TRUTH IN OUR INTERCOURSE WITH THE SICK.
On the question, whether strict veracity should be adhered to, in
every case and under all circumstances, in our intercourse with
the sick, there is very great difference of opinion, as well among
medical men, as in the community at large. Some are most scrupulously
strict in their regard to truth; others, while they are generally so,
make some few occasional exceptions in cases of great emergency and
necessity; while others still (and I regret to say that they are very
numerous) give themselves great latitude in their practice, if they
do not in their avowed opinions.
In examining this subject, it is not so much my intention to
discuss the abstract question, as to present the many practical
considerations that present themselves, illustrating them, so far as
is necessary, by facts and cases.
In order to introduce the subject, I will here quote a passage from
Percival’s Medical Ethics, which presents the views of those who are
in favor of an occasional departure from truth, where the necessity
of the case seems to demand it.
“Every practitioner must find himself occasionally in circumstances
of very delicate embarrassment, with respect to the contending
obligations of veracity and professional duty; and when such trials
occur, it will behoove him to act on fixed principles of rectitude,
derived from previous information and serious reflection. Perhaps
the following brief considerations, by which I have conscientiously
endeavored to govern my own conduct, may afford some aid to his
decision. Moral truth, in a professional view, has two references;
one to the party to whom it is delivered, and another to the
individual by whom it is uttered. In the first it is a _relative
duty_, constituting a branch of justice, and may properly be
regulated by the divine rule of equity prescribed by our Saviour,
_to do unto others as we would_, all circumstances duly weighed,
_they should do unto us_. In the second it is a relative duty,
regarding solely the sincerity, the purity and the probity of the
physician himself. To a patient, therefore, perhaps the father of a
numerous family, or one whose life is of the highest importance to
the community, who makes inquiries, which, if faithfully answered,
might prove fatal to him, it would be a gross and unfeeling wrong to
reveal the truth. His right to it is suspended, and even annihilated;
because its beneficial nature being reversed, it would be deeply
injurious to himself, to his family, and to the public. And he
has the strongest claim, from the trust reposed in his physician,
as well as from the common principle of humanity, to be guarded
against whatever would be detrimental to him. In such a situation,
therefore, the only point at issue is, whether the practitioner shall
sacrifice that delicate sense of veracity, which is so ornamental
to, and indeed forms a characteristic excellence of the virtuous
man, to this claim of professional justice and social duty. Under
such a painful conflict of obligations, a wise and good man must be
governed by those which are the most imperious, and will, therefore,
generously relinquish any consideration referable only to himself.
Let him be careful, however, not to do this but in cases of real
emergency, which, happily, seldom occur, and to guard his mind
sedulously against the injury it may sustain by such violations of
the native love of truth. I shall conclude this long note with the
two following very interesting biographical facts. The husband of the
celebrated Arria, Cæcinna Pactus, was very dangerously ill. Her son
was also sick at the same time, and died. He was a youth of uncommon
accomplishments, and fondly beloved by his parents. Arria prepared
and conducted his funeral, in such a manner, that her husband
remained entirely ignorant of the mournful event which occasioned
that solemnity. Pactus often inquired with anxiety about his son,
to whom she cheerfully replied, that he had slept well, and was
better. But if her tears, too long restrained, were bursting forth,
she instantly retired, to give vent to her grief, and when again
composed, returned to Pactus with dry eyes and a placid countenance,
quitting, as it were, all the tender feelings of the mother at
the threshold of her husband’s chamber. Lady Russell’s only son,
Wriothesley, Duke of Bedford, died of the small-pox, in May, 1711, in
the 31st year of his age. To this affliction succeeded, in November,
1711, the loss of her daughter, the Duchess of Rutland. Lady Russell,
after seeing her in the coffin, went to her other daughter, married
to the Duke of Devonshire, from whom it was necessary to conceal her
grief, she being at that time in childbed likewise; therefore she
assumed a cheerful air, and, with astonishing resolution, agreeable
to truth, answered her anxious daughter’s inquiries with these words,
‘I have seen your sister out of bed to-day.’”
The falsehood in the two cases related by the author is of the most
egregious character, and yet they are fair representations of that
kind of deception which many feel authorized to use in the sick room.
The equivocation which is practised, it is true, is not always as
gross and as labored, but it is as real. And whatever be the degree
or kind of deception, the same principles will apply to every case.
The question that presents itself is not, let it be understood,
whether the truth shall in any case be _withheld_, but whether, in
doing this, real falsehood is justifiable, in any form, whether
direct or indirect, whether palpable or in the shape of equivocation.
And we may also remark, that the question is not, whether those
who practice deception upon the sick are guilty of a criminal act.
