Chen recounts the patient saying. "Everyone always says they'll come back, but no one ever does."

The comment stung Chen. He made sure that he followed through on the patient's case, adjusting his antiemetic regimen and working with the team's social worker to finalize his transfer to the community living center.

"He was a different man when I saw him," Chen wrote. "He seemed to have hope again. We spoke at ease for a good 15 minutes; the reflexive second-guessing had dissipated, as had the dry-heaving and self-gagging that had paralyzed our first interactions."

To Chen's amazement, however, it turned out that the patient hadn't used the antiemetic for days. "I could only think: Oh what a dose of trust can do."

Chen told Medscape that, although he thinks about that case somewhat differently now, he said that "the question about whether it's okay to 'lie' in medicine depends, to me, on how we define that term."

"I think in my mind, semantically speaking, lying is an intent to deceive, and is never something I feel good about in medicine when it comes to communicating with a patient. But I think what I was trying to explore, and think about a lot, is how we represent the truth to patients," he said.

Chen further stated that he and most oncologists are "doing our best to represent a version of the truth but, at the end of the day, how the patient perceives the message from somebody they're really looking to as an expert, as an authority figure, is something we have to be mindful of.... [T]he responsibility falls on us to take into account how what we're saying is going to be perceived by the recipient of the message, because there are unintended consequences."

Dresser added that whenever she talks about this with medical students, she says that everyone remembers where they were when 9/11 happened, that it's vivid in the memory. "And I say, well, for patients hearing a bad diagnosis, it's the same thing—they remember everything. For you, it's just another day at the office, but for them, it's a very vivid and unforgettable experience."

No conflicts of interest were reported.

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