Should Doctors Lie to Their Patients About Their Survival Chances?
Human kind cannot bear very much reality, wrote T. S. Eliot, and a recent paper in the New England Journal of Medicine bears him out. The authors of the paper asked 1193 patients who had opted for chemotherapy for their metastatic cancer of the colon or lung how likely it was that the chemotherapy would cure them. The correct answer, of course, was that it was very unlikely (in the current state of the art); but 69 percent of patients with lung cancer and 81 percent with cancer of the colon had a much higher hope of cure than was reasonable in their circumstances.
The authors found that those patients with the least accurate estimate of the chances of cure (that is to say who were the most falsely optimistic) rated their doctors the highest for their communication skills. In other words it is possible that doctors who give an optimistic message are those that patients think have told them the most, in the best and clearest way; but it is also possible that optimistic patients view their doctors in a benevolent light. What doctors tell patients, and what patients hear their doctors tell them, may be very different as every doctor is, or ought to be, aware.
The paper raises the question of what constitutes truly informed consent. How many patients know or truly appreciate that, as the authors put it, “chemotherapy is not curative, and the survival benefit seen in clinical trials is usually measured in weeks or months”? For there to be informed consent, is it necessary for the doctor merely to have given the relevant information, or is it necessary for the patient to have inwardly digested it, to believe it? Is the onus entirely on the doctor, or does the patient have some responsibility? Is a doctor automatically to blame if a patient has not understood and absorbed his message? At any rate, the authors say that “this misunderstanding could represent an obstacle to optimal end-of-life planning and care.”
It could, of course; on the other hand, it might make tolerable what would otherwise be intolerable. Is false hope never better than, or to be preferred to, no hope at all?
Doctor Johnson, who was so wise on so many subjects, was firmly, one might say dogmatically, of the opinion that falsehood in the medical context was always wrong. “I deny the lawfulness” he said, “of telling a lie to a sick man for fear of alarming him. You have no business with the consequences; you are to tell the truth.” This is a little too categorical for my taste. My mother’s surgeon did not think my mother could bear the knowledge that she had an 80 percent chance of fatal recurrence of her cancer within a year, and she lived another nineteen years in ignorance of the fact (to say that it was blissful ignorance would be to put it too strongly).
Research cited by the authors of the paper suggests why patients may not hear, mark and inwardly digest what their oncologists say to them. On the whole oncologists do tell their mortally ill patients that they are dying; but, for very understandable reasons, they find the whole subject rather distasteful or embarrassing and move on to something else, namely what to do about it. This is altogether easier for them, and also for the patient; as La Rochefoucauld said back in the seventeenth century, one can stare neither at the sun nor at death for very long. In the modern world particularly, activity, even if it be futile, is preferable to resignation or fatalism. For us, there is no such thing as a good death, even though we shall all one day die.
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Image courtesy shutterstock / KimsCreativeHub
More on medicine from Theodore Dalrymple at PJ Lifestyle:
But what is memory, anyway? If I recall correctly
there was a study done in the ’70s or ’80s prompted by cardiac bypass patients’ complaints that their surgeon hadn’t even come to see them before the surgery.
So, in the study, the pre-surgery visits were videotaped and compared with the patient’s post operative accounts. The paper then speculated about the possible reasons for the memory lapse.
In the paper under discussion here: were the optimistic patients that way because of something the doctor told them or how the doctor told them whatever he/she told them — or because they tended to be optimistic about life in general?
the doctor works for the patient. not the patients family unless the family presents with power of attorney. the patient who wants to know, deserves the truth. the doctor who lies to his patient should lose his license. words can be softened and timing can be chosen. that is the art of medicine, not withholding the truth from one who asks for it. some don’t want to know. rare, but it happens. from them, you withhold it. but never lie to the patient.
I would compromise: “I don’t know when you’re going to die. Still, make a will.”
As an anesthesiologist/critical care physician of nearly 30years, I can relate, without equivocation, that at this point in our culture, the physician no longer works “for” the patient. It has been made exceedingly clear to doctors, that as recipients of payment from the state/3rd party payers, our first obligation is indeed to the “system”. Sad but true. In America, physicians interested in a livlihhood, work for the collective. I’ll leave it to the reader to imagine the “conflicts” that this engenders.
In the near future I forsee vast medical complexes located on “Indian” land right next to their Casinos. Someplace where all the medical personnel who plan to quit under obama-”The Retard”-care can practice free from it’s constraints. And where people seeking real care can go.
Just think, waiting rooms with slot machines…. now THAT is an improvement already.
“At any rate, the authors say that ‘this misunderstanding could represent an obstacle to optimal end-of-life planning and care.’
It could, of course; on the other hand, it might make tolerable what would otherwise be intolerable. Is false hope never better than, or to be preferred to, no hope at all?”
Or, more simply and directly, it might mean that since doctors must be “ethical” and explain to patients that the painful, debilitating, and expensive treatments will “really” just be painful and debilitating, and not actually do much of anything to extend to their lives, patients will then “rationally” choose to forgo such expensive treatments, “coincidentally” saving the government health care program a considerable amount of money.
In fact, since that principle almost certainly extends to a wide range of other treatments, we see yet more instances of where doctors being “ethical” and “honest” with their patients, fully informing them of just how little a chance those treatments have of doing anything “significantly” useful, as well as just how painful and debilitating they will be, patients will “rationally” choose massively less expensive palliatives for a wide range of treatments for “end of life care”.
