Truth-telling in Medicine

1
Truth-telling in Medicine

• And The Justification of Paternalism

2
Critical Analyses

• Difficult question!!
• Veatch As a rule is strongly in favor of almost
  unlimited patient autonomy-- BUT this reading was
  taken from a case book where Veatch was trying to
  lay out both sides of the issue and not take a
  stand himself

3
Critical analyses cont.

• Gawande Several mixed signals
• Title of paper
• Lazaroff example
• Mammogram example
• Mr. Howe example
• Which is the real Gawande?

4
Critical Analyses take home message

• Need to read the article at least once without a
  highlighter (dont ignore specific words and
  phrases but rather put them in overall context)
• Be sure to ask how each paragraph fits into
  overall scheme of authors argument

5
TRVTH
6
Traditional approaches to truth

• NO general duty to disclose
• Truth as medicine bad news can be harmful or
  fatal
• Subsumed under general duty of beneficence or do
  no harm (nonmaleficence)

7
How culturally bound is current US view?

• Only a tiny slice of the entire history of
  medicine is dominated by an autonomy ethic of
  truth-telling
• Majority of other world cultures still seem
  reluctant to embrace this ethic
• BUT at least some traditional cultures are moving
  in a Western direction (e.g. Japan)

8
Truth-dumping

• Violation of beneficence-- usually perceived by
  patient as cruel and uncaring
• Violation of autonomy?
• Does cruel disclosure make patient a better
  (freer) decision-maker?
• Does patient get a voice in how truth is told?

9
Reasonable Mix of Beneficence and Respect for
Autonomy?

• Robert Buckman, How to Break Bad News (Baltimore,
  Johns Hopkins U. Press, 1992)

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Truth Protocol (Buckman)

• Pick a good time and setting and assemble right
  people
• Find out how much the patient already knows
• Find out how much the patient wants to know

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Protocol (cont.)

• Share the information the patient seeks
• in sensitive manner
• in appropriate chunks
• Respond to patients feelings
• Planning and follow-through

12
Lessons from Buckman

• Effective truth-telling is heavy on listening and
  light on talking
• Most patients want to know more and can handle
  it a few dont want to
• Giving patient greater role in setting agenda is
  respectful of autonomy and is also compassionate
  and caring

13
Seldom the Question

• Should we tell the patient the truth, or conceal
  it from her?

14
Usually the Questions

• When to tell?
• How much to tell?
• What exact words to use?
• Whom should be there with the patient?
• What comes next?

15
When Can Paternalism Be Justified?

• Atul Gawande, Whose Body Is It Anyway? New
  Yorker, Oct. 4, 1999

16
Weak Paternalism

• Patient lacks important dimensions of capacity to
  make autonomous decisions
• Child
• Dementia
• Mentally ill
• Generally easier to justify

17
Strong Paternalism

• Patient appears to have full capacities for
  autonomous decision-making
• Provider nevertheless feels that decision is
  mistaken and will cause great harm
• Usually seen as much harder to justify-- threat
  to respect for autonomy

18
Gawandes defense of strong paternalism

• Dependent upon arguments in Carl E. Schneider,
  The Practice of Autonomy (Oxford U. Press, 1998)

19
Schneiders Approach

• Read ethics literature
• Read legal cases
• Read books written by people about their own
  experiences with illness (pathographies)
• Interviewed patients in a chronic renal unit

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Schneiders Conclusions

• Some people wish to exercise autonomy as per the
  ideal case in ethics literature today
• Many do not wish to and would wish to defer or
  delegate part or all of major health decisions to
  others including physician

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Schneider (cont.)

• The people who wish not to choose often have very
  rational reasons for this preference
• Weakness and fatigue
• Lack of knowledge or understanding
• Awareness of problems in own thinking process
• Avoidance of guilt

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What Does Respect for Autonomy Require?

• Forcing each patient into ideal autonomy mold
  regardless of preferences?
• Allowing each patient to select the degree to
  which she wants to be informed and to
  participate?

23
Gawandes Mr. Howe

• Traditional argument often offered as
  justification for strong paternalism-- Thank
  you test
• Is this an adequate ethical justification?
• Is Gawande a good physician or an arrogant,
  paternalistic physician (or both)?