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The norms and practices related to truth telling in medicine, especially around the diagnosis and prognosis of terminal illness, have varied throughout history and across cultures. A contrast is often drawn between open disclosure policies in the West and nondisclosure or indirect disclosure practices in non-Western societies. However, primary historical, sociological, and literary sources from the West and China reveal both complex cultural differences and surprising similarities that transcend history, society, and culture. For instance, while truth telling is a relatively new phenomenon in the West, with a history of several decades only, a tradition of medical truth telling in China dates back as far as the sixth century BCE. Thus, in spite of the striking and persistent cross-cultural differences, truth telling in general ought to be considered an essential ethical norm for healthcare and global bioethics. Although patients’ autonomy and rights constitute the salient ethical and political justiﬁcation for truth telling, other moral grounds are also important, including the inherent value of honesty, the therapeutic beneﬁts for patients or possible harms resulting from nondisclosure, and patient–physician trust. In practice, truth telling requires sensitivity, compassion, and practical wisdom. In being truthful, the practitioner must discern how much to communicate and when, based on an understanding of the individual needs of each patient.
The value of truthfulness is evident throughout history and across societies and cultures. It is difﬁcult to imagine a functioning society in which lying is a common norm and practice. Without truthfulness, human communication and relations would never be adequately established or, if established, be easily broken down. In many ways, the same is true in healthcare and therapeutic relationships. Although the UNESCO Universal Declaration on Bioethics and Human Rights has not speciﬁcally mentioned truth telling or veracity, truthful disclosure from medical professionals is the prerequisite of autonomy and consent – the two ethical principles highlighted in that historic document. Without truthful and accurate information, patients and research participants would never be able to exercise their autonomy or make informed decisions about whether or not to consent to medical intervention or participate in scientiﬁc research.
Health information, however, often has profound implications for patients and their families, and if badly communicated, it can leave the patient feeling hurt and even demoralized. At times, in order to protect patients from these harmful effects, doctors have thought it better not to truthfully disclose certain information and in some cases to actively conceal it from them, particularly when the information relates to the diagnosis or prognosis of a potentially fatal illness. Today ethical and legal standards in most countries require that healthcare professionals provide patients with adequate information relevant to their situations in a truthful and timely manner.
The following is a review of the historical, sociocultural, philosophical, and practical complexity of honesty or veracity in medicine on the global stage. As debates surrounding truth telling in medicine have often concerned news of a diagnosis of terminal illness such as cancer, the focus is primarily on this kind of situation.
Glimpses Into The Global Picture: Diversity And Similarities
From a global perspective, transcultural similarities, if not commonalities, are as striking as historical and sociocultural differences. This is evident in primary historical, sociological, and literary sources.
Yi Huan is a revered Chinese physician who lived nearly 2,600 years ago. According to the Zuo zhuan (the chronology of the State of Lu), one of the earliest surviving Chinese historical works, in the tenth year of Duke Cheng (579 BCE), Yi Huan was called in to treat the duke of the State of Jin. After examining him, the physician told Duke Jin in straightforward terms: “The disease is beyond a cure. It is above gao and below huang [unknown or controversial anatomical locations in traditional Chinese medicine]. … No medicine can reach the diseased place, so it is beyond curing.” The duke replied: “An excellent doctor indeed!” The physician was thanked by the patient with rituals and rewarded by generous gifts or liberal payment. Duke Jin died from a diarrhea-related illness shortly afterwards (cited in Nie 2011, pp. 103–104). Since then, “bing ru gaohuang” (the disease has attacked the vital area between gao and huang) has become the phrase commonly used to refer to terminal illness in both classical and contemporary Chinese. The story of Yi Huan and the origin of this Chinese idiom indicate that the diagnosis of terminal illness was inherently connected with the necessity of informing the patient about it honestly and openly from the beginning of Chinese culture and medicine.
