Respecting the cancer patient's right to know

- Jong-sik Reem, Ph.D.
Lecturer, Seoul National University, Seoul, South Korea
Email: jsreem98@chollian.net
Eubios Journal of Asian and International Bioethics 9 (1999), 117-119.


Although it is reasonably clear that there is a moral obligation to be truthful to others, it is not yet clear whether medical practitioners are bound to the same requirement when it comes to the relationship with their patients. Are paternalistically motivated lies and deception always wrong? Some try to answer the question by indicating a moral difference between lying and intentional deception. Jennifer Jackson, for example, maintains that doctors and nurses, even if they have a duty not to tell a lie, are not obliged to refrain from intentional deception. In this paper, I will attempt to show that Jackson's way of discriminating intentional deception against lying is unacceptable and that intentional deception and lying are morally on par. Then, I will consider the reason why physicians should not intentionally deceive patients and why they should respect the patients' right to act upon his own will.

There has been some consensus on the question of whether lying is morally worse than all forms of deceptions. Then what is the principal difference between lying and intentional deception? According to Jackson, the difference lies in whether the agent aims to mislead others. She defines deception and intentional deception as follows: "A deceives B if and only if A causes B to be misled"; whereas, "A intentionally deceives B if and only if A aims to mislead B: that is, if A acts as he does in order to mislead B." (1).

Jackson discriminates intentional deception against lying by the following definition of lying: "A lies to B if and only if A, in order to mislead B, informs B that something is the case although A believes that it is not the case." Even though the one who intentional deceives and the liar act as they do in order to mislead others, it is not required for the former, unlike for the latter, to believe that what he or she imparts to others is false. One intentionally deceives others if and only if one acts, as he or she does, in order to mislead them. Accordingly, "[w]hereas all liars intend to deceive not all who intentionally deceive tell lies": "Suppose, for example, that B thinks that A is going to lie to him and suppose that A is aware of B's suspicion. A might proceed to tell B the truth in order to mislead B who will take what A says to be false. In this case, A is not lying to B though plainly he is intentionally deceiving him."(2)."

Jackson tries to defend her thesis by appealing to a consequentialist calculation. That is, she defends a rule against lying by appealing to the necessity for a community to preserve trust: without this rule, fellowship as a community is not possible. But, according to Jackson, the same reason does not apply to a rule against intentionally deceiving. She illustrates her thesis by appealing to following examples, "(we) all intentionally deceive one another daily without a second thought. Women wear make-up, men cover their incipient balding with strategic combings, we smile at each other's feeble witticisms even thought we are not amused and we feign delight over gifts which fail to please." (3). If these are merely the cases of intentional deception, it might be said that in many cases intentional deception is morally better than lying; that is, in many cases intentional deception does not pose a significant threat to trust. Thus, it might be said, as she concludes, that "while doctors generally speaking should have no truck with lying, deliberate [intentional] deception need not in general pose a significant threat to trust."(4). However, my first question is: Could the examples presented by Jackson provide support for her thesis? A closer look at the structure of those examples seems reveal that it does not; for, it is unclear, in Jackson's context, whether those examples are the ones in which we intentionally deceive others. When we feign delight over gifts which fail to please, we do so in order to mislead others with the belief that what we impart to others is false. The other cases correspond accordingly. Thus, it seems that those cases satisfy Jackson's criterion for lying. If, as Jackson observes, those cases are not the ones posing a threat to trust, then it seems to me that those examples do not suggest that we are not obliged to refrain from intentional deception. Rather, what they suggest seem to be that our duty not to tell a lie is restricted within the cases of bringing about bad effects.

More fundamental question is why lying, unlike intentional deception, poses a threat to trust and thus threatens the community? As stated, according to Jackson, even if it is not the case that all who intentionally deceive tell lies, all liars intentionally deceive others. If one deceived others intentionally, he intentionally misled them (5). Thus, all liars intentionally mislead others. That is, according to Jackson's account, what makes intentional deception morally different from lying is not whether the agent intentionally misleads others but whether the agent misleads others with the belief that what he or she imparts to others is false.

