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TRUTHTELLING in medicine ROBERT WEIR* "To tell or not to tell" is a moral problem central to physician-patient relationships. How much "truth" is necessary—or advisable—in communicating a diagnosis to a patient? When and what should a physician communicate to a patient known to be dying? How much information is necessary for a patient to be "informed"—and thus give informed consent—prior to going to surgery? What are the defining limits of informed consent for randomized clinical trails which may or may not prove beneficial for a particular patient? What are the advantages and disadvantages of informing patients about the possible use of placebos? How much deception with parents is morally permissible in communicating the prognosis—or cause of death—of a defective neonate? Because ofits centrality in a number ofclinical contexts, truthtelling in medicine is one of the recurring themes in the field of biomedical ethics. Two problems exist, however, in the interpretations of truthtelling in the bioethical literature. First, the classic case of truthtelling—the case of the dying patient—dominates the scene to the point that many discussions of truthtelling in medicine rarely get beyond an analysis of conversations with terminal patients. Second, much of the literature on truthtelling in other medical contexts (e.g., those requiring informed consent) tends to be contextually isolated, suggesting that the moral requirements of truthtelling in one clinical situation have no application to other clinical situations. I intend to discuss the issue of truthtelling by focusing on its two dimensions of truth and truthfulness, showing how the requirement of truthtelling applies to two different clinical contexts, and putting forth reasons for regarding truthtelling as a moral obligation applicable to all medical fields. The clinical contexts are those involving dying patients and genetic counselees, the former chosen because it is the traditional "paradigm case" of truthtelling and the latter because genetic counseling is representative of a number of medical fields in which physicians regularly confront the issue of truthtelling with patients who are not dying. ?Associate professor and chairman, Department of Religious Studies, Oklahoma State University, Stillwater, Oklahoma 74074.© 1980 by The University of Chicago. 0031-5982/81/2401-0215$01.00 Perspectives in Biology and Medicine · Autumn 1980 \ 95 My purpose will be to demonstrate, using genetic counseling as the comparative context, that the issue of truthtelling in medicine is richer, more complex, and more central to the entire medical enterprise than it seems when limited to the traditional context of dying patients or when analyzed solely in one of the new clinical contexts requiring informed consent. The perspective from which I will be working is an understanding that the pivotal thinkers in Western philosophical and religious traditions have been in general agreement that (in Sissela Bok's words) "truthful statements are preferable to lies in the absence of special considerations " [1, p. 30]. The Physician as Truth-controlling Authority There can be little question that physicians are regarded as authority figures in their relationships with patients, nurses, and virtually everyone else in a hospital setting who has not received a medical degree. The precise reasons for their status as authority figures are varied and include their roles as restorers of health, masters of a technical knowledge, decision makers in crisis situations, combatants against disease and death, dispensers of powerful drugs, and choreographers of a vast array of technological procedures and equipment. In a nutshell, physicians possess a highly specialized knowledge and perform a number of highly specialized tasks which are valued by persons who are dependent on them. It is the possession of a specialized knowledge which is relevant to the issue of truthtelling in medicine. Dying patients seeking information— and persons seeking genetic counseling—are caught up in a dependency relationship in which a medical expert controls highly significant or risk-laden knowledge which is not generally accessible to nonmedical persons. Certain parts of this knowledge may be sought (and sometimes secured) from nonmedical sources, but in order to secure the most accurate and complete knowledge relevant to their medical conditions, both dying patients and persons seeking genetic counseling are dependent on an authority figure whose training gives him or her special access to the knowledge...


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