Two Russian literary masterpieces – The Death of Ivan Ilych by Leo Tolstoy (1886) and Cancer Ward by Aleksandr Solzhenitsyn (1967) – have vividly and powerfully illustrated a series of serious problems associated with a dominant medical practice of their times, viz., concealing the truthful diagnosis and prognosis from the concerned patient. Taking the standpoint of the patient, both Tolstoy and Solzhenitsyn called for a change to honest disclosure. In Tolstoy’s novella, rather than giving hope, the lie of the doctors, family members, and other people resulted in the abandonment of the patient and his corresponding despair. Nondisclosure for what were presumably benevolent intentions deprived the patient of the support and care he desperately needed at the time of suffering and dying. As a result, he suffered alone (being comforted only by a servant) and died a difﬁcult death. While The Death of Ivan Ilych is foremost a story about fundamental existential and moral issues facing humanity, Cancer Ward is ﬁrst a political allegory of a totalitarian system and an ethical account on how individuals can be corrupted or strive to live a moral life in an immoral society. Still, like its nineteenth-century counterpart, Solzhenitsyn’ twentieth-century novel about a provincial Soviet hospital in the 1950s can be read literally as a medical narrative which advocates truth telling as essential for not only a good society but good medicine. Like Ilych, the ex-prisoner of labor camps Oleg Kostoglotov and most of his fellow patients in the cancer ward are acutely aware of their dire medical condition in spite of the standard practice of nondisclosure. Different from Ilych who passively accepts the lie from others, Kostoglotov has actively sought the truth about his illness as well as the world where lies are authorized as truth.
In keeping with the spirit of the ancient Chinese medical sages and the Russian literary works, in the beginning of the twenty-ﬁrst century, the American Board of Internal Medicine (ABIM), the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), and the European Federation of Internal Medicine (EFIM) (2002) jointly issued a document, “Medical Professionalism in the New Millennium: A Physician Charter.” It encompasses a set of fundamental principles (such as the “principle of patient autonomy”) and professional responsibilities (such as the “commitment to honesty with patient”) that medical professionals should follow and aspire to. The Charter states that physicians have a moral and professional duty to ensure that their patients are “completely and honestly informed” before and after treatment so that they are “empowered” to give informed consent and make informed choices. The Charter has now been endorsed by medical associations throughout the world, not only in Western countries but non-Western ones including China (Nie et al. 2015).
While truthfulness is now established as an essential, often legally required, element of good medical practice in most Western societies, this is certainly not the case everywhere. In many non-Western societies, nondisclosure and/or indirect disclosure constitutes a common norm and practice regarding the information related to terminal illness. For instance, despite a long and well-established tradition of truth telling initiated centuries ago by such great healers as Yi Huan, in contemporary China (including Hong Kong and Taiwan), medical professionals customarily withhold from patients crucial information about terminal illnesses such as cancer. It is not uncommon for Chinese medical professionals, along with family members, to lie to patients about the diagnosis and prognosis of terminal illness. Nondisclosure or indirect disclosure through family members is the mainstream practice in other Asian countries such as Japan and Nepal, as well in other parts of the world such as the Middle East and Eastern and Southern Europe. In different countries or within different ethnic groups within the same country including native Americans and other aboriginal people, patients suffering from cancers and other terminal illnesses receive very different levels of information about their diagnosis, prognosis, and therapeutic options (e.g., Hancock et al. 2007; Tuckett 2004).
It is remarkable that, in a long globalized and increasingly globalizing world, such a striking cultural difference is still prevalent in the twenty-ﬁrst century. An editorial by an Italian physician in the journal Support Care Cancer describes a “persisting difference in truth telling throughout the world” (Surbone 2004). This author points out that although “a shift in truth telling attitudes and practice toward greater disclosure” has been happening worldwide, “partial and nondisclosure is still common in many cultures that are centered on family and community values” (Surbone 2008, p. 237). An editorial in another medical journal The Lancet observes that attitudes to truthfulness in medical practice can “vary between cultures.” China and Japan are cited as exemplary countries where “withholding the truth wholly or partially is not uncommon,” and the decision whether or not to tell the truth to the patient is left to family members, rather than medical professionals (The Lancet 2011).
Truth Telling In The West: A Relatively New Phenomenon
While the cultural differences have often been characterized as a clear-cut opposition between direct and open disclosure in the West versus nondisclosure or indirect disclosure through family members in non-Western societies, care must be taken not to oversimplify and stereotype the cultural features involved. Due to the prominent role of truth telling in contemporary Western medical ethics and medical law, one may assume that, historically and culturally, truthfulness has always been emphasized in Western medical practice. The fact is, however, quite the opposite. Telling terminally ill patients the truth has a history of only a few decades in the West.
