Truth Telling
ANTONELLA SURBONEa
Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
INTRODUCTION
Truth telling is an essential step in medicine and in the patient-doctor relationship.
I shall try to examine the epistemic, pragmatic and ethical dimension of truth telling
in medicine. It must first be said that neither “truth” nor “telling” are abstract words,
nor are they value-neutral. The act of truth telling in medicine is indeed an exchange
involving moral agents (the patient, the doctor, and society) with their sets of values
and norms, which in turn are derived from culture, personal and religious beliefs, and
traditions. Through their variance, complex and differentiated patterns of truth telling
emerge in different contexts: hence the different practices and degrees of truth telling
throughout the world.1 In the present work I wish to go beyond those differences
(which one might see as belonging to the “sphere of the expressive”) to explore the
underlying philosophical assumptions and questions which are inextricably intertwined with the ethical and pragmatic dimension of truth telling in medicine.
THE EPISTEMIC DIMENSION OF TRUTH TELLING
Epistemology, as the theory of knowledge, is concerned with truth. Whether it is
Plato, Nietzsche, or Foucault speaking, whether we equate it with the highest good
or we deny such intrinsic value, in the pursuit of knowledge we are interested in
knowing the truth.2
According to the Oxford Dictionary of Philosophy, the central questions of epistemology include the origin of knowledge; the place of experience and of reason in
generating knowledge; the relationship between knowledge and certainty; the relationship between knowledge and error; and the changing forms of knowledge that
arise from new conceptualizations of the world.3
All these questions are directly related to the issue of truth telling in medicine,
and I shall first analyze the relationship between truth and science insofar as it has
an impact on truth telling. Western epistemology can be said to be born with Plato,
whose initial epistemologic works were deeply connected with ontology.4 Indeed,
the early and middle Plato defines knowledge in terms of its object. In The Republic,5 Plato describes different degrees of knowledge according to what the objects of
knowledge are. Knowledge requires logos,6 and real knowledge (which he calls “science”) is only that of ideas, which are eternal and immutable, and are characterized
by “being.” Of these we have noetic knowledge, an immediate intuition. On the contrary, knowledge of the things of the world is of a lesser degree (it is doxa, opinion),
for these things are temporal and subject to change and are characterized by “becomaCurrent
address: 1045 31st Street, N.W., Washington, D.C. 20007, USA.
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ing.” Of these, we can only speak in terms of dianoetic knowledge, or discourse. Plato never excludes that the things of the world exist and can be known, but he
establishes the primacy of the knowledge of absolutes and calls it science.7
Plato’s last dialogue on epistemology is Thaetetus,8 a very modern work, whichfrees epistemology from ontology and is concerned with the distinction of three
types of knowledge: knowledge through sense perception, propositional knowledge,
and pragmatic knowledge. Despite Thaetetus and despite most of modern epistemology, in medicine we seem to hold the ontological view (whether we realize it or not,
whether we admit it or not). What we have done is a reshuffling of Plato’s early
thinking, leading to a worrisome conclusion: modern science, seen as eternal and
perfect, combines intuition and discourse; it no longer reflects Platonic ideas, but
rather the real state of the world. Truth only belongs to science, the scientific method
is the only true method of inquiry, and science is equal to objectivity.
The term “objectivity” implies the existence of an object, and the underlying assumption of such epistemic view is that truth corresponds to an external object and
describes it accurately.9 Aristotle defined truth as “to say of what is that it is, and of
what is not that it is not.”10 The dominant Western epistemology, relying heavily on
the Enlightenment and on the principles of positivism and empiricism, further attached to truth the ideas/ideals of pure objectivity and of value-neutrality.11 The basic assumptions of such dominant epistemology12 are that knowers are detached
neutral spectators who acquire knowledge by observation, and present it in propositions: truth then is a kind of sameness, and falsity a kind of diversity from the given.13 Propositions can be verified by others, again through observation. The purpose
of knowledge is to foster our capacity to control the external world.14 This view of
knowledge rests on the fact/value distinction as an effective way to maintain the
equation knowledge = science.
