Physician and patient

On the question, whether strict veracity should be adhered to, in every case and under all circumstances, in our intercourse with the sick, there is very great difference of opinion, as well among medical men, as in the community at large. Some are most scrupulously strict in their regard to truth; others, while they are generally so, make some few occasional exceptions in cases of great emergency and necessity; while others still (and I regret to say that they are very numerous) give themselves great latitude in their practice, if they do not in their avowed opinions.

In examining this subject, it is not so much my intention to discuss the abstract question, as to present the many practical considerations that present themselves, illustrating them, so far as is necessary, by facts and cases.

In order to introduce the subject, I will here quote a passage from Percival’s Medical Ethics, which presents the views of those who are in favor of an occasional departure from truth, where the necessity of the case seems to demand it.

“Every practitioner must find himself occasionally in circumstances of very delicate embarrassment, with respect to the contending obligations of veracity and professional duty; and when such trials occur, it will behoove him to act on fixed principles of rectitude, derived from previous information and serious reflection. Perhaps the following brief considerations, by which I have conscientiously endeavored to govern my own conduct, may afford some aid to his decision. Moral truth, in a professional view, has two references; one to the party to whom it is delivered, and another to the individual by whom it is uttered. In the first it is a relative duty, constituting a branch of justice, and may properly be regulated by the divine rule of equity prescribed by our Saviour, to do unto others as we would, all circumstances duly weighed, they should do unto us. In the second it is a relative duty, regarding solely the sincerity, the purity and the probity of the physician himself. To a patient, therefore, perhaps the father of a numerous family, or one whose life is of the highest importance to the community, who makes inquiries, which, if faithfully answered, might prove fatal to him, it would be a gross and unfeeling wrong to reveal the truth. His right to it is suspended, and even annihilated; because its beneficial nature being reversed, it would be deeply injurious to himself, to his family, and to the public. And he has the strongest claim, from the trust reposed in his physician, as well as from the common principle of humanity, to be guarded against whatever would be detrimental to him. In such a situation, therefore, the only point at issue is, whether the practitioner shall sacrifice that delicate sense of veracity, which is so ornamental to, and indeed forms a characteristic excellence of the virtuous man, to this claim of professional justice and social duty. Under such a painful conflict of obligations, a wise and good man must be governed by those which are the most imperious, and will, therefore, generously relinquish any consideration referable only to himself. Let him be careful, however, not to do this but in cases of real emergency, which, happily, seldom occur, and to guard his mind sedulously against the injury it may sustain by such violations of the native love of truth. I shall conclude this long note with the two following very interesting biographical facts. The husband of the celebrated Arria, Cæcinna Pactus, was very dangerously ill. Her son was also sick at the same time, and died. He was a youth of uncommon accomplishments, and fondly beloved by his parents. Arria prepared and conducted his funeral, in such a manner, that her husband remained entirely ignorant of the mournful event which occasioned that solemnity. Pactus often inquired with anxiety about his son, to whom she cheerfully replied, that he had slept well, and was better. But if her tears, too long restrained, were bursting forth, she instantly retired, to give vent to her grief, and when again composed, returned to Pactus with dry eyes and a placid countenance, quitting, as it were, all the tender feelings of the mother at the threshold of her husband’s chamber. Lady Russell’s only son, Wriothesley, Duke of Bedford, died of the small-pox, in May, 1711, in the 31st year of his age. To this affliction succeeded, in November, 1711, the loss of her daughter, the Duchess of Rutland. Lady Russell, after seeing her in the coffin, went to her other daughter, married to the Duke of Devonshire, from whom it was necessary to conceal her grief, she being at that time in childbed likewise; therefore she assumed a cheerful air, and, with astonishing resolution, agreeable to truth, answered her anxious daughter’s inquiries with these words, ‘I have seen your sister out of bed to-day.’”

The falsehood in the two cases related by the author is of the most egregious character, and yet they are fair representations of that kind of deception which many feel authorized to use in the sick room. The equivocation which is practised, it is true, is not always as gross and as labored, but it is as real. And whatever be the degree or kind of deception, the same principles will apply to every case.

The question that presents itself is not, let it be understood, whether the truth shall in any case be withheld, but whether, in doing this, real falsehood is justifiable, in any form, whether direct or indirect, whether palpable or in the shape of equivocation.

