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Article

Balancing truth-telling in
the preservation of hope:
A relational ethics approach

Nursing Ethics
19(1) 2129
The Author(s) 2012
Reprints and permission:
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10.1177/0969733011418551
nej.sagepub.com

Pernilla Pergert
Karolinska Institutet, Sweden

Kim Lutzen
Karolinska Institutet, Sweden

Abstract
Truth-telling in healthcare practice can be regarded as a universal communicative virtue; however, there
are different views on what consequence it has for giving or diminishing hope. The aim of this article is
to explore the relationship between the concepts of truth-telling and hope from a relational ethics
approach in the context of healthcare practice. Healthcare staff protect themselves and others to preserve hope in the care of seriously sick patients and in end-of-life care. This is done by balancing truthtelling guided by different conditions such as the cultural norms of patients, family and staff. Our main
conclusion is that the balancing of truth-telling needs to be decided in a mutual understanding in the
caring relationship, but hope must always be inspired. Instead of focusing on autonomy as the only guiding principle, we would like to propose that relational ethics can serve as a meaningful perspective in
balancing truth-telling.
Keywords
balancing truth-telling, caring relationship, hope preserving, relational ethics, transcultural care

Introduction
Truth-telling, such as disclosing factual information to patients and/or their families, is a basic moral rule in
the western healthcare system. Not to tell the truth can be viewed as jeopardizing trust in the healthcare staffpatient relationship, intruding on the patients existential integrity and undermining the patients possibility
for autonomy.1 In accordance, Jacques Thiroux2 presents truth-telling and honesty as universal principles
that underscore respect for a persons autonomy.
While honesty can be defined either as a universal principle or as a virtue3 in some cultures, truthtelling may not be in agreement with the moral norms of specific cultures. Disclosing facts may have
diverse meanings for patients or their family. For example, a practitioner that in the name of honesty
communicates a hopeless prognosis survival may be seen as an uncaring or non-compassionate person
by care-recipients who do not share the same moral norm. In some cultures withholding the truth may
be seen as an admirable act. From this perspective, viewing truth-telling as involving two main

Corresponding author: Pernilla Pergert, Department of Womens and Childrens Health, Karolinska Institutet, Stockholm,
Childhood Cancer Research Unit, Astrid Lindgren Childrens Hospital, Q6:05, SE-171 76 Stockholm, Sweden
Email: pernilla.pergert@ki.se

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Nursing Ethics 19(1)

inter-personal elements warrants a closer analysis; the practitioners reason(s) for telling the truth and the
intended receivers wish to know the truth. Keeping in mind that ethics is neither evidence based science
nor a matter of common sense, we cannot assume that to follow the suggestion to withhold the truth if a
patient so wishes1 may or may not be beneficial for the patient. Moreover, who makes the final judgment
regarding what is the truth?
We perceive whether to tell the truth or not as a complex question that requires reflection on why, what
and how. The why is concerned with the intention of telling the truth; whether it is based on a good intention, such as compassion, or not. The what refers to the substance and the how is the manner in which the
truth is conveyed in our language and interaction with others. Thus, truth-telling can be seen as something
more than a communicative act of disclosing information since the recipient interprets a meaning embedded
in this information.
The cultural aspect of truth-telling is a current issue in health care generally and specifically in the care of
patients with poor prognosis of survival. Many people from different countries and cultures have become
residents of the Swedish society and, as such, recipients of health care as well as healthcare providers. In
2009 foreign-born persons in Sweden represented 200 countries,4 thus, ethical perspectives on truthtelling in regard to a patients illness or condition is highly relevant in Sweden. Moral values are indigenous
to a particular culture and influence beliefs about health and illness and the role of both the patient and the
healthcare provider.5 The question concerning telling the truth or withholding it is not only a matter of cultural traditions but also concerns the obligation to follow healthcare legislation and professional codes of
ethics. Guven6 argues that healthcare staff can act in a paternalistic, i.e. autonomy restricting,3 way if they
assume that they know what the patient wants to know or not to know. Finding out what the patient wants to
know means that the ethical issue of truth-telling should be based on dialogue and building a meaningful
relationship with the patient.
The aim of this article is to explore the concept of truth-telling and truth-telling in relation to culture and
hope. An additional aim is to discuss how healthcare staff balance truth-telling and preserving hope and the
relevance of a relational ethics approach in this process.