Other theories of truth have been proposed which deny the primacy of the object
and of correspondence to it, and rather privilege more holistic and more pragmatic
views, where subjectivity is often taken into account, and knowledge is seen as “situated.”15 Disease is unfortunately one of the most solid proofs that there is an external reality, which occurs independent of our wish and escapes our control.16 Hence,
a narrow-correspondence view of truth in medicine is flawed not insofar as it rests
on the recognition of the undeniable reality of disease, but rather because it ignores
the role of the knower in generating truth: it lacks a sufficient account of the subjective and contextual dimension of knowledge. Recognizing that knowledge has subjective and contextual dimensions does not mean that we abandon epistemology to
enter the psychology of subjectivity, nor that we end with the pessimism of cognitive
and cultural relativism.17 On the contrary, it implies questioning the pure objectivity
and the value-neutrality of knowledge (and for us, of medical knowledge), by recognizing that there is a living subject, the knower, who has both reason and emotions,
and who holds a certain power position in a certain context. (The knower in medicine
is both the doctor and the patient, and they know differently.)
TRUTH TELLING VERSUS TRUTH MAKING
If we remain within the dominant “context-independent” model, the conclusion
is generated that “knowledge worthy of the name must transcend the particularities
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of experience to achieve objective purity and value neutrality.”18 Then, in medicine
and in the patient-doctor relationship we privilege the objective dimension of disease, and tend to ignore that disease is first a subjective event, a unique and disrupting—when not devastating—event in a person’s life. As the subjective dimension of
disease can hardly be measured with scientific methodology, we prefer to discard it
as non real. We all do so because we have equated “real” with “scientifically measurable”: this is the idolatry of scientific truth which we all share, whether doctors
or patients. Truth is perceived as only the opposite or absence of lie; truth is seen as
a static object, merely waiting to be described and verbalized; and medical truth is
assumed to reside only in the objectivity of quantifiable data.19 Hence, the emphasis
on the diagnostic aspects of disease, where the more objective data are located.
Hence, the obligation we feel to overwhelm our patients with obscure quotes from
the scientific literature and with statistics about morbidity, mortality, and survival.
(And too often we do so even when not requested, even on the first encounter with a
new person-patient, without taking into account the patient’s cultural and personal
context). Truth telling literally becomes the act of someone (the doctor, being the
only knower) who knows the truth and tells it to someone else (the patient, being
only the listener).
In this perspective, disease becomes reified. Reification of disease20 serves the
purpose of maintaining the supremacy of some over others—the most powerful over
the more vulnerable. The power in the patient-doctor relationship is on the doctor’s
side, for the relationship itself is an asymmetrical one, due to the unique state of dependency created in the patient by disease itself.21
There is, however, a quite different way to frame the issues of truth and truth telling in medicine. Truth is not a static object external to us and awaiting our neutral
discovery: truth is rather a relational state, which develops in time and space because
of interactions. Truth is not only something to be told: truth is rather something that
we make. Both the patient and the doctor contribute to this process of truth making,
where the “methodological solipsism” of those who hold that we can think effectively apart from considerations of social practice, is surpassed.
Interactions in medicine take place between the patient, the disease, the doctor,
the medications, with their efficacy or lack of efficacy, and finally with the context.
The patient-doctor relationship always has a third party, society.22 Society includes
both the micro-environment and the macro-environment, where each one of us acquires and develops his/her own set of beliefs. Personal beliefs, religion, and tradition all play an active part in the development of the medical truth, a development
that occurs within a relationship, requiring the active intervention of all partners. In
such perspective, truth telling acquires two different meanings: on one hand, it is the
duty and act of honesty of the more informed partner (the doctor, who is consulted
because of his/her scientific knowledge); on the other hand, information is just a first
step towards something that goes beyond it: communication. Information is never
exhaustive of truth, which, on the contrary, is created only in communication, a bidirectional process by definition.
