Hide Death?

Kübler-Ross took a job as an assistant professor of psychiatry at the University of Chicago. … She began a series of seminars, interviewing patients about what it felt like to die. … Many of Kübler-Ross’s peers at the hospital felt that the seminars were exploitative and cruel, ghoulishly forcing patients to contemplate their own deaths. At the time, doctors believed that people didn’t want or need to know how ill they were. They couched the truth in euphemisms, or told the bad news only to the family. Kübler-Ross saw this indirection as a form of cowardice that ran counter to the basic humanity a doctor owed his patients. ….

Kübler-Ross began to work on a book … It came out in 1969, and, shortly afterward, Life published an article about one of her seminars. … Angered by the article and its focus on death, the hospital administrators did not renew her contract. But it didn’t matter. Her book, “On Death and Dying,” became a best-seller. …

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance. … Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve.

More here.  Pause to see things from those old docs’ point of view.  While we usually prefer to be honest and forthcoming, we make exceptions.  Some of our reasons are selfish, but we also say that telling people some truths only makes them feel bad, without actually helping much to make decisions.

So isn’t imminent death a great examples of a truth that makes folks feel very bad without much helping decisions?  Look how fiercely people avoid thinking about death when it is only a slight possibility, and how more anxious they get as death becomes a larger possibility.

Sure, most folks say they want to be told the truth about imminent death.  But most folks also say they want to know if their partner is cheating, if their career is tanking, if their neighbors hate them, etc.  If you asked folks straight out, most would even say they want the truth on “do I look fat in this.” So if you are going to hide some type of truth from people for their own good, you must do so in the face of the fact that most folks say they want to be told.

Yes, we may like the closure of taking their time in saying goodbye to folks, but don’t similar modestly useful actions correspond to most truths we think of hiding from folks?  Does this gain so obviously outweigh the terror of knowing you will die soon?  I want to be told about my death, but I’m weird and want the truth on most everything.  What is a better example than imminent death of a truth we’d consider hiding from folks?

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  • Robert Koslover

    I assert that the biggest reason we should not hide knowledge of impending death from patients is that patients who are not dying may end up needlessly fearing that they really are dying, but that their doctors are lying to them! People are not fools. Example: An elderly close relative of mine had to have some non life-threatening surgery recently. She quickly found out that the surgeon to whom she had been referred was not just a general surgeon, but mostly specialized in cancer surgery. She immediately feared that she could actually have cancer and that her regular doctor was hiding this disturbing truth from her! I was only able to calm her down by assuring her that physicians don’t hide bad news from their patients nowadays.

  • Steve Reilly

    ” What is a better example than immanent death of a truth we should hide from folks?”

    The fact that a loved on died in excruciating pain. “He went painlessly” is the sort of lie that it’s hard to fault someone for perpetuating.

    • http://pancrit.org Chris Hibbert

      @Steve, yes, but by the same logic Robert Koslover used, most people now seem to realize (of if they don’t, why don’t they?) that the Doctor always says “He went painlessly”. I’ve never seen a case on TV or real life where they didn’t, so I believe it is an empty claim.

      • http://aryeh.name Simetrical

        Yes, but exactly because everyone always says it, if they didn’t say it, you’d assume that the relative went in horrible pain. So it does convey some meaning, it’s just greatly attenuated by overuse. This kind of thing seems to happen a lot to language/social conventions.

    • http://hanson.gmu.edu Robin Hanson

      By this logic, why doesn’t it make even more sense to lie to someone about how much pain they will die in?

  • seth

    I’m a physician who deals with these situations, and telling patients the truth is the only decent, ethical thing to do.

    Patients and their families hear what they want to hear, and the reality is that no one can say exactly when someone will die (unless you’re withdrawing ventilatory support)– these two factors modify the message and it’s interpretation.

    The older, patronizing style of medicine is not only outmoded and inefficient (patients do best when they help control their medical care), it increases a physicians chances of being sued.

    Now, if they would only pay us for counseling and educating, more of us would actually do it.

  • Andrew

    What Robert said above. A medical doctor will tell you that patients are easier to deal with the more they trust the doctor. In other words, the nature of their relationship is such that there is an extraordinarily high value placed on trust. Medicine is not a game of “Survivor” where you win with a timely act of betrayal after earning the trust of others.