Of course many patients and their families are too overcome by emotion to make those “rational” choices. Therefore we will be “fortunate” to have the government cost-analysis board set up to do it for them.
The question that study wants to ask is really:
“Should Doctors Tell Patients To Shut Up And Take Their Overdose Of Morphine So They Can Die Faster and Quicker And Save Money For The Rest Of Us?”
People say you can’t put a price on a human life but society does it all the time. Would we spend a million dollars to save a very sick child? Quite likely, yes. How about 10 million dollars? 100 million? A billion? At some point, we’ll say that we simply can’t afford to pay that much to save a life. At that point, we’ve set the price of a human life.
Now, change the scenario to an elderly man or woman. The price we as a society are willing to pay to extend that life will likely be much less than for a child. It isn’t nice but it’s rational.
We’re a nation on the edge of bankrupsy and medical spending is a big driver in government deficits. At some point, we’ll have to say that we can no longer take heroic measures to extend life. We’ll have no choice. And as a society, we’ll be worse off for it. Anything that can’t go on forever will, by definition, cease at some point. We’re getting there pretty fast.
And what if a person just wants to spend his own money on such treatment?
Or are we so far gone in accepting government control of healthcare that we accept they can make completely outlaw private expenditures?
Well, given how much is spent on cosmetic surgery every year in terms of doctors taking it as a specialty and how much “essential” healthcare they could provide if forced to be general practitioners or such by the government, I guess anything can be justified once you get that far.
In the modern world particularly, activity, even if it be futile, is preferable to resignation or fatalism.
But that’s the point, doctor, we are all taught to be optimistic in the face of facts, that is the good fight and the good death, so in your survey I’d say 90% of the respondents simply lied about their “beliefs”. IOW, bad survey, naive methodology. How many doctors lecture their patients about a positive mental attitude, basically all of them. I mean, come on.
I’m much more familiar with doctors lying about the efficacy of any and all treatments for any and all problems, being far too optimistic, on just these basis.
My mother died of pancreatic cancer at age 84. When she was first diagnosed, the attending physician (our longtime family doctor) told her she had six months. She died in three. (Being a CPA, she had her affairs in order in one.)
I concluded at first he had simply miscalculated. Then I found out that in these parts, doctors tell terminal patients they have six months, regardless of what the tests show.
Of course, the Hippocratic Oath is silent on the subject of lying to a patient, or the patient’s family, deliberately or by omission.
That doesn’t mean I necessarily approve.
clear ether
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Regardless, doctors have a legal obligation to follow the majority view as to the opinion of a patient’s opportunity to live and life expectancy. Failure to fully inform a patient will get a doctor in serious legal trouble should he or his survivors choose to pursue it.
If it’s my time, I want to know. I have things to do and affairs to close.
Every time I have a friend with cancer they tell me the doctor tells them their prognosis is “good.” Most of them die. One friend insisted her doctor’s were optimistic about her pancreatic cancer. I didn’t contradict her (not that cruel) but I wondered if she were putting on a brave face for her friends and family or if her doctors were lying to her. She was dead in less than 6 months.
Perhaps, under some circumstances, some people regard 6 months as pretty good. Beats getting hit by a bus.
She may well have just been putting on a good face in order not to distress her friends and family. I have some direct experience with this. I know that at least some people want to minimize the suffering of their loved ones, so they don’t spell it out directly. They want to have fun with their friends while they still can, and don’t want to be treated like a dead man walking.
A friend of mine has a type of cancer that is a virtual death sentence. He’s a rational, realistic person who simply wanted to know his real prognosis. Some doctors were pretty straight with him; others refused to give any specifics and were evasive and vague. He ultimately had to come to me (an academic but not a doctor) and we looked up the medical statistics in the journals ourselves.
When my wife and I were expecting, one of our OB/GYNs told us there was an increased risk of Downs. Increased? By how much? She refused to say, or even give us a ballpark of the risk. We could get an amnio, but that’s risky, too. Only, again, she wouldn’t say how risky. What was her advice? “Well, it’s your baby, so it’s your decision.” She was saying the absolute minimum she was expected to say as a doctor, and not one word more, presumably so she could avoid a lawsuit.
I ended up reviewing the medical journals to figure it out for myself. Ultimately, the risk of a birth defect was negligible, the risk of losing the baby with an amnio was low but noticeable, and we would have kept the baby anyway. We didn’t do the test, and baby was fine. I also found an article in a prestigious medical journal where they recommended lying to parents about ultrasound results to keep them from performing further tests.
So, what if I hadn’t been a researcher with access to academic journals and statistical training? I’d have been totally in the dark, completely at the mercy of doctors who increasingly resemble dishonest auto mechanics. A doctor who can lie to me for my own good can also lie to me for his own good.
Can a doctor treat a patient who, in full control of his faculties, has refused treatment? That’s really what we’re talking about here. There’s this treatment, called “lying”, that is potentially beneficial to the patient’s quality of life, but comes with some nasty side effects (poor judgment due to not having accurate information). The patient asking for the truth is essentially refusing to let the doctor lie to him.
Were I in my friend’s position, I would want to know the truth so I could get my affairs in order.
