2.3 Truth Telling
T.S. Callanan, MD, FRCPC
- To understand the relationship of the fundamental ethical principle of autonomy to truth telling
- To understand the relationship of truth telling (and in contrast, deception) with respect to the process of informed consent
- To consider the concept of truth telling in the face of clinical uncertainty and/or an unwanted diagnosis
Paul Green is a 71-year-old retired professional who lives with his wife of 45 years. They have two grown children who do not live in the family home. Since retirement, Mr. Green has remained active in several volunteer organizations in his community and also in the outdoor activities of hunting and fishing. He has been referred by his family doctor to a geriatric psychiatrist for evaluation at a memory clinic because of difficulties he was experiencing in remembering things, especially since beginning a strategic planning process with one of his community groups.
Mr. Green was accompanied to the clinic by his wife, who commented that from time to time she had noticed her husband misplacing things about the house and that occasionally he seemed to have difficulty finding words; however, she minimized these things by stating that she felt it was no different from her behaviour and that, between them, they managed to accomplish everything reasonably. She expressed concern that her husband's father had died almost 15 years earlier after a long battle with Alzheimer's disease. She said that her husband told her then, and repeated it from time to time over the years, that he would never burden her with having to care for him as he had seen his mother do and that he would end his own life if that time came. Mrs. Green also said that one of her husband's cousins had taken his own life shortly after developing memory problems and that her husband said his cousin had done the right thing. She pleaded that her husband not be told about the possibility of Alzheimer's disease if that was a consideration.
With respect to Mr. Green's assessment at the clinic, there was no evidence of mood disturbance and no apparent deficits in the psychiatric clinical interview other than the examples the couple provided and a Mini-Mental Status Examination score of 4 points below normal for his age and educational background. There was no personal or family history of depression or substance abuse. All routine and screening examinations were within normal limits.
- The psychogeriatrician feels that the most clear diagnosis at this time is one of a mild cognitive disorder (MCI) or cognitive impairment not dementia (CIND); however, he strongly suspects that this case will progress to Alzheimer’s disease. What degree of information should be conveyed to the patient at this time?
- If Mr. Green asks whether there any specific medications that he should be considering at this time, what degree of further information would need to be conveyed concerning cognitive enhancement therapies?
- How should questions of prognosis be addressed?
- Canadian Medical Association. CMA code of ethics (updated 2004). Ottawa: Canadian Medical Association; 2004. Available from: http://policybase.cma.ca/PolicyPDF/PD04-06.pdf
- Drane JF. Honesty in medicine: should doctors tell the truth? CIEB (Centro Interdisciplinario de Estudios en Bioética); 2002. Available from: http://www.uchile.cl/portal/investigacion/centro-interdisciplinario-de-estudios-en-bioetica/publicaciones/76983/honesty-in-medicine-should-doctors-tell-the-truth
- Freedman B. Offering truth. Archives of Internal Medicine 1993; 153: 572.
- Hebert PC, Hoffmaster K, Glass C, Singer PA. Bioethics for clinicians: 7. Truth telling. CMAJ: Canadian Medical Association Journal 1997; 156(2): 25–8. Available from: www.cmaj.ca/cgi/content/abstract/156/2/225
- Wynia M. Invoking therapeutic privilege. Virtual Mentor 2004; 6(2). Available from: http://journalofethics.ama-assn.org/2004/02/msoc1-0402.html