1. Defining the Term

The question discussed in this entry is:

Are we obligated or required to disclose the whole truth regarding the medical condition of a patient suffering from a severe, life-threatening disease, tell him only part of the truth, conceal the truth from him, or genuinely lie to him?

We are addressing mainly terminal patients or patients with severe, chronic diseases rife with suffering.

The decision whether to tell the patient the truth or not is dependent on the fact of the case and moral and halachic considerations. Similarly, there is a need to determine who is qualified to determine whether to tell a patient the truth or not, and what the proper method and approach is to make this decision.

2. Scientific Background

a. Moral and Evidence-based Reasons to Tell the Patient the Truth

One can divide the reasons to tell a patient the truth into two main categories:
1) General, Fundamental Reasons

• There is a fundamental moral obligation to tell the truth.

• The right to free will, the principle of individual freedom, and the obligation to respect others includes the basic right of the patient to know what they have.

• The right of patient autonomy, allowing them to make therapeutic decisions, requires telling the truth, so that the patient will be able to base their decisions on correct data.

2) Practical, Need-Based Reasons

• The need for a patient to know the truth in order to arrange their affairs, or prepare themselves for death through confessional, repentance, and prayer. 

• The need to create an atmosphere of truth around the patient, in order to provide the basis for the patient’s trust in the medical system, for if the patient suspects that they are lying to him he will lose trust in the caretaking team. Different treatments require patient cooperation, and not knowing the truth significantly lowers the chances of success; the level of communication between doctor and patient increases and improves when they do not need to discover things through a web of lies and concealment from the doctor, while additionally enabling the patient to be more open with honest, direct conversations with the medical team that will ease their mental state; fear arising from not knowing can at times be worse than the knowledge itself, and situations of doubt can be more psychologically difficult than knowing and understanding the facts.

Some patients know much more of the truth than what it seems to those around them, and at times their knowledge is warped and worse than the truth itself. Therefore, it is best to reveal to them the true facts; the public overall is much knowledgeable than they were in the past regarding medicine, due to improved means of communication and the diverse, open connections with the medical establishment, and it is certainly difficult nowadays to hide diagnostic knowledge such as cancer when the patient is begin treated in the oncology ward, and therefore concealing the truth and using codewords are no longer effective.

In the modern medical world, when tens of people are involved in different ways in treatment and approaching the patient, it is difficult to hide the truth from them, and at times it reaches them in a warped, extreme, and incorrect fashion by unqualified people, and under improper circumstances not beneficial for disclosing information. Thus, the doctor’s concealment of the truth does not prevent knowledge of the truth, and at times the patient will learn of their condition in a negative manner.

Concealing the truth can lead to malpractice suits by the patient and/or their family members, claiming that the concealment of the truth causes them suffering and financial and medical damages.

Studies have shown that the trend becoming more prevalent amongst the general public – the healthy, sick, and medical workers – is in favor of disclosing information and providing the facts; Analyzed data of the past years has shown that patients process information much better than doctors or rabbis expect, and the assumption that knowing the truth will harm the physical and mental wellbeing of the patient is not proven at all. On the contrary, regarding cancer patients there are proven facts that show disclosure of information lowers their level of fear and suffering, and concealing the truth increases it.

Kubler-Ross evaluated hundreds of terminal patients, and concluded that disclosing the truth caused the majority of them to go through five stages:

• Denial (“The diagnosis is incorrect; it cannot be”)
• Anger (towards family, friends, doctors, the medical staff)
• Bargaining (with the Creator or with the medical staff – “why specifically me?”)
• Depression (the hardest stage for the patient)
• Resolution (with reality, relative tranquility, better approach to their condition – the desired stage).

In my opinion, it is best to tell a patient information about their condition in order that they can reach the

end of the process and are at peace with their situation, then they can cooperate with the medical team and their mental state will significantly improve. One should emphasize that scientists disagree regarding the validity of this approach, for not all patients undergo these stages, not all undergo them in this order, some gravitate from stage to stage, some regress to earlier stages, and primarily, not everyone reaches the stage of resolution, or they do not stay there and regress to more severe stages. However, despite the criticism of the method, one cannot ignore it, for its main point is true, and one should utilize it properly and appropriately.
b. Moral and Evidence-based Reasons to Tell the Patient the Truth

