Ethics Quiz: The Dying Patient’s Denial

Let’s start off today’s ethics adventures with a quiz…

The New York Times this morning has an odd choice for its placeholder in the spot typically reserved for editorials: an essay by Dr. Daniela J. Lamas, a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston. The piece endorses lying to patients “for their own good.” The op-ed—that’s not what the times calls such essays any more, but that’s what it is and they are—is fine, raising a legitimate ethics issue for readers to ponder, hence the use of it here as an ethics quiz. The placement and timing is suspicious, however.

This could be called a “conspiracy theory,” I suppose, but such theories are germinated by a genuine and deserved development of distrust. Since I do not the trust the Times to report the news objectively and ethically, but believe with good reason that it manipulates its reporting and choice of opinion pieces to advance a progressive and usually partisan agenda, I suspect that this op-ed was given such prominent placement to plant the idea that doctors—like You Know Who—and health care “experts” are justified in using incomplete facts, false certainty and disinformation when communicating to the public regarding the pandemic, vaccines, masks and the rest for “the Greater Good.”

Dr. Lamas, whom I have no reason to believe intended her op-ed for this purpose (though the Times says she is a “contributing Opinion Writer,” so who knows?) writes about a colon cancer patient who might “have been cured had he not disappeared from medical care to return, nearly a year later, with cancer so advanced that it had torn through his intestines.” He finally reported to his doctor because he was in pain, but insisted that nothing was wrong with him, and that he wanted to get back home to watch a game on TV. Lamas immediately recognized his attitude as irrational denial. She writes,

“I might have left the room then. I might have told him that we were going to do everything we could to get him home, even though I knew it would be impossible. I might have reassured him that things were going to be all right. But there was a part of me, standing there receiving his anger, that wanted my patient to know the reality of his situation. Even now, months later, I am not sure why.”

Not sure why, as a trusted professional, you would tell a patient the truth? Okaaay….

She told the man, “I wish there were something we could do, but the cancer is too advanced. You’re dying. It could be hours now. I don’t think you will make it through the night.” The patient’s family, a long-estranged sister and the man’s son, arrived and turned the hospital television to the game he had wanted to see. They watched it with him until he died that night.

Now, we are told, the doctor believes telling him the truth was the wrong decision. She writes, “As a doctor and purveyor of science, it can be difficult to accept that sometimes the ‘truth’ is not what a patient needs. Denial was my patient’s only defense mechanism. And as soon as the words left my mouth, I realized how cruel it was to try to take this defense from him in the final hours of his life.”

Your Ethics Alarms Ethics Quiz is…

Was it unethical for the doctor to tell the man that he was dying?

I’ll make just a brief couple of comments before I leave the rest to you:

  • As with all ethical principles, truth-telling has exceptions under certain situations, and..
  • The fact that the doctor put quotes around “truth” makes me question her conclusion and her route to arriving at it.

34 thoughts on “Ethics Quiz: The Dying Patient’s Denial

      • Patient – Doc, how much time do I have?
        DR – About 5 ..
        Patient (interrupting) – Weeks? Months?
        DR (continuing) 4 … 3 … 2 …

        Regarding the quiz – a Dr’s duty is to the serve the patient and not to make herself feel better one way or the other. Telling him he would not last the night is correct. She could give him the option to return home or stay. That’s his choice and it should be an informed choice. She might encourage one option over the other where she thinks there is a benefit because Dr’s opinions are valid and can be helpful. But the choice is his.

  1. The truth in this case may have caused the terminal patient some stress and pain, true, but he was dying. To have misled him about that truth could have had much worse consequences. Generalizing, giving a patient the opportunity to set his affairs in order before he dies is probably more important than saving him some amount of mental anguish. Was there no analysis of how things might have transpired if the doctor had lied (the article is pay-walled, and I will not support the NYT)? What if the man decided to leave the hospital and his condition worsened to the point he wrecked a vehicle and killed someone else? What if he died at home, and his relatives learned the doctor had lied, and decided to sue the hospital?

    Worse, what would happen to the reputation of the medical field if it became known that it was common practice to lie to people for their own good?

