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EditorLou Marinoff

Reviews EditorNancy Matchett

Associate EditorDena Hurst

Technical ConsultantGreg Goode

Legal ConsultantThomas Griffith

PHILOSOPHICAL PRACTICE

Journal of the APPA

Volume 9 Number 2 July 2014

www.appa.eduISSN 1742-8181

Articles

David H. BrendelInsight and Action: The Relation between Professional Coachingand Philosophical Counseling

Michael Noah WeissDaimonion: Guided Imagery as a Tool for Philosophical Practice

Constantinos Athanasopoulos The Shield of Achilles: A Use for Philosophical Practice

Matthew Allen ButkusCompassionate Deception: Lying to Patients with Dementia

Reviews

Doing PhilosophyLydia Amir

Who’s in Charge? Free Will and the Science of the BrainTroy Camplin

Time and the Shared WorldLeslie C. Miller

Landscapes of the Mind: The Faces of RealityMichael Grosso

Biographies of Contributors

Nemo Veritatem RegitNobody Governs Truth

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Compassionate Deception: Lying to Patients with Dementia

MATTHEW ALLEN BUTKUS

MCNEESE STATE UNIVERSITY, LAKE CHARLES, LA

Abstract

Trust is essential in an effective clinician-patient relationship, and the default assumption is that clini-cians have an obligation to be truthful with their patients. This assumption is tested in cases when patientsare incapable of engaging in autonomous action due to a cognitive impairment. A case study is exploredwhich illustrates when engaging in deception may be acting in the patient’s best interest. The decisionflowchart in Sokol (2007) is explored as a means of justifying deception.

Keywords: dementia, lying, deception, ethics, autonomy, compassion

Trust is an intrinsic element of a healthy doctor-patient relationship; thus, there is a presumption that itis wrong to lie to a patient (Johnston & Holt, 2006; Tuckett, 2004). Clinicians depend on truthful accountsof a patient’s health practices—accurate information about medication, nutritional supplements, allergies,recreational drug use, and sexual practices is essential if we want to provide an accurate diagnosis andavoid adverse reactions to treatment. They are asking people to disclose information that may be person-ally embarrassing or shameful, baring their bodies and souls, which creates a number of bonds and rela-tional duties within that relationship—bonds of confidentiality, honesty and beneficence. Patients expectclinicians to be honest with them, and take breaches of these relational duties quite seriously (Ryan, deMoore, & Patfield, 1995).

Trust and honesty are essential elements of medical ethics—breaches of these risk devaluing the pa-tient (a violation of respect) as well as undermine her ability to be self-directing (a violation of personalautonomy; Beauchamp & Childress, 2012; Bostick, Sade, McMahon, & Benjamin, 2006; Hodkinson,2013; Jaworska, 1999; Ryan, de Moore, & Patfield, 1995). This does not mean, however, that trust andhonesty are absolutes. Medical ethicists recognize that there are circumstances when clinicians have anobligation not to respect a patient’s autonomy—for instance, when patients are dangers to themselves orothers and require hospitalization. But even within these circumstances we require minimally restrictiveenvironments to avoid violating patient rights and autonomy. In short, if a clinician is going to violate thetrust and autonomy of a competent patient, she must make sure that she has very compelling reasons fordoing so. This obligation to be truthful with patients is a prima facie duty—in general, clinicians ought to tellthe truth, but it is possible to imagine circumstances when it is not an absolute duty (Brown, 2008).

All of the above necessarily makes the assumption that we are dealing with a competent patient – ourduty to respect someone’s ability to be self-directing necessarily assumes a genuine capacity to engage inself-reflection, deliberation, and the weighing of options, which is why we tend not to speak of autonomyas it relates to toddlers, patients experiencing delusions, or other individuals with cognitive dysfunction.Rather, we tend to focus on other principles of medical ethics like beneficence, nonmaleficence, andcompassion. We may find circumstances when revealing the truth ends up dealing the patient a heavypsychological blow, potentially compromising the clinician’s ability to care for him or her. It is entirelypossible for the truth to produce both positive and negative outcomes— clinicians might cause genuineharm to their patients by being truthful with them. This has produced a discussion within the philosophical

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Philosophical Practice, July 2014, 9.2: 1388-96

