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week. Good stock, doctor, but a cruel business,” said he, with a most unearthly grin, and a shudder that shook his whole frame. “But thank heaven,' cried he, “I’ve escaped their clutches. Though they have ruined me, they shan’t have their twelve dollars a week out of me. No, I'll die first. Such systematic, cheating, lying oppression, I'll resist to the death.” It is evident that the treatment which this man received at the hands of his friends, tended to aggravate, instead of lessen his insanity. And we may remark too, that the notion which he derived from this treatment in relation to Retreats, false as it was, was founded on more plausible reasons, as they were presented to his mind, than are some of the opinions that are adopted by some sane men in the community. Fifthly. The general effect of deception, aside from the individual which it is supposed it will benefit, is injurious. The considerations on which we have already remarked, have had regard entirely to the person that is deceived, and we think that we have shown most clearly, that even taking this narrow view of the influence of deception, it is in almost all cases a bad influence; and.therefore as we can not tell in what cases this influence will be good, it is impolitic, and should be entirely discarded. We now go farther, and looking beyond the individuals who are the subjects of the deception, we see its influence extending all around from these individuals, as so many radiating points of influence, leavening the whole mass of society with a most poisonous leaven. It is not an influence that can be shut up in the case of any individual, in that one breast, or within that one chamber of sickness. That confidence, which should always exist in the intercourse of the sick with their physicians and friends, and which may be made the channel of great and essential
benefits to them, is materially impaired, often even destroyed by such deception. And this effect is unfortunately not confined to those who practice it, but the imputation rests upon others. The distrust thus produced often exerts a depressing influence in those cases where the cordial influence of hope is most urgently needed, and where it can be administered in consonance with the most scrupulous veracity. It is well if under such circumstances, the physician can appeal to the patient's own experience of his frankness in all his previous intercourse with him.
I call to mind an instance in which I was able to make this appeal with the most marked good effect. The patient was a lady who was in a great state of alarm in regard to the probable result of her sickness. She was indeed very sick, but there was good reason to hope that remedies would relieve her. At the same time I feared that the depressing effect of this state of alarm, if it should continue, would prove a serious obstacle to her recovery. But as I expressed to her the confident hope that she would get well, she said to me, “Physicians always talk in this way, and you do not really mean as you say. I shall die, I know that I shall die.”
I had been the physician of the family for many years, during which time they had gone through some trying scenes of sickness. Alluding to all this, I asked her if she could look back and call to mind a single instance in which I had not dealt candidly and frankly with her. She allowed that she could not. “Well,” said I, “believe me now ; I am in earnest; I do believe, and confidently too, that you will recover.” The tears were at once wiped away. Cheerfulness, the cheerfulness of hope, lighted up her countenance, and the case went on to a speedy and full recovery.
Every day we see evidence of the fact that so large a proportion of the medical profession practice deception upon the sick, that the profession, as a whole, has to a greater or less degree the imputation fastened upon it. Indeed patients often, as a matter of course, make the distinction between the obligations to professional veracity, and those of the man as a man in his ordinary intercourse; and the phy. sician who has an established reputation for the strictest veracity every where else but in the sick chamber, has there the suspicion of deception put upon him, and it is supposed to be no imputation of which he should complain, because deception is allowed here almost by general permission. For this reason, whatever of frankness and honesty there may be in our intercourse with the sick, often fails to produce the effect intended, in part at least if not wholly. And this result follows just in proportion to the extent to which deception is made use of in the profession.