Now we can raise a question. Does misleading others with the belief that what one imparts to others is false, unlike misleading others without that belief, undermine trust? It seems that it is not. Reflection on the following cases illustrates why not. Suppose that a life-sentenced criminal gets admitted to a hospital for the treatment of a sequela of an attempted suicide. Then, the state of his mind changes and he displays a strong will to live. Unfortunately, he is diagnosed with cancer. His doctor knows that his chance of survival is about 25%. The doctor - who thought that giving such a patient a medical treatment is a waste of money and energy - realizes that the patient suspects that his doctor is going to play down the gravity of the situation to spare his anguish. So the doctor decides to tell him the seriousness of his diagnosis to disturb him psychologically, thus making him to commit suicide again. Suppose again, as in the above case, a life-sentenced criminal, after getting admitted to a hospital for the treatment of a sequela of an attempted suicide, shows a strong will to live but is diagnosed with cancer. His chance of survival is 25%. His doctor - who thought that everyone has a right to act upon one's own will - sees that the patient is suspicions that his doctor may play down the seriousness of his diagnosis to spare him anguish. Recognizing the situation, the doctor tells his patient that his chance of survival is 50%, aimed to making him act upon his own will.

The first case is the one in which the agent acts as he does in order to mislead others without the belief that what he imparts to them is false. The second case is the one in which the agent acts as he does with the belief that what he imparts to others is false but acts without aiming to mislead them. If it is not the case that the doctor in the first case does not undermine trust whereas the doctor in the second case does, then Jackson's thesis will not do. That is, it cannot be said that what makes intentional deception morally different from lying is whether the agent mislead others with the belief that what he imparts to others is false. However, at first glance, it is baffling to say that the doctor in the first case does not undermine trust whereas the doctor in the second case does.

The comparison of the doctor in the two above cases - with the doctor in Jackson's example of the doctor using the patient's suspicions to persuade him to adopt a healthier diet - clearly shows a problem in Jackson's way of discriminating intentional deception from lying clearly: "I am alarmed by my symptoms and suspect as I relate them to my doctor that he is going to play down their gravity to spare me anguish. My doctor, realizing my suspicions, decides to take advantage of it to persuade me into adopting a healthier diet. Thus he proceeds truthfully to make light of my symptoms but he is at the same time intentionally deceiving me." (6) If, as Jackson observes, the question is whether or not the agent does as he does with the belief that what he imparts to others is false, then it should at least be the case that the doctor in the first case is not morally different from the doctor in Jackson's example, and that the doctor in Jackson's example is morally better than the doctor in the second case. Clearly there is a moral difference between the doctor in Jackson's example and the doctor in the first case. Furthermore, it is not at all clear whether the doctor in the second case is morally worse than the doctor in Jackson's example. It seems that the comparison of the two above cases with Jackson's example suggests that the heart of the question is whether the agent intentionally misleads others (or whether or not the agent intends the good effect).

A similar argument could be adopted in support of the view that the question here is whether or not the agent intentionally misleads others. According to Jackson's account, lying, unlike intentional deception, does not require that the agent succeed in causing others to be misled. Even if one lies to others, unlike the case in which one deceives others intentionally, others may not be misled. Then why should we assume that everyone has a duty to not tell lies, but do not have a duty to not deceive intentionally? To say that lying undermines trust is to say that lying undermine the trust even in the case in which the agent fails to cause others to be misled. It seems implausible to think that the question here is if whether or not the agent believes what he imparts to others is false.

Considering Jackson's example will urge one to adopt such a view. "B thinks that A is going to lie to him and suppose that A is aware of B's suspicion. A might proceed to tell B the truth in order to mislead B who will take what A says to be false. In this case, A is not lying to B though plainly he is intentionally deceiving him." Lets change Jackson's example slightly to make the point clearer. Suppose that P is going to lie to Q and suppose that P wrongly suspects that Q is aware of his plan. So even if Q in fact does not know that P is going to lie to Q, P proceed to tell Q the truth in order to mislead Q who, P thinks, will take what P says to be false. P in this case, like A in Jackson's example, is not lying. However, unlike in Jackson's example, P is not deceiving Q intentionally, for P failed to cause Q to be misled. We can raise the question again: Is P in the modified case morally different from A in Jackson's example? Even if P neither deceived nor intentionally deceived Q, it is hard to say so. Now suppose again that X is going to lie to Y. X is convinced that Y is not aware of it and thus X proceeds as planned. If the question is whether the agent believes what he imparts is false, then there must be a difference between P in the revised case and X in this case, but our intuition goes against saying that P is morally better than X. Thus, it seems more plausible to think that the heart of the question is neither whether the agent believes what he imparts to others is false nor whether the agent fails to cause others to be misled, but whether the agent intentionally misleads others.

