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Therapeutic lie: Happiness and dignity?

I recently read in "The New Yorker" an interesting article entitled "The Comforting Fictions of Dementia Care", which I recommend reading. Its author, the American writer Larissa MacFarquhar, invites us to reflect on the increasingly common use of fiction by people living with dementia. This opens up a debate that is as interesting as it is complex.

In his text he begins by telling us about the case of a woman with dementia who lives in a centre and who has the habit of asking about her husband. He died several years ago, but she does not remember him. Faced with such a situation: should we tell her the truth and cause her profound pain, knowing that she will forget him and that this moment of suffering will be repeated again and again, day after day? Or would it be better to simply tell her that she is at work? Is it better to confront reality than to offer understandable realities? What is more important for these people, dignity or happiness? Is direct lying different from other forms of deception, such as feeding false perceptions, or allowing the person's delusions or hallucinations to persist?

Very relevant authors, such as Mitchell, Templeton, McCormack and McCance, among others, have been reflecting on this very issue for some time. This is a subject that involves far-reaching ethical aspects, and whose concerns I share below.

First of all, we have truthfulness as a basic component of caring for the person and Person-Centred Care. On the other hand there is non-correction (not facing the truth, and letting the person continue in his thinking), which can also be seen as avoiding unnecessary truth, rather than a lie. Finally, a third approach would be what we would call a "therapeutic lie", which is a lie told to the person because he or she believes it is in his or her own interest.

If we put the therapeutic use of "lying" under the lens of ethics, we have to bear in mind that according to the principle of beneficence, we must offer people well-being. But what about, for example, the use of dolls by people with dementia? Doesn't this risk infantilising the situation and treating the person with dementia as a child? On the other hand, according to the principle of autonomy we must make it easier for people with dementia to realise their preferences, so if one of these people wishes to use dolls they should be supported in doing so.

Under this perspective, it is very important to incorporate into our work the reflection on each of the cases that are presented to us, bearing in mind that

  • Nothing is automatically good or bad.
  • The different interventions are no more than tools, they require a personalised application with meaning for each person.
  • We have to use the tools with respect and understanding, and favour practices that facilitate the self-determination of people with dementia.

As you can see, we are faced with a complex dilemma, the solution to which is far from simple. Perhaps because there is no "right" and universal answer for all cases. So, where would be the key? In my opinion, the conditions and circumstances of each person should be taken into account at all times. In a word: "personalisation".

I invite you to read and go deeper into the subject through the following readings:

» Mitchell G. and Templeton M. (2014). Ethical considerations of doll therapy for people with dementia. Nursing Ethics 21(6), 720–730. doi: 10.1177/0969733013518447
» Mitchell G. (2014). Therapeutic lying to assist people with dementia in maintaining medication adherence. Nursing Ethics 21(7), 844-521. doi: 10.1177/0969733014543886
» Mitchell G. and Templeton M. (2016). Therapeutic use of dolls for people living with dementia: A critical review of the literature. Dementia 15(5), 976-1001 doi: 10.1177/1471301214548522

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