The doctor's use of deception in appropriate circumstances has commonly been considered a necessity of the medical art. Resistance to full and frank communication is typical of many traditionally Catholic countries, and particularly of Italy, a western country where Catholicism remains particularly influential. The Catholic teaching on truth and lies, and the problem of telling the truth to a severely ill patient is discussed. It is suggested that the contemporary Catholic model of gradually telling a terminal patient the truth, which looks reasonable and feasible in theory, is rarely followed in practice, as in the majority of cases the truth is not told tout court. Problems stem from the way in which medicine is currently practiced in Italy; from the synergism between Catholicism and the medical tradition's grounded paternalism; and from the ambiguity of the term 'hope'. Catholic ethics in fact recommends that the truth must be told without destroying hope, but the Catholic meaning of 'hope' is very different from its meaning in current language. Keywords: Catholicismcommunication to terminal patientsdeception of prognosishopemedical deontologytruth-telling ACKNOWLEDGMENT This paper was written as part of the work of the European Commission funded Biomed II project PL96388 'European Palliative Care: Ethics and Communication.' Important organizational and financial support was provided by the Foundation 'Lino Maestroni'–Istituto di Ricerca in Medicina Palliativa, of Cremona, Italy. The Authors are grateful to Professor Maurizio Mori for advice and suggestions; to Dr. Elena Zucchetti of the Floriani Foundation of Milan for the bibliographical research; and to Dr. Angelo Giovinno and Bruna Crolla for help with the translation. Notes 1. Interestingly, there is a contradiction between the Italians' personal wish to be informed and their behavior when dealing with knowledge of a loved one's terminal disease: it would appear as if there are particular problems around the telling of the prognosis (CitationMosconi et al. 1991; CitationPronzato et al. 1994), rather than with the patients' awareness of it. 2. In an interesting paper, CitationGordon (1990), describes the tremendous power that still in Italy is attributed to naming and 'sentencing'. When the matter is death, decay, and suffering, it makes non-disclosure a major mechanism for keeping the terminally ill (the 'condemned') in this social world, and death in the 'other' world. Informing a patient of cancer means forcing him into a social death. 3. Charitas is the principle of the supernatural and unselfish love for Good over everything, without any care for one's happiness and of love for her/himself and for her/his fellow men because of Good. It is one of the three theological virtues (with Faith and Hope), effects, and shapes of the Grace given by Good through the baptism, which men cannot achieve by, nor preserve with, their only strength. The Augustinian idea of Charitas is a synthesis of both aspects of a neo-testamental (and Hellenistic as well) kind of "love": Éρ ω ς (eros, acquisitive desire) and Áγ π η (àgape, sacrificial giving). See CitationKegley (1970, 141–187), where the subject is profoundly discussed. 4. For an exhaustive treatment of theological concerns of truth in medicine, see CitationPegoraro (1991); Citation(1992). 5. About the different meanings of the word 'truth', it has to be noted that the oldest Christian texts (the Bible included) were known, discussed by the Fathers of the Church, and spread in the ancient world not in their original language (Aramaic) but translated into, or written in K o ι ν (Koiné), the official language of the Mediterranean area, spoken also by non-Greek acculturated people, used for trades and diplomacy, and for philosophical discussions. Koiné was the common Greek language, born after the conquest of Alexander the Great from several pre-existing 'Greeks'. It was spoken by Aristotle and Plutarch, and taught by the Grammar Schools. In the West, in the late ancient world and in medieval time, the Holy Books were read and known mostly—or only—through their translations from Greek to Latin. If St. Gerolamus (IV Century) was able to read Hebrew, St. Augustin was not, and he knew only very little Greek (CitationEco 1993). 6. Under the definition 'Fathers of the Church' are the earlier teachers, who instructed the Church in the teaching of the Apostles during its early growth, before the Council of Chalcedony (451 A.D.), but among the Fathers must undoubtedly be included some great theologians of the early Middle Ages (in the West, St. Gregory the Great († 604), St. Isidore of Seville († 636) and the Venerable Bede († 735), and in the East, St. John Damascene († about 754) and St. Theodore the Studite. It is frequently said that St. Bernard († 1153) was the last of the Fathers (Catholic Encyclopedia, n.d. -a). 