646
Journal of Pain and Symptom Management
Vol. 49 No. 3 March 2015
Humanities: Art, Language, and Spirituality in Health Care Series Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD
Discovering the Truth Beyond the Truth Gerhild Becker, MD, MTh, Karin Jors, MA, and Susan Block, MD Department of Palliative Care (G.B., K.J.), Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany; Department of Psychosocial Oncology and Palliative Care (S.B.), Dana-Farber Cancer Institute, and Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Abstract The question ‘‘What is truth?’’ is one of the oldest questions in philosophy. Truth within the field of medicine has gained relevance because of its fundamental relationship to the principle of patient autonomy. To fully participate in their medical care, patients must be told the truthdeven in the most difficult of situations. Palliative care emphasizes patient autonomy and a patient-centered approach, and it is precisely among patients with chronic, life-threatening, or terminal illnesses that truth plays a particularly crucial role. For these patients, finding out the truth about their disease forces them to confront existential fears. As physicians, we must understand that truth, similar to the complexity of pain, is multidimensional. In this article, we discuss the truth from three linguistic perspectives: the Latin veritas, the Greek aletheia, and the Hebrew emeth. Veritas conveys an understanding of truth focused on facts and reality. Aletheia reveals truth as a process, and emeth shows that truth is experienced in truthful encounters with others. In everyday clinical practice, truth is typically equated with the facts. However, this limited understanding of the truth does not account for the uniqueness of each patient. Although two patients may receive the same diagnosis (or facts), each will be affected by this truth in a very individual way. To help patients apprehend the truth, physicians are called to engage in a delicate back-and-forth of multiple difficult conversations in which each patient is accepted as a unique individual. J Pain Symptom Manage 2015;49:646e649. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Truth disclosure, physician-patient relations, personal autonomy
Introduction The famous Greek physician and philosopher Galen of Pergamon once wrote ‘‘quod optimus medicus sit quoque philosophus,’’ which means that an excellent physician also must be a philosopher. In philosophy, one of the most commonly pondered questions is ‘‘What is truth?’’ If we take Galen’s words to heart, then we as modern physicians also must confront ourselves with this age-old question. In recent decades, the topic of truth, or rather truth-telling, has received considerable attention in the field of medicine because of its fundamental relationship to the principle of respect for patient autonomy.1 To act autonomously and fully participate in their medical care, patients must be told the truth about their disease and potential treatment optionsd
Address correspondence to: Karin Jors, MA, University Medical Center Freiburg, Department of Palliative Care, RobertKoch-Strasse 3, 79106 Freiburg, Germany. E-mail: karin.jors@ uniklinik-freiburg.de Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
even in the most difficult of situations.2 Indeed, it is precisely among patients with chronic, lifethreatening, or terminal illnesses that truth plays a particularly crucial role. Truthdlike paindis multidimensional. This means that ‘‘telling the truth goes beyond delivering biomedical facts. It also entails humanity.’’3 In this article, we reflect on the biomedical as well as the humanistic aspects of truth by discussing its linguistic roots in Latin, Greek, and Hebrew.
Veritas In modern medicine, the truth is often equated with medical facts. Evidence-based medicine has its roots in Aristotle’s theory of empiricism, which holds that knowledge is based on experience and observation,
Accepted for publication: October 24, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.10.016
Vol. 49 No. 3 March 2015
Discovering the Truth
that is, evidence. Truth in this sense correlates most closely with the Latin veritas, which can be translated as that which withstands testing or the accuracy of a fact as determined by agreement between the statement and reality. Aristotle believed that one could verify something as true through experimentation and observation. However, this presents an important problem. If the truth depends on verification through observation, one would need to observe all possible cases to prove something true. For example, would it be possible to say that all swans are white without actually observing all swans? To solve this dilemma, Karl Popper introduced the theory of critical rationalism, which contests that a scientific theory must withstand falsification to be considered true. Accordingly, one would only need to find one black swan to prove that not all swans are white. However, if no black swans can be found despite multiple attempts to find one, then one can be quite certain that all swans are white. Critical rationalism thus suggests that the more often a theory withstands refutation, the closer it comes to an accurate description of the truth. Nevertheless, the fact that a theory has not yet been disproven does not prove that it is true. Rather, this simply implies that the unrefuted theory comes closer to the truth than prior disproven theories. Accordingly, through medical research we constantly grow closer to the truth, yet we remain grounded in the knowledge that it is not fully attainable. Especially in the field of palliative care, which emphasizes an individualized approach to patient care, we must, therefore, be willing to constantly question our convictions regarding the best diagnostic and therapeutic measures. Even when substantial evidence and well-established standards exist, there is no guarantee that such standards hold true for each individual patient. Thus, determining the best course of action requires physicians to enter into a dialogue with their patients, in which scientific truths (veritas) are discussed along with the personal needs of the patient. An essential aspect of this physician-patient dialogue is providing patients the scientific truths about their diagnosis and prognosis. Honestly communicating this information is indispensable. However, patients who receive bad news may hear the facts (veritas) but deny that they are true. In this case, the truth perceived by the individual (e.g., ‘‘I am going to be fine.’’) differs from the medical truth (e.g., ‘‘There is no cure for your disease.’’).