Definition of terms
Truth-telling
The challenge of truth-telling often arises in the care of persons with serious illnesses and what consequence truth has for giving or diminishing hope in the patient and family.6,7 Truth may concern factual
yet sensitive information about diagnoses, treatment and/or prognosis for example, information about a
cancer diagnosis, the risk of adverse effects, or the transition from curative to palliative treatment.7,8
The objective truth is a debated philosophical concept but truth here refers to the subjective truth;
that is, what healthcare staff, out of their qualified judgement believe and are convinced to be true.1
However, even when discussing subjective truth the matter of truthfulness is of relevance. Withholding
the truth could be viewed as deceiving or misleading even though a direct lie is not used. Moreover,
truth-telling is a prerequisite for trusting relationships. According to Kant9 truth-telling is a moral duty
and, according to Lgstrup10 reciprocal trust is an elementary component and, as such, creates an ethical
demand in our effort to sustain trust. In western cultures there is an almost exclusive focus on verbal
information and communication but there are different strategies for truth-telling including non-verbal,
symbolic and metaphoric communication.8,11 There is a great difference between saying/being told the
truth and knowing it8,12 and it is essential to individualize the information and to disclose it in a
slow12,13 and empathic way in order to make it bearable. There are also different strategies for withholding the truth, which could be used by family and staff.8

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Hope
Fitzgerald Miller describes hope as a statement of being characterized by an anticipation of a continued
good state, an improved state or a release from a perceived entrapment(p. 17).14 Hope has two different
aspects; to live in hope to hope for something specific such as cure or a good death; and to live in
the light of hope when hope is marked by suffering; for example, a hope to endure.15 This is similar to
hoping for something and living in hope.16,17 To live in hope is to reconcile oneself to life and
death.16 The concepts are confusing since Waterworth15 suggests to live in hope refers to the goal
oriented aspect of hope while by others 16, 17 it is suggested to represent the more existential aspect
of hope. Alternative names of these two aspects of hope are specific and general hope.18 These latter
terms might be preferable as it is clear what they refer to; the specific hope is to hope for something
specific while the generalized hope is referring to a vague inner or existential experience of hope.19 Our
understanding of hope influence what strategies we use to inspire hope but also our views of false
hope.14 Healthcare staff can use hope inspiring strategies and help patients and families move from a
specific hope to a more generalized hope.14 Hope is essential in life but also to handle sickness and
to prepare for death.14 To preserve hope is an important coping strategy for severely sick and a pillar
in palliative care.19

Culture
Culture has been defined as the learned and shared beliefs, values, and life ways of a designated or particular
group that are generally transmitted intergenerationally and influence ones thinking and action modes(p.9
10).20 Cultures change over time and there are great individual variations within groups.20 Furthermore, cultures influence all aspects of care, including end-of-life care20,21 and truth-telling.22 The care encounter takes
place between/across the culture of the patient and the culture of the healthcare staff. Also, the culture of the
healthcare setting will influence the interaction, including the medical culture, the nursing culture and the
culture of the organization.23
Many different aspects influence attitudes on truth-telling, and hope seems to be an important argument
for both telling the truth and withholding it in care.

Balancing truth-telling
Balancing is a process that emerged in the study of end-of-life care, which includes the shifting in care when
difficult information is disclosed.24 In the process of deciding how much truth to tell at a certain time, the
healthcare team may be attempting to be sensitive to the needs and wishes of the patient24 but is also influenced by individual attitudes and skills of healthcare staff. In the care of seriously sick patients and in endof-life care, healthcare staff protect themselves and others8 by balancing truth-telling with the aim of
preserving hope;24 truth-telling is influenced by different conditions as presented below. Facades are used
to manage others impressions and to protect oneself and others from suffering, emotions, vulnerability8
and to avoid diminishing hope.24

Conditions influencing the balancing of truth-telling


Withholding the truth is used to protect patients from negative impact25 such as a diminished hope, suffering,
physical impairment8,25 and to enhance compliance.26 Furthermore, the protection of healthcare staff from
discomfort has also been shown to be a reason for withholding information from patients.25,26 Reasons for
truth-telling includes autonomy, physical and psychological benefit, intrinsic good27 and improved compliance.28 In a Swedish study,7 healthcare staff consider truth-telling to be a prerequisite for honesty and trust

