Winter, 1998
Question:
A 59-year-old Chinese man was found to have a cancer in his left kidney. The cancer was resected by a urologic surgeon. During the postoperative period, before the pathology reports were available, the patient's wife met with the surgeon. She requested that, if the pathology reports indicated an unfavorable prognosis, her husband not be told the truth. She explained that in China it is considered detrimental to a patient's health and even mean spirited to tell them they have an incurable disease or that they may die.
The urologic surgeon always told his patients the truth and was troubled by the wife's request. How would you advise the surgeon?
Response:
This cross-cultural conflict raises many ethical issues. First is the nature of the doctor-patient relationship and medical decision making. Since the 1980s, shared decision making has been recommended to ensure that decisions are targeted to patients' goals and interests. 1, 2 Second, the dyadic, doctor-patient relationship often represents an oversimplification of social reality. In many families the emphasis on individual autonomy and control is culturally inappropriate. Thus, family members and community representatives often are involved in medical decisions. 3 Third, the moral foundation for veracity and informed consent is respect for persons, beneficence and avoiding harm. Sometimes, such as when cultural or religious traditions conflict with secular prescriptions, full disclosure may need to be modified to respect the underlying principles. 4 Lastly, there are situations when cultural traditions or sensitivities should not trump standard medical practices. When requested behavior is illegal, breaches professional integrity, or represents an offensive moral belief, accommodation to culture-related requests is probably not ethically justifiable. 5
Three sets of questions need to be answered before advising the surgeon.
- How long have the patient and wife lived in the United States? How are they employed? Do they live in a closed community? These questions help to characterize their degree of acculturation. A married couple may not share the same opinion about a cultural belief.
- How were medical decisions made previously? What was communicated in the informed consent process for surgery, and with whom? These questions may help characterize the patient's style of decision making and the role of family members.
- What was the nature of the patient's symptoms and concerns that lead to identification of a cancerous kidney? This question may illuminate the patient's expectations.
The surgeon should develop a deeper understanding of the patient's and wife's beliefs. The surgeon should ask the patient, "What do you think caused the symptoms?" This would help identify the patient's folk beliefs about the illness. 6 The surgeon should ask the wife, "Why is communication about these topics detrimental or mean spirited? How is negative information communicated or handled in your culture?" The patient and wife should be asked, "How was advance care planning discussed with your doctor?" The answers to these questions would help explain the meaning and significance of the wife's request, as well as identify family responses to similar situations.
The surgeon should ask the patient if he has any questions that he would like answered, and determine the patient's understanding of the reasons for the surgery. Sincere and repeated invitations to ask questions permit the surgeon to glean how much information the patient wants to hear. The patient's story about the need for surgery should provide insights about his handling of negative information.
If the surgeon discussed the surgical indications and possible complications during the informed consent process, and the patient discussed the possibility of negative outcomes, then the surgeon should proceed with an honest discussion about the pathology report. Prior to this discussion, however, the surgeon should communicate with the wife his rationale - including professional and ethical considerations - and any conversations with the patient that suggest acceptance of a shared decision-making role.
Alternatively, if the patient consented to surgery without understanding the implications, then depending on the patient's postoperative questions, the physician should tailor the amount of information to the questions asked and the wife's concerns. The precise style and content of the communication with the patient would likely benefit from discussions (negotiations) between the surgeon and the wife. This latter approach may undermine the patient's autonomy by not providing him with sufficient information to judiciously decide how to live his remaining life. However, if this approach accurately reflects the patient's values and beliefs, it demonstrates respect for persons, and likely maximizes good outcomes and minimizes harms. Presumably, giving incomplete information in this context does not transgress professional integrity. Therefore, in this case, partial disclosure is ethically permissible.
This type of case suggests the need for preventive strategies. Physicians should explore how their patients envision an ideal doctor-patient relationship and decision making. After learning about proscriptions (e.g., cannot discuss negative information), physicians should inquire how other patients and/or their families should be approached if something untoward is a possibility. Furthermore, incorporating the patient's cultural beliefs into shared decision making can be practiced on more mundane day-to-day decisions. Finally, discussions with cultural leaders in a patient's ethnic or cultural community and institutional ethics committees can facilitate understanding and resolution of cross-cultural ethical conflicts.
Robert A. Pearlman, MD, MPH
Director, Northwest Ethics Center for Veterans Health Care
Seattle, Wash.
Outcome:
The pathologic findings showed that the tumor had been completely removed. There was no additional bad news to deliver.
Footnotes
1 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. Washington, DC: U.S. Government Printing Office, 1982.
2 Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992; 267:2221-6.
3 Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient autonomy. JAMA 1995; 274:820-25.
4 Carrese JA, Rhodes LA. Western bioethics on the Navajo reservation. Benefit or harm? JAMA 1995; 274:826-29.
5 Jecker NS, Carrese JA, Pearlman RA. Caring for patients in cross-cultural settings. Hastings Cent Rep 1995; 25(1):6-14.
6 Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978; 88:251-58.
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Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
