The ethics of truth telling.

In India, we have traditionally presumed that patients repose their faith completely in their doctors and are content to follow their prescriptions, even without full knowledge of their condition and the course of treatment.[1] In turn, doctors respond by giving less than complete information to patients, preferring sometimes to communicate with the caregivers, virtually ignoring the presence of the patient. In a cultural context, where doctors are socially superior to patients and their authority is unconditionally accepted and patients feel obligated to obey their doctors, such an arrangement usually goes unquestioned.[2] However, as education levels rise and people have access to information through various sources, whether through newspapers, television or the internet, this arrangement may become increasingly unsatisfactory. In the present context, the informational needs of patients have become much more complex. As soon as a person has received a diagnosis, he or she inundated with advice, opinions, and information, which they do not have any means of validating. So, it is quite natural that they would develop anxieties and doubts about the future, which they would like their doctors to allay. Thus, the findings of recent study among cancer patients which indicate that patients are overwhelmingly in favor of receiving full information about their condition, the course of treatment, and possible side-effects does not come as a surprise.[3] This study makes a valuable contribution to initiating a discussion on truth telling, questioning established practices and widely held presumptions about the doctor-patient relationship in India.

Once we accept that patients want to be told the truth about their disease and their treatment, we must also confront the fact that most doctors do not know how to communicate with their patients. Our medical education system systematically devalues anything which, apparently, has no part to play in the ‘treatment’ as such, but only enhances the patient's well being. Thus, components such as communication skills, ethics, and empathy are relegated to a few random lectures scattered through the training period. It is not that lip service is not paid to the importance of these skills, but the actual organization of the curriculum and training leaves no space for them.[4] Typically, in our teaching colleges, history taking, communicating with patients and relatives, obtaining consent are delegated downwards to the junior-most member of the medical team and are carried out, mostly, without supervision. When they fail, it is attributed to their lack of interest in patient care and to a general decline in values among the young generation. However, the fact is that unless they see that their senior-most teachers are as concerned about communicating to patients as they are about the surgery or the chemotherapy and that it is an integral part of being a good professional, they will not develop the skills for it.

Going beyond the scope of this paper, one would find that patients not only want to know, they would also like to participate in the decision-making process. Some international studies have shown that professional dominance leads a high degree of dissatisfaction among patients, which they may not be able to articulate.[5] To avoid that, doctors have to be ready to give time to listen, to answer questions, to clarify doubts, and also to admit to the limitations of their skills and knowledge. It is quite usual to see a proactive patient as an interfering one.[6] Doctors are quick to interpret questioning as a lack of trust on the part of the patient. They do not recognize that patients need information to be more in control of their life, to make more informed choices and to empower themselves. In fact, if conversely, doctors invited questions and encouraged patients to seek more information, they would develop a greater trust in their doctors. While it is true, that, in most settings, the time available with the doctor for each patient is very limited, innovative means can be employed to meet the information needs of the patients. These could include group meetings, involving multi-disciplinary teams in patient care, use of educational material and peer education. What is required is an acknowledgement that information provision is an integral part of patient care and an organizational commitment to assure that resources and personnel would be made available for it.

It is time to acknowledge that the doctor-patient relationship in India is, generally speaking, undergoing a change. Several factors are contributing to this change. As noted earlier, educational levels are rising and exposure to medical information is increasing, secondly, medicine has become more commercialized and it has converted patients into consumers.[7] The inner working of medical institutions, which, hitherto, was invisible to the lay people, is now being increasingly exposed by the media, showing them, more often than not, in a negative light. In this situation, patients are unlikely to unquestioningly believe that hospitals and doctors are acting in their best interests. This does not mean that patients and doctors have now become adversaries. The patients’ need to trust is as great as the doctor's need to be trusted. What needs to be understood is that this trust has to be built on a more equal, transparent, and empathetic relationship.