MEDICAL MATTERS:'Truth is not an event; it is a process'
‘TWENTY YEARS ago the doctors gave her six months. And sure look at her now.”
We have all heard the occasional yarn similar to this; stories of a doctor’s prognosis being well off the mark.
The latest example is that of the recently deceased alleged Lockerbie bomber, Libyan Abdelbaset al-Megrahi, who was repatriated by the Scottish authorities three years ago on the basis of medical advice that he was terminally ill with only months to live.
Giving an accurate prognosis in terms of weeks or months is extremely difficult.
In my experience, it is only in the last days of a person’s terminal illness that one can be any way sure of how long they might have left. And in response to questions about “time left” from cancer patients shortly after the initial diagnosis, the only honest answer is “I don’t know.”
Admitting ignorance in the days of “God-like” doctors may have been difficult.
However, there is no such excuse for the modern practitioner, who receives extensive training in communication skills in the consultation.
Telling lies is not one of these skills.
Which is why I was somewhat taken aback by research published earlier this year in the journal Health Affairs in which about one in 10 doctors in the US admitted to having lied to a patient in the previous 12 months.
The 2009 survey of almost 1,900 physicians attempted to determine how closely the medical profession there adheres to the Charter on Medical Professionalism, which sets out standards on physician honesty and openness with patients.
Some 83 per cent of the survey respondents completely agreed with the statement that physicians should never tell a patient something untrue.
However, when it came to actual ethical practice, 11 per cent said they had told a lie to an adult patient or a child’s guardian in the preceding 12 months, and 15 per cent said that they had described a patient’s prognosis in a more positive manner than was warranted.
Two-thirds of those surveyed completely agreed that physicians should disclose all significant medical errors to affected patients. In practice, 20 per cent said that they had not fully disclosed a medical mistake to a patient in the last year because they were afraid of being sued.
Women doctors were more likely to follow professionalism guidelines; some 86 per cent of female physicians, for example, fully agreed that they should never tell patients something untrue compared with 81 per cent of male doctors.
In addition, female physicians were less likely to report telling a lie to a patient than their male counterparts.
So what is going on? Dr Art Caplan of the Department of Medical Ethics at the University of Pennsylvania points to some ethical grey zones.
“With respect to the ‘rosy prognosis’, if someone has cancer or Parkinson’s disease or Alzheimer’s disease, I’m not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics,” he says of the circumstance in which a better prognosis is offered than is really the case.
“You might say that telling the truth is a noble thing to do, an important thing to do, and it is the way that we are going to keep patients trusting the doctor.
“At the same time, however, truth is not an event; it is a process. The survey may have failed to capture that insight. Telling the truth is important, but letting it come across in a humane way, letting it come across sometimes in ‘dribs and drabs’ so that the patient can absorb it and not be psychologically devastated or emotionally harmed, is the right thing to do,” Caplan argues.
Lying about adverse outcomes is simply not acceptable. There are legal, ethical and professional reasons to tell a patient as soon as possible about a problem.
But most of all it’s about trust; without this vital ingredient it is difficult to see how a doctor could continue to treat a patient.