Malcolm Fisher:
Truth is a fundamental principle of Ethics.
Scenario One. A Hypothetical You are entertaining Mother Theresa for dinner. There is a knock on the door and you open it to find a Palestinian terrorist. He says he has heard Mother T is there and wants to shoot her. But ,he says,he recognizes you from a recent TV appearance,knows you are a truthful person,and will go away peacefully if you say she is not there. What is the correct response?.
Scenario Two. A real one. Mr R died in the unit 18 months ago. His wife rings and says she has some problems and you said she could come and see you if this occurred. She makes an appointment. Problem one is she thinks it was her fault she died and she should not have talked him into having an operation with a 75% mortality. That is easy fixed. Going over the conversation she can be convinced she merely supported her loved one's decision and no operation carried 100% mortality. Problem two is that when he was getting better and was allowed to eat a bit he wanted some icecream. The doctor said it was okay and she bought some and fed him. It got a little out of hand and he ate 3/4 of a litre. the next day when she came back to see him he was back on inotropes and the ventilator and the nurse said it was because he had inhaled food into his lungs. " Doctor, I have been worrying for nearly two years whether it could have been the icecream as he died two days after?" What is the right answer?
Scenario three Another real one. Abdul aged 61 is alert and communicates and understands. He wants to know the prognosis. It is zero. His son Yasser says he is not to be be told under any circumstances. it is explained to Yasser that this is unethical and unfair and it is Abdul's right to know. Yasser says that if his father is told one of my children might have a nasty accident. Yasser indeed knows where I live and which school they go to and tells me with feeling.. Abdul is asking. Do I tell him? Yasser is very menacing.
Stephen Streat: Malcolm Fisher wrote :
Scenario One. A HypotheticalYou are entertaining Mother Theresa for dinner... terrorist at the door .. will go away peacefully if you say she is not there. What is the correct response?.
I say:
I lie - I hate terrorists at my door, threatening my guests, messing up my fine Italian cooking. I doubt that he would trust my response any more than I would trust him - but I cannot see any good coming from my tellling him the truth. Besides - he has no right to know the truth given those murderous intentions. (I wonder where I left my Uzi..)
Scenario Two. A real one.Mr R died in the unit 18 months ago. His wife asks : "Doctor, I have been worrying for nearly two years whether it could have been the icecream as he died two days after?" What is the right answer?
I say:
Doubt that there is one. We reckon that there are certain ordure sandwiches that resist any attempt (Aussie tomato sauce, pepper, salsa , even thick lashings of wasabi) to enhance their flavour and this is one of those. Her fear may in fact have some basis in fact. If the facts clearly contradict her fear then I would tell her so and try to be reassuring. Given that the Palestinian terrorist thought that I looked pretty convincing on TV and went away after I lied to him then I shouldn't have too much trouble being convincing with someone I respect when I am really telling the truth.
If the facts are unclear or clearly show that he inhaled icecream (chunks of hokey-pokey up the ETT) I would have a more difficult problem. In general people find certainty (however unpleasant) more tolerable and capable of resolution than (perpetual) uncertainty. Perhaps she could be told the truth with some realistic hope that it would enable her to advance in her grief from still being troubled two years later. I'm not sure I'm the right person to deal with the resultant guilt/grief issues but maybe I/we could find someone who could help her/me. Doubt that I would be prepared to lie on this one. She has a right to know the truth IMHO.
Scenario three. Another real one.Abdul aged 61 is alert and communicates and understands. He wants to know the prognosis. It is zero. His son Yasser says he is not to be be told under any circumstances. It is explained to Yasser that this is unethical and unfair and it is Abdul's right to know. Yasser says that if his father is told one of my children might have a nasty accident. Yasser indeed knows where I live and which school they go to and tells me with feeling. Abdul is asking. Do I tell him? Yasser is very menacing.
I say:
My, how the neighbourhood in Sydneys leafy North Shore has gone down lately. Now they have terrorists in the ICU, not just messing up the dinner guests. Does Yasser have any respect for Abdul ? Is it possible to get them to communicate with each other directly on this issue ? Are there any other family members who can help deal with Yasser ? (preferably other than with the aid of tyre irons or baseball bats). Rule number one : No patient is worth an intensivist (that goes double for intensivists children as well). Rule number two : The patient is the one with the disease.
My sympathies are firstly for my children (and myself) and secondly for Abdul. Yasser sounds suitably rational (`explained to Yasser that this is unethical and unfair and it is Abduls right to know') rather than distraught with grief so at present my sympathies with Yasser are zero. I would be tempted to tell Abdul what he wants to know and report Yasser at once to the police for intimidation. Does he really have Australian residency? Will that work in New South Wales? More likely I will need a day or two to consult widely about my options. Will Abdul last that long? Can he be transferred to the nice private Arafat Memorial Hospital just along the way in Chatswood? Do I have an urgent need to visit Barcelona for a week or two ? Doubt that I would lie to Abdul.. more likely if my children were seriously threatened I would remain silent. (I'm sure I left that Uzi round here somewhere). Tell us oh laconic one `WHAT DID YOU DO ???'
