A New Perspective on Challenges in Truth-telling to Patients

Background and Objectives: Patient autonomy is a recognized principle in modern medical ethics, and truth-telling to the patient; thus, it holds special importance for its contribution to this principle. In practice, however, several challenges emerge that can lead to different responses. This difference is more marked in studies conducted in the Eastern and Muslim countries due to variations in cultural and religious beliefs. Truth-telling is a challenging concept respecting placebos, medical errors, and delivering bad news on diagnosis and treatment to patients.


Introduction
he physician-patient relationship is based on mutual trust, and the factors that obscure this trust may disturb the relationship. Truth-Telling corresponds with respect for individuals. Moreover, it is essential in establishing and maintaining trust between the patient and physician.
Honesty with patients was not addressed in classical medical ethics beginning with Hippocrates and his principles of medical ethics, or in the Declaration of Geneva and the early editions of the American Medical Association (AMA) code of medical ethics [1]. The reason was that non-maleficence was of such high value that justified lying to the patients. In modern medical ethics, beneficence and non-maleficence are regarded as essential principles. Accordingly, truth-telling is considered a rule in the modern codes of medical ethics [2].
Truth-Telling can be defined as refraining from lying, deception, misinformation, and non-disclosure [3]. It must be observed in all the communications between the physician and patient regarding diagnosis and treatment. However, the physicians might adopt a different approach. The concern about the patients' health following their awareness of and reaction to the truth has led to the physicians' paternalistic view of the patients in the past century, and occasionally the contemporary era. The emphasis on patient autonomy is the basis for truths disclosure in the physician-patient relationship in modern medical ethics. The swift change in today's world toward patient autonomy and informed consent originated in the West. This alternation impacted Asian and East Asian regions; it is opposed to withholding information in any form. However, there remains a certain difference in truth-telling to the patients between the physicians in Europe and the USA, and those in Asia and Muslim countries, as confirmed by several studies.
For example, with a review of several studies conducted in the middle-eastern countries, the authors concluded that healthcare providers' viewpoints on patients and their families were oriented toward withholding information to protect them from psychological repercussions. Moreover, there exist few educational programs on physician-patient communication skills available in these countries [4].
A study examined the codes of medical ethics on disclosure in cases of terminal diseases in 14 Muslim countries. Accordingly, it was found that the approaches to truth-telling varied greatly. The codes did not cover in-formation disclosure in 5 countries. Moreover, in 7 countries, they condoned withholding information from patients. Ethical codes in one country mandated disclosure and advocated non-disclosure in another [5].
In the majority of the studies, truth-telling is limited to life-threatening diseases or delivering the news on the diagnosis. However, truth-telling impacts all aspects of the physician-patient relationship, including using placebos and disclosing medical errors.
Initially, the common challenges in truth-telling were introduced. Next, the unaddressed debates in this area, medical errors, and placebos were discussed in this study. Then, the prominent approach in Islamic countries was evaluated to understand the patients' view on hearing the truth and whether or not the physicians act accordingly. The study also investigated how the patients and their families tend to receive the truth considering the predominant culture and religion. Moreover, the insight regarding the patients' and their families' perspectives can help manage truth-telling, particularly with bad news; therefore, physicians' performance across different societies and cultures was studied. Finally, the Islamic view was presented using the Verses of the Holy Quran and the Narrations from Inmate (Ahl Beit). Pay attention to this point is of grace; these Honorable Verses and the Noble Narrations are the predominant sources of decision-making in Shi'ite discourse.

Methods
This study was performed based on the unsystematic review of library and online sources using databases, such as Google Scholar, PubMed, Ovid, Springer, and the following keywords: "physician-patient relationship, truth-telling, placebo, medical error disclosure, and Islamic approach". More recent papers were given preference in use. Furthermore, Persian e-books and research papers were obtained from the Noormags website.

Results
The reviewed articles have studied the challenge of truth-telling in the field of health mainly in the 3 situations. The truth-telling challenge in placebo use, medical error reporting, and how to tell bad news, were the most challenging truth-telling cases discussed in these articles. In the second part of the discussion, the viewpoints of the Islamic countries about this topic were analyzed. Then, the domestic articles were analyzed. Finally, the Islamic point of view was analyzed.