In this perspective, the subjective dimension of disease is as important as the objective one, and sensitivity—both cultural23 and personal24—is required to gain access into subjectivity. Sensitivity implies respect for language as a form of life.25 For
instance, where autonomy is synonymous for “isolation,” truth telling in the Amer-
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ican way is unlikely to be beneficial to the patient or to foster his/her dignity.26 Even
in the American context, objective medical information needs not to be imposed onto, say, an unprepared patient, with a different cultural background or with different
beliefs,27 only out of fear of litigation, nor out of the abstract affirmation of the supremacy of our Western beliefs (a worrisome and widespread form of cultural
hegemony28). Different practices of truth telling should be accepted and respected:
they should be seen as stemming from differences in the modulation and expression
of the same basic principles of human dignity, embedded in different contexts. Cultural differences in truth telling seldom give rise to differences in the effectiveness
of truth making.30
THE EPISTEMIC RESPONSIBILITY OF THE DOCTOR
Disease, as previously said, undeniably carries an objective dimension, and the
doctor31 has an epistemic responsibility towards it, towards his/her patients, and to
society in its entirety. The previous discussion of truth and truth telling in medicine,
and of the cultural variability with respect to degrees of truth telling, might appear
to lead to the easy conclusion that subjectivity and relativism should triumph, and
that we should thus feel relieved of our professional responsibilities. On the contrary,
I maintain that the doctor first has a professional accountability, which is primarily
based on his/her respect for the scientific truth, as well as for the existential truth of
the particular patient. This accountability is at the same time towards evidence and
towards the individual and the community.32
The dichotic view of the “great yet uncaring doctor” (too busy knowing to have
any time left for personal or cultural sensitivity) contrasted with the “kind, yet not
so expert doctor” (too involved in the emotional turmoil of the patient to have any
time left to read scientific journals) is nonsensical insofar as neither of them would
be able to establish a therapeutic relationship with his or her patients. The knowledge
of the former is kept at such a distance from the patient that it becomes incommunicable: truth telling remains a matter of information only, and fails to reach the level
of communication. The warmth and compassion of the latter are at best temporarily
comforting, but are again non-therapeutic, as such a doctor betrays his/her epistemic
responsibility. There is no such thing as “unethical science” or “non-scientific ethics”: the epistemic dimension of truth belongs to science as well as to ethics.
THE PRAGMATIC DIMENSION OF TRUTH
A dynamic relational account of truth within the context of a relationship maintains that the patient-doctor relationship is based on mutual obligations33 and oriented towards a specific goal: that such relationship be therapeutic.34 In this
perspective, truth in medicine can be understood as instrumental. Instrumental does
not mean that truth should be defined in terms of its utility (as James put it), but rather that pragmatic aspects do contribute to make meaning possible, as Wittgenstein
suggested in saying that “meaning is use.”
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Indeed, truth telling has a pragmatic dimension, first because it is by definition
an act. Action belongs to the sphere of the practical and is oriented towards a goal.
The goal of truth telling in medicine is to achieve therapeutic efficacy.35 Truth telling
finds its justification in the context of (and in view of) a therapeutic project. We have
recognized the existence of a medical truth, which precedes (and in part is independent of) the therapeutic success: truth telling in medicine, however, is not merely descriptive. Truth telling in medicine is praxis: its goal is therapy (cure and care).
The patient-doctor relationship, as praxis, is at the same time a contractual relationship based on obligations, and an asymmetrical relationship based on the particular needs of one partner. In both instances, the patient-doctor relationship is based
on trust.36 And the patient primarily trusts the doctor’s ability and expertise to understand his/her disease, and to treat it properly. The patient’s trust is based on the
assumption that his/her particular disease has an objective dimension, which can be
known through scientific methodology, and can be taught and learned. Notably, the
doctor learns through generalization what the patient knows through his/her direct
singular experience. The assumption, however common to both the patient and the
doctor, is that there is indeed a medical truth (whether spoken or unspoken), and that
the doctor recognizes it and acts upon it.
