One purpose of the Ethics in Practice section is to encourage ethical discussion amongst our readers and, to that end, we appreciate Dr. Sokol’s letter. We do, however, wish to raise several issues with his views on deception. Not telling a patient he or she is fat or ugly is not an act of deception but mere politeness. In fact, for many orthopaedic patients, obesity is a central component of their illnesses and should be discussed, albeit in a respectful manner.

Dr. Sokol’s example of a patient asking his physician to withhold bad news is not deception on the physician’s part and is a very different scenario from family members demanding that information be withheld from the patient. Following a patient’s wishes is not “treating him like a child,” but if the physician or family members decide what the patient can or cannot hear, it is.

Lastly, putting antipsychotic medication into a patient’s tea is not a violation of the patient’s autonomy. Acutely psychotic patients lack decisional capacity and therefore, autonomy is not an issue.

We do agree that, occasionally, benign deception may be kind but it is never respectful.

To The Editor:

I would like to question some of the assumptions made by Capozzi and Rhodes in their thought-provoking article ‘A Family’s Request for Deception’ and, dare I say it, suggest a view less critical of benignly intended deception.

The authors assert that ‘over time, deception and lies are usually revealed’(1). This is a moot point. I suspect that most deceptions by physicians - whether selfish (e.g., to cover up an error or to avoid an awkward conversation) or benignly intended (e.g., to spare a patient some distress) - are never discovered. In a study I conducted as part of a PhD thesis (as yet unpublished), I asked 85 physicians working in the United Kingdom how often they believed deception was used by physicians. Forty five percent answered ‘often’ and 46% ‘occasionally’. These results suggest that physicians’ deception may be more prevalent than is commonly thought. I suspect only a fraction of these deceptive acts are detected by patients.

The authors also claim that deceiving patients is disrespectful and a denial of patient autonomy. Of course this may be true, but it need not be. A benign deception to a depressed, tearful patient in need of comfort may show a greater respect for that person than the harsh truth (“yes, I’m afraid you are rather fat and ugly”). Now, a successful deception always infringes a patient’s immediate autonomy but this does not mean it fails to respect the patient’s autonomy. I know of a patient who explicitly asked his physician to lie to him in the event of a grim prognosis. Would respecting his wishes represent a violation of his autonomy? Is it treating him like a child, as the authors propose? Furthermore, there may be situations when deceiving a patient will make him more autonomous in the long term, as when a physician covertly puts medication in a psychiatric patient’s tea (or indeed if deception is likely to prevent a life-threatening event, such as a heart attack or ruptured aneurysm).

Since public trust in physicians is partly founded on the belief that they will tell the truth, truth-telling should of course be the norm. Yet, very occasionally, a benevolent deception may be kinder, more respectful and more beneficent than an honest truth which, however compassionately delivered, will remain deeply distressing.

Reference:

1. Capozzi JD, Rhodes, R, A family's request for deception. J Bone Joint Surg Am. 2006;88: 907.