Truth Telling in Canadian Medical Practice

Introduction

Truth telling (veracity) is a fundamental ethical obligation in Canadian medical practice, deeply rooted in the CanMEDS Professional and Communicator roles. Historically, medicine operated under a model of paternalism, where physicians might withhold information if they believed it was in the patient’s best interest. However, modern Canadian medical ethics and law have shifted decisively toward patient autonomy.

For MCCQE1 preparation, it is crucial to understand that patients have a legal and ethical right to be fully informed about their medical condition, diagnosis, prognosis, and treatment options. This knowledge empowers them to provide informed consent.

🇨🇦

MCCQE1 Insight: In the Canadian context, withholding the truth is rarely justifiable. The concept of “Therapeutic Privilege” is extremely narrow and almost never accepted as a valid defense in Canadian courts or by provincial colleges.

Ethical and Legal Framework

Autonomy vs. Paternalism

The transition from paternalism to autonomy is the cornerstone of truth telling.

Feature	Paternalism (Historical)	Autonomy (Current Canadian Standard)
Decision Maker	Physician decides what is “best”	Patient decides based on their values
Information Flow	Filtered by the physician	Full disclosure (transparency)
Objective	Beneficence (doing good)	Self-determination + Beneficence
Legal Basis	N/A	Reibl v. Hughes (Supreme Court of Canada)

Fiduciary Duty

Physicians in Canada stand in a fiduciary relationship with their patients. This means there is a power imbalance, and the physician is legally obligated to act with the utmost good faith and loyalty. This includes the duty to be honest.

Clinical Pearl: The “Waiver”

While patients have a right to know, they also have a right not to know. If a patient explicitly states, “I don’t want to know the details, just talk to my spouse,” this is a valid exercise of autonomy (waiver). However, the physician must ensure this request is voluntary and not coerced.

Communicating Bad News

Breaking bad news is a high-yield topic for MCCQE1 and OSCEs. The standard framework taught in Canadian medical schools is the SPIKES protocol.

Step 1: Setting (S)

Ensure privacy. Involve significant others if the patient desires. Sit down to establish a non-rushed atmosphere. Manage interruptions (hand off pager/phone).

Step 2: Perception (P)

“Ask before you tell.” Assess the patient’s current understanding of their condition.

Example: “What have you been told so far about your symptoms?”

Step 3: Invitation (I)

Obtain permission to share the information. This respects the patient’s right not to know.

Example: “I have the results of the biopsy. Would you like me to explain the details to you now?”

Step 4: Knowledge (K)

Provide the information.

Give a warning shot: “Unfortunately, I have some bad news.”
Use clear, non-technical language.
Give the information in small chunks.
Avoid euphemisms. Use words like “cancer” or “died” rather than “growth” or “passed away” to ensure clarity.

Step 5: Emotions (E)

Address the patient’s emotions with empathy.

NURSE Mnemonic:
- Name: “I can see this is shocking.”
- Understand: “I can understand why you feel this way.”
- Respect: “You are asking good questions.”
- Support: “We will support you through this.”
- Explore: “Tell me more about what you are worried about.”

Step 6: Strategy and Summary (S)

Discuss the plan. Ensure the patient has a clear path forward (follow-up, treatment options, palliative care). Check for understanding.

Complex Scenarios in Truth Telling

For the MCCQE1, you will likely encounter scenarios that complicate the duty to disclose.

Family Requests Non-Disclosure

Scenario: A family member takes you aside and says, “Please don’t tell my father he has cancer. He will give up and die.”

Management:

Acknowledge the family’s concern (empathy).
Explain the legal and ethical obligation to the patient (autonomy).
Explore the patient’s preference for information privately.
Action: Ask the patient, “Some people like to know all the medical details, while others prefer to have family handle it. What is your preference?”
Outcome: If the patient wants to know, you must tell them, regardless of the family’s wishes.

Therapeutic Privilege

Therapeutic Privilege is the withholding of information by a physician based on the belief that disclosure would seriously harm the patient.

