Truth-Telling in Medicine

Question:  Should doctors always tell the truth to their patients? There is an ongoing debate among physicians, families and patients on this issue. The debates are complex but they usually come down to disagreements about the limits of paternalism and the proper balance between the principles of autonomy and beneficience.

The principle of nonmalficence – the duty to do no harm – and the principle of beneficience – the duty to act for the benefit of others – have ancient roots in the code of medical ethics. But truthfulness does not. The Hippocratic Oath does not mention an obligation of truth-telling or disclosure, and until 1980 even the professional code of the American Medical Association did not say anything about dealing honestly with patients. Over the years physicians viewed the truth as something to conceal or reveal in so far as it impacts the therapeutic welfare of the patient. For example, a physician might be reluctant to disclose the diagnosis of cancer to a vulnerable patient if he judges that the truth would be harmful, unsettling and depressing. This paternalistic approach – doctor knows best – is less common today. Now there is more of an emphasis on the principle of autonomy and informed consent.

Contrary to what many physicians have thought in the past, a number of studies have demonstrated that patients do want their physicians to tell them the truth about diagnosis, prognosis, and therapy. For instance, 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer’s disease. Similarly, a number of studies of physician attitudes reveal support for truthful disclosure. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, by 1979 97% felt that such disclosure was correct.

When physicians communicate with patients, being honest is an important way to foster trust and show respect for the patient. Patients place a great deal of trust in their physician, and may feel that trust is misplaced if they discover or perceive lack of honesty and candor by the physician.

In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient’s personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient’s ability to digest complicated or bad news is important.

There are two main situations in which it is justified to withhold the truth from a patient. As noted above, if the physicians has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal. This judgment, often referred to as the therapeutic privilege, is important but also subject to abuse. Hence it is important to invoke this only in those instances when the harm seems very likely, not merely hypothetical.

The second circumstance is if the patient states an informed preference not to be told the truth. For instance, some patients might ask that the physician instead consult family members. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.