Tom Stinson:
Scenario One:
Preserving a life is a more important value than telling the truth to a potential murderer. Tell him she isn't there; when he leaves call the police and give all details. They may be able to apprehend him and forestall future attempts on Mother Teresa's life. BTW, I don't know of any reason that "Palestinian terrorists" would want to harm Mother Teresa. Unlike some others, Mother Teresa has to my knowledge never done anything adverse to the Palestinian cause. I think that it is unfair to consider the Palestinians to be the default bad guys in such scenarios; most Palestinians that I have known have been upstanding people.
Scenario Two:
Unless I were sure that the ice cream was unquestionably the cause of the aspiration, I would equivocate. If it were, I would tell her so, she apparently already suspects as much.
Scenario three:
You do the same that you would if anyone threatened your children. You report this to the police and insist that they take all precautions to protect your family. When they are finished with Yasser he probably won't want to harm anyone. Once the police have taken care of Yasser, you tell the father his prognosis. If, perchance, the police cannot eliminate the threat from Yasser, you _don't_ tell Abdul his prognosis (again, truth-telling takes a backseat to the prevention of murder, especially of your own children). Telling the truth is certainly a moral virtue, but it is neither the only moral virtue worthy of respect nor, in a particular situation, the most important one.
Skip Nelson:
A brief reaction...Truth is positional. There is no absolute truth. We need to be careful that we not impose on patients and families the "truth from our position" rather than give them the information and then the opportunity to "see the truth from their position." Only a "rabid Kantian" would give up Mother Theresa. The real issue is why we seem to define "truth" in such a way that it then divides rather than unites families, disrespects rather than respects cultural and religious ways of establishing meaning in the face of illness, and seem to feel that "truth" is a western philosophical notion that is somehow poorly understood from other positions.
Dina Brown:
A philosophical response that provides little information. MAny patients seek the advice of their physicians because they are clueless on all events comprising the situation. "Seeing the truth from their position" many times would be like asking a child deprived of knowledge to excel in school. I don't beleive that "truth is defined in such a way to divide rather than unite families . . . . ." Universally, truth is truth and a lie is a lie. Most people, in all countries, know the difference. However, during difficult times, lies are often classified into white and black lies---a white lie being something that in itself may not be false, but that leaves out a great deal of info., and a black lie being a something that we know is false. ASk any child, I believe they will be able to tell you the difference. White lies seem to be a socially acceptable way to not hurt anyway we care about. However, what we must be careful about is that we don't rationalize ourselves out of the correct decision because of a misguided desire to protect those we love.
I think what complicates Malcolm's example is the involvement of family. What if you were the only MD in a room full of 20 people you did not know, and there terrorist, rather than stating he would kill your children, stated he would kill you, or spare you and kill all other 20 people? Would you save yourself, or the other 20? Tangents can be added endlessly to this . . . what if all 20 where children etc etc etc. As health care providers I think we must all keep in mind that we are there to help the patients, and that the decision to withhold the truth should be assessed for each patient and how it will effect their needs, not our own. The legal system can help to handle that segment.
Skip Nelson:
Nothing in my comments precludes the giving of advice. To be aware of the need of the "child" (note the parental metaphor) is to see the "truth" from their position. In the cases that were described, the "truth" was in dispute. The metaphor of parent-child is not apt in this setting. Our advice should speak more to the situation of the patient and the family (confession: I am in pediatrics and thus speak of families where others may speak of patient) rather than to our own needs to "speak the truth."
My intent was to point out that the "dilemma" of lying presupposes the assumption that we must speak the truth "from our point of view" rather than be sensitive to the needs of the patient and family, and to what their own views of "truth" may be.
P.Cumpston:
How about this Malcolm....You are babysitting a post-craniotomy patient because the surgeon has told the family that their father is very sick, and needs intensive care. It is four hours post-op, and he is fine. it is 18:00 when the proverbial hits the fan and you need the bed. You tell the family that he is stable and can be transferred, and that his bed is required. The wife tells you that if any harm comes to him, you will be killed.
In my case, I told her that she had destroyed any doctor/patient relationship, I could no longer care for him anyway, and the nurse looking after him was needed for somebody sicker. He was transferred, a detailed report lodged with the federal Police, and I received an apology from the family (via the neurosurgeon). What really got me angry was the accusation that the move was caused only because I was racially prejudiced. If I had not received an apology, she would have been done for assault.
Alan Meakes:
Contrary to Skip Nelson's assertion that truth is positional, the word itself, "truth", is an absolute. Anything other than truth is "non-truth". The basis of all philosophy is mathematics - logic - (some would argue that philosophy is the basis for mathematics). Perversion of truth is a product of rationalism, and as such makes any ethical statement meaningless - i.e. a matter of personal opinion, devoid of external standards of measure. Therefore, for ethics to exist, truth must be absolute.
