Conclusions

Many healthcare professionals have their own definitions of types of lies or are familiar with those described by Bok18 including white lies, excuses, lies in crisis, lies to protect others, and lies for the public good. Bok further adds that ‘some consider all well-intentioned lies, however momentous, to be white’. Bok describes her personal definition of the white lie as ‘a falsehood not meant to injure anyone, and of little moral import’.18 In our study, residents often justify lying as long as the patient is benefitted as pointed out by this resident, ‘I think the wording of LIE involves that we are out for our own interest and not the patients'. When in reality we are all about patient care.’

The residents themselves said that they are attempting to behave altruistically, or as Darwin19 put it, ‘incurring a personal cost that in turn benefits others’. Darwin's favourite example of altruism was honey bees. He found that in a hive there are sterile bees that do not reproduce but rather supply resources to those bees that do reproduce. These same bees will also defend the hive with their lives. While our residents are not giving their lives to gain additional insurance benefits for their patients, they are behaving altruistically.

When lying for the patient, the insurance company loses money, the patient may receive tests of questionable necessity with potential complications, and the physician is sacrificing moral integrity. However, deception for the benefit of the patient may be considered a form of benevolent deception, a concept described by Jonsen,7 but it is still a lie. In contrast, the insurance industry has a different view of lying that resides with a legal definition. The False Claims Act states any person who presents a false claim or makes a false record is liable pay a fine of at least US$5000 in addition to three times the amount of damages sustained.20

Occasionally, patients may actually approve of physician deception. A 2003 study by Alexander et al8 of 700 individuals showed that 50% stated it is acceptable to misrepresent facts and 41% stated it is acceptable to lie for the benefit of the patient. Moreover, 19% indicated that a physician had used deception on their behalf in the past. Our study showed that patients requested their doctors to lie to the insurance companies on their behalf, representing almost 6% of all types of lies reported.

Certain practices of insurance companies may be cause for some physicians to lie in retaliation. The California Medical Association reported three large suits against Health Net, Blue Cross and Wellpoint/Anthem within the past 4 years.21–23 In each of these suits, the companies were charged with a variety of actions including promising medical coverage, then dropping patients if they needed expensive treatment, engaging in practices that led to denials of claims, increasing premium charges to customers without advance notification, refusing to pay for patient care after pre-authorising the care, reducing reimbursement levels without appropriate notice and revoking patient health plans retroactively. The study in 2002 by Werner et al9 demonstrated that attending physicians are more likely to use deception with insurance companies if the denied claim appeals process involved more time or was associated with less success. Residents' animosity towards the insurance companies is also demonstrated in this sample post, ‘Insurances are here in business. They are not here for your patients’ well-being. If I think a test is necessary for my patient, then I will get it. I wouldn't accept a medically illiterate person to tell me what to do.' Our study also demonstrated some resident attitudes about the inequality of the lying game when physicians are expected to behave ethically with regard to insurance companies, while the insurance companies act in their own interests even to the perceived detriment of patient care.

Resident physicians are thus faced with balancing competing values—to maintain personal and professional integrity by doing what is ethically right, to do what they believe to be in the best interests of the patient, to do what is required by law, and to avoid harm. Some residents link the lying issue to legal requirements as this resident responds, ‘It's not really an argument about ethics. It's an argument about legality, a totally separate issue. If we are legally required to disclose this, we do it. The law trumps all.’ The American Medical Association also addresses the issue of legality in its Code of Ethics: ‘Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties. In some cases, the law mandates unethical conduct. In general, when physicians believe a law is unjust, they should work to change the law. In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal obligations.’24

When we asked residents about disclosing unanticipated events, we did not specify the event, but allowed them to come to their own conclusions. Over half (56%) chose to disclose the event. When we later asked the same residents about disclosing an unanticipated event if they knew a lawsuit would ensue, 75% chose to disclose the event. This demonstrates that the residents generally are more concerned with their patients than with their own wellbeing.

Residents' decisions are affected by many factors. International residents are less willing to lie to insurance companies about patient symptoms and to patients about unanticipated events than those who trained in the USA. However, they are less likely to report medical errors than those who trained in the USA. These are similar to results found in the study in 2004 by Lee et al,25 which showed that international graduates are less likely to change the patient's official diagnosis than US graduates. Does this mean that US medical schools are not addressing the ethics of lying or alternatively that international medical schools place less emphasis on doing what is best for the patient, whatever the cost?

A study by Garbutt et al15 in 2008 showed that surgeons are less likely to report medical errors. We found no significant difference between departments with regard to disclosing medical errors; however, significant differences do exist in lying to insurance companies and disclosing unanticipated events. Surgical residents are more willing to lie to insurance companies, and hospital-based residents are more willing to deceive about unanticipated events. Perhaps the surgeon is more focused on the mission to be accomplished and less concerned with the means used, whereas the non-surgical physician may be more contemplative regarding the consequences of how one arrives at the altruistic value. Is it possible that hospital-based residents have more experience with procedures and therefore encounter unanticipated events more often than those who are medically based?

A 1991 study by Roter et al26 showed that female physicians took more time with their patients, encouraged more patient–physician partnering, and gave more information during clinic visits than male physicians. Our finding that female physicians were more willing than male physicians to disclose unanticipated events may involve this willingness to spend more time to give patients information while encouraging them to be more proactive in their own health care.

A limitation of this study, as with all qualitative research, is that the coding process remains subjective even when two coders are involved. In addition, what residents report they would do while writing in an online classroom may not directly correlate with what they would do in reality. Having a multicentre survey might strengthen the breadth of the deception practices in the general population of resident physicians.

In practice no physician contemplates engaging in any dishonest behaviour. Such actions clearly go against the Hippocratic oath, but potentially engaging in deception confronts physicians in not uncommon situations, as graphically shown in the types of lies diagram (see figure 1). Doctors communicate in different ways that hopefully help patients understand their clinical challenges. A doctor may not tell all that is known because the patient cannot handle or understand the information. Doctors are careful not to take away hope when patients ask about impending death. Sometimes the question is not answered, but the patient is told that ‘we are going to take good care of you’. Becoming dishonest that involves legal issues such as insurance deception for the benefit of the patient or the doctor, or withholding or lying about information to protect a physician from a lawsuit clearly are more egregious forms of deception, some of which border on fraud and should clearly be avoided.

Our study demonstrates that the ethical issues related to deception that attending physicians face also exist at the resident physician level. Residents are trying to learn how to be professionals, but are also faced with concerns about deception. While the majority will disclose a medical error to the patient, only half will be truthful with the insurance company, and only one-third will consistently disclose near misses to their patients. Over half will disclose an unanticipated event to the patient, but in making a distinction between benefitting the patient and protecting themselves, three-quarters of the residents will disclose, even if such disclosure results in a lawsuit. Whereas our formal curriculum challenged the resident to consider the issues related to deception, it is clear that residents are still contemplating the matter and struggle with balancing altruism, egoism and beneficence. However, the overwhelming majority embraced an altruistic rationale regarding deception. Finally, residents may benefit from a formal educational curriculum to achieve a confident understanding regarding the ethical virtue of truth-telling in the current complex world of health care.