Thank you for sharing about your friend. If a stranger’s prayers will help, he is added to mine.
One of my challenges is a child with DS, conclusively diagnosed before birth via amnio, although the indicator was there with AFP levels. At any rate, the amnio results alerted my ob/gyn to monitor the baby’s progress much more closely, with more frequent ultrasounds to measure development and continued viability, and eventually saving the child’s life by detecting a life-threatening condition. At birth, they were prepared to deal with neo-natal possibilities common to DS, so he got better care from the outset. I was also able to connect right away with the Early Intervention program for infants in our state.
Distressing at it was to get the prenatal diagnosis, it was worth every bit of the risk, for my child’s sake.
I think I’d be more interested in a follow-up study of this population to see if there is any association between their ultimate longevity figures and measures of optimism.
I take the approach that for most of human history medicine was 90% futile but if you didn’t try we could not learn. Without continued futile treatments the Lister’s and Pasteurs would not have learned how the body works. When and If I am presented with this option I’ll ask what the best way for medicine to advance would be for my treatment. The cost management approach results in no advances period.
Families and individuals used to care about costs because the were paying. Now, costs are no concern because the government borrows the money from our children. Is this okay with you? What exactly is being learned from a patient administered standard chemo and/or radiation when that patient is not part of a study?
I get your point; however you stretch your point too far.
It is easy to take a hardline, Galt stance when you’ve never been directly affected. Given the statistics, someone close to you: a best friend, your spouse, your parent, a sibling, your child, your self, will be diagnosed with cancer at some point. When that happens, you will reach for anything that offers a glimmer of hope for a cure.
Get back to us when that happens and let us know if you still have this callous viewpoint.
I was diagnosed with lung cancer in January 2011. I was 39 at the time and I am now 41. You know what I have been told on how long I have to live? I haven’t been told anything. I have been always told basically that things are fluid and unless pallative care was called for, my life span could be in years, who knows? At least I am getting the truth, and I think doctors without question owe the unvarnished truth to their patients. If they can’t tell them, they should have never become a doctor in the first place.
God Bless you. I’ll pray for your good health. My dad was diagnosed with lung cancer in July of 1969 and died in October…I was 8 years old. Things have come a long way since then. Even lung cancer is no longer an immediate death sentence. A lady I know, age 90, who smoked for 70 years has a cancerous spot on her lung. Slow growing, they say. They’re going to watch it instead of treat it because she’ll probably die of old age before she dies of cancer.
Indeed – at least in some contexts the placebo effect is real. I don’t know about cancer though. But does it change the answer if lying to patients increases the survival rate a few percentage points?
The placebo effect is very real. In fact, cough medicine which tastes bad has been shown to work better than cough medicine which tastes good. That’s why most cough medicine is disgusting. (Drugs with a higher price tag also work better than the same drug when it’s on sale.)
But I don’t want to be treated with placebos, or anything else, without my informed consent. There are lots of artfully oblique ways a doctor can use to gauge a patient’s tolerance for the truth. Hell, ask a patient up-front, on day one, long before they’re sick with anything. If the patient wants lies, or even just for the doctor not to be too specific, then great.
The doctor has no right to make that decision for a patient. It’s unethical, pure and simple.
Sometimes, a doctor lies because he knows his patient. My grandmother was in a freak car accident in the sixties that nearly severed both her legs at the knee. After surgery, the hospital surgeons told my grandfather she would likely never walk again, but her family doctor insisted she would. He told my grandfather, “She can do anything she puts her mind to- but she has to believe it’s possible.” He’d known my mamau since she was a girl, knew the importance she placed on “expert” opinion…and he thought that if she heard how slim her chances were, she would not try. She recovered full use of her legs in about a year and a half.
I disagree. My mother was diagnosed with a very aggressive cancer and died 3 months later. I would have highly preferred the doctors to be honest (I had to push them to get the honest answer). I thought they didn’t tell me because I was 6 months pregnant at the time, but it sounds like they do this with every patient. Knowing the truth helps you prepare for it, not only mentally, but financially as well.
What I told patients was that no one was 20% cured. They were or they weren’t. I would give them the best odds I knew and for some who wanted more, I would print out review articles. For a few, such as a young couple with the husband newly diagnosed with cholangiolar carcinoma, I told them that chemotherapy offered little hope and they would be wise to spend time together doing things they wanted to do, until he was too sick to enjoy life. Then they could try chemo for another few months. The wife came to me after he died and thanked me for the advice. That, of course, was before liver transplant offered some hope.
Some people know without being told but most want the truth. It is not necessary to lie.
I am an oncologist and face this situation on a frequent basis. One of the problems we face is that our patients think we have all the answers.
We ran an international study about a decade ago, in which patients with metastatic cancer (spread to the bones) were being evaluated. We asked doctors to predict (guess, estimate) how long their patients would live. They tended to be optimistic by about three months, but that was the average. There was a wide range – some were wrong by more than a year! Any doctor who gives you a figure like “6 months to live” is just guessing, and you should realize that guess is probably wrong.
On the other hand, I think it does not help to tell a patient that s/he is going to die in 6 months. I usually give them a range (“most patients in your condition live for 3 to 6 months, but there are some who only live a few weeks and others who live for a year or more”), but also tell them two other things: 1) some patients live for a very long time, despite the grim prognosis, and 2) it is appropriate to have all your affairs in order, even if you are one of the lucky ones who lives for much longer.
