Hugh Tunstall-Pedoe
Dundee, Scotland

Different variants of the doctors’ Hippocratic Oath swear to a virtuous life, honoring their patients and respecting their confidences, but not specifically promising to tell them the truth!

Until recent decades it was not uncommon for doctors to avoid telling their patients specifically what was wrong, if serious, in order to avoid upsetting them or seeming unkind. This attitude extended even to heads of state. In Britain, King George VI (see figure) had become a heavy cigarette smoker when Duke of York, a naval officer in the First World War who fought at the battle of Jutland. When he developed lung cancer in 1951 and had a pneumonectomy, it was palliative, not curative, and he became terminally ill. He was not told what was wrong, nor was anyone else who should have known. In February 1952, Princess Elizabeth, heir to the throne, and her husband Prince Philip were on a state visit to Kenya overnighting for relaxation in a game-watching lodge called “Treetops”, when the news came that the King had died. Nobody had told the princess that she was on borrowed time before assuming the daunting responsibilities of Queen. Such a situation was common worldwide, and not just with heads of state.¹

Telling evasive lies to avoid upsetting the patient replaces one set of problems with another. Arguably acting to promote kinder information in life, the doctor is still obliged to write the true diagnosis on the death certificate given to the relatives, so the family learns the truth anyway, and cancer is equated with death. During life, telling lies creates a hazardous situation in modern medicine, as patients interact with several doctors and others caring for them. Telling the patient one thing and the relatives something else is also problematic, despite there being many instances of relatives begging the doctor not to tell the patient. It is one thing for doctors to lie, another for the nearest and dearest to do the same. But affairs need putting in order. The same truth can be told both gently with kindness or suddenly, brutally, and without empathy. The patient themselves may be part of an unspoken conspiracy with the relatives not to discuss the truth with them.

What is told may be unacceptable to the patient. The human brain is good at protecting its owner from what they do not want to hear. A frequent complaint is that “nobody tells me anything!” Some patients, given a detailed explanation of the diagnosis and prognosis, will not be able to face the facts and will deny them, professing ignorance and hoping to get a different story from someone else. Yet medical management and treatment are increasingly complex nowadays, necessitating ever more understanding, cooperation, and compliance from those involved, a major justification for them to be thoroughly informed and participate in their management.

Examples of the problems of truth from my experience:

• As a new clinical medical student, we admitted a strange homeless person who was squatting in a derelict shop. He had jumped off the counter, causing a large inguinal hernia. On admission, the resident carried out a routine examination and found a carcinoma of the rectum. Plans were changed. Just before surgery, the patient, dissatisfied with what he had been told, hailed me and said he had heard two cleaners going past his bed saying that he had cancer, and demanded, “Have I got cancer?” I was annoyed by the cleaners and by being put on the spot—but in retrospect he had almost certainly made up his story. I told him that if he really had what he thought was cancer, we would not be operating on him. After surgery the patient turned his face to the wall and died within a few days—I did not know why. Looking back, I now give myself high marks for sophistry—if not arrogance—but not for telling the truth! Nowadays the modern surgical consent form places an obligation for a full explanation. Back then, written consent existed, but from memory was considered in Britain largely as consent to a general anesthetic, and probably skimped on detail. Since, lawyers and ethicists have insisted on increasing accuracy.
• I can remember a teaching case conference in Guy’s Hospital where Lord Brock, the famous thoracic surgeon and President of the Royal College of Surgeons of London, reported in a loud voice as the patient was being trolleyed out of the lecture theatre, that the lung abscess from its site must be a carcinoma of the lung. The Professor of Medicine seemed very shocked and looked fearfully after the departing patient, presumably assuming the patient did not know. Medical discussions back then frequently took place across patients, assuming their ignorance, using medical code words such as “mitotic” and “non-benign” for malignancy. The public now is more sophisticated and has wised up—dangerous for doctors to assume anything!
• In outpatients, I saw an orchestral musician for follow-up, substituting for a colleague who was a consultant gastroenterologist. The patient remorselessly abused my colleague in front of me, apparently because she rejected his diagnosis of ulcerative colitis. She then switched on the charm and asked me to tell her what her diagnosis really was. I told her that she had ulcerative colitis. She was momentarily taken aback but then said in a subdued voice, “Oh, so that is alright then!” As in that example, the originator of bad news can be very unpopular. A patient is entitled to a second opinion, but it is unnecessary to abuse the giver of the first. Indeed, the first doctor may suggest a second opinion if having problems getting the diagnosis accepted by the patient.
• When registrar in hematology, I helped look after a student with terminal leukemia. He insisted that his parents were told only that he was being treated for anemia, and his general practitioner reinforced this stricture. His father had angina, and the son tragically saw his own illness as his failing of his father, that might kill him. After his death, his parents were heartbroken that they had been unable to share the last few months of his illness with him through this deception. I wondered whether we should have been more questioning of his decision.
• By contrast, when a medical student in pediatrics we admitted a toddler with undiagnosed leukemia. Having been put in the picture by the consultant—I do not know in what terms—the mother left the hospital in distress, saying she could not bear to see her child again. The student nurses argued with me that the consultant was cruel for having told the mother too much. I considered he had to tell her, her grief was inevitable, and I forecast the mother would be back—she returned after two days, thereafter staying all day.
• I received a letter from a general practitioner asking why his patient was still alive. He had been diagnosed with a malignancy years earlier, with a bad prognosis. I alerted the pathologists who reviewed the slides from their archive and held a case conference which decided how these had been wrongly reported. The general practitioner was informed, leaving him to correct what the patient had been told previously.
• In the 1990s I reviewed a patient for something else in a hospital clinic and discovered from a pathology report pasted in his case notes that he appeared to have been diagnosed with a malignancy some time earlier. I could not see that it had been communicated to him, or to anyone else. Silence is not necessarily golden. I felt obliged to tactfully discover what had—or had not—been going on.

Note: A recent furor about regrettable corporate dishonesty to patients in Britain, by the providers of health services, is outside the scope of this discussion.

End note

1. For comparison, in his family: the King, a heavy smoker, died age 56; his non-smoking wife Queen Elizabeth, the Queen Mother, died aged 101; his non-smoking elder daughter Queen Elizabeth II died aged 96; her only sibling, Princess Margaret, a lifelong smoker, died aged 71.