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charlie, computer cat

March 2019



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kitties - where'd it go?

Play along...

OK, just for fun, here is the essay question I will be answering this afternoon:

‘It is wrong to tell lies, so patients should always be told the truth about their condition.’ Is this a good argument?

I've turned off emailing comments on this and I promise not to look until I've written the essay (1000 words, in case you're interested). What do you think?


Whoah. Okay, so, yeah, there's a philosophy of language question in there for sure if we're talking about "truth".

First off, for this to be a good argument I'd expect it to be both logically sound and based on reasonable assumptions. Whether it's sound or not actually depends on what the assumptions are in this case, I think, and how you define the terms involved.

The first set of assumptions to tackle would be about what it means to lie, what it means to tell the truth, and whether not telling the truth is necessarily the same as lying. This is primarily a philosophy of language question.

The second assumption to tackle would be about whether lying (however it's defined) is wrong. This is primarily an ethical question and can only be dealt with once the philosophy of language question has been answered in some way or other.

I think I would actually be inclined to skip the second (ethical) question altogether and just argue that it's a bad argument because the conclusion doesn't logically follow from the proper definition of "lies" and "truth". But that's because I like arguing philosophy of language and dislike arguing ethics, so....
Yeah, I don't have the training to make the philosophy of language argument properly but I made a really basic dictionary definition stab at it because it was the first thing that leapt out at me too. Given that the course is called Ethics in Real Life though, I decided it was best not to skip over the ethical question entirely :) It just comes out as a bad argument either way, which is good - I think if the two had contradicted, I would have had to do some research on philosophy of language that I really don't have time for, given the submission date is today!

Edited at 2010-06-04 04:33 pm (UTC)
I think I'd contrast this with the principle First do no harm, which wikipedia informs is not in fact from the Hippocratic Oath as I had thought, but is a fundamental of medical ethics. If the truth would be harmful, I'd say that could override the general principle that lying is wrong (and, indeed, the more specific principle that lying to your patient is wrong).
I don't know, does that override the principle that lying is wrong, or mean that it's still wrong but *also* right? (Clearly I'm asking the question because I think it's both.)
I meant 'override' when considering how to act. As you say, you can (and (arguably) should) choose to do something that's morally wrong if the alternative is wronger, but that still doesn't somehow make the act right.
Yeah, that's one part of the Four Principles approach to medical ethics:

1) Autonomy - the patient has the right to automous decision making.
2) Benificence - doctors should strive for the best outcome for the patient
3) Non-malificence - doctors should strive to do no harm
4) Justice - resources should be fairly allocated with no one patient being privileged over another

Obviously, all those have interesting definitional arguements and I can provide examples when all 4 principles might support lying to the patient.
NB, these are not ordered and may well contradict eachother - they provide a framework of issues to consider when making decisions.
You'd wipe out a whole lot of potential placebo benefits if that was the case.
There are many ways to use the placebo effect without lying.
A standard formulation would be
"A lot of my patients have seen real improvements after taking homeopathic tablets - is that something you'd like to try?"
And of course "real" medicine uses the placebo effect as well - it doesn't stop working just because the treatment has an objective effect of its own.
It's not an argument at all it is a statement with a corollary that does not follow since telling the truth is not the same as not telling lies. 1000 words?
Yeah, that was the first half, then I hit up the medical ethics of lying in the second half, since that was the question they were expecting you to answer.
Maybe I've been out of school for too long, but this just doesn't seem like an *argument* to me, but rather two loosely related statements that don't actually follow each other.

I do think it's wrong to tell lies, but I don't think it always follows that one should tell the truth. Sometimes the wrong thing is the right thing.

And I'm pretty sure that some research has shown that some patients benefit from *not* being told the truth, specifically those who are certain stages of altzimers, where a true *feeling* environment is more important than a truthful one. And while I generally believe that a patient should be told the whole truth, it's because I believe that a doctor's job includes helping patients make informed decisions, not strictly because I believe it's wrong to lie.

So there's just something that doesn't sit right with me for this as an argument, and at least part of it is the *always*.
I absolutely agree (as I hope I made clear in our discussion above). Even if you assume that 'Don't tell lies' = 'Always tell the truth' (which seems a stretch), and agree that this is a good fundamental principle (which is at least arguable), I still don't think that it should be your most important consideration.
Technically it is an arguement, since it states a premise, followed by a conclusion. What I think you're saying (and I fully agree with) is that the conclusion is not actually justified by the premise, even if you accept the premise.

Always is a bad word in nearly all subjects apart from maths in my experience :) On the plus side, absolute statements are really easy to argue against, as you only have to find one counter example, which made my essay writing easier!
I agree, and support this argument, as ever, with web comics

Edited at 2010-06-04 04:54 pm (UTC)
lalalalalalala ethics & philosophy. I am terrible at all the rules and the defined this and that. So I shall simply weigh in on what I know! I will give you some examples where the second half of the statement isn't true-

1. The patient specifically asks that you do not tell him or his family the details of his condition. He may either wish to just receive treatment, or more commonly, to not receive treatment and just die in peace. At this point you can offer comfort care (i.e. pain meds, hospice, etc) if applicable and consented to by the patient. The patient should always be reassured that you will not abandon him.

