User:Wiki11~enwikibooks

Introduction
The doctor-patient relationship is a very unique association that is fundamentally and ethically based towards the best-interest of the patient. However defining exactly what the best-interests of the patient are, as well as the doctor’s role in achieving the patient’s best-interests, is a constantly changing topic of debate [multiple refs]. Many religious, cultural, legal and ethical beliefs provide sometimes differing views on how a doctor should act in providing care for his/her patient. There are strong arguments within ethical frameworks that both support and oppose the title statement [multiple refs]. Nevertheless it is important to explore the notion of the patient’s best interests as well as the notion of lying and deception. One extreme case that showed that the patient’s ‘best-interest’ can be seen differently depending on religious and ethical beliefs was discussed by [our wiki article]. This article showed an unusual situation where a Doctor was prolonging the life of a terminally ill infant at a great emotional and financial cost to the single mother because he believed it was in the best-interest of the infant. The above case shows how varying ethical views can influence the best interests of a patient. As such every doctor during a consultation should be aware of not only what the patient’s best interest is but also of non-maleficence as well as patient-autonomy.

The Doctor Patient Relationship
The doctor-patient relationship is such a complex, imperative relationship. So much so, that the first three guidelines described by the Australian Medical Association pertain to creating a caring relationship with an emphasis on respect for the patient’s autonomy and best-interests. It is not until the fourth guideline that the knowledge of the practitioner is referenced. [link to AMA guidline]

Lying
There are conflicting concepts in the literature surrounding the definition of lying. Some sources refer to clinician denial as a form of lying. [wiki article link] Some sources followed a deontological view [refs]. They stated that it is not an act of lying if the doctor had not intended to deceive, even if the patient felt they were lied to. However, the utilitarian theorists said all forms of deception both intended or unintended were lies if the patent was deceived by them [Backhurst 1992]. Jackson’s 1991 argument followed a similar approach. She suggested that telling a lie is both an act of lying and also an act of deception. Deception, however, could also be achieved by omission or denial, which was a non-lying act but resulted in the patient being deceived.

Best-Interests
Traditionally, doctors acting to the patients ‘best interest’ would take a paternalistic approach [,Chin, 2002]. Assumptions were made that the physician knew where the patients best interest lay, and would conduct his/her decisions and treatment accordingly. Furthermore the patient also would expect this treatment and would have little influence on the decision [Chin,2002]. However modern medicine is a lot different, increasing litigation, multiculturalism and differing religious ideologies as well as a bigger emphasis on patient autonomy is changing the perception of the doctor-patient role as well as what lie in the patients best interests [Mckinstry 1992].

It is never in the best interests of the patient to lie
Many authors had a deontological framework as the basis for this argument. Many people feel that it is intrinsically good to tell the truth even in a broader context than just the doctor patient relationship. (Nurs Ethics 2004) Richard 2010 referred to the Doctors duty to tell truth as patients have the right to know the truth (Richard 2010). Even if the author spoke of exceptions to the rule, the overwhelming consensus is that prima fasce as a Dr to not lie (Richard 2010) (Nurs Ethics 2004)(Gillon 1993)(sokol case study) He also states that openness and honesty are required to gain informed consent from a patient. This legal requirement is based on the expectation that medical practioners will be honest with their patients.

The principal of autonomy is referenced by many authors. They refer to the importance of empowering the patient with the truth giving them a chance to plan and be prepared. Any many authors found in the course of their studies that the majority of patients wanted to know the truth about their prognosis and condition (Nurs Ethics 2004)

Some referred to the doctor patient relationship and the ethics of care. Authors stated that trust is generated when the doctor is truthful, which leads to a better doctor-patient relationship and hence statistically better health outcomes for the patient. (Nurs Ethics 2004) Other authors focused not-only on the doctor-patient relationship and ethics of care, but more specifically on the non-maleficence principal. It was thought by many authors that harm is more likely to arise from the discovery of deception then if the (perhaps unpleasant) truth was told (Nurs Ethics 2004). Herbert et al 1997 stated that dishonesty lead to distrust which lead to poorer patient-doctor relationships (Herbert et al 1997). This in turn will lead to poorer health outcomes which is not in the patients best interests.

There are times when a medical practitioner should lie to uphold the best interests of their patient
Many authors agreed with the above statement, although the reasoning varied between them.

It is argued that patients have a right to know and not know (sokol case study, Richard 2010) based on the principal of autonomy. In that some cases, patients will chose not to know when given the opportunity, thus forcing the practitioner to lie by omission. (sokol 2007) This was found to be common among the elderly and terminally ill.(Nurs Ethics 2004) This lead to nurses withholding information from patients in cancer and geriatric wards at the request of the family. Withholding information/non disclosure was deemed ok if the patient had forfeited autonomy due to mental incapacitence (Nurs Ethics 2004).

A deontological approach can also support the use of lying (at times) in clinical practice. There is no rule, no specific guideline in the code of conduct stating that we must always tell the truth, but there is a rule for providing the best care for the patient. Normally telling the truth will deliver the best care, and hence the doctor will not lie. However, if the ‘best interests’ and ‘truth-telling’ are in opposition, following the rule of ‘best-interests’ is most inkeeping with a deontological approach using the code of practice [link] and medical guidelines [link]. (Richard 2010)

Many authors referred to the ethics of care and beneficence principals. Most doctor-lying was through the concealment of a diagnosis to some degree across the world (Nurs Ethics 2004). Lying to a child to take life saving asthma medications gives an outcome for the greater good for the patient. (Nurs Ethics 2004)

Other authors emphasized the utilitarian argument. Nurses used half truths rather than direct lying as it was for the greater good of the patient [see best interests](Nurs Ethics 2004)

Utility encourages lying in hospitals for the greater good eg not telling patients junior drs perform the operation and hence not worry the patient to the point of refusal, and junior dr learns. (Nurs Ethics 2004) 507 (sokol 2007)

Non-maleficence: In doctor patient relationship, the doctor may lie to provided no harm to the patient in a parternalists view (Nurs Ethics 2004) 507 (sokol 2007) Lying or deception in some way is necessary  to uphold other moral obligations such as to do no harm in some cases (sokol case study)

Uncertainty was also a reason not to tell the truth (Nurs Ethics 2004) 508 (Richard 2010)

Conclusion
In summary there were a range of answers to this ethical question. Many of the references that looked directly at the current practice, found that an overwhelming majority of health care providers will mislead patients in the course of their work. Furthermore, a majority of the references which had a strong emphasis on the real-life application of this dilemma, concluded that it may be acceptable to lie on the rare occasion but every case for lying should be considered individually (Richard 2010, sokol case, sokol 2007). The reasoning behind when it is reasonable was often not stipulated and when it was, the author(s) had their own set of very specific criteria.