In this sense, medical truth is—in part at least—a matter of correspondence, and
the doctor is accountable for adhering to such truth in order to achieve therapeutic
success. But medical knowledge is primarily techne, it is praxis.
Finally, truth exists in ambiguity37: there is a certain vagueness in truth, even in
scientific medical truth. The dichotomy truth/falsity is often replaced by a more
complex reality of vagueness, both epistemic38 and existential. It is via this ambiguity that we access the ethical dimension of truth telling.
THE ETHICAL DIMENSION OF TRUTH TELLING
The first ethical responsibility of the doctor is his/her professional responsibility,
which is not alleviated by recognizing the ambiguity of truth in medicine. On the
contrary, respecting such ambiguity calls for an expansion of the doctor’s responsibility to include the understanding of the patient’s personal and cultural context.39
The epistemic relationship between knowledge and certainty, and between
knowledge and error, finds a correlate in the two main areas of truth telling in medicine: diagnosis and prognosis. As previously said, the diagnostic aspect of disease
is where the more objective data lie, and where the epistemic responsibility of the
doctor is first founded. Prognosis, as the ability to predict the likely course of a patient’s disease, is far less objective; however, it is often said to be what is distinctive
of the medical profession. Rather than recognizing the element of uncertainty in
prognostication, modern medicine aims at increasing its accuracy and precision.
While this is an important task, all of us who have practiced long enough are very
familiar with the uncertainties of prognostication, and we are left with the unsettling
feeling that stressing certainty over uncertainty in prognostication betrays the complexity of life. It seems that we are again trying to reify disease, and to distance all
subjective elements from the patient-doctor relationship. By reciting survival statistics in front of our patients, rather than contributing to their self-determination, we
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most often acquire a tremendous power. The power that modern medicine seems to
have lost in terms of how the figure of the physician is perceived (no longer a god),
we re-establish through our easily pronouncing life and death sentences. Diagnosis
and prognosis are formidable tools indeed, and the magic can continue.
The play between certainty and uncertainty (both at the epistemic and at the ethical level) is particularly evident in the rapidly developing field of human genetics,
where the intertwinement of scientific knowledge and normativity is strikingly evident. By knowing our genome, we accomplish two major tasks: we find out about
genetic diversity and we are in the position of making predictions about the future.
First, genetics proves us that knowledge is subject to change (in its forms at least)
under the influence of new developments and new concepts of the world.40 This suggests that truth is also subject to change, both in the scientific and in the normative
realms. Second, whether or not genetic diversity will be felt to be compatible with
human equality41 depends not on the scientific meaning of genetic diversity,42 but
on the meaning and value that society attributes to “diversity,” to “sickness,” and to
“predisposition to a sickness.” Third, we all agree that the predictive power of genetics is quite limited, since genes do not exist alone, and the interactions between
genes and the environment are far from being known and even further from being
controllable. Yet, we already have some experts (and to a certain extent all physicians will have to quickly become experts in this field), who can make predictions
about future diseases based on the genome of their patients. Where is the truth here?
Is it true that genetics expands the control we have on our lives, or is it true that it
can paralyze us? Is it true that we can predict the future, or is it true that too many
other unknowns are at stake? More pragmatically, is it true that knowing herself to
be BRCA1-positive will enable a woman to exercise more effective prevention; or is
it true that a BRCA1-positive woman can be denied health care or a job or the adoption of a child? Indeed, these are all truths: the truth for each person (whether us or
our patients) is likely to be a unique whole, where some elements will figure more
and others less. As a consequence, the act of truth telling about genetic risks, for instance, is clearly not a neutral one, and the power held by those who make the predictions is tremendously high.
