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Truth-telling is not a new issue in medicine. Hippocrates warned of telling the patient the nature of their illness, 'for many patients through this cause have taken a turn for the worse.' 1 However, he admonished that the truth should be told, but to a third party instead of the patient. In 1903 Cabot analysed the professional ethics of truth and falsehood, writing 'The lies that the medical profession agree in condemning whenever the question arises are those told for personal and private gain.' 2 This historic conclusion was justified by utilitarian reasoning and was based on the paternalistic assumption that the 'doctor knows best'. This attitude in medicine led to the concept of a 'therapeutic privilege', which allowed the physician to do what he or she thought was best for the patient.
In recent decades, paternalism and therapeutic privilege have fallen into disfavour, while patient autonomy has come to dominate discussions in medical ethics. More emphasis is placed on principles-lying is wrong; the patient has a right to know. This change was clearly demonstrated when Novack reported that in 1961, 90% of physicians did not reveal a fatal diagnosis to patients, but in 1977, 97% did so. 3 About the same time, a layman argued for truth-telling, writing, 'The real issue is not whether the truth should be told but whether there is a way of telling it responsibly.' 4 This north American change is not necessarily the standard in all cultures, however. Pellegrino addressed cross-cultural practices of truth-telling and concluded that patient autonomy was not the universal principle, but rather respect for persons. 5 So if a person expected to be shielded from the truth, his or her personal belief should be honoured.
Still, physicians are frequently confronted with the ethical issue of deceiving for either the patient's benefit or their own. Physicians may lie to insurance companies, deceive about medical errors, withhold details about diagnosis at the family's request, misinform about unanticipated events, or not disclose information about near miss events. 6 Truth-telling is a foundational principle of medical ethics. 7 However, using a consequential method of reasoning rather than a principle-based method, professionals find situations in which telling the truth may not be in the best interest of those involved-the patient,...