Good lies and bad truths: What's the difference?

Every American knows the story of George Washington chopping down a cherry tree and telling the truth to his father. However, history records that the story is a myth. The cherry tree myth is one of the best-known legends about George Washington. In the original story, young George received a hatchet as a gift and damaged his father’s cherry tree. When his father discovered what George had done, he became angry. Young George bravely said, “I cannot tell a lie…I did cut it with my hatchet.” Washington’s father embraced him and declared that his son’s honesty was worth more than a thousand trees.

The George Washington story illustrates the importance of telling the truth. I would like to share a story of what I considered a good lie. I was discussing with a Jehovah’s Witness patient who was being consented in my office for a radical nephrectomy. The son, who accompanied his father, informs me that he and his father are Jehovah’s Witnesses and that he doesn't want his father to receive any blood or blood products before, during, or after surgery. I asked the father whether that was his wish, and he sheepishly agreed it was his decision as well. I had a consent with the appropriate documentation that would absolve me of any negligence if he should require a blood transfusion.

The night before surgery, I met with the patient alone in his hospital room. He confided in me that he was not as "religious” as his son, and if he needed blood, he wanted to receive the blood, but he requested that I should not tell him or his son if he received the transfusions.

I thought that was a prudent plan of action, and I documented this discussion in the patient's chart.

The surgery was a little more difficult than anticipated, and he lost several units of blood; he had signs of hypovolemia in the immediate post-operative period. At the end of the procedure, I ordered that the blood be given to the patient in the recovery room. I told the nurses not to allow any family members into the recovery room while the transfusions were given. I also had the nurses change the IV tubing after the transfusions were given so that there would be no tell-tale signs of blood in the IV tubing that could be seen by the family. I thought I had everything covered.

After the surgery, I walked out to meet with the family. The son asked me about the surgery, and I told him that his father was stable and in the recovery room. He asked me, “Did my father receive any transfusions or any blood products?” Pow! I know I had the look of a deer stunned by the headlights.

I responded, “Why do you ask?” The son said that someone from the blood bank came into the family lounge during the surgery and asked whether anyone in the family would consider donating blood, as their father was going to receive blood! I thought, do I tell the truth and risk rupturing the rapport between the father and the son? I was concerned about the legal ramifications the truth would subject me to. The other option was to lie to the son, which I considered a good lie. I decided that my responsibility was to the patient and that I would protect the patient’s wishes and preserve his relationship with his son.

Let’s look at the other side of the coin of bad truths. Examples might be:

“Your cancer is advanced. There’s not much we can do.”

“At your age, this surgery probably won’t help much.”

“Your insurance doesn’t cover this, so you’ll have to pay out of pocket.”

I believe we have a responsibility to tell the truth, but the truth should be delivered with empathy and compassion.

Responses to the bad truth examples might be:

“Yes, your cancer is not going to be amenable to standard treatments with surgery, radiation, or chemotherapy. However, I can promise you that I can help make you comfortable, and you will not experience pain or discomfort.”

“I would not recommend surgery for your situation as the risks and complications would be too great. However, there are other options that might apply to your situation, and you won’t face the complications that might occur with surgery.”

“We will check your insurance, and if this treatment is not covered, I will write a compelling letter to your insurance carrier and explain that the treatment is the standard of care and most appropriate for your situation. I have been very successful with this approach in the past, and I am sure we are going to obtain coverage for you.”

The take-home message on bad truths is that telling a bad truth isn’t necessarily about whether something is true, but about the wording used, when it is said, and how your message considers the patient’s emotional state.

Bottom Line: I know that the Good Book says, “Thou shalt not lie.” I am certain that there are exceptions to this heavenly advice. However, if any of the readers have an issue with good lies, reflect on one of your children asking about Santa Claus and the Tooth Fairy!

Neil Baum, M.D., is a professor of clinical urology at Tulane University in New Orleans, Louisiana. Dr. Baum is the author of several books, including the best-selling book Marketing Your Medical Practice: Ethically, Effectively, Economically, which has sold over 225,000 copies and has been translated into Spanish.