Esoteric morality in general practice: no place for noble lies in the consulting room

Richard Armitage is a GP and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on X: @drricharmitage

Esoteric morality refers to the idea that it might sometimes be right to do or recommend privately actions that it would be wrong to advocate openly, if doing so secretly would have better overall consequences.¹  This is conceptually similar to the “noble lie” described by Plato in his Republic,² which is the myth that all citizens are born from the earth and that their souls contain different metals (gold, silver, or bronze) which determine their social class and role in the city.  This myth was propagated by the rulers of the city to maintain social order, and is considered “noble” because it serves the ‘higher’ purpose of legitimising the city’s rigid class structure.  While similar to the noble lie, esoteric morality, is instead grounded in consequentialist theory and considers withholding information from the public to be ethically justified if doing so brings about maximally desirable consequences (and not only for those withholding the information).

Consequentialism is a collection of moral theories that assess the rightness and wrongness of actions according to their consequences (as opposed to, for example, the nature of the actions themselves, or the character of the individuals making the actions).³  In their 2010 paper, ‘Secrecy in consequentialism: a defence of esoteric morality’, Katarzyna de Lazari-Radek and Peter Singer – two contemporary consequentialist philosophers – argued in favour of esoteric morality on consequentialist grounds.¹

In their paper, de Lazari-Radek and Singer defend esoteric morality in the kinds of situations in which revealing a particular truth would generate negative consequences, such as public unrest or societal panic.  Under such circumstances, they argue, agents are justified in keeping these particular truths hidden from the public.  The ethical permissibility of esoteric morality, and de Lazari-Radek and Singer’s consequentialism-based defence of it, has received substantial criticism.^4-11

Esoteric morality applied to general practice

A requirement to deliberately withhold information from, or even actively lie to, the general public when doing so would bring about the best consequences is seemingly inherent to esoteric morality. In these situations, this necessitates us to act in a less than wholly truthful manner, either by acting without transparency or by allowing the public to form untrue beliefs by actively lying or failing to correct these errors.  This requirement seems entirely at odds with the GP’s duty to act with honesty and truthfulness as decreed by the GMC (“Honest” appears no fewer than 16 times in the GMC’s Good Medical Practice).¹²  This also seems to violate various fundamental requirements of alternative moral theories, such as deontological duty-based maxims that render lying permissible, and virtue-based accounts of morality that consider honesty to be virtuous.

With consequentialist-grounded justifications of esoteric morality seemingly at odds with alternative ethical theories and professional codes of ethics, what might esoteric morality look like in general practice, and could it ever be justified?  Three hypothetical general practice scenarios in which esoteric morality is deployed shall now be outlined, and the ethical problems they generate discussed.

Firstly, the use of a placebo.  Rather than prescribing the actual medication, the GP issues a placebo while allowing the patient to believe that it is the legitimate medication.  For example, the GP acts in this way when a patient, who presents with obvious viral symptoms, demands antibiotics and refuses to leave without them.  The GP foresees that, by agreeing to prescribe antibiotics, prescribing a placebo instead and withholding this information from the patient, the patient will nevertheless recover from her viral illness spontaneously, and will be spared the potential side-effects and antimicrobial resistance that the inappropriate use of antibiotics might generate, whilst preserving the doctor-patient relationship.  These consequences are more desirable than the alternative outcome, which would be the breakdown of the professional relationship, and potentially the patient’s development of mistrust towards doctors in general.

Secondly, the simplification or exaggeration of health information.  Rather than explaining the details, nuance and uncertainties regarding particular health behaviours, the GP might reduce this information to a totalising and unyielding message devoid of any caveats.  For example, in relation to alcohol consumption and red meat intake, the GP might advise a patient to avoid alcohol and red meat entirely, and withhold information regarding the potential benefits of occasional red wine consumption and low quantity red meat intake.  The GP foresees that, in the context of this specific patient, exaggerating the benefits of strict abstinence and omitting the benefits of regulated intake is likely to lead to more favourable health behaviours, which the GP predicts would likely lead to over-indulgence.

Thirdly, the withholding of a terminal prognosis.  Rather than informing a patient of the irreversibility and, ultimately, palliative nature of a diagnosis, the GP might withhold this information from particular patients.  For example, when a patient with a long history of severe health anxiety is diagnosed with idiopathic pulmonary fibrosis, the GP might not discuss the terminal nature of this illness, and withhold the details of its prognosis. The GP foresees that, due to this specific patient’s history of severe health anxiety, for which he is prescribed multiple medications and is under the care of a clinical psychologist, sharing the terminal nature of his diagnosis would likely induce an extreme psychological reaction, the consequences of which are less desirable than those of the patient not learning this information.