Challenges in truth-telling
Truth-Telling to the patient is correlated with challenges under certain circumstances. Prevalent cases include telling the truth about using placebos, medical errors, and delivering bad news to the patients.

Truth-Telling in use of placebos
Using placebos requires deliberate deception or non-disclosure of the whole truth. Evidence suggests that in some cases, placebos can create the desired effects even with the full or partial disclosure of information. However, the placebo effect diminishes with the patient's awareness of the truth; it begs the question of whether or not it is ethically acceptable to use a placebo without truth-telling1. Using a placebo for clinical research seems to be ethically justifiable, as constant research is a necessity for the progress of medical sciences. Medical research is mostly experimental. Moreover, they fall in the philosophical context of logical positivism. Therefore, medical researchers in these studies, especially clinical trials, are forced to use a placebo. However, using a placebo is ethically justified only when the subjects are told they may receive a substance without therapeutic effects as they are randomly classified into groups [6].
Some argue that only the non-deceptive use of a placebo can be justifiable. This is because the trust between physician and patient is more valuable than any placebo effect [7]. In clinical trials, patients deeply trust the clinical researchers and participate in the process even when the odds of personal benefits are negligible. Therefore, the researchers should further establish trust by honoring ethical standards [8].
Concerning placebo use in treatment, the situation is different. some believe that using a placebo cannot be condoned as it disturbs the physician-patient relationship based on honesty and trust. Thus, placebo use is more applicable in treatment.

Truth-Telling in medical error disclosure
Truth-Telling with regards to medical errors is an essential aspect of a physician's professional commitment. In the cases of medical error, non-disclosure (even if it is called an acceptable term, like confidentiality) is deemed unethical and should be evaluated. The disclosure of non-harmful medical errors is not mandatory; however, it is preferred for creating an atmosphere of honesty between the patient and the physician [9]. In any case, disclosure becomes essential as the risk or amount of harm to the patient increases; as the level of harm decreases, disclosure becomes less crucial [10].
A study assessed physicians' perspectives about the disclosure of medical errors. As a result, it was found that 90% percent of physicians considered error disclosure as a major challenge in healthcare and stressed the necessity of a comprehensive system for reporting medical errors. In this paper, >75% of the physicians supported the disclosure of major medical errors while only half of them supported the disclosure of minor errors [11].
The fear of patient complaints against physicians, the loss of professional reputation among peers, and emotional responses by the patients' families may attribute to the non-disclosure of medical errors to patients [12]. However, ignoring major errors can seriously threaten the medical profession and community [10].
To hide the medical error is undoubtedly a deception that can undermine trust in physicians [13]. Therefore, error disclosure should not conflict with truth-telling. However, measures should be taken to minimize the repercussions of disclosure.