This also needs to be a discussion which occurs over several visits, since most people will forget much of what is said on each visit.
Any doctor who gives you a figure like “6 months to live” is just guessing, and you should realize that guess is probably wrong.
When my uncle Charles was diagnosed with congestive heart failure, he was told he’d likely only have 6 months to live. He lived for several more years, long enough to see his only daughter get married and have a child. He was fortunate that his doctor’s estimate was wrong.
My brother Steve was sick for several years before finally being correctly diagnosed with a rare and aggressive T cell lymphoma. By that time, it had spread throughout his body. His doctor said that “if there was such a thing as stage 5, he’d be there.” He didn’t respond to the conventional treatment and they told him he was terminal. They tried an older chemo therapy and he responded amazingly well. In April of last year, they did a bone marrow transplant. In retrospect, I wish they hadn’t. He was in terrible shape after that and died a few weeks later. He was 58.
Cancer comes in so many forms and individual responses to treatment vary widely. Doctors and researchers are making progress but medicine is far from an exact science. When my time comes, I hope my doctors are truthful with me to the best of their knowledge. If I’m diagnosed with cancer, I may decline aggressive treatment if the probably of recovery isn’t good. I’d rather enjoy as best I can what time I have left than die like my brother.
As a two time cancer surivor (two different types of cancer; 16 years for one, 1 year for the other) I’ve had many frank conversations with my oncologists. Ibn the the first one I asked if what I had was curable. I didn’t care whether the percentage was 100 or 1. In another I asked my doctor if I was going to die. He aid yes. The goal was that I should die from something else. Then, after chemo I had to make a decision concerning whether to undergo radiation. My oncologist said they purpose of my traeatment was to extend my life expectancy for as long as possible. I do not know if I had too much optimism, but I do feel I was adequately informed. I also knew that I would not be 20, 50 or 80 percent cured.
One more point. No doctor can tell anyone when they will die, or how long they have to live.
It is false mercy to tell a dying man that he isn’t dying. He needs to prepare himself spiritually to meet his Judge. Call in a priest to give him the Last Rites as he draws near to death, and pray for God to heal what doctors cannot, but do not lie to him by denying that he is beyond the help of man’s medicine.
there is no way a doctor can state with 100% accuracy what any patient’s lifespan will be – there may be statistical analysis of 1 or more groups that suggest timeframes in which members of that group after the fact, on average, lived but that may or may not be applicable to an individual who is not of the already dead and measured group, i.e., someone who is still living. One does not know the actual life span or time to death until someone is dead and then life span can be measured accurately upon expiration of life. Its awful to see so many buy into medical care rationing-assumptions that doctors are somehow God and can miraculously predict date and timeframe of someone’s death. and then based on statistics decide that all members of future groups will 100% respond the same & thus should all be denied curative care. I was given a few weeks to live with stage 3b lung cancer & 2 other cancers 19 months ago – now I’m cancer free – I chose to fight it and told all the doc’s at the time. I know others who succumb in the timeframe given by their doctor because they don’t see any value in fighting since they actually listen when told they will die and then let go & give in to die. Ridiculous to presuppose any human, medical doctor or otherwise, can play God and tell someone that that person has x number of days or weeks or months to live. All they can definitely state is that a group of people with same disease were measured over time & x% of people in that group died within x% of time. Just awful to hear that so many here think every ill person needs to be told they’ll die in a certain amount of time based on some study of some dead group of people or other that may or may not have all identical characteristics as the person being told when they’ll die.
No doctor, or any Human will ever, ever predict anything with 100% accuracy. What we’re discussing here is honest prognosis.
My wife, a while ago saw the doctor over a concern that her cold wouldn’t go away, while everyone else’s did. The doctor referred her to the pulmonologist, who diagnosed lung cancer, small cell: extensive. The median survival time for patients in her state at presentation is 10 months. And that’s with treatment. Without, it might be 5 or 6 weeks. She chose the treatment, which twice almost killed her, and stuck with it, miserable as it was.
During a stay at the hospital for acute anemia and renal failure, (cisplatin, what cant it do?) a young doctor took the time to explain to her that all of the work we were doing, all of the complications, the pain, the weird symptoms, were Palliative. That this type of cancer was treatable, but Not Curable. We’re buying time here, half of it hell, the other half a little bit of freedom to be alive.
I don’t think she bought it right away, but I did. I’m no oncologist, but I am familiar with your neuroendocrine lung carcinomas, and this doctor, (please G-d, bless him in his long career) spoke the naked truth. With compassion, with kindness, but not denying the unavoidable, unarguable facts that he spent the time in med school to learn. This man is a friend to mankind.
My dear, lovely Wife toughed out exactly ten months.
Giving a best guess is certainly warranted, but patients and their families need to understand it’s only a guess. There is a God and we are not he. Predicting a date certain is a fools errand, as evidenced by the lady above that lived 18 more years.
Suppose it’s “true” that 90% of a population with a given condition will die in a year no matter what treatment is used. Knowing that an individual is among the 90%, or in the 10%, is very useful, but it’s unclear whether any individual should act on the basis of the population number because the individual outcome isn’t known. By the way, much can be said of ordinary life planning–it’s inconvenient not to know how much time any of us has, but would we want to know the year and month of our own death well ahead of time?
