The doctor's use of deception in appropriate circumstances has commonly been considered a necessity of the medical art. Resistance to full and frank communication is typical of many traditionally Catholic countries, and particularly of Italy, a western country where Catholicism remains particularly influential. The Catholic teaching on truth and lies, and the problem of telling the truth to a severely ill patient is discussed. It is suggested that the contemporary Catholic model of gradually telling a terminal patient the truth, which looks reasonable and feasible in theory, is rarely followed in practice, as in the majority of cases the truth is not told tout court. Problems stem from the way in which medicine is currently practiced in Italy; from the synergism between Catholicism and the medical tradition's grounded paternalism; and from the ambiguity of the term 'hope'. Catholic ethics in fact recommends that the truth must be told without destroying hope, but the Catholic meaning of 'hope' is very different from its meaning in current language.

This paper explores the implications for palliative care practitioners of the pre-eminence of autonomy as an ethical principle in contemporary health care ethics. It is suggested that some of the consequences of respecting patient autonomy might be unacceptable to carers, particularly when they feel their own autonomy might be compromised or their ethical values threatened.

When faced with a request for euthanasia, carers should not immediately assume that this has been generated by a failure of care. It is possible to distinguish between those patients who can be helped to want to live again and those who cannot. Within the second group there will be individuals who choose euthanasia not because of psychological problems but because they consider it a rational choice, given who they are and how they have lived their lives. In dealing with such patients, carers must respect their decision, even when they are unable or unwilling to accede to it. Such respect is only possible in a context where people feel free to discuss and explore the possibility of euthanasia. If the institutional philosophy prevents this, a harm is done to those who believe that there is nothing wrong with euthanasia in principle, and that, in fact, it is right for them in practice.

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