The second ethical obligation of the doctor is the correct use that he/she makes of
all these formidable tools, which allow him/her to convert the symptom experienced
into “a disease” (diagnosis always brings about an ontological change in the
patient44) and to predict the future (whether through prognostication or through risk
assessment). If used in the context of a relationship where reciprocity exists asymmetrically, these tools contribute to enable our patients to make informed choices
about their lives. If, on the contrary, diagnosis, prognosis, and risk assessment are
used to reify disease and to stigmatize our patients, then they only reinforce the already existing power imbalance between the doctor and the patient: truth then becomes another of the asymmetries of life.45
When we use truth telling to subjugate the person in front of us, to label her, to
make her silent, to quickly move on to the next patient, then we are serving power,
not knowledge. Then Nietzsche’s question: “This unconditional will to truth—what
is it?” is hardly answered in terms of truth. For truth is never the result of an imposition. Truth is something emerging, being discovered and being created, in the patientdoctor relationship, as in any other instance of our lives. And truth is about freedom.
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“AND YOU SHALL KNOW THE TRUTH, AND THE TRUTH SHALL
MAKE YOU FREE” (JOHN 8:32)
If truth is something dynamic that we make in a historical context, and not only
something static that we describe, then truth indeed contributes to freedom. Medicine also is about freedom: freedom from symptoms and from disease, but also freedom to make informed choices. In the medical vocabulary we often hide the
importance of the word “freedom”: suffice to think of some common abbreviations
in medicine, such as DFI (disease-free interval) and DFS (disease-free survival)—
they are indeed potent reminders of what medicine is about. Truth telling in medicine
is a precious instrument of this freedom, and as such shall be used.
So medicine is about freedom. Truth is about freedom. Freedom is about wholeness. Truth as formulated in language is always partial, as Bradley strongly suggested, and not everything can be verbalized.
The aim of truth telling is “truth” and not “telling.” If “telling” becomes an impediment to truth,46 then we should find truth in its wholeness beyond the spoken
word. If not everything can and should be expressed in words,47 then we shall not be
afraid to venture beyond words.
This is only possible when the patient-doctor encounter is not an isolated technical event, but a relationship: there the unspoken finds its proper place, and truth can
unravel in its integrity and dignity. There we cease to categorize about the universal
human nature, and we dare facing that particular person in front of us, emerging in
her wholeness and uniqueness. Such person, our patient, likely loves truth as much
as we also do—as physicians and as human beings first.
Because this is what we are in the patient-doctor relationship: human beings. If
Wittgenstein was right in one of his letters to Russell in 1914, saying: “How can I be
a logician before I’m a human being? Far the most important thing is to settle accounts with myself…,” maybe what we really need to do is settle our own account
with truth first. Maybe we will realize that at the existential level what we say “isn't
necessarily true, but it explains, just by the fact of saying it, our existence,”48 and
that this we also share with our patients. Then, we can take the responsibility of truth
telling beyond the narrowness of information and the abusiveness of power. Only
then, we can enter the challenging, yet so rewarding, world of the patient-doctor relationship, and tell the truth and make the truth.
This is possibly a new concept of truth in medicine. But “concepts are like multiple waves, which go up and down; but the plane of immanence is the unique wave,
which both surrounds them and unfolds them.”49
NOTES AND REFERENCES
1. A. Surbone, “Information, Truth and Communication: For An Interpretation of Truthtelling Practices Throughout the World,” in Antonella Surbone and Matjaz Zwitter
(Eds.), Communication with the Cancer Patient. Information and Truth [Volume 809
of the Annals of the New York Academy of Sciences] (New York: The New York
Academy of Sciences, 1997).
2. Truth here can be the truth we wish to know about falsehood, or about the power relationships that undermine it.
3. The Oxford Dictionary of Philosophy (Oxford: Oxford University Press, 1987).
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4. The best known and most quoted source of Plato’s epistemology is ironically one of
his latest works, Thaetetus, where indeed Plato surpasses its previous views. In the
conclusion of Thaetetus, Plato questions his own suggestion that “knowledge is true
beliefs plus logos.” Thaetetus. Trans. by R.A.H. Waterfield (London: Penguin
Books, 1987).