This depends altogether on the motive which prompts it, and it is
certainly often done from the best and kindest motives. The question
is stripped of all considerations of this nature, and comes before
us as a simple practical question—whether there are any cases in
which, for the sake of benefitting our fellow men, perhaps even to
the saving of life, it is proper to make an exception to the great
general law of truth.
The considerations which will bring us to a clear and undoubted
decision of this question, are not all to be drawn from the
preciousness of the principle of truth, as an unbroken, invariable,
and ever-present principle, the soul of all order, and confidence,
and happiness, in the wide universe. But the principle of expediency
also furnishes us with some considerations that are valuable in
confirming our decision, if not in leading us to it. In truth,
expediency and right always correspond, and would be seen to do so,
if we could always see the end from the beginning.
I will remark upon each of the considerations as I present them.
First. It is erroneously assumed by those who advocate deception,
that the knowledge to be concealed from the patient would, if
communicated, be essentially injurious to him. Puffendorf remarks in
relation to this point, that “when a man is desirous, and it is his
duty, to do a piece of service, he is not bound to take measures that
will _certainly_ render his attempts unsuccessful.” The certainty
of the result, thus taken for granted, is far from being warranted
by facts. Even in some cases where there was a strong probability
(and this is all we can have in any case) that the effect would
be hurtful, it has been found not to be so. I might here narrate
some cases to prove the truth of this assertion, but it is not
necessary. Suffice it to say, that it is confirmed by the experience
of every physician who has pursued a frank and candid course in his
intercourse with the sick.
Secondly. It is also erroneously assumed that concealment can
always or generally be effectually carried out. There are so many
ways by which the truth can be betrayed, even where concerted plans
are laid, guarded at every point, that failure is much more common
than success, so far as my observation has extended. Some unguarded
expression or act, even on the part of those who are practising
the concealment, or some information communicated by those who are
not in the secret, perhaps by children, or some evidence casually
seen, very often either reveals the truth, or awakens suspicion and
prompts inquiry which the most skilful equivocation may not be able
to elude. The very air that is assumed in carrying on the deception
often defeats the object. In one instance where this was the case,
the suspecting patient said very significantly, ‘How strangely you
all seem—you act as if something dreadful had happened that you mean
to keep from me.’ Even the little child often exhibits a most correct
discrimination in detecting deception in the manner, the modes of
expression, and even the very tone of the voice. And sometimes, nay
very often, people so far undervalue the good sense and shrewdness
of children, that their deception is even ridiculously bungling, and
justly excites an honest indignation in the bosom of the deceived
child.
I give the following scene as an illustration of the above remark.
‘Come, take this,’ said a mother to her child, ‘it’s something good.’
The child was evidently a little suspicious that he was not dealt
with candidly; but after a great many assurances from her on whom a
child ought to be able to rely, if upon any body in the wide world,
he was at length persuaded to take the spoon into his mouth. The
medicine, which was really very bitter, was at once spit out, and the
little fellow burst forth in reproaches upon his mother for telling
him such a lie.
‘No, my dear,’ said she, ‘I have told you no lie. The medicine _is_
good—it is good to cure you. That is what I meant.’
‘Good to cure me!’ cried he, with a look and an air of the most
perfect contempt. ‘You cheated me. You _know_ you did.’
The contempt which this child manifested towards such barefaced
equivocation was most justly merited, and yet this is a fair example
of the deceptions which physicians are almost every day obliged to
witness, and which, (may I not say?) some of them encourage both by
precept and example.
Thirdly. If the deception be discovered or suspected, the effect upon
the patient is much worse than a frank and full statement of the
truth can produce. If disagreeable news, for example, be concealed
from him, there is very great danger that it will in some way be
revealed to him so abruptly and unexpectedly, as to give him a severe
shock, which can for the most part be avoided when the communication
is made voluntarily. And then, too, the very fact that the truth has
been withheld, increases, for obvious reasons, this shock. I will
relate a case as an example. It occurred during the prevalence of an
epidemic. A lady was taken sick and died. The fact of her death was
studiously concealed from another lady of her acquaintance, who was
liable to be attacked by the same disease. She was supposed by her
to be doing well, until one day a child from a neighboring family
accidentally alluded to the death of her friend in her presence.
The shock which the sad news thus communicated produced upon her
was almost overwhelming, and it was of course rendered more intense
by the reflection, that her friends thought her to be exceedingly
in danger of dying of the prevailing disease, and therefore had
practised this concealment in order to quiet her apprehensions. She
soon followed her friend, and it is not an improbable supposition,
that the strong impression thus made upon her mind had some agency in
causing her death.
