O what a tangled web we weave, when first we practice to deceive.
—Sir Walter Scott1
Therapeutic lying, a concept that is currently seeping into the medical literature, is defined as the practice of deliberately deceiving patients for reasons considered in their best interest.2,3
This essay calls attention to the fact that therapeutic lying is a contradiction in terms—a combination of words whose meanings are in conflict with one another. If “therapeutic” is defined as “having healing or curative powers for the treatment of disease or disability” and “lying” is “making a false statement with the intention to deceive,” lying is not therapeutic and therapy is incompatible with lying. A statement from the Roswell Park Cancer Institute elucidates this:
If there’s one thing sacred in the doctor-patient relationship, it’s trust. Open and honest dialogue on both sides of the exam table is by all accounts critical to effective care. Patients have to be truthful to ensure diagnostic accuracy and an appropriate treatment plan, while doctors need to provide full disclosure about their patient’s health—the good and the bad—to help patients make informed decisions. Indeed, patient autonomy is the cornerstone of modern medicine and patient-centered care.4
Alternatives to deception
Therapeutic lying in the context of caring for dementia patients is a complex phenomenon. Its potential value is concisely stated in an article concerned with the subject:
Lies that reduce suffering and stress in patients unable to fully appreciate the cause of distress can be beneficial. Clinicians sanction their use in dementia care and see them as a manifestation of the ethical imperatives of beneficence and non-malfeasance.3
As an example of therapeutic lying, a caregiver may tell an argumentative patient with Alzheimer disease and hypertension, who is worrying about his wife’s whereabouts, that “she’s gone to the store” rather than telling the patient, “she died 7 years ago.” In this case, the lie is told to avoid a possible conflict that may cause a rise in blood pressure.
Clearly, in a person without dementia, lying may be disastrous. Consider its impact on the moribund protagonist of Tolstoy’s masterful novella, The Death of Ivan Ilyich:
What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and that he only need keep quiet and undergo a treatment and then something very good would result . . . this deception tortured him—their not wishing to admit what they all knew what he knew, but wanting to lie to him concerning his terrible condition, and wishing and forcing him to participate in that lie.5
Persons with cognitive deficits, it is assumed, will be unaware of such deceptions. This may be a mistaken assumption. The cognitively impaired may intuit being lied to and more aware of deception than one would think. Consider Benjy Compson, the mentally retarded and probably autistic narrator of Faulkner’s The Sound and the Fury, who cannot understand such abstract concepts as time, cause and effect, or right and wrong. Despite his cognitive deficits, he is hypersensitive to order and chaos, immediately sensing the presence of anything bad, wrong, or out of place. He senses, for example, his brother Quentin’s suicide, thousands of miles away at Harvard, and his sister Caddy’s promiscuity and loss of virginity.6
Dr Sperber is a Consulting Psychiatrist at the Neuropsychiatry/Behavioral Neurology Service of McLean Hospital in Belmont, Mass; and Supervising Psychiatrist at Thriveworks Boston in Cambridge, Mass.
1. Scott WM. Marmion: A Tale of Flodden Field. Edinburgh: J Ballantyne and Co; 1808. Canto VI, XVII.
2. Culley H, Barber R, Hope A, James I. Therapeutic lying in dementia care. Nurs Stand. 2013;28:35-39.
3. Ellison J, Hsu D. A dark side of dementia care. Psychiatr Times. April 15, 2014. http://www.psychiatrictimes.com/dementia/dark-side-dementia-care. Accessed June 12, 2014.
4. Schwartz SK. Is it ever OK to lie to patients? Roswell Park Cancer Institute. November 2010. https://www.roswellpark.org/partners-practice/white-papers/it-ever-ok-lie-patients. Accessed June 12, 2014.
5. Tolstoy L. The Death of Ivan Ilyich. New York: Penguin Red Classic Edition; 2006.
6. Faulkner W. The Sound and the Fury. New York: McGraw Hill; 1946.
7. Bier D. Habilitation therapy for Alzheimer’s and dementia care. http://psychcentral.com/lib/habilitation-therapy-for-alzheimers-and-dementia-care/00012873. Accessed June 12, 2014.
8. Dickinson E. Tell All the Truth but Tell It Slant. http://www.poetryfoundation.org/poem/247292. Accessed June 12, 2014.
9. Blanchard DL. Emily Dickinson’s ophthalmic consultation with Henry Willard Williams, MD. Arch Ophthalmol. 2012;130:1591-1595.
10. Cutcliffe J, Milton J. In defence of telling lies to cognitively impaired elderly patients. Int J Geriatr Psychiatry. 1996;11:1117-1118.
11. Thurman J. Her own society: a new reading of Emily Dickinson. The New Yorker. August 4, 2008.
12. Page JB. Informed consent and substituted judgement. 1999. http://forensicpsychiatry.stanford.edu/Files/Consent%20Page.pdf. Accessed June 12, 2014.