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and medical communities on the nature and scope of the duty to disclose information to patients—there aretimes when a clinician or caregiver might be morally permitted to withhold information from patients orengage in deception (Alzheimer’s Society, 2007; Brown, 2008; Day, James, Meyer, & Lee, 2011; Faden& Beauchamp, 1980; Hodkinson, 2013; Ryan, de Moore, & Patfield, 1995; Sirotin & Lo, 2006; Sokol,2007; Tuckett, 2012). This is not to say that clinicians no longer have an obligation or duty to be truthful,but the nature of that obligation becomes less clear. Rather, it may be justifiable to engage in deception ifa greater harm than benefit occurs as a result of telling the truth to a patient.

Case Example

The patient in question (“Stephen”) was a 70 year-old man with advanced non-Alzheimer’s dementiaseen in a geriatric psychiatry unit. Stephen was admitted for evaluation and introduction of pharmaco-therapy to reduce his anxiety. His medical history was also significant for an aggressive and treatmentrefractory bladder cancer of which he was unaware and which produced abdominal pressure that madethe patient constantly feel as if he had to urinate. He was fitted with a Texas catheter and encouraged tovoid whenever he could. However, this constant pressure caused him concern (and likely exacerbated hisanxiety), so he would constantly announce from his room that “I can’t pee!” or ask the nursing staff why hecouldn’t urinate.

The case was complicated by several factors—for instance, Stephen had significant difficulty remem-bering information and as a consequence needed constant reminders to orient himself to his place, time,and condition (every few minutes, and at some points during his hospitalization, every minute). The biggestethical complication was Stephen’s family request that the nursing staff not disclose the cancer to thepatient, as they believed that this would further increase his anxiety. These two factors could combine tocreate a pernicious and circular problem: if the nursing staff were to be truthful with him, they would needto remind him constantly of his cancer, which could easily maintain or amplify his existing anxiety. Simplyput, he would need to be reminded that he had a terminal cancer again and again and again. The nursingstaff was conflicted about whether to disclose Stephen’s diagnosis to him.

No case consultation was called—rather, the treatment team acquiesced to the family’s request anddid not tell Stephen about his condition while he was in the hospital. Instead, he was told that if he felt theneed to urinate, he should try, and that sometimes people “just had a hard time going.” During his stay,Stephen’s anxiety was treated pharmacologically, and he was discharged once he was stabilized on ananxiolytic.

Philosophical and Ethical Issues

There are a number of ethical issues raised by the case, but the primary conflict seems to be especiallyimportant—was it ethically appropriate not to disclose the cancer diagnosis to Stephen? There are anumber of related ethical issues. Most explicitly, does the presence of a cognitive impairment change thenature of our obligation to our patients in terms of truth-telling and respect for their autonomy? If so, inwhat contexts and capacities might this occur?

Truth-telling covers a wide range of potential issues in medicine and philosophy in general. Broadlyspeaking, most philosophies strongly advocate telling the truth to others. Truth can be challenging andcomplicated, however, whether it is understood as a philosophical or plain language concept. A full dis-course on the philosophical challenges posed by “truth” is well-outside the purview of this article, but

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paraphrasing a recurring question is germane: in a clinical context, what is truth? There are a number ofsubjective and probabilistic elements involved in diagnosing a patient and offering a prognosis (in bothpsychiatry and house medicine). Diagnostic standards change, new evidence emerges, new therapiesbecome available, and clinicians adopt particular diagnostic and treatment paradigms. In short, the chang-ing nature and scope of clinical evidence and clinical practice makes “truth” about a diagnosis and progno-sis a plastic concept (Richard, Lajeunesse, & Lussier, 2010). As such, a discussion about telling the truthwith one’s patient is necessarily going to recognize uncertainty. However, recognizing and accounting forthis uncertainty is not going to change the essential nature of making a good faith estimation of the patient’scurrent and future state of health.

What constitutes a lie also requires some clarification—is it intentionally passing on false information?Is it withholding information from a patient? Is it diverting a patient’s attention elsewhere? All of these canbe considered lying; a deceptive practice (even a benevolent deceptive practice or a “little white lie”) stillprevents a patient from getting the information that she is seeking (Day, James, Meyer, & Lee, 2011;Elvish, James, & Milne, 2010; Ryan, de Moore, & Patfield, 1995). Patient perceptions of dishonestymatter; while the clinician may attempt to categorize his practice as something other than lying, the effort todeceive or distract can be personally offensive and damaging to a relationship. Characterizing an act ofdeception or distraction as something other than lying seems to be a semantic dodge rather than an ex-cuse—the end result is the same in both contexts (Ryan, de Moore, & Patfield, 1995).

