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The Truth, The Whole Truth And Nothing But The Truth

A graduate of Kirksville College of Osteopathic Medicine in Missouri, Dr. Duerfeldt is Associate Professor of Family Medicine at Ohio University College of Osteopathic Medicine, where he is also coordinator of the Medical Ethics curriculum. In August 1989, the American College of Physicians published a twopart "Position Paper" on guidelines of medical ethics.' The paper is very thorough beginning with the "Historical View of the Evolution of Medical Ethics" and progressing to such detailed subjects as "Fee Sharing ,""Advertising," and "Physician Strikes." Interestingly, however, there is virtually no mention of any moral obligation "to tell the truth." In fact, the only direct reference to veracity at all is in an historical perspective. (The paper reports that: "Greek medicine . . was pragmatic. It permitted withholding the truth from patient and family if it served the patient's good."2)

The Position Paper came nearest to addressing the subject of veracity and fidelity for the modern physician through several indirect references embodied in these two statements:

"Through effective communication, the [physician/patient] relationship is sealed by understanding, mutual acceptance, trust and respect,"' and "The patient should understand and approve the treatment and should participate responsibly in the care."1

There are some significant shortcomings with general statements like these, and several valid reasons why an official statement regarding the practice of medical ethics remains relatively silent on the issue of veracity. These reasons center around the critical issue of the patient's loss of functional autonomy. To what extent can a patient who is ill "understand," "effectively communicate," or "participate responsibly" in his or her care?

The contemporary ethicist, Mary Crenshaw Rawlinson, points out that "all illness to some degree undermines the autonomy of the sufferers."5 She goes on to note that:

"The more serious the illness, the more the patient becomes dependent upon others not only for treatment, but also for assistance in meeting ordinary responsibilities and in carrying out the usual functions of daily life.

Under the best circumstances, physicians are continually trying to overcome "communication gaps" between themselves and their lay patients. The problem is multiplied many fold when the patient is seriously ill. With these factors in mind, are there times when beneficence may actually demand withholding the burden of "the whole truth" from a patient?

Physicians from Hippocrates to Oliver Wendell Holmes apparently recognized no moral dilemma in the idea of withholding portions of the truth from their patients. In fact, during the vast span of the history of medicine, the concept of paternal beneficence far outweighed any of the physician's other duties, including that of "always telling the whole truth." For centuries the medical profession "vigorously asserted the responsibility of the physician to protect the patient from knowledge that may be harmful to him or her and to practice such deception as may be essential to a cure."7 [emphasis mine] One author accurately observed that what doctors reveal, hold back, or distort, will matter profoundly to their patients. She noted that the reasons doctors give for their deception or concealment include - "not to confuse a sick person needlessly, or cause what may well be unnecessary pain or discomfort, not to leave the patient without hope, or to improve the chances for cure. Lying to patients has, therefore, seemed an especially excusable act."8 Plato reportedly argued that "doctors and only doctors, should be granted the right to manipulate the truth in ways so undesirable for politicians, lawyers and others."9 Likewise, Hippocrates emphasized that practitioners should "calmly and adroitly conceal most things from their patients . . . turning his attention away from what is being done to him . . . revealing nothing of the patient's future or present condition."10

Modem ethical theories, on the other hand, tend to place the respect for personal autonomy above all other duties. Rawlinson notes with some regret that "the traditional benevolent paternalism of the medical practitioner has come to be viewed as an offense against the patient's fundamental and indivisible right of self determination."" Because of this trend, the ancient and time-honored foundation of the physician/patient relationship - "beneficence" - has gradually succumbed to the legalistic principle of "informed consent."12

Much of contemporary ethics derive their basic precepts from the thinking of eighteenth century philosophers like Immanuel Kant. Kant, for example, was vigorous in his defense of absolute truthfulness. He said that "to be truthful (honest) in all declarations is . . a sacred, unconditional demand of reason, and not to be limited by any expediency."13 [emphasis mine] Perhaps Kant's most famous example is the case of the murderer who comes to the door, seeking to learn if his intended victim is at home. Even here, Kant insists that the murderer must be told the truth. His argument for absolute veracity is that in telling the truth "one does not do harm to him who suffers as a consequence; accident causes this harm."14 "To Kant the individual who so corrupts his or her own soul [by withholding the truth] is the most contemptible of creatures."15

