TO LIE OR NOT TO LIE—THE DOCTOR's DILEMMA

Sissela Bok

Should doctors ever lie to benefit their patients—to speed recovery or to conceal the approach of death? In medicine as in law, government, and other lines of work, the requirements of honesty often seem dwarfed by greater needs: the need to shelter from brutal news or to uphold a promise of secrecy; to expose corruption or to promote the public interest.

What should doctors say, for example, to a 46-year-old man coming in for a routine physical checkup just before going on vacation with his family who, though he feels in perfect health, is found to have a form of cancer that will cause him to die within six months? Is it best to tell him the truth? If he asks, should the doctors deny that he is ill, or minimize the gravity of the illness? Should they at least conceal the truth until after the family vacation?

Doctors confront such choices often and urgently. At times, they see important reasons to lie for the patient's own sake; in their eyes, such lies differ sharply from self-serving ones.

Studies show that most doctors sincerely believe that the seriously ill do not want to know the truth about their condition, and that informing them risks destroying their hope, so that they may recover more slowly, or deteriorate faster, perhaps even commit suicide. As one physician wrote: "Ours is a profession which traditionally has been guided by a precept that transcends the virtue of uttering the truth for truth's sake, and that is 'as far as possible do no harm'."

Armed with such a precept, a number of doctors may slip into deceptive practices that they assume will "do no harm" and may well help their patients. They may prescribe innumerable placebos, sound more encouraging than the facts warrant, and distort grave news, especially to the incurably ill and the dying.

But the illusory nature of the benefits such deception is meant to produce is now coming to be documented. Studies show that, contrary to the belief of many physicians, an overwhelming majority of patients do want to be told the truth, even about grave illness, and feel betrayed when they learn that they have been misled. We are also learning that truthful information, humanely conveyed, helps patients cope with illness: helps them tolerate pain better, need less medicine, and even recover faster after surgery.

Not only do lies not provide the "help" hoped for by advocates of benevolent deception; they invade the autonomy of patients and render them unable to make informed choices concerning their own health, including the choice of whether to be a patient in the first place. We are becoming increasingly aware of all that can befall patients in the course of their illness when information is denied or distorted.

Dying patients especially—who are easiest to mislead and most often kept in the dark—can then not make decisions about the end of life: about whether or not they should enter a hospital, or have surgery; about where and with whom they should spend their remaining time; about how they should bring their affairs to a close and take leave.

Lies also do harm to those who tell them: harm to their integrity and, in the long run, to their credibility. Lies hurt their colleagues as well. The suspicion of deceit undercuts the work of the many doctors who are scrupulously honest with their patients; it contributes to the spiral of lawsuits and of "defensive medicine," and thus it injures, in turn, the entire medical profession.

Sharp conflicts are now arising. Patients are learning to press for answers. Patients' bills of rights require that they be informed about their condition and about alternatives for treatment. Many doctors go to great lengths to provide such information. Yet even in hospitals with the most eloquent bill of rights, believers in benevolent deception continue their age-old practices. Colleagues may disapprove but refrain from objecting. Nurses may bitterly resent having to take part, day after day, in deceiving patients, but feel powerless to take a stand.

There is urgent need to debate this issue openly. Not only in medicine, but in other professions as well, practitioners may find themselves repeatedly in difficulty where serious consequences seem avoidable only through deception. Yet the public has every reason to be wary of professional deception, for such practices are peculiarly likely to become deeply rooted, to spread, and to erode trust. Neither in medicine, nor in law, government, or the social sciences can there be comfort in the old saying, "What you don't know can't hurt you."