    Oh, wait…

    • This was mostly what I was going to write. I would add that she is there to provide a service and while there may be exceptions to the truth, this wasn’t it. If you’re not going to do the job you were paid to do, then get out of the field.

      I’m not sure if its relevant, but the fact that he died that night might have been moral luck. He could have lived a few more days. It might have been an educated guess he would pass that night, but most of the time its still a guess.

  2. My father was diagnosed with terminal lung cancer on January 23, 2020. It had spread to his brain, and basically, nothing could be done. The doctor recommended immunotherapy to help prolong life, but he was honest to the point of being blunt that it wasn’t a cure, and that there was no cure. My father passed away at home the day after his 76th birthday.

    Last year was significant for nearly everyone because of Covid, and my family was of course impacted as well. It just wasn’t our primary concern, we had bigger fish to fry last year. I cannot express enough how much I appreciate the doctor’s honesty with my dad, and with our family. Without his honesty, our decisions may have been different regarding my father’s care.

    Because we knew his cancer was terminal, and because all care facility options were locked down, we had time to make a plan for my dad’s care at home. We knew to keep him home, so he wouldn’t die alone, or with strangers. Until his last few days, he was able to tell his wife of 49 years he loved her every morning, just like always. We held his hand, combed his hair, and lotioned his feet. I spent hours reading next to him, sharing chocolate covered raisins, and letting him know how much he was loved.

    All because a doctor was honest.

    • My mom died of uterine cancer in 2014. It was rather a sudden onset, actually. She had been examined in November 2013 and been clear. Unfortunately she began to have issues in February while in South Carolina, but the doctors there put it down to just a UTI. In April when she was back in NJ the doctors found the tumor, tried to remove it, but couldn’t do so without killing her. They leveled with us that they could give her some new drugs, but that we were just buying time, maybe weeks, maybe months at the outside. We decided to try, in the hopes of giving her one more birthday with her granddaughter, one more Thanksgiving, one more Christmas. Unfortunately, the journey from May to November and December is a long one when you are dying of cancer. She only made it to July. It did not come as much of a shock, though, because the doctors had told us not to have high expectations.

  3. This is hearsay, but supposedly a doctor told my sister not to look up the potential side effects of the meningitis drug soon to be administered to my deathly ill infant niece.
    Treatment was successful and no lasting effects, (moral luck?) but somehow this feels like it skirts informed consent.

    It certainly wasn’t lying though.

    The above doctor’s scenario feels much more like a Nazi doctor ushering her patient into a gas chamber saying “relax, it’s just a shower”. Maybe telling a fantasy to a dying person makes a good emotional ending in a film like Big Fish, but she certainly isn’t in the position to be doing that for someone in her care.

  4. The doctor was 100% correct in telling the patient the truth. Some of his family was able to see him in his final hours and he night have had enough time to dictate his last will. If he had been told that the doctor would do everything she could to get him home, he would not have called his family over and he would not have made his last will; he would have died alone with his affairs unsorted.

    Though it is not a requirement to obtain a medical license in the US, most doctors do take some form of the Hippocratic Oath. They are meant to help the patient in the best way possible. The only way I can think where a doctor lying to a patient might be justifiable is if the patient would have insisted on foregoing life saving treatment if told the truth or if telling the patient the truth would cause so much mental anguish that he dies immediately.

    For the first case, I would argue that a patient being able to decide his own fate outweighs the doctor lying to get the patient to agree to a life saving treatment. For the second, I would say that most doctors probably cannot gauge the mental state of a patient well enough to justify lying.

  5. I pay the doctor to provide me with information I am unable to gather on my own. If that doctor is incapable of providing that information I made a mistake in entering into a professional relationship with them.

    Also, I have grown to hate the word “truth”. Seems like it is very often used as an excuse not to share facts or to alter them.

  6. It’s the doctor’s responsibility to give an honest prognosis so that the patient can decide what they want to do. What the patient does in response to that prognosis is their own responsibility. I don’t believe people have a right to be deceived for their own comfort, and even if they did, who’s in a position to make that judgment call? Only a person capable of having their own memory erased would be able to make that decision for themselves (so, I guess people with anterograde amnesia could do it).

