Reviewed Book
An Anthropology of Lying: Information in the Doctor-Patient Relationship. Sylvie Fainzang. Surrey, England: Ashgate, 2015, 151 pp.
An Anthropology of Lying makes the provocative assertion that deceitful communication is an integral part of the doctor–patient relationship in French medical care for people with serious diseases. And lying becomes increasingly prevalent as the disease advances. A translation from the original French (2006), Sylvie Fainzang’s volume demonstrates that physicians and patients routinely obfuscate information from one another. Doctors are disingenuous about negative prognoses and therapeutic failures to protect patients from upsetting news. Patients underreport symptoms and hide nonadherence. This study reveals that, despite legal statutes governing obligatory disclosure, questions surrounding the ethics and clinical expediency of open communication continue to be vexing in French hospital medicine.
In fact, disingenuousness appears so ingrained in the norms of the French hospital that the ethnographer was sometimes unable to ensure informed consent from the patients whose medical consultations she observed. Obliged to wear the white lab coat of a clinician and often mistaken for a member of the medical team, Fainzang writes frankly about having her scholarly autonomy compromised by requirements of the medical institutions where she carried out her research.
For this study, Fainzang used a cross-sectional design, observing clinical visits and conducting interviews with clinicians and patients to examine the exchange of information during medical consultations and explore clinicians’ and patients’ perceptions regarding this aspect of the therapeutic relationship. The findings of the study are organized in three main chapters: two that address the practices and perspectives of doctors and patients, respectively, and a third about common misunderstandings that arise from their uncandid communication patterns.
Chapter 1, “The Doctors,” explores physicians’ perspectives about the ethics and pragmatics of sharing bad news with patients and their families. As cancer has transitioned from being a terminal to a chronic type of disease, physicians have become more forthright about cancer diagnoses. They continue to be evasive and often dishonest, however, about prognosis, metastasis, and failed therapies. In deciding how forthcoming to be about these matters, physicians make judgments about patients’ psychological preparedness to cope with the news. They rationalize withholding bad news from patients who might respond adversely as well as from patients they judge to be uninterested in knowing the truth about their condition.
Fainzang discusses the paternalistic rationale of these stances and criticizes their psychologizing logic, which obfuscates the sociocultural factors that mediate doctors’ provision of information. In her observation of clinic visits, Fainzang found that highly educated, high-earning patients were more likely to receive accurate information about their condition and treatment. Doctors’ responses in interviews revealed that their assessments of patient interest in and resilience to receiving bad news rested largely on judgments about patients’ “socioprofessional identities.” In light of this finding, Fainzang concludes: “Added to the sadly well-known social inequalities in patient access to healthcare, is thus a social inequality in access to information” (p. 42) that disadvantages patients who wield little cultural capital.
Chapter 2, “The Patients,” reveals that French patients are aware of and dissatisfied by the ethos of deception in their medical care. Fainzang argues in this chapter that, contrary to the claims of physicians, patients “generally want to know as much as possible about their affliction—the exact nature of the diagnosis, the development of the disease, the possible treatments and their effects and risks” (p. 64). Despite this desire for knowledge, patients often fail to ask questions. Fainzang attributes this failure to ask to patients’ perceptions of physician busyness and unwillingness to respond to questions. The latter part of the chapter addresses patterns in patients’ talk that the author also interprets within the frame of lying. First, patients sometimes misinform doctors about nonadherence to avoid potential disapprobation, a finding that aligns with research in the United States. In other cases, patients downplay or deny symptoms of disease when speaking to their doctors.
Fainzang interprets patients’ reluctance to report worsening symptoms as an interactional tactic aimed at preventing an unwelcome medical development from becoming reality. In describing one case, Fainzang argues that “to admit to pain … is to make the affliction exist and to make what [the patient] believed to be the failure of the therapy real” (p. 102). Drawing on speech act theory, this argument highlights the performative function of language, in which utterances effect changes in the world, as when an official pronounces a couple married or christens a ship with a name.
The idea that patients refrain from reporting their suffering to forfend against the worsening of their medical condition is unsatisfactory. It forwards a psychological explanation for patient behavior and ignores competing hypotheses that there are interactional and sociocultural factors that underpin these patterns. For example, talk in clinical settings is shaped by a range of countervailing cultural imperatives. Good patients should be frank and forthcoming, but they also should be stoic, try to get well, and maintain hope in the face of adversity. These latter social norms make it difficult for patients to report negative developments and should not be underestimated as potential reasons why patients downplay or deny suffering in their talk with doctors and family members.
Chapter 3, “Misunderstandings,” describes a series of problems that arise as a result of disingenuous communication. Patients have poor comprehension about clinical trials and informed consent procedures, sometimes leading them to jump to erroneous conclusions about their own medical condition when they are recruited or enrolled in trials. On some occasions, misunderstandings stem from discrepancies between doctors’ focus on medical matters and patients’ expression of lifeworld concerns. For example, one doctor dismissed a patient’s concerns about hair loss during chemotherapy. In other cases, doctors fail to resolve patient confusion and doubts. They use jargon that patients are unfamiliar with and moderate their talk based on preconceived ideas about a given patient’s receptiveness to medical advice. Such communication failures are consequential because they compromise patients’ ability to make informed decisions about their medical care.
The theoretical discussions that structure An Anthropology of Lying focus squarely on the ethical and pragmatic implications of lying as a communicative and social act. More relevant to readers of Medical Anthropology Quarterly, the book makes a valuable contribution to the growing body of research on medical discourse in circumstances of clinical uncertainty, despite the fact that discussion does not directly engage with the most recent literature on the topic. With its focus on clinical care, this volume may be best suited for teaching in medical, premedical, and graduate health services programs. Overall, the translation of Fainzang’s work into English is a welcome contribution to the ethnological record of how practitioners and patients across diverse sociopolitical contexts are responding to and constructing a globalized shift in conventional medicine away from interactional norms that shield patients and toward norms that valorize informed and engaged patienthood.