Yet afterwards I pondered on her story and I couldn’t get another, heretical thought out of my mind: why did the doctor have to tell the truth? There must have been a dozen ways in which she might have delayed or underplayed telling the man the full scan result, at least until a relative could be present – or until the patient’s usual doctor was available. It took little imagination to think of various forms of subterfuge that she might have used: ‘the result isn’t back yet…’, ‘it’s back but it’s not entirely clear…’, ‘I’m a bit puzzled about its significance and I need to discuss it with a colleague…’ If such prevarications had raised the patient’s anxiety, would that have been so terrible, especially by comparison with what actually did happen? I recalled that a generation ago, few doctors would ever have dreamed of telling this man the truth in this way. And surely no group of medical educators at that time would have failed to mention, or even to think, that it might have been done differently.
There has been a generational change, but culture makes a difference too. A week after this conversation, I was teaching a group of interpreters mainly from eastern Europe. The same theme arose again. One of them described, with horror, how a friend of hers had been to see a doctor in London who had told him – ‘by himself, on the spot, there and then’ – that he had cancer of the lymph glands. Back home, she said, no one would ever give someone such information without first checking with the family whether the patient had the resilience to absorb it, or to cope with it. When she said this, her peer group murmured their agreement and expressed their disapproval of the brutal and uncompromising frankness of British doctors.
As it happens, her views find support in cross-cultural research about death and dying. In many parts of the world, and among many cultures, people still take a far more circumspect approach to the disclosure of a terminal illness than we generally do in the West. According to medical anthropologists and family researchers, this may have nothing to do with paternalism or with a fear of being honest. Instead, it may arise from a belief in the crucial importance of sustaining hope as a life force, together with a radically different understanding of the duties of the individual towards the family and vice versa.
‘In cultures where the family is the unit of identity and responsibility,’ writes Lucy Candib from the University of Massachusetts, ‘interdependence is the higher value, not individualism… The patient knows that family is protecting her and that this is what families should do… Non-disclosure is not a matter of lying. Ambiguity may be seen as the most suitable strategy to allow the patient to maintain tranquillity.’ Candib also cautions against making simplistic assumptions that everyone from a certain culture will share the same preference for or against knowing the truth. She advises physicians to ‘offer the option of truth’ when breaking bad news, regardless of where the patient comes from. She suggests using questions such as these: ‘Will you want to be making the decisions about your care with the doctors, or do you want your family to be making those decisions?’ and ‘When we understand what is causing your illness, will you want us to tell you about it, or to talk with your family about it?’
This kind of sensitivity to cultural and individual norms is gaining increasing support among medical ethicists. Following several decades of so-called ‘principlist’ ethics (based on the four well-known principles of autonomy, non-maleficence, beneficence and justice), an increasing number of writers now seem to be moving towards a more flexible approach known as ‘narrative ethics’. One of its central tenets is that every situation is unique and unrepeatable, and cannot be fully captured by appealing to universal principles. Any decision or action is therefore justified in terms of its fit with the individual life story of the patient, and needs to be sought through conversation rather than based on prior notions.
Seen in this light, our colleague’s assumption that there was only one right action when faced with the jaunty man with pancreatic cancer might be seen as an example of die-hard principlism. And we may well see the pendulum swinging away from the practice of telling people the truth, the whole truth and nothing but the truth – at least until the timing and context for doing so are entirely right.