The Presence

of Deception

in Healthcare.

Truth telling and Lying…

Truth telling

Conflicts of Interest Conflicts of Interest

The Case of The Case of

Vendor RelationsVendor Relations

Truth telling

Conflicts of Interest Conflicts of Interest

The Case of The Case of

Vendor RelationsVendor Relations

Truth telling

The Purposes

• Will explore the issue of deception raised by cases of informed consent and truth-telling in medical ethics.

• Will explore the causes (personal and systemic), distinctions and tools to aid discernment of complex patient cases.

Truth telling

Conflicts of Interest Conflicts of Interest

The Case of The Case of

Vendor RelationsVendor Relations

Truth telling

Conflicts of Interest Conflicts of Interest

The Case of The Case of

Vendor RelationsVendor Relations

Truth tellingAutonomy and the Birth of

Bioethics• Henry K. Beecher, "Ethics and Clinical Research", New England Journal of Medicine, 247 (1966): 1354-1360.

• Maurice Pappworth, Human Guinea Pigs. (London: Routledge & Kegan Paul, 1976).

Truth telling

Misperception and Substituted Judgment

• Studies have shown that not only were clinicians’ willingness to withdraw life support influenced by personal characteristics such as age, religion and clinical experience, but personal preferences also impacted when they chose to withdraw life support.

• Studies have shown that some clinicians will misperceive their patients preferences and substitute their own preferences for those of the their patient. (Schneiderman, Journal of Clinical Ethics, 1993)

• Recent NIH Study on the accuracy of surrogates decisions, proxies were accurate 68% of the time, but off the mark in almost one out of every three cases.

Truth telling

May 19, 2009, Australian Journal of Nursing

• The drug company Merck was accused of paying nurses to sift through patient medical records in search of potential candidates for the drug Vioxx.

• The claim is that nurses identified potential users of Vioxx from patient records with physicians’ permission and then initiated contact with the intention to offer Vioxx as an alternative to their present medication.

Truth telling

Truth telling

Mr. SMr. S is 26 years old and has recently joined a family physician’s practice. He had an episode last year of unilateral arm weakness and visual blurring without headache that resolved within 12 hours. He was referred to a neurologist, who did several tests. Mr. S was subsequently told not to worry about the episode and thought no more about it. He has had no similar episodes since. In his medical records is a letter from the neurologist to the previous family physician stating that Mr. S almost certainly has multiple sclerosis. In the letter the neurologist explains that in order to prevent excessive worry he does not inform patients in the early stages of multiple sclerosis of their diagnosis.

Truth telling

Change: 1961- 1979

In a landmark study conducted in 1961, 90% of a sample of 219 US physicians reported that they would not disclose a diagnosis of cancer to a patient. Of 264 physicians surveyed almost 20 years later, 97% stated that they would disclose a diagnosis of cancer. Oken D. What to tell cancer patients: a study of medical attitudes. JAMA 1961;175:1120-8. Novack D, Plumer R, Smith R, Ochtill H, Morrow G, Bennett J. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979;241:897-900.

Truth telling

Coping/Trauma

WHO Definition of TRAUMA

• An event that is unpredictable.• An event that is without obvious

meaning.• An event where you witness the

actual or potential death of another.

Truth telling

Why I Choose? (Kohlberg and Gilligan)

Stage 1: I choose due to what causes me pain or pleasure.

Stage 2: I choose due to the loyalty to the group I belong.

Stage 3: I choose due to uniqueness of the situation and with impartiality.

Shifting from the personal to the systemic

Truth telling

2008, Journal of American Medical Assoc.• Published results of a national survey of medical school

department chairs was published in 2008:• Almost two-thirds have a personal relationship with industry

as consultant, board member, paid speaker or the like. • About one in five medical school departments enjoyed money

for equipment and unrestricted funds, one in three clinical departments received support for trainees and the majority of clinical departments received support for "continuing medical education.

• Department chairs themselves felt that the more a chair was involved with industry, the less able the department was to "conduct independent unbiased research

Truth telling

Question

• What are the other dynamics that causes lack of truth telling with patients?

Truth telling

Defining “A Lie”

A Lie is…

“an intentionally deceptive message in the form of a statement”.

Truth telling

Why is Lying Bad?

• It diminishes trust among human beings.

• Makes the possibility of human community more difficult.