5. Plato, The Republic (New York: Viking Press, 1977).
6. The view that knowledge requires logos recurs in Plato’s epistemology. What is meant
by logos probably varies according to different stages of Plato’s thinking, but the
fundamental view is that there is something which, added to true belief, converts it
into knowledge, and this appears to be primarily the ability to analyze, to work out
the reason. The best known example is found in Meno, where Socrates elicits a correct answer to a mathematical problem from an uneducated slave. That is not yet
knowledge: it is only when the slave understands why the proposition is correct, that
he can be said to have knowledge. (Meno, 85c) (Meno (97e-98a), Gorgias (465a),
Phaedo (76b), Symposium (202a), Republic (533b-c), Thaetetus (201c-210d), in Platone, Opere complete (Bari, Italy: Biblioteca Universale Laterza, 1996).
7. One might notice that the necessity of defining knowledge with a single term or sentence that can be substituted for the word “knowledge” every time we use it is also
platonic. This was the Socratic method of definition. The reality of knowledge, as
modern philosophy and epistemology shows, is likely more complex and admits of
more than one definition. This is particularly relevant to our discourse on truth telling in medicine.
8. Plato, op cit.
9. The correspondence theory of knowledge, also known as adequacy or adherence theory, is the view that truth consists in correspondence with the facts. Such theory
assumes that at the basis of knowledge there is “a given,” and hence a foundation of
knowledge upon which knowledge is built through confirmation and inference. Any
correspondence theory of knowledge privileges the role of experience as a mean of
discovering the given truth, while undermining the role of beliefs in accessing the
facts.
10. Aristotle, Metaphysics (1011b), in The Basic Works of Aristotle (New York: Random
House, 1941).
11. Lorraine Code, “Taking Subjectivity Into Account,” in L. Alcoff and E. Potter (Eds.),
Feminist Epistemologies (New York: Routledge, 1993).
12. Alfred J. Ayer, Logical Positivism (New York: The Free Press, 1959).
13. This is the classical philosophical theory of the priority of nature, and of truth as correspondence.
14. One might add: “to our benefit.”
15. Opposite to the correspondence theory, the coherence theory of truth affirms that the
truth of a proposition consists in its being coherent among a body of other propositions
not defined in terms of truth. According to coherence theories there are no given foundations, and the stability of the whole is maintained through the coherence of its parts.
Beliefs are privileged, as we can only see and speak of truth within a pre-existing set of
beliefs. One of the major criticisms of coherence theories of truth is that they underestimate the role played by experience not only in acquiring knowledge, but also in controlling our sets of beliefs. Other theories of truth include the identity theory, where
wholeness is stressed, and the existence of any partial truth denied; the redundancy or
semantic theory, offering a minimalist view of truth; and pragmatic theories of truth,
affirming the instrumental role of truth with respect to its use.
16. Lorraine Code writes: “The fact of the world's intractability to intervention and wishful thinking is the strongest evidence of its independence from human knowers.” Op.
cit., p.20.
17. Francesco Bellino, I Fondamenti della Bioetica (Roma: Citta’ Nuova, 1993).
18. Lorraine Code, op. cit., p. 19.
19. Antonella Surbone, “Informed Consent and Truth in Medicine,” European Journal of
Cancer, No. 14 (1994), p. 2189.
20. The concept of reification is the basis of History and Class Consciousness, written by
George Lukacs in 1923, and subsequently withdrawn upon the Third International
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21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
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accusation of “subjectivism.” According to Jurgen Habermas (writing on Lukacs in
his 1987 Theory of Communicative Action) “reification is a peculiar assimilation of
social relationships and subjective experiences to things, which we can perceive and
manipulate.” The reified thing is given, not made. Through the process of reification,
objective intrinsic power is attributed to things, whereas those same things are the
result of actions and of interactions. Positivistic reified science, according to Lukacs,
transforms social products into natural immutable facts, which in turn appear foreign
and deprived of any possibility of control by human beings. By “reification of disease” I intend to suggest a similar process of estrangement, leading us to privilege
the objective elements of disease to the detriment of its subjective interpersonal
dimension. See George Lukacs, History and Class Consciousness (Cambridge,
Mass.: MIT Press, 1971), trans. R. Livingston.
