Mapping the Moral Terrain of Clinical Deception

Abstract

Legal precedent, professional‐society statements, and even many medical ethicists agree that some situations may call for a clinician to engage in an act of lying or nonlying deception of a patient or patient's family member. Still, the moral terrain of clinical deception is largely uncharted, and when it comes to practical guidance for clinicians, many might think that ethicists offer nothing more than the rule never to deceive. This guidance is insufficient to meet the real‐world demands of clinical practice, and this article endeavors to articulate a framework to help clinicians better navigate the ethics of clinical deceit. The framework articulates four morally relevant dimensions of a potential deceptive act that should be examined to better determine the moral justification that might be required: the target of the act, the nature of the information, the nature of the act, and the context of the act.

Justifying Clinical Deception: Some Amendments to Brummett and Salter

“…Further, despite the sophistication, they make some vexing conceptual moves. First, their characterization of deception aligns with Sissela Bok's seminal work 6 in that the deceiver must intend to motivate others to accept the truth of a proposition that the deceiver believes to be false 7 . This distinguishes deception from other types of false communication, for example, when one intends to speak the truth but is unknowingly mistaken or when one is merely joking or participating in a game where misdirection is assumed.…”

“…Abram Brummett and Erica Salter adopt this moral sensibility in their excellent article in this issue of the Hastings Center Report . Relying on a principlist rather than a virtue‐based model of moral reasoning, they embrace that lying is sometimes the better moral course—even for the health care professional: “[I]n the real world of clinical practice, some situations may call for a clinician to engage in acts of lying or nonlying deception.” 5 But, of course, those acts should be the exception. Professionalism in clinical practice demands that health care practitioners strive for honest partnerships with patients and other decision‐makers; valid informed consent, a foundational component of ethical health care practice, is predicated upon honest communication.…”

The Problem of Clinical Deception and Why We Cannot Begin in the Middle

“…The authors are certainly to be lauded for the precision and lucidity of their argument, as well as the clarity with which they state the aims of it. For example, they inform their readers that their framework, while useful for clinicians who must navigate the extraordinarily difficult terrain of truth telling and deception, “provides a relative answer to the question, how strong must a justification be for this act of deception?” and that they “use examples throughout the presentation of the framework only to illustrate how a particular feature of a case is ethically relevant to the required justification.” 2 On this front, I think they succeed.…”

“…In Brummett and Salter's own words, they “endeavor to more accurately and comprehensively identify the ethically important features of possible acts of clinical deception.” 12 But it seems that they also intend their framework to do more than this. “Many clinicians,” they observe, “have found the categorical rejection of deception to be poorly suited to the complexities of medical care.” 13 By presenting their framework as an alternative to the categorical rejection of deception, they suggest that justifying an act of clinical deception can be accomplished by weighing the strength of the justification against the sum of other relevant factors, including the target of the act and the nature of the information.…”

Deception, Pain, and Placebo: Applying the Brummett‐Salter Deception Framework

“…However, we were considering withholding information about a treatment itself. This calls up the justificatory categories outlined in Brummett and Salter's article in table 1, where increased “likelihood and magnitude of good provided or harm avoided” correspondingly strengthen the ethical justification for deception 5 . But predicting likelihood and magnitude also is epistemically fraught, and, just as with diagnostic information, clinicians’ confidence in the effectiveness of an intervention may also increase or lessen the justificatory burden.…”