Mack Lipkin and Ridley’s Complimentary Patient Autonomy Arguments

Henrik Hiro Pettersson

Autonomy is integral to patients’ rights as it allows one to make decisions regarding their medical care without physicians, nurses, or other health care providers. It enables health care professionals to educate patients, but the ultimate decision lies with the patient. The moral issues discussed in this paper include patients’ autonomy, rights, and respect. In On Lying to Patients, Mack Lipkin examines the line between deception and what is best for patients, eventually concluding that one should be wary of simplistic statements and the “truth” is often abstract. Mack Lipkin raises a compelling case for what should not be said to patients, while Ridley’s response critiques and builds on Lipkin’s incomplete argument on patient autonomy and truth. The paper will first summarize Mack Lipkin and Ridley’s central argument, then follow with my analysis and critiques, in addition to an objection to my position. Lastly, I will refute that objection and conclude this paper.

Summary of Mack Lipkin’s On Lying to Patients

Is a physician obligated always to remain truthful to their patients? Recently, there has been a steadily increasing public discussion involving the ethical dilemma on this matter — without voicing physicians’ opinions. The intricate relationships between physicians and patients have led countless non-experts awry from the truth.

From a shallow view of the matter, it is evident that patients should be told the truth. Yet the renowned Harvard physiologist-philosopher, L. J. Henderson, writes, “To speak of telling the truth, the whole truth and nothing but the truth to a patient is absurd… it is absurd simply because it is impossible… another fallacy is also often involved, the belief that diagnosis and prognosis are more certain than they are” (Henderson 77).

The usage of medical terminology affects patients all in different manners. Words spoken to a patient dealing with an “anxiety-laden illness” are highly likely to be obscured. This is due to the tendency of selective hearing and confirmation bias ingrained in a patient’s mind. Physicians understand that not all concepts will be accurately passed onto a patient as not all patients understand the intricacies of human bodily functions and countless diseases. Cancer may be fatal for some while others can have a 99% survival rate; some may be relatively benign while others are highly malignant. Hearing a diagnosis of “serious illness” can push patients into unhealthy behaviors and irrational thoughts. Some physician patients have said that they do not want to know that they are diagnosed with a fatal illness, which may lead to further suffering. Patients should know the “truth” as long as they can rationally comprehend the information; no physician wants to “lie” to patients, but physicians need to know their patient’s preferences and need to determine how much they want and should know.

Lying to patients often boils to the usage of placebos and the moral permissibility of them. In medicine, a placebo is a treatment that lacks physical or chemical action on the patient’s condition being treated. It is provided to affect symptoms through the patient’s psychologic mechanism. Some say a placebo involves a “partial or complete deception” by the physician without considering the strength of their psychological effect. Placebos can induce or take away countless feelings, strengthen, paralyze, transform sleeping patterns, etc.

Communication between patients and physicians is integral as patients are often in fragile conditions and confused. Honestly should be essential in this relationship and the question of whether the placebo’s deception is meant to benefit the physician or patient. Physicians want to see positive results as not only their reputations but personal responsibility is on the line. Patients wanting to know the “full truth” may be harming themselves in the process, and as such, truth is often dubious and opaque and cannot be outlined in simplistic hot-takes such as “tell the truth.”

Summary of Ridley’s Response to Mack Lipkin’s On Lying to Patients

Ridley agrees with the efficacy of placebos and how one can not make simple interjections on matters about “lying” to patients. Ridley draws the line on whether the deception is intended for the physician or patient’s gain. Ridley asserts that Lipkin assumes that “well- intentioned dishonesty” (79) is morally permissible. Ridley provides a counter to this claim by offering an example of when the priorities and values of the patient and the physician are different. Perhaps a physician prioritizes “maximal physiological function,” but the patient only wants a treatment that does not impede on their mobility or well-being. Ridley provides an example of a piano player who, after an accident, has a severed top joint in their index finger. From a practitioner’s perspective, fixing the top joint may lead to complications on the rest of the joints, so it is best to focus on the entire finger. But from the patient’s perspective although attempting to fix the top joint may harm the next joint, it is in the patient’s best interest to attempt to fix the entire finger as that will greatly benefit their piano playing; the lose of two-finger joints is not much worse than simply losing one. If the physician withholds information on the other operation, they are deceiving and thus not fulfilling the patient’s wishes. Although the physician’s intent is pure, it may dupe patients into thinking they have no other option than the operation proposed by the physician.