The indirect and collateral effects of deception are often manifest in a family of children. Its influence extends beyond the mind and character of the deceived child. If the other children witness the deception, what hinders them from believing that their parents can deceive them whenever it suits their convenience 2 And if they do not witness it, the sick child will remember it when he recovers, and the rebellion which he has, in consequence, in his bosom towards an authority that rules by deceit, and is therefore deemed with good reason oppressive, is of course communicated to the other bosoms of the little flock. Many a parent, who supposed that he was doing nothing that would last beyond the present moment, has thus sown the seeds of rebellion among the little band of subjects, over whom God has placed him ; and who can tell what the fruits will be, or to what
extent or length of time they will grow ! We need barely say in concluding our remarks on this consideration, that the momentary good which occasionally results to individual cases from deception, is not to be put in comparison, for one moment, with the vast and permanent evils of a general character, that almost uniformly proceed from a breach of the great law of truth. And there is no warrant to be found for shutting our eyes to these general and remote results, in our earnestness to secure a particular and present good, however precious that good may be—a plain principle, and yet how often it is disregarded. Sixthly. If it be adopted by the community as a common rule, that the truth may be sacrificed in urgent cases, the very object of the deception will be defeated. For why is it that deception succeeds in any case ? It is because the patient supposes that all who have intercourse with him deal with him truthfully— that no such common rule has been adopted. There is even now, while the policy on this subject is unsettled and matter of dispute, enough distrust produced to occasion trouble. And if it should become a settled policy under an acknowledged common rule, the result would be general distrust, of course defeating deception at every point. And yet if it be proper to deceive, then most clearly is it proper to proclaim it as an adopted principle of action. Else we are driven to the absurd proposition, that while it is right to practice deception, it is wrong to say to the world that it is right. It is in vain to say that the evil result which would attend this adoption of occasional deception, as the settled policy of the medical profession, would find a correction in the very terms of the rule which should be adopted, viz. that the case must be an urgent one to warrant deception, and there must be a fair prospect that it can be carried through without discovery. For every patient, that was aware of the adoption of such a rule, might and often probably would suspect that his own case is considered as coming within the terms of the rule. Seventhly. Once open the door for deception, and you can prescribe for it no definite limits. Every one is to be left to judge for himself. And as present good is the object for which the truth is to be sacrificed, the amount of good, for which it is proper to do it, can not be fixed upon with any exactness. Each one is left to make his own estimate, and the limit is in each one’s private judgment, in each individual case as it arises. And the limit, which is at first perhaps quite narrow, is apt to grow wider, till the deception may get to be of the very worst and most injurious character. I will give a single illustration of this remark, which, though not taken from the practice of medicine, is appropriate to our purpose. It has always been allowed in the laws of war, to deceive the enemy by stratagems, false lights, &c. At one time some English ships in two or three instances, decoyed the enemy by counterfeiting signals of distress. The deception in this case is productive indirectly of the very worst consequences, for it manifestly tends to prevent relief from being afforded to those, who are actually in a distressed condition. Our feelings of humanity instinctively condemn such a stratagem, and yet it is only a mere extension of that deception, which has been by common consent allowed in war. It involves no different principles, and is only more objectionable, because it produces worse indirect results. It differs in degree only and not in kind. So it is with deception always. Its indirect effects are always bad to some extent, and to what extent they will prove so we know not in
each individual case. You can never know at the time how great is the sacrifice which you are making for a present good. While you may be thinking that you are only sacrificing your own veracity, and that the influence of the act will not extend beyond the passing moment, you may be producing disastrous results upon the interests of others, and those results may be both lasting and accumulative. A man who was captured by some Indians, was asked by them if there were any white men in the neighborhood. He told them that there were, and directed them to a spot where he was very certain that there were none. They immediately started in pursuit, leaving him bound and in the charge of one of their number. When they were gone, he contrived to make his escape. Almost every one would say, that this was a strong case, and that they could not blame him for telling a falsehood to Indians, in order to escape from their cruelty. Here was a great good to be obtained, the saving himself from torture, perhaps from death, and deceiving savages for such a purpose, it will be said, is not to be condemned. But mark the result of that deception. Five white men were found on the spot to which he directed them, and were captured. In order to make out a justification of deception, on the ground of expediency in any case, all the possible results, direct and indirect, must be taken into the account. But this is impossible except to omniscience itself. Even in those cases which appear the most clear to us, there may be consequences of the most grave character utterly hidden from our view. In the instance just related, the captive was very certain, from some circumstances, that he directed his captors to a spot where there were no white men. The uncertainty of our knowledge of the circumstances of each case prevents then our defining any limits, within which deception shall be bounded. We can make no accurate distinctions, which will enable us to say, that it can be beneficially employed in one case, while in another it will be inexpedient. I have now finished the examination of the various considerations, which have been suggested to my mind in relation to this subject. And I think that they settle the question as to the expediency of deception beyond all doubt. I