I am currently a cancer patient. I have metastatic neuroendocrine tumors (the same thing Steve Jobs had). Other than the first blush information, before the biopsies came back (when everyone thought they were looking at an adenocarcinoma or exocrine pancreatic cancer which is what Patrick Swayze had), my health care professionals, both doctors and nurses, have been remarkably up front with me. The message is “This is going to kill you.” and that they don’t know how long that will take and there are things they can do to push the time back (which they are doing). But, still, the underlying and overarching messages are and remain “This is going to kill you.”
An important article for all of us who grow older and see people younger than ourselves become ill and die. My deepest fears and sadness concern the loss of children. At age 69 with a full life behind me, I think I can deal with the truth. Sadly, I suspect that those who have not been brought up in a Judeo/Christian tradition will have a lot harder time facing the truth of death. I’m not talking about last rites, just the idea that we live on in the minds of people we have loved and cared for.
Let’s just say for the sake of argument that I am familiar with this subject intimately.
That is, I am the one giving this talk to people.
It is something that I am thought about constantly since the beginning of my training (I am now a senior attending oncologist at a major US medical center and a Professor of Medicine).
First, thanks for this opportunity to change the subject from the depressing state we MDs now find ourselves in after last week’s election. Most of know what is coming, and the severe disruptions that are about to happen. That’s why 80-90% of US MDs voted against Obama. We will still take care of you (although some of us may retire), but it may get a lot more difficult. But this is for another time.
Our duty is first and foremost to the patient, and to nobody else. Yes, when someone is dying you have to think about family and loved ones, and how they will carry on afterwards–but you do not forget, ever, who you are responsible for.
Most people with advanced cancer understand the serious situation they are in. They understand that they have a very good chance of dying of their disease.
What most people want to know is (a) is there any chance, no matter how remote, of my being able to survive; (b) is there any chance, no matter how remote, of my being able to live a reasonable life for a reasonable amount of time, with what I have; (c) what exactly is going to happen to me?
Our job as oncologists is to help people understand this process and these answers in a way that is appropriate to their level of understanding an need. It is not being dishonest, and it is not being a pollyanna.
It is far too easy for a health care provider to tell someone “you’re going to die soon, so prepare,” since that requires little thought on the part of the provider. It is a gross oversimplification of a very complex set of facts and circumstances. With current therapies there are always 1-5% of people, for example, that live 5 years with metastatic adenocarcinoma of the pancreas–how do I know who those people are?
What people want to know is ‘will you always be there for me?” They want to know “will you not abandon me, even though things do not look good?” They want to know “Will you continue to help me fight this, since I still want to, even though the odds look bad?”
What I tell people is “I will always be there for you, through thick and thin. I do not know precisely how long you are going to live, but I’ll fight for as long as you want me to. When there is not much left to keep the cancer at bay, I’ll let you know that too, so you can choose to stop. But we can always do something, whether it is making you more comfortable, making you more lucid, or allowing you to spend more time awake with your family.” There is always something to look forward to.
This is something that my more pointy headed friends from Harvard Medical School (I trained there, so I can criticize) don’t quite get. There is a human side to medicine that is sometimes lost in the abstract analysis of a clinical trial for the NEJM. I try to pound this fact into my trainees daily.
Guess what? It turns out that slowly but surely, some people with “metastatic incurable cancer” are starting to live longer due to slow and incremental improvements in therapy. In my field (metastatic breast cancer) we are starting to see people alive 8-10 years and more. If that’s not progress, I’m not sure what is. We could have told these patients “you’re going to die” and left it at that–it would have been easier. But we didn’t, and neither did they, and everyone is better for it.
I’ve said enough for now.
Well done, Interested Party. I learned something from you. Thank you.
After five years of on and off stomach problems, and a couple of colonoscopies, my mother was finally diagnosed with Stage III stomach cancer. We didn’t know what do do, but the tumor was bleeding heavily and starting to close off her digestive system.
I read every article I could find, and decided that surgery at her age might be fatal, but chemo would probably be even worse. She was 85. We had the surgery done, and I chased away the oncologist. That was 18 months ago, and she is doing fine, one of the lucky few.
“Should a professional whom I’ve engaged to deal with the area of his expertise feel free to lie to me about my situation?”
What a horrifying question. What a terrifying ignorance of the most basic ethical principles – those having to do with honesty and with refraining from harming others through dishonesty. “Is it OK to lie to people if I want to?”
No. Doctors should not lie to their patients, neither by commission nor by omission. Those who do lie about a patient’s medical situation should lose their license to practice and their reputation. The fact that doctors even find this sort of behavior admissible is frightening.
(Lies come in many forms, and the most common is the doctor’s pretense of certainty and knowledge. “You’re sure to die in six months” is just as much a lie as “Nah, nothing to worry about” when dealing with a cancer patient. Diagnosis is tricky and prognosis even trickier, but this isn’t an excuse to pretend to knowledge you don’t have.)
This is even apart from the fact that the lie may well cause the patient harm. People talk about the faulty ethics of lawyers, but lawyers do not even ask these questions. A lawyer who admitted lying a client about his or her legal situation for any reason – let alone to make the client feel “better” or “more optimistic” – would get sanctioned so fast his or her head would spin. A lawyer who falsely told a client that he or she had no chance of going to prison, to the client’s ultimate detriment, might well lose the right to practice for a while.
