By G. Owen Schaefer
Honesty and integrity are pillars of medical professionalism which I and many others teach to healthcare students. Sometimes, though, they can be in tension with other considerations – as illustrated in a distressing case study reported in Slate magazine, concerning medical decision-making in the US when ICE comes knocking.
The case, briefly described, involves a Venezuelan man presenting to the emergency room for injuries requiring stitching and imaging. However, ICE (Immigration and Customs Enforcement) agents are waiting outside. The treating doctor expects that, if discharged, the patient may be detained in abusive, inhumane and unjustifiable conditions. In order to protect the patient from this abuse, the doctor apparently entered into the medical record a false suspicion of pneumonia in order to admit the patient to hospital, at which point the ICE agents depart because the patient was out of reach. (The rest of the article focuses on policy questions of ICE presence in hospitals, but here I’ll focus on the doctor’s dilemma)
The tension here is that, in order to protect the patient from harm (instantiating duties of beneficence, which go beyond narrow medical well-being), the doctor made a dishonest diagnosis (violating standards of honesty and integrity). Could such dishonesty be justified? The patient’s situation indeed warrants sympathy and reasonable protective action, but in this professional context I would suggest deception is not advisable.
The case is reminiscent of a famous challenge to absolute honesty, where in response to a critic Immanuel Kant considers a deranged murderer knocking on a door asking if their intended victim is at home. Kant insists, following his Categorical Imperative, you must be honest even if it means the death of your guest. But many of us dissent from Kant’s exceptionless honesty, especially in light of a less theoretical version of the scenario where moral heroes would hide Jews and other persecuted people from Nazis seeking to exterminate them – typically involving deception, such as that portrayed in the classic film Schindler’s List. An exceptionless moral theory that would condemn such brave deception is not widely accepted. (other ethical questions arise concerning appropriate use of medical resources and impact of a false diagnosis in the medical record on future treatment, but given space I will set those concerns aside and focus on the issue of honesty)
So do we have an updated version of Kant’s (or, technically, Benjamin Constant’s) case with ICE at the door? And if so, is the lesson that this may be an exception to general prohibition on deception? Two key disanalogies are worth highlighting. First is the stakes – the murderer case and historical examples from Nazi Germany involve high likelihood of death, which may well outweigh the wrongness of deception. But while there have been deaths in ICE custody, those deaths are at present only a small percentage of the tens of thousands detained. One may still argue the level of abuse and degradation is sufficient to justify dishonesty, but the case at least is not so straightforward.
Moreover, healthcare workers have special obligations that make it even harder to justify deception. Professional standards to uphold honesty are not merely based on general prohibitions on deception; honesty is furthermore integral to the integrity and reputation of the medical profession. If patients and the public come to view healthcare workers as unreliable in diagnosis, this can undermine public trust in the profession, make it less likely patients will trust medical decisions and recommendations, and degrade public support for health institutions.
In a way, this is a sort of professional-level Kantian argument. One formulation of the Categorical Imperative is to only act in ways that one could generally will others to do; lying is prohibited because widespread lying would undermine all speech, even the intentions behind the act of lying itself – no one would believe anyone anyway. Narrowed to the professional sphere, if the Slate case deception were to become widespread, the trustworthiness of medical diagnoses are undermined.
Arguably, a one-off or carefully delineated case of deception will not undermine the profession as a whole. (A similar ‘just this once’ line was given by Tyrion Lannister in reaction to Jon Snow’s Kantian opposition to lying) Disciplinary tribunals, though, may sometimes reasonably sanction even individual behaviors that are disreputable enough. And in any event, we see this case publicly reported and promulgated. If the deception is seen as widely endorsed by healthcare professionals, it could well contribute to loss of trust in healthcare professionals, particularly among those who may support ICE’s actions.
On the flip side, some readers opposed to ICE may see the story and become even more trusting of healthcare workers, as doing what it takes to protect their interests. That may be the case, but turning medical trust into a partisan matter could have serious deleterious consequences for healthcare as a whole, and we are already seeing the devastating effects of such partisanship around trust emerge in relation to vaccines. Indeed, to the extent that the Slate article author is arguing against ICE intrusion into medical spaces due to the essential need to uphold a special sphere protected from outside influence, dishonesty could undermine the ability to leverage trust in medical professionals to protect the medical sphere from such political machinations.
The above is meant to be a tentative analysis as there is a real moral dilemma at play, and there may be further ethically relevant factors that are not apparent from the brief case description in Slate. Still, it is a reminder that medical ethics requires careful consideration not only of general ethics but of the special obligations of healthcare workers that bind the professions – and an illustration that, particularly in the present historical moment in the US, doctors may be left to grapple with true moral dilemmas where there are no good options.
Author name: G. Owen Schaefer
Author affiliation: Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore (all views expressed above are solely the position of the author and not of CBmE/NUS)
Conflicts of interest: Owen Schaefer is an editor of the JME Forum. This post was reviewed by another editor of the Forum before posting.
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