And we may also remark, that the question is not, whether those who practice deception upon the sick are guilty of a criminal act. This depends altogether on the motive which prompts it, and it is certainly often done from the best and kindest motives. The question is stripped of all considerations of this nature, and comes before us as a simple practical question—whether there are any cases in which, for the sake of benefitting our fellow men, perhaps even to the saving of life, it is proper to make an exception to the great general law of truth.

The considerations which will bring us to a clear and undoubted decision of this question, are not all to be drawn from the preciousness of the principle of truth, as an unbroken, invariable, and ever-present principle, the soul of all order, and confidence, and happiness, in the wide universe. But the principle of expediency also furnishes us with some considerations that are valuable in confirming our decision, if not in leading us to it. In truth, expediency and right always correspond, and would be seen to do so, if we could always see the end from the beginning.

I will remark upon each of the considerations as I present them.

First. It is erroneously assumed by those who advocate deception, that the knowledge to be concealed from the patient would, if communicated, be essentially injurious to him. Puffendorf remarks in relation to this point, that “when a man is desirous, and it is his duty, to do a piece of service, he is not bound to take measures that will certainly render his attempts unsuccessful.” The certainty of the result, thus taken for granted, is far from being warranted by facts. Even in some cases where there was a strong probability (and this is all we can have in any case) that the effect would be hurtful, it has been found not to be so. I might here narrate some cases to prove the truth of this assertion, but it is not necessary. Suffice it to say, that it is confirmed by the experience of every physician who has pursued a frank and candid course in his intercourse with the sick.

Secondly. It is also erroneously assumed that concealment can always or generally be effectually carried out. There are so many ways by which the truth can be betrayed, even where concerted plans are laid, guarded at every point, that failure is much more common than success, so far as my observation has extended. Some unguarded expression or act, even on the part of those who are practising the concealment, or some information communicated by those who are not in the secret, perhaps by children, or some evidence casually seen, very often either reveals the truth, or awakens suspicion and prompts inquiry which the most skilful equivocation may not be able to elude. The very air that is assumed in carrying on the deception often defeats the object. In one instance where this was the case, the suspecting patient said very significantly, ‘How strangely you all seem—you act as if something dreadful had happened that you mean to keep from me.’ Even the little child often exhibits a most correct discrimination in detecting deception in the manner, the modes of expression, and even the very tone of the voice. And sometimes, nay very often, people so far undervalue the good sense and shrewdness of children, that their deception is even ridiculously bungling, and justly excites an honest indignation in the bosom of the deceived child.

I give the following scene as an illustration of the above remark.

‘Come, take this,’ said a mother to her child, ‘it’s something good.’

The child was evidently a little suspicious that he was not dealt with candidly; but after a great many assurances from her on whom a child ought to be able to rely, if upon any body in the wide world, he was at length persuaded to take the spoon into his mouth. The medicine, which was really very bitter, was at once spit out, and the little fellow burst forth in reproaches upon his mother for telling him such a lie.

‘No, my dear,’ said she, ‘I have told you no lie. The medicine is good—it is good to cure you. That is what I meant.’

‘Good to cure me!’ cried he, with a look and an air of the most perfect contempt. ‘You cheated me. You know you did.’

The contempt which this child manifested towards such barefaced equivocation was most justly merited, and yet this is a fair example of the deceptions which physicians are almost every day obliged to witness, and which, (may I not say?) some of them encourage both by precept and example.

Thirdly. If the deception be discovered or suspected, the effect upon the patient is much worse than a frank and full statement of the truth can produce. If disagreeable news, for example, be concealed from him, there is very great danger that it will in some way be revealed to him so abruptly and unexpectedly, as to give him a severe shock, which can for the most part be avoided when the communication is made voluntarily. And then, too, the very fact that the truth has been withheld, increases, for obvious reasons, this shock. I will relate a case as an example. It occurred during the prevalence of an epidemic. A lady was taken sick and died. The fact of her death was studiously concealed from another lady of her acquaintance, who was liable to be attacked by the same disease. She was supposed by her to be doing well, until one day a child from a neighboring family accidentally alluded to the death of her friend in her presence. The shock which the sad news thus communicated produced upon her was almost overwhelming, and it was of course rendered more intense by the reflection, that her friends thought her to be exceedingly in danger of dying of the prevailing disease, and therefore had practised this concealment in order to quiet her apprehensions. She soon followed her friend, and it is not an improbable supposition, that the strong impression thus made upon her mind had some agency in causing her death.

In another case of a similar character, the first intimation which a lady had of the death of a friend was from seeing the husband of this friend pass in the street with a badge of mourning. She was immediately prostrated upon her bed, and was a long time in recovering from the shock.