Lawyers understand clearly that lying to clients is not acceptable. Plumbers understand this. Why don’t doctors?
‘ Plumbers understand this. Why don’t doctors?’
Maybe because human beings are infinitely more complex than blocked pipes.
So, for all of you “holier than thou” types calling their physicians liars and wanting to pull their licenses for the unforgivable fact that they cannot accurately foretell the future:
Do any of you know of a surefire way for any doctor to predict just how long any patient will live?? I sure don’t.
If you do know of any, please tell the rest of us. Else, stop being so hypocritical and self-righteous.
In response to jaed at 25 above, lawyers know no to lie to their clients,but most lawyers know their clients cannot understand the full issues or facts. Surely doctors are the same. The patient cannot understand the details of his condition. So you have to simplify it so the patient/client understands the essence of what you are saying. But in the end, the patient/client does not understand it the way the doctor/lawyer does. The best he can hope for is to take your advice.
Every society has shamans. We invest our shamans with great power. Doctors in our society are our shamans. Yes, they use the scientific method and wondrous technology, but much of their power is shamanistic. The white coat and the stethoscope possess powerful meaning.
When a patient invests the doctor with so much power and wisdom, a doctor’s estimate of mortality can be as final and as fatal as a pin pushed into a voodoo doll. On the other hand, when a patient has a mind of his own, he treats the doctor’s advice as information which may or may not shed light on his other sources of information and his beliefs.
The late professor and writer, Stephen Jay Gould, of Harvard was given a fatal diagnosis and a short timeline. He, however, knew that the bell curve should be applied to the mortality figures. Some patients would die very early, other patients would die very late, and the bulk of patients would die within intermediate time frames. Gould died very late or at the extreme of the bell curve.
In my own case, I was diagnosed with coronary artery disease over a decade ago. I was repeatedly told that I would die in very short order unless I submitted to the placement of stents or to by-pass surgery. I researched my options. I concluded that in my case a medical rather than a surgical approach would be appropriate. This was not the conventional opinion at the time, although I recently read this very advice in Readers Digest (October, 2012—50 Secrets Surgeons Won’t Tell You)! I have avoided stents and the surgical knife. I have also not had a heart attack.
Patients must take an active part in their own recoveries. With respect to their doctors, patients must not automatically play Ingrid Bergman to the doctor’s Humphrey Bogart. Patients should replace “Oh Rick. You have to think for both of us!” with “Thank you doctor for your opinion. I will consider it.”
All of us have a survival chance of zero.
Think about it.
My problem with all this is in my life i have had doctors tell me someone was going to die, when it turned out the someone just needed a doctor with a pair of eyes.
So pardon my skepticism.
“hear, mark and inwardly digest” – Your Anglicanism is showing.
My oncologist (not the most felicitous phrase ever spoken) declined an estimate of my stage 3ish colon cancer survival rate since I was 48 and there were so many unknown factors. I didn’t really think it was worth knowing anyway. I have made it for 12 years. We’ll see. I still would have done the cheno in any case.
I had the honor and privilege of taking care of my father when he was dying of cancer (as well as my older sister, when her time came.) Up until the last week of his life, as long as he was conscious, when a relative or nurse would ask him how he was doing he would say “just fine.” I reckon he figured there was no point in burdening anyone else with his doubts and pain, though he wasn’t really the sort to complain in general.
My sister died of pancreatic cancer, and was well aware of how short her life would likely be whether she chose to get treatment or not. She chose quality of life over quantity, and I certainly couldn’t fault her for that.
Both of them made their end of life decisions based on information from their doctors, as well as their own knowledge and values. If their doctors had held back information, I don’t think it would have been fair to them.
With proper qualification of how percentages work, folks should understand reality. The exception would be children. However, if one is an adult, then one must put away childish things and be an adult.
Agreed. However, the parents should be given all of the truth – how else can they make the best decisions for their children, fight like hell for them, comfort them, allay their fears, or prepare them for death if necessary?
I’m so sorry that Dr. Dalrymple has stopped being funny.
In response to your question, “Is a doctor automatically to blame if a patient has not understood and absorbed his message?,” the the answer is beyond a doubt, YES! As a consultant, the doctor has the ABSOLUTE obligation to ensure that the patient has been given the truth and understands that truth! False hope is a lie, and torture of the patient and the family!
@35 Robert
Lying to a patient is certainly wrong, but what you’re insisting on here is impossible. Any communication is a two-way process, and while the caregiver has a responsibility to be honest with the patient, he cannot force the patient to be honest with himself. Patients say they want the truth, but they also want certainty, and for whatever reasons many believe doctors and nurses can provide it. Oftentimes in the case of chronic disease with a terminal prognosis the truth is simply that the doctor does not know exactly what will happen, but an honest admission of this fact, given with a layout of the possibilities, often leaves people thinking they are being deceived or otherwise jerked around because they didn’t get a straight answer. This gets into the question of the patient’s ability to understand, which is a lot more complicated than it seems – for instance, how is the doctor supposed to convey in a few 20-minute sessions what it has taken years of study and practice to understand?
