Abdulkabir A Ayanniy
Department of Ophthalmology, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria.
Even when lies are being notoriously used by people in ordinary daily transactions, there will be untoward consequences on the health system if healthcare professionals tell lies to their patients. It will damage a trusting health professionals-patients relationship, expose health professionals to unnecessary litigations, damage health professionals and health facilities reputation, and cause the patients needless pains. Every health professional should tell the truth and nothing but the truth to their patients. The need for the health professionals to apply tact in telling the truth to their patients is underscored.
Health profession, truth-telling, health professional-patient relationship
Lying is believed to be an everyday social interaction process. It has been thought to be essential for societal survival and its continuity has been advocated . To its advocates, a lie has the capacity to douse tension across divides, provide ideological support for status quo in societies and maintain social bonds. [1, 2] However, the adverse effects on both trust and cooperation between health professionals and patients make lying unacceptable in health practice. Lying engenders misgivings about the worth of health professionals, undermines health institutions; and creates suspicion, sense of betrayal, or alienation in patients. It is disrespectful to the patient. The health professional-patient relationship is special, serious and delicately balanced on trust. There are high expectations that health professionals will be honest with their patients. There is no justification whatsoever for health professionals to lie to their patients.
A health professional lies to a patient if she knowingly communicates a false statement with the intention to deceive such patient who in turn believes the lie as truth [2, 3]. The statement can be verbal or coded. [2, 3, 4] A lie has grave consequences as in the following example. Brown is a 21-year-old promising athlete with high hopes of winning gold medals in an Olympic competition. He has body aches having trained so hard and he, therefore, decides to visit a health practice. A pain relieving injection is prescribed for quick relief. Brown asks Nurse Augusta before getting a buttock injection if the injection can cause any problem. Augusta assures Brown of no harm whatsoever. Augusta knows buttock injection can cause leg paralysis as her former health facility was closed down because of the huge debt it incurred from compensating a patient who suffered paralysis after a buttock injection. Brown notices he can no longer control his leg after the injection. Brown’s career crashes as he can no longer use the leg to run again. He feels deceived, disappointed, unfulfilled, angry and depressed. Augusta attempts suicide because of ensuing litigation and professional deregistration. The health practice pays huge compensation and loses its reputation.
A lie is comparable to violence  or worse in many respects. Like violence, a lie is intended to coerce patients against their wishes. The patients suffer similar harm but a lie is worse as it can manipulate even a strong man to destruction, a feat which violence may fail to achieve. Our vulnerability to lies also underscores the importance of truth-telling. When a patient realizes that he has been lied to, he subsequently views the health care system with resentment, disappointment and suspicion. The patient felt controlled, and deprived of informed choices and decisions. Lies come with secrecy and manipulation, which patients despise. It is a nasty experience to be lied to even if a lie is told in one’s interest. A lie is a lie whether trivial or major. A lie unduly empowers health professionals to the detriment of the patients.
Health professionals are experts who provide healthcare services. Patients consult them for their services based on trust. The health professionals are obligated to truthfully deploy their expertise to serve the patients. The ultimate aim of health care is to improve or maintain patients’ wellness through the provision of care based on patients’ best interest and sound expertise. 
This essay will defend the assertion that ‘there is never a justification for health professionals to lie to their patients’. The defence will be based on medical case analysis, public rejection of lies, empirical studies, the doctrine of informed consent, consequentialism, Kantianism and virtue ethics.
Medical Case, Analysis and Defense
June and her 15-year-old only child, Stone, sustain a fatal motor accident where Stone dies. June is in a bad condition but briefly awakens and asks the health professional if Stone is okay.
Two interpretations are worthy of consideration based on June’s inquiry if Stone is okay. First, June knows that people can die in a motor accident. June believes Stone is dead. June is already internalising and processing the possibility of Sone’s death. Lying to June evokes her disbelief (or surprise), Stone cannot be alive! A lie interferes with the ongoing process of internalisation and its beneficial rationalization. There is no need to lie to June.
