Clinical ethics
To lie or not to lie: resident physician attitudes about
1
Loma Linda University,
California, Loma Linda, CA, USA
2
Department of Obstetrics and
Gynecology, Loma Linda
University, CA, USA
3
Department of Internal
Medicine, Loma Linda
University, CA, USA
4
Risk Management and Patient
Safety, Glendale Memorial
Hospital and Health Center,
California, CA, USA
5
Fletcher Allen Health Care,
University of Vermont College of
Medicine, Burlington, Vermont,
USA
Correspondence to
Jo P Everett, Chan Shun
Pavilion, 11175 Campus Street,
Loma Linda, CA 92350 USA;
joeverett7@gmail.com
Received 12 October 2010
Revised 6 December 2010
Accepted 10 December 2010
Published Online First
2 February 2011
J Med Ethics 2011;37:333e338. doi:10.1136/jme.2010.040683
the use of deception in clinical practice
Jo P Everett,1 Clifford A Walters,2 Debra L Stottlemyer,3 Curtis A Knight,1
Andrew A Oppenberg,4 Robert D Orr5
ABSTRACT
Background Physicians face competing values of
truth-telling and beneficence when deception may be
employed in patient care. The purposes of this study
were to assess resident physicians’ attitudes towards
lying, explore lie types and reported reasons for lying.
Method After obtaining institutional review board review
(OSR# 58013) and receiving exempt status, posts
written by Loma Linda University resident physicians in
response to forum questions in required online courses
were collected from 2002 to 2007. Responses were
blinded and manually coded by two investigators using
NVivo software. Qualitative and quantitative analyses of
the data were performed with links to various attributes.
A 95% binomial proportion CI was used to analyse the
attribute data.
Results The study found that the majority of residents
(90.3%) would disclose the truth about medical errors.
Similarly, many residents (55.7%) would disclose the
truth regarding unanticipated events, especially if the
error was serious enough to result in a malpractice suit
(74.7%). However, many residents (40.9%) would not
reveal a near miss event because they believe it has no
impact on patient health. Some residents (47.3%) would
deceive the insurance company for additional patient
benefits. Of those willing to lie, only a small group (4.2%)
gave self-serving reasons.
Conclusions This study demonstrates that the ethical
issues related to deception that trouble attending
physicians also exist at the resident physician level.
Residents primarily lie for altruistic reasons and rarely for
egoistic or self-serving purposes that may or may not
result in harm to patients, insurance companies and/or
physicians themselves.
Truth-telling is not a new issue in medicine.
Hippocrates warned of telling the patient the nature
of their illness, ‘for many patients through this cause
have taken a turn for the worse.’1 However, he
admonished that the truth should be told, but to
a third party instead of the patient. In 1903 Cabot
analysed the professional ethics of truth and false-
hood, writing ‘The lies that the medical profession
agree in condemning whenever the question arises
are those told for personal and private gain.’2 This
historic conclusion was justified by utilitarian
reasoning and was based on the paternalistic
assumption that the ‘doctor knows best’. This
attitude in medicine led to the concept of a ‘thera-
peutic privilege’, which allowed the physician to do
what he or she thought was best for the patient.
In recent decades, paternalism and therapeutic
privilege have fallen into disfavour, while patient
autonomy has come to dominate discussions
in medical ethics. More emphasis is placed on
principlesdlying is wrong; the patient has a right
to know. This change was clearly demonstrated
when Novack reported that in 1961, 90% of
physicians did not reveal a fatal diagnosis to
patients, but in 1977, 97% did so.3 About the same
time, a layman argued for truth-telling, writing,
‘The real issue is not whether the truth should be
told but whether there is a way of telling it
responsibly.’4 This north American change is not
necessarily the standard in all cultures, however.
Pellegrino addressed cross-cultural practices of
truth-telling and concluded that patient autonomy
was not the universal principle, but rather respect
for persons.5 So if a person expected to be shielded
from the truth, his or her personal belief should
be honoured.
Still, physicians are frequently confronted with
the ethical issue of deceiving for either the patient’s
benefit or their own. Physicians may lie to insur-
ance companies, deceive about medical errors,
withhold details about diagnosis at the family’s
request, misinform about unanticipated events, or
not disclose information about near miss events.6
Truth-telling is a foundational principle of medical
ethics.7 However, using a consequential method of
reasoning rather than a principle-based method,
professionals find situations in which telling the
truth may not be in the best interest of those
involveddthe patient, the physician, or the insur-
ance company.
This ethical issue also has legal implications.
Lying for the benefit of the patient in order to
secure additional insurance benefitsdsomething
patients may actually desiredcould easily result in
charges of fraud. Alexander showed that 26% of
individuals would prefer their physician to deceive
the insurance company after a claim has been
denied.8 Previous studies reported practising
physician deception of insurance companies ranged
from 11% to 57.7%.9e11
However, patients do not want to be deceived
about their care. Fein et al12 described the disclosure
patients desire including admission of the error, the
proximate effects, and any harm caused. Lying about
a medical error may save the physician from
a malpractice suit, but could also result in further
harm to the patient. Gallagher et al13 and Kaldjian
et al14 reported that attending physicians revealed
medical errors to the patient between 51% and 92%
of the time, whereas minor errors were only divulged
to the patient between 32% and 73% of the time.
While it may not be illegal to refrain from
disclosing near misses (events that almost
333
 Clinical ethics