There are reasons, however, to ask whether telling lies are an a priori or prima facie wrong. Forinstance, consider a patient who presents to an emergency department following a motor vehicle accidentwhich killed his family and who requires stabilization. The physician’s efforts to stabilize him are hamperedby his frantically asking about his family’s welfare. At least three possible courses of action are suggested:telling the truth (“Your family is dead”), lying (“Your family is fine”), and omitting information (“I haven’theard anything—let me stabilize you and I’ll go check”).1 Options two and three certainly both involve nottelling the truth (or the complete truth), but it is reasonable if a moral agent were to avoid calling themidentical or morally equivalent. While some patients consider any deception wrong (Day, James, Meyer,& Lee, 2011), a compelling case could be made that truth-telling is a prima facie obligation—in thiscircumstance, it might be better to delay telling the patient the truth until he is in a better state to hear theinformation.

Naturally, this leads to concerns about paternalism—we can see a potential framework for withholdinginformation from patients “for their own good,” which is very difficult ethical territory, as it undermines thepatient’s decision-making ability. Caregivers are especially prone to rationalize deceptive practices in aneffort to ameliorate distress and improve compliance with care (Blum, 1994; James, Wood-Mitchell,Waterworth, Mackenzie, & Cunningham, 2006; Tuckett, 2012). Withholding information or distractingthe patient out of concerns for his or her well-being would seem to put acting beneficently directly at oddswith respecting the patient’s autonomy.

Patient autonomy is generally understood to involve a capacity for setting personal goals, the ability toestablish personal moral principles and values, and to act upon them (Beauchamp & Childress, 2012).Proper exercise of personal autonomy involves taking in information, analyzing it in terms of personalmeaning and interpretation, and acting upon the resultant conclusion. We expect clinicians to act with ahealthy respect for an individual’s autonomous decisions. However, we also understand that patient au-tonomy is not absolute—we recognize exceptions like the ability to refuse to provide medically inappropri-ate treatments (like dialysis for a head cold), the ability to hospitalize patients against their will when they

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present a danger to themselves or others, and the decisional incapacity brought on by delirium. The ques-tion that arises, therefore, is whether a particular instance of paternalism is justified, and quite reasonablywe set that standard high.

Does dementia lower this standard? There are some obligations we owe to people qua people—cognitive challenges do not fundamentally change our human nature. But the rights we enjoy within amedical context are not as inviolable or innate—some rights arise only in particular circumstances or whenparticular standards are met. We do not, for instance, ask an infant about its treatment preferences, andwe have created an entire ethical and legal framework for proxy decision-making. At issue here is whenthe agency shift occurs—when does the patient stop being the primary decision-maker for his or her care?We accept that when someone is severely demented, another needs to step in to make important medicaldecisions, but where is the threshold point?

In the context of informed consent, respect for personal autonomy and truth-telling generally revolvesaround disclosing what a reasonable competent patient would want to know or what a reasonable clinicianought to disclose to a patient (Faden & Beauchamp, 1980). Even patients who are facing personalchallenges like cancer or the onset of dementia have expressed a desire to know what is happening to them– their anxiety and worry is not ameliorated by withholding information (Downs, 1999; Fallowfield, Jenkins,& Beveridge, 2002; Shahidi, 2010; Tuckett, 2004). The only circumstances when it might potentially beacceptable to lie to a competent and autonomous patient are in situations of life and death, i.e., times whenthe truth would compromise the ability to care for the patient or the patient’s ability to make decisions(Ryan, de Moore, & Patfield, 1995). The experience of autonomy for individuals with more profoundcognitive issues, however, can be very different. In fact, in cases of psychosis, delusion, or advanceddementia, the patient’s autonomy has already been compromised by the underlying disease process—herautonomy has been derailed (Hertogh, The, Miesen, & Eefsting, 2004; Ryan, de Moore, & Patfield,1995; Tuckett, 2012). This creates a new duty for clinicians and caregivers— treating the patient withdementia or cognitive impairment with respect as she attempts to engage with her world without necessar-ily upholding her decisions or personal autonomy (Blum, 1994; Jaworska, 1999). In essence, there is apoint when our duty to respect a person means a duty not to do what the person tells us to do (Conly,2013). This is, in essence, a justifiable form of paternalism, and one that opens the door to the permissi-bility of deceptive practices done in the patient’s best interests.

