Bioethics, Chapter 4

Truthfulness can be specified by two hypothetical commands:  If you communicate, do not lie (refusing to communicate is not lying)  You morally must communicate, if others have a right to communication (not everyone has a right to know what you know, or all you know) (Vaughn doesn’t try to define truthfulness; these specifications are from Garrett, p112)

What is lying? Garrett cites a traditional understanding of lying, calling it “speech against the mind” … “something at odds with what the speaker believes to be true” –p112 That definition is rejected, though, as it leads us to classify assertions in play acting, humor, games, etc., as lies, which seems wrong. Instead, we’ll call those speech acts against the mind, falsehoods.

Lies will then be…  falsehoods uttered in circumstances where others have a reasonable expectation of the truth Why not “where others have a right to the truth”? A lie surely does occur when we utter falsehoods to those with a right to the truth, right? Consider: “Is your car in the parking lot?”

Garrett provides 3 ways to assess “reasonable expectation”:  The place of communication (in public, in a church, synagogue, or mosque, at a funeral, etc.)  The roles of the communicators (teacher/student, boss/employee, etc.)  The nature of the truth involved (personal matters: sex, finances, secret ambitions, etc.) All 3 are connected with the obligation of confidentiality and the right of privacy

Special contexts that affect reasonable expectation:  business  advertising  law (self-incrimination)  volunteering information  being asked

In medical contexts we have a right to the truth from others, or conversely, an obligation to provide it to them, regarding the:  information in informed consent  information paid for by patients  information needed for important nonmedical decisions

Like what important nonmedical decisions? Like the right of patients to know that they are dying, which is important for settling…  financial affairs  personal affairs  making peace with God  settling disputes with family, friends, enemies  simply saying goodbye

The Placebo Problem: Placebos involve medical deception. Can they ever be used outside of research? (if you consent to participate in a research study knowing you may not be treated with active pharmacological agents, the deception is trivial)

Garrett discusses all the ways placebos can be used to good effect. Then says this: If the physician says “I am going to prescribe something that often helps in these cases and has no bad side effects,”  it is hard to see how he is deceiving the patient.  Certainly he is not lying.  In such a presentation, the patient knows what she or he needs to know in order to give informed consent.  No untruth is spoken, and  no information to which the patient has a right is suppressed Does this sound right to you?! (note my italics) What holiday would this need to fall on?

Vaughn discusses consequentialist and non- consequentialist justifications for valuing confidentiality. Consequentialist reasons: confidentiality is necessary to protect …  Physician/patient trust  Patient’s access to insurance  Patient’s relationships (familial and other)  Patient’s public stature

Non-consequentialist reasons:  You have a simple right to privacy based on the good of self-determination … and self- determination is limited when you cannot control the distribution of personal information.  Also, if a physician has promised (perhaps implicitly) not to divulge information about you, the promise is ethically binding.

“Confidentiality is concerned with keeping secrets.” Garrett -p117 “A secret is knowledge that a person has a right or obligation to conceal.” Garrett again, –p117 -note that that isn’t true. A secret is simply knowledge intentionally concealed There are: 1. Natural secrets 2. Promised secrets 3. Professional secrets

1. Natural secrets: Secrets whose revelation would cause harm by nature: Letting others know what you know about someone’s  binger  social disease  Infidelity  foot odor problem  bad grade

2. Promised secrets: “… knowledge we have promised to conceal.” - p118 “The special evil of revealing promised secrets arises from the harmful effects of breaking promises.” –p118 -note that that is false for Kantians, deontologists generally (again with consequences … sheesh!)

3. Professional secrets: “…knowledge that, if revealed, will harm not only the professional’s client, but will do serious harm to the profession and to the society that depends on the profession for important services.”

3. Professional secrets (cont.): Exceptions:  Medical consultation (to figure out how to treat)  State law (gun and knife wounds need reporting)  Court decisions (similar logic to law, different standard)  Unusual relationships (if doctor’s role is to determine health status for company, army, etc.)  Proportionality (good of revelation outweighs bad of divulging a confidence)

3. Professional secrets (cont.): Exceptions (cont.):  Family (law has changed to exclude immediate family from doctor-patient confidence … family is not considered the patient as it once was)  Children and adolescents (teen pregnancy, social disease, drug use, etc.; states forbid to varying extents physicians sharing such information with parents)  Media publicity for celebrities and politicians  Third party payers (insurance companies need to know medical information)  Public good (AIDS and HIV information)  HIV-positive provider (must disclose information to patient?)

Read about the Tarasoff case and “A Duty to Warn” in Vaughn, p Read “Applying Major Theories” on p. 110.

Vaughn, L. (2010). Bioethics Garrett, T. M., Baillie, H. W., Garrett, R. M. (2001). Health Care Ethics (4 th Edition)