happened, but did not) or unanticipated events (undesirable
events that were not covered in the informed consent), the
argument continues as to whether the patient should be
informed or whether the information would only serve to
increase patient anxiety. Even so, many attending physicians
(73%) disclose near miss events.15
The purposes of the current study were to assess resident
physicians’ attitudes towards lying, compare with published
data, and explore the types of lies identified by resident physi-
cians as well as their rationalisations for lying in health care.
METHODS
First and second-year resident physicians from 22 specialties at
Loma Linda University (LLU) Medical Center participated in
a required online programme. These courses were taught each
year from 2002 to 2007 to assist in meeting the Accreditation
Council for Graduate Medical Education requirement to
demonstrate core competencies.16 This online series of courses
entitled the Graduate Medical Education core curriculum
programme, taught on a Blackboard platform, allowed residents
and instructors to access the lesson material and interactively
respond in an asynchronous virtual classroom. Weekly require-
ments included reading the lesson material, discussing the forum
questions at the end of each lesson and replying substantively to
at least one classmate’s online message as well as all instructor-
posed questions.
After obtaining LLU institutional review board review and
determination of exempt status (OSR# 58013), resident
responses were downloaded from three lessons that addressed
deception (table 1), given a unique ID number to maintain
confidentiality, and imported into NVivo, a software coding
qualitative analysis program.
The key to these ID numbers was only available to the
primary investigators to ensure unbiased coding. At least two
researchers were manually involved in the coding process of
resident responses. No coder developed preconceived categories,
but simply allowed the posts to fall into specific branches
according to content. Posts in each of the three lessons were
divided into major categories based on whether residents would
lie or not and then further stratified into secondary and tertiary
categories based on reasons to lie.
Cases were linked to specific resident attributes including
gender (56% were male and 44% were female), resident specialty
and location of medical school graduation. The training
programmes were divided into three groups: 56% were medicine
oriented (internal medicine, family medicine, psychiatry, etc);
20% were surgery oriented (general surgery, obstetrics, urology,
etc); and 24% were hospital oriented (anaesthesiology, emer-
gency medicine, radiology, etc). The medical school locations
were divided into three categories: international graduates
(17%), LLU graduates (36%), and non-LLU US graduates (47%).
Coded descriptive information was listed by number and
percentage. Statistical analysis was performed using the 95%
binomial proportion CI to compare the difference among the
resident attributes. After determining that a resident was
committed to a specific response, all additional supporting
responses in the same lesson were eliminated from statistical
analysis in order to use the number of residents and not the
number of responses as the denominator when calculating
percentages.
In order to categorise the types of lies identified in coding,
a scale of lies was created based in part on the work of St
Augustine (box 1).17
The scale was expanded to include our data followed by lie
examples that were coded from resident responses. Not all of
St Augustine’s categories fit with the lie examples provided by
residents.
RESULTS
The categories of deception that were identified in the coding
process are shown in table 2. The varying number of residents in
each category correlates with the number participating in each
lesson.
Deception of health insurance companies
Out of 636 residents who responded to the forum question
related to deceiving insurance companies, approximately half
(47.3%) would consider lying to the health insurance companies.
The other half (51.3%) report they would tell the truth to the
insurance company. Residents who graduated from interna-
tional medical schools (32%, 95% CI 0.23 to 0.40) are signifi-
cantly less likely to lie to insurance companies than US (49%,
95% CI 0.43 to 0.55) or LLU (51%, 95% CI 0.45 to 0.58) grad-
uates. Residents in surgical fields (58%, 95% CI 0.49 to 0.66) are
significantly more willing to lie to insurance companies
compared with those in medicine-related (43%, 95% CI 0.37 to
0.48) or hospital-related (48%, 95% CI 0.40 to 0.56) specialties.
Deception about medical errors
Out of 774 residents who responded to the question relating to
medical errors, only a few (2.8%) would lie or withhold infor-
mation from the patient, while a majority (90.3%) reported they

