1. Simone, Joseph V. MD

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This is the third in a series begun nearly a decade ago concerning lies and truth told to patients and families by medical caregivers. This version of the third and final entry has been updated and lightly edited.

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At the beginning, I had read three articles published in the medical literature that dealt with physicians' candor and "truth-telling." I was reminded of Pontius Pilate. In the Gospel of John, this Roman political leader was asked to decide whether Jesus should be executed. He believed Jesus had committed no capital crime. When he questioned Jesus about his actions, Jesus said that he was there to bear witness to the truth. Pilate famously responded, "What is truth?" and ultimately agreed to have him executed to placate the angry and powerful crowd. Christian tradition vilifies him because he chose to sacrifice one powerless innocent man for political reasons. But there is a little bit of Pontius Pilate in all of us, as these articles attest.


Lindsay Rockwell, DO, an oncology fellow, wrote a heartfelt essay (J Clin Oncol 2007;25:454-455) that laments the lack of "truth-telling" in oncology, particularly when it comes to the issue of death. She describes a young man with myelodysplastic syndrome and his father. The father complained to her that no one had told the family that the young man was dying, despite the short remissions and the inevitability of death. She is dismayed that death was not discussed and instead the discussions concerned additional therapy, none likely to succeed.


Her essay was followed by a commentary written by Timothy Moynihan and Linda Schapira. They express concern at the potential damage failing to communicate can do and that we often do not prepare our young physicians sufficiently in this art. But though they are in general agreement with the major points of the essay, they wonder whether the father was told but didn't hear the information, whether Rockwell was present for all discussions, or whether the father refused to give up and would not to face the reality of the impending death of his son. They even wonder, "Could it be that Rockwell is expressing her own grief as guilt for not speaking up when she saw the inevitable truth?"


What Is Truth?

Farr Curlin, MD, and colleagues conducted a random survey of physicians in all types of practice by mail and received 1,144 responses to questions devised to determine the physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for ethical or religious reasons (N Engl J Med 2007;356:593-600). Examples are abortion for failed contraception, giving terminal sedation to dying patients, and prescribing birth control to adolescents without parental consent. (The authors report that 52% of all respondents had ethical or religious objections to abortion for failed contraception.)


Most physicians responded that all doctors have an obligation to present all options (86%), that it is ethically permissible for doctors to explain to patients their moral objections (63%), but that they should then refer patients to another physician that has no objection to the requested procedure (71%). The authors then estimated the number of patients affected by the minority, if generalized to the entire population. They conclude that 40 million-100 million Americans have physicians who feel no obligation to present all options or who would not explain that they have moral or religious objections to the procedure and feel no obligation to refer them to a more agreeable physician.


Without questioning the sincerity and conviction of the respondents, we may ask who is more truthful, a physician who believes on ethical grounds that abortion for failed contraception is always wrong and doing anything to abet the procedure is also wrong, or the physician who believes abortion is wrong, but also holds that he cannot impose his views on patients so helps them find a willing physician? One could argue that the first is more truthful to his convictions and the second more truthful with the patient. One could also argue that the physician's first obligation is to the patient's well-being, so he must help the patient obtain the procedure she desires, even though he thinks it wrong. The counterargument is that if he believes abortion in this case is murder, that he has no choice but to avoid abetting the patient.


Telling the Truth

The third article by David Studdert, LLB, ScD, MPH, and colleagues takes an economic look at telling the truth (Health Aff J 2007;26:215-226). They asked whether full disclosure of adverse outcomes actually reduces the providers' liability exposure, as some believe. They tested this theory by modeling the litigation consequences of disclosure. They compiled data on the historical frequency of litigation when the patient suffers a severe medical injury, both when due to negligence and when not. To obtain an estimate of the net impact of litigation, the authors polled 78 experts in patient safety, risk management, malpractice liability insurance, and plaintiff litigation, including lawyers on both sides. They defined serious injury as that which leaves the patient with a permanent disability or with a temporary disability that is very severe while it lasts.


They concluded from their study that, among patients whose severe injury was due to negligence, full disclosure would deter 32 percent of patients from suing and would prompt claims by 31 percent of those who would not otherwise have sued. Among patients whose injury was not due to negligence, disclosure would deter 57 percent of those who would have sued and prompt 17 percent of those who would not have sued. Overall, the experts predicted there was a 5 percent chance that the volume of claims would decline or remain the same and a 95 percent chance they would increase; the predicted outcome of compensation cost was the same, a 6 percent chance of declining and a 94 percent chance of increasing.


The authors make a key point: about 80 percent of all serious injuries due to negligence never trigger litigation. Thus, there is a huge reservoir of unlitigated injuries meaning that a small shift in that group could have much greater financial repercussions for doctors, hospitals, and insurers than the deterrence from suing of an equal percentage of patients. Though the authors predict that full disclosure would cause an expansion of litigation and monetary consequences of potentially great magnitude, they do not say, "don't tell the patient if not forced to."


The main audience of the report is policy makers, cautioning them to consider the consequences of full disclosure policies. They point out the broad consensus that disclosure of unanticipated outcomes is desirable because, as in other industries such as aviation, openness about error is critical to development of effective prevention. They continue, "there are also compelling ethical reasons for telling patients the truth about all aspects of their care."


So what will policy makers in government, the private health industry, and medical practices do? A cynic will say they will continue to follow traditional risk management procedures, which does not include full disclosure, to contain litigation costs and overall health costs. The optimist will say they will do the right thing, full disclosure, so errors may be addressed and corrected and improve the quality of care.


So, What Is Truth?

I am confident that every reader has opinions about each of these circumstances and I am equally confident that the most of those opinions are strongly held. But as is true for discussions of politics and religion, such case studies as those presented above often don't allow room for subtleties on any side for fear of taking a step onto a slippery slope that endangers one's bedrock principle. One may hold a bedrock principle, but the specific circumstances tend to be messy and influenced by the many complexities of day-to-day living and by our own internal conflicts.


We each have a moral/ethical compass formed by our parents, culture, education, and religious faith, or lack of it. However, these positions are not immutable; they can be modified by preachers, scientists, literature, travel, and other external influences, as well as by experience and the greater wisdom (we hope) that comes with age. But we still make "right" and "wrong" decisions.


So, what is truth? I don't have the answer, but I have an answer for myself. Truth in dealing with patients is based on transparency with humanity and charity that attempts to ease their burden. And for life in general, I believe my professor of moral theology had it right: for each individual, a considerate, thoughtful, and well-informed conscience that takes all potential consequences seriously must be the final arbiter of right and wrong. My conscience always lets me know, at times reminding me even decades later, when I have already acted against it.