Scenario One:
Immediately a question of "situation" ethics. Why Mother T... why not an old doddering grandfather with Alzheimer's? If you are a truthful person as he thinks, then you CANNOT lie. The terrorist probably doesn't know you, especially if he only has the TV image as a means of conclusion. "Truth" ethics places character, integrity and virtue as higher than personal safety/advantage/survival. Truth ethics will call for an admission of her presence and defence against the intrusion even at the risk of personal injury/death.
"Situation" ethics, denies truth as having "fundamental" merit is decision-making. Therefore, if the end justifies the means, lying is senn as a "good", rather than an "evil". The problem with "situation" ethics is that they create yet another situation -- what happens when the terrorist finds out you lied?
Scenario Two:
"No, it was not the ice cream. It was a problem with his stomach and esophagus brought about by the necessity of tubes in his throat and GI tract, combined with the medications he required for his underlying illness." Had he been fed chicken soup, the same problem might well have occurred.
Scenario three:
You call the hospital security and in the presence of Yasser you confront him regarding the threat made. (Publicity has its positive effects, too). You then discuss the threat with his father and ask the father if he still wants to know. (The father still carries the family-line authority).
Mike Darwin:
Sadly, I must beg to differ with Al Meakes if not in fact, then in spirit. By this I mean that you are mistaken only in picking the wrong animal. The radical animal rights people in the Western world have saying, used mantra like, which is: "A rat is a dog is a boy."
While I think this statement magnificent in the economy with which it defines a a whole mind-set and philosophy, I find this comparison particularly odious since I like Armadillos much more than rats. And, to be honest with you, given the generally horrible behavior of small children I increasingly observe in stores and public places, I'm not so sure I would rank the armadillo above the boy. As to dogs, there is little doubt in my mind that many of them are far superior to most of the humans I've met. At very least, from a utilitatarian aspect alone, most dogs have been a hell of a lot nicer to me (as a group) than most humans (as a group).
Skip Nelson
I agree that "truth" is essential to ethics, but I disagree that truth is thus an absolute, external standard defined from outside of "our" point-of-view. Holding this position does not commit us to relativism, situation ethics, or any other such "ism" which those who hold too truth as an absolute standard would attempt to apply. See, among others, the work of Hilary Putnam, especially Reason, Truth and History, where he beings to develop a notion of "internal realism" and "truth" that does not posit an objective, external, absolute standard from a "God's-eye-point-of-view." Enough philosophy. This is a critical care list after all, isn't it?
Dick Burrows:
Scenario One.
It is all relative. The situation may be similar but the person you are asked to protect may be the Son of Sam, Charles Manson etc. We discuss ethical principles and all too often find them to be apparently at odds with each other therefore we decide on a hierarchy of ethics - killing is worse than lying. "Truth" under these circumstances is almost impossible to define. "Truth" is, that being an upstanding member of society I would probably s*** myself tell a fat lie and hope to extricate myself as quick as possible.
Scenario Two:
Unless I were sure that the ice cream was unquestionably the cause of the aspiration, I would equivocate. If it were, I would tell her so, she apparently already suspects as much. You do not have to volunteer the truth. But as she obviously suspects as much it is only reasonable to put her fears at rest. This is the kind of situation that makes me glad I am a fully paid up member of the Medical Protection society!
Scenario Three:
You do the same that you would if anyone threatened your children. You report this to the police and insist that they take all precautions to protect your family. When they are finished with Yasser he probably won't want to harm anyone. Once the police have taken care of Yasser, you tell the father his prognosis. If, perchance, the police cannot eliminate the threat from Yasser, you _don't_ tell Abdul his prognosis (again, truth-telling takes a backseat to the prevention of murder, especially of your own children).
This is nasty. Especially if the police decide to back Yasser, and in certain parts of the world that is quite possible. In any society where people interact there are always likely to be differences of opinion. When these explode to violence or threats of violence then society is supposed to intervene in such a way as to protect the innocents. If this fails then the likely outcome is self- preservation with vigilante law. In the Western world the police should sort out Yasser but if they don't I only have a few options:
What is all too often forgotten is that principles have to be tempered by pragmatism, compassion, trust and a pile of other abstract phenomena that help us to interrelate with each other. Slay me for a heretic!
Dick Burrows:
Contrary to Skip Nelson's assertion that truth is positional, the word itself, "truth", is an absolute. Anything other than truth is "non-truth". The basis of all philosophy is mathematics - logic - (some would argue that philosophy is the basis for mathematics). Perversion of truth is a product of rationalism, and as such makes any ethical statement meaningless - i.e. a matter of personal opinion, devoid of external standards of measure. Therefore, for ethics to exist, truth must be absolute.
While "truth" may be an absolute based on mathematical logic it is not possible to define that absolute, as the pursuit of that absolute "truth" must necessarily proceed to a point of infinity, at which point chance ultimately determines the difference. The mathematical pursuit of "thruth" by Hegel and Niezche has been philosophically argued to be the cause of the rise of Hitlerism. Give me a bit of compassionate humanism any day!