Bulletin of the Transilvania University of Brașov Vol. 2 (51) – 2009 [620790]

Bulletin of the Transilvania University of Brașov • Vol. 2 (51) – 2009
Series VII: Social Sciences and Law

“SECRETS AND LIES”: (NOT) TELLING
BAD NEWS IN ITALIAN ONCOLOGY

Marco MARZANO1

Abstract: The problem that I treat in this paper is about the fact that people
who are about to die in hospital are not usually informed about the fate
awaiting them. In Italy, this attitude has remained intact over time despite the
extraordinary changes which have taken place in clinical techniques and
therapies, and despite the spread of hospices and palliative care wards. In
this paper I shall describe the strategies adopted by Italian oncologists to
prevent the dying from knowing their fate, the exceptions to this rule, and
some of the structural and organizational factors which make changing the
situation difficult. The discussion conducted in this paper is based on an
ethno graphical research carried out by the author in a large hospital in
northern Italy.

Key words: imminent death, conspiracy of silence, “no tell” policy,
communicative strategy .

1 University of Bergamo . In Italy, as probably happens in other
countries of the world (Seale et al. 1997;
Elwyn et al. 1998; Seale 1998; Field and
Copp 1999), people who are about to die in
hospital are not usually informed about the
fate awaiting them. To use Glaser and
Strauss‟s expression, a context of “closed
awareness” prevails. In Italy, this attit ude
has remained intact over time despite the
extraordinary changes which have taken
place in clinical techniques and therapies,
and despite the spread of hospices and
palliative care wards. The policy of „not
telling‟ has been adjusted to the new
circumst ances.
In this paper I shall describe the
strategies adopted by Italian oncologists to
prevent the dying from knowing their fate,
the exceptions to this rule, and some of the
structural and organizational factors which
make changing the situation difficul t.
The discussion conducted in this paper is
based on a year of ethnographic observation of social interactions at an
oncological ward of a large hospital in
northern Italy and on dozens of interviews
carried out by the author in the same place
in the same period .
For the good of the patient: the truth
concealed by Italian oncologists.
When faced by a patient afflicted with an
incurable tumour, Italian oncologists
generally choose to lie about the prognosis
(but not always about the diagnosis). This,
of cou rse, is a „morally legitimate‟ lie, in
the sense that according to the oncologists
it is an untruth intended to protect patients,
to insulate them against the terrible truth of
their imminent death [Gordon 1990;
Surbone 1992; Gordon and Paci 1997,
Campione 2004]. This behaviour is
justified by the so-called benevolence
principle , according to which doctors have
some sort of mandate deriving from the
fact that patients have placed their trust in
them [Pellegrino 1992; Pellegrino,

