Journal of Clinical Research & Bioethics

Ethics for Clinicians and Surgeons: Speaking the Truth

Ivan Dieb Miziara^1* and Carmen Silvia Molleis Galego Miziara^{2 1}Department of Legal Medicine and Ethics, Sao Paulo University, São Paulo, Brazil
²Department of Legal Medicine and Bioethics, ABC School of Medicine, Santo André, Brazil
^*Correspondence: Ivan Dieb Miziara, Department of Legal Medicine and Ethics, Sao Paulo University, São Paulo, Brazil, Email:

Received: 18-Feb-2021 Published: 11-Mar-2021, DOI: 10.35248/2155-9627.21.12.369

Introduction

A common dictionary has several meanings for the word “cancer”. For the average person, any one of them has a horrible meaning, a death sentence implicit in its biological sense. Depending on the patient, his ability to understand the intricacies of medicine, listening to this type of diagnosis can eventually precipitate disastrous events capable of preventing the long march necessary for healing. The same is true of other chronic and incurable diseases. They can cause profound discouragement in the patient, limiting or impeding his ability to fight the disease.

Many doctors hide the truth from their patients and insist that "telling the truth will cause them a greater evil". The English bioethicist classifies this type of thinking and conduct as a “fetish”, adopted since the times of Hippocrates [1].

Besides, lists other arguments used by doctors to not tell the truth to their patients, such as "the Hippocratic obligation to do good and do no harm"; “the difficulty in communicating technical and scientific elements to a layman in medicine”; and, finally, the patient's desire not to know that he has a serious and potentially fatal disease or condition.

Vaughn, for his part, states that "since ancient times the principle of non-maleficence-the duty not to cause harm-is embedded in the codes of medical ethics"-as explained in the Hippocratic Oath that refers to the doctor's obligation to speak the truth to his patient. However, until 1980 the American Medical Association's professional code did not refer to the need to honestly relate to patients the nature and the gravity of their illness. This author says that “many doctors regard the truth as something to be revealed or hidden as a therapeutic benefit to the patient. For them, the most important principle is beneficence (or non-maleficence), which will be better performed depending on what patients know about their cases. The truth can cause harm, be discouraged, depress-so why inflict harm on vulnerable patients? ”A question must be asked: based on what do they support these arguments? I do not believe that it is based on solid scientific arguments” [2].

As Vaughn quotes, in a classic formulation of this type of thinking at the beginning of the last century, Collins said: “Doctors must often hide the truth from their patients, which corresponds to telling a lie [3]. Furthermore, because the doctor learns early that the art of medicine consists largely of a skillful mix of lies and truth”.

Paternalism and Respect for People

Hippocratic precepts, in general, have a paternalistic connotation. As Robert Veatch [4] states, one of the criticisms of hippocratic ethics is the doubt about the subjective judgment of the doctor about what “benefit to the patient” is and that this is a definitive standard of medical action. According to the author, "this type of ethical action maintains a focus only on the patient's well-being, centered solely on beneficence and nonmaleficence, excluding any consideration about the well-being of other parties involved".

Other criticisms are also made of the hippocratic stance. Medical ethics must take into account rights and duties in the doctor-patient relationship, as well as benefits and possible harm. “The general problem,” says Veatch, it is that sometimes an action can be morally incorrect even when it produces good consequences. “Duty-based ethics progressively replaces or supplements that based exclusively on consequences.”

Not so much to the sea or the land. This is a problem with ethical theories that determine certainties. Whether that theory is based on duties, or that supported by consequentialist thinking. To paraphrase William Frankena, in this pattern of moral deliberation someone (“who knows everything”) determines what the other person should do in a particular situation by referring to certain strict principles and standards of conduct [4,5].

Speaking the truth is a basic moral (and, sometimes, religious) principle, a form of respect for the interlocutor. But the truth can have multiple angles and multiple versions. "What is the truth?" Jesus asked Pilate. As stated by Hengelhardt, the patient, when he comes to see the doctor, is in unknown territory [6]. The sick individual in this context is a foreigner, a lonely person in a different country, where he does not know what to expect and has no control over the environment.

