If there's one thing sacred in the doctor-patient relationship, it's trust. Open and honest dialogue on both sides of the exam table is by all accounts critical to effective care. Patients have to be truthful to ensure diagnostic accuracy and an appropriate treatment plan, while doctors need to provide full disclosure about their patient's health — the good and the bad— to help patients make informed decisions. Indeed, patient autonomy is the cornerstone of modern medicine and patient-centered care.
That patients are entitled to the truth, then, is a given, but just how much doctors are obligated to reveal is in fact a matter of much debate — particularly as it relates to the sick and dying. Physicians are often forced to balance compassion with the patient's right to know. There are patients, for example, who are too emotionally frail to be told about the progressive symptoms of their disease. There are accident victims who are alert enough to learn of a loved one's death — but whose relatives ask that the news be delivered later by a family member. There are elderly patients with dementia who would be mercilessly forced to relive the loss of a spouse on a daily basis. There are adult children who demand that you spare their elderly parent from a grim diagnosis. And there are patients whose cultural beliefs differ greatly on the topic of medical disclosure. Such scenarios beg the question: Is it ever appropriate to spin the truth or withhold information from a patient? Is it ever OK to lie?
"There are rarely cut and dry ethical issues because you've got competing interests," says Nancy Berlinger, a research scholar who specializes in end-of-life healthcare ethics at The Hastings Center, an independent bioethics research institute in Garrison, N.Y. "It's very complex. No one in medicine gets up in the morning and says, 'I'm going to lie to people today.' It's more about saying, 'How do I balance my obligation to be truthful with my desire to be compassionate and how does that work, really, in practice?'"
Informed consent wasn't always the mantra. Thirty years ago, cancer patients in the United States were frequently misled about the extent of their illness. "I remember being in medical school years ago and being distinctly told that when a person has lung cancer, never tell them they have lung cancer," says Peter Dixon, a former oncologist and current primary-care doctor with a geriatric group in Essex, Conn. "We were told to give them a dose of morphine and wash our hands of it. Things have certainly changed." Today, doctors are expected to treat patients as partners, delivering a complete picture of their prognosis and treatment options so patients can take an active role in their own healthcare.
Aside from the ethical mandate of truth telling in the modern age of medicine, physicians in most states are also legally obligated to disclose all relevant health information to patients. At least one exception, however, exists. Earlier this year, the Oklahoma legislature passed a law that prevents women who give birth to a disabled child from suing a doctor who misled them or outright lied about the health of their baby while they were pregnant — including cases where the fetus had a fatal anomaly that would not allow it to live outside the womb. Bill sponsors say the law is designed to prevent lawsuits by women who wish, later on, that their doctor had counseled them to abort. But opponents say it protects physicians who mislead pregnant women on purpose, to prevent them from having an abortion.
Sean F. X. Dugan, a medical malpractice defense trial lawyer and senior partner with Martin Clearwater & Bell LLP in New York, says he's also starting to see some "cracks in the citadel" over which parties physicians are obligated to be truthful to. "The law clearly indicates that the physician's fiduciary obligation runs to her patient — period," says Dugan, "But over my 30 years in practice, I've seen that iron-bound rule start to crack." In recent years, he notes, several lawsuits have been passed up through the courts in which a physician informed the spouse of a patient who was diagnosed with a life-threatening sexually transmitted disease. "Once, that would have been summarily dismissed, but now we as a society are beginning to dip our toe in the water," says Dugan. "Some courts are now beginning to say that maybe, under those circumstances, the doctor should go beyond the physician-patient relationship, and that they have a duty to disclose information to another party if they know someone is in danger." Where to draw that line is the trick. Consider patients with a contagious and deadly disease who live with someone they are not married to, or with young kids.