Second, June knows that people can survive motor accidents; after all, she is a survivor. June believes Stone is alive. Also, there are two considerations, depending on June’s level of consciousness. One, if unconscious or semiconscious, a lie or the truth is of no use, June cannot process the information. Two, if June is conscious, again, two considerations depending on her perception of the health professionals.
First, June believes health professionals may lie about Stone’s death because they fear the bad news will send her into shock. Such fears, even when unfounded, are well known among health professionals and patients’ relations [6, 7]. A fearful conspiracy among physicians and patients’ relations to lie to patients has undesirable consequences. [8, 9] Higgs  holds that an antidote to fear is an open discussion. June will interpret the health professionals’ lie as false, meaning Stone is dead. June refuses to be deceived. The lie has not had the desired effect, and hence, there was no gain in lying to June.
Probably, June has witnessed an experience or has read articles that reinforce her belief. For instance, Collins’s article painstakingly but erroneously argues that health professional should lie to their patients in critical health conditions . Perhaps, June may belong to a category of patients who genuinely prefer not to know the truth about their health conditions.  Furthermore, it is a known fact that a liar is hardly believed again. Also, the converse is true. For example, in a convent, a nun lies to a supervisor to protect somebody. The supervisor believes her simply, because of her known honesty.  Also, terrorists (suicide bombers) wreak havoc in Muslim populated communities in Nigeria by wearing a hijab that disguises them as virtuous Muslim women. Generally, women are known for non-violence, this fact is reinforced when women are affiliated with virtuous causes. Furthermore, back to June’s story, June believes health professional will not lie to her about Stone’s death. June now believes Stone is alive, whereas, he is dead. This is a great injustice as it denies June the opportunity to make use of what is termed the natural coping mechanism for stressful information . It is an inherent human psychological defence mechanism of denial. It has been theorized that many patients seem to transfer bad news to their unconscious minds and deny it.  Bad news is ‘any information that adversely and seriously affects an individual’s view of the future’.  A fatal motor accident is bad news that will definitely elicit grief. Grief is an emotional process in which seriously ill patients or their close relations pass through during imminent death or death. It has five stages . First, denial, June refuses to accept the death of Stone. June will not acknowledge it. This stage provides a buffer against immediate shock. Then, June goes into the stage of anger, wondering why Stone should die in the first instance. June’s anger may be directed against the health professionals, the car or even Stone. The third stage is bargaining. June may ask God to restore Stone’s life in exchange for being more pious. This leads to depression, where June may become withdrawn, moody or cry. Then, the fifth stage which is acceptance. June comes to term with the reality of Stone’s death. June may make statements like ‘it is okay, it is the will of God’.
Therefore, lying to June is unjustified as it interferes with the natural and healthy grieving process that occurs to overcome the bad news of Stone’s death. A lie disrupts and unnecessarily prolongs the healing process for June. Grief explains why it is healthy crying at the loss of close relation. It is a myth that bad news makes patients go into shock; rather anxiousness is part of grief.
Definitely, a lie cannot help June in her vulnerable state. She is vulnerable as her energy and willpower have been affected by her circumstance. June needs truth, not only as a concerned mother but also to take the decision on diverse life issues. The truth about Stone’s death will assist June’s family to plan Stone’s burial. Moreover, lying compromises health professional known standard over the years. For example, people may start to doubt the authenticity of documents bearing health professionals’ signatures. 
Empirical studies, also, do not support health professionals to lie to June
Lying to June is odd, contrary to available facts. Empirical studies across the globe confirm that most patients (or would be patients) prefer knowing the true state of their health [14, 15, 16]. In a survey among 1,251 Americans, 96% would prefer information on their cancer status if diagnosed; also 85% wants to know the estimate of life expectancy in case of grave prognosis.  The European patients’ wishes on disclosure agree with those of the Americans. In a study among 250 cancer patients in an oncology centre in Scotland, 91% desired to know their chances of cure and 94%, the side effects of therapy.  Moreover, a survey among 114 Saudi Arabian cancer patients, shows 99% would appreciate all the information about their conditions. Also, most would appreciate knowing the benefits, 98% wants to know the adverse effects of therapy, and all the patients (100%) want to know the cancers’ prognosis . Contrarily, it is doubtful if there is any report where patients would express a preference for lying by health professionals on their health conditions in the circumstance June finds herself. Real harm rarely results from telling the patient the truth. 
