Telling the truth

When one begins to try to engage practitioners and novices alike with ethical issues related to healthcare practice, the problem of truthtelling is generally a good place to start. Novices will see the conflict between being honest with patients while not wanting to harm them. Very many experienced practitioners will have encountered situations in which they have been torn between being truthful to their patients and protecting them from perceived harm. Sometimes the healthcare professional (HCP) may feel that the right thing to do is to tell the patient the truth, but feel constrained by what other colleagues expect of them, or constrained by what patients’ relatives have requested of them. In spite of the emphasis on patient autonomy which is said to have taken place over the past 20 years or so, problems of truthtelling have not gone away. There are problematic situations involving patients of all ages which stem from issues relating to truthtelling. Why has it remained so difficult for HCPs to tell the truth to patients? Relevant professional codes in the United Kingdom seem relatively unambiguous on this matter: ‘You must behave with honesty and integrity . . . ’; ‘as a doctor, you must be honest and trustworthy’; ‘You must be open and honest . . . ’. Surely to behave with ‘honesty’ entails being truthful? Sometimes relatively inexperienced HCPs and student HCPs will stumble into a situation where the truth is being withheld from a patient – this in spite of that patient being a mature patient, not a very young child. The junior colleague may be told that at the request of the patient’s relatives, or general practitioner (GP), the patient should not be made aware of the gravity of her condition. When discussing such cases in the classroom, almost the whole group will agree that the patient has a ‘right to know’, or ‘should be told’, but when asked whether they should be the one who does this – sensitively of course, not brutally – the typical response is that it is not their place to do so. Someone who knows the patient better than me should do it, or someone more senior than me it is often said. Obvious questions which can be posed to such responses include reminding people that no law is broken by being truthful with patients, nor (perhaps) is any clause of the relevant professional codes. Moreover, given the importance of autonomy-related aspects of care such as informed consent, one might think that it is necessary for patients to be aware of the nature of their condition – including their prognosis – before any medication, examination or procedure is dispensed. Sometimes, other parts of the codes are appealed to in order to defend withholding the truth from patients (and let us focus here just on patients who are capable of understanding the relevant information). Thus, for example, a nurse may point to the part of the Nursing and Midwifery Council (NMC) code which states ‘You must work cooperatively within teams and respect the skills, expertise and contributions of your colleagues’. Or, it may be pointed out that there is sufficient ambiguity in the clause to justify withholding the truth from patients, for example, ‘work with others to protect and promote the health and wellbeing of those in your care’. Surely, it may be claimed that in withholding the truth from a patient, one may be said to be protecting them from harms, and thus one is protecting the well-being of the patient. So there appears to be a sufficient level of ambiguity in the codes to make a case for withholding the truth from patients. When healthcare students see experienced HCPs withholding information from competent patients, the impression is fostered that these other clauses are more important than the ones which focus on honesty. Also, consider a situation in which a