French anthropologist Sylvie Fainzang examined how lying is used in the doctor-patient relationship in a landmark book. She highlights the contradictions at a time when the medical community promotes increased patient autonomy.
A survey conducted by the market research firm YouGov found that one-third of Germans lied to their doctors in 2018. These falsehoods range from harmless, such as hiding the fact that they don’t eat five fruits and vegetables per day, to more problematic, for example not saying that they didn’t follow their treatment properly. These lies and omissions reflect a fear of being judged by the moral authority embodied by physicians.
When it comes to untruths and euphemisms, doctors use their fair share, sometimes hiding the seriousness of an illness from their patients. This practice dates back to ancient times when doctors believed in “therapeutic lying”, a balm that patient autonomy and new codes of ethics seemingly removed from pharmacopoeia over the course of the 20th century. This deception and withholding of truth have concrete effects on medical practice. Author of La relation médecins-malades: information et mensonge(The doctor-patient relationship: information and lies), an in-depth probe into the subject published by Éditions PUF (2006), French anthropologist Sylvie Fainzang looks at these increasingly topical issues amid the truths and untruths currently floating around online.
It is in no way essential but has been an underlying element in building the whole doctor-patient relationship. To extend the metaphor, we can refer to lies in terms of a prescription. Some doctors think it’s necessary to lie, adapting the dose to each patient. You can also talk about side effects, even adverse ones. Patients can be in situations where they are not necessarily aware of how serious their condition is because it is hidden from them, or they won’t trust the doctor and get the information they want elsewhere.
That’s a complex question. Some psychologists believe that being informed of the seriousness of their condition can discourage patients and be harmful to their health. But what I’ve observed is that not knowing the truth often has a negative effect. I’ve attended many consultations during which patients absolutely could not understand why they were being encouraged to get back into chemotherapy quickly, while at the same time being told everything was fine. Sometimes the discussion would last a very long time. The patient would try to better understand what was happening until, after 45 minutes of talking about it, the doctor, frazzled, would end up bluntly spouting out that the cancer had metastasised. And that would get the patient to agree to go back into treatment. That shows how not providing necessary information can prevent patients from making the right decisions.
I consider it lying from the moment the speaker considers that the truth is not being told.
It’s worth noting that there is a whole literature on this issue, produced by doctors themselves: essays, reports, experiences, etc. Everyone takes their own stance on the subject, and they talk to one another about it a lot. But it’s as if, when you’re not a doctor, you’re not allowed to use the term. There’s something iconoclastic about saying that doctors lie when you’re not a doctor yourself.
There are doctors who don’t want to harm the patient. This is lying out of kindness. Others lie because they feel the patient can’t understand the information about their condition. Still others do it because they think the patient can’t handle the truth. However, those who argue in favour of telling the truth believe it’s useful. They think that telling the truth is necessary to get the patient to agree to care, i.e. to defend a position of principle: the patient’s right to information that concerns him or her.
No, I think that a lot of doctors who try to be comforting in the way they talk to patients and soften the truth a bit don’t realise that they’re lying or hiding the truth, especially with patients from certain social backgrounds.
Yes actually, a lot of doctors feel that patients can’t understand or hear information, which they attribute to their cognitive or psychological abilities. In fact, you realise that there is a judgement against people from working class backgrounds. Doctors aren’t necessarily aware that it’s happening. I remember a consultation where a doctor gave full information to a company executive who exuded poise and confidence, but he had no desire to know all the details about his illness. I’ve seen the opposite happen too – people from lower-income backgrounds who wanted as much as information as possible, but it wasn’t given to them. There is not necessarily any correlation between social background and the patient’s ability to receive information about their problem.
You can also see it in more innocuous situations, such as when a doctor wants to convince a patient to take medicine by saying that it has no adverse side effects. But it’s true that the issue is more crucial in cases of serious diseases. In my research, I’ve noted that the word “cancer” is now used easily, as is “cancerous tumour”. However, the taboo has shifted to the word “metastasis”. Many doctors avoid using it, for fear of overly worrying the patient. In these cases, it’s the seriousness that is hidden, not the disease itself.
It’s as if revealing a diagnosis meant sealing one’s fate.
Often, patients don’t want to tell their doctor that they didn’t take their treatment or that they didn’t follow medical recommendations, fearing that they’ll be judged. There is also a striking sociological aspect to it. People from poorer population groups tend to act more like children with their doctor, as if they’re children lying to their parents because they’re afraid of being scolded. They’d rather pretend that they took their medicine as they should, even if it’s not true, than admit to not complying with their treatment. That can cause all kinds of problems. They doctor might decide to change the treatment, believing that it’s ineffective. But the patient can also experience serious adverse effects without talking to their practitioner about it.
Sure, in that doing so goes against the values of “democracy in healthcare”, i.e. patient autonomy and accountability. But doctors get caught between conflicting guidance.
On one side, the law says they should provide patients with complete information, while on the other, the code of medical ethics allows them to hide certain things from patients if they believe it is justified, even if that means treating the patient like a child.
Similarly, patients have to manoeuvre between expectations to act like an autonomous, responsible individual, and a fear of the doctor, who remains an authority figure. The doctor-patient relationship is undergoing deep change, and these contradictions reflect that rift.
Some doctors accept it without a problem, as they realise it’s now part of our society. But others, unfortunately many of them, ridicule or mock the patient, “Ah! You’ve gone to see Dr Google.” That ends up encouraging patients to start hiding things, preventing the doctor from invalidating false information. It would be more useful to explain that bona fide medical websites exist alongside less credible forums and blogs.
Sylvie Fainzang is a French anthropologist and research director at the French Institute of Health and Medical Research in Paris. Her current work focuses on issues relating to self-medicalisation and demedicalisation. She is also editor of the journal Anthropologie & Santé.