think it perfectly evident, that the good, which may be done by deception in a few cases, is almost as nothing, compared with the evil which it does in many cases, when the prospect of its doing good was just as promising as it was in those in which it succeeded. And when we add to this the evil which would result from a general adoption of a system of deception, the importance of a strict adherence to truth in our intercourse with the sick, even on the ground of expediency, becomes incalculably great. In the passage, which I quoted in the beginning of this article from Percival's Medical Ethics, the writer makes I conceive, a false issue on the question under consideration. He assumes that the injury, which results from a sacrifice of the truth for the good of the sick, comes upon him who practices the deception, and that in doing it, “he generously relinquishes every consideration referable only to himself.” But the considerations that I have presented show, that the injury is very far from being thus confined. Often the very person intended to be benefited is injured, perhaps deeply, in some cases even fatally. And then the indirect effects can not be estimated. There are many illustrations, used by those who advocate deception, which are plausible but fallacious. I will cite a single example. Dr. Hutcheson of Glasgow, as quoted
by Dr. Percival, in remarking on the maxim, that we must not do evil that good may come, says, “ Must one do nothing for a good purpose, which would have been evil without, this reference 2 It is evil to hazard life without a view of some good; but when it is necessary for a public interest, it is very lovely and honorable. It is criminal to expose a good man to danger for nothing; but it is just even to force him into the greatest dangers for his country. It is criminal to occasion any pain to innocent persons, without a view to some good; but for restoring of health we reward chirurgeons for scarifyings, burnings and amputations.” I would remark on this that the infliction of pain is not in itself a moral act, but the purpose for which it is done gives it all the moral character that it has. Aside from this, it affects no moral principle, as the infliction of an injury upon truth certainly does, independent of the object for which it is done. The infliction of pain then for a good purpose can not be said to be doing evil that good may come—it is doing good. The sacrifice of life which the writer speaks of, is the sacrifice of a less good for a greater one simply, and not the sacrifice of any principle. But when the truth is sacrificed for what is deemed to be a greater good, it is in fact the sacrifice of a greater good, for not only a less, but an uncertain good—a sacrifice of the eternal principle, which binds together the moral universe in harmony, for a mere temporary good, which after all may prove to be a shadow instead of a reality. I can not leave this subject without making some explanations of a few points, in order to guard against some erroneous inferences to which the sentiments that I have advanced might otherwise be liable. I wish not to be understood as saying that we should never take pains to withhold knowledge from the sick, which we fear might be injurious to them. There are cases in which this should be done. All that I claim is this—that in withholding the truth no decóption should be practiced, and that if sacrifice of the truth be the necessary price for obtaining the object, no such sacrifice should be made. In the passage which I have quoted from Dr. Percival, he states a case in which he very properly says, that the patient's right to the truth is suspended; but I do not agree with him, that in withholding the truth we have the right to put absolute falsehood in its place. It is always a question of expediency simply, whether the truth ought to be withheld. And it is a question that depends, for its proper decision, upon a variety of considerations in each individual case. It is very often decided injudiciously. There is generally too great a readiness to adopt an affirmative decision. It is too easily taken for granted, that the knowledge in question will do harm to the patient if it be communicated to him. The obvious rule on this subject is this—that the truth should not be withheld unless there be a reasonable prospect of effectually preventing a discovery of it, and that too by fair and honest means. It has often been said that the physician has no right to excite too much hope in the mind of a patient by directing his attention, as is often done, to any favorable symptoms that may appear in his case. But I ask, how is it known that too much hope is excited The physician is fallible, and is by no means answerable for putting just the right degree of hope into the patient's bosom. It is not to be expected of him that he shall always tell each patient just how his case stands. His own mind is often filled with conflicting hopes and fears, and he
can not decide clearly what the probabilities are in many cases. And if he thinks that he can do so, he may be very much mistaken. Estimates are often made most unwarrantably. An exactness is often aimed at which is impracticable. The patient in many cases has no right to such an estimate, for while it may be a mere guess, he may look upon it as a well founded estimate, made upon a real knowledge of his case. He will therefore draw false inferences from it, and this the physician is bound to prevent, and in so doing he actually prevents deception. The physician should always remember that though he may be aware himself of his liability to err in making any such estimate, the patient may have such confidence in his judgment, that he will consider the opinion which he may express to be of course a correct one— almost beyond the possibility of a mistake. So that however guarded he may be in expressing an unfavorable opinion of the probable issue of any case, that opinion may have too much weight in the patient's mind. It is by no means true that all direct questions on the part of the sick, must be directly and fully answered. For example, suppose the patient asks the physician, “Do you think on the whole that I shall recover”—a question that is sometimes asked under very embarrassing circumstances. If the physician thinks that he will probably not recover, he has no right to say to him that he will, for this would be falsehood. But he has a right, and it is his duty if he thinks it for the good of the patient, to withhold his opinion from him, if he can do it without falsehood or equivocation. He may say to him something like this. “It is difficult to decide that question. Perhaps it is not proper for me at this stage of your case to attempt to do it. You are very sick, and the issue of your sickness is known only