Edmund D. Pellegrino, “Altruism, Self Interest, and Medical Ethics,” JAMA, No. 258
(1987), pp. 1939–1940.
Antonella Surbone, “The Patient-Doctor-Family Relationship: At the Core of Medical
Ethics,” in L. Baider, C.L. Cooper, and A. Kaplan De-Nour (Eds.), Cancer and the
Family (West Sussex, England: John Wiley & Sons Ltd., 1996).
Lawrence O. Gostin, “Informed Consent, Cultural Sensitivity and Respect for Persons,” JAMA, No. 274 (1995), pp. 844–845.
For a moving and convincing account of the importance of sensitivity and respect in
medicine, see the recent book by Dr. Jerome Lowenstein, describing his experiences
as Director of the Humanistic Medicine Program at New York University. Cf. J.
Lowenstein, The Midnight Meal and Other Essays About Doctors, Patients, and
Medicine (New Haven: Yale University Press, 1996).
Language is the vehicle for truth telling, and a precious instrument for communication.
But there is often a major gap between the spoken word and the word that is heard, as
we all know from our experience with patients. Then language can even become an
obstacle of communication.
A. Surbone, “Truth Telling to the Patient,” JAMA, No. 268 (1992), pp. 1661–1662.
Jerome Lowenstein, The Midnight Meal, op. cit., p. 76.
The initial work on cultural differences in medicine originated as a reaction to Western
cultural imperialism. See Ian E Thompson, “Fundamental Ethical Principles in
Health Care,” British Medical Journal, No. 295 (1987), pp. 1461–1465.
Edmund D. Pellegrino, “Is Truth Telling to Patients A Cultural Artifact?,” JAMA, No.
268 (1992), pp. 1734–1735.
Dr. Levy from Zimbawe, writes that in her country “it is not uncommon for a specific
disease to be attributed to an expression of displeasure by an ancestral spirit, and the
remedy will be seen to lie in acts of appeasement. Another cause of illness is
believed to be the casting of spells by grudge-bearing individuals. Faith in traditional
healers is deeply ingrained in Shona culture. It is believed that the traditional healer
will determine the cause of illness and decide what must be done to propitiate the
offending spirit…. Occasionally a healer may recommend that the patient consult a
doctor; others advise against any approach to the formal health centers….There is no
word in the Shona vocabulary for cancer…. No Shona patient has ever asked me how
long he or she has to live.” Dr. Levy’s success in communicating with her cancer
patients and in providing cure and care is undeniable evidence that it is making the
truth that counts, not reciting information. (Lorraine M. Levy, “The Cancer Patient
in Zimbawe,” in A. Surbone and M. Zwitter (Eds.), Communication with the Cancer
Patient: Information and Truth, op. cit.
Throughout this essay, the word “doctor” is used as a short form for “health care
worker.” It is clear that truth telling is also the responsibility of nurses and of anyone
else engaged in a therapeutic relationship with a person/patient.
Lorraine Code, Epistemic Responsibility (Hanover, NH: University Press of New
England, 1987).
That obligations in the patient-doctor relationship are mutual is well exemplified by
the case of truth telling. In fact, it behooves both partners to tell the truth, and reciprocity certainly must exist with respect to truth telling (the doctor not only has a
duty to be truthful, but he/she also expects the patient’s narrative to be truthful to
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34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
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what the patient experiences, for correct diagnosis, prognosis, and treatment to be
possible).
