Truth-telling is the ethical duty of veracity. We're told as children, "Honesty is the best policy." But then there is Jack Nicholson's dramatic speech as Colonel Jessep in the movie A Few Good Men: "You can't handle the truth!" These lines remind me of basic problems with telling the truth.
Can't Handle the Truth
Often when people in health care read a new published study, they decide on the validity, the truthfulness of the outcome, by reading the conclusion, rather than reading the methods. If they like the conclusion, even if the methods are so bad as to invalidate the study, it becomes a new truth. On the other hand, if the conclusion is one they don't like because they "can't handle the truth," the study is deemed a lie, even if the methods show it to be done well. I've seen the latter tactic in the e-mail I've received from mailing lists about the CCGPP low back best practices document. It leads me to think some in our profession can't handle the truth. While some have criticized the methods, most seem to be critical of the outcome because the best evidence doesn't fit their belief in chiropractic as a panacea. They then find a way to criticize the methods that produced the outcome - the truth they can't handle.
Some patients can't handle the truth that their condition might be permanent. There are those diabetics who will keep testing to see if they can do without insulin, thinking the diabetes will just go away.
"You mean my insurance won't pay for this?" This may be less common in the era of managed profits - rather, managed care. People figure their insurance doesn't cover much. Still there are times when a patient just can't believe their insurance won't pay for everything their heart desires in the health care marketplace. Think of the patient who gets an advertisement offering to supply a motorized scooter for the disabled, paid for by insurance, when the patient isn't really that disabled. The patient can't believe this device designed to ease their life actually might not be an insurance-covered expense.
It seems there are patients who want to walk into our offices and say, "Doc, here's my spine, call me when you've fixed it." These patients can't believe they are actually responsible for their own spinal health. They might not be able to handle this truth because so much information distributed in the media makes them think health is just a pill or surgical procedure away, and of course, that isn't something they are responsible for. I've found it seems to take two recurrences of someone's spinal pain syndrome for them to actually accept the truth - that they must accept responsibility for the function of their back. The patient's third case history often starts with them saying, "OK doc, I know, I need to do my exercises. I'll do them this time."
Can't Get the Truth
Every semester in my ethics class at the University of Bridgeport College of Chiropractic, I do a role-playing exercise on truth-telling. I play a man whose symptoms are typical of metastatic prostatic carcinoma. The student, playing the doctor, is going to send the patient for a radiograph. As the patient, I ask the "doctor," "What do you think I have, doc?" Rarely, if ever, will the "doctor" tell me they are trying to rule out cancer. In fact, no matter how hard I try to find out if cancer is in the differential diagnosis, they won't tell me. I've even gone so far as to tell the "doctor" that I started chiropractic college and know about having a list of differential diagnoses, and want to know what they are; they still won't tell me. The student who plays the role of doctor often will say afterward that they were only trying to protect the patient from what might be devastating news. Rather than thinking about the patient's rights to hear the truth and use that information to make prudent health care choices, they instead want to, in a paternalistic way, control the flow of information to "protect" the patient. They want to hide the truth when it is the patient's right to hear it.
It is said that in war, the first casualty is truth. Sometimes it seems our profession is at war and each side has its own truths. This is most amazing when the facts are clearly visible to anyone who will look for them, but often the "soldiers" on each side just accept the "general's" definition of truth without even looking at the facts.
Conflicts of interest create different truth for some. It is not uncommon to find someone selling some device who neatly packages their interpretation of the scientific literature for easy reading. Such a conflict of interest should put you on guard when deciding if the "truth" they present is really the truth.
Finally, what was true in the past may no longer be true anymore, as the state of knowledge is constantly changing. The problems this creates are summed up nicely by Quine and Ullian in their book, The Web of Belief. They write: "The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge."1 Maybe some can't handle, get or trust the source of the truth, but it is our duty to accept it, provide it and continually search for it.
- Quine WV, Ullian JS. The Web of Belief, 2nd edition. New York: Random House; 1978.
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