In both of these cases the concealment of the truth was prompted by the best of motives—pure kindness; and yet nothing is more plain than that it was a mistaken kindness. Whatever may be true in other instances, the result showed this to be the fact in these two cases. And if it be true, as I think all experience will prove, that success, and not failure, in the attempt at concealment, is the exception to the general fact, it clearly follows that deception is impolitic as a measure of kindness, and therefore, aside from any other consideration, it should be wholly discarded in our intercourse with the sick.

I have a case in mind, which exhibits in contrast the influence of frankness and of deception.

A little girl, the daughter of a farmer, had her arm torn to pieces up to the elbow in a threshing machine constructed very much like a picker. As her mother was confined to her bed with severe sickness, the child was carried into the house of a neighbor. When I arrived, I was told that her mother was in great distress, and fears were expressed that the accident would have a very bad influence upon her case. I asked if she knew what had happened. ‘No,’ said her husband, ‘not exactly. She found out by the children that Mary was hurt, and then sent for me, and asked me what was the matter. I told her at first that she had got her finger hurt. She said she knew that was not all, and I at length, after she had begged and begged me to tell all, told her that her hand was hurt badly. And now she is crying most piteously, and says that we are deceiving her, and that she knows that Mary is almost killed.’

I immediately went in to see the mother, and found her indeed almost distracted with the great variety of dread visions that had suggested themselves to her fancy in regard to her darling child. As I entered the room she cried out, ‘Oh, she’s dead, doctor, or dying—torn to pieces—in agony—Oh, isn’t it so? tell me, tell me the truth!’ ‘Be quiet,’ said I, ‘and I will tell you all the truth. I will not deceive you.’ I assured her that she need give herself no anxiety about the life of her child—that was safe. This announcement quieted her in a good measure, and I went on to tell her that the arm was badly torn, and that I must amputate it above the elbow. I told her that this would take but a minute or two, and then the child would be essentially well. It was necessary to go into these particulars in answer to her inquiries, (which were the more minute from the fact that she had been deceived,) or else I should forfeit her confidence, and thus commit the same error that had already been committed. She thanked me for being so frank with her, and said, that though it was hard to think of the operation, she could bear that, if the child’s life was only spared. She grieved still, it is true; but there was none of that overwhelming distraction that results from vague apprehension.

Fourthly. The destruction of confidence, resulting from discovered deception, is productive of injurious consequences to the persons deceived. The moment that you are detected in deceiving the sick, you at once impair or even destroy their confidence in your veracity and frankness. Everything that you do afterward is suspected, and a full and unshrinking trust is not accorded to you even when you deserve it, though you may try to obtain it by the most positive and solemn assurances. If, for example, you wish to encourage a patient, and you tell him that though the bow of hope is dim to his eye, it is bright to your own: ‘Ah!’ he will think, if he does not say, ‘how do I know but that it is as dim to him as it looks to me—he has deceived me once, and perhaps he does now.’

Every physician has seen the injurious influence of deception upon children. Sometimes it is of a most disastrous character, and occasionally, I have not a doubt, it proves fatal. Deception is more frequently practiced upon children than upon adults, and many seem to think that they have not the same right to candor and honesty in our intercourse with them. But a child can appreciate fair and honest treatment as well as an adult can, and he has as good a right to receive it at our hands. He sometimes claims this right in terms, and by acts not to be mistaken. And when it is taken from him, he shows his sense of the wrong by remonstrances and retaliatory language, and by a system of rebellion to an authority which he despises, as well as fears, for its falsehood.

Suppose a mother succeeds in giving a dose of medicine by stratagem, the administration of every dose after it is accompanied with a fearful struggle. The strife which results from the spirit of resistance thus engendered, perhaps in the beginning of a long sickness, and which might in most cases have been avoided by frank and candid treatment, continues through the whole course of the disease to the last hour of life if the case prove fatal, the little creature feebly but obstinately resisting its mother, till the exhaustion of coming death puts an end to its struggles; and, though she plies every art that fondness can devise to win back the lost confidence of her darling child, it is all in vain.

If the reader have any adequate idea of the importance of quietness in the management of the sick, I need not spend time to prove, that this resistance of the sick child has an injurious effect upon the disease, and that in those cases where life has but a feeble trembling hold, where the silver cord is worn down almost to its last thread, such a struggle may break that thread by its violence. I have not a doubt that many a child has died under such circumstances, that might otherwise have recovered.