It is important to note that deception can be not only compatible with respect for a patient, but also beendorsed by the patient herself. Tuckett (2012) suggests that caregivers considering deception apply theGolden Rule and ask themselves whether they would want to be lied to. A number of studies haveanswered this in the affirmative—both caregivers and patients have endorsed lying and deception whenthey are clearly done for the patient’s best or therapeutic interests (e.g., reducing distress; Elvish, James, &Milne, 2010), when they occurred after the patient was no longer aware of the lie or the severity of the liewas minor (a “little white lie”; Culley, Barber, Hope, & James, 2013; Day, James, Meyer, & Lee, 2011).

How might a clinician decide whether a particular lie or act of deception is morally permissible? Rely-ing on personal intuition alone is not sufficient – while the clinician does possess specialized knowledge andtraining, that alone does not allow the him to substitute his own judgment, as the subjective patient experi-ence is relevant to treatment decisions (Brown, 2008; Johnston & Holt, 2006). Instead, it is necessary toconsider guidelines for acceptable deception. Brown (2008) argues that a clinician should withhold medi-cally relevant information when “she reasonably expects both that (a) full disclosure would seriously com-promise her patient’s permissible ends and that (b) her nondisclosure will not compromise other morally

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important interests” (pp. 333-334). This serves as a formal norm—a broad guide that orients the cliniciantowards ethical conduct in deception. Complementing this formal norm, Sokol (2007) proposes a specificsystem evaluating the deception, including examining the justifications for the action, efforts to avoid unnec-essary deception, the likelihood of the deception being successful, objections to the lie, and the willingnessof the lying agent to undergo formal inquiry by a professional body or court of law and whether the patientconsent to the lie if aware of the facts. This algorithm is not quick or easy—it requires the clinician toengage in significant reflection and examination of her actions and motivations, necessarily producing asmall set of circumstances in which lying becomes morally permissible.

Applying Sokol’s Model

In order to clarify Sokol’s proposal, we turn back to the case of Stephen and the questions asked ofthe clinicians considering deception.

Is the act deceptive?

Clearly we are withholding his cancer diagnosis from him and encouraging him to believe his bladderpressure is due to something else, and as such, the practice is deceptive.

What justifications exist for engaging in deception?

Both the family and treatment staff believed that Stephen’s dementia would prevent him from beingable to cope with the diagnosis—the forgetfulness produced by his dementia would require constantreminders that he had an aggressive disease which would undermine the effectiveness of his anxiolytic.While the staff was conflicted, the family believed that his interests were better served by validating hisconcern about his bladder pressure and providing the catheter to encourage voiding rather than disclosehis full diagnosis. This justification would likely fail in a patient who was not experiencing dementia. Asnoted above, the obligation to disclose diagnostic information to competent individuals is part of a verypowerful concern about individual autonomy in making treatment decisions. However, the nature ofStephen’s dementia undermines his ability to make these decisions, shifting the responsibility to treating himwith respect and helping him to make sense of the world around him in a compassionate manner. Sokolincludes a number of relevant factors that would allow us to proceed through the deception flowchart,including the “prevention of great physical or psychological harm to the patient,” “compassionate decep-tion to reduce great stress or anxiety,” and a patient who “is not emotionally or cognitively equipped todecide or cope with the truth” (2007, p. 985). Had the treatment staff disclosed his inoperable cancerdiagnosis (and reoriented him to it every few minutes), his anxiety would have worsened, potentially to thepoint that his care would have been compromised, as anxiety impacts morbidity, mortality, hostility andcombativeness (Moser, et al., 2011; Olafiranye, Jean-Louis, Zizi, Nunes, & Vincent, 2011; Watkins, et al.,2013; von Kanel, Dimsdale, Adler, Patterson, Mills, & Grant, 2004), and the risks of simply increasing hisanxiolytic medication are well-documented (Bulat, Castle, Rutledge, & Quigley, 2008; Carlsten, Waern,Holmgren, & Allebeck, 2003; Chan & Lin, 2010; Grad, 1995; Kirby, Denihan, Bruce, Radic, Coakley, &Lawlor, 1999; Muscatello, Spina, Bandelow, & Baldwin, 2012; Neutel, Skurtveit, & Berg, 2012; Tamblyn,Abrahamowicz, du Berger, McLeod, & Bartlett, 2005; van der Hooft, et al., 2008; Wang, Bohn, Glynn,Mogun, & Avorn, 2001; Wu, Wang, Chang, & Lin, 2009). Very clearly, the decision to withhold the truthfrom Stephen meets Sokol’s criteria.