The fundamental obligation of the medical team is to abstain from causing harm to a patient and act in the interests of preserving their health and life, and if knowing the truth could harm them, one should hide it. At times, knowing the truth can bring a patient to despair, depression, and even suicide, and on the other hand, not knowing the truth can strengthen hope, in itself helpful for assisting rehabilitation; truth is not an absolute value, and therefore there are circumstances where it is permissible to deviate from it; the value of life is a loftier principle than the value of autonomy, and therefore in situations where disclosing the truth can harm the patient’s life and health the principle of autonomy is overridden, even if the patient requests it; not always is the patient’s request to know the truth their genuine desire, and at times it specifically is an expression of their wishes of protecting themselves from the truth; there are doubts regarding scientific-medical truth, and at times there is doubt regarding the reality of the what the doctor knows to be true, whether in the diagnosis or the expected disease progression as well as the patient’s condition, such that what seems like truth could perhaps be a mistake, or the situation will change in an unexpected manner.

c. Statistical Data

Until not long ago the opinion was prevalent not to disclose the truth regarding a patient’s condition, in order to prevent loss of hope and not to aggravate their situation.

In a survey issued in 1961 in America, 90% of doctors opposed openness in this topic.

As of late – mainly in the United States – there has been an extreme change in this trend towards telling the entire truth.

In a survey issue in 1977, only 2% of doctors opposed telling the whole truth, and another survey from that year in America concluded that 80% of doctors talk about death with their terminal patients.

The data from different surveys of healthy individuals or individuals sick with non-serious conditions in the United States showed that 80-98% stated that one should tell the truth to cancer patients; a survey of cancer patients in the US showed that close to 90% of them declared their wishes to know the truth, and to contrast, in British surveys, only half to two thirds of cancer patients stated that they were interested in knowing the truth about their condition. In a small survey performed in Israel amongst cancer patients, it became clear that the overwhelming majority supports disclosing the diagnosis to patients. Furthermore, most knew that they suffered from cancer, even if it wasn’t told to them by their doctors, and those that were told their diagnosis directly by physicians were more optimistic about their state than those who learned of their condition from other sources. In another survey in Britain where the truth about cancer was told to all the patients, it was found that 7% of them were unhappy that the truth was disclosed to them.

In a comparative study between patients and families who had the truth hidden from them and those who were told the truth, it became clear that despite the fact that the initial psychological response was more difficult for those who were told the truth, after continued follow-up until their death, considerable more significant psychological disorders were seen in the group which was hidden from the truth, and it was generally found that the most common complaint of patients against their doctors was lack of disclosure of information and explanation of the facts.

d. The Proper Method to Tell the Truth

Disclosing the truth requires expertise, education, experience, and an honest desire to achieve the best outcome for each patient in accordance with their unique situation. A proper solution requires an appropriate response to the following topics: Who? Why? What and how? Where?

The most appropriate person to tell the patient the truth is the doctor, especially a doctor who has created a good rapport with the patient, for he understands the facts of the case best, is able to answer the patient’s questions, and has prior experience in these situations. However, at times there is priority to other people, such as a partner or parents [in the case of a terminally ill child], rabbi, social worker, or psychologist. One should assess each case individually, whether it is better that the information provider and the patient be alone when the information is disclosed whether it should be done in the presence of a doctor, relative or close friend, or whether in the presence of a rabbi, social worker, or psychologist.

The best time to disclose the information to the patient is generally after the diagnosis is reached, when the data is clearer. At times there is a very fundamental suspicion from the first meetings, or the patient pushes to know the data already in earlier stages of the medical evaluation. Regardless, it is best to defer the disclosure of detailed information until after the assessment is complete and update the patient immediately after the diagnosis is clear.

The central issue is the method of communication and transfer of information to the patient. The truth itself can be difficult and cruel, however the method of giving it to the patient should not be cruel, rather one should give over the information with great sensitivity and total consideration of the expected psychological response of the patient, in light of the preliminary information regarding their character and personality, culture, education, intellectual capacity, etc.

One should allocate professional support staff and an appropriate time in order to be ready to deal with the patient’s response and questions properly. Therefore, one should set up a second meeting for clarifications and answer questions that arise after the initial shock of providing the information, and one should be available to the patient at any time they feel necessary. One should be prepared to take care of the patient’s responses with the help of proper and skilled rehabilitative-support staff such as a rabbi, social worker, psychologist, etc.

During the conversation, one should make sure that their method of delivery, content, and general behavior should express on the one hand seriousness and on the other hand hope. One should tell him that he is sick with a severe condition, however, do not say that he is terminally ill or that the condition is terminal, or that he has no hope, and generally it is proper for the physician to abstain from providing an assumed life expectancy. The doctor should not lie; however, they should not tell them all the truth in detail, at least in the first meeting. One should navigate the amount of information based on the need for and importance of said information for the patient, according to the doctor’s discretion.