2. The patient is a young child (or minor, really). In this case, the parents of the child decide what information that the patient gets to hear about their condition. While you should never ever lie to the patient (true), you are ethically required to respect the wishes of the parent in what the child can be told. If the child asks about their condition, we are taught to ask them, "What have your parents told you about your condition?" and go from there.

3. If the patient asks how long they have left to live, you are never to give them an actual time frame in months, even if your past experience suggests beyond all shadow of doubt that once a person has reached a certain point in a disease, they have exactly four months to live. You are to always give ranges, like, "At this stage in the disease, many patients usually have around half a year to live." Or "months to a year" or "a few years". The reason for this is obviously that there is always the possibility for some spontaneous miracle and you do not want people determining to "prove the doctor wrong" by "outliving" the exact time estimate given.

Those are just some things that came off the top of my head. I could also get into the "it is wrong to tell lies" part as it applies to medicine... like what I got asked at during my med school interview - "Say a kid needs a surgery NOW. If he doesn't get it, he'll live, but, he will never be able to walk or run again. Insurance won't approve it for another couple of weeks. But if you lie to the insurance company and say that he needs this surgery to save his life now, he will be able to walk and run again. What do you do?" and his follow up, "As you know, there are limited resources, what if this kid's surgery meant that 100 people could not get their medicine?" :P

I've worked in various medical settings, and I've seen doctors do things like declare that a patient has depression (when they didn't really), just so that the insurance company would pay for buproprion for smoking cessation purposes (which the insurance company will not pay for). You could say that the insurance companies themselves are highway robbers unto themselves, but that's not a discussion I care to get into while my brain is still waking up. XD

But yeah. As always, you make lovely points, Prissi. <3

Yeah, my opinion re: lying to insurance companies is this - really you shouldn't do it because it's better not to lie, but when quality of a patient's life is at stake, or life-saving treatment is needed, I think as physicians and human beings our ultimate responsibility is to other human beings, not corporations. Obviously going to a religious school, the 10 commandments came up during that conversation, and my answer was basically that the first five commandments are about our relationship with God, while the last five are about how we should relate to our fellow human beings. I do believe, ethically and morally and spiritually and whatever else, that our responsibility as *PEOPLE* are to other people first and then only to some giant institution/corporation. You could pick this apart many different ways, and obviously I do not believe that it is ethical or moral to completely ignore the HMOs' rules and regulations just because people >>> corporations, but I do believe that as a general statement, a physician's ultimate responsibility is to humanity, and to do what it takes and what is possible to preserve the quality of life of each patient.

I don't know that I'd be willing to continually record that a pt has depression just so they could get buproprion, something like that done habitually, I feel would compromise my integrity over time. though why the hell do they not cover something like that, I cannot imagine... O_____O smoking being the #1 cause of preventable death and diet & exercise levels being #2... it's gotta cost a lot more to take care of the emphysema and stroke and the other fallout. O___________O seriously? insurance companies don't cover wellbutrin for smoking cessation? there is something seriously wrong here.
That's really interesting stuff! (1) was dealt with in some of my course reading, but 2 and 3 are examples I haven't considered at all.

Do American doctors get given a specific ethical framework to work with (e.g. the Four Principles, as I outlined to Alex above) or do you get given general instruction and left to figure things out yourself?
Aside from what others have said, I don't think patients should be told the truth of their condition just because "it's wrong to lie" so much as it is that they have a right to know about anything that affects them. If a doctor withholds information from the patient, they could be preventing that patient the opportunity to research and educate themselves and their loved ones on their condition, and the opportunity to make whatever preparations as needed. Furthermore, deliberately misleading someone can lead to some very awkward moments (not to mention anger and distrust) later on if/when the person learns the truth, especially if it's through other means.

This, of course, mainly applies to people who can have a basic cognitive grasp on the situation. If it's a very young child, as Prissi said, and the child isn't yet at a point where they can understand the complexities of their condition, perhaps they can be given a modified but still true account of their condition. Kids are surprisingly savvier than we grown-ups tend to think; while we may not want to scare them or hurt their feelings, I think we do at least need to give them some credit. =/

Anyway, I'm sure none of this made sense, sorry. =/
This makes perfect sense, and yes, the whole anger and mistrust thing is a huge part of it. The last thing that you want as a physician is to damage the physician-patient relationship in such a powerfully irreparable way. If there isn't trust, then there isn't... compliance. We hate that word, because you ideally want the relationship to be a partnership, not a "you do this, because I said so, because I am the doctor" type thing, but there really is no other way to state it. :x
There's also a distinction or a point to be made about the whole truth versus truthful statements. The original question implies the doctor would / should sit down and explain it all, including negative things which might impact on the patient's will to live (cf prissi's comment below) or otherwise not be helpful (cf brixtonbrood's comment about the placebo effect). You can say true things without telling the truth, if the latter is understood to mean "the whole truth".