Truth Telling in Medicine: “Tell all the Truth but Tell It Slant”
I have posted many times in the past about truth. Truth is an important component of the fiduciary responsibility of the physician to his or her patient. But as with the physician’s prescription of a medication for treatment of a patient's illness, the maximum dose is not often the appropriate dose to prescribe, should the dose of truth administered to a patient be titrated too? But is a little truth not really truth at all?
With the words of Aristotle, “Poetry is finer and more philosophical than history; for poetry expresses the universal, and history only the particular”, I have looked to poetry for help in this ethical issue. I found the poem by Emily Dickinson titled “Tell All the Truth” which reads:
Tell all the Truth but tell it slant
Success in Circuit lies
Too bright for our infirm Delight
The Truth's superb surprise
As Lightening to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind
I am not sure the poem has helped me in considering telling the truth in medical practice. Do doctors really know the real “truth” that they may pass on to their patients? Certainly there are unknowns. When the patient asks the physician “how long do I have to live?”, can the doctor know the truth to answer the patient? If the doctor doesn’t know the truth, should he or she simply say to the patient “I don’t know”? If you were a patient, would you want the doctor to tell you “the truth and the whole truth” or just a bit of the truth? If you were the doctor would you “slant” the truth as Emily Dickinson suggest? Any answers? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:17:00 PM
4 comments
4 Comments:
If I were the patient I would want to know the whole truth. If I were the doctor I would ask the patient how much information he or she wanted. If I didn’t know the truth I would admit it. If pushed I would admit which parts were guess work. Further explaining what the guess was based on. If I had trouble telling the whole truth I would admit that too. “This is not easy for me. I have trouble with this type of…”
"As Lightening to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind"
To approach truth in this manner takes skill and a steady course. Otherwise it’s nothing more than an act of cowardice covered by a false perception that one is taking the kindest path for another. The focus must be respect and a wise hand with the final outcome being the truth. In some cases telling the truth is an art form. Other times an example of strength of character. I would suggest more often than not whether a person tells the truth, slants the truth, or creates the ‘truth’ is a habit. How often do people actively work to make sure they have retained details exactly as discovered, or repeat information within the exact context offered originally? I suspect telling the truth is much like using profanities. Some people swear all the time. Some swear only in certain environments. Others never… or only in extreme moments of stress.
Thanks Anonymous for a beautiful and clear answer to my questions. Truth, even a simple truth, is a complex adventure to tell to somebody, particularly one's patient. And what the physician may consider "simple" may represent the most complex of considerations which now must be faced by the patient. The better a wise physician knows the patient, the more constructive and supportive the delivery of truth can be. ..Maurice.
To me, truth telling in medicine should not be as complex an issue as some make it out to be - give them the truth but deliver the truth with compassion. I suppose the process of delivery will have to be a carefully honed skilled that must be learned over the years. Physicians who attempt to deliver the truth in as compassionate a manner to the patient at least have a chance to show empathy towards the patient and even console the patient and the family. That way, no matter the "news," at least the doctor leaves with respect. Even if the truth is that the doctor made a mistake, truth telling has a better chance of keeping the doctor from getting sued later on. It's all in the method of delivery. Maybe all doctors should preface their presentation of diagnoses with, "How would you like me to tell you the truth? Bluntly, or not?" That way the patient can then respond, "Give it to me straight, doc."
I helped edit and proof a book by philosopher Gregory Pence at UAB entitiled "The Elements of Bioethics". The first chapter opened with the very dilemma you are pointing out, Dr. Bernstein. However, it added another variable: physician-physician friendship. What if your friend was the doctor (or resident) on call who made the mistake, like failing to notice a trouble spot on the x-ray, and this friend didn't want you to tell the patient after you discovered the spot on the x-ray in his charts months later?
ace, again the issue is one of trust. When you are a physician who has a doctor-patient trusting relationship with a patient but also a friendship with another physician who trusts that you will remain a friend who will not harm him or her, which trust trumps the other? To me the answer is obvious. Ensuring the patient's trust is the physician's professional responsibility and in dealing with professional issues, that trust trumps all other professional obligations at the moment or non-professional courtesies.
It was almost a custom, even promulgated by insurance lawyers, for physicians to avoid disclosure and apologizing for personal medical mistakes. Now, this custom is being scrutinized and there is even evidence that open disclosure is the most ethical, humanistic and compassionate approach to the patient and that this approach may benefit the physician by actually reducing the risks of malpractice suits. In your example, I would educate the physician friend and encourage him or her to communicate with the patient about the error. ..Maurice.
Post a Comment
<< Home