The society abhors lying and medical advances enhance healthcare
Truth-telling remains a gold standard in health practice. A lie is not acceptable for many reasons. First, the public abhors health professionals lying to patients.  Second, physicians are increasingly willing to disclose health information to their patients.  This is reasonably justified. Advances in medicine and technologies, undoubtedly, lead to improved management of difficult diseases. Cancer patients are now surviving unlike before when a cancer diagnosis was a death sentence. Also, fears of litigations by the patients and the public have discouraged the practice of lying . Nevertheless, it is unlikely to have health professionals being arraigned for telling the truth to their patients. Truthful communication with the patients on their conditions appeals natural justice. The change has a philosophical basis for achieving health care goal of optimal care free of harmful paternalism that exploits patients’ vulnerable state. 
Nature of health professional-June relationship
On another note, there are models of relationship. Health professional-June relationship is fiduciary [4, 20]. Fiduciary empowers June to retain significant authority and responsibility for decisions within the relationship. Fiduciary is not paternalistic, where health professional takes the decision without June’s informed consent. The health professionals have independent responsibility for their acts on behalf of June. They deploy their superior position to service the true interests of June that should have a lasting and beneficial effect. If the health professionals are not trustworthy, their relationship with June is not fiduciary.
Moreover, two moralities are of interest to relationships namely ordinary and professional . The ordinary morality oversees all interests while professional morality caters for only interests in a professional relationship. For instance, it is not a health professionals’ duty to block depressing news from June, even if it is health related. However, health professionals are free to exercise the ordinary morality. Nevertheless, lying has no appeal to the fiduciary which guides health professionals-patients relationship.  Culture of trust is a crucial and dominant factor in health care system. Trust entails having firm faith in not being betrayed in a relationship.
Lying violates June’s autonomy
In another perspective, a lie is not justified as it violates June’s autonomy. Autonomy is premised on freedom and respect for June as a person. Autonomy means June having the freedom to choose or self-determination. June cannot achieve this without correct information. Informed consent requires June’s access to information on Stone’s death.  Lying is insulting as it deprives June true information and she is kept out of deliberation on her health.  A lie to June means health professionals are acting paternalistically. That is health professionals taking health decision considered best in June’s interest but without her consent.  This is an approach a father will take to protect his minor child from being harmed. However, June is a competent adult. Competency means the capacity to ‘receive, weigh, process and retain relevant information’. 
Lying is paternalistic and it is not encouraged
Paternalism fails on two grounds by erroneously assuming a lie is in June’s best interest and violating June’s autonomy as informed consent is inhibited with dire consequences.  Moreover, paternalism is often forceful, prone to abuse and mistakes that may culminate in suffering. Paternalistic protection can suffocate and exploit.  Paternalistic benevolent appeal is not real but a decoy to deprive June the autonomy to participate in the decision on her health. Medical paternalism is abhorred, unjust and unfair.
Consequentialist abhors health professionals telling lie to June
From consequentialist perspectives, lying to June is not the right thing to do. Consequentialism holds that an act is right only if there is a good consequence. [25, 26] According to Hare  ‘act’ means ‘making some difference to what happens – to the history of the world’. Lying is an act with negative consequences including a break in a trusting relationship. The omission of lie holds positive consequence by preserving a trusting and a healthy professional-June relationship. Moreover, it serves the public preference for not lying. It respects and protects June’s autonomy to an informed decision. It allows June to undergo a natural grieving process that is essential for her full recovery. Also, it saves health system/professionals unnecessary calamities. Definitely, a health professional lying to June is not good, it is a bad practice. A lie in health practice has a negative effect over time with a greater harm being caused than good. [28, 29]
Rule consequentialism holds an act is right based on the consequences of a rule rather than the consequence of the act . However, a rule with the best consequences among a set of rules is preferred.  For instance, consider two rules. Rule one -to lie to June, and rule two – not to lie to June. In rule one, bad outweighs good consequences. In rule two, good outweighs bad consequences. Rule two appeals to rule consequentialism. A lie is not right. Health professional should not lie to June about Stone’s death. Honesty is a conduct that is sanctioned by the general public as well as health professionals’ codes.
