Lying to patients — and vice versa

Deception has a long and distinguished career in medicine. A little goes a long way

By Lucas Rosa

Dante, the 13th century Italian poet who wrote the The Divine Comedy, took a dim view of liars and deceivers. They were banished to the ninth and lowest level of hell where Satan himself resides. Such sinners are enshrined in ice with their mouths frozen shut for eternity. That's a nasty fate for anyone, but particularly a Canadian physician who's spent a lifetime in these icy climes. So what about those little lies you tell your patients to spare their feelings? Are these deceptions presumably performed for the greater good exempt from the damnation of the inferno? The whole question of lying is particularly sensitive when it comes to medicine.

Most in the profession agree that failing to tell the truth has degrees of seriousness. Consider this case. Mrs Humphrey, a patient in an assisted living facility, now in her early 90s, has been doing well for the last five years. A routine cold develops into pneumonia and you have her hospitalized. She recovers, but during the stay it's discovered that she has colorectal cancer. You call her daughter and tell her and her first reaction is to beg you not to tell her mother. The woman has only a short time left, why add the fear and worry of cancer to her last months? Why indeed. You agree not to tell her. Good decision -- you won't get much flack on the call from your colleagues.

In a similar vein, a Chatham, NB family physician still recalls stopping to help at a serious traffic accident. A minivan had been struck by a truck and rolled over several times. The passengers -- three young children -- had been thrown clear of the wreck. Two survived and had been taken to hospital when the doctor arrived; the third, about two years old, had not. Her small body lay in the grass covered by a tarpaulin. The mother remained trapped in the van with what were clearly terminal injuries. As the doctor tried to comfort her, she asked if her children were all right. The doctor, without thinking about it, assured her that her children were all "in good hands, " not quite a lie perhaps but clearly less than the truth. The woman died a short time later. A deception of this nature would be given the nod by most doctors who would argue that the greater good was served.

TRAINED TO LIE?
Cases that are less clear often come up in connection with doctors in training. Teaching hospitals are known to bend the rules when physicians deem it's necessary for the education of their young charges. About a year ago a med student wrote to the British Medical Journal (BMJ) concerned that "For the second time our student group has been advised to lie when reporting patient information. " In a similar vein, a Montreal oncologist, taking a page from the story of the New Brunswick doctor and the traffic accident victim, advises students to deflect questions about dying from patients with what he calls "positive generalities. " Asked how long they have to live after a particularly bleak diagnosis, the doctor might say, "This hospital is devoted to the living " or "Life is a powerful force that's full of surprises.

Teaching hospitals across the country have, at one time or another, presented medical students and interns to patients in a way that disguises their true status. One Vancouver grand rounds veteran introduces them as "junior docs. " An Edmonton internist uses the term "my young colleagues. "

A year ago, a BMJ study found that a full quarter of all rectal and vaginal examines on anaesthetized patients were performed by medical students without patient consent. One student who questioned the practice was told that the best way to practice was on patients who were unconscious.

Implying to the patient that someone is a physician when they are not has a long history. A dozen years ago a New York state Ob/Gyn had his license suspended when it was discovered that he regularly invited his brother and a friend, suitably garbed in white coats, to be present at internal exams performed in his office.

There's another form of physician deception with a long history -- being less than honest on insurance forms. Universally practised, and always with the best interests of the patient at heart, it has probably reached its zenith in the US. South of the border the paucity of coverage and staggering premiums invite fraud, especially for the benefit of patients with few financial resources. A survey of American physicians reported in the New York Times two years ago found that more than half would lie to insurance companies in order to assure payment for heart bypass surgery for a patient in need. Almost 50% replied that they would deceive an insurance company in order to obtain medication for a dying cancer patient.

FIBBING PATIENTS
There is, of course, another side to the story. Doctor-patient deception is a two-way street.

Patients lie to doctors all the time. They lie about everything from the nature of their symptoms to the medications they're ingesting. Those who crave attention exaggerate symptoms, those who fear a negative diagnosis minimize them. Patients lie about the medications they're on, usually understating the variety or number either because they're confused, think fewer is better or, in the case of addiction, that more is better. Some do it out of a need for attention.

Regular New York Times writer Dr Sandeep Jauhar calls the problem confusing and the management of it unsatisfying. More importantly, he points out that there's very little guidance provided to doctors for handling malingering patients.

In medicine, as in life in general, telling less than the full truth is a long and honoured tradition. A physician who never lied would likely soon develop a reputation as a cold and callous practitioner. Lying in medicine generally comes from pure motives -- then again, the way to hell is paved with such intentions.