7. "But every liar says the opposite of what he thinks in his heart, with purpose to deceive." Trans. Prof. Shaw (Dr. Dods's series of Augustin's Works, 3rd ed. (1883). Edinburgh: T. & T. Clark. The translation is available at the Christian Classics Ethereal Library at Calvin College, http://www.ccel.org/a/augustine.html). 8. "But who so shall think there is any sort of lie that is not sin, will deceive himself foully, while he deems himself honest as a deceiver of other men," (trans. Albert C. Outler in Library of Christian Classics, CitationJohn Knox, Westminster, 1955. The translation is available at the Christian Classics Ethereal Library at Calvin College, http://www.ccel.org/a/augustine.html). 9. For instance, an innocent man is hidden in your house. If you are asked by murderers whether the person they have come to kill is in, you can give no answer: but, if your silence is not enough to save his life, you may answer 'No', restricting this sentence by the mind (subintelligendo) to the sense 'He is not here for you, who have no right to know' and not to the sense 'He is not physically in this place'. The speaker simply does not specify which of the several ways his answer "NO" could be understood, he is using. 10. For instance, as recorded by the Dean of Durham, in 1606 a certain Father Ward, Catholic, questioned by the magistrate" First, […] swore he was no priest, that is (in a subsequent explanation), not Apollo's priest in Delphi [and], second, […] swore he was never across the sea, it's true he saith, for he was never across the Indian Seas" (CitationJonsen and Toulmin 1988, 205). 11. "Charity and respect for the truth should dictate the response to every request for information or communication. The good and safety of others, respect for privacy, and the common good are sufficient reasons for being silent about what ought not be known or for making use of a discreet language. The duty to avoid scandal often commands strict discretion. No one is bound to reveal the truth to someone who does not have the right to know it" (CitationCatechism of the Catholic Church, 1993, Part. 3, Sect. 1, Art. 7, Paragraph 1817). 12. 'God, let we be spared from a sudden death' (auth. trans.). 13. The Protestant stand about veracity is varied, from the total rejection of lying, reminding that of St. Augustin, of Calvin (CitationCalvin, 1970) to the theory of "due truth" of CitationGrotius (1925) and CitationPufendorf (1934). Martin Luther, following the tradition of the Ancient Church, distinguished three categories of lies: "Jocose Lies," as the tales mainly told to children, where the initial seriousness quickly dissolves into laughter; "Damaging Lies," that are told with the intent to deceive and to harm our neighbors; and "Useful Lies"—or White Lies—that consist in not telling the truth out of love and compassion in order to protect our neighbors (CitationLuther 1880–1891; CitationPlass 1959). More recently, the Methodist John Wesley claimed that some untruths, though intentional, are not lies (Wesley n.d.). The Anglican Samuel Johnson, too, admits that the general rule of telling the truth has some exceptions (CitationBok 1978, 40), as well as the Unitarian Presbyterian CitationJames Martineau (1898). 14. "Hope is the theological virtue by which we desire the kingdom of heaven and eternal life as our happiness, placing our trust in Christ's promises and relying not on our own strength, but on the help of the grace of the Holy Spirit." "Let us hold fast the confession of our hope without wavering, for he who promised is faithful." "The Holy Spirit … he poured out upon us richly through Jesus Christ our Savior, so that we might be justified by his grace and become heirs in hope of eternal life" (CitationCatechism of the Catholic Church, 1993, Part 3, Sect. 1, Art. 7, Paragraph 1817). 15. "The theological virtues are the foundation of Christian moral activity; they animate it and give it its special character. They inform and give life to all the moral virtues. They are infused by God into the souls of the faithful to make them capable of acting as his children and of meriting eternal life. They are the pledge of the presence and action of the Holy Spirit in the faculties of the human being. There are three theological virtues: faith, hope, and charity" (CitationCatechism of the Catholic Church, 1993, Part 3, Sect. 1, Art. 7, Paragraph 1813). 16. "By despair, man ceases to hope for his personal salvation from God, for help in attaining it or for the forgiveness of his sins. Despair is contrary to God's goodness, to his justice—for the Lord is faithful to his promises—and to his mercy" (CitationCatechism of the Catholic Church, 1993, Part. 3, Sect. 2, Art. 1, Paragraph 2091).
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