The Ethical Dilemma of Truth-Telling in Terminal Prognoses: A Couples Therapy Perspective
Tuesday, August 27, 2024. This is for J, who wanted to know for C&D.
The question of whether a family member deserves to know the truth about a terminal prognosis, especially when the remaining time is expected to be of low quality, presents a profound ethical and emotional dilemma.
This issue is particularly complex within the context of couples therapy, where the relational dynamics between partners can deeply influence the decision to disclose or withhold such information.
Ethical Considerations: Autonomy vs. Beneficence
In medical ethics, the principles of autonomy and beneficence often come into conflict when deciding whether to disclose a terminal prognosis.
Autonomy supports the patient’s right to be informed about their health status, enabling them to make decisions about their care and personal affairs (Beauchamp & Childress, 2019).
However, beneficence, which focuses on the well-being of the patient, can sometimes lead caregivers to withhold information to prevent psychological harm, especially if they believe the patient cannot cope with the truth (Quill, 2004).
In couples therapy, this ethical conflict can become particularly pronounced.
One partner may feel strongly that the truth should be disclosed, respecting the autonomy of the ill family member.
The other partner, however, might fear that revealing the prognosis will cause undue distress, exacerbate anxiety, or diminish the quality of whatever time remains.
The therapist’s role in such scenarios is to facilitate a balanced discussion that honors both ethical principles while considering the unique relational dynamics at play.
The Psychological Impact of Truth-Telling
Research suggests that the psychological impact of learning about a terminal prognosis can vary significantly depending on the individual’s personality, coping mechanisms, and the quality of their relationships.
For some, knowing the truth allows them to plan, say their goodbyes, and find closure, which can be empowering and even reduce anxiety (Gawande, 2014). For others, the knowledge may lead to despair, depression, and a diminished quality of life (Back et al., 2008).
Within couples, these differing reactions can strain the relationship.
One partner may seek to protect the other by avoiding difficult conversations, while the other may feel isolated or even resentful if they sense information is being withheld. A study by Lobb et al. (2010) found that withholding information, even with the intent of protecting a loved one, can lead to feelings of betrayal and complicate the grieving process for both parties.
Relational Dynamics and the Need for Truth
In couples therapy, it’s essential to explore how each partner perceives the role of truth in their relationship.
Some couples may have a history of open, honest communication and may view truth-telling as a fundamental aspect of their bond. In these cases, withholding the prognosis might be seen as a violation of trust, potentially causing more harm than good (Kissane et al., 2003).
Conversely, other couples may prioritize emotional protection over complete transparency.
In such cases, one partner may decide to shield the other from the harsh reality of a terminal diagnosis to preserve their peace of mind. This approach can be seen as an act of love, though it risks undermining the ill partner’s autonomy and ability to make informed decisions about their remaining time (Baile et al., 2000).
Therapeutic Interventions: Balancing Truth and Compassion
Therapists working with couples facing this dilemma often employ a delicate balance of truth-telling and compassionate support.
One approach is to gradually introduce the concept of the prognosis, allowing the patient to process the information at their own pace (Back et al., 2008). This can involve checking in with the patient regularly to gauge their emotional state and readiness for more detailed discussions.
Another approach is to explore the couple’s values and beliefs about truth and protection, helping them find a middle ground that respects both autonomy and emotional well-being.
Narrative therapy techniques can be particularly effective here, as they allow the couple to co-construct a shared understanding of the prognosis that aligns with their relational values (White & Epston, 1990).
Final thoughts
The question of whether a family member deserves to know the truth about a terminal prognosis, particularly when quality of life is compromised, is agonizing and often complicated.
In the context of couples therapy, this decision is influenced by ethical considerations, psychological impacts, and the unique dynamics of the relationship.
Ultimately, the goal of therapy should be to support the couple in making a decision that honors both the autonomy and well-being of the ill partner, while also preserving the integrity of their relationship.
Be Well, Stay Kind, and Godspeed.
REFERENCES:
Back, A. L., Arnold, R. M., & Quill, T. E. (2008). Hope for the best, and prepare for the worst. Annals of Internal Medicine, 149(3), 209-213. https://doi.org/10.7326/0003-4819-149-3-200808050-00008
Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302-311. https://doi.org/10.1634/theoncologist.5-4-302
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. Metropolitan Books.
Kissane, D. W., Bloch, S., Dowe, D. L., Snyder, R. D., Onghena, P., McKenzie, D. P., & Wallace, C. S. (2003). The Melbourne family grief study, I: Perceptions of family functioning in bereavement. American Journal of Psychiatry, 153(5), 650-658. https://doi.org/10.1176/ajp.153.5.650
Lobb, E. A., Kristjanson, L. J., Aoun, S. M., Monterosso, L., Halkett, G. K. B., & Davies, A. (2010). Predictors of complicated grief: A systematic review of empirical studies. Death Studies, 34(8), 673-698. https://doi.org/10.1080/07481187.2010.496686
Quill, T. E. (2004). Palliative care and ethics. Oxford University Press.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Norton & Company.