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and thereby a prerequisite for the caring relationship. A reason for this is that nonverbal communication
might contradict the verbally communicated message and thereby suggest deceit.8 Furthermore, in that same
study,7 truth-telling was thought to give the patient a possibility to prepare, cope and deal with the situation,
which has also been found in other studies.29
Truth-telling to children varies with different conditions, and cultural differences have been found in
regard to telling the child about their cancer diagnosis.28 Variables that influence truth-telling to children also
include the age of the child, the childs explicit interest in knowing and the parents attitudes to truthtelling.28 We propose that truth-telling to children should always be decided with the childs best interest
in mind and rather than balancing truth-telling to children on the age of the child, the level of maturity, independence and understanding should be taken into account. In Sweden, a minor who is decision-competent
can understand consequences of different alternative actions and come to a decision, have the right to make
informed decisions in care themselves,30 thus demanding truth-telling. In a study on traumatized children
Almqvist and Broberg31 describes a family survival strategy, which includes strategies of silence and denial
in a mutual protection of each other; the parents are protecting the child from the truth and the child is
protecting the parents. When parents wish to withhold information from their child, a sensitivity and respect
for the family dynamics is needed since agreement between family and healthcare staff is central to the generalized hope.14
Differences in attitudes towards truth-telling occur within and between individuals from the same country,7,32 but culture is a major factor contributing to views of truth-telling.13,33-35 Peoples basic attitudes
towards life and death are socially and culturally developed. This could mean that hearing the truth concerning a terminal illness, is experienced by that person as a communicative act of transgression of cultural
values. Thus, the cultural aspect is evident in transcultural care in areas where different attitudes towards
truth-telling meet. Tuckett27 argues that attitudes of truth-telling are a cultural artefact and it is important
to know that cultures are dynamic as they change under different circumstances.20 Guven6 argues that the
claim of cultural incompatibility of truth-telling with the Turkish culture is paternalistic and is foremost
advocated by healthcare staff and influenced by their attitudes. In accordance with the claim of Guven,6 staff
attitudes as well as lack of training in giving difficult information to patients and families have been suggested to contribute to a practice of withholding the truth.36,37 In Swedish, as well as western care, there
is a strong movement toward truth-telling,13,27,32 related to a high emphasis on patient autonomy. It has been
argued7 that the views of healthcare staff on truth-telling as crucially important could lead to a risk of cultural
ethnocentrism, that is, a conviction that ones own way is the best or the only right way. Furthermore, there is
a risk of ethical imperialism(p.160)6 in individual autonomy, and the latter is a delicate area in paediatric
and psychiatric care where the authors of the present article are active.
We would argue the importance of healthcare staff not only being able to communicate difficult and
sensitive information to the patient and family but also being able to convey alternative/generalized hope
and support when the specific hope of, for example, cure diminishes.

Preserving hope
Hope preserving is an important argument in choosing to withhold the truth or telling the truth in care.
With a restricted view on truth-telling it is often believed that truth-telling will risk bereaving hope from
the patient, causing the patient suffering and physical and psychological harm8,27 or even hastening
death.29 But measures of withholding information that aim to protect the patient from suffering, could
lead to concealed suffering and hopelessness rather than preserving hope.25,38 Furthermore, to suggest
that hope is versus truth39 or that hope needs to be balanced with honesty/truthfulness40 may distort you
to believe that truth and hope are irreconcilable dichotomies. On the contrary, truth-telling have been
found to support hope.40-42

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To communicate truth is to acknowledge a threat and/or a suffering and will thereby stimulate hope.14 The
unspoken and concealed suffering increases and leads to a feeling of hopelessness.38,43 Furthermore, the fantasy of the patient can interpret the withheld information and imagine a more horrifying picture of what is
happening.8,25 What is made visible is easier to bear than the hidden truth43 as this quote from Bjorklund
and Leijonhielm (p.24)44 also suggests:
To see the reality as it is; is to begin with almost unspeakably painful. But to be able to hope in a realistic way, one
has to let go and fall down in hopelessness. Strangely enough the strongest hope can come out of the deepest
despair.

When truth-telling is practiced, patients and families may need to change from a specific hope to a more
generalized hope. To exchange the hope of life and cure, no matter how small, to the hope of a good
death demands that healthcare staff are convinced that it is possible to live in a generalized hope and
can inspire it. On the contrary, healthcare staff are often sad, or even disappointed, that the curative treatment has failed. This could be related to the grief of healthcare staff over the patients suffering. According to our experience, some patients have to pay a very high price, in the form of suffering, for a
sometimes very small hope that is rather to be defined as wishful thinking or false hope. Thus, attitudes
toward truth-telling are influenced by the views on possibilities to instil hope and for that relational
ethics and the caring relationship are key.

