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The woman had a large, benign brain tumor. Subsequent surgery was successful; the tumor was removed in its entirety.

Later, the neurosurgeon asked the neurologist why he'd ordered the scan. "Call it a hunch or gut feeling," the neurologist answered. The neurosurgeon said that he probably wouldn't have bothered to get the scan as it was so much trouble to go through bureaucratic channels for such a low yield possibility. (The claims adjuster may have been correct from a cost-effectiveness standpoint. The chance of an uncomplicated headache of 10 years duration being secondary to brain tumor is quite small).

The neurologist confided to me that he alters approximately 10 percent of submitted claims in order to get scans approved. I asked if this bothered him. He laughed. "Absolutely not. This is the new medicine. You either lie or the patients die." This is from a doctor that I highly respect, to whom I have referred my own family members.

In earlier times, when the concerned doctor was solely the patient's advocate and wasn't wearing opposing hats, we could tolerate, even appreciate his lying as primarily well-intended. Now, when we realize that the physician's very job might be at stake, we are less certain. If he will lie to help me, will he also lie to save his ass, or to save the insurance company, or even to get a bigger year-end bonus? Doesn't the very knowledge that your physician is willing to lie undermine the doctor-patient relationship?

On a lighter note, an endocrinologist called to tell me that "white lies don't count." He gave the example of osteoporosis, for which bone-density scans are HMO-approved mainly for post-menopausal women. But men, primarily the elderly, can also get osteoporosis. If the endocrinologist wants to get a scan on a man, he makes sure that the indication on the request form reads: 40 years of amenorrhea (lack of periods). The endocrinologist leaves out any of mention of gender. He says that gender isn't on the claims examiners' list of indications for disapproval, as long as the person is post-menopausal!

Certainly there is some philosophical or theological way out of the woods on this. Some higher authority must have considered the distinctions between good and bad lies. I consulted St. Augustine and his 40-page tract on mendacity, and found nothing but split hairs. I checked out several recent books on lying; all indicated the problem was epidemic, but were surprisingly weak in the area of moral distinctions.

I ran across a book on patient falsification. Here's an amazing statistic: Three percent of "kidney stones" passed in emergency rooms are fictitious (bits of gravel, pieces of concrete, even flecks of paint), the purpose being for the patient to get immediate narcotics.

Lying is everywhere; it is as intrinsic to daily life as any search for truth. The ethical problem of the lie now is subjective, self-referential, in the eye of the beholder.

I am interrupted from my writing. A close friend with mild multiple sclerosis is on the line. Over the past three years I've been very frank with her, explained all the intricacies of the disease, including the pros and cons of treatment. She isn't really a candidate for medication as she has no disability and only intermittent mild fleeting symptoms of extremity numbness. But now she's very excited. This morning she saw an acupuncturist who told her that he'd been to three years of medical school in Japan and that, in his opinion, she did not have M.S. "What do you think?" she asks.

I have seen her MRI scan. There are multiple lesions, though this doesn't necessarily dictate the severity of symptoms or absolute prognosis. She worries constantly about what might happen, yet is playing tennis regularly. "I'm glad that you are feeling better," I say, wondering if avoidance is a lie. She doesn't ask again, thanks me and hangs up.

I go back to the article on lying. What would the state supreme court justice have done if he were an HMO physician? What would he have said to my friend with M.S.?

I conclude: Trust one's heart. As Mark Twain once said, "An awkward, unscientific lie is often as ineffectual as the truth."
salon.com | Nov. 1, 1999

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