We don’t even have to get into anything as devastating or complex as cancer, this is something that comes up all the time in routine healthcare, with regard to things we are certain about. Take the common cold. I can tell you from years of clinical nursing that it is practically impossible to convince the average person that a no one catches a cold (or the flu, for that matter) simply by going outside with wet hair. You can talk about viral transmission and handwashing till you’re blue in the face, many remain unconvinced.
Moreover, it doesn’t seem to matter what the patient’s educational level is. People who should know better will often adhere to so-called common sense ideas about their health that may sound perfectly rational to a layman but have no relation to how the body actually functions. The anti-vaccine movement is a good example of people rejecting the best available medical evidence about infectious disease (which is the “truth” as far as we know it) in favor of alternative hypotheses that have no supporting medical evidence but flatter their prejudices about homeopathy or corporate pharmaceutical greed or whatever.
So while I agree that patients should never be lied to, and that as caregivers we have an absolute obligation to explain the truth as best we are able, we cannot control the patient’s mind.
Is false hope never better than, or to be preferred to, no hope at all?
According to the philosopher William James, it’s ok to have the false hope that god exists if it somehow helps you get on in life. Here it’s pretty much the same thing. Let the patient believe what he wishes, if that works for him.
Believe me, it is more devastating to think you’ve beat an illness, only to have it come roaring back. Better to be told you have an 80% or 40% or even 5% chance of survival than to be lied to – at least you have some reality in what is at best a surreal situation, and can set your expectations accordingly.
Being informed is the best defense you can make, from researching treatment options and the efficacy and effects thereof, to survival stats, to rate of relapse. And even though far too many doctors resent like hell having an informed patient who wants to see every report or asks questions and “wastes” the doctor’s valuable time, we do ourselves a disservice by just looking at the doctor as if he’s some god, infallible and omniscient. He’s not, he isn’t, and you’re not the only patient he has, so you can fall through the cracks, or the doctor might overlook an option or be uninformed about something being tried with success elsewhere. Being the doctor’s backup in research and keeping your disease on its proper track is the best medicine you can have. Key to this is having the truth up front.
Best advice if you hear you have the Big C: insist on a PET scan during your staging. No other test will show so clearly just how far it’s gone, and the results may change the treatment regimen chosen. It might save your life.
I had a friend who was diagnosed with pancreatic cancer and given 3 months to live. She fought it with humor and a fierce mental resistance and NO CHEMO. She survived for 18 months (a remarkably happy and tranquil time (considering the circumstances). My brother was diagnosed with pancreatic cancer and given 3 months to live. He passed on after two months. The intense pain (even with opiates) just wore him down to where he didn’t want to go on. Death comes to us all eventually. How hard we resist it is a personal matter but for a doctor not to give us the information about what we are up against is (in my opinion) just wrong.
We seem to have a lot of cancer in our family. I have known several to go through chemo, suffer the unpleasant side-affects and then die. I have known a couple to refuse chemo, gradually decline and die. From what I have observed those who refused chemo may have died a little sooner, but enjoyed a better quality of life until the time came for the morphine.
I find it highly likely to be in that situation eventually, as it is so prevalent in our family. I will absolutely refuse chemo. I have no fear of death. We are all mortal. My doctor, she been my doctor for 15 years, and I am very candid with her. If the time comes when I have to see a specialist I will ask her to mote in my files that I insist on the truth.
My first husband dies at age 30 from Glioblastoma Multiforme a.k.a. GBM. His brain surgeon, that had research experience with this type of cancer, when asked point blank “how much longer?” Said he could not tell us, since he did not know. He knew of patients told a range and like an timer, they died on the schedule. He had another patient with a brain cancer that he thought would not make the reminder of the week, that was still alive a decade later.
What he told us was, my husband had the “rest of his life to live… do the necessary stuff just in case, but only G-d knew the measure of it.” We knew we only had borrowed time together, that burns away the fluff and junk and leaves only the true realities.
My husband lived another 6 weeks, and was in a coma for one more before his death. Those 6 weeks however, he DID LIVE, even if disabled and crippled from the effects.
So…many of you would prefer to hear a lie, over hearing the truth. (That explains a lot.)
Personally, if I ever learned of a doctor who lied to his patients, that is the last doc on earth that I’d ever want to see. If he/she is willing to lie about one thing, who knows what else they’ll lie about…
If they lie, they can’t be trusted. Period. Dot. End of discussion. This is my life and health we’re talking about, here. Life or death and you want to be lied to? GMAFB.
Doctors should tell the truth but must be very careful to not state something as an absolute truth that is not…and there are few absolute truths.
If a patient has inoperable canceer, the patient should be told that in x% of such situations, death occurs within y months, but that such and such a treatment plan allows z% to survive for q months.
I don’t see it as much of an ethics problem for a doctor. If a patient elects to be overly optimistic, then it’s not the doctor’s problem.
Now, if you are in favor of death panels (or by default, to force doctors to become dealth panels), it becomes a bigger issue, doesn’t it? If an 85 year old person can be refused treatment because it is too expensive for somebody that old, how large a step is it to refuse treatment to an infant with a serious hearth condition, or to refuse treatment to a mentally disabled child who, in the panel’s optinion, won’t have a sufficiently high quality of life, or ultimately to somebody who dissents from the current regime?
All of these issues, it seems to me, get back to a cost benefit study of medical care. And the problem I have with that isn’t the cost benefit analysis itself, but the fact that so many people want the government to do it. Frankly, it seems inevitable, but think about it…what could be more horrifying than having some political appointee (particularly by somebody like our current Criminal in Chief), making such decisions.