Is Kant's allegiance to absolute veracity in every circumstance reasonable? Is it Biblical? Is it even possible? One notable Harvard philosopher, L.J. Henderson, once commented:

"To speak of telling the truth, the whole truth and nothing but the truth to a patient is absurd. Like absurdity in mathematics, it is absurd simply because it is impossible . . . the notion that the truth, the whole truth and nothing but the truth can be conveyed to a patient is a good specimen of that class of fallacies called . . . "the fallacy of misplaced concreteness."16

To adequately consider the Biblical perspective, perhaps we, like Pontius Pilate, should ask, "What is truth?"17 Jesus had a great deal to say about the truth. For example, He said that the Spirit of Truth would be the believer's constant companion" and guide." He said the truth would give us freedom.18 He also said, He Himself was the truth.19 In addition, the Apostle John wrote, "For the law was given through Moses; grace and truth came through Jesus Christ." On the surface this sounds reasonably straightforward. If we are followers of Jesus Christ and are being led by His Spirit, there is no room for untruthfulness in our words or actions. However, the Biblical ethic of "truthfulness" is somewhat more complex. John Murray, in his excellent book, Principles of Conduct, makes the following observation:

"Truth in these passages does not simply mean true in contrast to false - fact in contrast to fiction. The law is not false or untrue. Truth is the absolute as contrasted with the relative, the permanent as contrasted with the temporary, the complete in contrast with the partial, the substantial in contrast with ethereal, the eternal as contrasted with the temporal."23

"Therefore, when Jesus says, `I am the truth,' He is stating the fact that He embodies the ultimate, the eternal, the absolute, the underived, the complete. Such a concept broadens our definition of truth. To Biblical writers "truth" is more then simply fact versus fiction, or true versus false."24

The Bible throughout both Old and New Testaments affirms that to speak or to live a lie is a sin against God. 25,26,27,28,29 However, a strong Biblical case can be made (1) that deliberate falsehood or deception is one thing, (2) falsehood in understanding or limited knowledge is another and, (3) concealment of truth is still another.

Undoubtedly, the classic and most widely discussed cases of partial disclosure of the "full truth" involve the diagnosis of cancer. Beauchamp and Childress, in their book Principles of Biomedical Ethics, point out that there has been a dramatic shift in physicians' practices of disclosure over the past three decades.30 They go on to show that the reasons for this shift appear to have little to do with any sense of moral obligation to veracity.

"The reasons for the changes include the availability of more treatment options for cancer (including experimental treatments), improved rates of survival . . . fear of malpractice suits, involvement of [multiple health care] professionals, altered social attitudes about cancer, and increased attention to patients' rights."31

Unfortunately, a patient's "right to information" may take a back seat to a number of other considerations. As the physician struggles with the reality of the patient's loss of functional autonomy, issues such as the patient's age, intelligence, and emotional stability begin to surface. Also, not surprisingly to those of us in clinical practice, the pressures of "family wishes" often play a significant role in a physician's decision to disclose information. In fact, in a 1979 survey, 51% of physicians identified "a relative's wishes regarding disclosure to the patient" as the deciding factor!32 This unsettling statistic prompted Beauchamp to raise the pointed question:

"By what right did the physician initially disclose information to the family without the patient's consent?"33;

The implied answer, of course, is the physician had no right to do so!

Consider the following scenario:

A 62 year old man comes to a clinic for an annual checkup. The patient has no symptoms and has no reason to believe that he is not perfectly healthy. He adds that he is planning a two-week vacation as soon as possible. His attending physician is additionally aware that the gentleman is currently undergoing psychiatric counseling for depression and a suicide attempt six months ago. The patient seems willing to discuss his counseling openly, and says he "is feeling better."

On physical examination, the physician discovers an enlarged and nodular prostate. He is concerned that the nodule may be malignant and would like to obtain a biopsy. If the biopsy is positive, because of the size of the nodules the prognosis would be very poor even with extensive chemotherapy. The physician is convinced that chemotherapy would only add to the misery of the patient's last days.

For the physician there are now several choices involving truthfulness. Should he tell the patient what he has learned, or conceal it? If asked, should he deny it, fearing a relapse of the patient's depression or another suicide attempt? If he decides to reveal the diagnosis, should he delay doing so until after the patient returns from his vacation? Finally, if the physician does reveal the serious nature of the diagnosis, should he mention the possibility of chemotherapy and his reasons for not recommending it in this case? Or should he encourage every last effort to postpone death?34

Physicians encounter these kinds of choices almost daily, and often under much more urgent circumstances. How should the Christian physician respond to these issues? For many modem ethicists,35,36,37 as well as Kant, these are really non-issues, because all cases of deception are morally reprehensible. However, we shall see that there are examples in Scripture which seem to suggest that the "issue of truthfulness" may not always be so straightforward.