Continued provision of information and its breadth are greatly dependent on the explicit and implicit desires of the patient, in accordance with their questions, requests, and responses to the preliminary information given to them. Generally, one should abstain from providing too many scientific and complicated details and give over important and required information in a style and language that is simple and understandable, with the goal of conserving hope and support. In any case, one should reinforce the patient, tell them that they will do all that is possible to be done for treatment, comfort, and to prevent suffering.

The amount of truth disclosed can be dependent on the age of the patient, the characteristics of the condition, and chances of alleviating or curing it, as well as the opportunities for open discussion in their state.

The proper place for providing information must be quiet and private, and not in a room with other patients, hallway, waiting room of the operating room, etc.

3. Halachic Aspects

a. The General Moral-Halachic Imperative of Telling the Truth

There is no doubt that truthfulness is a very important ideal, describing one of God’s attributes, Torat Hashem, and His mitzvot. Truth is one of the three pillars on which the world stands. There exists an obligation to tell the truth, even within one’s heart, that they should not speak one thing and mean another, and all of a person’s speech should be language of truth with proper spirit and a pure heart. A person is obligated to do business with faith, that both what is yours and what is not is acted upon with righteousness. One should abstain from telling falsehood, for lies are abnormal and abhorrent, and one should avoid trickery, and some say that all those who lie and cheat are liable for desecration of God’s name (Chilul Hashem) as well.

Yet, according to halacha, telling the truth is not an absolute moral value, and therefore in situations where there is conflict or contradiction between the value of truth and other values (such as human life, peace, etc.), it is permissible to deviate from the truth:

It is permissible to use alternative wording to preserve peace like we have found by the brothers of Yosef, and there are those who say that it is a mitzvah to deviate for the sake of peace. We see this when God changes his wording in order to preserve peace between Avraham and Sarah, and the angels used alternative wording by Manoach and his wife; all falsehood is prohibited, but it is permissible to lie in order to promote peace between man and his friend.

However, some say that the statement that it is permissible to deviate from the truth for peace is only applicable to matters that have occurred in the past, but for matters in the present and future it is prohibited to lie, even for peace. There are those who disagree with this principle, and certainly, when necessary, one may be lenient even in the present. We have also found other examples where deviation from the truth was permitted, such as “teach your tongue to say, ‘I do not know’, perhaps you will become entangled in a web of deceit”; a talmid chacham is defined as one who is careful about the truth, but deviates for the sake of peace and matters of modesty; and for pikuach nefesh one is permitted to sign something that is false. 

There are those who write that the Torah does not require one to distance themselves from falsehood unless the falsehood can cause harm to one’s friend, however if the lie does not lead to evil, the Torah did not prohibit it.

b. Disclosing Information to a Patient

A number of sources from Tanach and halacha act as the foundation for the discussions of the halachic authorities regarding whether to tell the truth to a patient regarding their condition or avoid it altogether:

• The story of Elisha and Ben Hadad:

“Your son Ben Hadad, king of Aram, has sent me to you to ask: will I live from this illness? and Elisha said to him, go say to him, ‘You will recover [the word is written as ‘לא’ (no) but is read as ‘לו’ (to him)]. However, God has revealed to me that he will die”.

A number of explanations have been brought for this account, according to which some have learned how to act when confronted with the issue of disclosing truth to a sick person. At first glance it seems that according to the verse, one should tell the patient the truth [Elisha told Ben Hadad: he shall not live, as God had shown him], according to the spoken version, one should lie to a patient [Elisha told Ben Hadad: he shall live, and God showed him that he will die]. There are those who interpret that according to what is written Elisha told others that he will not live, so they will not say that a false prophet has spoken, but he lied to Ben Hadad himself and said that he will live, as appears from the spoken version.

• The matter of Yishayahu and Chizkiyahu, where the prophet tells the king: ‘instruct your household, for you are dying and will not live’. 

The sages say:

“Chizkiyahu said to Yishayahu, as customary in the world, a person who comes to visit a sick person, says to him: the heavens should have mercy on you, and a doctor who comes to visit him says eat this food and don’t eat this, drink this and don’t drink that, and even if he sees that he is dying, he does not tell him to instruct his household, so that his resolve not be weakened”.

• The matter of confessional:

When a person becomes bedridden, people enter and tell him words that do not revive nor bring about death, and tell him to focus on his matters, and when he becomes sick and is dying, they tell him to confess.

There are those who hold that we specifically wait until he is dying for confessional, but we do not tell a person who is not dying to confess, so as not to break his spirit. There are those who write that confessional will oftentimes alleviate sickness, and there are those who write that confessional is a necessity of the soul, for he must confess well with total regret and with a broken heart and settle his matters so that he does not remain liable for sins. This should not occur as is commonplace, where we wait with these matters until the soul is despondent and the patient has no consciousness, unable to think in proper repentance.