Table 1 Lessons related to lying

Lesson title
Being a patient advocate without
getting caught in the ‘white lie’
Uh-Oh! How to approach medical
mistakes
Clinical risk management strategies:
patient informed consentdcan you talk?
Forum questions
A 34-year-old man comes to your office requesting a screening colonoscopy because his older brother was recently diagnosed
with colon cancer. You share his concern and concur that, given the family history, the colonoscopy is warranted, but there
are no abdominal symptoms and his exam is normal. His insurance plan will not pay for the colonoscopy, but they would
if you stated that there had been recent weight loss or change in bowel habits.
What will you do? Finally, given that the reimbursement policies of the insurance companies are often absurd and seem designed
to benefit their pocket books by not providing patient services, is it ever justified in this current medical economic climate to
produce a ‘white lie’ that will ‘beat’ the insurance company at their own gaming strategies?
During clinic yesterday you injected the arthritic knee of an elderly gentleman with what you thought was Depo-Medrol. At the
end of the day you realised you had picked up the wrong phial and actually used Depo-Provera. You told your attending physician,
and together you checked two textbooks, learning that there is not likely to be any adverse consequence from this mistake. First
thing this morning you called the patient and learnt that the knee was no betterdand fortunately no worse.
Should you tell him what happened? Why or why not? What else should you do?
Is it ever ethical to not disclose an unanticipated event to a patient? Should disclosure occur if the patient does not receive a bad
result, but almost did, (as in the ‘near miss’)? What if disclosure might result in the physician being sued or disciplined? Should
disclosure still occur?