Let us look particularly at the issue of "concealment," i.e., withholding a part of the whole truth. The Bible gives several examples when concealment appears to be both justified and commended by God. Perhaps one of the most pointed examples is found in 1 Samuel 16. In this passage of Scripture, the Lord himself gives Samuel the following instructions:

"Fill your horn with oil, and go; I will send you to Jesse the Bethlehemite, for I have selected a king for Myself among his sons. But Samuel said, 'How can I go? When Saul hears of it, he will kill me.' And the Lord said, 'Take a heifer with you and say [to Saul]. I have come to sacrifice to the Lord."38

Without a doubt, here is Divine authorization for concealment of the truth. Samuel is instructed to speak a statement which does not disclose the primary purpose of his visit to Jesse. One may call this "evasion," but regardless of semantics, the general issue is concealment of the essential facts of Samuel's mission.

The case of Elisha the prophet is similar. The King of Syria has surrounded the city of Dothan for the purpose of capturing Elisha. By Divine intervention the Syrians do not recognize Elisha when he comes out to them and says, "This is not the way, nor is this the city; follow me and I will bring you to the man whom you seek."39 Elisha then leads the Syrians to Samaria where they, in turn, are surrounded by Israelite forces. After revealing his identity to the Syrians, Elisha persuades the King of Israel to show them mercy. The Syrians agree to leave the country in peace. "The marauding bands of Syria did not come again into the land of Israel."40

A third Biblical example of concealment is found in the story of the Hebrew midwives and Pharaoh. Pharaoh castigated the midwives for their failure to kill the male children born to the Hebrews.

"So the King of Egypt called for the midwives, and said to them, 'Why have you done this thing and let the boys live?' And the midwives said to Pharaoh, 'Because the Hebrew women are not as the Egyptian women, for they are vigorous, and they give birth before the midwife can get to them.' So, God was good to the midwives."41

These examples make it apparent that it is proper, under certain circumstances, to conceal or withhold part of the truth. It is an important distinction to note, however, that in all three situations it does not appear as if actual untruth was ever involved. Samuel did come to sacrifice. Elisha did lead them to the man they were seeking. And there is good reason to assume that many Hebrew women did deliver their children without the benefit of midwives.

This raises another question: Is there a moral difference between the act of lying and the inaction of withholding the truth? At times, the distinction between "lying" and "concealment" may appear to be a subtle one. Nevertheless, the distinction is crucial to our understanding of the question of truthfulness. Philosophers have struggled over this difference for many years. For example, the contemporary ethicist, Robert Veatch, writes:

"It may, in part, hinge upon the different relationships that may be established in the two cases. In an action (telling a lie) the actor invariably thrusts himself or herself into a relationship with another party. Morally and legally, the actor is in the causal nexus. Once the actions follow their way through the causal chain to their impact on the other party, we can say that the actor was responsible for the outcome. Whether the outcome was intentional or not, whether it was good or bad, the causal chain is established in such a way that responsibility is attributed. In omissions (withholding the truth), however, the pattern is more complex. There is still a causal chain such that if the actor had done some other particular act, a different impact would have been felt by the other party . . . but we do not conclude in the same way that [the actor] was responsible for the [outcome] . . . it was, of course, in this [actors] power to have acted differently, changing the causal chain [but he] was not in either nexus of responsibility until he chose to enter one of diem."42

John Murray in Principles of Conduct explains the distinction this way:

"It is quite true that the Scripture warrants concealment of truth from those who have no claim upon it. We immediately recognize the justice of this. How intolerable life would be if we were under obligation to disclose all the truth. And concealment is often an obligation which truth itself requires . . . [emphasis mine] It is also true that men often forfeit their right to know the truth and we are under no obligation to convey it to them. But these facts of the right and duty of concealment and of forfeiture of certain rights are not to be equated with our right to speak untruth. . . there is a chasm of difference between the forfeiture of right to know the truth which belongs to one man, and the right to speak untruth on the part of another."43

The Dictionary of Christian Ethics concludes that "concealment of truth does not necessarily constitute lying"44 and, we "are not always obligated to reveal everything."45