Aletheia How are we as physicians to understand that patients sometimes deny an accurate description of
647
reality (veritas) as the truth? The Greek term for truth, aletheia, reveals a less common understanding of the truth. Aletheia literally means not hidden. In the 20th century, the German philosopher Martin Heidegger devoted considerable thought to the term aletheia. In his famous work ‘‘Being and Time’’ as well as ‘‘On the Essence of Truth,’’ Heidegger describes aletheia as a process of unconcealment, emphasizing that truth is an opening, or a revelation of what is. In ancient Greece, aletheia was used in theater to describe the process of slowly drawing the curtain and revealing what had been hidden. The metaphor of drawing the curtain is a useful image in understanding how both revealing and apprehending the truth is a process. Physicians must be cautious not to provide medical facts like pouring a bucket of cold water over the patient’s head. Rather, physicians must hold out the truth like a jacket, welcoming and encouraging patients to slip into it at their own pace. Imagine a humble butler who holds out the jacket to his master; he stands at the service of the master without forcing the jacket on him before he is ready. In the same way, physicians should not try to force the truth on their patients. For patients diagnosed with a life-limiting illness, accepting the medical facts (veritas) as existential truths (aletheia) that affect their very being takes time and multiple conversations. Our responsibility as physicians is to accompany patients in the process of unconcealment until the curtain is slowly drawn back to reveal medical truths as existential realities.
Emeth In the process of understanding and accepting the truth, the physician-patient relationship plays a vital role. Emeth, the Hebrew term used for truth in the Old Testament of the Bible, emphasizes that truth involves relationship. Truth, in the Hebrew sense, is not an abstract concept but rather a concrete experience that occurs in our encounters with others. The word emeth stems from the Hebrew verb amam, which means to support and make firm. Thus, emeth characterizes the reliability and steadfastness of things, facts, people, and even God. Throughout the Old Testament, emeth is used to describe God’s active faithfulness to the Israelites. Through his actions, not simply through his being, God proved that his promises were true. Likewise, truthfulness, defined as acting in accordance with the truth, is perhaps the most fitting translation of emeth. A parallel to this understanding of the truth is Martin Buber’s ‘‘I-Thou’’ relation. Buber proposes that the most intimate reality, or truth, of the person is unfolded in encounter with others. According to
648
Becker et al.