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Is the deception likely to succeed in light of the patient’s mental state, and is it possible for us tomeet our objectives without the deception?

Clearly, the cognitive challenges Stephen is experiencing make the deception likely to succeed –Stephen’s need for constant reorientation places him in a position that would not allow him to discover theinformation being withheld from him, nor would he be able to reflect upon it or integrate it into his experi-ence of the world around him. Further, the alternative to the deception is revealing the truth to him abouthis cancer diagnosis, and constantly reminding him of that aggressive illness would likely exacerbate theanxiety that brought him to the hospital in the first place. As such, it would seem that the decision towithhold the diagnosis meets these two requirements, allowing us to continue to possible objections.

Do the justifications for deception outweigh the objections that can be raised?

Sokol raises a number of important challenges, including our general orientation towards honesty (as aprima facie concern), existing codes of ethics, the impact on relationships and the emotional distress if thelie is disclosed, patient autonomy concerns, and personal biases and difficulty weighing harms and benefits.Each of these is a salient concern when a clinician is considering deception with a patient who is notexperiencing a cognitive challenge. Stephen, however, is, meaning that his autonomy concerns and ourobligations towards him are less clearly defined. We can help orient him to his world and help him makesense of his experiences – a key goal when considering patients with dementia (Day, James, Meyer, &Lee, 2011; Hertogh, The, Miesen, & Eefsting, 2004; Jaworska, 1999) – but we would not assign him thesame cognitive status and capability as we would a cancer patient without dementia. Because his au-tonomy is already compromised by his illness, a different set of principles becomes relevant, includingrespect and compassion. The very nature of prima facie principles entails that certain contexts and circum-stances may allow us to substitute a stronger duty over our default orientation – in this context, our orien-tation towards the truth is superceded by our orientation to provide compassionate care. We care forStephen and his well-being, and we recognize that we must treat him with respect, which in this contexttransforms the duty to disclose truthful diagnostic information into the duty to address his concerns in a waythat doesn’t exacerbate his anxiety. The duty to disclose becomes the duty to withhold, as the benefit ofthe deception outweighs the harm.

Can we defend this decision to a professional board or court of law?

This is a significant concern, and Sokol includes this step in order to debias professionals and to remindthem of the severity of their actions. Failure to disclose medically relevant information would violate theprinciple of informed consent if we were dealing with a patient who was capable of making his ownmedical decisions. In this context, however, we are not dealing with such a moral agent – patients who areincapable of making their own medical decisions rely upon proxy decision-makers (normally family mem-bers or appointed proxy agents). As the family strongly endorsed the non-disclosure, there does notappear to be any real conflict. Since the principle of informed consent also entails the ability to waive it(i.e., situations where a patient may say “I don’t want to know, just fix me”), and it is entirely ethicallysound to waive informed consent to hearing bad news (Rudnick, 2002), it is entirely defensible not todisclose the cancer diagnosis to Stephen.

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Would the patient consent to the lie in advance?

As noted above, while cancer patients would generally want to know their diagnosis when they werecapable of processing the information (Shahidi, 2010), caregivers and patients with dementia have notedthat they would prefer not to hear information that would only cause them distress (Culley, Barber, Hope,& James, 2013; Day, James, Meyer, & Lee, 2011; Elvish, James, & Milne, 2010). As such, the decisionnot to disclose his cancer to diagnosis would seem to meet Sokol’s criteria and be a justifiable instance ofdeception.

