The Presence of Deception in Healthcare.

Truth telling and Lying… The Presence of Deception in Healthcare.

Conflicts of Interest The Case of Vendor Relations

The Purposes • Will explore the issue of deception raised by cases of informed consent and truth-telling in medical ethics. • Will explore the causes (personal and systemic), distinctions and tools to aid discernment of complex patient cases.

Conflicts of Interest The Case of Vendor Relations

Autonomy and the Birth of Bioethics • Henry K. Beecher, "Ethics and Clinical Research", New England Journal of Medicine, 247 (1966): 1354-1360. • Maurice Pappworth, Human Guinea Pigs. (London: Routledge & Kegan Paul, 1976).

Misperception and Substituted Judgment • Studies have shown that not only were clinicians’ willingness to withdraw life support influenced by personal characteristics such as age, religion and clinical experience, but personal preferences also impacted when they chose to withdraw life support. • Studies have shown that some clinicians will misperceive their patients preferences and substitute their own preferences for those of the their patient. (Schneiderman, Journal of Clinical Ethics, 1993) • Recent NIH Study on the accuracy of surrogates decisions, proxies were accurate 68% of the time, but off the mark in almost one out of every three cases.

May 19, 2009, Australian Journal of Nursing • The drug company Merck was accused of paying nurses to sift through patient medical records in search of potential candidates for the drug Vioxx. • The claim is that nurses identified potential users of Vioxx from patient records with physicians’ permission and then initiated contact with the intention to offer Vioxx as an alternative to their present medication.

Mr. S Mr. S is 26 years old and has recently joined a family physician’s practice. He had an episode last year of unilateral arm weakness and visual blurring without headache that resolved within 12 hours. He was referred to a neurologist, who did several tests. Mr. S was subsequently told not to worry about the episode and thought no more about it. He has had no similar episodes since. In his medical records is a letter from the neurologist to the previous family physician stating that Mr. S almost certainly has multiple sclerosis. In the letter the neurologist explains that in order to prevent excessive worry he does not inform patients in the early stages of multiple sclerosis of their diagnosis.

Change: 1961- 1979 In a landmark study conducted in 1961, 90% of a sample of 219 US physicians reported that they would not disclose a diagnosis of cancer to a patient. Of 264 physicians surveyed almost 20 years later, 97% stated that they would disclose a diagnosis of cancer. Oken D. What to tell cancer patients: a study of medical attitudes. JAMA 1961;175:1120-8. Novack D, Plumer R, Smith R, Ochtill H, Morrow G, Bennett J. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979;241:897-900.

Coping/Trauma WHO Definition of TRAUMA • An event that is unpredictable. • An event that is without obvious meaning. • An event where you witness the actual or potential death of another.

Why I Choose? (Kohlberg and Gilligan) • Stage 1: I choose due to what causes me pain or pleasure. • Stage 2: I choose due to the loyalty to the group I belong. • Stage 3: I choose due to uniqueness of the situation and with impartiality.

Shifting from the personal to the systemic

2008, Journal of American Medical Assoc. • Published results of a national survey of medical school department chairs was published in 2008: • Almost two-thirds have a personal relationship with industry as consultant, board member, paid speaker or the like. • About one in five medical school departments enjoyed money for equipment and unrestricted funds, one in three clinical departments received support for trainees and the majority of clinical departments received support for "continuing medical education. • Department chairs themselves felt that the more a chair was involved with industry, the less able the department was to "conduct independent unbiased research

Question • What are the other dynamics that causes lack of truth telling with patients?

Defining “A Lie” A Lie is… “an intentionally deceptive message in the form of a statement”.

Why is Lying Bad? • It diminishes trust among human beings. • Makes the possibility of human community more difficult.

Reasons for Lying • Protection • Avoid harm • Maintain Confidentiality

Mr. Smith Mr. Smith is 75 years of age, fragile but alert and competent. He is a multi-year survivor of cancer and, after a few months of feeling poorly, just completed diagnostic tests that showed the cancer has returned and is beyond curable treatment. The current oncologist has not cared for Mr. Smith previously. She informed Mr. Smith’s only child, Chris, and was stunned by the response:

Mr. Smith (con’t) Do not tell him the cancer has returned. Please refer him back to his family physician. He and I agree that the news will destroy him; in fact, the doctor kept his own mother’s diagnosis of cancer from her as long as he could in order to strengthen her will to live and not destroy hope. We plan to tell my father that the symptoms are due to something else that is treatable.

Common Principle “Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.” (ERD 27)

Practice: Professional vs Personal • Flattery: “you look lovely” • Gratitude: “that's just what I wanted” • Bargaining: “my best price is $500” • Generalization: “it always rains in Seattle” • Unpredictable situations: “it won't rain today” • False excuses: “he's in a meeting”

Lies told in teaching religion Lies which hurt someone and help nobody Lies which hurt someone but benefit someone else Lies told for the pleasure of deceiving someone Lies told to please others in conversation Lies which hurt nobody and benefit someone Lies which hurt nobody and benefit someone by keeping open the possibility of their repentance Lies which hurt nobody and protect a person from physical 'defilement. St. Augustine’s Hierarchy of “Lying”

Malicious lies: lies told to do harm Malicious lies are mortal sins 'Jocose lies': lies told in fun These are pardonable 'Officious' or helpful lies These are pardonable Thomas Aquinas on Types of Lying

Sissela Bok’s “Test” for Lying… • Are there some truthful alternatives to using a lie to deal with the particular problem? • What moral justifications are there for telling this lie - and what counter-arguments can be raised against those justifications? • What would a public jury of reasonable persons say about this lie?

Outcomes Truth telling… • Increases patient compliance (1984) • Reduces the morbidity such as pain (1964) • Informed patients are more satisfied with their care and less apt to change their physicians than patients not well informed. (1995)

Diversity: Does the Principle Hold? After a survey of 800 seniors from four different ethnic groups showed that Korean-American and Mexican-American subjects were much less likely than their European-American and African-American counterparts to believe that a patient should be told the truth about the diagnosis and prognosis of a terminal illness, we undertook an ethnographic study to look more deeply at attitudes and experiences of these respondents. European-American and African-American respondents were more likely to view truth-telling as empowering, enabling the patient to make choices, while the Korean-American and Mexican-American respondents were more likely to see the truth-telling as cruel, and even harmful, to the patients. Further differences were noted in how the truth should be told and even in definitions of what constitutes “truth” and “telling”. Blackhall LJ, Frank G, Murphy S, Michel V. Bioethics in a different tongue: the case of truth-telling. Journal of Urban Health. 2001 Mar;78(1):59-71

Mrs. Lee An 80-year-old Asian widow is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her oldest son approaches the physician and asks that the patient not be told, stating that in their culture the elderly are protected from such distressing news. In mainland China, tuberculosis was considered fatal and to tell her would be like giving her "a death sentence." Should you respect the son’s approach?

Narrative Ethics

A Key Paradigm Shift From diagnosis and treatment of disease ….to understanding how illness integrates into my life story.

The Explanatory Model Arthur Kleinman, Ph.D. • Culturally sensitive approach to asking about a health problem • What do you fear most about your illness? • What are the chief problems your sickness has caused you? • Anyone else with the same problem? • What have you done so far to treat your illness: What treatments do you think you should receive? What important results do you hope to receive from the treatment? • Who else can help you?

The LEARN ModelBerlin and Fowkes Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment

3 Questions Preference Hope Fear

“Hope is not the expectation that things will turn out well; it is the belief that there is meaning no matter how things turn out.” Vaclav Haval

The Presence of Deception in Healthcare.