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

In the last issue of this newsletter I presented a case that was originally printed in the Hastings Center Report. That case involved an elderly woman who suffers from Alzheimer's, and who routinely asks a particular physician for information regarding the health of her son. The son, unfortunately, died of a heart attack and the patient in question was unable to retain that information. She would ask how her son is, be told that he had died, and experience profound grief as if she had just been told for the first time that her son was dead. This process of forgetfulness, inquiry regarding her son, revelation of her son's death, grief and forgetfulness repeated itself several times. The staff involved with the patient began to wonder whether truthful response to her queries was really appropriate.

In the last newsletter I indicated that there are three possible responses to this case. First, it is possible that the staff could actively deceive their patient by indicating that her son is alive and well. Second, they could continue to be truthful and attempt to help the patient retain the information. Finally, they could remove stimulus that causes the patient to wonder about her son, and thus avoid the problem altogether. In other words, they could attempt to create a situation in which they passively allow the patient to continue to operate under a misconception, without actively lying to her. To begin the moral evaluation of truthfulness and lying, it might be best to consider the extent of our commitment to the truth. As I suggested previously, our commitment to the truth is not absolute. I previously provided two clear examples of lies that seem acceptable to most people. The first example regarded children ("of course there is a tooth fairy"), and the second example deals with friends ("I love your outfit"). An additional example of an acceptable lie would be one that is told to our enemies ("I don't know where the squad is located"). In fact, we might even feel that there are times when our leaders can lie to us for the sake of national security ("We have no plans for a rescue operation at this time").

But even though we may recognize that lying is acceptable in certain circumstances, there is a clear presumption that truthfulness should be the norm. The presumption of truthfulness is generally based on two distinct types of arguments. The first argument that is often given in favor of truth telling is based on the old saying "Oh what a tangled web we weave when first we practice to deceive". This argument is primarily concerned with the practical effects that follow from the practice of lying. Many would argue that telling a successful lie is difficult, and that more often than not, life goes worse for everyone involved when lies are told. In the provided example, our patient with Alzheimer's may become frustrated if her son, whom she has been led to believe is still living, never visits. She may desire more detailed information about her son, and the staff may be forced to develop successively complicated lies. Eventually, the lie will be discovered. When it is, the provider-patient relationship will be destroyed. Trust will erode, and it will become increasingly difficult for the health care facility to provide quality care.

The second argument in favor of truthfulness is based on the idea that even if life will go better for a patient if she is deceived, she continues to have a right to know the truth.

It is important to keep the second argument distinct from the first. One possible continuation of argument two is that the reason that we all have a right to the truth is that there is no way for anyone other than ourselves to accurately determine what is in our own best interests. Truth that may be harmful to you might be extremely beneficial to me. I may, for instance, take pride in overcoming diversity or in knowing any number of arcane bits of trivia. Therefore, although there are truths in the world of which you would rather not be aware, I cannot live a rewarding existence unless I know them. Your judgment that the truth would be harmful to me is based on your own values, not mine. Therefore, you are in a poor position to properly evaluate the effect of the truth on me.

If this is how we support the claim that we have a right to know the truth, then the two suggested arguments are identical. All that has been said so far is that life will most likely go better if the truth is known.

There is an alternate version of the second argument that needs to be made clear. It is plausible that I may have a right not to be lied to even though my life really would go better if I were shielded from the truth. I might argue that my life is mine to run, no matter how poorly I might do the job. When you rob me of the truth, you might really make me happier. Still, I maintain that it simply isn't your job to take over my life decisions. As a human, there is value in living my own life autonomously, even if I do a poor job of it by most standards.

If either of these arguments is correct, then we are still left with the difficult fact that there are very good reasons for telling the truth, and yet none of us believe that the truth ought always to be told. How can we determine when the above arguments don't apply, and how do we deal with patients in the clinical setting?

The answer: stay tuned!