Vol. 49 No. 3 March 2015
Buber, ‘‘Whatever the word truth might mean in other areas, in encounters with others it means that people convey themselves to each other as that which they are.’’4 This ‘‘I-Thou’’ encounter requires acceptance of the other and an openness to dialogue. Applied to the physician-patient relationship, truth then becomes not simply a one-sided presentation of facts but rather an open dialogue between two equal subjects. This dialogue ‘‘must be directed in such a way that those aspects are discussed that are relevant for his/her recovery and also for planning how to lead his/her life further [.]. These aspects can be recognized only in an intensive encounter with the patient or with the patient and his/her family.’’5
The Individual Approach Each encounter with a new patient requires openness to the uniqueness of that individual. The French philosopher Levinas, who expanded on Buber’s theory, emphasized that in our encounters with others, the uniqueness and foreignness of the other can never be fully comprehended. As discussed earlier, even the best clinical research can only bring us closer to the truth, but it is not guaranteed to hold true in every situation. This means that despite many years of experience, extensive clinical knowledge, and scientific evidence, physicians must be cautious in assuming that they know what is best for each patient. When we presume to know all the answers, we run the risk of viewing patients ‘‘not as Henry Jones, but as ‘that case of mitral stenosis in the second bed on the left.’’’6 Caring for a patient as ‘‘that case of mitral stenosis’’ only accounts for his or her disease. However, just as veritas is only one aspect of the truth, the disease is only one part of the patient. Entering into the physician-patient relationship involves not only a thorough knowledge of scientific truths but also an awareness of the emotional, spiritual, and social truths of each individual. The more one moves away from the general treatment of disease and toward the holistic treatment of individuals, the more physicians are called to use their own insight and intuitiondto be philosophers. Aristotle believed that physicians need not only episteme (theoretical knowledge) and techne (experience and skill) but also phronesis (understanding and insight for each individual case). Heidegger sometimes translated phronesis as conscience, meaning the innate ability to judge what is right in a situation regardless of knowledge or skills. Thus, truthful encounters with patients require physicians to apply
Fig. 1. ‘‘Nuda Veritas’’ (1902). Gustav Klimt. Belvedere, Vienna. Available from http://commons.wikimedia.org. Public domain.
Vol. 49 No. 3 March 2015
Discovering the Truth
their best medical knowledge and experience along with their own conscience to assess and administer the best treatment according to the situation.
649
strict adherence to medical facts and open the door for an individual approach.
Disclosures and Acknowledgments Conclusion Physicians have a responsibility to tell patients the truth. Yet, particularly when faced with breaking bad news, physicians often fear that the truth will adversely affect the patient’s state of mind and, therefore, struggle to communicate openly.7 Certainly, presenting only the ‘‘naked facts’’ in a perfunctory manner can have harmful consequences.8 As written on Klimt’s drawing of ‘‘Nuda Veritas’’ (Fig. 1), ‘‘The truth is fire and speaking the truth means to shine and burn.’’ Truthdlike firedcan have damaging effects when not handled in an appropriate manner, but it also can be a valuable tool to light our path and guide us in the right direction. As we have discussed here, truth is multifaceted. Truth must be understood as a process (aletheia) and must be experienced in genuine encounters (emeth) in which the patient and physician engage in the delicate back-and-forth of multiple difficult conversations. Throughout this process, ‘‘individualized disclosure’’ of the truth emerges as the ideal.9 This individual approach calls physicians to rely not only on their medical knowledge (episteme) and experience (techne) but also on their best judgment ( phronesis) of the situation. When patients experience the truth within the framework of a relationship in which they are recognized as unique individuals, the truth has the power to ‘‘dispel uncertainty and fear and enhance healing and patient satisfaction.’’1 Knowledge of the truth can free patients to actively participate in their medical care. Likewise, a deeper understanding of the truth can free physicians from
No funding was received for this article nor do the authors have any conflicts of interest. All authors participated in the drafting of this manuscript.
References 1. Snyder L. American College of Physicians ethics manual, 6th ed. Ann Intern Med 2012;156:73e104. 2. Tattersall M. Truth telling and consent. In: Hanks G, Cherny N, Christakis N, Fallon M, Kaasa S, Portenoy R, eds. Oxford textbook of palliative medicine, 4th ed New York: Oxford University Press, 2010:290e295. 3. [No authors listed] Truth telling in clinical practice. [editorial]. Lancet 2011;378:1197. 4. Buber M. Das dialogische Prinzip. Gerlingen, Germany: Schneider, 1994. 5. Klocker J. Truth in the relationship between cancer patient and physician. Ann N Y Acad Sci 1997;809:56e65. 6. Peabody FW. The care of the patient. JAMA 1927;88: 877e882. 7. Shahidi J. Not telling the truth: circumstances leading to concealment of diagnosis and prognosis from cancer patients. Eur J Cancer Care 2010;19:589e593. 8. Ad Hoc Committee on Medical Ethics, American College of Physicians. American College of Physicians ethics manual. Part I: History of medical ethics, the physician and the patient, the physician’s relationship to other physicians, the physician and society. Ann Intern Med 1984;101: 129e137 9. Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol 1995;13:2449e2456.
