170411P - DISCLOSURE AND TRUTHFULNESS

Presentation at a Grand Round, King Abdullah Medical City held at Makkah AlMukarramah, Saudi Arabia on 11 April 2017 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.

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 procedures in order for them to make autonomous informed consent.
• Deception violates fidelity.

WHAT IS DISCLOSED

• Disclosure of some forms of information may constitute maleficence.
• 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.

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. 

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 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.

GIVING BAD NEWS 1

• The 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 of 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.

GIVING BAD NEWS 2

• 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 be contradicted by a 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.

SCENARIO 1

An 80-year fully conscious and competent old man with advanced incurable cancer needed palliative chemotherapy.  The family objected when the doctor wanted to obtain informed consent from the patient because that would involve disclosing the diagnosis which would make the patient very sad and depressed.  The family wanted to make the decision without informing the patient.  What should the doctor do? Provide your moral reasoning.

SCENARIO 2

A pediatrician examined a child with multiple trauma wounds and suspected that the father was responsible. He was reluctant to report because the father would be imprisoned and the family would lose its breadwinner. What do you think is the correct approach?