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 Clinical ethics

Table 2 Resident responses to lying scenarios

Box 1 St Augustine scale of lies in decreasing order of No of Percentage
severity residents (%)
Would you deceive insurance? n¼636
Lies in religious teaching (not applicable to current study) Would lie 301 47.3
Lies that harm others and help no one (no data fell here) Would not lie 326 51.3
Lies that harm others and help someone No decision 9 1.4
< Lies that harm individual and directly benefit ones self (eg, Would you deceive about a medical mistake? n¼774
Would lie 11 1.4
doctor lies to patient to decrease malpractice risk)
Would not tell whole truth 11 1.4
< Lies that harm and help same individual (eg, doctor gives
Would admit truth 699 90.3
medication to create symptoms to justify tests)
Raise questions about truth-telling 19 2.5
< Lies that harm an individual and indirectly benefit ones self
Would defer to attending physician 34 4.4
and do not help patient (eg, doctor withholds harmful Would you deceive about an unanticipated event? n¼672
unanticipated event from patient) Would always disclose 374 55.7
< Lies that harm an individual and indirectly benefit ones self but
Would never disclose 22 3.3
still help patient (eg, doctor lies to patient about medical error) Would disclose with qualification 276 41.1
< Lies that harm an organisation and provide benefit to ones self Would you deceive even if a lawsuit might ensue? n¼419
(eg, doctor lies for reimbursement) Would disclose despite risk to self 313 74.7
< Lies that harm an organisation and provides benefit to others Would disclose more if lawsuit is inevitable 71 16.9
but at their own detriment (eg, doctor coaches patient Would question if disclosure is necessary 35 8.4
regarding symptoms to justify tests) Would you deceive about a near miss? n¼492
< Lies that harm an organisation and provide benefit to others Would always disclose 164 33.3
but with poor intentions (eg, doctor maliciously deceives Would never disclose 201 40.9
insurance for patient benefit) Would disclose with qualification 127 25.8
< Lies that harm an organisation and provide benefit to others
but with mixed intentions (eg, doctor lies to colleagues for
patient benefit) Deception about unanticipated events
< Lies that harm an organisation and provide benefit to others Out of 672 residents who answered the forum question relating
indiscriminately (eg, doctor usually lies for patient benefit) to disclosing unanticipated events, a minority (3.3%) stated they
< Lies that harm an organisation and provide benefit to others would not disclose unanticipated events to patients. A
judiciously (eg, doctor lies for patient only as a last resort) substantial group (41.1%) would not disclose the information
< Lies that harm an organisation and provide benefit to others unless specific circumstances overrode their reticence, such as
and are requested by others (eg, patient requests doctor to lie importance to patient health or being directly asked by the
to insurance for benefits) patient. Over half (55.7%) reported they would always disclose
Lies told for the pleasure of lying (not applicable to current unanticipated events to patients.
study) US (51%, 98% CI 0.44 to 0.57) and LLU (46%, 98% CI 0.39 to
Lies told to please others in smooth discourse (not applicable 0.54) graduates are significantly less likely than international
to current study) graduates (71%, 98% CI 0.62 to 0.80) to disclose an unantici-
Lies that harm no one and help someone pated event. Residents in hospital-based specialties (42%, 98%
< Lies initiated by doctor that have potential to harm in the CI 0.33 to 0.50) report unanticipated events significantly less
future (eg, doctor withholds benign unanticipated event from than those in medicine-related (57%, 98% CI 0.51 to 0.63)
patient) specialties. Surgical residents (53%, 95% CI 0.43 to 0.62) tend to
< Lies initiated by doctor that do not harm (eg, doctor withholds disclose more than those in hospital-based specialties (42%, 95%
near miss from patient) CI 0.33 to 0.50).
< Lies initiated by others who may know the situation better Disclosure about unanticipated events is the only category of
(eg, family requests doctor to lie to patient) deception in which gender is significant. Male residents (46%,
Lies that harm no one and that save someone’s life (no data 95% CI 0.42 to 0.51) report unanticipated events significantly
fell here) less than female residents (60%, 95% CI 0.55 to 0.66). However,
Lies that harm no one and that save someone’s purity (not male residents (43%, 95% CI 0.39 to 0.48) choose to disclose
applicable to current study) under certain circumstances (eg, if the patient asks) significantly
Bold headings are from St Augustine. more than female residents (32%, 95% CI 0.27 to 0.38).