Journal of Pain and Symptom Management
Vol. 49 No. 3 March 2015
Humanities: Art, Language, and Spirituality in Health Care Series Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD
Discovering the Truth Beyond the Truth Gerhild Becker, MD, MTh, Karin Jors, MA, and Susan Block, MD Department of Palliative Care (G.B., K.J.), Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany; Department of Psychosocial Oncology and Palliative Care (S.B.), Dana-Farber Cancer Institute, and Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Abstract The question ‘‘What is truth?’’ is one of the oldest questions in philosophy. Truth within the field of medicine has gained relevance because of its fundamental relationship to the principle of patient autonomy. To fully participate in their medical care, patients must be told the truthdeven in the most difficult of situations. Palliative care emphasizes patient autonomy and a patient-centered approach, and it is precisely among patients with chronic, life-threatening, or terminal illnesses that truth plays a particularly crucial role. For these patients, finding out the truth about their disease forces them to confront existential fears. As physicians, we must understand that truth, similar to the complexity of pain, is multidimensional. In this article, we discuss the truth from three linguistic perspectives: the Latin veritas, the Greek aletheia, and the Hebrew emeth. Veritas conveys an understanding of truth focused on facts and reality. Aletheia reveals truth as a process, and emeth shows that truth is experienced in truthful encounters with others. In everyday clinical practice, truth is typically equated with the facts. However, this limited understanding of the truth does not account for the uniqueness of each patient. Although two patients may receive the same diagnosis (or facts), each will be affected by this truth in a very individual way. To help patients apprehend the truth, physicians are called to engage in a delicate back-and-forth of multiple difficult conversations in which each patient is accepted as a unique individual. J Pain Symptom Manage 2015;49:646e649. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Truth disclosure, physician-patient relations, personal autonomy
Introduction The famous Greek physician and philosopher Galen of Pergamon once wrote ‘‘quod optimus medicus sit quoque philosophus,’’ which means that an excellent physician also must be a philosopher. In philosophy, one of the most commonly pondered questions is ‘‘What is truth?’’ If we take Galen’s words to heart, then we as modern physicians also must confront ourselves with this age-old question. In recent decades, the topic of truth, or rather truth-telling, has received considerable attention in the field of medicine because of its fundamental relationship to the principle of respect for patient autonomy.1 To act autonomously and fully participate in their medical care, patients must be told the truth about their disease and potential treatment optionsd
Address correspondence to: Karin Jors, MA, University Medical Center Freiburg, Department of Palliative Care, RobertKoch-Strasse 3, 79106 Freiburg, Germany. E-mail: karin.jors@ uniklinik-freiburg.de Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
even in the most difficult of situations.2 Indeed, it is precisely among patients with chronic, lifethreatening, or terminal illnesses that truth plays a particularly crucial role. Truthdlike paindis multidimensional. This means that ‘‘telling the truth goes beyond delivering biomedical facts. It also entails humanity.’’3 In this article, we reflect on the biomedical as well as the humanistic aspects of truth by discussing its linguistic roots in Latin, Greek, and Hebrew.
Veritas In modern medicine, the truth is often equated with medical facts. Evidence-based medicine has its roots in Aristotle’s theory of empiricism, which holds that knowledge is based on experience and observation,
Accepted for publication: October 24, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.10.016
Vol. 49 No. 3 March 2015
Discovering the Truth
that is, evidence. Truth in this sense correlates most closely with the Latin veritas, which can be translated as that which withstands testing or the accuracy of a fact as determined by agreement between the statement and reality. Aristotle believed that one could verify something as true through experimentation and observation. However, this presents an important problem. If the truth depends on verification through observation, one would need to observe all possible cases to prove something true. For example, would it be possible to say that all swans are white without actually observing all swans? To solve this dilemma, Karl Popper introduced the theory of critical rationalism, which contests that a scientific theory must withstand falsification to be considered true. Accordingly, one would only need to find one black swan to prove that not all swans are white. However, if no black swans can be found despite multiple attempts to find one, then one can be quite certain that all swans are white. Critical rationalism thus suggests that the more often a theory withstands refutation, the closer it comes to an accurate description of the truth. Nevertheless, the fact that a theory has not yet been disproven does not prove that it is true. Rather, this simply implies that the unrefuted theory comes closer to the truth than prior disproven theories. Accordingly, through medical research we constantly grow closer to the truth, yet we remain grounded in the knowledge that it is not fully attainable. Especially in the field of palliative care, which emphasizes an individualized approach to patient care, we must, therefore, be willing to constantly question our convictions regarding the best diagnostic and therapeutic measures. Even when substantial evidence and well-established standards exist, there is no guarantee that such standards hold true for each individual patient. Thus, determining the best course of action requires physicians to enter into a dialogue with their patients, in which scientific truths (veritas) are discussed along with the personal needs of the patient. An essential aspect of this physician-patient dialogue is providing patients the scientific truths about their diagnosis and prognosis. Honestly communicating this information is indispensable. However, patients who receive bad news may hear the facts (veritas) but deny that they are true. In this case, the truth perceived by the individual (e.g., ‘‘I am going to be fine.’’) differs from the medical truth (e.g., ‘‘There is no cure for your disease.’’).
