Autonomy & Truth I
Michael A. Gillette, Ph.D.

Medical ethics is often approached on the basis of principles that exert some force over the types of decisions that we are allowed to make and the way in which we are allowed to make them. It is often assumed that the project of moral thinking involves identifying the issues in a certain situation, clarifying the principles that impact on that situation, and adjudicating any conflicts between those principles. The specific principles involved may vary, but a basic list would include considerations such as autonomy, beneficence, nonmaleficence and truthfulness to name only a few. I would like, this month, to begin to consider the principle of truthfulness.

The following case was presented in the January-February edition of "The Hastings Center Report" (Volume 25, Number 1). I have italicized the entire extended quotation.

Mrs. C, an eighty-six-year-old Italian American woman, is moderately demented due to Alzheimer disease. She had been living with her son Tony and his wife Isabella, but when Tony suffered a heart attack two years ago, everyone agreed that it would be better if Mrs. C were moved to a nursing home. She adjusted to life at Beech Hill quite successfully, and enjoyed the weekly visits from her son and daughter-in-law.

The director of the Alzheimer Unit at Beech Hill, Dr. L, somehow reminded Mrs. C of her son. She developed a pattern of asking Dr. L four or five times a day how Tony was doing. Dr. L always told her, "Tony isn't in good health, but Isabella is taking good care of him." This answer seemed to satisfy Mrs. C, who prayed for Tony and Isabella because, as she said, she wanted to do everything she could for them.

Last month, word reached the nursing home that Tony had had a massive heart attack and died. Dr. L consulted with the rest of the staff and decided Mrs. C must be told -- a task he undertook himself. She understood what he was saying and begged to attend her son's wake, so arrangements were made for a member of the family to take her there, and an aide helped her into her good black dress.

In the days immediately following the funeral, however, Mrs. C forgot her son had died. She began asking Dr. L the old question, "How's Tony doing?" After another consultation with the rest of the Beech Hill staff, Dr. L decided that he should try, at least for a while, to answer her question truthfully.

Each time he did so, Mrs. C experienced the pain of her loss as if for the first time -- she became distraught and could not be comforted. This was hard on everyone, bur Dr. L hoped persistence and patience would eventually help her to retain the bad news. The only alternative, it appeared, would be a sustained deception on the part of the staff as to Tony's whereabouts. After Dr. L had told her of Tony's death perhaps fifteen times, the aide wondered if the black dress Mrs. C had worn to the wake might prod her memory. The dress was brought out and put on her, and it did help her to remember about her son. She no longer asks how he's doing, although she often speaks of him when she sees Dr. L. Did Dr. L and the Beech Hill staff do the right thing in response to Mrs. C's bereavement? ("Case Study: The Forgetful Mourner", Hastings Center Report, Volume 25 Number 1 January-February 1995, p. 32) The first move in dealing with a case of this nature is to identify the possible responses along with the reasons that can be given in support of each. It is interesting to note that the staff at the Beech Hill Nursing Home identified only two possible courses of action. They believed that their choices were limited to either active deception or compelling Mrs. C by various means to recognize the truth. It seems to me that there is a third alternative which the staff may have overlooked. Since Dr. L is apparently the only staff member who triggers questions from Mrs. C regarding her son, the entire issue might be avoided if a different doctor could be assigned to this case. If Mrs. C no longer sees Dr. L, she may forget all about her son and never ask of his whereabouts again.

This third option may not work out practically, or it may turn out to be a passive form of the first option involving deception. It is not clear, however, that allowing people to maintain their ignorance is morally equivalent to lying to them. Therefore, I believe that option three deserves distinct moral treatment from the other possible responses.

The relevance of this case to the Training Center environment should be obvious. There may be any number of situations is which clients are shielded from traumatizing information by their families or by the staff. Medically, there may even be times when it is indicated to keep secrets or to deceive individuals, either for their own best interests or in order to engage useful research involving placebo trials.

It should also be made clear that our commitment to the truth is anything but absolute. While we do assign a high value on truthfulness, we also lie routinely to our children (Santa Claus) and to our friends (Yes, that is a beautiful haircut). Therefore, from a moral perspective, it is necessary to consider just exactly how important the truth is to Mrs. C. In future months I will carefully explore the above options one two and three.