Deception about near miss events

would tell the patient the truth. Smaller groups of residents pose
questions and hesitations about telling the truth (2.5%) or
would defer to an attending physician (4.5%). US graduates
(93%, 95% CI 0.90 to 0.95) are significantly more willing to
admit an error than international (83%, 95% CI 0.77 to 0.89)
graduates, but international graduates (11%, 95% CI 0.06 to
0.16) are significantly more willing to defer to an attending
physician than US (3%, 95% CI 0.01 to 0.04) or LLU (3%, 95%
CI 0.01 to 0.05) graduates. LLU graduates (90%, 95% CI 0.87 to
0.94) fell inbetween US and international graduates in their
willingness to admit an error.
Out of 492 residents who answered the question regarding
disclosing near miss events, over one-third (40.9%) reported they
would not reveal the near miss. A smaller group (33.3%) indi-
cated they would always disclose the near miss. Smaller still was
the number of residents (25.8%) who would only disclose under
certain circumstances (importance to patient health). None of
the attributes examined were significant.
Types of lies
Figure 1 depicts the characteristics of lies described by resident
physicians that depart from the truth in four directions:

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 Clinical ethics

Figure 1 Types of lies.

altruistic lies, egoistic lies, and lies either resulting in harm or no CONCLUSIONS
harm. Whereas altruistic lies are those that provide benefit to the Many healthcare professionals have their own definitions of
patient, egoistic lies are those that provide benefit to the types of lies or are familiar with those described by Bok18
physician. Lies that cause harm refer to any harm done to including white lies, excuses, lies in crisis, lies to protect others,
patients, insurance companies, or even the physician. The table and lies for the public good. Bok further adds that ‘some consider
depicts possible combinations of lie characteristics. For instance,
a physician exaggerates symptoms (harming the insurance
company) in order to secure benefits for the patient (altruistic Table 3 Resident reported reasons to lie
towards patient). The placement of these points on the graph No of resident Percentage
responses (%)
was based on St Augustine’s (box 1) continuum of lies that
identified degrees of harm as well as who benefits from the lie.17 Lies to Insurance company n¼238
Following St Augustine we placed the most serious lies (those Concern for patient health 134 56.3
that harm others and benefit oneself) and the least serious lies Beat insurance at their own game 77 32.4
(those that harm no one and provide benefit to another) at Avoid malpractice suits 9 3.8
Appealing to the insurance company is 7 2.9
opposite corners of the graph. The remainder of the lie categories
too time consuming
was placed on a continuum within the four quadrants based on Financial gain for physician 6 2.5
the degree of lie seriousness as assessed by the authors. The size Lies are necessary for good patient care 5 2.1
of each point graphically represents the percentage of residents Lies to patient about near miss n¼324
willing to deceive as found in our study. Event did not actually take place 142 43.8
Event is not important to patient health 101 31.2
Reasons to lie Avoid decreasing patient trust 43 13.3
Table 3 outlines the reasons that residents choose to lie in each Avoid increasing patient stress 38 11.7
of the scenarios. Lies to patient about unanticipated events n¼347
When lying to the insurance company the most common Event is not important to patient health 234 67.4
reason is obtaining treatment for the patient, followed closely Patient does not want to know 70 20.2
by wanting to ‘get back’ at the insurance companies. In near Avoid increasing patient anxiety 16 4.6
miss situations, residents stated the reason not to disclose was Patient did not ask 15 4.3
that the event did not take place and was most likely unim- Avoid decreasing patient trust 9 2.6
portant to the patient’s health. Patient health is also the fore- Not enough time to disclose all events 3 0.9
most reason for non-disclosure in an unanticipated event. Lies to patient about medical error n¼25
Finally, those few residents who chose to deceive about Do not want to admit to mistake 8 32.0
No harm done 7 28.0
a medical error most commonly do so because they prefer not to
Avoid malpractice suit 6 24.0
admit that they made a mistake. Of the responses indicating
Avoid losing patient trust 2 8.0
willingness to lie, only a small group of residents’ lies (4.2%)
Avoid increasing patient anxiety 2 8.0
were self-serving.