Let me not be understood to imply that the resistance made by children to the administration of medicine is invariably the result of deception practised upon them, though this is the cause undoubtedly in quite a large proportion of the cases, and those too of the worst and most unconquerable character. And it may be remarked, that in many cases this may be the cause of the difficulty where it is little suspected. For it is so common a habit to deceive children in this matter, that it is often done unconsciously. But though the parent may not remember it, the child does, and the cruel oppressive act (for so it may be properly called) locked up in the memory of the child, wakes up rebellion in his heart that is not easily quelled. Many a parent has thus in a moment, for the sake of a slight temporary advantage, sown the wind to reap the whirlwind.

Deception has very often been made use of in the management of the insane, though recently not to the same extent that it once was. The consideration which I have been illustrating and enforcing lies against the practice of it in our intercourse with this unfortunate class of patients, with the greater force, because in their case the mind is diseased, and any bad mental influence has therefore a worse effect than it would have upon a case of mere bodily disease. The reason is obvious—it acts directly upon the seat of the disease in the former case, but indirectly in the latter.

Besides, let the insane man once see that you have deceived him, and you lose the principal, perhaps we may say the only, moral means that you have for curing his malady. Confidence is essential to any good moral influence that you may exert upon him. I might cite many facts to prove this, but will advert to only one. The wife of an insane man was the only person among all his friends that had any control over him, and she could manage him with perfect ease. After his recovery she asked him the reason of this fact, and his reply was, ‘You was the only one that uniformly told me the truth?

The bad influence of deception upon the insane man is rendered the more certain and effectual from the fact that his insanity incapacitates him for appreciating the kind motives which may have prompted the deception. You cannot convince him as you can the sane sick man, that you have deceived him for his own good. His suspicious eye sees nothing but a sinister purpose in the cheat which you have practised upon him.

One of the most vivid recollections of my childhood is that of a scene which illustrates these remarks. A poor crazy man who wandered about the streets was thought to have become dangerous, and it was proposed to confine him in the common jail. A plan was laid to do it by stratagem. He fancied himself to own some large possessions, and talked much about going to Boston to see his friend the governor, and attend to his business there. A neighbor offered to go with him, and he accepted the offer. As they passed by the jail, his friend proposed to visit it. As they entered one of the cells he adroitly slipped out, and the door was closed upon the insane man. His dream of earthly happiness and wealth was in a moment at an end, and he beheld himself the victim of base treachery in the narrow cell of a prison. Never shall I forget how eloquently he pleaded for his release, how he asked what crime could be charged to his account, how he denounced those who had thus without cause shut him up like a felon, and especially with what sorrowful but burning indignation he spoke of the man, ‘who under the guise of friendship, had decoyed him into this snare of his enemies.’ Though a mere boy, I pitied him. I sympathised with him. I had known him only as a pleasant old man, who used to amuse us as we met him in the streets with stories of his immense wealth and of the splendid plans of building on which he loved to speculate. I felt that it was wrong to confine him among vile criminals, and wondered not that the keen sense of such injury prompted to the utterance of curses on those who inflicted it. But these natural feelings gave way in my bosom, as they did in older ones, to what was then supposed to be the necessity of the case—a necessity which, I rejoice to say, has since that been found not to exist in similar cases. A very great improvement has been effected in this as well as in other respects, in the management of the insane. Most of those whom it was once thought necessary to confine with bolts and bars, and perhaps chains, and upon whom deception was continually and systematically practised, thus adding poignancy to the pangs of the oppressed spirit, are now permitted to have so much liberty, that they are cheerful and happy, reposing entire confidence in their attendants, who are careful never to deceive them. And those whom it is thought necessary to confine, are not doomed to the cheerlessness and disgrace of the cell of the felon, but they are placed in as agreeable circumstances as is consistent with safety. And it has come to be an established rule with those who have the care of the insane, that force is always preferable to deception. But still, erroneous views are very prevalent in the community on this subject. It is common to this day, even among the excellent and well informed, to propose to send their insane friends to a Retreat by stratagem, and this has often been done even by the advice of physicians. So far as I recollect, in all the cases of insanity that have gone to Retreats from under my care, this mode of management has been spoken of by some, and generally by many, as the only proper mode. The public need to be instructed and reformed on this point.