Infringing on a patient’s autonomous interests, even with the intent of “greatest benefit,” may cause lasting harm to patients as it devalues their autonomy. Misleading patients based on assumptions fail to justify a dishonest act. Lipkin also writes how patients cannot understand medical terminology, which is not a justification not to inform them. The physician’s obligation is to inform and answer any questions patients have on their illness or operation. Regrading telling patients information that may worsen their psychological state or behavior, Ridley writes that physicians should “work one more human ways of telling the truth (80).” Essentially, there are ways to better bring up uncomfortable topics to patients in a way that does withhold the truth and does not worry patients more than they need to. In the end, a patient’s wishes should be upheld: if they wish to be kept in the dark, then that wish must be honored unless the patient’s ignorance can undermine their self-interests.

Analysis

Mack Lipkin’s argument is mostly valid, and Ridley fills in the gaps by addressing their concerns regarding the patient’s best interest. Rather than opposing stances, Ridley’s response serves as an addition or clarification to Lipkin’s writing by addressing aspects not considered in On Lying to Patients. Lipkin continuously iterates the importance of not simplifying the argument surrounding “lying” and deception towards patients. There is too much nuance involved and as such, boiling down the topic to just “truth” or not is unjust. Lipkin references a fascinating statement from L. J. Henderson, a renowned physiologist-philosopher. He wrote, “the belief that diagnosis and prognosis are more certain than they are” (Henderson 77). Here Dr. Henderson addresses the notion that many non-physicians hold. Many trust the physicians in full when in reality, the physicians themselves are constantly hypothesizing and discussing the best course of treatment for a patient. If a patient was told the “truth” that the physician — who is thought to know all the answers — in fact, does not know the best course of action, this would only lead to further preventable suffering and anxiety. In certain scenarios, it is in the best interest of the patients do not know the full picture, as the patient’s imagination would go haywire, when they are already in a place of immense stress and confusion. Lipkin argues for a (partial) blissful ignorance for the patient as this will let their mind stay calm and allow themselves to rest. As imagination is a double-edged attribute — reminiscing of Michel de Montaigne — the mind can play tricks on hospitalized patients, tormenting them more than necessary. As such, Lipkin asserts that sometimes it is ok not to tell the full picture to patients.

Regarding Ridley’s critiques, Ridley interjects and provides an anecdote with a pianist suffering from a severed finger joint. Through I understand what Ridley is attempting to describe — a situation where the physician and patient’s interests are not aligned — the example is rather extreme and can easily be solved with a simple conversation. Although with a valid point, Ridley attempts to make this dilemma larger than it truly is, detracting from this argument regarding patient autonomy. However, Ridley does address the — old-fashioned or not — patriarchal nature of medicine with the “doctor knows best” (80) quote. Historically, the autonomy and wishes of patients were not respected as highly as physicians were thought to have all the answers. Patients’ rights and opinions were not as thought out, and patients simply followed what the physicians instructed them to do. With patient autonomy as one of the core principles of bioethics, the wishes of patients and the physicians’ need to educate them on all procedures about them are integral for trust in the patient-physician relationship.

Counter Argument

Some may say that as patient autonomy is the most integral aspect of medicine, in no reasonable way can this right be infringed upon. But what happens when the patient lacks decision-making capabilities? If one is suffering from dementia or Alzheimers, is the physical obliged to listen and follow the patient’s wishes on every instance? They may be speaking at one time when the patient’s mind is clear and another time when not. How can a physician reconcile these two? If their family is still in the picture, who truly gains autonomy in this sense?

Rebuttal

As patient autonomy is the most integral aspect of medicine, in no reasonable way can this right be infringed upon — usually? Even if a physician leaves the patient in the dark, if the patient initially consented to this, it is morally permissible to proceed with such actions as the patient’s wishes were granted. Abusing patient autonomy through the withholding of information is never, if rarely, permissible as core bioethical principles are neglected. It is the physician’s duty to instruct and educate patients on the best course of action and by withholding information. But regarding the Alzheimer’s case where patients lose decision-making skills, the physician must discuss, preferably before the later stages, how to deal with certain aspects of one’s behavior. As behavior changes throughout stages of Alzheimer’s, the will of one’s autonomy does as well, and if the patient’s wishes are always supposed to be respected, there may be a slippery slope present if Ridley’s methodology is followed through fully.

Conclusion

Mack Lipkin’s On Lying to Patients and Ridley’s response sheds light on the importance of patient autonomy and respect — two concepts integral to uncovering the fine lines between autonomy, rights, and practicality. With the four pillars of bioethics, patient autonomy is highly respected relative to the past, and as such, cases brought up such as the pianist or Alzheimer patients must be individually examined to determine what is best for the patient’s life. In the end, only the patient can make the best decision for themselves, physicians, peers, and family can only provide advice and guidance for what they believe is best.