Breaking the bad news

Nitpickerus: Isn't it possible to tell lies and yet be motivated by love?

Dionysius: But if loving God means obeying him,[1] and if obedience involves speaking the truth,[2] then...

Nitpickerus: I'm thinking of situations where telling the truth and showing love appear to conflict.

Dionysius: Such as?

Nitpickerus: Let's take the example of an otherwise fit person who presents with widespread secondaries from an adenocarcinoma of unknown primary site. Surgery, radiotherapy and chemotherapy have nothing to offer and all they have to look forward to is death. Is it right to tell them the diagnosis when you have nothing to offer?

Dionysius: Why not?

Nitpickerus: It would be devastating. It would drain them of all hope.

Dionysius: But you're not going to stop caring for them. They still have many needs that need to be met. There may be physical symptoms to be treated, wills to be written, relationships to be repaired, arrangements to be made for family and job. Most importantly of all, there may be major spiritual issues to be faced. How is a person going to be prepared to deal with all these if they don't know what's happening to them?

Nitpickerus: Shouldn't we just wait to see if they ask?

Dionysius: But they may be afraid to,[3] or embarrassed to, or they may wrongly assume that nothing is wrong because we haven't said so.

Nitpickerus: They may not want to know.

Dionysius: Most patients do want to know; even if for some reason they can't bring themselves to ask. Shouldn't we give them the benefit of the doubt? They may not want to hear. They may shut it out, but at least we must give them the opportunity.

Nitpickerus: But if by so doing we deprive them of any last enjoyment they may have had, how can that be loving?

The eternal perspective

Dionysius: If death was really the end, if enjoyment in this life was all that mattered, if hope was only for this world and if love simply meant protecting people from anything that might disturb their emotional equilibrium Nitpickerus, you would be making a powerful argument.[4] But none of these things are true. Death leads to judgment[5] and either heaven or hell.[6] It's what happens to us in the next life that's ultimately important.[7] What good will it be for a man if he gains the whole world yet forfeits his soul?[8] Suffering and death only really make sense when viewed from an eternal perspective.[9]

Nitpickerus: But our patients may have no interest in these spiritual matters.

Dionysius: Perhaps, but then we need to pray that the reality of their own suffering and impending death creates an interest.[10] If we help unbelieving patients deceive themselves into thinking that they are not dying, or that death is the end or some wonderful release then we are doing them a grave disservice.[11] Worse than that, we are denying our Lord who wants everyone to come to repentance.[12] We need to pray for and be open to the opportunities God gives us to share what real hope is[13] especially when patients are facing death without hope.

Why we lie

Nitpickerus: Why are we tempted to lie in these apparently hopeless situations?

Dionysius: Sometimes it's lack of time. We think we are too busy. Sometimes it's lack of humility. We think that we ourselves have failed by not being able to offer a cure. Sometimes it's lack of expertise. We've simply never been taught how to break bad news sensitively. We need to make time,[14] humble ourselves[15] and learn the skills from those who have them.[16]

Nitpickerus: Isn't it often that we don't know the answers to our patients' questions?

Dionysius: Quite possibly. We may be uncertain of the disease's course. It's far better to be honest and admit our limitations, to say we'll cross each bridge as we come to it rather than to pretend. We may have not yet finalised our plan of management because the results of investigations or consultations with other doctors are awaited. We should let the patient know so they don't think we are deliberately withholding information from them. Most of all our patients need to know that they can trust us - that we care for them, that we know what we should reasonably be expected to know and that we are competent people of integrity.[17] If they sense that we are more concerned about covering our own mistakes than we are about them, or that we are talking to relatives behind their backs[18] then we will lose that trust.

The right spirit

Nitpickerus: So love and truth go hand in hand?

Dionysius: Yes. It is more loving to speak the truth, even if the truth causes suffering. True Christian love cares as much about what the person loved becomes as it does about relieving their suffering.[19] of course it's quite possible to speak the truth without love.[20]

Nitpickerus: Do you mean that we can do the right thing for the wrong reason?

Dionysius: Indeed. It's possible even to preach the Gospel,[21] or to teach,[22] or to heal or prophesy[23] for the wrong reasons. We could be motivated by pride, or fear or jealousy rather than love. We can be simply obeying the letter of the law and neglecting its spirit.[24]

Nitpickerus: Can you give me a clinical example?

Dionysius: Take the doctor who is insistent on telling his patients the truth, but then does it in a way that betrays he is not genuinely concerned about them. For example he may break bad news in the middle of a busy ward round, in front of people whom the patient would rather were not present or in a voice loud enough for everyone in the whole ward to hear. Or he may give the patient no opportunity to ask questions or delegate everything to someone else who lacks the appropriate skills. Or even worse he may tell the truth but dressed up in so much medical jargon that the patient can't comprehend it. This sort of approach shows that the doctor is more concerned about preserving his own conscience than about showing love. We must do God's work God's way.

Informed consent

Nitpickerus: What do you think about informed consent?

Dionysius: I think the principle of patients being given information about the risks and consequences of investigations or procedures which they are about to undergo is a good one. However in any situation where one person in a transaction possesses much more knowledge than the other there has to be an element of trust. If I take my car to be repaired I want a simple description in words I understand of what the basic problem is, and an estimate of how long it will take, what it will involve and how much it will cost. If there is a range of options then I expect to be informed and if necessary consulted along the way. I don't need or expect an exhaustive description of the mechanics of the procedure or to have every combination and permutation of outcomes discussed in detail. I would end up a nervous wreck. How would I know whether I was being told the truth anyway?

Nitpickerus: But people are not cars.

Dionysius: Granted, but similar principles apply. Most importantly I want to know if I can trust the person. If he is competent, knowledgeable and a man of good reputation and integrity, then I will relax far more than I will after an exhaustive resume from someone I feel I can't trust. If I know he will treat my car in the same way he would like his to be treated,[25] I can rest content.

Nitpickerus: So what is a medical parallel?

Dionysius: When doctors feel constrained to give, or when patients demand, an exhaustive catalogue of the percentages of obscure complications and side-effects of a particular drug or procedure, it is a sign that trust has broken down and if trust has broken down, even long discussions are unlikely to repair it. God does not give us answers to every question about our futures either, but he does give us enough revelation about his character and power for us to be able to trust him.

Lying to evil people

Nitpickerus: Is it ever justifiable for a Christian to lie in order to obstruct an evil person or protect the innocent? What about those people who sheltered Jews during the Second World War and lied to the Nazi authorities?

Dionysius: That sort of question I feel should wait for the next edition of nucleus.