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Autonomists who insist always on full disclosure usually set aside questions about uncertainties which permeate the clinical context.

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But, medical diagnoses and follow-up therapeutic regimens are rarely a matter of mathematical certainty. Psychiatric diagnoses for example, like diagnoses in many other specialties, develop from hypotheses which are then tested out through continuing symptom evaluation and carefully watched responses to therapeutic interventions. Does every feasible hypothesis require disclosure to a patient? Is every bit of data about a disease or therapy to be considered information to be disclosed?

Generally speaking, relative certainties and realistic uncertainties belong within honest disclosure requirements because they qualify as information that a reasonable person needs to know in order to make right health-care decisions. But reasonable persons do not want full disclosure even if such were feasible.

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Telling the truth in a clinical context is an ethical obligation but determining just what constitutes the truth remains a clinical judgment. Autonomy cannot be the only principle involved. Truth telling has to be linked with beneficence and justice and protection of the community. We can see the clinical context's influence on truthful disclosure when we look at an emerging new field like genetic medicine. What truth should be communicated to a patient who has just undergone a diagnostic test which indicates a possibility that the patient will develop an incurable disease?

Should the simple facts be disclosed? By whom?

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To whom? After what kind of broader patient assessment? What if the patient has a history of suicidal tendencies? If a genetic test reveals predisposition to certain diseases, who interprets predisposition or increased risk? What should be disclosed to a worrisome patient? If a genetic test indicates that a certain disease at some point will be expressed, for which there is no cure or therapy, should the eventual disease manifestation simply be disclosed? The patient may die from another cause before the genetically potential disease appears.

All these questions make one simple but important point; that disclosure of the truth in a clinical context requires a clinical judgment and is not a matter of simply stating what is factually or scientifically true or telling everything and letting the patient decide.

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  • New York hospitals have just altered an institutional ethic policy on truthful disclosure about H. Previously H. Now both are automatic. The shift reflects a re-evaluation of the risks and benefits associated with H. Now truth, in the sense of reporting known factual information, is considered a public health responsibility and more important than a patient's right to control or to individual autonomy.

    This is another example of a changing medical context and delicate clinical judgment about disclosure of truth. The concept of clinical context can extend over to the financial dimensions of medical practice. Lawyers, driven by self interests, have permeated the clinical context with the fear of malpractice suits and this situation makes revealing mistakes and errors imprudent or even self destructive.

    Ideally, truthful disclosure of physician or hospital errors to patients would be recommened and would likely strengthen the trust between doctor and patient, but this is rarely the case in today's clinical context.

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    Withholding information from a patient does not always undermine veracity or violate the truth principle. Sometimes patients request that information be withheld. Doctors sometimes are asked to make decisions for patients without communicating relevant information. Ordinarily, respecting such requests violates no major ethical principle: neither autonomy, nor truth, nor beneficence. But clinical judgement is always required because in some cases, even a reluctant and intimidated patient who requests not to be informed, needs to know some truths.

    Not knowing may create a serious danger to self or to others, and if so, the patient's request that information be withheld cannot be respected because it violates the core principles of benefience and nonmaleficence. Certain traditional cultures see the patient not as an autonomous entity with inviolable rights but as part of an extended family unit. Family members rather than the patient are given medical information, especially threatening information like a fatal diagnosis. Medical ethics requires respect for cultural practices because these are closely related to respect for individual patients.

    And yet, cultures change, and families are different, and some cultural practices are ethically indefensible. Clinical judgment may require that a patient be included in the information cycle rather than cooperating with a cultural practice which prefers painful isolation and communication only with the family.

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    Sometimes, a particular family member may be the designated decision-maker for an incompetent patient who later regains competency. Then who gets what information? Ordinarily both family and patient can be kept informed and will agree about options, but not always. Again, the clinician has to make a judgment not only about patient competency but about what information the patient can handle and when the family should take charge. If family members give a doctor or nurse important medical information not known to the patient, ordinarily they would be told that professional medical ethics requires that a patient be given such information.

    However, as with other contextual variations, great sensitivity and subtle clinical judgment is required. No one could pretend to speak for every patient in every context but generally speaking, patients want to know the truth about their condition and doctors are unlikely to be correct when they judge this not to be the case.

    Some patients who are given a cancer diagnosis and a prognosis of death may use denial for a while and the bad news may have to be repeated, but the use of denial as a coping device does not mean that patients would prefer to be lied to or that truth is not important to them. Patients need the truth even when it tells them about their death.

    To live without confronting the inevitability of death is not to live in anything approaching a rational or moral way. It is wrong to assume that patients prefer irrationality and moral superficiality. A death notice is a shock and a pain and yet patients can derive benefit from being told the truth even about their own death. Without the disclosure of truth in a dying situation, patients are likely to be subjected to aggressive treatments which will turn their dying into a painful, expensive and dehumanizing process. It is just this kind of situation which has contributed to increasing support for the euthanasia movement.

    Patients rightfully are afraid that they will not be told the truth about their medical condition and therefore will die only after futile interventions, protracted suffering, and dehumanizing isolation. On the other hand, the benefits of being told the truth may be substantial; for example, improved pain management, even improved responses to therapy, etc. But harm too may come from telling the truth about death. Harm may be rare, but still it must be guarded against.

    The doctor who tells a dreadful truth must do so at a certain time, and in a certain way. The communication of truth always involves a clinical judgment. Truth telling in every clinical context must be sensitive and take into consideration the patient's personality and clinical history.

    Generally speaking, however, in case of doubt it is better to tell a patient the truth. In complex clinical contexts, it may be difficult to draw the line between truthful disclosure and a violation of truth. Reasons could certainly be advanced to justify not telling a certain patient the whole truth.

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    • Outright lies, on the other hand, rarely are excusable. Something less than full and complete truth is almost inevitable. The good clinician is not just good at medicine and a decent person; he or she is also good at judging just what the principle of truth telling requires in a particular clinical context. Classical Catholic natural law tradition, beginning with Augustine 6 and continuing with Aquinas 7 and beyond, considered every instance of lying to be a sin.