Moreover, utilitarian looks at the aggregate goodness to all concerned. Utility means useful. A lie does not benefit both parties. Hedonic or hedonistic utilitarianism is useful in promoting pleasure and avoiding pain . Telling a lie to June will only cause more trouble and pain to her. The truth of Stone’s death enables June to grieve. Grief is a preferential satisfaction or preference utilitarianism. Grief is preferred to being lied to, as lie benefits nobody. Health professionals lying to June about Stone’s death evokes the bad public perception of health, loss of public trust and the health system suffers for it.  For the utilitarian, autonomy is a crucial moral issue . A lie disrespects June by depriving her of rational deliberation. A lie can rarely be justified by utilitarian save when lie optimizes the good. This will even be rejected on critical analysis of its moral worth. For instance, executing an innocent man to prevent a riot or killing a healthy person and harvesting his organs to save many lives.  Expectedly, welfare will be enhanced by honesty and frankness. Certainly, health professionals cannot guarantee welfare through a course of lying.  June should be allowed to decide whether the truth will improve her welfare or not. Also, disclosure facilitates rationalization that in turn allows the health professional to get June’s feedback.
Deontologist abhors health professionals telling lie to June
Lying to June is not justified based on two formulations of Kantian Categorical Imperative . First, ‘Act only on the maxim through which you can at the same time will that it be a universal law’.  A health professional cannot will a lie to be a universal law. A lie is not right. Lying to June is immoral. A lie is not the duty of health professionals. Duty is obligatory, the truth is obligatory. Lying to June is forbidden.  This is a moral absolutism commanding honest dealings with June by health professionals. Truth should be told always irrespective of the circumstance. 
Second, ‘So act as to treat humanity, whether in your own person or in that of any other, never solely as a means but always also as an end’.  June should be respected and treated as an end and not just means to an end. Lying implies June is used to accomplishing health professionals’ own selfish end of avoiding breaking bad news. June deserves respect as an autonomous being. Respecting June’s autonomy requires that she has correct information about Stone’s death rather than imposing a lie on her. A lie is disrespectful to June’s dignity. It deprives her of the rational deliberation on Stone’s death. 
Virtue ethics abhors health professionals telling lie to June
Additionally, virtue ethics holds that “ An action is right if and only if it is what an agent with a virtuous character would do in the circumstances” Also, Aristotelian virtue ethics holds the characteristic-traits that count as virtues are those that enable us to live a humanly flourishing life.  Aristotelian virtue ethics appeal social relationships and good character trait. To Aristotle, a lie is unkind and blameworthy but the truth is preferable to a lie.  There are many virtuous characteristic-traits including justice, honesty, courage, and beneficence. However, some particular characteristic-traits are professionally required to achieve ‘flourishing life’. For instance, health professionals should possess certain characteristic-traits to achieve the primary goal of the health of the patients.
Health professionals would be able to live a ‘humanly flourishing life’ with characteristic-traits of beneficence, courage, integrity, and trustworthiness. Each characteristic-trait would qualify as a virtue. For example, a virtue of beneficence directs health professionals to do good to June or what is in June’s interest. A lie is harmful to June and it is not in her best interest. Courage helps health professionals to dutifully disclose information on Stone’s death to June rather than lying. A characteristic-trait of integrity will assist health professionals to resist unethical practice especially lying to June. Moreover, trustworthiness enables health professionals to share the truth with June on Stone’s death and concurrently respecting her autonomy. 
The goals and structure of health care require moral virtues.
