Bioethics Discussion Blog: Is It OK for Doctors to Lie?

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Thursday, January 10, 2008

Is It OK for Doctors to Lie?

If, after reading the title of this thread by those visitors to my blog who are NOT doctors, may well respond with "that is the dumbest question I ever heard! Of course, it's NOT OK for doctors to lie!". Well, perhaps it would be educational for that visitor to take a little quiz and see the issue of lying with the eyes of a doctor who has a trusting and therapeutic relationship with a patient.

This quiz (which was modified slightly by myself) was written by Martin Donohoe, MD, FACP who is adjunct lecturer in the Department of Community Health at Portland State University and a hospitalist at Kaiser Permanente Sunnyside Hospital. He serves on the Board of Advisors of Oregon Physicians for Social Responsibility (PSR) and is Chief Scientific Advisor to Oregon PSR’s Campaign for Safe Foods. His website is "Public Health and Social Justice" bears the text of the original quiz and many more tools for public and professional education about the medical issues covered by the website title. Please go there by clicking on the link. You will find the site expansive in terms of issues covered (from food and safety to women's health and women's rights). It is a valuable resource.

BUT FIRST, before you go. TAKE THIS QUIZ. But pretend you are a DOCTOR. Consider the nuances regarding lying which a doctor might have to face. And then write your answers as comments to this thread. This quiz is not as simple as it might at first appear. ..Maurice.


THE ART OF MEDICINE:

TRUTH-TELLING IN MEDICINE
============

AS A PHYSICIAN:

I. Would you “lie” in the following situations?:

1. A 26 year old male presents to the ER after suffering a radial fracture in an auto accident in which he was driving. He appears intoxicated, and a blood alcohol level is 0.17. When he sobers up, he asks you not to report him to the DMV, as he is afraid of losing his license. Do you report him?

- yes?

- no?

- only if he hit another vehicle, rather than, say a lightpost?

- only if someone else was injured in the accident?

- if he’s a bus driver, would that influence your decision?

- if he’s a pizza delivery guy, and needs the job to support his sick infant?

2. A 33 year old female is admitted to the ICU with severe pneumonia. Evaluation is consistent with PCP pneumonia, and an HIV test is positive. She dies after 3 days. Her parents request that you leave the diagnoses of AIDS and PCP off of the death certificate. Do you accede to their request?

- yes?

- no?

- if she is a celebrity or public figure, and the media may find out and inform the public?

- if the parents are fundamentalist Christians, and were the obituary to read AIDS, they tell you that they might be ostracized from their church?

3. A 45 year old licensed Nurse Practitioner at University Hospital comes to your office with symptoms of major depression. She requests that you do not include any information on her mental illness on the chart. She is afraid that one of her colleagues may access the computerized medical record and discover she is taking antidepressants, and that this could lead to her being ostracized or even losing her job. How would you handle this situation?



II. Would you lie in any of the following situations?

- diagnosis of cancer (at patient’s family’s request)

- STD (sexually transmitted disease) (at patient’s request)?

-“fudging” date of disease onset to avoid patient’s being classified as having a pre-existing condition?

- assuring an anxious patient that the surgeon he’s chosen is well-qualified, if you know her to be shaky? unsafe? alcoholic?

-Record the degree service provided as less than what occurred for the visits for self-pay patients?

- Record the degree service provided as greater than what occurred for the visits for well-insured patients?

III.. Finally, Is it OK for doctors to lie?

- always?

- never?

- sometimes? (If so, when? who decides?)

13 Comments:

At Friday, January 11, 2008 3:11:00 PM, Anonymous Anonymous said...

We had a medical director of an ambulatory surgical center lie to us regarding who would be doing a personal intimate surgical skin prep on the genital area. We reported it to the medical board of the state. It is okay for a doctor to lie according to the medical board. That is WRONG!!

 
At Friday, January 11, 2008 4:04:00 PM, Blogger Maurice Bernstein, M.D. said...

The moral significance of a lie is related to the intent of the one who is said to have lied. It is impossible to tell from the information supplied by Anonymous whether the medical director intentionally lied or did this unexpected person to do the skin prep was simply a necessary logistic switch without you being informed in advance. Hopefully you spoke to the medical director after the procedure and without naming names what was the explanation given? ..Maurice.