336 J Med Ethics 2011;37:333e338. doi:10.1136/jme.2010.040683


all well-intentioned lies, however momentous, to be white’. Bok
describes her personal definition of the white lie as ‘a falsehood
not meant to injure anyone, and of little moral import’.18 In our
study, residents often justify lying as long as the patient is
benefitted as pointed out by this resident, ‘I think the wording
of LIE involves that we are out for our own interest and not the
patients’. When in reality we are all about patient care.’
The residents themselves said that they are attempting to
behave altruistically, or as Darwin19 put it, ‘incurring a personal
cost that in turn benefits others’. Darwin’s favourite example of
altruism was honey bees. He found that in a hive there are sterile
bees that do not reproduce but rather supply resources to those
bees that do reproduce. These same bees will also defend the
hive with their lives. While our residents are not giving their
lives to gain additional insurance benefits for their patients, they
are behaving altruistically.
When lying for the patient, the insurance company loses
money, the patient may receive tests of questionable necessity
with potential complications, and the physician is sacrificing
moral integrity. However, deception for the benefit of the
patient may be considered a form of benevolent deception,
a concept described by Jonsen,7 but it is still a lie. In contrast, the
insurance industry has a different view of lying that resides with
a legal definition. The False Claims Act states any person who
presents a false claim or makes a false record is liable pay a fine of
at least US$5000 in addition to three times the amount of
damages sustained.20
Occasionally, patients may actually approve of physician
deception. A 2003 study by Alexander et al8 of 700 individuals
showed that 50% stated it is acceptable to misrepresent facts
and 41% stated it is acceptable to lie for the benefit of the
patient. Moreover, 19% indicated that a physician had used
deception on their behalf in the past. Our study showed that
patients requested their doctors to lie to the insurance compa-
nies on their behalf, representing almost 6% of all types of lies
reported.
Certain practices of insurance companies may be cause for
some physicians to lie in retaliation. The California Medical
Association reported three large suits against Health Net, Blue
Cross and Wellpoint/Anthem within the past 4 years.21e23 In
each of these suits, the companies were charged with a variety of
actions including promising medical coverage, then dropping
patients if they needed expensive treatment, engaging in prac-
tices that led to denials of claims, increasing premium charges to
customers without advance notification, refusing to pay for
patient care after pre-authorising the care, reducing reimburse-
ment levels without appropriate notice and revoking patient
health plans retroactively. The study in 2002 by Werner et al9
demonstrated that attending physicians are more likely to use
deception with insurance companies if the denied claim appeals
process involved more time or was associated with less success.
Residents’ animosity towards the insurance companies is also
demonstrated in this sample post, ‘Insurances are here in busi-
ness. They are not here for your patients’ well-being. If I think
a test is necessary for my patient, then I will get it. I wouldn’t
accept a medically illiterate person to tell me what to do.’ Our
study also demonstrated some resident attitudes about the
inequality of the lying game when physicians are expected to
behave ethically with regard to insurance companies, while the
insurance companies act in their own interests even to the
perceived detriment of patient care.
Resident physicians are thus faced with balancing competing
valuesdto maintain personal and professional integrity by doing
what is ethically right, to do what they believe to be in the best
J Med Ethics 2011;37:333e338. doi:10.1136/jme.2010.040683
Clinical ethics
interests of the patient, to do what is required by law, and to
avoid harm. Some residents link the lying issue to legal
requirements as this resident responds, ‘It’s not really an argu-
ment about ethics. It’s an argument about legality, a totally
separate issue. If we are legally required to disclose this, we do it.
The law trumps all.’ The American Medical Association also
addresses the issue of legality in its Code of Ethics: ‘Ethical
values and legal principles are usually closely related, but ethical
obligations typically exceed legal duties. In some cases, the law
mandates unethical conduct. In general, when physicians believe
a law is unjust, they should work to change the law. In excep-
tional circumstances of unjust laws, ethical responsibilities
should supersede legal obligations.’24
When we asked residents about disclosing unanticipated
events, we did not specify the event, but allowed them to come
to their own conclusions. Over half (56%) chose to disclose the
event. When we later asked the same residents about disclosing
an unanticipated event if they knew a lawsuit would ensue, 75%
