From the standpoint of Catholic moral theology it is not advisable for a physician to withhold information from a patient that the patient has a right to know. Not informing a patient that he or she is dying because the physician wants to "shield" them from bad news violates the principle of patient autonomy and does not allow the patient to come to grips with the diagnosis and hopefully begin the grieving process so that he or she can eventually come to the point where they have accepted what is taking place. While it is possible that the patient may not ever come to the stage of acceptance, it is still not the doctor's right to withhold such information. The truth is that most people have a keen intuitive sense that they are dying. They realize that their body is shutting down at some level and they want to know that what they are experiencing is grounded in some medical reality.
The physician's bedside manner comes into play at this point. How does the physician explain to the patient that he or she is dying? This needs to be done in a compassionate, caring, sensitive manner so that the patient does not lose all hope and he or she is given assurance that the physician and hospital staff will do as much as they can to make the patient's stay as comfortable as possible.
Following the principle of the Golden Rule, which accepted by every religion, we would want to teach the patient in the same way that we would want to be treated if the roles were reversed.
Withholding information due the fact that there might be a possible malpractice lawsuit involved is extremely dishonest on the part of the physician. Once again, the patient has a right to know what has transpired and it is up to the individual patient to determine whether or not they will bring legal action against a physician or the hospital, rather than allowing the physician to determine that no legal action will be brought simply because the patient will not be informed of any possible errors.
These are two examples of Paternalism at its worst. Paternalism, one of the principles of the doctor-patient relationship which was quite prevalent for many years here in the United States operates on the notion that the physician is functioning as a surrogate parent and in the same way that children are often shielded from "bad news" the physician shields the patient from information which he or she believes the patient does not need to know.
The reality is that the patient is an acting agent who needs clear, concise information in order to be able to make an informed decision and be able to able to give consent to possible treatment options. The fact that you or I might believe that we would be able to deal with certain information does not mean that we have a right to withhold information from someone who is entitled to it.
With this being said, it is also important to keep in mind that there are times when a physician cannot crudely tell the whole truth, especially when he or she knows that the patient does not have the strength to deal with such a revelation.2 A physician is forbidden to lie, according to the Eighth Commandment; however, telling a patient the whole truth when he or she knows that this person cannot handle it is a violation of the principle primo non nocere (first do no harm).
The doctor-patient relationship is based upon trust. In order for a physician to properly treat a patient it is essential that the patient feel comfortable with his or her doctor so that sensitive and important information be provided. The patient, for his or her part, believes that any information provided to the physician will be kept confidential, provided that the patient has no intention of hurting herself or others. Based upon her professional training and knowledge of a given patient, the physician is in the best situation to whether that person has the capacity to be able to handle difficult or painful information and it is essential that information be provided clearly and in a way that the patient clearly understands what is being said. Lying undermines trust and once that trust is gone the doctor-patient relationship is over.
We live in a culture that does not deal well with the issue of death. It was not that many generations ago that grandparents would have lived in the same home with their grandchildren and the entire family would be at the bedside as the patient passed from this life into Eternity. Now we live in a culture where death takes place in a hospital or nursing home often in very sterile conditions and the only person that may be at the bedside is the on-duty nurse. The topic of death is normally not addressed to children due to fact that parents feel that they are "shielding them". While this may seem like a good idea, the fact is that doing so actually makes it difficult for the child to understand the "cycle of life" and as he or she gets older it becomes more difficult for them to be able to the death of their own parents or friends when the time comes. How much one tells a child should be based upon the child's capacity to understand; however, talking to a child about death can be a teachable moment and can assist him or her to understand what is going on.
In many cases those who are dying receive few, if any, visitors in the hospital largely because people feel uncomfortable with death and avoidance is one way of dealing with that lack of comfort. In Questions of Ethics Regarding the Fatally Ill and the Dying3 it states that the family, chaplain, and the group providing medical care, must assume their share in the duty to inform the patient that he or she is dying. As stated earlier, it is essential that the patient know that he or she is dying; however, this does not mean that informing the patient should destroy whatever hope there might be, especially if death is not imminent.
In addition to violating the Eighth Commandment, lying to a patient about the fact that he or she is dying also prevents that person from taking the necessary steps to get their affairs in order. If the patient is a Roman Catholic, he or she may wish to avail themselves of the sacraments as a way of preparing for death. Making a good confession can help one to unburden herself and put her mind at ease while receiving the Anointing of the Sick can give her the strength to face her condition with hope.
On a secular level there may be other business affairs which need to be put in order as well as information that the patient needs to share with his or her family prior to death and this opportunity is lost if the patient is unaware of her condition because she was not informed or, even worse, lied to.
While we might say that we would rather not know that we are dying because we would not be able to handle it, the fact is that we have no idea what we can or cannot handle until we are put in a situation where we are forced to come to grips with something.
In the summer of 2006 I spent eleven weeks as chaplain to the Oncology, General Surgery, Surgical ICU and Trauma units at the Reading Hospital and Medical Center in West Reading, PA as part of my CPE training. One of the patients I visited quite often in Oncology was a 72 year old woman whose condition was getting progressively worse. Her children, who lived locally, would visit her from time-to-time. At one point her Oncologist spoke to the patient's children and informed them that their mother is dying. Death would not be imminent, but the severity of the condition indicated that she could be dead within a month.
I spoke with the oncologist who informed me that her children insisted that he not tell their mother that she is dying because "she would not be able to handle it." The doctor informed them that he has an obligation to be open and honest with their mother and that everything would be done to keep her comfortable. The doctor informed the patient about her condition. He said that initially there was silence, but in a few moments she asked, "What is the next step?" He said that instead of falling apart, as her children had predicted, this woman wanted to know what her options are and how do we proceed so that she can remain as pain-free as possible until the end. He said, "Had I followed the advice of her children and not told her she would never have been in a position to make that decision to proceed and would likely have felt that she was being abandoned because she would know that something is wrong and no one is saying anything."
Telling the truth with compassion and love is always the best option. The fact is that we have no idea how God is working in a person's life. As I once heard stated, "There are two rules in medicine. Rule Number 1 is that patients die and Rule Number 2 is that doctors cannot change Rule Number 1." While doctors cannot change Rule Number 1, being as honest and forthright as possible with the patient can assist him or her as they come face to face with Rule Number 1.
End Notes
1 Rosamond Rhodes et al (ed.) The Blackwell Guide to Medical Ethics (MA: Blackwell Publishing, 2007), pp. 88-103
2 Pope Pius XII, "Christian Principles and the Medical Profession" (Nov. 12, 1944), The Human Body: Papal Teachings, pp. 62-63
3 Pontifical Council Cor Unum, Questions of Ethics Regarding the Fatally Ill and the Dying, Vatican Press, 1981
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