Marzano , M.: “Secrets and Lies”: (Not) Telling Bad News in Italian Oncology 23
Mazzarella and Corsi 1992; B eauchamp
and Childress 1994; Engelhardt 1996].
This principle purportedly requires doctors
to work for what they believe is the good
of patients, or indeed in consideration of
health and life itself (or of their duration)
as goods in themselves not freely and
immediately available to persons. The
patient thus enters the state which Glaser
and Strauss [1965] called „closed
awareness‟.
The strategy of concealing the truth from
patients is made feasible because many
people do not recognize (or they remove)
the signs of their imminent death, or they
simply do not feel authorized to talk about
them with a doctor. Whatever the case may
be, for the strategy to be successful,
secrecy must be strict maintained, and a
so-called “conspiracy of silence” must be
activate d [Ariès 1991].
For this reason, all available forces must
be immediately enlisted. The first actors to
be involved in the conspiracy are relatives
and friends: in short, those people closest
to the patient and who are able to filter and
control the flow of information about the
illness. Unlike the patient, these people are
rapidly and expressly informed of the
diagnosis and the prognosis. In many
cases, it is they who activate the
conspiracy by beseeching the doctor not to
reveal the dramatic nature of th e prognosis
to their loved one.
In this regard, also an ability to lie – or,
better, to “pay lip service” – may prove
useful. An oncology intern told me how
useful he had found his experience as a
waiter in Brussels, where he had learned
how to communicat e with people and give
them “that feeling of warmth and affection
which allows a human relationship to be
established”, greeting them by looking
them in the eye, inviting them to sit down,
then asking about their jobs, and finally
joking and laughing with them.
The decision not to reveal the truth holds
firm even when patients explicitly ask for
information. In these cases, the replies are
evasive, or they concentrate on aspects and
particular details of the therapy, or on
secondary symptoms. This induces the
patient to think that if the doctor is
concentrating on these relatively minor
problems, the situation cannot be so
serious [McIntosh 1977]. The same
function is performed by the witticisms of
doctors (in these cases, patient tell
themselves, “if the doctor dares to make
jokes, it must mean that I am not so badly
off”). Doctors often respond to more
specific requests for information – for
instance, whether the illness will have
disabling consequences – with
probabilistic paradoxes of the type “there‟s
more chance of me dying of a heart attack
in two years‟ time than of you becoming a
paraplegic”.
A door may be left open to justify future
deterioration in the patient with
expressions like “We‟re working as hard as
we can to get the best results, but you
know … it‟s very difficult. Let‟s hope we
succeed”, or by pointing out the dangers of
not taking therapeutic action (“Of course,
if you stopped the chemotherapy, the
consequences would be unpredictable”).
In any case, the strength of the 'no tell'
policy – Glaser and Strauss (1965) again
point out – resides in the large -scale
deployment of resources (those of the
doctors, nurses, family, etc.) against one
man – the patient – or in the fact that the
medical staff and family join together as a
team agains t a single individual weakened
by disease. The weakness of policy resides
in the instability of the structural
conditions i.e. in the difficulty of
maintaining it unchanged over time.
The main advantage gained by the
hospital from restricting the patient‟s
decision -making capacity is control over a
potential source of environmental

Bulletin of the Transilvania University of Brașov • Vol. 2 (51) – 2009 • Series VII
24
turbulence which might disrupt the
organization‟s routine. The greatest costs
are aggression by patients made anxious by
the uncertainty of their fates, and the
amount of resourc es that must be deployed
to keep patients ignorant. Maintaining
patients in a psychological state of „closed
awareness‟ inevitably involves
construction for them of a „fictitious‟
future where, upon conclusion of the
treatment, they will resume their norma l
lives. In the meantime, however, there
arise events and circumstances which
contradict that scenario. The first is the
persistence of (indeed, in many cases, an
increase in) the painful symptoms
signalling the disease‟s progress. The
second is hospitaliz ation. Once in the
hospital ward, the patient makes the
terrible discovery that he is surrounded by
others subject to devastating cycles of
high-dose therapy or awaiting the death
that often occurs in hospital. Dreadful
questions now begin to preoccupy the
patient: “Am I also one of these dead men
walking? One of these temporary
survivors?”. Whence derives the necessity
for the doctors to dispel these „harmful
imaginings‟ with constant and increasingly
difficult creative effort.
Doctors justify the choice o f this
communicative strategy by saying that
they do not want to inflict, with gratuitous
cruelty, further suffering which would
make the life left to the patient unbearable.
Or, more rarely, they cite one or two cases
where disclosure of the diagnosis has had
tragic consequences (primarily the
patient‟s suicide). Some doctors, indeed,
deny the cognitive importance of
communicating a grim prognosis. When I
asked a female oncologist how she
communicated bad news, she told me
“What‟s the point of telling some one
they‟re going to die? Don‟t we all have to
die? Why tell him and not someone else?”.
In other cases, I was told that it is impossible to make accurate forecasts in
oncology. And yet such forecasts are
formulated with precision and immediately
communica ted to the patient‟s relatives.
Doctors very often maintain that patients
“know”. The fact that patients do not ask
for explicit confirmation of their
conjectures is interpreted as signalling a
desire not to discuss their condition, to
maintain reserve and silence about it. The
problem is that, as we shall see, this
situation comes about at a rather advanced
stage of the disease when communication
has ceased: that is, at a stage when it is
unlikely that the patient‟s imminent death
will be a topic of conver sation with those
around him or her.