In another case of a similar character, the first intimation which
a lady had of the death of a friend was from seeing the husband
of this friend pass in the street with a badge of mourning. She
was immediately prostrated upon her bed, and was a long time in
recovering from the shock.
In both of these cases the concealment of the truth was prompted by
the best of motives—pure kindness; and yet nothing is more plain
than that it was a _mistaken_ kindness. Whatever may be true in
other instances, the result showed this to be the fact in these two
cases. And if it be true, as I think all experience will prove, that
success, and not failure, in the attempt at concealment, is the
exception to the general fact, it clearly follows that deception is
impolitic as a measure of kindness, and therefore, aside from any
other consideration, it should be wholly discarded in our intercourse
with the sick.
I have a case in mind, which exhibits in contrast the influence of
frankness and of deception.
A little girl, the daughter of a farmer, had her arm torn to pieces
up to the elbow in a threshing machine constructed very much like a
picker. As her mother was confined to her bed with severe sickness,
the child was carried into the house of a neighbor. When I arrived,
I was told that her mother was in great distress, and fears were
expressed that the accident would have a very bad influence upon her
case. I asked if she knew what had happened. ‘No,’ said her husband,
‘not exactly. She found out by the children that Mary was hurt, and
then sent for me, and asked me what was the matter. I told her at
first that she had got her finger hurt. She said she knew that was
not all, and I at length, after she had begged and begged me to tell
all, told her that her hand was hurt badly. And now she is crying
most piteously, and says that we are deceiving her, and that she
knows that Mary is almost killed.’
I immediately went in to see the mother, and found her indeed almost
distracted with the great variety of dread visions that had suggested
themselves to her fancy in regard to her darling child. As I entered
the room she cried out, ‘Oh, she’s dead, doctor, or dying—torn to
pieces—in agony—Oh, isn’t it so? tell me, tell me the truth!’ ‘Be
quiet,’ said I, ‘and I _will_ tell you all the truth. I will not
deceive you.’ I assured her that she need give herself no anxiety
about the _life_ of her child—that was safe. This announcement
quieted her in a good measure, and I went on to tell her that the
arm was badly torn, and that I must amputate it above the elbow.
I told her that this would take but a minute or two, and then the
child would be essentially well. It was necessary to go into these
particulars in answer to her inquiries, (which were the more minute
from the fact that she had been deceived,) or else I should forfeit
her confidence, and thus commit the same error that had already been
committed. She thanked me for being so frank with her, and said, that
though it was hard to think of the operation, she could bear that,
if the child’s life was only spared. She grieved still, it is true;
but there was none of that overwhelming distraction that results from
vague apprehension.
Fourthly. The destruction of confidence, resulting from discovered
deception, is productive of injurious consequences to the persons
deceived. The moment that you are detected in deceiving the sick, you
at once impair or even destroy their confidence in your veracity and
frankness. Everything that you do afterward is suspected, and a full
and unshrinking trust is not accorded to you even when you deserve
it, though you may try to obtain it by the most positive and solemn
assurances. If, for example, you wish to encourage a patient, and you
tell him that though the bow of hope is dim to his eye, it is bright
to your own: ‘Ah!’ he will think, if he does not say, ‘how do I know
but that it is as dim to him as it looks to me—he has deceived me
once, and perhaps he does now.’
Every physician has seen the injurious influence of deception upon
children. Sometimes it is of a most disastrous character, and
occasionally, I have not a doubt, it proves fatal. Deception is more
frequently practiced upon children than upon adults, and many seem to
think that they have not the same right to candor and honesty in our
intercourse with them. But a child can appreciate fair and honest
treatment as well as an adult can, and he has as good a right to
receive it at our hands. He sometimes claims this right in terms, and
by acts not to be mistaken. And when it is taken from him, he shows
his sense of the wrong by remonstrances and retaliatory language, and
by a system of rebellion to an authority which he despises, as well
as fears, for its falsehood.
Suppose a mother succeeds in giving a dose of medicine by stratagem,
the administration of every dose after it is accompanied with a
fearful struggle. The strife which results from the spirit of
resistance thus engendered, perhaps in the beginning of a long
sickness, and which might in most cases have been avoided by frank
and candid treatment, continues through the whole course of the
disease to the last hour of life if the case prove fatal, the little
creature feebly but obstinately resisting its mother, till the
exhaustion of coming death puts an end to its struggles; and, though
she plies every art that fondness can devise to win back the lost
confidence of her darling child, it is all in vain.
If the reader have any adequate idea of the importance of quietness
in the management of the sick, I need not spend time to prove, that
this resistance of the sick child has an injurious effect upon
the disease, and that in those cases where life has but a feeble
trembling hold, where the silver cord is worn down almost to its last
thread, such a struggle may break that thread by its violence. I have
not a doubt that many a child has died under such circumstances, that
might otherwise have recovered.
