Search Salon

- - - - - - - - - - - -

Salon Columnists
Follow these links for the most recent column by:
Susie Bright
Robert Burton, M.D.
Joe Conason
Sean Elder
David Horowitz
Garrison Keillor
Anne Lamott
Greil Marcus
Joyce Millman
Camille Paglia
Amy Reiter
Mary Roach
Scott Rosenberg
Ruth Shalit
Michael Sragow
Virginia Vitzthum
Sarah Vowell
Cintra Wilson
Burt Wolf

+ Columnists' schedule

- - - - - - - - - - - -

Recently in Salon Health & Body

Complete archives for Health & Body

- - - - - - - - - - - -

- - - - - - - - - - - -

-- Amazed

Dear Amazed,

Doctors lie all the time. Lying is intrinsic to the practice of medicine.

A family story can serve as an example. My father had a quadruple coronary bypass for intractable angina. Post-op, he continued to have some chest pain. The surgery had been successful, except for one small marginal coronary artery that was technically inaccessible and could not be bypassed. The surgeons told me that they doubted that the tiny vessel would make a symptomatic difference. They told my father nothing. My father continued having chest pain. Maybe it was post-surgical, maybe it was residual angina, and maybe it was partly apprehension. Further diagnostic tests were inconclusive.

He consulted his internist, a bright, capable, dear man with sparkling blue eyes and an impeccable sense of honesty. The internist told my father that one of the diseased vessels hadn't been bypassed. My father went home, plopped down in his chair and gave up. He never left the house again.

After he died, my mother asked me whether I thought his internist was wrong in telling him that one bad artery was left behind. No further treatment was available, so what was the point?

I asked his doctor. He answered, "Your father wanted to know. He was my friend. I felt I had to level with him." (I did not mention that a third of patients undergoing a sham bypass procedure will actually experience symptomatic improvement via the placebo effect, so strong is the power of suggestion in such serious matters.)

A variety of remedies for pain work exclusively via placebo effect. The irony is that the more convinced the physician is that his unproven treatment is of value, the more likely it is to have this non-specific benefit. A conscientious physician who is honest ("I don't know if this will work or not; there's no firm evidence") is less effective than the cavalier doc who ignores statistics ("I know this will work. All my patients get better. You will be fine.").

Both good medicine and quackery rely in part on this peculiar, paradoxical relationship between lying and patients' health. Honesty is not always in a patient's best interest, yet dishonesty always puts the doctor in an ethically difficult position. There are no guidelines. Even the best of intentions can have an unexpected outcome.

When I first read the recent Archives of Internal Medicine survey that the newspaper story you refer to was based on, I wasn't surprised. Everyone in the medical trenches realizes that the war is on, that the HMO doctor now occupies an intermediate territory -- he is simultaneously the employee of the insurance company and the patient's advocate. Pitting the patient against the insurance company is white hats against black -- it's no contest. I dismissed the article as obvious.

Then I reconsidered.

Twenty years ago I had dinner with a close friend's father, the chief justice of a state supreme court, a man of the highest intellectual and ethical standards. We were discussing his adamant anti-death-penalty stance. "Robert," he said, "I could not stand the thought of allowing one innocent man to be executed, even if it meant a thousand guilty ones are one day released back into society. Each and every man is more important than any presently prevailing majority opinion. Remember, always err on the side of the individual."

He paused, stroked his chin, looked out into his garden. A long silence ensued. Then he turned back to me, his eyes brimming with tears. "Do you think I'm wrong? Sometimes I feel so old, as though maybe I'm out of touch. But," he added, his voice firm, "that's what I believe in. The individual. So shoot me if I'm wrong."

Next page | "You either lie or the patients die"