Can deceiving patients be morally acceptable?
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39184.419826.80 (Published 10 May 2007) Cite this as: BMJ 2007;334:984
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Perhaps we should read Sokol's piece as satire, in which case his
idea for a "Deception Flowchart" is brilliant. And even if he did not
intend it as satire, then I suggest we regard it as such nonetheless. As
a consequentialist, I can affirm that would be for the best!
Competing interests:
None declared
Competing interests: No competing interests
about as often as God plays dice with our lives ?
( acknowledgements to Blaise Pascal )
Competing interests:
the chance of an after-life
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My big problem with doctors playing God is that they presume that
they're right in their assessment of a situation, when we don't actually
know how often they get it wrong.
Just anecdotally, in my own personal experience of serious illnesses
affecting four members of my family aged under 40 over the past 16 years
we have been given awful life-changing and potentially life-threatening
information that later turned out to be wrong.
What's worrying is that as far as I know the four consultants
involved who provided this information and advice at different times and
at different hospitals in the UK do not know that they were later proved
wrong.
Competing interests:
None declared
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This "analysis" was thought provoking, but flawed. The author
impresses us with his everyday clinical experience by using terms such as
"pre-oxygenation" but then gives away his academic occupation with a
suggestion to consider a formal psychological assessment part of the way
through the flow chart, (there is usually at least a twelve month wait for
such a thing). Other practical implications he might consider, including
in the case of the unhopeful anaesthetist, are the implications for
witnesses to deception: one's colleagues are all potential patients too
and might be harmed by the undermining effect on respect for the medical
profession. Finally, is there not an imeasureable harm done to the person
committing the deception?
Competing interests:
None declared
Competing interests: No competing interests
Sokol’s flowchart (Can deceiving patients be morally acceptable? BMJ
12 May 2007, Vol 334, pp984-986) for helping doctors to make considered
decisions about whether, in special circumstances, to lie to their
patients, is rather one-sided. It contains mainly considerations of the
consequences of lying to patients and very few deontological
considerations, i.e. considerations of duty or what is the right thing to
do. People who have an ethical stance which is deontological would say
that lying is simply wrong, despite its consequences. Sokol does not place
much weight on the fact that doctors have a duty to tell patients the
truth, on the fact that nearly all patients do not want to be deceived by
professionals in whom they have placed their trust, that patients have a
right to be told the truth, and that telling the truth is a practice which
is intrinsically valuable, regardless of the consequences.
Secondly, Sokol does not seem to take the perspective of the patient
sufficiently into account. For the doctor who is lying intentionally for
the perceived good of the patient, lying seems more excusable or harmless
than it would to the person who is on the receiving end of a lie, namely
the patient. Being deceived in this way arouses suspicion and destroys
trust. Sokol wants the doctor to make sure that the patient does not
discover the deception, but this cannot usually be guaranteed.
Thirdly, Sokol seems to think that “non-lying deception” is
preferable to lying although non-lying deception is still deception, and
even some true statements can be intended to deceive (e.g. by deliberately
omitting relevant information or by containing so much information that
the person supposed to take in this information becomes confused).
Paul Crichton
Consultant Psychiatrist
London
Competing interests:
None declared
Competing interests: No competing interests
Dear editor
Title "deceiving patients"seems little absolute, this is why to me it
can never be justified to deceive a patient.
But an aproach based on "in the best interest of patient" could provides
us with a chance to communicate with patients in relative terms.
Communication with a ptients varies alot,there fore it is important
for physician not only to know what he wants to communicate, but also why
and when he communicates.
No doubt to be honest to patients is essence of clinical ethics,but
square honesty without clinical wisdom may backfire some time.
Patients with physical illnesses are with meagre psychological energy to
cope with and process the undesirable informations and this little shock
absorbing capacity render them very suceptible to negative emotional
reactions.Thus communicating with emotionally unstable patient may be
quite different from the one who is stable.
Therefore to my mind communication with them should be holistic
keeping in view physical ,psychological and social wellbeing.
It is beyond doubt that discussion about illness is important because
it is understood that no illness should be an automatic death sentence for
patients,they have every right to know about it but at the same time
physician should think through the question that ,is it always right to
tell every thing to the patient in one go?
Willard Gaylin, a psychoanalyst and cofounder of the Hasting
Institute in reaction to a policy based on the patient's strict "right to
know" noted the need to distinguish between "truth dumping and truth
telling.
Competing interests:
None declared
Competing interests: No competing interests
Sokol’s attempt to address the unpalatable prospect of deceiving
patients was welcome, but there was one glaring omission from the decision
flowchart which exemplifies the profession’s disinclination to be informed
about difficult truths of their own. Nowhere was considered the necessity
of ‘deceiving’ a patient (by act or omission) for the prevention of great
physical or psychological harm to others. Some doctors are frequently
faced with the decision of whether to be less than entirely truthful with
their subject for the protection of others. In my experience, this is
true of psychiatrists and especially forensic psychiatrists specialising
in the assessment and management of mentally disordered offenders, but no
doubt other doctors are also frequently affected in their routine
practise. An example would be the need to disclose child abuse to
authorities with a parent returning to the victim. Sometimes it may be
possible to discuss fully the need for disclosure, but there are other
times when this would compromise the safety of the potential victim(s).
As alluded to in the summary points, Sokol’s analysis is limited only
to ‘benign deceptions’ where the patient is intended, by whichever means,
to be the recipient of the ethical good. These deceptions are the easy
ones to decide upon.