Let me not be understood to imply that the resistance made by
children to the administration of medicine is invariably the
result of deception practised upon them, though this is the cause
undoubtedly in quite a large proportion of the cases, and those
too of the worst and most unconquerable character. And it may be
remarked, that in many cases this may be the cause of the difficulty
where it is little suspected. For it is so common a habit to deceive
children in this matter, that it is often done unconsciously. But
though the parent may not remember it, the child does, and the cruel
oppressive act (for so it may be properly called) locked up in the
memory of the child, wakes up rebellion in his heart that is not
easily quelled. Many a parent has thus in a moment, for the sake of a
slight temporary advantage, sown the wind to reap the whirlwind.
Deception has very often been made use of in the management of the
insane, though recently not to the same extent that it once was.
The consideration which I have been illustrating and enforcing lies
against the practice of it in our intercourse with this unfortunate
class of patients, with the greater force, because in their case the
mind is diseased, and any bad mental influence has therefore a worse
effect than it would have upon a case of mere bodily disease. The
reason is obvious—it acts directly upon the seat of the disease in
the former case, but indirectly in the latter.
Besides, let the insane man once see that you have deceived him, and
you lose the principal, perhaps we may say the only, moral means that
you have for curing his malady. Confidence is essential to any good
moral influence that you may exert upon him. I might cite many facts
to prove this, but will advert to only one. The wife of an insane man
was the only person among all his friends that had any control over
him, and she could manage him with perfect ease. After his recovery
she asked him the reason of this fact, and his reply was, ‘You was
the only one that uniformly told me the truth?
The bad influence of deception upon the insane man is rendered
the more certain and effectual from the fact that his insanity
incapacitates him for appreciating the kind motives which may have
prompted the deception. You cannot convince him as you can the sane
sick man, that you have deceived him for his own good. His suspicious
eye sees nothing but a sinister purpose in the cheat which you have
practised upon him.
One of the most vivid recollections of my childhood is that of a
scene which illustrates these remarks. A poor crazy man who wandered
about the streets was thought to have become dangerous, and it was
proposed to confine him in the common jail. A plan was laid to do it
by stratagem. He fancied himself to own some large possessions, and
talked much about going to Boston to see his friend the governor,
and attend to his business there. A neighbor offered to go with him,
and he accepted the offer. As they passed by the jail, his friend
proposed to visit it. As they entered one of the cells he adroitly
slipped out, and the door was closed upon the insane man. His dream
of earthly happiness and wealth was in a moment at an end, and he
beheld himself the victim of base treachery in the narrow cell of
a prison. Never shall I forget how eloquently he pleaded for his
release, how he asked what crime could be charged to his account,
how he denounced those who had thus without cause shut him up like
a felon, and especially with what sorrowful but burning indignation
he spoke of the man, ‘who under the guise of friendship, had decoyed
him into this snare of his enemies.’ Though a mere boy, I pitied him.
I sympathised with him. I had known him only as a pleasant old man,
who used to amuse us as we met him in the streets with stories of
his immense wealth and of the splendid plans of building on which he
loved to speculate. I felt that it was wrong to confine him among
vile criminals, and wondered not that the keen sense of such injury
prompted to the utterance of curses on those who inflicted it. But
these natural feelings gave way in my bosom, as they did in older
ones, to what was then supposed to be the necessity of the case—a
necessity which, I rejoice to say, has since that been found not to
exist in similar cases. A very great improvement has been effected
in this as well as in other respects, in the management of the
insane. Most of those whom it was once thought necessary to confine
with bolts and bars, and perhaps chains, and upon whom deception was
continually and systematically practised, thus adding poignancy to
the pangs of the oppressed spirit, are now permitted to have so much
liberty, that they are cheerful and happy, reposing entire confidence
in their attendants, who are careful never to deceive them. And
those whom it is thought necessary to confine, are not doomed to the
cheerlessness and disgrace of the cell of the felon, but they are
placed in as agreeable circumstances as is consistent with safety.
And it has come to be an established rule with those who have the
care of the insane, that force is always preferable to deception.
But still, erroneous views are very prevalent in the community on
this subject. It is common to this day, even among the excellent and
well informed, to propose to send their insane friends to a Retreat
by stratagem, and this has often been done even by the advice of
physicians. So far as I recollect, in all the cases of insanity that
have gone to Retreats from under my care, this mode of management has
been spoken of by some, and generally by many, as the only proper
mode. The public need to be instructed and reformed on this point.
It is a common observation that the insane are apt to look upon
their best and most intimate friends as their enemies. Why is this?