1. For Love or Money: when the Truth
Can Be Told
Saying that Italian doctors generally lie
to their patients by not disclosing their
prognoses is not, of course, to imply that
such behaviour is universal – that is,
adopted without exceptions in all
circumstances. Of importance, in fact, is
the choice by the patient of a particular
communicative strategy and the presence
of specific conditions.
In regard to the latter, among the
conditions justifying the truthful disclos ure
of the prognosis, doctors regularly cite the
presence of large economic assets or a
business, and the presence of children.
In other words, the truth can be disclosed
more easily when the patients show that it
has some „practical importance‟ in that i t
concerns a realistic and socially approved
project, such as managing a business or
caring for children. As an oncologist told
me: “You‟re always asked for the truth by
people who somehow want to plan their
lives. A person who doesn‟t have affairs to
set in order is less interested in knowing
the truth”.

Marzano , M.: “Secrets and Lies”: (Not) Telling Bad News in Italian Oncology 25
My impression on this point is that at
least two other factors favour
communication of the truth:
1) the first concerns maintenance of the
social order within the healthcare
organization. If the doctor rec eives from
the patient „good reasons‟ for telling the
truth, s/he somehow obtains a guarantee
that the patient will make good use of
the information and will not, for
instance, use it to commit suicide or
engage in alienated behaviour or reject
treatment;
2) frankness in a doctor‟s communication
with a patient may be facilitated if the
latter belongs to the same social class
[The 2002 1], or by some other form of
identification (for example, being of the
same age, having children of the same
age, etc).
These conditions enable the doctor to
establish an otherwise difficult intimacy
with the patient and be sincere with him
about the prognosis.

2. Truths, Half Truths, Lies: how Much
Information?
Whilst doctors general try not to reveal
to patients the gravit y of their situations, is
also obvious that they cannot abstain from
giving them at least some information
about the diagnosis or the therapy. The
„line‟ of doctors on this point is to disclose
only the information deemed essential for
implementation of th e therapeutic
decisions taken by the medical team .
In accordance with the benevolence
principle, patients are never abandoned by
the healthcare organization even after the
worst of prognoses. Instead, the decision is
often taken to give them radiotherapy or
chemotherapy intended to prolong their
lives (for some weeks or months at most)
or for palliative purposes, that is, to reduce
pain pharmacologically.
It is essential to ensure the cooperation
of the patient, who must agree to the therapy, keep his/her appointments at the
day hospital (and often wait many hours
for the first phleboclysis), undergo all the
examinations required, or agree to
hospitalization and accept the harsh
discipline of hospital. Consequently, a
completely false diagnosis (a liver tu mour
passed off as an ulcer) is usually only
given to patients for whom therapy is
foreseen.
For the same reason, the truth may be
disclosed „for therapeutic purposes‟: as in
the case of a 70 -year-old woman, of low
education, with a metastatic tumour of th e
oesophagus, for whom a „first line‟ of
palliative chemotherapy was decided. Her
relatives implored the attending doctor not
to reveal anything about the prognosis to
the woman. As almost always happens in
these cases, the doctor complied and
prescribed c hemotherapy for the woman,
without informing her about the diagnosis.
The woman‟s body reacted well enough to
the treatment, with few undesirable side –
effects (nausea, vomiting, asthenia, etc.).
However, after the first chemotherapy
sessions, the woman beg an to waver and
then resisted continuation of the therapy,
because she could not understand why
such drastic treatment had to be inflicted
on her to deal with a minor problem (a
cyst, so she had been told). Whereupon the
doctor decided to tell her truth an d
informed her tha t without the
chemotherapy she would soon be dead,
because she had a tumour and not a cyst.
The lady thanked the doctor and decided to
continue the therapy.
In general, full or partial disclosure of
the diagnosis serves three main purpose s:
a) to get patients to accept that, at least for
a certain period, they will not be able to
lead their usual lives; b) to get them to
cooperate; c) to give them the impression
that the organization is doing something
for them.