That the patient-doctor relationship aims at being therapeutic is the presupposition of
the relationship itself. The sick person consults a professional for his/her expertise in
the medical field and asks him/her for care and cure.
Doctors are rarely consulted for information only: even when this occurs, such as, for
instance, in the case of genetic counseling, the information sought by the patient is
strictly instrumental to his/her decisions about prevention or about family planning,
and a therapeutic dimension, albeit indirect, is present. Throughout this essay, the
sentence: “truth telling in medicine,” refers to truth telling to patients. Truth telling
is also to the scientific community, and in this perspective its goal, at times, can be
mere information or speculation, not necessarily directed at therapy.
For a thorough discussion of the role of trust in ethics, see Annette C Baier, Moral
Prejudices: Essays on Ethics (Cambridge, MA.: Harvard University Press, 1994).
For an extensive and illuminating discussion of ambiguity, see Merleau Ponty’s work
on perception and our knowledge of the body. Maurice Merleau-Ponty, Phenomenologie de la Perception (London: Routledge & Kegan Paul, 1962).
The concept of epistemic vagueness is far more challenging and less intuitive than that
of existential vagueness, with which we are all very well acquainted in our personal
lives. Epistemic vagueness can be found even in the most basic observations, which
often admit of borderline cases. Moreover, the emergence of new realities and of
new discoveries often makes the classification of new cases hard enough that they
become vague. The impact of technology on modern medicine well illustrates the
point: suffice to consider the definition of death in the context of organ transplants.
The discussion of cultural variability and of cross-cultural stability is now particularly
lively because of the multi-ethnicity of most of our societies and of the increasing
value that democratic societies attribute to pluralism.
This inevitably prompts a reconsideration of the classical philosophic tenet that knowledge and becoming exclude one another. Science is not only about being, as Plato
thought.
Paul Reilly, “ASHG Statement on Genetics and Privacy: Testimony to United States
Congress,” American Journal of Human Genetics, No. 50 (1992), pp. 640–642.
Indeed when we will know all the secrets of our genome, we will all be subject to
genetic diversity. That should be enough to discourage any discrimination based on
genetic information. Yet, there is something in our collective unconscious which
makes genes seem to all of us as carrying some deeper, more drastic, more inevitable
sense of diversity and of sharing in the risks associated with such diversity.
Antonella Surbone, “The Moral Challenge of Genetic Testing for Breast Cancer,”
Medicina e Morale (1999).
Aristotle wrote that “it is not because I think that you are pale, that you are pale.
Rather, it is because you are pale, that he who says this has the truth.” However, consider what happens when the doctor makes a diagnosis (i.e., gives a name to a symptom). When the feeling of palpitations becomes a mitral valve prolapse, a new
ontological state is created in the patient.
“Differences between true and false do not exist apart from the practice in which these
values are produced and evaluated and statements made to circulate as true, as
known or probable…. The practical conditions situate truth amid the major asymmetries of social power, undermining its status as common good.” Allen Barry, Truth in
Philosophy (Cambridge, MA: Harvard University Press, 1995 ).
As seen previously in Dr. Levy’s account, in some culture the word for cancer does
not exist. What would the Western use of such a word do to the truthfulness of such
patient-doctor relationships? Western language would be very likely an impediment
to establishing a truthful relationship in that context. Similar considerations need to
be made when speaking to a Western patient who does not want to know about his/
her disease (mastering silence can be very important too).
One of the most quoted propositions of contemporary philosophy is Wittgenstein's
“Whereof we cannot speak, thereof we must be silent.” It also is one of the most
often ignored, in our cult of verbalization.
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48. Cesare Pavese, as cited in Stein Husebo, “Communication, Autonomy and Hope. How
Can We Treat Seriously Ill Patients with Respect?,” in Antonella Surbone and Matjaz
Zwitter (Eds.), Communication with the Cancer Patient: Information and Truth, op. cit.
49. Gilles Deleuze, Quest'est Que C'est Que la Philosophie? (Paris: Minuit, 1991).