In healthcare professions, the idea of lying to a patient is not welcome at most times, not even about the slightest thing. However, recent cases turn conventional wisdom on its head, suggesting compelling reasons why telling therapeutic “white lies” is becoming a new norm, especially for geriatric care. While the code of ethics and ethos remain unchanged, Barnhill & Miller (2014) and Cantone et al. (2019) suggest that compassionate deception has been proven to improve health outcomes for many patients diagnosed with dementia, Alzheimer’s, and other old age-related conditions that affect cognition. Without arm-twist the values and goals of ethics in medical and nursing conduct, this paper presents an argument favouring “well-regulated deception” in healthcare, especially for mentally deficient patients who are incapable of prioritizing their health.
The problem
Patients in senior care can be the most restless, and there are not so many techniques to calm them when it comes to some issues, primarily about memories and nostalgia. The problem is signalled by their low tolerance to handle naked truth, which begs caregivers to invent techniques to distract them whenever they become over-demanding on some non-compromising issues. For Instance, a study published in the Western Journal of Medicine revealed that 38% of patients with severe dementia and 13% of those with mild Alzheimer’s found the results of their diagnoses devastating and mischievous, eliciting outrage, regret, or near-paralysis (as cited in Akter, 2019). That calls for diplomacy in conveying such information, which might work well if a little therapeutic fibbing is employed. Notably, medical deception proceeds in three dimensions – in verbal communication, therapeutic administrations (disguised drugs in foodstuffs), and environmental manipulation. Caregivers are tempted to utilize any of these techniques in addition to the usual remedies to save the patients from anxiety, depression, intense stress, or agitation. However, the ethical aspect of medical deception lies in the fact that the decision to lie is made with the medic, as the responsibility entirely lies with them.
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An argument based on utilitarianism
The ethical dilemma with administering “comparable placebo treatments” (CPTs) without the patient’s consent usually boils down to one consideration – whether the doctor is “lying” or only “misleading” the patient. Technically, Cohen & Shapiro (as cited in Barnhill & Miller, 2014) maintain that although doctors are not transparent to the patient in placebo treatment, their opaqueness amounts to deception. Either way, the practice is a departure from the unyielding moral expectations of the caregiver. However, Barnhill & Miller (2014) suggest that utilitarianism could help evaluate the issue’s validity. This way, we seek to rationalize “therapeutic lies” by their outcomes, and if they offer moral goodness for a greater number than not lying at all, we can shelve our reservations.
Cheah et al. (2018) weigh heavily on the utilitarian aspect of deception with the case of placebo treatment in Ebola and HIV in West Africa in the early 1990s. In their case, Cheah et al. (2018) observed a significant improvement in self-perception, improved esteem, and general wellbeing in about 32% of HIV & AIDs patients, which translated to better immunity. Consequently, while medical deception might not always be justified, its use is often imperative in many cases, given the benefits it accrues to the patients.
An argument based on situational ethics
In cases where the patient is traumatized by the truth, medical deception should be accepted as a normative technique to restore the ‘time-shifting’ that often follows suit. In such a scenario, patients often view themselves as living in the past, expressing their craving to commune with their long-gone relatives or attachments with particular environments. In such cases, caregivers are compelled to fabricate false ideas to protect them from the haunting desires that often come with retrogressive effects such as negative responses to drugs and worsening mental and physical health. Abdool (2017) rationalizes the need for ‘deceitful interventions’ for the intuitive solutions that unshielded truth cannot afford.
Consider the case of an elderly woman (in her late 90s) mounting pressure on the elderly home caregivers to return home out of dementia. Also, considering that there is no caregiver at home, the chances of her wellbeing improving are null. Consequently, a nurse will be driven by situational ethics in fabricating the narrative that her family moved to the other side of town or that they or an extended business trip. Even though the ‘lies’ might not hold forever, they are just enough to help the woman stay longer, gaining chances to access credible healthcare. In fact, Cantone et al. (2019) reason that the disconnect most caregivers experience (7 out of 10) before using deception is concrete proof of their innocence. They note that in most cases, deception is the last resort and should therefore be justified because of its pragmatic and positivist utility. Concerning situational ethics, the moral value in ‘therapeutic lies’ lies in the fact that there isn’t much that can be done to help the patient beyond it.
A counterargument and its refutation
The most reasonable argument against medical deception is that it compromises the caregiver’s professional ethics and thus is a betrayal of one’s consciousness. Thankfully, the counterargument of violating the patient’s right to autonomy is out of the question here. That is because cognitively impaired patients have a limited capacity to understand and correctly process some information (Cantone et al., 2019). The objection reasons that medical deception contravenes the General Medical Council’s requirement that doctors “must be honest and trustworthy in all … communication with patients” (General Medical Council, 2013). The principle requires total veracity in medical conduct and further assumes non-maleficence as a product of competency. More so, the counterargument faults proponents of normalization of particular medical deception techniques for complacency, suggesting various other alternatives to “sugar coating” the truth.
Ideally, the counterargument is neither false nor justified because of the situational uniqueness of each incidence of compassionate deception. The fundamental role of any medical practitioner is universal and simple – to promote wellbeing. Therefore, it is up to the caregiver to find all means to accomplish the noble duty, as long as the principle of non-maleficence is honoured (Cheah et al., 2018). More so, the argument trivializes the importance of social value, which is a strong pillar of virtue ethics. Technically, social value comports with utilitarianism, that the real moral value of an action lies in the social value it avails (for the majority). And that is accomplished, be in PCTs, therapeutic fibbing, or “white lies.” Similarly, the counterargument openly ignores the practical value of medical lies. A compelling volume of statistical evidence presented by Barnhill & Miller (2014), Cantone et al. (2019), and Abdool (2017), among other studies and reviews, support the feasibility of using premeditated lies to improve the lives of patients with cognitive impairment.
In conclusion, lying to patients with dementia and other cognitive impairments is reasonably justified. However, the approval by a significant majority of geriatric care professionals and researchers does not instantly make it ethical, although it makes it imperative. Above all, situational ethics and utilitarian ethics offer the most compelling support in favour of medical deception, given their proclivity to outcomes rather than the methodology. Despite the opposition by a section of professionals who think ethics should be given precedence over human life, the need to let caregivers make judgements on their own is important. However, I would advocate for more regulation of the technique. In particular, concerned institutions should establish a framework stipulating the conditions and regulations guiding caregivers when using lies to help a patient. Patients should sign consent forms acknowledging that lies might be used in part of their management to do away with consent violation.
References
Abdool, R. (2017). “Deception in Caregiving: Unpacking Several Ethical Considerations in Covert Medication.” The Journal of Law, Medicine & Ethics , 45 (2), 193-203.
Akter, N. (2019, May). “Should We Tell the Truth to Dementia Patients?” Seniors Matter. Retrieved https://www.seniorsmatter.com/should-we-tell-the-truth-to-dementia-patients/2491884
Barnhill, A., & Miller, F. G. (2014, December). “Placebo and deception: a commentary.” In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine (Vol. 40, No. 1, pp. 69-82).
Cantone, D., Attena, F., Cerrone, S., Fabozzi, A., Rossiello, R., Spagnoli, L., & Pelullo, C. P. (2019). “Lying to Patients with Dementia: Attitudes Versus Behaviours in Nurses.” Nursing Ethics , 26 (4), 984-992.
Cheah, P. Y., Steinkamp, N., Von Seidlein, L., & Price, R. N. (2018). “The Ethics of Using Placebo in Randomised Controlled Trials: A Case Study of a Plasmodium Vivax Antirelapse Trial.” BMC Medical Ethics , 19 (1), 1-5.
