East to West: Differing Approaches to Truth-telling in Medicine

East to West: Differing Approaches to Truth-telling in Medicine

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By: Parita Shah

Would you want to know the truth or be lied to? The attitudes and practices in providing or withholding medical diagnoses from patients differ between cultures and countries. In western countries, approximately 80 to 90% of patients are informed about their diagnosis, whereas the figures can range from 0 to 50% in non-western cultures.1 As such, while honesty is a key element to developing a good doctor-patient relationship, truth-telling (i.e. diagnosis disclosure) should be done in the context of ethical values, legal obligations, and cultural considerations.

Doctor-patient communication has evolved over the years. The traditional paternalistic model of care assigned doctors as the key decision makers; they assessed patients and prescribed medications to save life and avoid death but rarely educated patients of their diagnoses and treatment. However, with the introduction of contemporary bioethics, the traditional medical practice evolved to an autonomy-based model of care.2 In this new view, patients are informed of their diagnoses and they are equally involved in the decision-making process of their treatment plan as the doctors. However, the degree to which the new autonomy-based model of care has been adopted varies across countries and cultures.

In western countries, physicians are trained to tell the whole truth about their patient’s diagnosis, regardless of how bad the news. This practice is based on ethical principles, namely patient autonomy (i.e. right to make informed decisions), justice (i.e. fair treatment), beneficence (i.e. benefit others), and non-maleficence (i.e. do no harm). Truth-telling can establish a lasting doctor-patient relationship based on trust, and provide patients opportunities to actively participate in the decision-making process of their treatment plan, often resulting in better outcomes. However, in an environment that demands efficiency, explaining diagnoses and treatment options, along with addressing patient concerns, can take substantial time. Additionally, if given in haste, disclosure can cause undue distress or anxiety for patients and their families after receiving the diagnoses.

In some non-western cultures, doctors fear communicating bad news because of the belief that it would cause great psychological distress to patients. These cultures put emphasis on the role of family in patient care, operating within more paternalistic approaches to patient care. For example, in many traditional Chinese medical practices, death and related issues are taboo subjects and the emphasis on non-maleficence leads to withholding the truth to patients. Patients in these cultures may be psychosocially dependent on their family as these members act as key decision makers. As such, doctors may respect a family’s decision to withhold a diagnosis to the patient in order to protect the patient from psychological distress. However, this decision can cause more harm to the patient if their family fails to act in the patient’s best interests. Further, it can be argued that patients in these cultures only seek medical help in order to be relieved of their symptoms and are less likely to engage in preventative care (e.g. regular health screenings), as preventative care is more closely associated with the patient as decision-maker.

While medical practice on truth-telling is culture-specific, patients’ attitudes on disclosure increasingly appear to be more influenced by personal factors rather than cultural ones. One study found that patients with above-average income, college education, and those younger than 60 years old are more likely to be interested in knowing the truth about their condition.3  Overall, most patients, regardless of their culture, want to know the truth about their illness.4,5 The consensus of patients’ desire for transparent diagnoses is in contrast to some doctors’ truth-telling practices. This incongruity points to how patients from highly family-oriented cultures may not be able to request an honest diagnosis, as this act of rebellion could insult the very people who make medical decisions on their behalf: their family. However, more research is needed to understand this possible phenomenon.

When culture demands adherence to the traditional paternalistic model, it can pose a challenge for doctors who wish to undertake the autonomy-based model of care approach. Given the challenges to truth-telling across cultures, doctors can use communication strategies to minimize the negative impact of unfavourable news on a patient’s well-being.6 For example, doctors may need to understand patients’ and their families’ perspectives in a cultural context, correct misbeliefs, be empathetic, and connect them to an interdisciplinary health support team (e.g. social workers and nurses) for ongoing psychosocial support. Further, they may need to recognize instances when withholding diagnoses can be justified. For example, if doctors have reasonable evidence that truth-telling will cause preventable harm to the patient or if the patient has made an informed request to not know the truth, then withholding diagnoses from the patient may be justifiable.7

The extent to which patients are told the truth about their illness exists on a continuum, with western countries more likely to give a full disclosure and non-western countries more likely to give partial or no disclosure to patients. There is an increasing trend and evidence in favour of not withholding medically-indicated information from patients.2,7 If done carefully, in the context of ethical obligations and cultural considerations, revealing diagnoses to patients may be far superior in improving patient outcomes than withholding information in most situations. After all, honesty matters – to doctors, patients, and their families.

References

  1. Gold M. Is honesty always the best policy? Ethical aspects of truth telling. Intern Med J. 2004;34(9-10):578-80.
  2. Zahedi F. The challenge of truth telling across cultures: a case study. J Med Ethics Hist Med. 2011;4:11.
  3. Sullivan R.J., Menapace LW, and White RM. Truth-telling and patient diagnoses. J Med Ethics. 2001;27(3):192-7.
  4. Laxmi S and Khan JA. Does the cancer patient want to know? Results from a study in an Indian tertiary cancer center. South Asian J Cancer. 2013;2(2): 57-61.
  5. Glass E and Cluxton D. Truth-Telling: Ethical Issues in Clinical Practice. Journal of Hospice and Palliative Nursing. 2004;6(4): 232-242.
  6. Baile W.F. et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4): 302-11.
  7. Braddock CH. Truth-telling and Withholding Information. 2008; Available from: https://depts.washington.edu/bioethx/topics/truth.html.