The Hippocratic Oath, translated from the original Greek, reads, “into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption”.[3] This image of the moralistic physician is ingrained into our modern society. Most people would instinctively agree that a doctor should be well-intentioned, honorable, and honest in his or her practice. In addition to these ethical intentions, a doctor should do all within his/her ability to help his/her patients by sparing them from suffering and increasing their likelihood of recovery. However, there are occasions in which these moralistic ideals are at odds with patient recovery. In this article, I will consider cases in which physician honesty prevents the best possible patient outcomes. If it holds true that a doctor should prioritize patient outcomes over other moralistic ideals, it appears that there are various situations in which a physician should lie to his patients in order to act in their best interests.

If it holds true that a doctor should prioritize patient outcomes over other moralistic ideals, it appears that there are various situations in which a physician should lie to his patients in order to act in their best interests.

The premise of this argument might sound strange and self-contradictory. It is difficult to imagine situations in which lying to a patient would benefit his recovery. However, these situations can be observed when patient optimism is a significant factor in recovery or remission. Two important examples of this effect are in the treatment of certain cancers and mental illness. Several studies have shown that optimism is an important factor in patient recovery. One study, for instance, performed a meta-analysis on cancer patients who had also taken a psychological test that screens for level of optimism. The study found that among lung cancer patients “five-year survival rates…were 32.9 percent for non-pessimists and 21.1 percent for pessimists.” while controlling for “smoking status, cancer stage, treatment, comorbidities, age and gender.”[5] This study reveals the important role optimism holds in the recovery of these lung cancer patients. In another study, focusing on head and neck cancer patients, researchers gave the psychological test less than two weeks after the cancer diagnosis and found that level of optimism was a statistically significant predictor of one year survival,[1] indicating that level of optimism after diagnosis is an important factor in predicting survival.

Given the importance of level of optimism on recovery, doctors should consider the effect their prognosis may have on the mental disposition of patients. A poor prognosis can have a devastating effect on the outlook of patients; for instance, a terminal prognosis is accompanied with major depression in up to 77% of cases.[2] In these terminal cases, doctors should be weary of giving a negative, though possibly realistic, prognosis as it could lead to depression, damage the patients sense of optimism and render his chance of survival even slimmer. Rather, doctors should consider providing the patient with a more optimistic prognosis, highlighting the chance of survival, even if it may err somewhat from the most realistic outcome. This example of terminal disease highlights the impact a doctor can have on his patient’s emotional disposition and level of optimism. For any patient, a doctor should consider the effect his prognosis will have on the patient’s level of optimism and consider the impacts this will have on his/her health.

Given the importance of level of optimism on recovery, doctors should consider the effect their prognosis may have on the mental disposition of patients.

Likewise, in the case of depression and other mental illnesses, patient optimism is particularly important. This importance is related to the significance of the placebo effect in the treatment of these disorder. A placebo is a pharmacologically inert treatment that should have no medical effect on the patient, but frequently will benefit the patient or make him feel better due to the psychological effect of receive a treatment. The placebo works only because of the patient’s expectations and feelings about it.  One paper on this topic describes the power of placebos in depression treatment explains, “placebo-treated patients receive all the components of the treatment situation common to any treatment, i.e., a thorough evaluation; an explanation for distress; an expert healer: a plausible treatment; a healer’s commitment, enthusiasm, and positive regard; an opportunity to verbalize their distress” and ultimately concludes that “expectations by both patients and clinicians play a significant role in the magnitude of treatment effects.” [4] The significance of expectations in this case make it clear that, in order for the antidepressant to be as effective as it can be, the clinician should demonstrate optimism about the treatment, even if its slightly unreasonable or dishonest.  In effect, telling a patient that a treatment is unlikely to work, even if true, would not be conducive to his recovery and would in fact make successful treatment less likely.

One might now ask, if lying is sometimes permissible, how do we draw the line between when it is appropriate and when it is not? An essential component of healthcare is a patient’s informed consent on any procedure or medication including potential benefits and side effects. This consent is considered extremely important in the doctor-patient relationship because we feel that the patient’s personal preferences about his own treatment should be respected. The model for treatment typically goes something like the following: doctor presents a treatment (A), patient gives consent to (A), and the doctor proceeds with (A). However, when the treatment (A) is or involves a lie, a patient cannot give consent. A patient cannot give consent to being lied to, as being informed of the lie would render the mistruth or exaggeration useless in helping the patient. For example, if a doctor wants to exaggerate the effectiveness of a depression treating medication in order to boost his patients sense of optimism about the treatment, he obviously cannot ask the patient for consent to exaggerate. This poses a problem: (A), the lie, might be beneficial to the patient, but is incompatible with informed consent. How can a doctor come to terms with this?  How can he provide the best treatment for his patient via a lie, despite valuing honesty and integrity?

To solve this problem, a simple heuristic has been suggested to approximate consent: Would patient choose the lie over the truth if he could choose?[6]  For example, if a burn victim asks a doctor, “will my injuries leave scars,” he obviously desires to know the honest answer. If the doctor lies in response, while he may spare the patient of the emotional pain of the knowledge he robs the patient of the truth for which he asked. If the doctor had asked the burn victim, before the answer was given, to choose between a hard truth, or a lie that eases suffering, one would expect the burn victim would choose the hard truth. After all, the patient asked the question—he seems to want to know the truthful answer. However, in cases in which a lie potentially improves outcomes, if patient were asked to choose between the hard truth and a lie that might help improve chances of survival, he would likely choose the latter. Few people would rather hear an honest evaluation if it meant they would be worse off medically.

When patient optimism and expectations are likely significant factors in outcomes, such as in cases of some cancers and depression, it is important that physicians consider honesty and how that affects outcomes when giving prognoses. It is likely advisable in these cases to provide a highly optimistic prognosis, even if it is not necessarily most probable, in order to best help the patients. While this attitude may force the doctor to violate some norms of medicine regarding honesty, it is often a necessary evil to give the best possible patient care.

References:

[1] Allison, Paul J., Christophe Guichard, Karen Fung, and Laurent Gilain. 2003. “Dispositional Optimism Predicts Survival Status 1 Year After Diagnosis in Head and Neck Cancer Patients.” Journal of Clinical Oncology 21 (3):543–48. https://doi.org/10.1200/JCO.2003.10.092.

[2] Fine, Robert L. 2001. “Depression, Anxiety, and Delirium in the Terminally Ill Patient.” Proceedings (Baylor University. Medical Center) 14 (2):130–33.

[3] “Greek Medicine – The Hippocratic Oath.” n.d. Exhibitions. Accessed November 5, 2017. https://www.nlm.nih.gov/hmd/greek/greek_oath.html.

[4] Khan, Arif, and Walter A Brown. 2015. “Antidepressants versus Placebo in Major Depression: An Overview.” World Psychiatry 14 (3):294–300. https://doi.org/10.1002/wps.20241.

[5] “Lung Cancer Patients with Optimistic Attitudes Have Longer Survival, Study Finds.” n.d. ScienceDaily. Accessed November 5, 2017. https://www.sciencedaily.com/releases/2010/03/100303131656.htm.

[6] Sokol, Daniel K. 2007. “Can Deceiving Patients Be Morally Acceptable?” BMJ : British Medical Journal 334 (7601):984–86. https://doi.org/10.1136/bmj.39184.419826.80.