Truth Telling and Withholding Information

1. Idara C. Eshiet Truth Telling and Withholding Information

2. Case 1 • Mr. Z, a 70 year- old Cantonese – speaking man, with a change in bowel habits and weight loss is found to have Colon cancer. The daughter and son ask the physician not to tell their father that he has cancer. They say that people in his generation are not told they have cancer and that if Mr. Z is told he will lose hope.

3. Reasons given for deception and nondisclosure • It prevents serious harm to patients • It is culturally appropriate • It may enhance patient autonomy • There are no less problematic alternatives

4. Reasons against deception and nondisclosure • Most patients want to know their diagnosis and options for care • Patients need information for decisions • Disclosure has more beneficial than harmful consequences • It requires more deception • It might be impossible • Abuses might occur

5. When is It justified to withhold the truth from the patient? • If the physician has a compelling evidence that disclosure will cause real and predictable harm. E.g. Disclosure would make a depressed patient actively suicidal. • If the patient him or herself states an informed preference not to be told the truth.

6. Resolving Dilemmas about deception and nondisclosure • Determine what the patient wants • Elicit the family’s concerns- finding alternatives validate the family’s feelings as the natural reactions of loving relatives. • Focus on how to tell the diagnosis, not whether to tell- explain to the family how disclosure of bad news can be done in supportive ways that help patients cope.

7. Physicians should soften bad news by being compassionate, responding to the patient’s concerns, offering empathy and helping mobilize support. • If you are withholding information, then plan for future contingencies. • Maintain Transparency and Accountability • Respect patient’s preferences

8. For case 1 above, what is the best action you will take? • “ what do you fear most about telling your father he has cancer? • “ I have to tell your father of the diagnosis” • “ since you all agree about not telling your father, I won’t tell him” • “ my not telling your father his diagnosis might present it’s own problems”

9. Deception or Nondisclosure to third parties A patient asks a physician to sign a form excusing an absence from work. He says that he had a severe upper respiratory infection, but has now recovered. The physician did not see the patient while he was ill.

10. Resolving Dilemmas about Deception to Third parties • Consider whether an important health benefit is at stake – you need to ask in what sense you are helping the patient • Deception might not be necessary • Exhaust other alternatives • Involve patients who request deception

11. Is it ethically justifiable to deceive a patient with a placebo? The deceptive use of placebos is not ethically justifiable. Specific exceptions should be rare and only considered when the following conditions are met: • The condition is known to have a high placebo response rate. • The alternatives are ineffective and / or risky.