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Lecture for 6th year medical students at KFMC 16th January 2010 1-3pm by Professor Omar Hasan Kasule Sr.
Summary
This lecture summarizes ethical guidelines on how a physician can fulfill the duty of being truthful to the patient under different scenarios. It provides some case studies for analysis.
1.0 OBLIGATION TO TELL THE TRUTH
As part of the professional contract between the physician and the patient, the physician must tell the whole truth. Veracity is based on respect for autonomy, fidelity, and confidentiality. Patients have the right to know the risks and benefits of medical procedure in order for them to make an autonomous informed consent. Deception violates fidelity.
The principle of veracity is derived from
2.0 WHAT IS DISCLOSED
Disclosure of some forms of information may constitute malefacence. There is no obligation to disclose information that the patient does not request or does not want. Some patients may prefer not to know the truth. There is no obligation to disclose unwanted information. Patients should be told only what they need to know or what they want to know.
3.0 PARTIAL DISCLOSURE and WHITE or TECHNICAL LIES
Partial disclosure can be considered a half truth and therefore a form of lying. Technical lies are statements that are apparently true and whose truth can be defended using data and reasoning but they contain an element of untruth that any person privy to the whole information will be able to discern. The physician may consider telling ‘white lies’ for the sake of the patient welfare. The physician should be guided in his communication by the background and understanding of a patient. Some patients can be given a lot of information and they do not get disturbed. Some types of information agitate patients. The prophet taught talking to each person according to his ability to understand.
4.0 DISCLOSURES TO OTHERS ABOUT THE PATIENT
It may be necessary that the physician shares some confidential information with members of the family in order to get involve them in patient care. This may take the form of getting more information about the patient, consultation about the best care or trying to interpret and understand the patient’s choices and decisions. In general divulging unsolicited information to governmental or other authorities is frowned upon.
5.0 GIVING BAD NEWS
Bad news is common in medicine. The patient may have to be told about a diagnostic result that indicates a more serious disease than had been anticipated. The prognosis may be bad or the treatment may fail. In general it is better to keep quiet than to pronounce anything that is uncomfortable. However the obligation or veracity and transparency force the physician to give bad news to the patient and the family.
Telling the patient half truths or white technical lies may be a way out of the dilemma of giving bad news but it destroys the confidence and trust that patients put in doctors. Telling a straight lie is forbidden. Each case should be evaluated on its own merits by balancing benefits and injuries. In the end it may be better to be straight in dealing with the patient and warn them before giving bad news. Their permission could also be asked. Some may prefer that they be not told the whole truth because that would distress and disturb them.
Some bad news is better given to the relatives. They can find a way of conveying the information in a gentler way that minimizes the mental injury to the patient. They may also make a better judgment of what to tell and what not to tell the patient.
Some bad news may be given to authorities in the form of medical certification for temporary or permanent disability, sick leave, and return to work.
Physicians should be careful about their body language. It is very difficult to hide feelings inside. The patient will read the body language and will believe it more than verbal language. A verbal reassurance of the patient that he will so well can be contradicted by show of worry and agitation on the face of the physician. This is perhaps one argument for telling the whole truth to the patient whatever the consequence because they can read it for themselves from the physician’s body language.
6.0 CASE STUDIES
Case #1: Midwives refused to inform a mother and hid a congenitally malformed baby from her for a week. They gave the mothers various excuses for not showing her the baby. When the mother became very angry the pediatrician came to talk to her and told her that she had an abnormal baby. He said ‘in my experience children with this type of abnormality do not survive longer than a month’. When the patient asked for the cause of the abnormality the pediatrician replied ‘It is all your fault, you should not have become pregnant above the age of 40’. The mother broke down and cried. She left the hospital 2 hours later without being formally discharged.
Case #2: A medical researcher stationed at the hospital used to take an aliquot from every blood specimen to test for HBV. The hospital authorities knew what he was doing but the patients were not informed because he did not record names of patients. One day out of curiosity he tested a specimen for HIV and found it positive. He was confused what to do regarding disclosure. He called a meeting of the senior staff in the hospital to discuss the matter. He also included a respected lawyer from the town to provide a non-medical perspective.
Case #3: A community pediatrician had reported abuse of a couple’s first child to the authorities. The authorities called in the parents to discuss the matter. The abusing father was so angry that he divorced his wife for giving information to the pediatrician. He later took the wife back under the rujuk provisions of the Law. At the next visit the pediatrician noted signs of child abuse and asked the mother. The mother confirmed the abuse but asked the pediatrician not to follow up the matter for the sake of her marriage and family. The pediatrician this time did not report to the authorities.
Case #4: A midwife who had contracted HIV due to transfusion hid her status for 5 years. She was very meticulous during deliveries observing all precautions and during that time no patient was reported to have been infected. After a family quarrel her husband revealed her status to the newspaper. The editor failed to interview her before publication of the report. The midwife refused a request by the head of obstetrics to have an HIV test. The hospital suspended her and charged her for criminal negligence in the high court.