It is a common observation that the insane are apt to look upon their best and most intimate friends as their enemies. Why is this? It is clear, that it is in part to be ascribed to the influence of deception, waking up, as might be expected, feelings of resentment and enmity in the bosom of the insane, which would not otherwise be there. This point I have commented upon in the Chapter on Insanity, and I need not dwell upon it here.

The extent to which deception is practised upon the insane cannot be fully appreciated, except by those whose attention has been specially called to this subject. As I have already remarked in regard to children, so also it is with the insane—deception is so common, that people often make use of it almost unconsciously. The whole course of management on the part of their friends, is often characterized throughout by an absence of candor and veracity.

The tendency of such a course is invariably to increase insanity, making it more intense and obstinate. And not only so, but it modifies to a greater or less degree its character. Deception prompts the insane man to exercise his ingenuity in forming plans to foil and circumvent his deceivers, whom he supposes very naturally to be his enemies. Of course, new feelings and thoughts are thus excited in his bosom, giving in some measure a new cast to his insanity.

I will here relate a case that illustrates these remarks.

The friends of an insane gentleman determined to send him to a Retreat by stratagem. For this purpose, he was induced by one of them to go a journey with him. On, their way, his friend proposed to him to visit an Insane Retreat as a matter of curiosity. When they arrived there, he was given to understand that he was to remain as an inmate. Great was his rage at being so grossly deceived. After the first burst of indignation was passed, he saw that it was of no use to say anything or to make any resistance. He was a shrewd man, and therefore, as a matter of policy, he submitted with apparent cheerfulness to his new situation. He did not forget, as the insane sometimes fortunately do, the wrong which his friends had done him, and as he was decoyed there by stratagem, it is no wonder that he at length made his escape by stratagem also. He came out, as might have been expected, with his insanity more thoroughly fixed than it was when he went in, and he added to it a deep hatred of Retreats, and of course of the man who had betrayed him into one.

Another attempt was made to carry him to the same Retreat, which from mismanagement utterly failed. The insane man was victorious, and he felt himself to be so, over his friends, who he supposed were bent upon cheating and oppressing him. All this not only made him more crazy, but it gave a new shape to his insane ideas. In a conversation which I chanced to have with him, he said to me, ‘It is perfectly evident, doctor, that these Insane Retreats are joint-stock institutions, and the stockholders are chiefly lawyers and doctors and ministers. And it’s good stock too. Just see how much they charge for board—full double at least of the actual expenses. I need not tell you anything about it, however, for you own some of this stock, and you know how profitable it is to you.’

‘Oh no,’ said I, ‘this is all new to me.’ He looked at me as if he would look me through. He had been deceived so much, that he believed, he trusted no one. Although I gave him the most positive assurance that I owned no such stock, still, in spite of the confidence which he ordinarily reposed in me, he showed that he did after all suspect me on this point, so firmly was this notion about Retreats fastened in his mind. He went on to give his reasons for his opinion.

‘I can look back,’ said he, ‘to my very childhood, and see that from that time to the present, there has been a series of efforts on the part of these stockholders to make me a crazy man; and they at length succeeded, and then contrived the mean plan of tricking me into one of their Retreats. The minister that I lived with when I was ten years old began this scheme, and all the ministers and lawyers and doctors, that I have had anything to do with since that time, have had a hand in it—have exerted their influence on me, all in relation to this one object. It’s a regular money-making business. Of course the stockholders all want to see these Retreats well filled up. Just see how they have treated me lately. They have combined to cross my purposes, break up my plans, defeat my projects, ruin my business, and all this to irritate and disappoint me, and thus craze me. And then, to cap the whole, they lied to me and betrayed me into their prison to die a slow death, paying them all the time about twelve dollars a week. Good stock, doctor, but a cruel business,’ said he, with a most unearthly grin, and a shudder that shook his whole frame. ‘But thank heaven,’ cried he, ‘I’ve escaped their clutches. Though they have ruined me, they shall not have their twelve dollars a week out of me. No, I’ll die first. Such systematic, cheating, lying oppression, I’ll resist to the death.’

It is evident that the treatment which this man received at the hands of his friends, tended to aggravate, instead of lessening his insanity. And I may remark, too, that the notion which he derived from this treatment, in relation to Retreats, false as it was, was founded on more plausible reasons as they were presented to his mind, than are some of the opinions that are adopted by some sane men in the community.

