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Therapeutic Lying: A Contradiction in Terms

Therapeutic Lying: A Contradiction in Terms

COMMENTARY

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

Therapeutic lying
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

Instead of lying to a patient with dementia, it may be possible to validate the person’s feelings. For example, the hypertensive patient with Alzheimer disease could be told, “It sounds like you’re thinking about your wife. Would you like to tell me more about her?” As the patient starts reminiscing, he may share his underlying feelings. In this way, one neither agrees nor disagrees with his misperception of the wife’s demise.

In addition to validation, redirection might be helpful. Redirection involves diverting attention to something pleasant. With respect to the Alzheimer patient, one could say, “Where is that photo of you and your wife? Can you help me find it?” This validates that the patient misses his wife and redirects him to a different activity. Neither involves lying.

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