Aletheia How are we as physicians to understand that patients sometimes deny an accurate description of
647
reality (veritas) as the truth? The Greek term for truth, aletheia, reveals a less common understanding of the truth. Aletheia literally means not hidden. In the 20th century, the German philosopher Martin Heidegger devoted considerable thought to the term aletheia. In his famous work ‘‘Being and Time’’ as well as ‘‘On the Essence of Truth,’’ Heidegger describes aletheia as a process of unconcealment, emphasizing that truth is an opening, or a revelation of what is. In ancient Greece, aletheia was used in theater to describe the process of slowly drawing the curtain and revealing what had been hidden. The metaphor of drawing the curtain is a useful image in understanding how both revealing and apprehending the truth is a process. Physicians must be cautious not to provide medical facts like pouring a bucket of cold water over the patient’s head. Rather, physicians must hold out the truth like a jacket, welcoming and encouraging patients to slip into it at their own pace. Imagine a humble butler who holds out the jacket to his master; he stands at the service of the master without forcing the jacket on him before he is ready. In the same way, physicians should not try to force the truth on their patients. For patients diagnosed with a life-limiting illness, accepting the medical facts (veritas) as existential truths (aletheia) that affect their very being takes time and multiple conversations. Our responsibility as physicians is to accompany patients in the process of unconcealment until the curtain is slowly drawn back to reveal medical truths as existential realities.
Emeth In the process of understanding and accepting the truth, the physician-patient relationship plays a vital role. Emeth, the Hebrew term used for truth in the Old Testament of the Bible, emphasizes that truth involves relationship. Truth, in the Hebrew sense, is not an abstract concept but rather a concrete experience that occurs in our encounters with others. The word emeth stems from the Hebrew verb amam, which means to support and make firm. Thus, emeth characterizes the reliability and steadfastness of things, facts, people, and even God. Throughout the Old Testament, emeth is used to describe God’s active faithfulness to the Israelites. Through his actions, not simply through his being, God proved that his promises were true. Likewise, truthfulness, defined as acting in accordance with the truth, is perhaps the most fitting translation of emeth. A parallel to this understanding of the truth is Martin Buber’s ‘‘I-Thou’’ relation. Buber proposes that the most intimate reality, or truth, of the person is unfolded in encounter with others. According to
648
Becker et al.
