Autonomy, paternalism, and the doctor's duty of care.

Autonomy, paternalism, and the doctor 's duty of care Everything has its season, and there is a time for everything under the heavens: A time to be born and a time to die. .. A time to be silent and a time to speak. Ecclesiastes 3:1–7 Medicine constantly holds the tensions of contrasts. Of life and of death. Of fighting and of folding. Of truth and of deceit. Herein lies the art of medicine. Holding the balance of the rational advance of science against the relative world of values and attitudes. This tension, in turn, ref lects the human condition, wherein man is both symbolic and physical. Some time ago I had a case that brought these issues into sharp relief. I had been asked to consult on an 86-year-old Russian lady who spoke only a few words of English. She had a slowly advancing head and neck tumor for which no further antitu-mour treatment was possible. She had neuropathic pain, which settled with a tincture of anticonvul-sant. At the first consultation her son pushed urgently in front of her and whispered emphatically to me, " Do not tell her that she has cancer. If she knows, it will kill her. " I nodded neutrally. After 15 minutes of preliminaries, she blurted out in broken English, " Do I have cancer? " There was no time to ref lect as in an editorial—there was no interpreter to impartially dissect the question—and the son's presence loomed large. I simply did not know her. I answered her in a ref lex, as these thoughts f lashed through my mind. Robert Twycross, the British doyen of palliative medicine, recently wrote about the challenge of " truthful communication between health professionals and patients. " ~Twycross, 2006!. He cites the literature and 30 years of clinical experience to conclude that " although truth may hurt, deceit hurts more. " And that " a conspiracy of silence or of words " leads to " desolation, depersonalization. .. and suffering " of the patient. Telling the truth ~or not! has a particular ethical framework. A broader paradigm that incorporates truth telling would be of autonomy and paternal-ism. Should I, the doctor, paternalistically decide what information to reveal or to conceal? A common defense for not telling the truth to the patient and deferring to the family is that the ethical and social unit is the family, not …