 
At Saturday, January 12, 2008 1:17:00 PM, Blogger #1 Dinosaur said...

Many of the situations in your quiz are problematic:

1. Drunk driving may or may not be a reportable offense, but it would be to the police and not the DMV, and would not automatically result in loss of the license. Or were you trying to imply a situation that would result in loss of a license? In most such cases reporting is mandated, and I would have to inform the patient that I do not have a choice. ie, No, I wouldn't lie.

2. Death certificate data doesn't have to show up in an obituary. In general, I would say it's pretty hard to imagine a scenario where actual harm could be caused by accurate death certificate data. Perhaps fudging the date of death (if it were near enough to midnight) for insurance purposes, either medical or life. I don't know if I would do that.

3. Although many patients with mental conditions such as depression (although more so with bipolar) are concerned about stigmatization at work, they are usually wrong in this day and age. I submit that the fear and request of the patient described is more a symptom of her depression that should be directly addressed. There ought to be access limitations on an EMR, and accessing a fellow worker's medical record, much less acting on it, are likely a firing offense at a "University Hospital."

I am more likely to lie by stating that the diagnosis for the visit is "fatigue" or some other physical symptom (while still documenting the psychiatric symptomatology in the note) because several insurers who have "carved out" behavioral health have decided not to pay me for "psychiatric" visits, ie, visits with a psychiatric ICD-9 diagnosis. Here's how I justify this "insurance fraud": They've contracted with me to provide medical care. If my medical assessment results in a diagnosis that happens to be "psychiatric" and they don't pay on those grounds alone, who is defrauding whom?

About lying in other situations mentioned:

Cancer: probably not, in this day and age, although with extensive discussion with the family member making the request.

STDs: Probably not, again with extensive counseling. Hard to imagine a scenario where confidentiality issues didn't do much of the work for me.

Fudge date of onset/pre-existing condition: Hard to do, if insurers are going to look at records (which they usually will.)

Incompetent surgeon: Presumably the patient chose the surgeon without my input. No, I wouldn't reassure someone if I thought they had made a poor choice. I'd try to help them find one I had more confidence in, whom I could recommend without hesitation (and would then be able to assuage their anxiety over.) That's not lying; that's a no-brainer.

Charges based on insurance status:
1. Fudge upwards with good insurance: never.
2. "Downcode" a self-pay: the technical answer is no, but I do give discounts, making sure that the patient understands that I'm giving him a break. That's actually quite important, otherwise patients believe they have become entitled to a lower price.

So the overall answer to "Is it ok to lie?" I'd say that it probably isn't nearly as necessary as many may think. Depending on how you define "lie" (omission vs. making an actual false statement) I would say "no", though with enough infinite situational permutations that of course it slides into "sometimes." Who decides? The doctor, on a case by case basis, and only when "truth telling" in his/her opinion would cause the greater harm.

If you think about it, though, precisely same points can be made for lying in general, not just by doctors.

 
At Sunday, January 20, 2008 8:42:00 PM, Blogger Maurice Bernstein, M.D. said...

Does anyone think that when a patient makes a request that, if followed by the physician, represents lying, that the patient is beyond attempting to get something to their advantage, also testing the morality and the interest of the doctor towards the patient? If the doctor fails the test, there is a degradation of the doctor-patient relationship.

A question I have also is how should a doctor say "no" to the patient? I would be interested to read a response both from the doctor but also the patient's point of view. ..Maurice.

 
At Sunday, February 10, 2008 3:48:00 PM, Anonymous Anonymous said...

To Dr. Berstein,
regarding the medical director lying about who would do the skin prep, I can tell you that he lied to make it easy for the surgery center. It was routine procedure for the female circulating nurse to do the skin prepping. This involved an extensive shave and cleansing for 10 min of the naval down to the scrotal area, side to side to the table. How many others has he lied to and misled over the years. People go in thinking one thing and are handled by someone they perhaps would NOT want to be handled by. This is verrry unethical. People can ask, have every right to ask, they tell you to ask and when you get lied to...? He gave no answer. Never appologized, never responded to the patient personally, had the administrator of the small surgery free standing facilty respond. No guts. Knew he was wrong, and was for once CAUGHT! And they wonder why patients get pissed off with the medical world today. We have lost all faith and will never trust anyone again. We eventually went to corporate and let them all have the egg on their face they deserved.