Truth-Telling in delivering bad news or diagnosis
There are numerous arguments about disclosing the diagnosis of terminal or refractory diseases to patients. The perspective and beneficence toward the patient, determine the trajectory of such decisions. By respecting patient autonomy, all information on diagnosis, treatment, and prognosis of the disease, as well as the costs and effectiveness of each available treatment must be provided to the patient. But practically, however, the realization of this right is met with numerous professional, emotional, and psychological challenges [14]. ( That is why some professionals do not recognize truth-telling as an absolute duty; they rather believe that it should be balanced concerning other ethical considerations, like nonmaleficence [15].
The results of the majority of studies on truth-telling to patients in Iran indicated that physicians and the healthcare teams preferred not to tell the truth and even considered it wrong; fearing that disclosing the truth can disappoint patients and disturb the treatment process [16,17]. Same studies reported that patients preferred to be fully informed of their situation. Several studies revealed that patients who were unaware of the diagnosis experienced a better quality of biopsychosocial life [18]. However, contemporary medical ethics' turn towards respecting patient rights, which has impacted Eastern societies, including our country. This point was explained in a study conducted in 2010 in Isfahan, Iran. In this study, 90% of the explored physicians supported informing the cancer patients of truth during the early stages of the disease, and 70% supported it in the advanced stages [19].
Patients have the right to be fully informed of their situation, in return, it is the physicians' obligation to tell the truth. In some cultures, withholding the truth from patients is preferred as a form of protective deception. They also expect the physicians' cooperation in hiding the truth from the patient.
Truth-Telling is significant in terms of respecting patient autonomy and having the right to make decisions; it also strengthens the physician-patient relationship and helps the treatment process. A patient who is aware of the diagnosis better cooperates with the medical team in choosing the diagnosis and treatment methods. However, hiding the whole or part of the truth is justified if truth-telling results in serious harm to the patients and their depression, isolation, or suicide [20]. A conflict may arise between the patients' autonomy and the principle of non-maleficence. While in some cases, the patient can be prepared through step-by-step disclosure, there are always cases where this conflict cannot be resolved. Metaphors, rather than the harsh truth have been suggested as a strategy for truth-telling [21]. However, the practical efficacy of this strategy remains questionable.
The right to information is recognized in the Patient's Rights Charter of the Islamic Republic of Iran. In paragraphs 1-2, it is emphasized that healthcare must be delivered based on honesty [22]. However, it does not explicitly address the delivery of bad news.
For a Muslim patient, the awareness of the truth, especially regarding a terminal disease is valuable in terms of preparation for death and using the final days of life. Patients can take advantage of their remaining days to compensate for the past, seek forgiveness, pay back their debts, and make a will. The will-making is highly recommended in Islam [23]. Also, it is a good time for repentance, i.e., acceptable until the moment of death according to the hadiths from the fourteen infallibles [24].
Although truth-telling is essential, there are always cases where it is justified or necessary to withhold the truth. Therefore, a framework is required to serve as a measure under particular circumstances. Considering the Islamic and cultural background in Iran, the Islamic perspective on the justification or necessity of withholding the truth or either lying occasionally can help define ethical standards.

Truth-Telling in Muslim countries
Studies in Saudi Arabia reflected that most patients prefer their diagnosis to be disclosed to their relatives. Moreover, in the organizational law of the country (Article 20,1990), it is asserted that in cases of terminal disease, the physician can decide whether to disclose the truth or withhold it from the patient.
In Libya, per Article 17, Act 1986, the physician is required to tell the truth to the patient under all circumstances, even in cases of terminal disease [25].
A study in the UAE reported that its citizens responded differently to truth-telling based on the nature of the truth. They also prefer to know the truth about curable diseases while they prefer not to know about refractory or terminal diseases (with <50% odds of survival over 6 months) personally [26].
In Lebanon, physicians prefer not to share information regarding cancer and refractory diseases with the patients. They believe that such an approach serves the patients better concerning their culture [27].
The physicians in Egypt employ a similar approach based on their culture and conditions. Additionally, research indicated that surgeons believe they should refrain from disclosing the information with patients encountering refractory diseases as it disappoints them [28].
Physicians in Turkey also retain the legal right to decide whether or not they should share the information with patients after examining them [29].
Contrarily, several Muslim countries employ a different approach that may reflect the dominant culture and traditions in those countries. For instance, in Kuwait, according to Act 1981, physicians are obligated to inform the patients of their clinical status and to disclose the truth even during the advanced stages of the disease. Meanwhile, under no circumstances is it permissible to deny the truth to raise the patient's hope.

