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Nearly all doctors, at some time, will question the wisdom of telling a grim truth to a patient. To help doctors resolve such dilemmas, I have developed a "deception flowchart." By providing a sequence of questions and a checklist of relevant moral considerations, the flowchart might help the ethically sensitive doctor make a more informed decision about when to over-ride the duty to be honest. It might also be useful to teachers of medical ethics, who can use it to illustrate the complexity of this puzzling area of medicine.
The ongoing deception debate
It is a truth universally acknowledged that ethical doctors will not intentionally deceive their patients. The American Medical Association states: "A physician shall . . . be honest in all professional interactions, and strive to report physicians . . . engaging in fraud or deception, to appropriate entities." 1
Similar injunctions are offered by the World Medical Association and the United Kingdom's General Medical Council. 2 3 The situation at the bedside may well be different, however. 4 5 6 7 8 When it comes to disclosing a grim prognosis, doctors may control information by using euphemisms, ambiguities, evasions, and other strategies. 5 7 9 In some countries, doctors commonly withhold an adverse diagnosis and prognosis from patients. 10 11
I have argued elsewhere that benignly intended deception by doctors may, in some cases, be morally acceptable. 9 12 Although deception in medicine is generally wrong, as it tends to undermine patients' autonomy and erode the trust between doctor and patient, the ethical duty to be honest is not absolute. Some moral goods, such as the avoidance of severe physical or emotional suffering and the preservation of life or long term autonomy, may over-ride the prima facie duty not to deceive. When a distressed mother asks if her beloved daughter suffered in her dying moments, or when on the operating table a patient with a ruptured abdominal aneurysm asks the unhopeful anaesthetist whether he will be all right (see box), the usually strict need for honesty gives way to compassion and humanity. I acknowledge, however, that many readers will believe that doctors' truthfulness, as a cornerstone of trust and respect, is an absolute requirement that allows for no exceptions.
Case study: the...