The frequently debated question, 'Should the doctor tell?', tends to carry a false implication that the doctor knows all about the patient's approaching death and the patient knows nothing. The resultant discussion and controversy is therefore often not to the point or only touches slightly upon the real problem. Doctors are far from knowing everything. Even if they have no doubt that their patients' condition will be fatal, they can rarely predict the time of death with any accuracy unless it is close at hand. Furthermore, patients are not necessarily unaware of what is happening; many have a very clear idea that they are dying.
Rather than putting a choice between telling or not telling, it would be more useful to ask other questions. Should we encourage the patient, or hide the truth from a patient who begins to speak of matters that will lead to talk of dying? How freely should we speak about it? Should we lie if we suspect patients only want to be told that all will be well? If there is a sincere willingness to know whether the illness will be fatal or not, should the patients' suppositions be confirmed? If there are no direct questions, have we a duty to tell the truth? Is it right to deny knowledge of dying to those who ask, or wrong to tell those who show no wish to know? Should we allow the awareness of dying to grow gradually, or should patients who are mortally ill know this early on, so that they may come to terms with a greater acceptance of dying? If they are to be told more openly, how should such knowledge be given? How do people react to being told? These questions, all part of that over-simplified, 'Should the doctor tell?', can have no universally accepted answer. Individuals differ and moral beliefs or current opinions will influence judgement.
There are some good reasons for speaking freely about the possibility of dying to those with fatal conditions. An ill person who strongly suspects approaching death, but is denied the least opportunity to question or discuss this, can feel cruelly isolated if the people around the patient remain silent. The patient may be surrounded by people whose every apparent word or action is designed to deny or avoid the fact that death is approaching, and therefore the patient has an awareness of being deceived. How can one gain the ease of wholly sincere talk with others if all continue to pretend that the immediate departure from life, the loss to them for ever, is just not taking place?
The view that we have a duty to inform those about to die has some support on material and spiritual grounds. If a doctor hides from a patient the fact that death is near, the person may fail to order family affairs or may start business ventures which would not be thought of if it were known that death was likely. The doctor's legal responsibility to warn the dying person appears to be a matter of debate. Most doctors, however, will bear in mind how far people need to set their affairs in order, when considering what they should tell a dying patient. Giving advice that it might be a good idea to make preparations for one's death serves more than that single function. Delicately put, it is a hint that an ill person can discuss further with the doctor if there is a wish to know more, or it is advice that can be just accepted at its face value.
The spiritual need for a person to know that death is near may well be more important than material matters in the terminal phase. Frequently the dying person suddenly turns or returns to religious beliefs. The dying person may already have prayed for help in serious illness, perhaps with a rather unfamiliar voice. If it appears that recovery is unlikely, most people in the religious world hold strongly that the patient should know this, so that preparations can be made for eternal life.
At times there is an increasing need to be frank with a patient over the prediction concerning the outcome of the disease, because there are short periods of feverish hopes followed by long periods of despairing misery. The patient may waste effort and money on unjustified and quite hopeless treatments, only to have bitter disappointment as well-known cure-alls fail. If a patient is seriously ill and appears to be getting worse while the doctors appear content with ineffective remedies, it may be felt that opportunities for a cure are being lost. This may lead to a feeling of frustration or a desperate tour of other doctors. Of course, a second opinion from a respected source may be a great help to all concerned. This may bring assurance that no important possibility is being neglected. When a troubled patient who has been seeking fruitlessly for cure comes to a better understanding with the doctor on the nature of the disease and how much hope is justifiable, confidence may be regained and greater peace found.
In spite of these arguments which favour frankness with the dying, many doctors are unwilling to speak with them of death. They feel that most patients do not wish to raise the subject except to get reassurance, and that the truth is likely to be hurtful. This common medical attitude is uncomfortably combined with a considerable hesitation over deliberately avoiding the topic and deceiving patients who have put their trust in the doctor, even if the 'white lies' are intended to avoid distress. Some doctors who speak in a direct way, however, make plain their belief that it does patients no good to be told that they are dying. It is a viewpoint easy to attack on theoretical grounds; but when truth can give rise to considerable distress, when kindly half-truths do not materially alter the course to death and when dying people would like to hear that they will recover, it takes a very convinced person to disapprove of lies, or even the occasional untruth. Many honest people who care for the dying find themselves hiding the truth in a manner they always wished to avoid.
In practice relatively few doctors tell patients that there is no hope of recovery. In one study of medical opinion, for example, a group of over two hundred doctors, working in hospital and private practice, were asked if they favoured informing those patients found to have a cancer very likely to prove fatal. Patients so defined would include, of course, some whose signs of illness were examined early while they were in reasonable general health with death some way off. Such patients might have little reason at this stage to suspect their illness to be fatal and if a doctor did tell them, it would give them some unexpected bad news. Eighty-eight per cent of these doctors would not tell the patient, although some of them would make exceptions. The doctors felt that usually the patient's questions were wishes for reassurance. The other twelve per cent usually told the patients that they had cancer especially if the latter were intelligent and emotionally stable. Most of the doctors felt that they should inform a relative and were glad to share the burden of their knowledge. By the way, no less than sixty per cent of these same doctors said that they would like to be told if they themselves had an equally fatal form of cancer. This disagreement in opinions between giving and receiving such information was explained by the doctors on the basis of their own greater strength of mind or responsibilities. It might be so, but it is more likely to be the emotionally determined attitude found among non-professional and medical people alike. This was indicated by the fact that these physicians were not any more frank with other doctors whom they treated for cancer than any other patients with cancer.
The unwillingness to admit to a sick person that an illness may be fatal is not confined to doctors. One survey of people's wishes to be told if they had cancer indicated that they themselves would prefer to be told but were less in favour of recommending that others in a similar condition should be informed. In one particular study of terminal care in Britain the relatives and friends of those who died appeared to know more and expected to be told more than the dying person about the true condition. About half of these patients were aware of their condition. Although many of those asked in this study accepted the degree of either knowing or not knowing shown by the dying, there was stronger approval of the patient not knowing than of his being aware. From a recent inquiry into the way married people deal with their partners' fatal illnesses, it appears that hardly a quarter openly discuss each other's situations even though an unspoken understanding may be' there.