Is it ever ok to lie to your patients?

You all know where this is going, I am going to say “sometimes”, but that goes against everything we are taught, everything we believe and it pulls our ethical heartstrings. Interestingly, a search of the General Medical Council’s “Good Medical Practice” publication, the document that sets out the values and standards of doctors, does not find the words “lie” or “truth” in any section.

The ethical framework we work to instead discusses kindness, compassion, courtesy and respect. It is within those themes I believe our words and decisions may sometimes be acceptable even when they are not the truth.

I remember Orwell’s theme of “doublespeak” in his novel 1984, the intentionally ambiguously vague reframing of words, particularly used by politicians, to make hard truths more palatable. I think of “white lies” where the untruth is about something trivial and the speaker is trying to be polite or kind to not hurt feelings. I also consider accidental lies, socially acceptable lies like the tooth fairy and exaggerations which contain a nugget of reality. All these lies are on the left hand side of a scale that goes from truth to lie in completely subjective and non-discrete intervals.

We probably all have examples we can relate to in our specialties, I can only share the ones I have come across in my time as a haematologist.

Further to the right hand side of that scale are lies of omission, the withholding of important information without saying anything untrue. There are deliberate, nasty shameless lies presenting completely the wrong facts. There are lies for personal gain, whether that is financial, self-protective or manipulative. I should also mention lies of commission when false information is deliberately presented as true, different to  pathological lying, when liars cant seem to differentiate truth from lie.

As I write that last sentence, I think the last thing I would ever want to be thought of as, is a “liar”. That tarnish would run deep in me, yet I know sometimes I have not spoken the whole truth, sometimes I have withheld information, sometimes I have made light of something awful and at times I have reframed a crisis.

We probably all have examples we can relate to in our specialties, I can only share the ones I have come across in my time as a haematologist. I want to share a few stories and leave myself open to your judgement.

The first was late on a Friday afternoon, I received the results of a biopsy and had promised to ring the patient as soon as I had them. This was a patient with multiply relapsed lymphoma, she had a lot of plans that weekend, it was Christmas Eve and it was going to be with her family as she knew things could be bad. I didn’t ring her until the day after Boxing day. I lied by not calling her on the Friday and I lied again on the Wednesday when I told her I had just received the results.

The second was in a busy clinic. A routine six monthly visit for a patient with chronic lymphocytic leukaemia. There were not on chemotherapy and have never required any treatment for their blood. He told me he had had some really bad abdominal pains and their GP had arranged an endoscopy, but they had had the results yet. It was nearly three weeks since the scope and they were getting a bit worried. I said I would look. A quick click on the computer in front of me showed up a histology result recently released to view. Another click and a scroll and I now knew the person sitting in front of me had an aggressive gastric cancer. I lied and said the results were not through yet. I did suggest they could call their doctor to chase things up though.

The third was a patient with some really complex scan, biopsy and blood results. A treatment decision was going to be complex and I needed to do that through our multidisciplinary meeting (MDT). I had booked to see her to go through all the results, but had the dates wrong, it was two days before the MDT. I didn’t know exactly what I was going to do for her and made out like I didn’t have all the results to hand to be able to discuss things now. That was a lie, I did have all the results.

The fourth was a patient I found very challenging. Someone who I could never see in fifteen minutes, someone who came with several generations of family, lists of questions and some very conflicting beliefs about medicine. We had multiple consultations. I would usually try to put this person at the end of clinics to give them the time they needed. I am self-aware enough to know that “challenging” is me reframing my feelings and reactions. It is always an internal alert for me  - to take time and listen, to reconsider diagnoses, treatment and plans. That is what I was doing, but I was overrunning severely, I had an important meeting booked with one of my trainees who was in a bit of a personal crisis.  I lied and said there was an emergency I had to go to.

The first was a white lie, the second was an outright lie, the third a lie of omission and the fourth a lie of commission. Does this make me a pathological liar?

Sokol (2007) argued that “on rare occasions benignly deceiving patients can be morally acceptable”. He suggests a “deception flow chart” which could be useful to some. I am not one for flow charts though, I find them a bit restrictive as life and people are far more nuanced and complex than a series of yes/ no questions. What is clear to me, and I hope you, is that the times I lied, I never caused harm and I never gave false hope. I believe I was kind, compassionate and respectful but I know I was teasing the edges of honesty. Can I get anyone to admit they would have done the same?

Reference: Sokol DK. Can deceiving patients be morally acceptable? BMJ. 2007 May 12;334(7601):984-6.