Warren I don’t think a doctor should ‘lie’ but experience has shown a doctor can be convinced someone is going to die that in fact is still alive today, nearly 10 years later. Now as she is pushing 90 and has already seen many doctors retired I am sure someday a doctor predicting here imminent demise will be proven wrong.
And my how angry everyone was about my refusing to sign off on some do not offer care order which in fact they never had the opportunity to carry out.
Play god on your own time.
From my perspective, playing god seems to be what the rest of you are doing.
Because we have lived long enough to see people die that the doctors said were fine, and people live that were going to die?
Fine.
A phenomenal void exists between reality and hope in end of life situations.
First, all doctors, except hospice doctors, have devoted their entire lives to extending viable and active life. Your death is evidence of their failure, even though death becomes us all, the moment or circumstances mere color to the inevitable event. Doctors certainly know this, but, as warriors who give their lives in a hopeless battle, they try to tiptoe around the fact that everyone dies, and if you’re already seeing an oncologist, it ain’t gonna be long for you.
Now, some history: my first wife had breast cancer at 26. She had treatment, and was fine until she was 42, when a truly bizarre grand mal seizure told us the jig was up. She was not ready to die, so she fought tooth and nail. Aside from her brain slowly turning into Swiss cheese, she was a remarkably fit and healthy person. It would have been much better had she not been. It just made it all happen so much more slowly and painfully.
I am now married to her best friend, who happens to be a Hospice Nurse of some experience. You might guess that we discuss death perhaps more often than the average household. Add to that my chronic renal failure which was only brought up with a round turn by my beloved giving me her extra kidney, and we simply wallow in mortality and its contemplation. Yet, familiarity makes one less afraid. “Use makes master”. She is a Master of Death, and I am not entirely unacquainted with it.
Everyone dies. “Of the time and place, we know not”. Exactly.
My wife sells death. Not usually to the patients. Having been truly at death’s door prior to my transplant, I can assure you that when the moment comes, you feel so shitty, death is no longer to be feared. Instead my Lovely sells death to the families, who simply can’t grasp that they are no longer effective agents; it is now between the dying and their maker. You may rail at the Moon, the stars, God himself. It makes no difference. They are dying. Making their passing gentle and kind, instead of painful and tormented, is what hospice is all about.
Very few patients come to my wife having had all this explained to them by their Physicians. I think it makes them very uncomfortable. After all, they’ve been caught in a lie. “Put your trust in me, and I can save you”. They really can’t. But remember, my first wife lived many years after her first bout, and watched her son grow to manhood, which had been her prayer when she was diagnosed with a three year old at home. Sometimes they ARE right. Sometimes they win. They really don’t know.
Maybe the Doctors who are saving us SHOULD emphasize the positive. My Dear will be more than able to sell them on dying when the time comes. Perhaps that’s as it should be.
Remember. Everyone dies. “Of the time and place, none can tell”.
My advice: Die heavily in debt. If you are diagnosed with a really virulent disease for which there really is no cure, take out the biggest loan you can hoodwink the bank into, and get a cabin on a really nice cruise ship. Hire a nurse, if you must. Give her instructions that Morphine and Atavan are our friends. Start drinking heavily.
It certainly couldn’t hurt!
What’s it gonna do? Kill ya’?
I do not believe that anyone, professional or not, can be morally or legally required to lie to anybody. A patient is simply an individual in a certain situation, and those who insist on absense of truth on prognosis can certainly choose their physician based upon PR rather than medical knowlege and experience. Nature and her God determine death. To reject that verdict is simply foolish, although physicians can misdiagnose and be wrong; so there is nothing wrong, eyes wide open, with hope either.
“Incurable” means that the doctors cannot cure you. It does not mean you cannot be cured. There are doctors who may be able to help you. There are methods that may be able to cure you. You have to do the research now, while you can.
There will be folks who tell you that doctors like Burzynski are quacks. There are also people who will swear out affidavits that he’s cured them. And Dr. Burzynski is not the only doctor who may be able to cure you when others have failed. It’s up to you, now, before you need extra help, to do the research, and figure out how you’ll pay for “custom service”
Richard Nixon was treated for his phlebitis using chelation therapy, an unapproved technique. Suzanne Somers has been treated using unapproved techniques for cancer.
You do not need to be rich or famous to be treated effectively using the best possible techniques which just may be standard techniques. But you need to be educated now, about a disease you do not have and may never get. That’s your responsibility.
It’s not a great leap. Just as we know smoking causes cancer, and so we cannot claim ignorance, we should know what the odds are for the diseases we may be suffering from, or not suffering from yet, if ever.
For years, Chinese witch doctors had been using a “local cure” against leukemia. If you asked for that treatment in 1980, you would be told it was quackery. That technique is now used at Sloan Kettering and other top of the line, mainline, expensive cancer centers. The active ingredient in the Chinese witch doctor’s cure was arsenic, which, as it turns out, can make certain forms of leukemia into a chronic disease. So the cure existed for centuries before it was considered accepted by the AMA.
There are cures extant which you can use to save your life, possibly. Once again, it is your responsibility to do the research, now. Blow it off, call me anything you want. The ball is in your court.