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Lying to Patients – Is It Ever Ethical?

      Doctors are supposed to tell the truth, both when writing in the medical record and when speaking with patients. Lurid newspaper stories continue to crop up involving doctors who lied to patients and to insurers for financial gain. Some of these individuals are now serving substantial prison terms as a result of these mendacities. Fortunately, such events are rare, and most patients are secure in the belief that their doctor is telling them the truth.
      I am a fan of the Scottish writer, Alexander McCall Smith who grew up in Southern Rhodesia (now Zimbabwe), holds a law degree from the University of Edinburgh, and taught medical law and bioethics for many years at that institution. He is a prolific writer covering a wide range of topics including, among other subjects, a lady detective from Botswana, events in the life of average residents of Edinburgh and London, a professor of Romance languages specializing in Portuguese irregular verbs, and Isabel Dalhousie, a mother in her early forties who is a philosopher and the editor and owner of the journal Review of Applied Ethics.
      Isabel invariably gets herself involved with events in her community where her strong ethical sense often overtakes her more rational self. The resulting conundrums are what makes the books so interesting to read. Of course, this is McCall Smith's area of expertise. In his most recent book in this series, The Geometry of Holding Hands, the question just posed (ie, is it ever ethical to lie?) is one of the central issues.
      • McCall Smith A
      The Geometry of Holding Hands.
      At one point in the novel, the author writes:
      “Now the issue was clear: she could…rely on a lie to save her embarrassment, or she could tell the truth. She thought of Immanuel Kant. He spoiled the comfort of lies for so many people—or at least for those who had read some philosophy; Kant would never have lied. Never. And he was right, of course, although there were circumstances as surely everybody would accept, where it was permissible to lie—to save a friend, for instance, when a murderer intent on killing him asks you his whereabouts. Not only could you lie in such a case, but you might have a moral duty to do so. Kant was wrong to suggest that one would have to tell the truth even in such a case; he was simply wrong. Or Kant himself was lying when he wrote that in the case of the enquiring murderer it would be wrong to lie. He was lying because he did not believe what he said.
      • McCall Smith A
      The Geometry of Holding Hands.
      I imagine that this inner series of thoughts reflects McCall Smith's own attitude toward lying—There are rare circumstances when it is appropriate to lie. The question that I have asked myself is whether such circumstances ever occur in clinical medicine, thus allowing or even mandating that the doctor should lie. Philosophers like to create scenarios such as the one above, mentioned by McCall Smith, in order to examine alternative approaches. Here is one that I just imagined:
      A woman is dying of metastatic cancer. She has been your patient and a friend for many years and has told you disturbing events from her life, including being raped by an older cousin when she was 13 years old. You have just been informed that this cousin has called your office and said that having heard about the impending death of his relative, he is flying in to be with her during her final hours. His plane is delayed, and the patient dies before he arrives at the hospital. He asks to see you and, with tears streaming down his face, tells you of the rape, and how it has tortured him throughout his life. “I just wanted to ask her forgiveness” he says. As her doctor, there are several options for your response. The first option involves telling him that you were told about the rape, and you know that she forgave him in the distant past. The second option is to reassure him that the patient had told you during this hospitalization that she forgave him for this awful event, and that she was at peace with herself. A third option would be to say that this happened a long time ago, and that you were sure she had laid it to rest. None of these statements is, of course, true. As the woman's doctor, you knew that she was deeply troubled by the rape, even in her senior years.
      The question then becomes, do you relieve the incriminated cousin with one of the untrue explanations or do you just say, I am so sorry that this has happened. As I thought about it while writing this essay, I decided that my response would depend on my sense of how repentant I perceived the cousin to be. If he convinced me that he was seriously unhappy and repentant, then I would probably have told him one of the three lies.
      It also occurred to me that this is the same situation faced by Catholic priests and other spiritual personnel when faced with a confession of a serious offense such as rape or murder. Does one offer forgiveness to the offending individual? The Catholic Church does allow the priest to offer forgiveness, but Protestants believe that forgiveness can only come from God and not from any earthly person.

      St. Mary's Catholic Campus Ministry. Why do Catholics confess their sins to a priest? Available at: https://www.sfacatholic.net/why-do-catholics-confess-their-sins-to-a-priest.html. Accessed June 18, 2021.

      What about the legality of lying to patients? Most of us, including myself, at times will not tell patients “the truth, the whole truth, and nothing but the truth,” understanding that such a frank discussion could invoke the nocebo effect. Usually, small lies are told to give the patient or his or her loved ones hope where it otherwise would not exist. For example, telling a family that a person in a coma can hear what they are saying even when it is impossible to know if this were true.
      Almost all doctors tell these types of so-called “white” or benign lies, or rather, untruths. It is not done to deceive those hearing these statements, but instead to help patients and families in dark times.
      Although these types of “white lies” may not be strictly ethical, they are not against the law unless they cause harm to the patient or others. Lies that doctors tell to mask mistakes, cover up medical errors, or disguise fraud are, of course, illegal. Such lies can and do injure patients (physically, emotionally, and financially) and are seriously against the law and are forbidden by our code of ethical behavior.
      I expect that I will receive a lot of emails about this commentary and look forward to the discussion. Feel free to respond at [email protected]

      References

        • McCall Smith A
        The Geometry of Holding Hands.
        Knopf Doubleday Publishing Group, New York, NY2020
      1. St. Mary's Catholic Campus Ministry. Why do Catholics confess their sins to a priest? Available at: https://www.sfacatholic.net/why-do-catholics-confess-their-sins-to-a-priest.html. Accessed June 18, 2021.