 
At Sunday, February 10, 2008 6:18:00 PM, Blogger Maurice Bernstein, M.D. said...

It is my opinion that informed consent for a surgical procedure also involves the preparation of the patient for the procdure. That means the patient should be fully and correctly informed about any pre-op medications to be administered and other general details of the preparation. If the patient requests to know the gender of the person who does the shaving, the patient should be informed as truthfully as the informant knows. Lying to the patient regarding the pre-op is not allowing the patient to receive information to allow fully informed consent. ..Maurice.

 
At Monday, February 11, 2008 11:01:00 AM, Anonymous Anonymous said...

Yes, Dr Bernstein, you are VERY correct with your statement. I could on with quoted verse from ALL sorts of guidelines, but to save you all of that I won't.
The problematic issue is that ONCE this kind of wrong is done to a patient, there is no way to reverse the harm, anger, hurt, issue the patient received by the actions. It may or may not seem trivial to someone else, but truly it is an issue with some people, as your bioethics discussion desmonstrates. The other issue with this kind of "wrong" is that there is nothing a patient can do to the offender. That is the very frustrating thing. And, the healthcare workers, in our opinion, feel no remorse or feel they did anything "out of the ordinary." I think there should be some way all of this is discussed with a patient ahead of time so people know what is going to take place once they are "knocked" out. Just because a patient is anesthesized either with sedation or general should in no way VOID their patient rights.
How would you personally handle a situation as this? Or how would you suggest to deal with it?

From what I have read and seen the OR thinks they just do it our way, the patient should not care or speak up and it is no big deal to any of them, so why should it be anything to the patient. Clearly it is a wrong attitude that has thrieved for many many years. It needs to change.

 
At Monday, February 16, 2009 7:30:00 AM, Anonymous Anonymous said...

Telling a falsehood and lying may be different. Lying is making a false or intentionally omissive statement to an individual who has a right to the truth.
Ex. The panhandler on the street asks: "hey buddy have you got a dollar" You answer No or walk away. Does he have a right to the truth? Another example: A 60y/o patient with end stage renal disease had been on a transplant list for several months. He is anxioius and brings in his 22y/o healthy son and states: "here's my donor doc". You evaluate the son and he is in excellent physical health, able to tolerate a donor nephrectomy. He has always been adamant he wishes to be a donor.
On the day before the surgery he confides in you.. the surgeon that he is scared and wishes to go on with his life. He doesn't want his father to knwo he has weakened. He asks you to say he is not a good donor and make up some reason to his father. Interesting situation.
Do you report the accurate statements and risk damaging the relationship between father and son? Do you honor his wish and state some spun or false information to honor your patient's wish. Does the father have a right to the truth. This is an interesting conflict I am sure faced by transplant physicians and surgeons. I am not sure what I would do.

 
At Monday, February 16, 2009 8:37:00 AM, Blogger Maurice Bernstein, M.D. said...

Excellent dilemma, however I think there is a resolution of the dilemma. First decide, to whom does the surgeon have primary responsibility? It is the sick father. The relationship of the surgeon to the healthy son is one of screening for conditions which would prove harmful to the son or to the father if procurement and transplant of a kidney was performed. The fiduciary (trusting) relationship is to the father, though if the son had agreed to submit to the surgery, there would also have to been developed a trusting relationship between son and surgeon.. trusting that the surgeon make a correct evaluation of the son both as a donor and for whatever procedures the surgeon would carry out on the son. Since the son has rejected being a donor, the fiduciary responsibility of the doctor is toward the father.

In this regard, the doctor must, by words and action, say and do what is in the best interest of the father, be beneficent and therapeutic. If the doctor decides that the sick father knowing the son's voluntarily rejection of the previous offer to donate would be psychologically harmful and would not in the patient's best interest to do so, the physician should not disclose that information. Disclosure, if done, should be by the son to the father.

What should the surgeon explain to the father that would not be a lie?

The explanation should be that, on examination, simply, the son would not be a candidate for a donation.
If the father wants more details of the basis for that decision, the truthful and legal response by the physician would be that the surgeon cannot divulge this medical information to the father without the adult son's consent. The surgeon should follow this by realistic encouragement to the father regarding opportunities for a kidney to be obtained from another donor. The surgeon should have informed the son of how the surgeon intended to handle the son's decision. In this way, the doctor has been fair and beneficent to both parties and has not lied.