Iranian view on truth-telling
A study on the Iranian patient preference revealed that concerning internal medicine and general surgery, >84% of patients preferred to receive the information, while only 56.2% were satisfied with the extent of disclosed information [30].
Kazemiyan et al. explored physicians' perspectives on truth-telling to patients with refractory diseases; accordingly, 35% of the respondents believed that the patients had the right to be informed of their disease. Contrarily, 6% did not recognize any rights of this type for the patients and 59% believed this right to be subject to specific cases and the realization of certain circumstances. This study determined the patients' cultural class as an essential factor in the physician's decision [31].
Taveli et al. evaluated 142 Iranian patients in Tehran. They concluded that only 48% of patients with gastrointestinal cancer were aware of their diagnosis [32].
Meanwhile, 90.4% of patients under cancer treatment in the Cancer Institute wanted to know their diagnosis. Only 39% were provided with sufficient information from their physicians. Moreover, 61.2% of families believed that the patient must be informed of the diagnosis. Besides, 84% of the family companions preferred to know the diagnosis in case they were diagnosed with cancer [33]. However, Kazemi et al. suggested that 72% of physicians maintain that the decision on disclosing the truth to the patients can differ based on their sociocultural status [14].
In a review article, Zahedi et al. suggest that the dominant culture in the Iranian community is that the physicians prefer to share the information regarding the status of the patients with their family members instead of the patients [23].
According to 2-1-4 paragraph of the Patients' Rights Charter in the Islamic Republic of Iran, the physician is obligated to provide all the information regarding the diagnosis and treatment methods and the possible adverse effects, the disease, prognosis, as well as all the information regarding the progress of the disease [22]. If the patient refuses to receive this information, it should not be provided to them. However, this Charter notes that the information must be presented at a suitable time and place considering the patient's condition.
In that regard, how the news is delivered to the patient is of paramount importance. Moreover, the special conditions of the patient and the risk of serious harm should be accounted for.

Truth-Telling in Islamic view
Honesty is highly valued in Islam. The keyword of "Sidgh" and its derivates, is repeated 155 times and used in 144 Honorable Verces of 49 Blessed Chapters of the Holy Quran. The Holy Quran introduces the events of the day as a means of testing to distinguish the truthful from the false claimants 1 . Elsewhere, he announces the truthfulls to the rewarders for their valuable and ethical work 2 . Another noteworthy point is that the Holy Quran calls the opposite of truthful as hypocrites 3 and infidels 4 elsewhere. This way of coping with the hair address the significance of honesty in the Holy Quran.
Numerous accounts are available on the importance of honesty and refraining from lying in Noble Narrations. Evaluating these Narrations indicated that in addition to strengthening the relationship between man and his creator and bringing him closer to the heavenly sublime by veracity; it can also guide human relations towards benevolence. A statement attributed to Imam Ali (PBH) asserts that: "The honest is close to bliss and prosperity, and the liers are on the verge of downfall and humiliation" [34].
He (PBH) also said: "God bestows honesty upon a servant He loves" [35]. When a physician who has been nurtured with religious teachings, such as 'honesty is the pillar of Islam and the pillar of faith' [36] or 'honesty is the best way in every thing' [37] and recognizes them as the foundation of his or her faith and virtuosity encounters a patient who was subjected to a medical error or encounters a life-threatening disease, truth-telling is only natural unless there is a good reason for acting otherwise.
In deontological ethics, Kant asserts that honesty is an absolute concept, i.e., not annulled under any circumstances. He condemns lying even when it is a victim's only escape from a murderer. Contrarily, from a utilitarianists standpoint, lying is a neutral act regardless of the harm or benefit it may bring. In every situation, the best action is the one that brings the most benefit to the humans, even where this benefit give by lying or the only approach for this benefit be honesty. Accordingly, utilitarianists recognize white lies and believe that these lies are generally beneficial and in compliance with the principle of utility [38].
The Islamic view is different to an extent; while it strongly condemns lying and recommends honesty, it does not accept the severe harming of a faithful or Muslim human. As the prophet Muhammad (PBH) said: 1. "We certainly tried those that were before them and assuredly God knows those who speak truly, and assuredly He knows the liars." Blessed Chapter of Al-Ankabout, Honorable Verce of 3. 2. "That God may recompense the truthful ones for their truthfulness, and chastise the hypocrites, if He will, or turn again unto them Surely God is All forgiving, All compassionate." Blessed Chapter of Al-Ahzab, Honorable Verce of 24. 3. ibid 4. "That He might question the truthful concerning their truthfulness and He has prepared for the unbelievers a painful chastisement" Blessed Chapter of Al-Ahzab, Honorable Verce of 8.
'Dear Ali, the Lord in heavens views lying (to promote) good as a friend and honesty (to promote) Evil as an enemy [39].