Relational ethics as a tool for balancing truth-telling


Relational ethics seems to be appropriate in general for deliberation of moral issues in nursing,45 in guiding
healthcare staff in the care of patients with existential concern,46 in dealing with taboo and difficult issues
such as contagious diseases,47 unresolved pain in children,48 and oppression in psychiatric care.49 We would
like to argue for relational ethics as a tool for deliberating the balance of truth-telling in each interaction when
conveying difficult information in care.
Relational ethics is based on the assumption that ethical practice is situated in relationships.50 Relational
ethics has a strong emphasis on an authentic dialogue respecting emotions as well as reason expressed by the
persons involved.47,49 From this perspective, the issue of truth-telling can be approached by an awareness of
the relational context rather than relying on principles alone.51 Moreover, the strong emphasis on autonomy
in western health care implies an independency on others. This is a misconception considering that we are
born into relationships and could not survive life without them. Relational ethics respects the essential meaning of the principle of autonomy as well as realizing that a patients dependency on the healthcare provider or
the healthcare system may mean that autonomy cannot be applied in all situations.46 In a virtuous ethics
approach to truth-telling, the acting person, the one telling or withholding the truth, is the core.52 In relational
ethics, in contrast to both principle ethics and virtue ethics, the core is the dialogue within the relationship.
The caring relationship is the foundation of care53 and the quality of the relationship is a key in relational
ethics in deliberating on moral decisions such as truth-telling.46 Therefore, it is of importance to a patient
and the family that healthcare staff identify and bridge cultural and communicational obstacles to transcultural caring relationships.54 Likewise, it is central that healthcare staff are able to be there and bear the different emotions of suffering43 and to hear the patients suffering. Furthermore, according to relational ethics
the context is of importance in ethical decisions and actions.47

Relational ethics, truth-telling and hope a case


We would like to present a case to use as an example arguing this point.

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Jasmine is a 15 year-old girl in end-of-life care. After many years of cancer treatment she is very mature
psychologically and in her social contacts with adults. Her parents are firmly against telling the girl that the
curative treatment has failed and stopped. They argue that truth-telling is against their culture and that she
would lose hope. However, the nursing staff thinks that it is unethical not to tell the girl and they argue, on
the basis of principles, that they need to tell her the truth; to respect her autonomy the girl is competent to
hear and understand the truth, and to do good (beneficence) she could prepare for her death and gain a
general hope rather than a false hope. Finally, if she is not told the truth this would do her harm (nonmaleficence) since she would be denied the possibility to prepare, or even worse, she probably already knows
that she is dying and might be alone in this knowledge. Physicians, on the other hand, argued that jeopardizing the relationships with the parents would not be to do good, but rather to do harm.

In applying relational ethics the decision is rooted in the relationships, interactions and in a genuine
dialogue with Jasmine and her parents. Thus, even though principles of ethics are relevant, contextual
factors, such as her parents view on truth-telling, is essential in the ethical decision. The ethical
problem would be solved in dialogue with the parents and the girl, promoting good relationships and
trust. Furthermore, if the issue of truth-telling could be genuinely discussed in the relationship this
would mean that also the views of the healthcare staff would be taken into account, and would most
probably lead to a mutual agreement or a compromise between the healthcare staff and the parents.
This agreement could include that healthcare staff are allowed to give an honest answer to all Jasmines questions, while focusing on what can be done; for example, treating pain. Furthermore, the
parents are strengthened and encouraged to discuss existential issues with Jasmine in a way that is
congruent with their culture.

Conclusion
In this article we explore many different conditions influencing balancing of truth-telling. Truth-telling or
withholding the truth should always be chosen with the best interest of the patient and family in mind,
rather than motivated by protection of healthcare staff from difficult and embarrassing situations. Cultural norms influence attitudes to truth-telling; thus, curriculums in teaching ethics, in for example nursing and medical education, need to become more focused on attitudes and practices in truth-telling from
a transcultural perspective, including cultural self-awareness.55 Hope preserving is an important argument
in balancing truth-telling in care. We believe that most people can sympathize with the central role of
truth-telling in hope, but at the same time many of us have experienced situations when truth-telling
needs to stand back in the relationship with the patient in his/her social context and with respect for the
culture of the family. We have found relational ethics to be relevant in balancing truth-telling and in
hope inspiring care. Good communicational skills and being genuinely interested in getting to know the
patient and the family is essential in conveying both the truth and hope. The balance of truth-telling
always needs to be decided in a mutual understanding with the patient and the family in the caring relationship, but hope must always be inspired.
Funding
The first author received funding from the Swedish Childhood Cancer Foundation.
Conflict of interest statement
The authors declare that there is no conflict of interest.

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