This is not a case in which I could support telling the whole truth. It would be cruel to tell Mr. B everything about his prognosis at this time. I believe he should be misled, possibly even lied to, for a while. Full disclosure right now seems to me like "truth-dumping," as Norman Cousins put it (p.10). The doctor would be more interested in keeping his own hands "clean" than in what is really good for the patient.
The major, overriding reason to deceive Mr. B is that the truth puts him in serious danger. He has a history of serious depression, even when his wife was near and could support him. Right now she's thousands of miles away; he's probably not coping well just with ordinary life without her, and is already fairly stressed because of his daughter's pregnancy. To learn that he has incurable, untreatable cancer would just be too much. He would probably plunge into a clinical depression, and that would rob him of the few good months he has left. Instead the doctor should tell Mr. B to make an appointment for, say, three months from now, "to follow up and see how you're doing." If Mr. B ordinarily brings his wife, that's good; otherwise the doctor might try to think of a way to suggest that she come with him. He will then hear the bad news in a supportive environment, with his daughter’s pregnancy over (and probably successful, but anyway, over with.) Being together when they hear the bad news should help their relationship grow even stronger.
I thought what Martha Weinman Lear said was quite interesting: "The doctor has lied ever since Hippocrates, and in most of the world, truth-telling is still considered bad medicine. . . In much of Europe, South America, most of Asia -- they consider it unethical to tell. They say, `America is so brutal, you make it so difficult for the patient, and we are kind and gentle.'"(p. 17) It's not that I think doctors should usually lie. I think the new custom in America, of being honest, is basically good. But this comparison with the rest of the world is useful. It reminds us that telling the whole truth can cause a lot of pain and a lot of trouble. Sometimes it causes so much harm that it would be wrong to tell the truth.
Besides the harm to Mr. B., there's the fact that the usual reason for telling patients the truth doesn't apply in his case. Usually doctors should be candid with patients in order to respect their autonomy. As Miller says, "the concept of a person as an autonomous agent places an obligation on physicians .. . to respect the values of patients." (Miller p. 35) Respecting a patient's values means telling them what they need to know, not only so that they can choose among treatments, but also so that they can run the rest of their lives. A man like Mr. B, who doesn’t have long to live, needs to set his affairs in order. I understand that. But the point is, a clinically depressed man wouldn’t be able to set his affairs in order. While I think Howard Brody is right, that in primary care the doctor should help the patient understand the doctor's thinking (p. 8), there is no way Mr. B could follow the doctor's thinking. He would be too upset. The basic reason for telling patients the truth just doesn't hold with Mr. B. What Mack Lipkin said of patients in general is especially true of Mr. B: "In the presence of anxiety-laden illness, there is a strong tendency to hear selectively and with emphases not intended by the doctor."(p.288) Telling Mr. B the truth wouldn't help him and it would hurt him. So it shouldn't be done.
Not everyone will agree with me on this. They will point out how important a habit of truth is, how being able to depend upon it is like having solid ground under your feet. That's true, in general. But I'm not suggesting habitual lying. This is one particular case and not an everyday occurrence. Truth is certainly important, but other values can outweigh it. It's all right, for instance, to lie if that's the only way to save a life. And in this case, as I pointed out earlier, the truth could cause Mr. B to collapse emotionally and die earlier. If Mr. B eventually finds out that the doctor lied, the doctor can explain why he did it, and assure him that he has never lied to him otherwise. Mr. B should be able to understand that this was really an exceptional case.
Another argument against lying is that it cheapens language; it makes words worth less, in the way that counterfeit money can make real money worth less. Or the way Sissela Bok put it: "The veneer of social trust is often thin. As lies spread . . . trust is damaged. . . When it is damaged, the community as a whole suffers. . ." (p. 26ff) In general I think that's true, and I'm glad that in this particular case outright lying would probably not be necessary. When Mr. B asks "What's the verdict, doc?" the doctor could say something like, "The verdict is: Go to China! There's no reason in the world not to. I don't want to see you until next year --unless, of course, you start feeling bad." So lying, strictly speaking, probably won't be necessary. But if it is, I would still support doing it, for the reasons I gave above.
Finally, some people would argue that the doctor's own integrity demands that he tell the truth. This seems to me like a cold and selfish version of integrity. It’s the position that a doctor should keep his own hands (or soul) clean no matter what the cost to the patient. It's a little like suggesting that a doctor should practice defensive medicine -- ordering tests the patient doesn't need, in order to protect the doctor. A doctor's first concern should be the welfare of his patient. In fact that's what his integrity should demand of him: a whole-hearted dedication to his patient.
In summary, then, the doctor should deceive Mr. B, and even lie to him if necessary, because his welfare depends so much on his not knowing the truth. Although in general deception and lying are bad things, in this particular case outright lying probably won't be necessary. Deception that is so limited and done for such good reasons will not damage the doctor-patient relationship, and should not make it harder for the doctor to live with himself. Honesty is usually the best policy--but not quite always.
Paolo Bacigalupi is the author of "Ship Breaker," a 2010 National Book Award Finalist in Young People's Literature. He has also won the Hugo, Nebula and John W. Campbell Awards.
I suspect that young adults crave stories of broken futures because they themselves are uneasily aware that their world is falling apart.
The truth of the world around us is changing and teens want to read something that isn't a lie.
We might pummel them with advertising that says they should buy a new iPod, or Xbox, or Droid XYZ, and that everything in the world is shiny and delightful -- but whether we're looking at the loss of biodiversity, or the depletion of cheap and easily accessible energy, or the hazards of global warming, our children will inherit a world significantly depleted and damaged in comparison to the one our parents handed down to us. And they know it.
With "Ship Breaker," a novel set in a future when oil has run out and New Orleans has drowned under rising sea levels, I was trying to illuminate the sort of world that we adults are handing off to them. In the story, child laborers tear apart ancient oil tankers and freighters, recycling the last valuable resources from "the Accelerated Age." Quality of life is significantly reduced from our present circumstances, and judging from teenagers' responses, they crave precisely that sort of truth-telling. Which doesn't really surprise me. As a teen, I remember that I craved truth-telling as well, and devoured it wherever I could find it.
Unfortunately, the truth of the world around us is changing, and so the literature is morphing to reflect it. Teens want to read something that isn't a lie; we adults wish we could put our heads under the blankets and hide from the scary story we're writing for our kids.
Topics: Culture, books, teenagers