Fifthly. The general effect of deception, aside from the individual which it is supposed it will benefit, is injurious. The considerations on which I have already remarked, have had regard entirely to the person that is deceived, and I think that I have shown most clearly, that even taking this narrow view of the influence of deception, it is in almost all cases a bad influence: and therefore as we cannot tell in what cases this influence will be good, it is impolitic, and should be entirely discarded. Let us now go farther, and looking beyond the individuals who are the subjects of the deception, we shall see its influence extending all around from these individuals, as so many radiating points of influence, leavening the whole mass of society with a most poisonous leaven. It is not an influence that can be shut up in the case of any individual, in that one breast, or within that one chamber of sickness.

That confidence, which should always exist in the intercourse of the sick with their physicians and friends, and which may be made the channel of great and essential benefits to them, is materially impaired, often even destroyed by such deception. And this effect is unfortunately not confined to those who practice it, but the imputation rests upon others. The distrust thus produced often exerts a depressing influence in those cases, where the cordial influence of hope is most urgently needed, and where it can be administered in consonance with the most scrupulous veracity. It is well if, under such circumstances, the physician can appeal to the patient’s own experience of his frankness in all his previous intercourse with him.

I call to mind an instance in which I was able to make this appeal with the most marked good effect. The patient was a lady who was in a great state of alarm in regard to the probable result of her sickness. She was indeed very sick, but there was good reason to hope that remedies would relieve her. At the same time I feared that the depressing effect of this state of alarm, if it should continue, would prove a serious obstacle to her recovery. But as I expressed to her the confident hope that she would get well, she said to me, ‘Physicians always talk in this way, and you do not really mean as you say. I shall die, I know that I shall die.’ I had been the physician of the family for many years, during which time they had gone through some trying scenes of sickness. Alluding to all this, I asked her if she could look back and call to mind a single instance in which I had not dealt candidly and frankly with her. She allowed that she could not. ‘Well,’ said I, ‘believe me now; I am in earnest; I do believe, and confidently, too, that you will recover.’ The tears were at once wiped away. Cheerfulness, the cheerfulness of hope, lighted up her countenance and the case went on to a speedy and full recovery.

Every day we see evidence of the fact that so large a proportion of the medical profession practice deception upon the sick, that the profession, as a whole, has to a greater or less degree the imputation fastened upon it. Indeed patients often, as a matter of course, make the distinction between the obligations to professional veracity, and those of the man, as a man, in his ordinary intercourse; and the physician, who has an established reputation for the strictest veracity everywhere else but in the sick chamber, has there the suspicion of deception put upon him; and it is supposed to be no imputation of which he should complain, because deception is allowed here almost by general permission. For this reason, whatever of frankness and honesty there may be in our intercourse with the sick, often fails to produce the effect intended, in part at least if not wholly. And this result follows just in proportion to the extent to which deception is made use of in the profession.

The indirect and collateral effects of deception are often manifest in a family of children. Its influence extends beyond the mind and character of the deceived child. If the other children witness the deception, what hinders them from believing that their parents can deceive them also whenever it suits their convenience? And if they do not witness it, the sick child will remember it when he recovers, and the rebellion which he has, in consequence, in his bosom towards an authority that rules by deceit, and is therefore deemed with good reason oppressive, is of course communicated to the other bosoms of the little flock. Many a parent, who supposed that he was doing nothing that would last beyond the present moment, has thus sown the seeds of rebellion among the little band of subjects, over whom God has placed him; and who can tell what the fruits will be, or to what extent or length of time they will grow!

I need barely say in concluding my remarks on this consideration, that the momentary good which occasionally results to individual cases from deception, is not to be put in comparison, for one moment, with the vast and permanent evils of a general character, that almost uniformly proceed from a breach of the great law of truth. And there is no warrant to be found for shutting our eyes to these general and remote results, in our earnestness to secure a particular and present good, however precious that good may be—a plain principle, and yet how often it is disregarded.

Sixthly. If it be adopted by the community as a common rule, that the truth may be sacrificed in urgent cases, the very object of the deception will be defeated. For why is it that deception succeeds in any case? It is because the patient supposes that all who have intercourse with him deal with him truthfully—that no such common rule has been adopted. There is even now, while the policy on this subject is unsettled and matter of dispute, enough distrust produced to occasion trouble. And if it should become a settled policy under an acknowledged common rule, the result would be general distrust, of course defeating deception at every point. And yet if it be proper to deceive, then most clearly is it proper to proclaim it as an adopted principle of action. Else we are driven to the absurd proposition, that while it is right to practice deception, it is wrong to say to the world that it is right.

