“A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities,” notes the American Medical Association (AMA) in its Code of Medical Ethics.
This guidance promotes honesty and healthy ethical practice among physicians, which is expected by the vast majority of patients. In fact, about two in three Americans (67%) rate the honesty and ethics of medical doctors as “high” or “very high,” according to the latest Gallup poll on the general public’s perception of honesty and ethical standards across 22 occupations.
Nevertheless, the AMA is merely making a general recommendation about lying, which begs the question: Is there any gray area in this topic? Are there situations in which a physician may lie if it is in the best interest of the patient? Alternatively, are there situations where a physician may lie to a patient without serious consequence? The answers are complicated.
More from the AMA
The AMA doubles down on its non-lying stance with the following:
“It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions.”
In situations where medical complications have resulted from a physician’s mistake or misjudgment, the AMA notes that the physician is ethically obligated to tell the patient all the facts necessary to ensure comprehension of what has occurred. Only in the light of such disclosure can a patient make an informed decision about ongoing medical care
Physicians should also notify patients of any change in diagnosis that transpired after retrospective review of charts. Even if a patient’s treatment or options remain unchanged in the advent of new information, the patient needs to be truthfully informed.
Finally, the AMA advises that concerns over legal implications or consequences should not alter a physician’s honesty with a patient.
Do physicians lie?
Some insightful research has been done on the practice of lying among physicians. This research extends past the practice of telling small lies (eg, “you’ll get better soon”) and into more troubling territory, such as physicians failing to disclose serious medical errors to patients, which is a concerning lie of omission.
In a survey of more than 1,800 practicing physicians, about one-third of respondents did not completely agree with disclosing serious medical errors to patients, one-fifth did not completely agree that physicians should never tell a patient something that is untrue, and approximately two-fifths did not completely agree that they should share their financial industry relationships with patients.
Furthermore, more than half of respondents reported having framed a patient’s prognosis as better than it was. Lastly, just over one-tenth of respondents said they had told patients something untrue in the previous year.
“Our findings raise questions about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients,” wrote the researchers.
In another study published in JAMA Internal Medicine, researchers found that some physicians lie when dealing with third-party payers—especially Medicaid and managed care. These physicians are fine with lying to secure care that they deem necessary for the patient, thereby obviating the need for a lengthy appeals process. In these cases, “deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient,” according to the authors.
It seems that lying about smaller issues starts early in a physician’s career. Researchers of one study published in the Journal of Medical Ethics showed that 40.9% of Loma Linda University medical residents would not inform a patient about a near-miss event because they believed it has no effect on patient health, and would only cause unwarranted worry and anxiety. Furthermore, about half of all residents said that they would be willing to deceive insurance companies to secure additional patient benefits. Importantly, of those willing to actively lie, fewer than 5% offered self-serving reasons.
With respect to medical errors, however, the findings of the study were more encouraging. In total, 90.3% of residents reported that they would disclose the truth regarding medical errors, and 55.7% reported that they would disclose the truth about unanticipated events—especially in serious cases with the potential to result in malpractice suits.
The problem with being dishonest
Lauren B. Smith, MD, a clinical ethicist and hematopathologist at the University of Michigan, Ann Arbor, MI, provided her thoughts on the ethics of lying to patients in an exclusive interview with MDLinx.
In the vast majority of cases, Dr. Smith is against lying to patients. “The problem with being dishonest is that it goes against our concept of autonomy. Patients should be able to make informed decisions based on honest information,” she said.
But Dr. Smith does recognize that there are gray areas that require more research and thought.
First, there’s the issue of white lies—little lies like “you’ll feel better” or “the pain will go away.” These little lies are sometimes told by physicians who want to lighten their patients’ psychological burdens and offer some hope.
“If [the motivation] is truly to be deceptive, then I think it’s wrong,” Dr. Smith said. “But if you actually believe what you’re saying to the patient, then even if it ends up being wrong, I don’t think that’s anything we can avoid. If you knowingly tell a patient that they’re going to feel better and you know they’re not going to, I don’t see the benefit to the physician or patient in that situation.”
Second, cultural differences may make a lie of omission, or the practice of withholding information from the patient, prudent. For instance, some cultures and religions dictate that the husband or head male family members make all medical decisions for women.
“We’ve had situations where we might have a cultural difference between the patient and family, and they request that the patient not know certain information,” said Smith. “We can consent the patient to ‘not know.’”
In these situations, it’s important that the physician speak with the patient privately and ask whether the patient doesn’t want to know their diagnosis. If the patient doesn’t want to know, ask who the patient does want to know this information. The physician must also stress that the patient can change their mind at any time.
This scenario, however, only holds for reasons like cultural differences. “I think that if a person who grew up in the United States says, ‘I don’t want to know,’ it would be a harder decision to make,” said Dr. Smith.
Third, many physicians don’t report “near misses” to their patients. “Do you think it would be beneficial for a patient to know that something awful almost happened to them?” Dr. Smith pondered. “I don’t know. I’m not sure that it would benefit them psychologically during their illness to know that. I think it would be worse if you said nothing happened when something did.”
Concealing serious medical errors is something Dr. Smith recommends against.
“Errors do happen,” she said. “What should be the protocol? I don’t think there’s a national standard on when errors should be disclosed to patients. Patients definitely do want to know. Physicians get scared to tell the truth because of legal ramifications. At the University of Michigan, we have a policy of apologizing to patients, and it’s been very successful.” Of note, such apologies at the University of Michigan can be followed by financial compensation to the patient.
Finally, Dr. Smith sees the issue of lying to patients resolving in the future.
“I think there’s been more emphasis on how to effectively deal with medical errors in a way that’s fair to patients—more patient-centered care,” she said. “We’ll hopefully get to a place where people don’t worry so much about the ramifications of doing the right thing. Most people don’t sue you for the errors you make; they sue you because they don’t particularly like you or you don’t have a good bedside manner. Once people understand that they are not as at risk legally as they think they are, there might be more of a tendency to do the right thing.”