What subsequently occurs in communication between the son and father is out of the surgeon's immediate professional responsibility.

Telling the truth and not lying does not mean telling the whole truth if that additional information cannot be legally divulged and even maybe not in the patient's apparent best interest.

Anyway, this is my resolution of the dilemma. Any other ideas? ..Maurice.

 
At Monday, February 16, 2009 6:13:00 PM, Anonymous Anonymous said...

Great analysis Dr. Bernstein.
I submit the the Moral or fiduciary duty is primarily to the Son. Who happens to be a healthy individual overrides the duty to the Father. The father is not going to die as a result of his disease. Kidney transplantation is life enhancing (in most cases) not life saving. It is an ethical dilemma ameliorated by separating the evaluation of the donor and the recipient. Going as far as having the donor evaluated and the procedure performed by separate individuals. With separate doctor-patient responsibilities.
I interpret your solution as a falsehood. It could be interpreted that the son is not a candidate but, Medically he is. It is his will that stands in the way. Call it a psychological contraindication. But, the fact is the recipient(father). Has no right to a live donor. His physician has no moral obligation to assure him anything but an appropriate evaluation and listing as any other patient. Live donation, at least in this country is a gift. The Father is not entitled to his son's kidney. He is however entitiled to the equal treatment as any other transplant patient. I like your explanation that the surgeon should not divulge the details. However, this is ommission of information. And yes the Son should tell his
Father the truth. Yet, this seldom happens. The i have referred to this as emotional coercion.
I have been in this situation several times in my career. It is always difficult. My solution has been to separate donor and recipient evaluation with different physicians.
Great job! Love the discussion.

 
At Monday, February 16, 2009 8:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from 6:13pm, I presume that you are not the same Anonymous who at 7:30am presented the ethical issue here. (Golly.. I wish you visitors who want to remain anonymous at least identify your posts with a consistent pseudonym or initials so there can be some continuity in following the discussion!)

In any event, you have raised important points, though a surgeon's conclusion that the son is not a candidate for organ procurement is a valid one since various psychologic, social and biologic factors must be considered when removing a vital organ from a donor (even though he has 2 kidneys to begin with.)

As for a "right" of the father to be entitled for a kidney from a live donation, I agree he has no "right" nor does he have any "right" to a kidney from a deceased donor. He does have an ethical right to be treated in a just and fair manner as do all other patients awaiting a kidney donation.

I also agree that there is an ethical conflict of interest which can develop if the same surgeon removes the organ from the donor and then later transplants it into the recipient, particularly if the organ is from a live donor. The surgeons should be separate individuals with their full responsibility to their individual patients. This is the same concern that has led to protocol which denies access of the procuring surgeon to the donor patient until that patient is pronounced dead by the attending physician. Similarly, the attending physician is not to request and obtain permission for the donation from the family but this is done by some independent and trained non-caregiver.

Thanks for the compliments. ..Maurice.

 
At Tuesday, February 17, 2009 7:25:00 AM, Anonymous Anonymous said...

I believe we have beat this to death. Your point about identification of Anonymous is well taken. My compliments are sincere. You perform a needed eductional service to the medical community. I was the same "anonymous at 7:30am and apologize for no id.
I will definiely continue to follow your site.
Sinhue... Just a surgeon

 
At Thursday, January 09, 2014 6:04:00 PM, Anonymous Anonymous said...

Iv had 2 back surgeries in past 2years.First surgery was installing 2 artificial discs.Iv had nothin but serious nerve pain as result of the artificial disc .The area where disc were installed was L 3/4/5. After 10 months of complaining to back Dr he advised me to have the second surgery which back Dr said he was going to remove the L 4/5 artificial disc, and fuse it with bone , screws , and whatever else Dr are supposed to do. After another 10 months of complaining after 2nd surgery Dr said he could no longer help me and that bone fuse and everything was ok . So I contacted another Dr he sent me for x rays and mri. Well long story short there r still 2 artificial discs in my back with screws and rods . So in short 1st Dr lied saying he fused it and removed disc, in which disc still there . Can the 1 st Dr get into trouble for lying to me and not doin what he said he was going to do? REMOVING 1artifical disc and using another .

 

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