Telling the truth

Thirty years ago, I was working in a teaching hospital in England. If a child, even a teenager, with a bone tumour needed their leg amputated, one consultant orthopaedic surgeon would never tell the child or permit anyone else to tell the child in advance. The child would go to the operating theatre being told they were to have a biopsy and ‘anything necessary’. The surgeon insisted that knowing in advance would make the child unnecessarily anxious, and it was kinder for the child not to know beforehand. He ignored any nurse, social worker or doctor who had the temerity to suggest it was kinder to let children prepare mentally for amputation and would probably help them cope better. Modern theories on anxiety disorders support the idea that children should be kept as informed as reasonably possible and so does modern bioethical thinking about the importance of respecting children’s autonomy.Was the surgeon lying to the child ormerely being ‘economical with the truth’, an expression used by Mark Twain, among others, about politicians as a euphemism for lying? Post-modern philosophy has agonised over what is truth and whether or not truth even exists. Western thinking has tended to treat scientific knowledge as being independent of context, persons and values and having its own static existence: something is true or false. However, to take such a strictly context-independent attitude to truth and knowledge in medicine ignores the subjective nature of disease and the values and beliefs that frame the apprehension of truth and knowledge by patients and doctors. The framing of information has a large effect on perception. In a randomised study, Harvard physicians told that a cancer treatment had a 90% survival rate were more likely to recommend treatment than their colleagues whowere told that the treatment had a 10%mortality. Theway information is perceived by physicians and the way it is framed and conveyed to patients is inherently value-laden. A doctor counsels a patient from a position of power and that brings ethical obligations and responsibilities. Doctors can err in being too directive or ‘paternalistic’ and constraining choice, aswith the example of the orthopaedic surgeon. But doctors can also err by excessive disclosure of information. Unfiltered information given to children or their parents, either because of the doctors’ own anxieties and fears or because of concern about litigation, may be unhelpful and unnecessary. Such ‘over-disclosure’ is unfortunately a common feature of the modern managerial policy of ‘open disclosure’. The patient(or parent-) doctor relationship is based on trust. Truth-telling in relationships is foundational to developing andmaintaining trust. Furthermore, truth-telling is broadly considered a virtue to cultivate (Fig. 1), and there is an almost universal acceptance that doctors have anobligation to tell the truth andnot to lie. In theUnited Kingdom, ‘the duty of candour’ has clear implications for paediatricians and other health professionals. The way we frame information should take into account the patient’s beliefs, culture and situation, what might be called their existential truth. This is part of the art of medicine. In his excellent book on end-of-life counselling, AtulGawande refers to this as an interpretive approach.Our primary aim should be to allow children and parents to make informed decisions about children’s lives. In order to achieve this, counselling should involve real communication, a bidirectional conversation rather than a unidirectional process of simply conveying information. In an increasingly complicated health-care environment, this sort of partnership with families may indeed help them find the truth.