My discussion thus far suggests that there is a moral relevance in regarding intentional deception in the same light with lying. According to Jackson, lying threatens a community by undermining trust. But why does lying undermine trust? According to Jackson, all liars intend to deceive, while one deceives others intentionally if he intentionally misleads them (7). Thus, it can be said that the liar also intentionally misleads others. Thus, in Jackson's account, we can think of two answers to the question of lying undermining trust. First, the liar believes what he imparts to others is false. Second, the liar intentionally misleads others. But, as we saw, what makes intentional deception morally different from lying is not whether the agent mislead others with the belief that what he imparts to others is false but whether the agent intentionally misleads others. And thus we saw that what matters in determining whether lying undermines trust is not the former but the latter. This explains why lying is morally wrong, and thus, why intentional deception is not morally different from lying.

Now what we need to know is why it is morally wrong to deceive others intentionally, that is, why it is morally wrong to mislead others intentionally. Support for the moral duty not to deceive intentionally might be claimed in the belief that we should respect others' natural rights. Traditionally, the proponents of natural-law theories have believed that human beings have natural rights, simply by the virtue of the fact that they are human beings; such as, the right not to be interfered with, the right not to be misled by others, or the right to act upon their own will. If each person has the right not to be misled by others, then each person also has the corresponding duty not to mislead others, or the duty not to make others act against their will. Without this corresponding duty, each person cannot exercise his or her corresponding right.

I am partial to taking this view because there is a distinction between a negative duty and positive duty with the general priority of the former over the latter. When this is applied to the physician-patient relationship, patient's negative right, the right not to be interfered with (the right not to be misled or the right to act upon one's own will) conflicts with doctor's positive right, the right to benefit the patient with the priority of the former over the latter. And thus doctor's negative duty (the duty not to interfere with the patient) comes prior to his or her positive duty (the duty to help his or her patient). Furthermore negative right, that is, the right not to be interfered with comes prior to positive right, that is, the right to be benefited.

In my view, positive right, and their corresponding positive duties, generally spring from the agreements of a particular group, the customs of a particular society, and the laws of a particular state (8). For example, as long as one is elaborate, one has a right to exercise one's franchise. On the other hand, I believe that negative rights, and their corresponding duties, do not exist by convention, and thus cannot be localized to a particular group, society and state. Furthermore, negative right and duties do exist regardless of the consequences of keeping them. Even if positive rights and duties might outweigh negative rights and duties, negative rights and duties exist in many cases in which they conflict with positive rights and duties.

I share the feeling that human beings have the natural right to be not misled. As stated, according to Jackson's account, both the one who intentionally deceive and the liar act as they do in order to mislead others. And thus they both violate others' negative right not to be misled or to act upon their own will, the right they have simply by virtue of the fact that they are human beings. This supports the rationale for prohibiting intentional deception, for regarding intentional deception in the same light with lying. It also support the rationale that everyone has a moral duty not to intentionally deceive others and that medical practitioners are bound to the same requirement when it comes to their relationship with their patients.

References
1. Jennifer Jackson, "Telling the Truth," J. Medical Ethics 17 (1991): p. 6.
2. Jackson., p. 6. Sissela Bok offers the view that the difference between intentional deception and lying hinges on the question whether or not deceptive message is stated: "I shall define as a lie any intentionally deceptive message which is stated" (Sissela Bok, Lying Moral Choice in Public and Private Life (Vintage Books Edition, 1989) New York: A Division of Random House, Inc.: p.13). However, Jackson's example shows that this way of differentiating lying from intentional deception is unacceptable.
3. Jackson, p. 7.
4. Jackson, p. 9.
5. Remember that, according to Jackson, "A deceives B if and only if A causes B to be misled"; whereas, "A intentionally deceives B if and only if A acts as he does in order to mislead B."
6. Jackson., p. 6.
7. Remember that, according to Jackson, "A deceives B if and only if A causes B to be misled"; whereas, "A intentionally deceives B if and only if A acts as he does in order to mislead B."
8. This does not mean that all positive rights and corresponding duties are conventional. For example, John Locke seems to recognize a natural right to welfare.


Short Comment on Jong-sik Reem's Paper
Masahiro Morioka
Jong-sik Reem concludes that intentional deception and lying are morally on par, contrary to Jennifer Jackson' s position. I agree with Reem that there is no significant difference between these two concepts in terms of bioethics. Even if there is a difference it would be a very small one. In clinical settings the heart of this discussion lies in whether the disclosure of information on the patient's body is the point of our discussion or not. In the case of the patient's body, the information should be basically revealed to the patient because the right to have information belongs to the patient, not the doctor. In this case both lying and intentional deception should be considered as morally wrong. On the other hand, if the disclosure of information on the doctor is the point, we do not have to think about this seriously because it is under the doctor's free will whether to speak the information about his/her body or privacy. Jackson's example about intentional deception falls upon the latter case, hence, we do not have to take account of her discussion on this point so seriously.
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