The ethics of care underscores worthy traits in close personal relationships such as sympathy, compassion, fidelity and love.  Honesty and truth are good character traits while lying is not. Truth is utility because patients need to make informed judgments about their health. For instance, a patient may wish to modify her lifestyle or habits if it affects her health. This would require sincere and unambiguous communication  by health professionals. Pellegrino and Thomasma  argue that truth is a kindness grounded in virtue as a lie is a setback that can discourage the victim of lie from serious and life-restoring relationships. Also, a lie compromises a liar’s relationship and deprives her of virtue and moral development. Health professionals should not lie to June as it is the right thing to do, a utility, and a kindness. It is right as a mark of respect to June and an obligation of trust in health professional-June relationship. Kant holds that human society depends on truth, rather than lie since it is the basis of trust, covenants, contracts, and promises. 
Professional ethics abhor health professionals telling lie to June
From antiquity, health care has been guided by ethical codes devoid of lies. For example, the American Medical Association’s ‘Principles of Ethics’ of 2001 enjoins physicians to ‘deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence, or who engage in fraud and deception’.  Moreover, the training of doctors is designed to produce sound professionals that abhor lies. It is calamitous in the health system setting for trust to be broken.  Withholding truth from June is temporal; it will come out.  Lying to June can only raise false hope about Stone. Then, health professionals bear avoidable guilty burden such as how to (later) confront June with the truth of Stone’s death and the guilty conscience of lying. Other burdens on professionals include diminished integrity, poor patronage and avoidable lawsuit. A lie threatens health care.
Health professionals breaking the bad news to June
Finally, a bad news is a fact of life, rather than lying to dodge breaking bad news  health professionals should dutifully communicate bad news to June. They must be prepared for kind responses but not lies.  They should interview June to gain insight into her likes, dislikes, and fears; and affirm or correct June’s perceptions. This establishes a more trusting relationship even, to the level of a confidant. The truth told by a confidant will rarely provoke bad reactions. The approach will enhance holistic care for June. Moreover, there is a six-step protocol called SPIKES, designed by Baile et al.  for disclosing unfortunate information to patients in a sympathetic and empathetic manner rather than lying. The SPIKES include ‘setting up the interview, assessing the patient’s perception, obtaining the patient invitation, giving knowledge and information to the patient, addressing the patient’s emotion with emphatic responses, and strategy and summary’. Stone’s death is bad news and June will benefit from SPIKES, not a lie.
The essay discussed that there is no justification for health professionals to lie to their patients. The essay made use of medical case analysis and argued its position based on demerits of lie, human psychology, societal demand for truth, facts of empirical studies, the doctrine of informed consent and moral theories.
A lie has the inherent danger that threatens health system including damaging a trusting relationship, professional integrity and health care. To the patient, a lie is embarrassing, shocking and elicits the feeling of betrayal. It leaves the health professional with guilt. The health system/professional suffers image and welfare crisis.
A lie interferes with grief, a natural psychological coping mechanism that protects the patient against bad news. This grief period has five stages including denial, anger, bargaining, depression and acceptance. This underscores why health professional should tell the truth about critical health conditions.
The public rejects lies in health care. There are studies that reinforce the fact that most patients prefer truth on their health conditions. Also, health professionals are willing to disclose information to their patients.
The health professionals-patients relationship is fiduciary, which is based on trust. A lie is an anathema to a fiduciary relationship.
A lie is paternalistic and violates patients’ autonomy which is a gold standard in health care.
A lie has bad consequences and not right from the consequentialist perspective. The consequences of a lie are not good to patients, health professionals and the health system.
A lie is absolutely wrong by Kantian Categorical Imperative. It lacks generalizability. A lie is not a duty to health professionals. It treats patients as means and not an end thus, it fails to respect patient autonomy.
Finally, a lie is not a virtuous characteristic-trait for a health professional. Lying-trait is dangerous for the health professionals as harmless lies are on a slippery slope to lies that may cost lives.
Many thanks to Dr. Sorcha Ui Chonnachtaigh of Centre for Professional Ethics at Keele (PEAK), Keele University, Staffordshire, United Kingdom for her useful comments on the manuscript.
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