The extreme complexity of the issue of truthfulness for the Christian cannot be fully appreciated without at least a brief reference to the more difficult case of Rahab and the Israelite spies. In this example, we are fully confronted with a situation where Rahab does not simply "conceal the truth;" but rather she fabricates a deliberate lie:

"But the woman [Rahab] had taken the two men and hidden them, and she said, 'Yes, the men came to me, but I did not know where they were from, and it came about when it was time to shut the gate at dark that the men went out; I do not know where the men went.' But she had brought them up to the roof and hidden them in the stocks of flax . . ."46

To Kant, this would be an exact equivalent of his case of the murderer coming to the door, asking the whereabouts of his intended victim. Thus, according to Kant, one must refuse to commit even the benevolent lie, because its commission "vitiates one's very status as a moral agent."47 Kant therefore, would condemn Rahab's action as blatantly immoral.

Kant's judgment notwithstanding, the Word of God appears to take an entirely different view of Rahab's behavior. Despite her lie (or perhaps because of it) she is listed in the Scripture as "having gained approval through [her] faith"48 and as one of the giants of faith "whom the world is not worth."49 Scripture would seem to suggest, that when it comes to the preservation of human life, there are circumstances when even a deliberate lie is occasionally justified.

Even setting aside the extreme example of Rahab, one can still conclude that there is ample, valid, Scriptural justification for acts of concealment. Nevertheless, even if we agree that concealment is not lying, does concealment or deception have any place in the physician-patient relationship?

Veatch argues that withholding information from a stranger with whom there is no special duty to communicate is one thing, "withholding information while in a special contractual relationship, however, is quite different . . . in such a situation withholding information that is reasonable to suspect the other person would find meaningful is a violation of that covenantal bond."50

John Murray uses much the same reasoning when defending Samuel's concealment of purpose from Saul or the Hebrew midwives concealment from Pharaoh. Neither Samuel nor the midwives, Murray says, had a "covenantal duty" to disclose "the whole truth."51

The physician, on the other hand, does have that duty based upon the covenantal physician-patient relationship which has been established. Veatch points out that it is human nature

"to possess the capacity for rational and free choice and to make covenantal relationships both as individuals and moral communities. If this is a reasonable understanding of the human, then there seems to be something dehumanizing about a refusal to have the knowledge necessary to be an active and equal participant in decision making."52

Unfortunately, the grim reality is that illness is itself "dehumanizing." By definition, illness precludes culpability. When one is ill, one is absolved (at least temporarily) from one's normal responsibilities. This is entirely appropriate, because illness usually imposes both mental and physical debilitation upon the patient, frequently to a severe degree. The very sick patient is often entirely unable to "be an active and equal participant in decision making." Similarly, nearly every clinician has experienced situations where simply giving the news of a serious illness may drive some patients to irrational or destructive behavior. One physician, for example, recounts the following incident:

"A distinguished philosopher forestalled my telling him about his cancer by saying, `I want to know the truth. The only thing I couldn't take and wouldn't want to know about is cancer.' For two years he had watched his mother die slowly of a painful form of cancer."53

An incident like this is not a rare or isolated event. Such encounters occur to nearly every physician, every day. Illness and disease are dehumanizing. From time immemorial, Satan has used all human infirmities to rob our patients of that precious quality we call "functional autonomy." It was Jesus Himself who pointed out it is "The thief (Satan) [who] comes to kill, steal and destroy."54 A physician cannot take from his patient that which has been taken by another. Indeed, it is because of this very fact that the "beneficience of concealment" seems most humane and apropos. The moral issue of concealment hinges not on the act itself, but rather on the motive behind the act. Rawlinson succinctly notes that,

"In deceiving the patient, the physician's purpose is not actually to deceive, but to cure. The deception . . . should be practiced only to the degree that it is therapeutically necessary. And the physician's allegiance to his or her duty to benefit the patient distinguishes him or her morally from the individual who merely lies out of self-interest."55

Other physicians agree with Rawlinson. "Honesty should be evaluated not only in terms of slavish devotion to language, but also in terms of intent. The crucial question is whether the deception was intended to benefit the patient or the doctor."