However, even in this strange land, he seeks to find comfort; he intends to make the doctor (in addition to a capable professional) a friend and confidant. And, looking from this other angle, true friends do not lie (or omit) to their friends. As stated by Pellegrino and Thomasma, the doctor and the patient meet as friends in search of good health [7].

Autonomy and the Principle of Autonomy

Not telling the patient the truth, even if driven by good intentions (the hippocratic "pious lie") is a way of disrespecting the patient's autonomy. The concept of autonomy, complex by its very nature, is relatively recent. In political terms, it goes back to the Enlightenment period as an affirmation of the individual's right to get rid of tyranny, unjust laws. Under the moral aspect, autonomy refers to an inalienable human right: the right of people to act freely according to their conscience and to be respected as agents capable of making their judgments.

As Gillon states, “Autonomy is a subclass of freedom or liberty, but not all freedom or liberty is autonomy. The concept of autonomy incorporates the exercise of what Aristotle called man’s specific attribute, rationality. ” It is important to highlight a subtle difference that exists between autonomy and the principle of autonomy (often treated as synonyms). The latter can best be defined as the “principle of respect for autonomy”. Respect for the individual's autonomy is an indisputable moral obligation, as long as, by respecting it, we do not harm others or even the community [8].

However, even though respect for patient autonomy is a touchstone of the current doctor-patient relationship, some questions remain when it comes to transmitting information to patients. Jonsen, Siegler, and Winslade, for example, question what kind of information patients need to make a conscious decision [9].

In the case mentioned above, what information should be transmitted to our patient JBR? By old and paternalistic standards, this option is at the discretion of the doctor, centered on what the professional believes will be in the best interest of his patient. According to the current model, the answer should be patient-centered and if he wants to know everything about his illness, everything must be revealed to him.

Jonsen, Siegler, and Winslade also cite a third way, called “subjective”, which is specific to each patient: the information to be passed on to a particular patient is constructed according to the need that he has to be informed and in his ability to understand the facts to be revealed [9,10].

The patient's ability to understand is equally important and the information to be provided must suit this condition. In the case of Mr. JBR, a rural worker (obviously endowed with little scientific knowledge), several studies demonstrate that the understanding of the facts, treatments, and prognoses is limited and inadequate-which only increases the patient's stress or collaborates for the appearance of a depressive condition, and ends up implying a non-adherence to the proposed treatment.

Exactly why the physician has an ethical obligation to make every effort to ensure that the patient correctly understands what is being informed. The explanations must be clear and simple. Questions should be asked to ensure that the patientyour friend-has understood everything that has been passed on to you.

However, there is an undeniable difficulty in the practical implementation of respect for the autonomy of our patients. There are factors intrinsic to the patient that we often overlook, such as denying the diagnosis, the disease and the prognosis-as a defense mechanism. A possible solution would be the one suggested by Gillon of instituting a standard questionnaire for the patient to fill out before his first consultation. This questionnaire would include questions such as "Have you already prepared your advance life or living will guidelines?"; "Would you like to be informed about having a serious or fatal disease?"; “If you don't want to be informed, who in your family will be able to receive that information on your behalf?”, and so on. This simple step would greatly facilitate the physician's work in situations such as that of Mr. JBR.

Conclusion

Communication between doctor and patient must be true. The information transmitted to the patient must be by the facts. If the facts are uncertain, if the prognosis is not predictable, that uncertainty and lack of predictability must be reported. As in medicine, uncertainty often prevails over predictability. Thus the doors should not be closed entirely to factors that are out of the doctor's control. It may sound corny, but hope and faith are important factors in the treatment and eventually healing process. In the case of our patient JBR, despite the contrary opinion of his family members, his desire to know about his health status needs to be respected. As Davies stated, the patient has the right to know the truth. However, this information must be transmitted with care, with affection, with understanding and empathy, with delicacy on the part of the doctor. In the same way, that bad news is transmitted to a childhood friend.

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