    As for deceiving people so they make the right decision, that’s a more complicated question, but my general answer is that it’s a dangerous thing to find yourself accepting, so it’s always important to look for develop trust that people will handle the honest truth constructively, even if the costs they pay and the risks they take aren’t ones you would haven chosen for them,

  7. “Was it unethical for the doctor to tell the man that he was dying?”

    No.

    It’s never “ethical” for a medical Doctor to lie to a patient, or guardian of the patient, that’s being medically diagnosed and any medical Doctor that does so should be permanently stripped of their medical license.

    • That said; it’s extremely helpful for the patient and the family if there’s a counselor such as a Hospice professional there with the Doctor when notifying the patient and the family of their pending death. The discussion was very helpful for all involved when my Mother died 7 weeks ago.

  8. Is it ethical for a Doctor to lie to a patient? No. Never.

    Why?

    Simple. Once you lie, trust is gone.

    My mother in law died of cancer in 2019. It was her fourth bout with it. in 2018 (former nurse) she noticed some black spots on her chest X-ray. The Doctor said it was nothing to worry about. She said it was signs of cancer. Doctor denied it.

    We noticed behavioural changes, like speaking to us in Mandarin (her first language) when some of us didn’t speak it. It was dismissed by her doctor.

    When her health deteriorated she was in the hospital for a month, then got out. Then back in a few days later. When she went back in, she wasn’t always lucid. The medical team waited until the family left, then when she was no longer lucid had her sign the assisted suicide papers. My mother in law and the rest of us were furious when we found out.

    We managed to get her into a hospice and she died within a week. What was the result of those events?

    Frankly, my wife and I question anything a Doctor tells us to do for our health. We’ve seen members of their profession lie, so our trust in them is gone. Health care is expensive, and it seemed the people entrusted with her care were more interested in the costs than her quality of life or autonomy.

    Once a profession has proven that it will accept lies to their clients, they have forfeited their right to call themselves “professionals”. The truth is hard. It’s often unpleasant and reactions are often negative. But I have never regretted telling someone the truth. Telling someone a lie “for their own good” is simply saying that you are afraid that the truth will lead them to a different conclusion. One that you don’t like. But it is the person’s life, and their decision. Not anyone else’s.

  9. No. It is unethical to lie to a patient. The doctor must give proper information and allow the patient to make informed decisions.

    Case in point: my brother suffered serious health issues. Over the last year has health deteriorated to the point that he was in an assisted living facility. At the end of August he was in the hospital because he couldn’t swallow solid food. The hospital staff informed me of the condition and probable outcomes.

    Upon release from the hospital I talked to the facility owner to assess what to do. During my conversation the owner informed me my brother was sitting up, eating a liquid diet, watching TV, and in good spirits; yet, 45 minutes later, my brother’s caregiver called to tell me that he had passed away during the night in his sleep.

    It was obvious the owner of the facility had absolutely no clue and simply lied, or he simply didn’t care. Either way, he was/is incompetent.

    The crazy and infuriating thing is that three days later he sent me and email encouraging me to refer new residents to his facility.

    jvb

  10. It has been routine, even recommended, for doctors to lie to patients and guardians about intersex status, in order not to inflict the psychological damage thought to occur should the patient find out they are neither biologically 100% male nor 100% female.

    A secondary objective was to conceal this in order to prevent persecution by society at large.

    • Jack asked a very specific question, “Was it unethical for the doctor to tell the man that he was dying?”

      zoebrain replied, “It has been routine, even recommended, for doctors to lie to patients and guardians about intersex status, in order not to inflict the psychological damage thought to occur should the patient find out they are neither biologically 100% male nor 100% female.”

      You gave an example that turns out to be a deflection but since you brought it up, your example is unethical. Your example is using rationalization #10 and in my opinion I think I detect some or a version of all the following rationalizations too: 3, 8, 8A, 13, 14, 22, 28, 29, 52A; there may be more in there that I’m not seeing.