Amongst the authorities and researchers who deal directly with the issue of disclosing information to a patient we have found a few opinions: there are those who hold that one should not disclose any information to a mortally wounded patient about their condition, in order not to dampen their soul and place a toll on their healing; even if his father commands him to reveal what is wrong with him when he is critically ill and suffering tremendously, the son is forbidden from disclosing this to him.

There are also those who add that even if a patient suspects that they have an incurable disease, it is prohibited to tell them, and even if there are patients who respond well to disclosure of information, since there is a chance that even a single person will respond negatively and his death will be brought closer due to the revealing of this information, it is prohibited to do this in all circumstances.

There are those who write that generally it is best to remain quiet and avoid the truth, unless we know definitively that the matter will not harm the patient, but if there is a concern that disclosure of information will harm the patient, one should not reveal it, and if the patient forces the doctor to swear that this is the truth, he should not swear falsely, unless it is clear to the doctor that without this oath the patient will enter a life-threatening state.

There are those who write that it is prohibited to tell a patient negative news because of the verse “and one who expresses slander is a fool”, yet when there is a need to inform the patient of their condition, this does not apply.

To contrast, there are those who write that if a patient is terminally ill and requests from their doctor to tell them the truth so they do not go insane, he should tell them the truth if they are suffering greatly, very elderly, or must dictate heavenly matters, and one should prepare a terminally ill patient for the possibility that they will not emerge from their sickbed, to arrange their affairs and confess, but one should provide support in their words and only say what needs to be said, without breaking their spirit.

Since the goal of medical care is to lessen the suffering of a patient, encourage them, and support them, one should also strictly evaluate each case individually and determine what the best treatment method is for them, and oftentimes it is better to tell the truth than to avoid it altogether.

There are those who differentiate between types of patients:

Those who have a chance of recovery, and the assessment is that telling the truth will encourage them to better deal with their condition and cooperate with rehabilitation, should be told the truth, and one should reveal this first to the close family members of the patient, afterwards to the patient accompanied by them and with their knowledge, to disclose the information to the patient about their situation, through encouragement and instilling of hope.

Regarding those who are terminally ill and have no treatment for the disease, aside from treatment for the pain, one should only disclose to the family members and not to the patient.

Regarding those who modern medicine has no available treatment for, but can potentially die suddenly at any moment, one should tell them to confess. Nevertheless, this is not the custom nowadays.

There are those who write, that since according to halacha the problem of whether to tell the truth or not is dependent on the question of what will benefit the patient, then it is impossible to say a defined and absolute statement, and one should evaluate each case separately, what is best for the patient, and nevertheless it is prohibited to prove to the patient that their condition and suffering is a punishment for their sins, and should not engage in a discussion the way that Iyov’s friends did.

Telling the truth for the purpose of medical experimentation – see the entry ‘medical experiments’.

4. General Ethics

For all of history, doctors and ethicists have pondered: is it better to tell the truth to a patient or hide it from him?

In Hypocrites’ works, doctors are warned to hide the truth from critical patients, for knowledge of the truth can cause a decline in their medical condition.

A similar approach was commonplace amongst physicians in medieval times up until the last few years. Thus, in the past the accepted approach was to hide the truth, and this was provided moral support by the English doctor Thomas Percival, who claimed that the wellbeing of the patient stands above the consideration of the patient’s right to know the truth. This approach dominated the entire world until the middle of the 1960s, and many places still accept this approach as the proper method. However, the developing tendency nowadays in different countries, primarily the United States, is to dissociate from the approach of downplaying the truth, hiding it, or providing false information, towards being very open and maximizing the amount of truth exposed to the patient. This approach fits with the common moral views today, mainly the principle of autonomy, and the legal approach, with the concern of malpractice lawsuits. Together with this there is consideration of facts of the case, such that if the medical assessment is that a certain patient will be harmed by disclosing the truth one should not reveal it to him, but they should secretly disclose the matters to his relatives.

The accepted approach nowadays, however, is not: “should we tell the patient about his condition?” but: “How should we tell the patient about his condition?”

One should note that according to Kant, truth is a supreme moral value that one should not violate under any circumstances, and therefore even if conserving it would cause damage one should make sure not to lie, however many philosophers disagree with him and hold that under certain circumstances there is justification to deviate from the truth and even to lie. There are those who differentiate between genuine falsehood which is prohibited, and not telling the truth or wording the statement in a manner that can be interpreted both ways, which is permissible under certain circumstances.