Problems with esoteric morality in general practice

These scenarios generate three main ethical problems for esoteric morality in general practice.  Firstly, it is inherently paternalistic.  When doctors override their patient’s autonomy in order to benefit or prevent harm to the patient – meaning they act in the patient’s best interest – they act paternalistically.  Medical paternalism is generally regarded as ethically impermissible when patients have capacity to make autonomous decisions about their lives, because it is good for individuals to be able to learn from their mistakes, and individuals are in stronger positions than others to know what is best for themselves.^11,13  In each of the three scenarios, the GP prevents the patient from exercising their autonomy: by allowing the patient to believe they are taking an active medication, by withholding information about the potential benefits of controlled alcohol and red meat intake, and by not sharing the terminal prognosis of the patient’s diagnosis.  By keeping these truths secret, the GPs violate their duty to respect their patients’ autonomy which, for some commentators, is considered the bioethical principle that is, “First among equals.”¹⁴

Secondly, esoteric morality might lead to public distrust and scepticism in GPs, general practice and the medical professional generally.  If it became widely known that GPs, at least on some occasions, would deliberately withhold information from, or even actively lie to, their patients, the public would be less inclined to consult GPs when they need to, or less willing to share their information with them freely.  This, in turn, would lead to poorer health outcomes on a population scale, thereby generating consequences that are less desirable than those that would otherwise occur had the GP acted honestly and transparently.  Therefore, while the GP’s esoteric morality might be grounded in a consequentialist ethic in the context of individual patients, consequentialism might ultimately reject esoteric morality if it is deployed by all GPs, thereby making it internally incoherent.

Thirdly, esoteric morality might justify a creeping expansion of power held by GPs over their patients.  If GPs are initially allowed to withhold information from and lie to their patients when doing so will generate better consequences, they might next be justified in behaving dishonestly towards their patients under conditions other than genuine moral concern, such as when doing so benefits them practically, professionally, or financially.  This slippery slope argument foresees the initial asymmetrical power held by the GP as granted by esoteric morality to inevitably lead to increasing power accrued by the GP, which portends abuse of that power.

Additional issues for esoteric morality include: epistemic concerns (how can GPs be certain that withholding information from or actively lying to patients will generate the best consequences, especially over prolonged time horizons?); incompatibility with other moral frameworks and codes of professional ethics (such as deontological duties to not lie, and the GMC’s requirement for honest doctors?); and the risk of undermining progress (by keeping certain truths secret, society might be deprived of the chance to grapple with them openly, thereby stunting progress).

In conclusion

The hypothetical scenarios above suggest that, in some situations, there might be a role for esoteric morality in general practice.  However, the objections to this strategy are numerous, substantial and revealing of this ethic’s fundamental violation of what it means to be a contemporary GP practicing within Western philosophical values.  It therefore seems that noble lies have no place in the consulting room.

References

1. K de Lazari-Radek and P Singer. Secrecy in consequentialism: a defence of esoteric morality. Ratio 2010; 23(1): 34-58. DOI: 10.1111/j.1467-9329.2009.00449.x
2. Plato. The Republic. Book III,  GRF Ferrari, (ed), T Griffith (trans). Cambridge: Cambridge University Press, 2000.
3. H Sidgwick. p.489, in The Methods of Ethics. 7th edn, London: Macmillan, 1907.
4. M Cholbi. What’s wrong with esoteric morality? The Ethics Forum 2020; 15(1-2): 163–185. DOI: 10.7202/1077533ar
5. B Caplan. Singer and the Noble Lie. Bet On It (Substack). 19 October 2022. https://betonit.substack.com/p/singer-and-the-noble-lie [accessed 28 October 2023]
6. B Williams. p.109 in, Ethics and the Limits of Philosophy. 1st edn, London: Fontana, 1985.
7. J Rawls. p.112 in, A Theory of Justice. Cambridge, MA: Harvard University Press, 1971.
8. Bernard Girt. p8-11 in,  Morality: Its Nature and Justification. New York: Oxford University Press, 1998.
9. TM Scanlon. p.5 in, What We Owe to Each Other. Cambridge, MA: Harvard University Press, 1998.
10. D Parfit. p.40, Reasons and persons. Oxford University Press: Oxford, 1984.
11. B Hooker. p,85, Ideal Code, Real World: A Rule-Consequentialist Theory of Morality. Oxford: Oxford University Press UK, 2000.
12. General Medical Council. Good Medical Practice. 2013. https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf [accessed 28 October 2023]
13. JS Mill. Chapter 5, On liberty. London: Longman, Roberts, and Green, 1864.
14. R Gillon. Ethics needs principles—four can encompass the rest—and respect for autonomy should be “first among equals.” Journal of Medical Ethics 2003; 29: 307-312. DOI: 10.1136/jme.29.5.307

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