Withholding Information: An Introduction to the Moral Issue

Issues of truthfulness and disclosure are among the most difficult and delicate ethical issues for healthcare professionals. Nurses in trauma centers face distinct ethical challenges as questions arise about whether withholding information to patients is ever justified. After reading Tom L. Beauchamp’s “There Are Circumstances in Which a Doctor May Withhold Information” from Arp and Caplan’s Contemporary Debates in Bioethics, I will present the paternalistic and therapeutic privilege approaches to this case to suggest that trauma nurses and other healthcare professionals have an obligation to manage information in a way that “sometimes withholds information and at other times stages disclosures over time” (Arp and Caplan 409).

The Case

“Case 3: Emergency and Trauma Nurses: When to Give Bad News” explores the question of when to tell the truth in situations when, given the patient’s physical and psychological condition, delivering devastating news might potentially jeopardize a patient’s health, and possibly life. In this case,  Amira is driving on the highway with her partner, Casey, and their daughter, Samantha; they are hit by a drunk driver in a multi-vehicle accident.  Casey’s vital signs are absent, while Amira, unaware of her partner’s death, is in the trauma room in need of surgery. When she asks about Casey, the nurses fear that stress may further impair her capacity to survive the surgery; they are also afraid that she may die in the operating room without knowing the truth about her partner (Yeo, Moorhouse, and Khan).

The Best Response:

A. Paternalistic Approach

Paternalism is the intentional overriding or limitation of one person’s autonomous choices or actions by another person or institution, where the latter justifies the action-a nurse’s withholding information-by appeal to the goal of providing a benefit or of preventing or mitigating harm to the person whose choices or actions are limited or overridden (Arp and Caplan 413). The motivation is therefore “the beneficent promotion of physical or psychological health and welfare of those whose autonomous choice is limited or overridden” (Arp and Caplan 414).  The moral thesis is that as risk to Amira’s welfare increases, the likelihood that withholding information is justified correspondingly increases.

B. Caring for Patients Who Have Received Bad News: Therapeutic Privilege

The primary concern of emergency and trauma nurses should not at the onset be the disclosure of all available pertinent information. While some information can be delayed, some of it may justifiably never be mentioned (Arp and Caplan 415). The trauma nurse’s fundamental obligation at the beginning of the process of disclosure is to calm down and reassure Amira, while engaging sympathetically with her feelings and conveying the presence of a caring, knowledgeable medical authority (cf. Quill and Townsend, 1991). The nurse’s emotional investment in the feelings of the Amira should be joined with a detached evaluation of what the patient’s medical and informational needs are; cases in which the risk of harm and burden will be substantially increased if all pertinent information is disclosed call for a “skilled management of each item of information” (Arp and Caplan 415). Moreover, how should the trauma nurses decide how and when Amira should be told the bad news about her partner?

Based on the therapeutic privilege, there is a commonly understood and “morally intuitive difference” between lying to someone with the intention to deceive and withholding the truth from someone to “avoid a perceived negative, detrimental, or painful physical or psychological consequence” (Arp and Caplan 404). Considering Amira’s best interest, can disclosure of Casey’s death therefore be delayed justifiably?

Contemporary Issues: Skilled Management of the Truth — Not Always Justifiable

Harvard University’s Justice with Michael Sandel presents “A Lesson in Lying.” Sandel discusses the realm of freedom and the realm of necessity as well as the carefully worded denials in the Monica Lewinsky affair of Bill Clinton (~16 minutes).  Although skilled management of the truth is not always justifiable, in the case of Amira, the decision of a trauma nurse to withhold information is founded on the best interest of the patient. As Sendel discusses, in the light of Kant, is there something morally at stake in the distinction between a lie and a misleading, but true evasion? If so, is this adequate for rendering information withholding by healthcare professionals morally impermissible?

Works Cited

Arp, Robert, and Arthur L. Caplan. Contemporary Debates in Bioethics. Chichester, West Sussex: Wiley Blackwell, 2014. Print.

Quill, T, and Townsend, P. (1991). Bad news: Delivery, dialogue, and dilemmas. Archives of Internal Medicine, 151, 463-464.

Yeo, M., A. Moorhouse and P. Khan. “Case 3: Emergency and Trauma Nurses: When to Give Bad News.” Concepts and Cases in Nursing Ethics.