Courtesy of Medscape (registration required)

"Honesty is the best policy" and "the patient always comes first."

As absolute and correct as those aphorisms may be, they can be hard for doctors to apply in the complex world of modern medicine.

A recent Medscape medical ethics survey of over 10,000 physicians found that when it comes to patient treatment, a significant number of physicians struggle when it comes to topics relating to honest, straight-forward communication, and even pain management. Physicians from a broad range of specialties answered 3 questions pertaining to patient treatment:

-     Would you ever hide information from a patient about a terminal or preterminal diagnosis, because you believe that it will bolster their spirit or attitude?
-      Would you ever prescribe a treatment that's a placebo, simply because the patient wanted treatment?
-      Would you ever undertreat a patient's pain, because of a fear of repercussions or because you are concerned that a patient -- even a terminal patient -- might become addicted?

Open Communication Is Often Difficult

When it comes to delivering bad news, 59.8% of physicians indicate they "tell it exactly as I see it," while 14.6% indicate that they soften the news and "give hope even if there is little chance." Two percent indicate that unless a patient is going to die imminently, they don't tell him or her how bad the situation is and nearly one quarter (23.8%) say "it depends."

"The kind of compassion that brings people into medicine is the type of compassion that is needed for delivering bad news," says Kenneth Goodman, PhD, Director of the Bioethics Program at the University of Miami and author of Ethics and Evidence-Based Medicine: Fallibility and Responsibility in Clinical Medicine. But that compassion should never compromise the truth, he cautions.

Many of the physicians surveyed augmented their responses noting that, while they are honest, they try hard to deliver bad news in the most gentle, humane, and supportive way possible. That's exactly what patients should expect from their doctors, Goodman advises. But in "softening" the truth, he believes that doctors don't need to deviate from it.

"If there is something positive you can say, by all means say it. But only tell the truth: 'I will be there with you. I will help you manage your pain. I will see to it that you can arrange your affairs.' Those are truthful things," Goodman says.

When doctors withhold information, they make it more difficult for patients to chart their course and undermine their own credibility.

From the patient's point of view, "If I don't know my time is limited I can't put my affairs in order. I can't say, 'I'm sorry,'" he says. What's more, "it's not like patients are asking Dr. Kildare, 'What are my chances, Doc?' Patients are increasingly educated. If you don't tell them, they're going to be looking it up on the internet the next day, so you should probably be the source of the data, because you're a human and you care about them."