This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and has now been updated.
Ethics in a practical context
We cannot get very far in our ethical development without also understanding the distinctions between rules and consequences – deontology and teleology – in ethical debate and whether we individually tend more towards rules or consequences in our practice.
Truth telling should be considered as part of a matrix of core healthcare values. Apart from the importance of communicating facts to patients and relatives, it is equally important to have the skill to do it well, to speak the truth with kindness. Thus, having good communication skills is itself and ethical imperative. Part of that ethical imperative is the need to understand the significance of the patient’s (or family’s) narrative within their frame of reference. Thus, awareness of personal sensitivities forms part of the ethics of communication. Aspects that may hinder good communication may include:
How might these issues directly relate to pain management? Most obviously, different cultures may have different perceptions of what constitutes pain and suffering. Men may think they are stronger than women or vice versa and tolerate any pain or suffering in silence. Older people with long term chronic pain may consider additional pain as not greatly significant, especially if they see themselves as ‘copers’. In some religious perspectives, suffering may be seen as a punishment, or something that is ‘good for the soul’.
Although we must be aware of the effects incurred through stereotyping, it is nevertheless ethically important to be aware of these sensitivities in truth telling. The most obvious area where truth telling has to be especially skilled is in the breaking of bad news. This process is as much a matter of getting the practical things right as it is having the personal skills to do it.
Breaking bad news needs the ability to communicate effectively and at a basic level, it is unethical not to use clear and unambiguous language. Communication is only realistic when the carer has taken some time to consider the frame of reference of the hearer. For instance, the influence of culture, gender and other factors mentioned earlier as well as the level of intellect, level of consciousness or even the ability to hear in those to whom we are communicating need to be considered.
The carer has to have self-confidence and to have developed an ability to answer questions honestly, but not brutally and to be able to assure him or herself that what has been said has been heard; that the meaning and implication of what is heard, is the same as that which was intended by the speaker.
The carer must learn the skill of imparting devastating news incrementally in sufficient amounts that the hearer has time to comprehend the implications of what is being said. The carer must be prepared to reinforce the message that is given on more than one occasion. This is a matter of patience but it is also a skill.
The carer should have the insight through training to understand the processes of premature grieving, as well as the ability to recognize and manage the patients’ emotional, psychological and spiritual distress. The key to this is for carers to be aware of their own feelings and emotions about these issues. If you do not know yourself, how can you begin to understand those in your care?
Information giving is the foundation of trust but it is only a beginning. It is not just a matter of telling the truth but also the manner of telling. There should also be no hint that some things are different for the carer to be open about. It is equally unethical to withhold information as it is to speculate inappropriately when some information is not fully known. There is a large range of skills to be learned. A knowledge of family dynamics is helpful as it a sensitivity to the issues of confidentiality.
Breaking bad news has four distinct, but complementing aspects:
- Giving the initial information to the patient and/or family;
- Responding to immediate questions;
- Reinforcement of information and continued personal support;
- Updating of information.
Since breaking bad news is part of a process of support and not one single event, it will involve more than one person. Clear communication between all the individuals involved is crucial to the delivery of appropriate personal support of patients and their families and to consistent information giving. In an ideal world, clear information should always be given to the patient first. It is a matter for personal judgment whether sufficient exceptional circumstances exist to deviate from the ideal norm.
Let us briefly explore the theoretical justification of confidentiality. Confidentiality is justified in terms of rules (deontology) by relating it to, for example, the duty of promise keeping, or the respect (autonomy) for the individual to whom the promise is made. If one were to justify confidentiality in consequentialist (teleological) terms then one might claim that the outcome of keeping patient confidentiality is always to preserve the carer to cared-for trusting relationship and makes it easier for further disclosure and openness.
Here we can see two different people agreeing on the importance of confidentiality but from two very different ethical perspectives.
If you consider when breaking bad news, you can see that both the deontologist and the teleologist would be able to support it but perhaps for different reasons. As well as highlighting the importance of confidentiality in the context of truth telling, illustrated here by breaking bad news, it is important to be aware of the legal as well as the ethical boundaries of information giving and in some cases the withholding of information. The danger inherent in the withholding of information is that of paternalism.