It is clear, that it is in part to be ascribed to the influence of
deception, waking up, as might be expected, feelings of resentment
and enmity in the bosom of the insane, which would not otherwise be
there. This point I have commented upon in the Chapter on Insanity,
and I need not dwell upon it here.
The extent to which deception is practised upon the insane cannot be
fully appreciated, except by those whose attention has been specially
called to this subject. As I have already remarked in regard to
children, so also it is with the insane—deception is so common, that
people often make use of it almost unconsciously. The whole course
of management on the part of their friends, is often characterized
throughout by an absence of candor and veracity.
The tendency of such a course is invariably to increase insanity,
making it more intense and obstinate. And not only so, but it
modifies to a greater or less degree its character. Deception prompts
the insane man to exercise his ingenuity in forming plans to foil and
circumvent his deceivers, whom he supposes very naturally to be his
enemies. Of course, new feelings and thoughts are thus excited in his
bosom, giving in some measure a new cast to his insanity.
I will here relate a case that illustrates these remarks.
The friends of an insane gentleman determined to send him to a
Retreat by stratagem. For this purpose, he was induced by one of
them to go a journey with him. On, their way, his friend proposed to
him to visit an Insane Retreat as a matter of curiosity. When they
arrived there, he was given to understand that he was to remain as
an inmate. Great was his rage at being so grossly deceived. After
the first burst of indignation was passed, he saw that it was of no
use to say anything or to make any resistance. He was a shrewd man,
and therefore, as a matter of policy, he submitted with apparent
cheerfulness to his new situation. He did not forget, as the insane
sometimes fortunately do, the wrong which his friends had done him,
and as he was decoyed there by stratagem, it is no wonder that he at
length made his escape by stratagem also. He came out, as might have
been expected, with his insanity more thoroughly fixed than it was
when he went in, and he added to it a deep hatred of Retreats, and of
course of the man who had betrayed him into one.
Another attempt was made to carry him to the same Retreat, which
from mismanagement utterly failed. The insane man was victorious,
and he felt himself to be so, over his friends, who he supposed
were bent upon cheating and oppressing him. All this not only made
him more crazy, but it gave a new shape to his insane ideas. In a
conversation which I chanced to have with him, he said to me, ‘It is
perfectly evident, doctor, that these Insane Retreats are joint-stock
institutions, and the stockholders are chiefly lawyers and doctors
and ministers. And it’s good stock too. Just see how much they charge
for board—full double at least of the actual expenses. I need not
tell you anything about it, however, for you own some of this stock,
and you know how profitable it is to you.’
‘Oh no,’ said I, ‘this is all new to me.’ He looked at me as if
he would look me through. He had been deceived so much, that he
believed, he trusted no one. Although I gave him the most positive
assurance that I owned no such stock, still, in spite of the
confidence which he ordinarily reposed in me, he showed that he did
after all suspect me on this point, so firmly was this notion about
Retreats fastened in his mind. He went on to give his reasons for his
opinion.
‘I can look back,’ said he, ‘to my very childhood, and see that from
that time to the present, there has been a series of efforts on the
part of these stockholders to make me a crazy man; and they at length
succeeded, and then contrived the mean plan of tricking me into one
of their Retreats. The minister that I lived with when I was ten
years old began this scheme, and all the ministers and lawyers and
doctors, that I have had anything to do with since that time, have
had a hand in it—have exerted their influence on me, all in relation
to this one object. It’s a regular money-making business. Of course
the stockholders all want to see these Retreats well filled up. Just
see how they have treated me lately. They have combined to cross my
purposes, break up my plans, defeat my projects, ruin my business,
and all this to irritate and disappoint me, and thus craze me. And
then, to cap the whole, they lied to me and betrayed me into their
prison to die a slow death, paying them all the time about twelve
dollars a week. Good stock, doctor, but a cruel business,’ said he,
with a most unearthly grin, and a shudder that shook his whole frame.
‘But thank heaven,’ cried he, ‘I’ve escaped their clutches. Though
they have ruined me, they shall not have their twelve dollars a week
out of me. No, I’ll die first. Such systematic, cheating, lying
oppression, I’ll resist to the death.’
It is evident that the treatment which this man received at the
hands of his friends, tended to aggravate, instead of lessening his
insanity. And I may remark, too, that the notion which he derived
from this treatment, in relation to Retreats, false as it was, was
founded on more plausible reasons as they were presented to his mind,
than are some of the opinions that are adopted by some sane men in
the community.
Fifthly. The _general_ effect of deception, aside from the
individual which it is supposed it will benefit, is injurious.
