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Don’t you hate that conversation?  Most physicians have had it at one time or another.  ‘Your drug screen shows amphetamines (or opiates; or benzos, etc.. ) When did you use last?’

‘Doc, I swear to God I haven’t used in six months (or a year or since the Nixon administration, or Woodstock).’

We know that these tests aren’t perfect.  But it isn’t as if we interrupted them as they gave their dissertations on gene therapy or the influence of John Locke on the American system of law.  They were impaired or agitated, unconscious or arrested.  Their families sat nearby with teary eyes, or with wringing hands.  Or refused to come.  ‘I’m finished with her.’

Or their complaints were so utterly ridiculous and convoluted that we said ‘I just have to know,’ and ordered the test.

And then came the discussion.  One of the hardest for us to have sometimes.

‘You’re lying.’

‘No man, I mean it!  I’m not lying!’ Or they unleash some other expletive-laced invective against our parentage or some other quality or trait beyond our control.  If they said ‘well, so what Leap.  You’re fat,’ at least I’d know they were awake, alert and paying attention.  And I’d eat a donut to comfort myself.

Sometimes there are tears, sometimes complaints to administrators or the nursing supervisor.  Sometimes they storm out.  Occcasionally hospital administrators rush to their rescue.  ‘You can’t talk to people like that! They’re customers!’

Rarely, oh so rarely, they say, ‘yep, you got me. I really want to stop.  I hate this.’

The thing is, we hate to accuse them because we physicians (and indeed probably a majority of well-educated, erudite Americans) are all taught that people are fundamentally good and simply do not lie.

We know that’s a lie, but it’s a lie we like.  It fits the world-view we want to be true.

It’s painful and confrontational to address lies. To speak truth.  And it’s so unpopular these days!  Truth is relative, or truth is hurtful, or patriarchal, or based on privilege or gender or some other new, shiny modifier designed to shut us up.

But truth remains truth.  And when we speak it, we do honor to those who receive it. Because it’s hellishly easy to say ‘well, whatever, it’s up to you and I’m not judging.’  That’s the wide door by which many enter, as it were.

Painful truths lead us to the narrow door.  The eye of the needle.  And to hope and good and life.

If you don’t believe this, lie to your children and your loved ones about everything they do that is wrong or dangerous.  Tell them it’s fine.  Buy them more alcohol when they drive drunk. Let the kids skip school whenever they feel tired or the test will be hard.  Inform your daughters and sons that it doesn’t matter to you if they share their bodies and beds with strangers.  The arguments to the contrary might be uncomfortable; it might make you feel nervous and them feel bad.

Folly, yes?

Then why does anyone want us to lie to our patients?  To make up false diagnoses and confabulated diseases, to give them pointless medications or whatever daily sedation they desire.  This is easy; at first.

Then it becomes hard.  And harder.  And deadly.

We have become so good at lying. For metrics and bonuses, for pats on the back and the dopamine drenched rush of approval by patients and colleagues.

We are almost ashamed to speak truth.  We are fearful of the word ‘wisdom’ since has such an old-fashioned, ‘intolerant’ tone.

We would consign generations to misery and poverty and early graves rather than be thought old, out of touch or God-forbid, ‘judgmental.’

But if we want to transform lives, God speed some judgment.  And God give us courage and humility to speak truth to folly.  And God open the hearts of our patients trapped in their decisions, mired in the belief that they can do anything, anytime, any way, and they can be rescued and applauded, rewarded and empowered, all as they marching to their deaths.

I pity them, I do, for as Jesus ‘took pity on them for they were like sheep without a shepherd.’  If we love them, we will be honest, and sometimes unkind.  Even accusatorial.  The abscess needs to be opened.

However, I think I pity us more.  Shepherds afraid to guide the sheep entrusted to us.

What does it say that we sleep so easily afterward?