Bulletin of the Transilvania University of Brașov • Vol. 2 (51) – 2009 • Series VII
26
To achieve these purposes, doctors very
often engage in sophisticated language
games where the semantic ambiguity of the
terms „control‟, „containment‟, „recovery‟
is skilfully used to induce a certain
reaction in the patient. This is what
happens when a doctor says to a patient
that s/he cannot fully recover, but in
compensation the doctor can help him/her
contain the disease and indeed make it
retreat. This is not an outright lie. Rather, it
is a half truth, because being kept hidden is
the fact that the former expression refers to
the prognosis, the latter to the tumour. The
doctor sometimes also provides a concrete
measure of this action, for instance by
saying that “Your tumour has got smaller
by two centimetres, diminishing from 5.8
to 3.8 centimetres”, without specifying,
howev er, that a decrease in the size of the
cancerous mass does not signify that the
patient has a chance of surviving even a
single day longer. Likewise, the language
used by doctors in communication with
patients is devoid of reference to the most
dreadful co nsequences of the disease. The
words cancer , metastasis and malignant
are never used (Herzlich and Pierret 1994),
being replaced with more reassuring
expressions like „cells gone mad‟,
„anomalous activity‟, „suspicious
formation‟, „problem‟ [2]. The use of
dubitative expressions [Mc Intosh 1977]
indicates to the patient, together with the
presence of a real danger that often
justifies violent and invasive therapy, an
uncertainty which induces hope: the
patient thinks that «if the situation was
really so bad the doctor would not have
any doubts and would expressly talk of
„tumour‟ or „cancer‟».
The expressions „failed recovery‟ on the
one hand, and „containment of the disease‟
and „remission‟ on the other, belong to two
different semantic codes, to two differ ent
“chains of signification” [Barley 1983]
with different implications for social action. [3] The former refers to constant
cohabitation with the disease and evokes,
together with irreversible changes in
lifestyle and expectations, the need for
constant me dical tests, more or less
intensive therapies, a regime of strict
clinical control. The latter instead
promotes the idea of peaceful cohabitation
with the illness, and indeed its slow
(because this is a remission, not a victory)
disappearance. Their simult aneous and
ambiguous presence in the discourse
favours the transmission of two messages
which though contradictory are equally
crucial for the medical discourse: that of
discipline and control on the one hand, and
that of hope on the other [Del Vecchio
Good et al. 1990; Perakyla 1991; Nuland
1993]. The implicit objective is to
persuade patients of the gravity of their
condition while simultaneously convincing
them that final victory is possible, and
therefore of the need to cooperate and
meekly accept the s pecialists‟ instructions.
Continuation of the therapy is one of the
conditions essential for patients to be kept
in a state of unawareness, the principal
means with which they are distracted from
inquiring about their prognoses, and so that
they suppress t heir worst forebodings [The
2002]. For many patients, suspension of
the treatment means that nothing more can
be done to save them, and that the
organization has declared its defeat by the
disease.

3. “The First Move is the One that
Counts”: the Imprintin g of
Communication
The communicative decisions taken in
the early stage of disease heavily condition
all subsequent events through an
„imprinting‟ effect whereby “it is first
move that counts”. This effect stems from
the action of trust mechanisms and is
therefore related to the “context of
expectations with positive value for the