The considerations on which I have already remarked, have had
regard entirely to the person that is deceived, and I think that I
have shown most clearly, that even taking this narrow view of the
influence of deception, it is in almost all cases a bad influence:
and therefore as we cannot tell in what cases this influence will
be good, it is impolitic, and should be entirely discarded. Let
us now go farther, and looking beyond the individuals who are the
subjects of the deception, we shall see its influence extending
all around from these individuals, as so many radiating points of
influence, leavening the whole mass of society with a most poisonous
leaven. It is not an influence that can be shut up in the case of
any individual, in that one breast, or within that one chamber of
sickness.
That confidence, which should always exist in the intercourse of
the sick with their physicians and friends, and which may be made
the channel of great and essential benefits to them, is materially
impaired, often even destroyed by such deception. And this effect
is unfortunately not confined to those who practice it, but the
imputation rests upon others. The distrust thus produced often exerts
a depressing influence in those cases, where the cordial influence
of hope is most urgently needed, and where it can be administered in
consonance with the most scrupulous veracity. It is well if, under
such circumstances, the physician can appeal to the patient’s own
experience of his frankness in all his previous intercourse with him.
I call to mind an instance in which I was able to make this appeal
with the most marked good effect. The patient was a lady who was
in a great state of alarm in regard to the probable result of her
sickness. She was indeed very sick, but there was good reason to hope
that remedies would relieve her. At the same time I feared that the
depressing effect of this state of alarm, if it should continue,
would prove a serious obstacle to her recovery. But as I expressed
to her the confident hope that she would get well, she said to me,
‘Physicians always talk in this way, and you do not really mean
as you say. I shall die, I know that I shall die.’ I had been the
physician of the family for many years, during which time they had
gone through some trying scenes of sickness. Alluding to all this, I
asked her if she could look back and call to mind a single instance
in which I had not dealt candidly and frankly with her. She allowed
that she could not. ‘Well,’ said I, ‘believe me _now_; I _am_ in
earnest; I do believe, and confidently, too, that you will recover.’
The tears were at once wiped away. Cheerfulness, the cheerfulness of
hope, lighted up her countenance and the case went on to a speedy and
full recovery.
Every day we see evidence of the fact that so large a proportion
of the medical profession practice deception upon the sick, that
the profession, as a whole, has to a greater or less degree the
imputation fastened upon it. Indeed patients often, as a matter of
course, make the distinction between the obligations to professional
veracity, and those of the man, as a man, in his ordinary
intercourse; and the physician, who has an established reputation for
the strictest veracity everywhere else but in the sick chamber, has
there the suspicion of deception put upon him; and it is supposed to
be no imputation of which he should complain, because deception is
allowed here almost by general permission. For this reason, whatever
of frankness and honesty there may be in our intercourse with the
sick, often fails to produce the effect intended, in part at least if
not wholly. And this result follows just in proportion to the extent
to which deception is made use of in the profession.
The indirect and collateral effects of deception are often manifest
in a family of children. Its influence extends beyond the mind and
character of the deceived child. If the other children witness the
deception, what hinders them from believing that their parents can
deceive them also whenever it suits their convenience? And if they
do not witness it, the sick child will remember it when he recovers,
and the rebellion which he has, in consequence, in his bosom towards
an authority that rules by deceit, and is therefore deemed with good
reason oppressive, is of course communicated to the other bosoms
of the little flock. Many a parent, who supposed that he was doing
nothing that would last beyond the present moment, has thus sown the
seeds of rebellion among the little band of subjects, over whom God
has placed him; and who can tell what the fruits will be, or to what
extent or length of time they will grow!
I need barely say in concluding my remarks on this consideration,
that the momentary good which occasionally results to _individual_
cases from deception, is not to be put in comparison, for one moment,
with the vast and permanent evils of a _general_ character, that
almost uniformly proceed from a breach of the great law of truth.
And there is no warrant to be found for shutting our eyes to these
general and remote results, in our earnestness to secure a particular
and present good, however precious that good may be—a plain
principle, and yet how often it is disregarded.
Sixthly. If it be adopted by the community as a common rule, that
the truth may be sacrificed in urgent cases, the very object of the
deception will be defeated. For why is it that deception succeeds
in any case? It is because the patient supposes that all who have
intercourse with him deal with him truthfully—that no such common
rule has been adopted. There is even now, while the policy on this
subject is unsettled and matter of dispute, enough distrust produced
to occasion trouble. And if it should become a settled policy under
an acknowledged common rule, the result would be _general_ distrust,
of course defeating deception at every point. And yet if it be
proper to deceive, then most clearly is it proper to proclaim it as
an adopted principle of action. Else we are driven to the absurd
proposition, that while it is right to practice deception, it is
wrong to say to the world that it is right.