There is, without question, a covenantal relationship between a physician and his patient which imposes upon the physician a duty to provide clear and accurate information to the patient under his care. However, insofar as the patient's illness makes him or her unable to adequately process or act upon that information, the physician is not obligated to always disclose "the whole truth." When Paul admonishes the Church to "speak the truth in love"" he is setting love above truth as the modifying factor. In fact the Dictionary of Christian Ethics goes so far as to state that, "the concealment of truth may well be the proper action which certain situations call for and require."" [emphasis mine] For the Christian physician, therefore, there may be times when the love of Christ compels him to seek God's Wisdom as to "how much truth" should be revealed. Neither duty nor Divine directive ever demand blind and callous allegiance to "the truth, the whole truth, and nothing but the truth."

References

1. Annals of Internal Medicine, Vol. 111, No. 3 (1 August 1989) pp 245252 and No. 4 (15 August 1989) pp 327-335

2. Ibid. p. 246

3. Ibid. p. 248

4. Ibid. p. 248

5. Rawlinson, M.C. "Truth Telling and Paternalism in the Clinic: Philosophical Reflections on the Use of Placebos in Medical Practice," Placebo: Therapy, Research and Mechanisms, White, Tursky, and Schwartz (Editors), Guilford Press, N.Y., 1985, p. 414.

6. Ibid. p. 414

7. Ibid. p. 405

8. Bok, S. "Lies to the Sick and Dying," Munson, R., Intervention and Reflection: Basic Issues in Medical Ethics, Wadsworth Publishers, Belmont, CA, 3rd Ed., 1988, p. 239.

9. Ibid. p. 239

10. Hippocrates, "Decorum," Hippocrates (Vol. 2), Harvard University Press, Cambridge, MA, 1979

11. Rawlinson, op, cit., p. 403

12. Ibid. p. 403

13. Kant, Immanuel, "On the Supposed Right to Tell Lies From Benevolent Motives," translated by TA. Abbot, in Kant's Critique of Practical Reason and Other Works on the Theory of Ethics, Longmans Pub., London, 1909, pp 361-365.

14. Rawlinson, op. cit., p. 412

15. Ibid., p. 413

16. Liplin, Mack, "On Telling Patients the Truth," Munson, R. Intervention and Reflection: Basic Issues in Medical Ethics, op. cit. p. 237

17. John 18:38 (NAS)

18. John 14:17

19. John 16:13

20. John 8:32

21. John 14:6

22. John 1:17 (KJV)

23. Murray, J. Principles of Conduct, Win. B. Eerdmans Pub. Co., Grand Rapids, Ml, 1957.

24. Ibid.

25. Exodus 20:16

26. Exodus 23:1

27. Exodus 23:7

28. Zechariah 8:16-17

29. Ephesians 4:25

30. Beauchamp, T .L. and Childress, J.F, Principles of Biomedical Ethics, (2nd Ed.), Oxford University Press, NY, 1983, p. 311

31. Ibid. p. 311

32. Novack, Dennis H., "Changes in Physicians' Attitudes Toward Telling the Cancer Patient," JAMA, Vol. 241, 1979, p. 897-900

33. Beauchamp, op. cit., p. 312

34. Adapted from Bok, S., op. cit., p. 239

35. Bok, Sissela, Lying: Moral Choice in Public and Private Life, Pantheon Books, NY, 1978

36. Beauchamp and Childress, op. cit.

37. Veatch, R.M., A Theory of Medical Ethics, Basic Books, NY 1981

39. I Samuel 16:1-2 (NAS) II Kings 6:19 (NAS)

40. II Kings 6:23 (NAS)

41. Exodus 1:19-20 (NAS)

42. Veatch, op, cit. p. 224

43. Murray, J., op. cit. p. 146-7

44. Henry Carl E (Ed.), Baker's Dictionary of Christian Ethics, Baker Book House, Grand Rapids, Ml, 1973, p. 401

45. Ibid. p. 401

46. Joshua 2:4-6 (NAS)

47. Rawlinson, op. cit., p. 412

48. Hebrews 11:39

49. Hebrews 11:38

50. Veatch, op. cit., p. 225

51. Murray, op. cit., p. 140

52. Veatch, op. cit., p. 218

53. Lipkin, Mack, "On Telling Patients the Truth," Newsweek, 4 June 1979, p. 13 John 10:10

54. Rawlinson, M.C., op. cit., 412

55. Lipkin, M., Newsweek.- OP- Cit., P. 13

56. Ephesians 4:15

57. Henry, C.F., op. cit., p. 679

[ JBEM Index / Volume 4 / Number 3 ]

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