Informing the patient about a fatal disease: from paternalism to autonomy--the Jewish view.
Until the late 20th century, withholding a fatal diagnosis functioned as a paradigm for sharing other medical information with patients. The obligation of confidentiality was emphasized and disclosure was ignored. Ethicists perceived the doctor-patient relationship as oriented to therapy, reassurance, and avoiding harm. Physicians were to provide lies and truth instrumentally only insofar as they aided therapy (Jameton, A. Information disclosure. Ethical issues. In Encyclopedia of Bioethics. Revised Ed.; Reich, T.N.T., Ed.; MacMillan: New York, 1995; Vol. 3, 1225-1232). This was the era of paternalism. Since the 1960s, opinion on the role of disclosure was changed rapidly in the United States stimulated by the patient's rights movement and the rise of bioethics. The current climate supports honest and complete disclosure of medical information. In 1972, the Board of Trustees of the American Hospital Association affirmed A Patient's Bill of Rights, which states that the patient has the right to obtain from his physician complete current information concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand (Lee, A.L.; Jacobs, G. Workshop airs patient's rights. Hospitals 1973, 47, 39-43). Bioethicists now favor full disclosure as a means of respecting patient autonomy (Katz, J. The Silent World of Doctor and Patient; Free Press: New York, 1984). The American College of Physician Ethics Manual states that disclosure to patients is a fundamental ethical requirement (American College of Physicians. American College of Physicians Ethics Manual, 3rd Ed. Ann. Intern. Med. 1992, 117, 947-960). The era of patient autonomy ended the traditional pattern of withholding information, which was characteristic of the previous era of paternalism. The Jewish view toward full disclosure of a fatal illness to a patient and especially a patient who is terminally ill is in general a negative one because of the fear that the patient may give up hope, suffer severe mental anguish (tiruf hadaat), become despondent, and die sooner than otherwise. Shortening a patient's life is strictly forbidden because Judaism espouses the concept that God given life is sacred, even only a short period thereof. Disclosure should be couched in the context of optimism. The most positive outlook should be imparted to the patient. Disclosure must be imparted with compassion, sensitivity and hope thus giving the patient an opportunity to "set his house in order" and recite the confessional penitent prayer known as viduy.