It is in vain to say that the evil result which would attend this
adoption of occasional deception, as the settled policy of the
medical profession, would find a correction in the very terms of the
rule which should be adopted, viz. that the case must be an urgent
one to warrant deception, and there must be a fair prospect that it
can be carried through without discovery. For every patient, that was
aware of the adoption of such a rule, might and often probably would
suspect that his own case is considered as coming within the terms of
the rule.
Seventhly. Once open the door for deception, and you can prescribe
for it no definite limits. Every one is to be left to judge for
himself. And as present good is the object for which the truth is to
be sacrificed, the amount of good, for which it is proper to do it,
can not be fixed upon with any exactness. Each one is left to make
his own estimate, and the limit is in each one’s private judgment, in
each one’s individual case as it arises. And the limit, which is at
first perhaps quite narrow, is apt to grow wider, till the deception
may get to be of the very worst and most injurious character. I will
give a single illustration of this remark, which though not taken
from the practice of medicine, is appropriate to my purpose. It
has always been allowed in the laws of war, to deceive the enemy
by stratagems, false lights, &c. At one time some English ships in
two or three instances decoyed the enemy by counterfeiting signals
of distress. The deception in this case is productive indirectly
of the very worst consequences, for it manifestly tends to prevent
relief from being afforded to those, who are actually in a distressed
condition. Our feelings of humanity instinctively condemn such a
stratagem and yet it is only a mere extension of that deception,
which has been by common consent allowed in war. It involves no
different principles, and is only more objectionable, because it
produces worse indirect results. It differs in degree only and not in
kind.
So it is with deception always. Its indirect effects are always bad
to some extent, and to what extent they will prove so we know not in
each individual case. You can never know at the time how great is the
sacrifice which you are making for a present good. While you may be
thinking that you are only sacrificing your own veracity, and that
the influence of the act will not extend beyond the passing moment,
you may be producing disastrous results upon the interests of others,
and those results may be both lasting and accumulative. A man who was
captured by some Indians, was asked by them if there were any white
men in the neighborhood. He told them that there were, and directed
them to a spot where he was very certain that there were none. They
immediately started in pursuit, leaving him bound and in the charge
of one of their number. When they were gone, he contrived to make his
escape. Almost every one would say, that this was a strong case, and
that they could not blame him for telling a falsehood to Indians,
in order to escape from their cruelty. Here was a great good to be
obtained, the saving himself from torture, perhaps from death, and
deceiving savages for such a purpose, it will be said, is not to be
condemned. But mark the result of that deception. Five white men were
found on the spot to which he directed them, and were captured.
In order to make out a justification of deception, on the ground
of expediency in any case, all the possible results, direct and
indirect, must be taken into the account. But this is impossible
except to omniscience itself. Even in those cases which appear
the most clear to us, there may be consequences of the most grave
character utterly hidden from our view. In the instance just related,
the captive was very certain, from some circumstances, that he
directed his captors to a spot where there were no white men.
The uncertainty of our knowledge of the circumstances of each case
prevents then our defining any limits, within which deception shall
be bounded. We can make no accurate distinctions, which will enable
us to say, that it can be beneficially employed in one case, while in
another it will be inexpedient.
I have now finished the examination of the various considerations
which have been suggested to my mind in relation to this subject.
And I think that they settle the question as to the expediency of
deception beyond all doubt. I think it perfectly evident, that the
good, which may be done by deception in a _few_ cases, is almost as
nothing, compared with the evil which it does in _many_ cases, when
the prospect of its doing good was just as promising as it was in
those in which it succeeded. And when we add to this the evil which
would result from a _general_ adoption of a system of deception, the
importance of a strict adherence to truth in our intercourse with
the sick, even on the ground of expediency, becomes incalculably
great.
In the passage, which I quoted in the beginning of this article
from Percival’s Medical Ethics, the writer makes, I conceive, a
false issue on the question under consideration. He assumes that the
injury, which results from a sacrifice of the truth for the good of
the sick, comes upon him who practices the deception, and that in
doing it, “he generously relinquishes every consideration referable
only to himself.” But the considerations that I have presented show,
that the injury is very far from being thus confined. Often the
very person intended to be benefited is injured, perhaps deeply, in
some cases even fatally. And then the indirect effects can not be
estimated.
There are many illustrations, used by those who advocate deception,
which are plausible but fallacious. I will cite a single example.
Dr. Hutcheson of Glasgow, as quoted by Dr. Percival, in remarking
on the maxim, that we must not do evil that good may come, says,
“Must one do nothing for a good purpose, which would have been evil
without this reference? It is evil to hazard life without a view
of some good; but when it is necessary for a public interest, it
is very lovely and honorable. It is criminal to expose a good man
to danger for nothing; but it is just even to force him into the
greatest dangers for his country. It is criminal to occasion any pain
to innocent persons, without a view to some good; but for restoring
of health we reward chirurgeons for scarifyings, burnings, and
amputations.”