      No zoebrain, it’s not the Doctor that’s inflicting psychological damage on the patient it’s the presence of the condition. Not telling the patient and the patients guardian does not make the condition go away, it setups the patient and the guardians for a psychological failure down the road both in the shock of finding out about the condition at a later date and the shock that their Doctor(s) have been openly lying to them.

      The doctors should be telling their patients and their patients guardians the truth, the whole truth and nothing but the TRUTH and immediately introduce them to a professional source to help deal with psychological issues that may surface as a result of the condition.

      Lying to a patient and their guardians is unethical.

  11. Perhaps, the patient “knew” the truth, was not confused and delusional, and chose the path of dying watching a beloved game surrounded by family. Perhaps it was the doctor who was confused and delusional.

  12. oh . . . Oh . . . OH . . . this one is such an easy call for me that it makes me want to scream.

    A Doctor’s Lie Almost Killed Me

    A few notes:
    – When I was born my mother was already older than was considered advisable to have children at the time.
    – I have two older brothers, but I was my mother’s fourth pregnancy. The third ended in miscarriage.
    – Because of the various conditions in play and from the examinations and tests they performed, the doctors predicted (incorrectly) that I would be born brain-damaged and mentally retarded and (correctly) that I would be born with life-threatening birth defects.
    – Because of the above, the doctor encouraged my parents to abort the pregnancy.

    So, as the story goes, (after all, I wasn’t there to witness it myself for obvious reasons) at one point my mother’s doctor gave her some pills and encouraged her to take them. When asked what they were for, he essentially wouldn’t answer.

    My parents were suspicious, and decided not to take the pills. Instead, they took the bottle to a different doctor and asked what the medication actually was.

    It would something that would have encouraged a miscarriage.

    THAT . . . is simply . . . unforgivable.

    I’m only here today typing at my computer because my parents had enough skepticism to question the situation and seek the truth (not to be confused with the “truth”).

    No doctor has any right to lie to a patient . . . EVER. To do so is to usurp the agency of the patient to have the final say on his or her own medical care and treatment. No doctor has that right.

    And sure as fuck no doctor had the right to try to miscarry me without my parents’ informed consent.

    –Dwayne

    P.S. THANK YOU, Mom and Dad. I love you.

  13. Well, we can thank the NYT for reducing the public’s trust in another profession. I don’t even understand this doctor’s wish to lie to this patient. It would be one thing if the doctor thought the patient was terrminial and would die in 6 months and was trying to ‘ease’ them into that realization by saying something like ‘this is a serious condition and I want to schedule a time to talk with you about it after we do some more tests’. This doctor thought the patient could die within the next few hours and was considering letting them go home none the wiser? What did the doctor think was going to happen when they get home, start watching the game and start bleeding profusely and then die right after seeing the doctor? What would the effect be on that patient’s family? What would the people who could have had a chance to say goodbye didn’t? What about the ones who were there but in their room on their phone instead of spending their last hours with a loved one?

    The doctor’s reason doesn’t make any sense. My suspicion is that this doctor doesn’t like confrontation. It was not pleasant to explain to this guy that he was dying. He was in denial and defiant and dealing with that isn’t fun. Well, tough. This person went to med school and makes more money than 98-99% of US families (based on avege specialist salary) and this is part of your job.

    I wonder if this is a new thing in medicine. A family friend was having breathing problems week ago. Well, he went to the cardiologist just 3 weeks ago and his heart was fine (same blood pressure medicine), his kidney function was normal, and nothing really wrong to speak of so he wanted to see if he had COVID. They ran tests, kept him overnight and said everything was fine. His son picked him up and took him to his house for lunch. At lunch, our friend collapsed. They took him to another hospital and it turns out he is in stage IV renal failure, end stage COPD, and needs a heart valve replacement. The first hospital saw his results, but after looking at his labs and exam from 3 weeks ago didn’t think there was anything that could be done.

    • The doctor’s reason doesn’t make any sense. My suspicion is that this doctor doesn’t like confrontation.

      The doctor said she wished she’d (falsely) promised to do everything to get him home. She expected he would die before discharge was an option. The lie would have been the “going home” part.

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