Truth telling

Reasons for Lying

• Protection

• Avoid harm

• Maintain Confidentiality

Truth telling

Mr. SmithMr. Smith is 75 years of age, fragile but alert and competent. He is a multi-year survivor of cancer and, after a few months of feeling poorly, just completed diagnostic tests that showed the cancer has returned and is beyond curable treatment. The current oncologist has not cared for Mr. Smith previously. She informed Mr. Smith’s only child, Chris, and was stunned by the response:

Truth telling

Mr. Smith (con’t)

Do not tell him the cancer has returned. Please refer him back to his family physician. He and I agree that the news will destroy him; in fact, the doctor kept his own mother’s diagnosis of cancer from her as long as he could in order to strengthen her will to live and not destroy hope. We plan to tell my father that the symptoms are due to something else that is treatable.

Truth telling

Common Principle“Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.” (ERD 27)

Truth telling

Practice: Professional vs Personal

• Flattery: “you look lovely” • Gratitude: “that's just what I wanted” • Bargaining: “my best price is $500”• Generalization: “it always rains in Seattle” • Unpredictable situations: “it won't rain today” • False excuses: “he's in a meeting”

Truth telling

St. Augustine’s Hierarchy of “Lying”• Lies told in teaching religion

• Lies which hurt someone and help nobody

• Lies which hurt someone but benefit someone else

• Lies told for the pleasure of deceiving someone

• Lies told to please others in conversation

• Lies which hurt nobody and benefit someone

• Lies which hurt nobody and benefit someone by keeping open the possibility of their repentance

• Lies which hurt nobody and protect a person from physical 'defilement.

Truth telling

Thomas Aquinas on Types of Lying

• Malicious lies: lies told to do harm

– Malicious lies are mortal sins

• 'Jocose lies': lies told in fun

– These are pardonable

• 'Officious' or helpful lies

– These are pardonable

Truth telling

Sissela Bok’s “Test” for Lying…

• Are there some truthful alternatives to using a lie to deal with the particular problem?

• What moral justifications are there for telling this lie - and what counter-arguments can be raised against those justifications?

• What would a public jury of reasonable persons say about this lie?

Truth telling

Outcomes

Truth telling…• Increases patient compliance (1984)• Reduces the morbidity such as pain

(1964)• Informed patients are more satisfied

with their care and less apt to change their physicians than patients not well informed. (1995)

Truth tellingDiversity: Does the

Principle Hold?After a survey of 800 seniors from four different ethnic groups showed that Korean-American and Mexican-American subjects were much less likely than their European-American and African-American counterparts to believe that a patient should be told the truth about the diagnosis and prognosis of a terminal illness, we undertook an ethnographic study to look more deeply at attitudes and experiences of these respondents. European-American and African-American respondents were more likely to view truth-telling as empowering, enabling the patient to make choices, while the Korean-American and Mexican-American respondents were more likely to see the truth-telling as cruel, and even harmful, to the patients. Further differences were noted in how the truth should be told and even in definitions of what constitutes “truth” and “telling”.

Blackhall LJ, Frank G, Murphy S, Michel V.  Bioethics in a different tongue: the case

of truth-telling.  Journal of Urban Health.  2001 Mar;78(1):59-71

Truth telling

Mrs. LeeAn 80-year-old Asian widow is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her oldest son approaches the physician and asks that the patient not be told, stating that in their culture the elderly are protected from such distressing news. In mainland China, tuberculosis was considered fatal and to tell her would be like giving her "a death sentence."

Should you respect the son’s approach?

Truth telling

Narrative Ethics

Truth telling

A Key Paradigm Shift

From diagnosis and treatment of disease

….to understanding how illness integrates into my

life story.

Truth tellingThe Explanatory Model Arthur Kleinman, Ph.D.

• Culturally sensitive approach to asking about a health problem

– What do you fear most about your illness?– What are the chief problems your sickness has caused you?– Anyone else with the same problem?– What have you done so far to treat your illness: What

treatments do you think you should receive? What important results do you hope to receive from the treatment?

– Who else can help you?

Truth telling

The LEARN ModelBerlin and Fowkes

Listen to the patient’s perception of the problem

Explain your perception of the problem

Acknowledge and discuss differences/similarities

Recommend treatment

Negotiate treatment

Truth telling

3 Questions

Hope Fear

Preference

“Hope is not the expectation that things will turn out well;it is the belief that there is meaningno matter how things turn out.”

Vaclav Haval