Vol. 49 No. 3 March 2015
Buber, ‘‘Whatever the word truth might mean in other areas, in encounters with others it means that people convey themselves to each other as that which they are.’’4 This ‘‘I-Thou’’ encounter requires acceptance of the other and an openness to dialogue. Applied to the physician-patient relationship, truth then becomes not simply a one-sided presentation of facts but rather an open dialogue between two equal subjects. This dialogue ‘‘must be directed in such a way that those aspects are discussed that are relevant for his/her recovery and also for planning how to lead his/her life further [.]. These aspects can be recognized only in an intensive encounter with the patient or with the patient and his/her family.’’5
The Individual Approach Each encounter with a new patient requires openness to the uniqueness of that individual. The French philosopher Levinas, who expanded on Buber’s theory, emphasized that in our encounters with others, the uniqueness and foreignness of the other can never be fully comprehended. As discussed earlier, even the best clinical research can only bring us closer to the truth, but it is not guaranteed to hold true in every situation. This means that despite many years of experience, extensive clinical knowledge, and scientific evidence, physicians must be cautious in assuming that they know what is best for each patient. When we presume to know all the answers, we run the risk of viewing patients ‘‘not as Henry Jones, but as ‘that case of mitral stenosis in the second bed on the left.’’’6 Caring for a patient as ‘‘that case of mitral stenosis’’ only accounts for his or her disease. However, just as veritas is only one aspect of the truth, the disease is only one part of the patient. Entering into the physician-patient relationship involves not only a thorough knowledge of scientific truths but also an awareness of the emotional, spiritual, and social truths of each individual. The more one moves away from the general treatment of disease and toward the holistic treatment of individuals, the more physicians are called to use their own insight and intuitiondto be philosophers. Aristotle believed that physicians need not only episteme (theoretical knowledge) and techne (experience and skill) but also phronesis (understanding and insight for each individual case). Heidegger sometimes translated phronesis as conscience, meaning the innate ability to judge what is right in a situation regardless of knowledge or skills. Thus, truthful encounters with patients require physicians to apply
Fig. 1. ‘‘Nuda Veritas’’ (1902). Gustav Klimt. Belvedere, Vienna. Available from http://commons.wikimedia.org. Public domain.
Vol. 49 No. 3 March 2015
Discovering the Truth
their best medical knowledge and experience along with their own conscience to assess and administer the best treatment according to the situation.
649
strict adherence to medical facts and open the door for an individual approach.
Disclosures and Acknowledgments Conclusion Physicians have a responsibility to tell patients the truth. Yet, particularly when faced with breaking bad news, physicians often fear that the truth will adversely affect the patient’s state of mind and, therefore, struggle to communicate openly.7 Certainly, presenting only the ‘‘naked facts’’ in a perfunctory manner can have harmful consequences.8 As written on Klimt’s drawing of ‘‘Nuda Veritas’’ (Fig. 1), ‘‘The truth is fire and speaking the truth means to shine and burn.’’ Truthdlike firedcan have damaging effects when not handled in an appropriate manner, but it also can be a valuable tool to light our path and guide us in the right direction. As we have discussed here, truth is multifaceted. Truth must be understood as a process (aletheia) and must be experienced in genuine encounters (emeth) in which the patient and physician engage in the delicate back-and-forth of multiple difficult conversations. Throughout this process, ‘‘individualized disclosure’’ of the truth emerges as the ideal.9 This individual approach calls physicians to rely not only on their medical knowledge (episteme) and experience (techne) but also on their best judgment ( phronesis) of the situation. When patients experience the truth within the framework of a relationship in which they are recognized as unique individuals, the truth has the power to ‘‘dispel uncertainty and fear and enhance healing and patient satisfaction.’’1 Knowledge of the truth can free patients to actively participate in their medical care. Likewise, a deeper understanding of the truth can free physicians from
No funding was received for this article nor do the authors have any conflicts of interest. All authors participated in the drafting of this manuscript.
References 1. Snyder L. American College of Physicians ethics manual, 6th ed. Ann Intern Med 2012;156:73e104. 2. Tattersall M. Truth telling and consent. In: Hanks G, Cherny N, Christakis N, Fallon M, Kaasa S, Portenoy R, eds. Oxford textbook of palliative medicine, 4th ed New York: Oxford University Press, 2010:290e295. 3. [No authors listed] Truth telling in clinical practice. [editorial]. Lancet 2011;378:1197. 4. Buber M. Das dialogische Prinzip. Gerlingen, Germany: Schneider, 1994. 5. Klocker J. Truth in the relationship between cancer patient and physician. Ann N Y Acad Sci 1997;809:56e65. 6. Peabody FW. The care of the patient. JAMA 1927;88: 877e882. 7. Shahidi J. Not telling the truth: circumstances leading to concealment of diagnosis and prognosis from cancer patients. Eur J Cancer Care 2010;19:589e593. 8. Ad Hoc Committee on Medical Ethics, American College of Physicians. American College of Physicians ethics manual. Part I: History of medical ethics, the physician and the patient, the physician’s relationship to other physicians, the physician and society. Ann Intern Med 1984;101: 129e137 9. Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol 1995;13:2449e2456.