Global Context: Accepted in some jurisdictions.
Canadian Context: Extremely rare.
- It is not justified simply because the news will cause distress, anxiety, or depression.
- It might be considered only if disclosure would cause immediate, serious biological harm (e.g., inducing a massive myocardial infarction or immediate suicide attempt in a strictly controlled psychiatric setting).
- MCCQE1 Rule of Thumb: If an option suggests withholding information to “protect” the patient from being upset, it is likely the wrong answer.

Canadian Guidelines

CMA Code of Ethics and Professionalism

The Canadian Medical Association (CMA) explicitly states:

“Provide the patient with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.”

CMPA (Canadian Medical Protective Association) on Disclosure

The CMPA advises that physicians must disclose:

The facts of the incident.
The steps taken to care for the patient.
An expression of regret or apology.

Cultural Safety and Truth Telling

In Canada’s multicultural society, some cultures prioritize collective/family decision-making over individual autonomy.

Approach: Do not assume. Ask the patient how they wish to receive information.
If a patient from a collectivist culture explicitly waives their right to know and designates a family member, respecting that waiver is respecting their autonomy.

Key Points to Remember for MCCQE1

Autonomy is King: The patient’s right to know supersedes family wishes.
Ask Before You Tell: Always assess how much the patient wants to know.
No Lying: Never deceive a patient, even for their “benefit” (anti-paternalism).
Errors: Always disclose medical errors that cause harm. Apologize.
Waivers: A patient can validly choose not to know.
Minors: Mature minors (demonstrating capacity) are entitled to truth telling and confidentiality, even excluding parents in specific situations.

Sample Question

Case Presentation

A 72-year-old man presents to the clinic for follow-up of a suspicious lung nodule. A biopsy was performed last week. The pathology report confirms a diagnosis of small cell lung carcinoma with a poor prognosis. Before you enter the examination room, the patient’s daughter intercepts you in the hallway. She appears visibly distressed and says, “Doctor, I know the results are likely bad. Please, do not tell my father he has cancer. In our culture, we protect our elders from such news because the loss of hope will kill him faster than the disease. Tell him it’s an infection that needs strong medicine.”

Question

Which one of the following is the most appropriate next step in the management of this situation?

A. Agree to the daughter’s request and inform the patient he has a severe lung infection.
B. Inform the daughter that you are legally obligated to tell the patient the diagnosis immediately.
C. Invite the daughter into the room and ask the patient how much detail he would like to know about his condition.
D. Refer the patient to an oncologist to handle the disclosure of the diagnosis.
E. Tell the patient he has a “growth” but avoid using the word “cancer” to minimize anxiety.

Explanation

The correct answer is:

C. Invite the daughter into the room and ask the patient how much detail he would like to know about his condition.

Detailed Explanation: This scenario tests the conflict between family wishes (often culturally rooted) and the Canadian ethical standard of patient autonomy.

Option C is correct. It respects the daughter’s concern without violating the patient’s autonomy. By asking the patient about his preference for information (“Invitation” step of SPIKES), the physician allows the patient to either request full details or waive his right to know (potentially delegating to the daughter). This aligns with a culturally sensitive approach to autonomy.
Option A is incorrect. This involves lying to the patient, which breaches the Code of Ethics and fails the requirement for informed consent regarding treatment (chemotherapy/radiation cannot be consented to for an “infection”).
Option B is incorrect. While truth-telling is the standard, stating you must tell him “immediately” ignores the possibility that the patient may validly choose not to know (waiver). It is also confrontational and lacks cultural safety.
Option D is incorrect. This is “passing the buck.” The physician who ordered the test generally has the responsibility to follow up on the results.
Option E is incorrect. Using euphemisms creates confusion and prevents the patient from making informed decisions. It is a form of soft paternalism.

References

Canadian Medical Association (CMA). (2018). CMA Code of Ethics and Professionalism.
Canadian Medical Protective Association (CMPA). (2023). Disclosing harm from healthcare delivery: Open and honest communication with patients. CMPA Good Practices Guide
Medical Council of Canada (MCC). MCCQE Part I Objectives: Ethical, Legal and Organizational Aspects of Medicine.
Baile, W. F., et al. (2000). SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist.
Supreme Court of Canada. Reibl v. Hughes, [1980] 2 S.C.R. 880.