It is in vain to say that the evil result which would attend this adoption of occasional deception, as the settled policy of the medical profession, would find a correction in the very terms of the rule which should be adopted, viz. that the case must be an urgent one to warrant deception, and there must be a fair prospect that it can be carried through without discovery. For every patient, that was aware of the adoption of such a rule, might and often probably would suspect that his own case is considered as coming within the terms of the rule.

Seventhly. Once open the door for deception, and you can prescribe for it no definite limits. Every one is to be left to judge for himself. And as present good is the object for which the truth is to be sacrificed, the amount of good, for which it is proper to do it, can not be fixed upon with any exactness. Each one is left to make his own estimate, and the limit is in each one’s private judgment, in each one’s individual case as it arises. And the limit, which is at first perhaps quite narrow, is apt to grow wider, till the deception may get to be of the very worst and most injurious character. I will give a single illustration of this remark, which though not taken from the practice of medicine, is appropriate to my purpose. It has always been allowed in the laws of war, to deceive the enemy by stratagems, false lights, &c. At one time some English ships in two or three instances decoyed the enemy by counterfeiting signals of distress. The deception in this case is productive indirectly of the very worst consequences, for it manifestly tends to prevent relief from being afforded to those, who are actually in a distressed condition. Our feelings of humanity instinctively condemn such a stratagem and yet it is only a mere extension of that deception, which has been by common consent allowed in war. It involves no different principles, and is only more objectionable, because it produces worse indirect results. It differs in degree only and not in kind.

So it is with deception always. Its indirect effects are always bad to some extent, and to what extent they will prove so we know not in each individual case. You can never know at the time how great is the sacrifice which you are making for a present good. While you may be thinking that you are only sacrificing your own veracity, and that the influence of the act will not extend beyond the passing moment, you may be producing disastrous results upon the interests of others, and those results may be both lasting and accumulative. A man who was captured by some Indians, was asked by them if there were any white men in the neighborhood. He told them that there were, and directed them to a spot where he was very certain that there were none. They immediately started in pursuit, leaving him bound and in the charge of one of their number. When they were gone, he contrived to make his escape. Almost every one would say, that this was a strong case, and that they could not blame him for telling a falsehood to Indians, in order to escape from their cruelty. Here was a great good to be obtained, the saving himself from torture, perhaps from death, and deceiving savages for such a purpose, it will be said, is not to be condemned. But mark the result of that deception. Five white men were found on the spot to which he directed them, and were captured.

In order to make out a justification of deception, on the ground of expediency in any case, all the possible results, direct and indirect, must be taken into the account. But this is impossible except to omniscience itself. Even in those cases which appear the most clear to us, there may be consequences of the most grave character utterly hidden from our view. In the instance just related, the captive was very certain, from some circumstances, that he directed his captors to a spot where there were no white men.

The uncertainty of our knowledge of the circumstances of each case prevents then our defining any limits, within which deception shall be bounded. We can make no accurate distinctions, which will enable us to say, that it can be beneficially employed in one case, while in another it will be inexpedient.

I have now finished the examination of the various considerations which have been suggested to my mind in relation to this subject. And I think that they settle the question as to the expediency of deception beyond all doubt. I think it perfectly evident, that the good, which may be done by deception in a few cases, is almost as nothing, compared with the evil which it does in many cases, when the prospect of its doing good was just as promising as it was in those in which it succeeded. And when we add to this the evil which would result from a general adoption of a system of deception, the importance of a strict adherence to truth in our intercourse with the sick, even on the ground of expediency, becomes incalculably great.

In the passage, which I quoted in the beginning of this article from Percival’s Medical Ethics, the writer makes, I conceive, a false issue on the question under consideration. He assumes that the injury, which results from a sacrifice of the truth for the good of the sick, comes upon him who practices the deception, and that in doing it, “he generously relinquishes every consideration referable only to himself.” But the considerations that I have presented show, that the injury is very far from being thus confined. Often the very person intended to be benefited is injured, perhaps deeply, in some cases even fatally. And then the indirect effects can not be estimated.

There are many illustrations, used by those who advocate deception, which are plausible but fallacious. I will cite a single example. Dr. Hutcheson of Glasgow, as quoted by Dr. Percival, in remarking on the maxim, that we must not do evil that good may come, says, “Must one do nothing for a good purpose, which would have been evil without this reference? It is evil to hazard life without a view of some good; but when it is necessary for a public interest, it is very lovely and honorable. It is criminal to expose a good man to danger for nothing; but it is just even to force him into the greatest dangers for his country. It is criminal to occasion any pain to innocent persons, without a view to some good; but for restoring of health we reward chirurgeons for scarifyings, burnings, and amputations.”

