The ethics of telling the patient

Abstract

The author, a consultant psychotherapist who works with dying patients in a National Health Service (NHS) hospital, argues that the moral issue is not simply whether or not to tell cancer patients the truth, but more importantly how to do so. Lies and the bald unprepared-for truth may both be damaging. Time and trouble is needed to understand patients and help them understand their situation. Dr Goldie warns that putting oneself into the patient's shoes, as doctors so often do, is the best way ofnot knowing what another feels. Such misunderstanding may lead to medical decisions based on 'nothing more than fantasiesuninspired guesses about what other people think and feel. It is the equivalent ofprescribing for patients without examination'. The question whether or not to tell a patient the truth usually arises in connection with cancer. One would expect it to arise with other diseases but it does not do so. There does not appear to be the same debate about telling patients they have disseminated sclerosis, or coronary disease as there is with cancer. The issue, therefore, is not simply a matter of telling the truth it is a matter of telling the truth in one circumstance and not in another. Thus what the word 'cancer' signifies to the patient is supposed to influence the doctor in his decision to lie about the diagnosis. In fact I believe the decision is more influenced by the doctor's own feelings about cancer than by the patient's. Virtually all patients attending for diagnostic, exploratory, or other procedures, in the early stages of any malignancy, have in mind the possibility of cancer. The doctor's decision, therefore, is not whether to tell the patient the truth, or to deny it, but whether to play out a charade, with the patient, of normal life and prospects, in the presence ofincontrovertible symptoms and signs of the growing cancer. The charade may include other players; a surgeon may tell a spouse not to use the word cancer to the patient and urge a pretence that it is something else by using words like, 'lump', 'ulcer',

Deception, Catholicism, and Hope: Understanding Problems in the Communication of Unfavorable Prognoses in Traditionally-Catholic Countries

“…on the living context which acts as a hermeneutic key" (authors' translation). The truth must be told, for the patient's good and dignity, as the endpoint of a process of communication (Goldie 1982;Vidal 1991). The doctor has to consider potential conflicts and difficulties, focusing his/her actions mainly on how and when to tell rather than on what kind of truth to impart (Ashley and O'Rourke 1997, 405).…”

The goals of communicating bad news in health care: do physicians and patients agree?

“…A primary goal for communicating bad news is to provide patients with clear and complete information about undesirable outcomes. Patients need accurate and clear information to make informed decisions and plan for their future 11–13 . This need for information is the ultimate justification for disclosing bad news 14–16 …”

`Listen, listen trust your own strange voice' (psychoanalytically informed conversations with a woman suffering serious illness)

“…Writing of the application of psychoanalysis in medical settings, Goldie (1982) suggests that ordering experience through language can be a powerful means of surviving and relieving suffering. Psychoanalytically informed conversations, Goldie (1982) believes, might reveal truths for people who are seriously ill. Consequently, the person is freed to act and assume responsibility for his or her life.…”

“…Writing of the application of psychoanalysis in medical settings, Goldie (1982) suggests that ordering experience through language can be a powerful means of surviving and relieving suffering. Psychoanalytically informed conversations, Goldie (1982) believes, might reveal truths for people who are seriously ill. Consequently, the person is freed to act and assume responsibility for his or her life. Nonetheless, the idea of empathic understanding, or putting oneself into the place of another, is rejected by Goldie (1982) as leading to decisions based on the listener's fantasies and uninspired guesses about what a person is feeling.…”

“…Psychoanalytically informed conversations, Goldie (1982) believes, might reveal truths for people who are seriously ill. Consequently, the person is freed to act and assume responsibility for his or her life. Nonetheless, the idea of empathic understanding, or putting oneself into the place of another, is rejected by Goldie (1982) as leading to decisions based on the listener's fantasies and uninspired guesses about what a person is feeling. Goldie (1982) contends that many covert yet injurious forces manifest themselves in hospitals as social systems and group pressures that restrict individual freedom of thought and action.…”