The difficult decisions arise from situations where the patient is
not the main recipient of any beneficial action and may even receive a
disbenefit (in their eyes at least). Forensic psychiatrists are
frequently requested to assessment the future violence risk/dangerousness
of mentally disordered defendants. Therein lies the possibility of
identifying mental disorder for which treatment might be offered reducing
the suffering experienced by the patient and the risk they pose to other
people. However, an unfavourably review of risks may support more severe
court disposals. Non-participation in such work by doctors would remove
the possibility of treatment for a proportion of defendants. In any case,
the doctors might argue that it is not unethical to use their skills to
protect others.
Sokol’s analysis is founded in the traditional medical ethical
principles of beneficence and non-maleficence. Could it be that the
reason this flowchart cannot fit all doctors be that traditional medical
ethics cannot fit all doctors? Taking forensic psychiatry as a paradigm,
O’Grady has argued that clinician engaged in court work should be guided
by a theory of mixed duties which, in addition to tradition medical
ethics, incorporates justice ethics (truthfulness, respect for autonomy
and respect for the human rights of others)(1). This approach has been
discussed further by the Royal College of Psychiatrists in trying to
elucidate an ethical foundation for providing evidence for sentencing
violent and sexual offenders(2) . Such concern for third parties may
conflict with the duty of a doctor to “make the care of your patient your
first concern” as set out in Good Medical Practice(3).
One response to the worries of those with prominent third party
concerns might be that in making these disclosures, which may include
‘deceptions’, the doctor is acting as a citizen and not a professional,
doing no more than their public duty. Yet, I contend that if such actions
resulted in complaint there is a significant likelihood the matter would
be submitted to the procedures of the GMC. Contemporary professional
ethical guidelines need to be amended to reflect the centrality of third
party considerations to many doctors’ practise. This article, though a
commendable in stimulating discussion of an area many would prefer to
ignore, is axiomatic of mainstream medical satisfaction with guidelines
that may be appropriate and convenient for a majority, but not for a
minority of the profession.
References:
(1)O’Grady J (2002) Editorial: Psychiatric Evidence and Sentencing:
Ethical Dilemmas. Criminal Behaviour and Mental Health, 12: p179-184.
(2)Royal College of Psychiatry (2004) Psychiatrists, Courts and
Sentencing: The Impact of Extended Sentencing on the Ethical Framework of
Forensic Psychiatry. Council Report CR129.
(3)General Medical Council (2006) Good Medical Practice. GMC: London,
p2.
Competing interests:
None declared
Competing interests: No competing interests
Daniel Sokol’s article raises a number of issues that are very timely
and often appeal to the mind and heart of physicians from different
cultures. Some, unfortunately, read it as a “carte blanche” that justifies
deceiving patients when the physician thinks it is for the good of the
patient and hence, a trip backwards towards paternalism. More critical
readers might see in it an exception that applies only to “compassionate
deception.” The danger of course is when readers fail to critically read
through the deception chart which, at its top, states that if the
objectives can be met without recourse to deception, then “use non-
deceptive means to achieve the objectives”. Sokol himself says that “the
demanding nature of the flowchart reflects the stringency of the duty not
to deceive.” When, if at all, is it permissible to deceive a patient in
order to spare him/her distress? The conclusion which states that a “[p]
ropsed deception is morally permissible” is a dangerous one. Deception
undermines the physician-patient relationship and the trust which is at
the center of this fiduciary relationship. Physicians who are willing to
study the chart, use their phronesis and then decide to resort to
compassionate deception, will have to make sure that their act will not
destroy whatever trust their patients (and their future patients) have in
them. Once deception starts, where do you draw the line? Who decides what
‘compassionate deception’ is? How do we know the true harms and benefits
since they cannot really be scientifically measured? Another question that
arises is whether allowing ‘compassionate deception’ is the first step
down a dangerous slippery slope?
Competing interests:
None declared
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The fact that the editors have published this article under a heading
of “ANALISIS” indicates they at least think the question in the title
“Can deceiving patients be morally acceptable?” is worthy. It isn’t
worthy. It’s patronizing.
Professionals generally are patronizing toward the people they claim to
serve, and questions are raised as to whether professions follow
attitudes of leading professions such as medicine.
IT professionals are a convenient case in point. Relative newcomers to the
professions, they use terms like “download” when they mean “get”,
“software” when they mean “how”, “update” when they mean “pay”, “pop up”
when they mean “pushy dealer”. These disguise meaning, much like the
erstwhile Latin speak of medical doctors. But IT professionals don't claim
altuism. I simply refuse to read the article.
Competing interests:
None declared
Competing interests: No competing interests
Lying is fine for the all-knowing
Revisiting Dr Sokol's case study:
'A patient with a ruptured aortic aneurysm is rushed to the operating
theatre. The anaesthetist knows the patient's chances of survival are
poor. Just as preoxygenation is about to begin, the distressed patient
asks "I am going to be all right, aren't I, doctor?"'
Dr Sokol argues that lying is morally acceptable in this situation,
but what if....
The doctor looks the patient in the eye, and says, "To be honest your
chances of surviving this operation are poor."
The patient says, "Write this down for me. Tell Laura I love her as
much as the day I married her and that I forgave her for everything a long
time ago, I am sorry I didnt tell her before this. Tell my son Andrew
that I love him dearly and am SO proud of him. I should have told him
directly. Tell him that my greatest wish for him is that he will be man
enough to express his love to his children. Finally, tell Laura that all
the financial information is in my office draw, thats important because
she will think its at home. And finally, thank you doctor for having the
guts to be straight with me."
Competing interests:
None declared
Competing interests: No competing interests