I would remark on this that the infliction of pain is not in itself a moral act, but the purpose for which it is done gives it all the moral character that it has. Aside from this, it affects no moral principle, as the infliction of an injury upon truth certainly does, independent of the object for which it is done. The infliction of pain then for a good purpose can not be said to be doing evil that good may come—it is doing good.

The sacrifice of life which the writer speaks of, is the sacrifice of a less good for a greater one simply, and not the sacrifice of any principle. But when the truth is sacrificed for what is deemed to be a greater good, it is in fact the sacrifice of a greater good, for not only a less, but an uncertain good—a sacrifice of the eternal principle, which binds together the moral universe in harmony, for a mere temporary good, which after all may prove to be a shadow instead of a reality.

I can not leave this subject without making some explanations of a few points, in order to guard against some erroneous inferences to which the sentiments that I have advanced might otherwise be liable.

I wish not to be understood as saying that we should never take pains to withhold knowledge from the sick, which we fear might be injurious to them. There are cases in which this should be done. All that I claim is this—that in withholding the truth no deception should be practised, and that if sacrifice of the truth be the necessary price for obtaining the object, no such sacrifice should be made. In the passage which I have quoted from Dr. Percival, he states a case in which he very properly says, that the patient’s right to the truth is suspended; but I do not agree with him, that in withholding the truth we have the right to put absolute falsehood in its place.

It is always a question of expediency simply, whether the truth ought to be withheld. And it is a question that depends, for its proper decision, upon a variety of considerations in each individual case. It is very often decided injudiciously. There is generally too great a readiness to adopt an affirmative decision. It is too easily taken for granted, that the knowledge in question will do harm to the patient if it be communicated to him. The obvious rule on this subject is this—that the truth should not be withheld unless there be a reasonable prospect of effectually preventing a discovery of it, and that too by fair and honest means.

It has often been said that the physician has no right to excite too much hope in the mind of a patient by directing his attention, as is often done, to any favorable symptoms that may appear in his case. But I ask, how is it known that in the case in relation to which this remark is made, too much hope is excited? The physician is fallible, and is by no means answerable for putting just the right degree of hope into the patient’s bosom. It is not to be expected of him that he shall always tell each patient just how his case stands. His own mind is often filled with conflicting hopes and fears, and he cannot decide clearly what the probabilities are in many cases. And if he thinks that he can do so, he may be very much mistaken. Estimates are often made most unwarrantably. An exactness is often aimed at which is impracticable. The patient in many cases has no right to such an estimate, for while it may be a mere guess, he may look upon it as a well-founded estimate, made upon a real knowledge of his case. He will therefore draw false inferences from it, and this the physician is bound to prevent, and in so doing he actually prevents deception.

The physician should always remember that though he may be aware himself of his liability to err in making any such estimate, the patient may have such confidence in his judgment, that he will consider the opinion which he may express to be of course a correct one—almost beyond the possibility of a mistake. So that however guarded he may be in expressing an unfavorable opinion of the probable issue of any case, that opinion may have too much weight in the patient’s mind.

It is by no means true that all direct questions on the part of the sick must be directly and fully answered. For example, suppose the patient asks the physician, “Do you think on the whole that I shall recover”—a question that is sometimes asked under very embarrassing circumstances. If the physician thinks that he will probably not recover, he has no right to say to him that he will, for this would be falsehood. But he has a right, and it is his duty if he thinks it for the good of the patient, to withhold his opinion from him, if he can do it without falsehood or equivocation. He may say to him something like this: “It is difficult to decide that question. Perhaps it is not proper for me at this stage of your case to attempt to do it. You are very sick, and the issue of your sickness is known only to God. I hope that remedies will do so and so (pointing out somewhat the effects ordinarily to be expected) but I cannot tell.” Something of this kind, varied according to the nature of each case, especially in the amount of hope communicated, it is perfectly consistent with truth and good faith to say; and very often when more is said, even in very dangerous cases, the physician goes beyond the limits which infinite wisdom has thought best to set to his knowledge. It is very common, as the reader has already seen in the preceding chapter, for persons to recover, particularly in cases of acute disease, when the physician had supposed that they would die. This fact should make him somewhat cautious in giving definite opinions to the sick in relation to the probable final result of their sickness.