chose to disclose the event. This demonstrates that the residents
generally are more concerned with their patients than with their
own wellbeing.
Residents’ decisions are affected by many factors. Interna-
tional residents are less willing to lie to insurance companies
about patient symptoms and to patients about unanticipated
events than those who trained in the USA. However, they are
less likely to report medical errors than those who trained in the
USA. These are similar to results found in the study in 2004 by
Lee et al,25 which showed that international graduates are less
likely to change the patient’s official diagnosis than US gradu-
ates. Does this mean that US medical schools are not addressing
the ethics of lying or alternatively that international medical
schools place less emphasis on doing what is best for the patient,
whatever the cost?
A study by Garbutt et al15 in 2008 showed that surgeons are
less likely to report medical errors. We found no significant
difference between departments with regard to disclosing
medical errors; however, significant differences do exist in lying to
insurance companies and disclosing unanticipated events.
Surgical residents are more willing to lie to insurance companies,
and hospital-based residents are more willing to deceive about
unanticipated events. Perhaps the surgeon is more focused on the
mission to be accomplished and less concerned with the means
used, whereas the non-surgical physician may be more contem-
plative regarding the consequences of how one arrives at the
altruistic value. Is it possible that hospital-based residents have
more experience with procedures and therefore encounter unan-
ticipated events more often than those who are medically based?
A 1991 study by Roter et al26 showed that female physicians
took more time with their patients, encouraged more patiente
physician partnering, and gave more information during clinic
visits than male physicians. Our finding that female physicians
were more willing than male physicians to disclose unantici-
pated events may involve this willingness to spend more time to
give patients information while encouraging them to be more
proactive in their own health care.
A limitation of this study, as with all qualitative research, is
that the coding process remains subjective even when two
coders are involved. In addition, what residents report they
would do while writing in an online classroom may not directly
correlate with what they would do in reality. Having a multi-
centre survey might strengthen the breadth of the deception
practices in the general population of resident physicians.
In practice no physician contemplates engaging in any
dishonest behaviour. Such actions clearly go against the
337
 Clinical ethics
Hippocratic oath, but potentially engaging in deception
confronts physicians in not uncommon situations, as graphi-
cally shown in the types of lies diagram (see figure 1). Doctors
communicate in different ways that hopefully help patients
understand their clinical challenges. A doctor may not tell all
that is known because the patient cannot handle or understand
the information. Doctors are careful not to take away hope
when patients ask about impending death. Sometimes the
question is not answered, but the patient is told that ‘we are
going to take good care of you’. Becoming dishonest that
involves legal issues such as insurance deception for the benefit
of the patient or the doctor, or withholding or lying about
information to protect a physician from a lawsuit clearly are
more egregious forms of deception, some of which border on
fraud and should clearly be avoided.
Our study demonstrates that the ethical issues related to
deception that attending physicians face also exist at the resi-
dent physician level. Residents are trying to learn how to be
professionals, but are also faced with concerns about deception.
While the majority will disclose a medical error to the patient,
only half will be truthful with the insurance company, and
only one-third will consistently disclose near misses to their
patients. Over half will disclose an unanticipated event to the
patient, but in making a distinction between benefitting the
patient and protecting themselves, three-quarters of the resi-
dents will disclose, even if such disclosure results in a lawsuit.
Whereas our formal curriculum challenged the resident to
consider the issues related to deception, it is clear that residents
are still contemplating the matter and struggle with balancing
altruism, egoism and beneficence. However, the overwhelming
majority embraced an altruistic rationale regarding deception.
Finally, residents may benefit from a formal educational curric-
ulum to achieve a confident understanding regarding the ethical
virtue of truth-telling in the current complex world of health
care.
Funding Funding was internal and provided by the GME Core Curriculum Program.
Competing interests None.
Ethics approval This study was conducted with the approval of the institutional
review board, OSR# 58013.
Provenance and peer review Not commissioned; externally peer reviewed.
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