Beware the lies of patients

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A decade ago I started my PhD. I took great pride in the simplicity of my research question, which was reducible to eight words: “Should doctors always tell the truth to patients?” The answer, after three years of hard labour, was “most of the time.” The other 99 000 words merely elaborated on that answer, but there was one digression that examined how patients deceive doctors.

This fascinating and understudied issue appears in the Hippocratic corpus in the 4th and 5th centuries BC. One passage advises readers to “keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed.”1

In the early 1990s Burgoon and colleagues reported that 85% of the patients they interviewed admitted concealing or equivocating about information to their doctors, and roughly a third claimed to have lied to their doctors.2

Patients deceive doctors for various reasons. With some patients, the deception forms part of their attempt to assume a “sick role,” as in factitious disorders such as Münchausen’s syndrome. Other patients deceive to get disability benefits, to maximise damages in personal injury litigation, to avoid a sojourn in prison, or, in countries with mandatory military service, to evade conscription.3

Some patients deceive to enjoy the shelter, warmth, and food of the hospital. One doctor told me of a homeless patient in his hospital’s emergency department who claimed to have no sensation in his legs but who jumped up in agony when pricked with a pin.

In my doctoral research patients and doctors identified ways in which patients feigned ignorance to obtain an independent second opinion or even to “test” the knowledge of an unfamiliar doctor.

Ten years on I read medicolegal reports on a weekly basis about patients with whiplash injuries sustained in road traffic crashes. Some of these reports detailed injuries that seemed grossly disproportionate to the violence of the impact. One senior member of the insurance industry told me that some doctors were flown in from abroad to examine patients one after the other in a cheap hotel room and draft brief medicolegal reports on a pro forma document before returning to their country of origin. At least some of these doctors were complicit in the lies of patients told to insurance companies.

General practitioners will know of patients who claimed that they could not bend their back but effortlessly picked up a magazine from the low table in the surgery’s waiting room or those who averred that they could barely walk without excruciating pain but could be seen outside ambling in apparent comfort. Some patients present with unexplained pain and insist that only strong opioids can soothe the pain. These patients join online groups giving tips on ways to get the desired drug. When the GP or other staff explore non-opioid alternatives, the patients may not be interested.

In my work on academic appeals, university students often get letters from doctors, written months after the event, stating that they were unwell (depressed, usually) at the time of the exam. The doctors’ letters are based solely on the student’s account, sometimes in exchange for a fee.

Doctors are advocates for patients. They must act in the best interests of their patients and respect their autonomy. Yet these are not absolute injunctions. Doctors are moral agents whose autonomy is also deserving of respect. Complying with the requests of patients must not undermine clinicians’ moral and professional integrity. If a request requires the doctor to act in a manner that is morally wrong (such as making them complicit in fraud) or not medically indicated, then the doctor should politely decline.

Barristers are occasionally asked to make arguments by the lay client or the client’s solicitors that they believe is hopeless. Only last week I was asked to recover the cost of an item that, in law, was plainly irrecoverable. “Give it a go,” the solicitor said. The Bar Code of Conduct states that a barrister “must not make a submission [in court] which he does not consider to be properly arguable.” The same principle should apply to doctors: their actions must, from a medical perspective, be properly arguable. If doctors could not defend their action, or omission, to a group of peers, then they should turn down the patient’s request and suggest a second opinion.

The manner in which this is done is important. It should be without a hint of reproach. In some cases, however, the relationship will be irretrievably damaged, however diplomatic and sensitive the doctor’s language. As complaints may follow, doctors should keep detailed and objective notes of the clinical findings and the encounter generally.

It is true that complicity in the deception may be the easier option (at least in the short term), avoiding a potentially long and awkward discussion. Sadly, however, doing the right thing is sometimes more onerous than the alternatives.