  • http://aryeh.name Simetrical

    You probably mean imminent throughout, not immanent.

  • Mark

    What if you knew you learned you had a disease that would kill you in about ten years? Would you want to think about that every day, or would you mostly want to not think about it?

    Would you want all your friends to ask you once a month “How is it going?” or would you keep it quiet to most of them?

    • anon

      Most supercentenarians ought to be reasonably aware that they are likely to die in about ten years; we don’t do much to hide this truth from them.

      Nevertheless, many of them will avoid thinking about that every day, and their friends would also not confront them with their uncomfortable circumstances. Why should your example be any different?

  • http://www.uncrediblehallq.net/ Chris Hallquist

    Here’s a game theory-inspired answer: we want to be frequently, though not always, uncertain as to the truth when it’s in our interest to have a policy of responding to certain situations in certain ways, but not interest to act in that way *every* time such a situation occurs. For example, it might be in your interest to have a policy of shunning people who dislike you, but if you were always able to determine who strongly dislikes you, it might greatly impede your social interactions too much. Or: it’s in your interest to have a policy of getting a divorce if your spouse cheats, but on some particular occasion, following that policy might not be in your interests.

    Ignorance can also be in your interest if people will behave in a way more favorable to you if they believe you to be ignorant, and actual ignorance is the best way to avoid that.

    • http://www.uncrediblehallq.net/ Chris Hallquist

      Afterthought: the first kind of case may just be a special case of the second, since one of the big benefits of following a policy may be having others believe you are following the policy to the best of your ability.

  • clay

    What about suicide? Wouldn’t it be better to tell friends and family that their loved one died in some sort of accident than taking their own lives? This seems like a situation where many people can even event and convince themselves of some sort of lie. One famous case is Turing’s death and his mother’s belief that it was an accident.

  • mjgeddes

    “I’ve seen things you people wouldn’t believe. Attack ships on fire off the shoulder of Orion. I’ve watched C-beams glitter in the dark near the Tannhauser Gate. All those moments will be lost in time, like tears in the rain. Time to die”

    I’ve seen things

  • curious

    So isn’t imminent death a great examples of a truth that makes folks feel very bad without much helping decisions?

    not really. a patient who doesn’t really know s/he is dying is deprived of the opportunity to make informed decisions about how much treatment s/he needs/wants to endure.

    doctors themselves say that terminal patients choosing aggressive treatments often don’t even realize that they’re dying and regret their choices later.

  • Hal Finney

    This New York Times article, http://www.nytimes.com/2009/08/20/health/20doctors.html , offers a look at the issues facing doctors when they tell patients they are dying. As Seth says above, patients are sometimes unwilling and more or less unable to process the news. The article implies that sometimes the doctors leave it at that, and allow patients to cling to false hope if it brings them comfort. I don’t know how that squares with the perception that doctors today always deliver the brutal truth.

  • http://timtyler.org/ Tim Tyler

    “Although nobody makes a brief for ignorance generally, there are many special cases in which ignorance is cultivated – in order, for example, to protect national security, sexual innocence, jury impartiality; to preserve anonymity for patients, clients, reviewers, and voters; to create suspense in films and novels; to protect trade secrets; to measure the placebo effect and avoid various research biases; and to create mental challenges for gaming and study.”

    http://www.nickbostrom.com/information-hazards.pdf

  • http://hanson.gmu.edu Robin Hanson

    People seem to be missing the point that I was trying to focus on comparing being frank about death to being frank about other things. If you say we should be frank about death, and death is on the face of it a pretty good case for hiding, then why don’t you think we should be frank about everything?

    • Tim Tyler

      You asked which truths were worth hiding. Nick’s “information hazards” paper is all about when it is worth hiding the truth. Have you worked through his lists?

  • Anshuman

    Robin, you do look fat in that dress.

  • Eneasz

    I wasn’t frank about war after my brother joined the army. I didn’t send him a copy of War Is A Force That Gives Us Meaning, as it could do harm.

    • http://entitledtoanopinion.wordpress.com TGGP

      How about “War is a Racket”? It was written by Major General Smedley Butler.

  • http://www.uncrediblehallq.net/ Chris Hallquist

    Robin: *obviously* a huge part of why we’re not frank about everything is selfish reasons. Even if I thought I would be making the universe a better place by being frank about everything, that’s a larger sacrifice than I’m willing to make.