PERIPHERALIA

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On occasions my friend Henry and I meet for lunch at the 
Sagewood Café   and have deep discussions on nefarious 
subjects over toasted sandwiches.  Today was a debate on 
whether one should rather tell a lie that softens or the truth 
that hurts. We also turned it the other way around with the 
proposition that it was better to be hurt by the truth than 
comforted by a lie.  This arose from a patient I was looking 
after in an old age home who suffers from pre-dementia. I get 
asked the same question by this patient, “will my husband be 
coming today?”  Her husband has been dead for several years.  

In this manner another perennial ethical dilemma arises 
when one has to inform a patient that they have cancer or a 
life threatening disease. Decisions of this kind are influenced 
by the patient’s character and beliefs as well as those of 
family members. This is all weighed up with the stages of 
the disease, the prognosis and the context within which the 
patient lives.  

One of the benefits of general practice is that giving 
information is not necessarily a now-or-never affair but is 
often a considered process over the progression of time. This 
process often depends on choosing the right time to give 
the information; what the French call le moment juste. It is an 
intuitive moment which gives one an opening to discuss a 
sensitive subject. 

In recent years the right to know has become paramount in 
bioethical circles unless there are exceptional circumstances 
involving cultural, religious or personal beliefs. Dilemmas, 
though, arise when a competent patient requests not to 
know a diagnosis or prognosis. 

There is also the “white lie” which is the grey area (if you will 
pardon the chromatic metaphors) between the absolute 
pure truth and the deliberate dishonest lie. The white lie 
involves the subtle variations between the absolute truth 
(which is a disputed phenomenon in philosophy) and the 
black mendacious lie. Between the two are the relativistic 
approaches of partial disclosure as well as the concept of 
therapeutic privilege. 

Therapeutic privilege allows physicians to withhold 
information when they think a patient may be unable to cope 
with the information or may be harmed by the information. 
In official language this goes “except in circumstances where 
there is substantial evidence that such disclosure would 
be contrary to his/her best interests.” (National Health Act 
2003,9, Section 6 (1)(a)).  

One of the main reasons for not informing the patient of the 
full truth may be the doctor’s concern that the patient may 
refuse a treatment that is in their best interests. The other 
common reason is that the news may cause extreme anxiety 
especially in those who are already anxious or already suffer 
from a general anxiety or psychiatric disorder.  

Lying can be defined as the direct communication of a 
statement one knows to be false. There can also be several 
gradations to these communications. Deception, for instance, 
is actively and intentionally causing a patient to adopt a 
false belief and is done with deliberate intent. This raises the 
complex philosophical dilemma between always telling the 
truth exactly as it is (the Kantian deontological approach) and 
giving false statements or partial disclosure in order to procure 
a good outcome (the consequentialist/utilitarian approach). 
Another slight variation on this theme is “concealment” when 
one intentionally avoids communicating all the relevant 
information to a patient. Almost unintentionally, we may use 
“misleading” euphemisms and what Winston Churchill called 
“terminological inexactitudes”. Even silences and non-verbal 
responses may be used to create either an impression of 
affirmation or disapproval. 

In some cultures there is a belief that statements may generate 
a self-fulfilling prophecy such as informing the patient of 
side effects, which will  then make them happen,  almost like 
letting the genie out of the bottle. Into this complex mixture 
is the choice of words one uses and the different forms of 
language manipulation that influences the patient.  The tone 
of voice, timing, inflection and emphasis or lack of emphasis 
all play a part in how information is conveyed and interpreted.

It is never completely possible to eliminate our agendas 
to help the patient and therefore we may convey our 
information in many one-sided ways. “If falsehood, like truth, 
had only one face,” said Michelle De Montaigne in  the 16th 
century, “we would be in better shape. For we would take as 
certain the opposite of what the liar said. But the reverse of 
truth has a hundred thousand shapes and a limitless field”.                                  

During the long years of medical training, we are imprinted 
with ways to seek and tell the finite truth or as nearly as we 
can get to it. In our mechanistic thought processes, we work 
in a linear way towards an objective (diagnosis) and a goal 
(outcome). This gives us security of purpose in a clinical and 
technological discipline. The apotheosis of this training is the 
concept of evidence-based medicine. We rationalise within 
systems and like to order our thoughts deterministically 
in order to achieve cures and outcomes, which we believe 
are medically best for the patients. This is the doctor’s truth 
but this may not be the truth for the patient. Vladimir Lenin 
putatively said “Do not ask, is it true? Ask, true for whom?”  

“True for whom” is one of the enigmas in medical practice 
when giving information to patients and when helping 
patients make decisions.

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

E mail: cristobalellis@gmail.com

THE TRUTH
“It takes two to speak the truth, one to speak and another to hear.”

Henry David Thoreau