Conclusion

The above case and analysis should reinforce the severity of the decision to deceive patients. Thereare very few circumstances when it is morally permissible to violate our general obligation to be truthfulwith patients, and rightfully so. Any violation of that basic trust must have strong justification, and it isimportant to follow a rigorous evaluation process when moving forward with deception. But it is importantto remember that there are times when the best thing we can do for our patient is provide him with comfort—sometimes the truth is harsh and harmful. Sometimes the best thing we can do is not to tell him news thatwill make things worse. Sometimes the best way for us to show respect is to show compassion.

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Downs, M. G. (1999). How to tell? Disclosing a diagnosis of dementia. Generations , 23 (3), 30-33.Elvish, R., James, I., & Milne, D. (2010). Lying in dementia care: An example of a culture that deceives in

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van der Hooft, C. S., Schoofs, M. W., Ziere, G., Hofman, A., Pols, H. A., Sturkenboom, M. C., et al.(2008). Inappropriate benzodiazepine use in older adults and the risk of fractuce. British Journal ofClinical Pharmacology , 66 (2), 276-282.

von Kanel, R., Dimsdale, J. E., Adler, K. A., Patterson, T. L., Mills, P. J., & Grant, I. (2004). Effects ofdepressive symptoms and anxiety on hemostatic responses to acute mental stress and recovery in theelderly. Psychiatry Research , 126 (3), 253-264.

Wang, P. S., Bohn, R. L., Glynn, R. J., Mogun, H., & Avorn, J. (2001). Hazardous benzodiazepineregimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. American Journalof Psychiatry , 158 (6), 892-898.

Watkins, L. L., Koch, G. G., Sherwood, A., Blumenthal, J. A., Davidson, J. R., O’Connor, C., et al.(2013). Association of anxiety and depression with all-cause mortality in individuals with coronary heartdisease. Journal of the American Heart Association , 2 (2), 710-712.

Wu, C. S., Wang, S. C., Chang, I. S., & Lin, K. M. (2009). The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data. American Journalof Geriatric Psychiatry , 17 (7), 614-620.

Note

1. For the sake of argumentation, I am not including statements like “We can discuss that later”— it isdifficult to predict how effective such statements would be with a patient who is agitated.

Correspondence: mbutkus@mcneese.edu

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EditorLou Marinoff

Reviews EditorNancy Matchett

Associate EditorDena Hurst

Technical ConsultantGreg Goode

Legal ConsultantThomas Griffith

PHILOSOPHICAL PRACTICE

Journal of the APPA

Volume 9 Number 2 July 2014

www.appa.eduISSN 1742-8181

Aims and Scope

Philosophical Practice is a scholarly, peer-reviewed journal dedicated to the growingfield of applied philosophy. The journal covers substantive issues in the areas ofclient counseling, group facilitation, and organizational consulting. It providesa forum for discussing professional, ethical, legal, sociological, and politicalaspects of philosophical practice, as well as juxtapositions of philosophical prac-tice with other professions. Articles may address theories or methodologies ofphilosophical practice; present or critique case-studies; assess developmentalframeworks or research programs; and offer commentary on previous publica-

tions. The journal also has an active book review and correspondence section.

APPA Mission

The American Philosophical Practitioners Association is a non-profit educa-tional corporation that encourages philosophical awareness and advocates leadingthe examined life. Philosophy can be practiced through client counseling, groupfacilitation, organizational consulting or educational programs. APPA mem-bers apply philosophical systems, insights and methods to the management ofhuman problems and the amelioration of human estates. The APPA is a 501(c)(3)tax-exempt organization.

APPA Membership

The American Philosophical Practitioners Association is a not-for-profit edu-cational corporation. It admits Certified, Affiliate and Adjunct Members solelyon the basis of their respective qualifications. It admits Auxiliary Members solelyon the basis of their interest in and support of philosophical practice. The APPAdoes not discriminate with respect to members or clients on the basis of nation-ality, race, ethnicity, sex, gender, age, religious belief, political persuasion, orother professionally or philosophically irrelevant criteria.

Subscriptions, Advertisements, Submissions, Back Issues

For information on subscriptions, advertisements and submissions, please seethe front pages of this document. For information on back issues, APPA Mem-berships and Programs, please visit www.appa.edu.

Nemo Veritatem RegitNobody Governs Truth