I would remark on this that the infliction of pain is not in itself
a moral act, but the purpose for which it is done gives it all the
moral character that it has. Aside from this, it affects no moral
principle, as the infliction of an injury upon truth certainly does,
independent of the object for which it is done. The infliction of
pain then for a good purpose can not be said to be doing evil that
good may come—it is doing good.
The sacrifice of life which the writer speaks of, is the sacrifice of
a less good for a greater one simply, and not the sacrifice of any
principle. But when the truth is sacrificed for what is deemed to be
a greater good, it is in fact the sacrifice of a greater good, for
not only a less, but an uncertain good—a sacrifice of the eternal
principle, which binds together the moral universe in harmony, for a
mere temporary good, which after all may prove to be a shadow instead
of a reality.
I can not leave this subject without making some explanations of a
few points, in order to guard against some erroneous inferences to
which the sentiments that I have advanced might otherwise be liable.
I wish not to be understood as saying that we should never take pains
to withhold knowledge from the sick, which we fear might be injurious
to them. There are cases in which this should be done. All that I
claim is this—that in withholding the truth no deception should be
practised, and that if sacrifice of the truth be the necessary price
for obtaining the object, no such sacrifice should be made. In the
passage which I have quoted from Dr. Percival, he states a case in
which he very properly says, that the patient’s right to the truth is
suspended; but I do not agree with him, that in withholding the truth
we have the right to _put absolute falsehood in its place_.
It is always a question of expediency simply, whether the truth ought
to be withheld. And it is a question that depends, for its proper
decision, upon a variety of considerations in each individual case.
It is very often decided injudiciously. There is generally too
great a readiness to adopt an affirmative decision. It is too easily
taken for granted, that the knowledge in question will do harm to
the patient if it be communicated to him. The obvious rule on this
subject is this—that the truth should not be withheld unless there be
a reasonable prospect of effectually preventing a discovery of it,
and that too by fair and honest means.
It has often been said that the physician has no right to excite too
much hope in the mind of a patient by directing his attention, as is
often done, to any favorable symptoms that may appear in his case.
But I ask, how is it known that in the case in relation to which this
remark is made, too much hope is excited? The physician is fallible,
and is by no means answerable for putting just the right degree of
hope into the patient’s bosom. It is not to be expected of him that
he shall always tell each patient just how his case stands. His own
mind is often filled with conflicting hopes and fears, and he cannot
decide clearly what the probabilities are in many cases. And if he
thinks that he can do so, he may be very much mistaken. Estimates are
often made most unwarrantably. An exactness is often aimed at which
is impracticable. The patient in many cases has no right to such an
estimate, for while it may be a mere guess, he may look upon it as
a well-founded estimate, made upon a real knowledge of his case. He
will therefore draw false inferences from it, and this the physician
is bound to prevent, and in so doing he actually prevents deception.
The physician should always remember that though he may be aware
himself of his liability to err in making any such estimate, the
patient may have such confidence in his judgment, that he will
consider the opinion which he may express to be of course a correct
one—almost beyond the possibility of a mistake. So that however
guarded he may be in expressing an unfavorable opinion of the
probable issue of any case, that opinion may have too much weight in
the patient’s mind.
It is by no means true that all direct questions on the part of the
sick must be directly and fully answered. For example, suppose the
patient asks the physician, “Do you think on the whole that I shall
recover”—a question that is sometimes asked under very embarrassing
circumstances. If the physician thinks that he will probably not
recover, he has no right to say to him that he will, for this would
be falsehood. But he has a right, and it is his duty if he thinks
it for the good of the patient, to withhold his opinion from him,
if he can do it without falsehood or equivocation. He may say to
him something like this: “It is difficult to decide that question.
Perhaps it is not proper for me at this stage of your case to attempt
to do it. You are very sick, and the issue of your sickness is
known only to God. I hope that remedies will do so and so (pointing
out somewhat the effects ordinarily to be expected) but I cannot
tell.” Something of this kind, varied according to the nature of
each case, especially in the amount of hope communicated, it is
perfectly consistent with truth and good faith to say; and very often
when more is said, even in very dangerous cases, the physician goes
beyond the limits which infinite wisdom has thought best to set to
his knowledge. It is very common, as the reader has already seen in
the preceding chapter, for persons to recover, particularly in cases
of acute disease, when the physician had supposed that they would
die. This fact should make him somewhat cautious in giving definite
opinions to the sick in relation to the probable final result of
their sickness.