Imam Ja'far Al-Sadiq (PBH) said
'If a Muslim asks a question from another Muslim and is told the truth that results in his suffering, the Lord will count the respondent among the liars, and if a Muslim asks a question from another Muslim and is told a lie that benefits him or her, the Lord will count the respondent among the honest' [40].
As understood from the general outlook of these accounts, withholding the truth and even lying to prevent harm and corruption is not only justifiable, might even be necessary in some cases.
In another account, Imam Reza (PBH) said: 'If someone tells his faithful brother a truth that harms him, God counts him among liars, and if someone lies to his faithful brother to benefit him, God counts him among honest men' [41].
This emphasis on preventing harm to a Muslim is in concordance with the 'La-Zarar' (No Harm) principle in the Shi'ite fiqh. Based on this principle, the Holy Share' (The God) announces that harmful rules are not his. Therefore, this rule can render other rules null if they lead to harm. It is even argued that this rule can confirm rules that cannot be proved based on other reasons [42]. Essentially, any individual religious duty that brings harm in any way is ruled out in Islamic Shari'a, and Islam does not condone causing harm and damage to others [43].

Discussion
This view in Islamic studies establishes a guideline of moderation, i.e., never addressed so thoroughly in any other philosophical discipline. This form of protection provided for humans within the framework of Sharia reflects the value of humanity in precious Islam. Notably, corruption or harm to a Muslim individual or Muslim community must be regarded as a severe logical issue. This permission to "white lies" cannot become an excuse for any small and major lies "beneficial" lying through life. Legenhausen so delicately noted: 'An individual who adheres to divine prudence uses even white lies with the utmost care, a faithful person lies rarely and only out of absolute necessity (i.e. in defense of beliefs or to establish peace among people)' [38].
Essentially, the philosophy of medicine is based on helping patients and reducing their pains. Considering the unique condition of each patient, a perfect solution cannot be prescribed for all of them and the same strategy to manage all cases. The emphasis on truth-telling in the Islamic view is no less than other schools of thought. In addition to the benefits that truth-telling brings, Islam considers truth-telling as the manner of human excellence towards God. However, Islam is a guideline for human life at all times. Furthermore, it includes different aspects of human existence. Therefore, it has evaluated various conditions of man under different circumstances and never demands anything from him that he cannot endure.
Despite numerous practical challenges and conflicts with the principle of beneficence to the patients, the principle of autonomy is the effective approach to truth-telling to the patients, especially in the West. Truth-Telling is supported and justified in terms of the physicians' professional duty and due to the better results that it brings for the patients. However, it is not logical to view it as a perfect infallible practice. A physician's measure in truth-telling must be presenting the most benefits while preventing or minimizing harm to the patients. Moreover, causing severe and certain harm to a subject by telling the truth is not permissible from a religious perspective.
Considering the importance of truth-telling and its impact on the establishment of trust and improvement of the physician-patient relationship, it is necessary to find a way to minimize the harm to the patient while avoiding lies, deception, and misleading as much as possible. Additionally, the same argument can be used to limit nondisclosure to cases when the patient is faced with severe, irreparable harm. As a result, the question arises as to what are the examples of severe harm and damage to the patients and how to minimize them. Multiple approaches to communications in the physician-patient relationship are proposed to minimize the harm to the patients that are outside the scope of this research. However, by employing these methods and proper communication skills, it is the truth that can be presented to patients as much as possible. Furthermore sociocultural environment, patients' opinions, as well as patients' family and their support can help in managing the information disclosure.

Conclusion
Considering the great significance of truth-telling, all possible approaches, to tell the truth, should be evaluated and truth-telling should be given priority; however, in specific circumstances and the mentioned examples, other options can be exceptionally considered. Thus, if disclosing the truth may expose the patient to certain, serious biopsychological risks, denying the whole or a part of the truth might be advisable, and even infrequent cases lying to protect the patient can be justified.

Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
This research did not recive any grant from funding agencies in the public,commercial,or non-profit sectors