Marzano , M.: “Secrets and Lies”: (Not) Telling Bad News in Italian Oncology 27
social actor and formulated in conditions
of uncertainty”. Studies on the matter have
identified two main dimensions of trust:
the systemic or impersonal one where the
recipient o f the expectations is the natural
and social organization as a whole, or in its
single institutional and collective
components; and the personal dimension,
where the recipients are other social actors
(Mutti 1996). The object of former type of
trust is the production and stability of the
social order, whilst that of the latter
consists in interpersonal relations, and in
particular the expectation that the
communication will not be altered or
manipulated and that the behaviour of the
actors will be sincere. In social interactions
whose object is truth about life and death,
and which involve complex organizations
like modern hospital structures, personal
trust and systemic trust interweave and fuel
each other [Giddens 1990]. Consequently,
if doctors are to get patients to obey their
instructions, and in order not to lose „face‟
[Goffman 1967], they must offer sufficient
guarantees that the personal
communication will not be manipulated
and that they will not resort to
concealment, or indeed to lies, fraud, or
deception. But they must simultaneously
acknowledge the goodness of all the
decisions taken in the past by their
colleagues. They must, that is, support the
patient‟s „systemic trust‟ in the healthcare
system, the hospital, the medical
community, and theref ore in all the
„abstract systems‟ for whose safeguarding
they are jointly responsible [Giddens
1990]. If this does not happen, for instance
if a doctor gainsays a diagnosis made by a
colleague, the risk is that patients will start
to doubt the sincerity of their interlocutors,
imagine themselves as victims of a
conspiracy, and in the worst cases become
angry at the thought of everything that they
have had to suffer without being informed.
What the maintenance of a high level of systemic trust s erves to prot ect, therefore,
is the social reputation of the „care
system‟, whose representatives are
recognized as being equally competent and
skilled, and whose superiority is
guaranteed by possession of a consolidated
stock of technical -scientific knowledge. To
be p revented, by contrast, are conflicts
which would confirm the discretionary
nature of therapeutic decisions and would
culturally disclose the cognitive limitations
of bio -medical culture and the culturally
connoted nature of modern medicine.
It is for this reason that the first
information given to the patient is so
important. This information delimits the
level of legitimate expectations to which
the patient‟s hopes of recovery can aspire.
Consider the effects that denial of the
original diagnosis would ha ve on the
patient, not so much on cognition as on his
or her trust in the care system. The many
doctors who will examine the patient in the
weeks and the months following the first
tests, and who are convinced that the
patient‟s greater awareness is advisa ble,
will ask themselves a question which runs
as follows: “How do I tell this person, who
for weeks or months has been subject to
often devastating therapies, that he is
terminally ill and that the treatment which
he has suffered has only been palliative? ”.
It is precisely for this reason that many
interactions between doctors and new
patients start with the question “What do
you know about this illness?”. The reply
immediately marks out the boundaries of
the doctor‟s responsibility, establishing the
cogni tive limit which he or she cannot go
beyond.
The main perverse effect of this
interweaving between systemic trust and
personal trust is therefore the fact that
errors cannot be corrected. In order to
maintain trust in the „system‟ of which
they are membe rs, doctors are forced to
keep on lying to patients even when they

Bulletin of the Transilvania University of Brașov • Vol. 2 (51) – 2009 • Series VII
28
are aware of the numerous harmful
consequences of that communicative
strategy on the mental health of the sick.
Another factor that explains the onset of
this effect is the particular organ izational
structuring of the care system . Oncological
care is organized in Italy like any other
specialist branch of medicine. Indeed, the
exceptional complexity and dangerousness
of cancer have increased the specialist
fragmentation of care services and
heightened the likelihood of the
„imprinting effect‟. From the beginning of
the disease, a patient comes into contact
with, and receives information on his/her
illness from, a medley of doctors, from the
general practitioner to the surgeon, to the
oncologis t, and finally to the specialist in
pain therapy and palliative care.
Furthermore, in every operational unit,
despite the constant efforts by patients and
family members to construct a privileged
relationship, the doctors constantly
„rotate‟, and patients can never be sure that
the next doctor to examine them will be
same doctor that examined them
previously. In other words, patients with
advanced -stage tumours are very likely,
and often in the same hospital, to come
into contact with (and be informed by)
dozens of different doctors (some
belonging to the same unit, others to
different ones), none of whom is able fully
to assume the task of following the
patient‟s case at first hand. Hence, patients
are deprived of single referent within the
organization, an d they are forced by these
communicative difficulties to concentrate
more on collecting and selecting reliable
clinical information that on managing the
disease as a whole.
On the other hand, the harmful effects on
patients notwithstanding, it is difficu lt not
to recognize the benefits of this
organizational structure for the hospital
system. These benefits consist mainly in: 1. the reduced risks of burnout to which
the doctors would be exposed if they
were required to accompany patients
until death. The dea th of a patient is, as
we shall see, not only a professional
„defeat‟ for the doctor but also an
emotionally painful event if proximity
with the patient has been close and
prolonged;
2. the decreased likelihood that a single
doctor will be held liable for t herapeutic
choices and possible errors of
assessment, responsibility for which is
shared by all members of the team;
3. avoidance of conflicts over the amount
of information to give to the patient
[McIntosh 1977];
4. the homogeneity of the criteria applied
when decisions are taken, without
explicit socialization, by newcomers,
the reduced complexity of decision –
making, a reliable routine, and
simplification of the doctors‟ cognitive
work when dealing with patients.
This last point should be expanded
further. The fact that doctors know that
they do not have to inform patients about
prognoses relieves them from having to
decide from case to case . This concerns a
routine useful and important for the taking
of critical decisions [Taylor 1988]. Let us
see why. Doctors maintain that they apply
different strategies according to the „real
desires‟ of patients. But these desires are
very difficult to identify with certainty. For
example it is highly plausible to argue, as
do many doctors, that patients who ask for
informati on about their state of health
really want only reassurance, not accurate
information; that is, they want to receive
only positive news from their doctors. In
this case, lying can be considered a
legitimate action by the doctor. The point
is that the docto r knows too little about the
patient, his/her personality, his/her possible
reactions, his/her relationship with the
disease and death, to be able to decide

Marzano , M.: “Secrets and Lies”: (Not) Telling Bad News in Italian Oncology 29
from case to case according to individual
exigencies. And how could it be otherwise
if the interact ion between the two lasts no
longer than the half hour of an out -patient
examination?
The only alternative is therefore to choose
between two “policies of communication”:
telling the truth to all patients or not telling
it to any of them [Mc Intosh 1977]. The
intermediate solutions are either too costly
(they might, for example, require the
regular intervention of a psychologist and
careful evaluation of the patient‟s clinical
history) or too risky, both to the team‟s
social cohesion and to its legal and mo ral
responsibility, which thus remains
collective.
Individualization, or treatment
differentiated case by case, is therefore
mainly a rhetorical strategy used in
interaction with patients [Schou 1993] in
order to:
(a) prevent them from learning of their
fates through comparison of their
condition with that of other patients. I
frequently heard doctors making
statements of the kind “Don‟t look at
what‟s happening to the person in the
next bed, Mrs Brown. Every case is
different. Your neighbour has a different
disease from yours. Concentrate on your
own case”. In this way, the doctor sought
to reassure the patient and convince her
that what she saw in her room -mate did
not anticipate her own demise;
(b) indicate the body of the patient, of that
specific patient, as the source of the
disease and the resistance to the care
therapies and the healing actions of the
medical team. The fact that the disease
does not have an external manifestation,
that it is not immediately visible, and
must be diagnosed by complicated and
precise tests, convinces many patients
that they are ignorant of their bodies and
the dangers that lie within them [Lupton
1998]. The message is that chemotherapy must be beneficial
because it fights the treacherous disease
that lurks in that body.
It is b y now quite clear that the decision
not to inform patients and the principle of
collective responsibility interweave and
sustain each other. The lie becomes
anonymous; it does not assume the features
of a specific face and it does not involve
single respon sibility or a real choice. It
becomes practicable without the system
being required to bear excessively high
human and organizational costs.
From the more general point of view,
what the Italian oncological care system
does not recognize is the exceptiona lity and
the force of cancer as a disease, the extreme
difficulty of medicine in fighting and
defeating it, and its contiguity with the end
of life. Tumours are instead equated with
diseases of other kinds, to which the
principles of specialization and col lective
responsibility are less problematically
applicable. In the case of curable diseases,
in fact, it is simpler to justify the
concentration of the medical team‟s efforts
on the organs to repair or the functions to
restore, without too much concern for the
persona of the patient as a whole. In these
cases, in fact, the patient‟s condition is
provisional, just as his/her absence from
everyday life is temporary.

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Notes

1. Also according to The ( 2002),
better -educated and better -off patients
often ask for more precise and detailed
information; they possess modes of

Marzano , M.: “Secrets and Lies”: (Not) Telling Bad News in Italian Oncology 31
communication that facilitate dialogue
with doctors; and they want to
participate more closely in decisions
on therapies.
2. Schou and H ewison [1999] have
observed the same behaviour among
English doctors, who seek to „to
minimize‟ and to conceal the gravity
of the disease by speaking of a
„growth‟ rather than a „cancer‟,
resorting to humour to conceal the
seriousness of the news to be announced, delaying disclosure of the
diagnosis as long as possible, reducing
to the minimum the time devoted to
interaction with the patient, or again,
leaving the task of giving bad news to
junior doctors, and failing to mention
that further treatment will be necessary
after surgery.
3. The [2002] has signalled the ambiguity
that also surrounds the terms „to treat,‟
„treatment‟, „treatable‟ so often used in
communication about tumours.