It is true that there is a salient and strong opposition to lying in Western religious, literary, and philosophical traditions and in some cases a ruthless pursuit of truth and truthfulness. Truth and truthfulness are of critical importance in the Judeo-Christian biblical tradition, theological discussion from Augustine onward, the philosophy of Kant, Greek tragedies, and modern Western literature (Bok 1989; Williams 2002). Nevertheless, against this cultural background, throughout history Western physicians regularly withheld information about terminal illness from their patients, a practice apparently tacitly accepted by laypeople (though some exceptional physicians have stressed veracity in their professional practice).
Indeed, the history of the patient–physician relationship in the West has been summarized as a “history of silence,” a history that goes back to ancient Greece (Katz 2002 ). Honesty to patients was rarely, if at all, mentioned in the major works of Western medical ethics such as the Hippocratic Oath or modern codes. In the Decorum, Hippocrates, the father of medicine in the West, admonished physicians not to practice disclosure, but to “conceal most things from the patient while you are attending to him” and to “reveal nothing of the patient’s future or present condition.” The inﬂuential 1847 Code of the American Medical Association (section 4 of Article I) stipulated that physicians should “not be forward to make gloomy prognostications.” Only “if absolutely necessary” should the physician disclose the information to the patient. Based on the paternalistic presumption that a terminally ill patient is in too frail a state to receive the facts about their medical condition, the Code states that the physician has a “sacred duty” not to speak truthfully and openly or, in its own words, “to avoid all things which have a tendency to discourage the patient and to depress his spirits” (in Katz 2002 , p. 231).
As vividly recorded The Death of Ivan Ilych and Cancer Ward, the norm and practice of nondisclosure on terminal illness was widespread. In New Zealand, arguably one of the more progressive Western countries, the practices of direct disclosure and informed consent did not become an explicit ethical and legal requirement until the late 1980s and early 1990s. The 1847 Code of AMA was adopted by the New Zealand branch of the British Medical Association no later than 1887. Even a century later, in the well-known Cartwright Inquiry (1987–1988) into the “unfortunate experiment” involving women with cervical abnormalities, several doctors who served as expert witnesses objected to the necessity (and even possibility) of truth telling and informed consent in such circumstances. Then president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists testiﬁed that telling patients the truth about their complications “would frighten a very large number of people from having necessary treatment, and it would also be beyond the intellectual comprehension of a considerable proportion of the population” (cited in Nie and Anderson 2003, p. 347).
During the 1960s and 1970s, a profound and far-reaching change occurred in ethical norms relating to truthful disclosure in the West and elsewhere, and truthful and direct disclosure of the diagnosis and prognosis of terminal illness became a standard procedure. In the United States, for instance, 90 % of physicians surveyed in the early 1960s favored not telling the truth about a dire medical diagnosis and prognosis to their cancer patients (Oken 1961). However, by the late 1970s, in a survey which posed a questionnaire almost identical to that used in the 1960s study, 97 % of physicians said that they would prefer telling their cancer patients about their diagnosis and prognosis (Novack et al. 1979). In other words, in less than two decades, US physicians’ attitude had been completely reversed, from concealing truth to truth telling.
The historic change from nondisclosure to honest and open disclosure has been a part of the sweeping political and sociocultural movement of civil rights, women’s rights, patients’ rights, and, more generally, human rights. It is in this historical context that the doctrines of informed consent and autonomy of persons has become the centerpiece of contemporary medical ethics and medical law worldwide. In many countries, honesty is something that patients have come to expect and which physicians have promised to provide (as clearly expressed in the aforementioned “Physician Charter on Medical Professionalism”).
In reality, however, giving patients truthful and adequate information remains a constant challenge. As revealed in a French anthropological study (Fainzang 2015), in spite of legal and professional documents promoting patients’ right to be fully informed, cancer patients often do not receive adequate information from their healthcare providers and rarely complain about this inadequacy due to their sense of disempowerment. Moreover, telling lies is still common on both sides of the patient-physician relationship – even in France, a country that historically has championed human rights.
In China: The Return Of A Long But Forgotten Tradition
China offers a telling case on the complexity of cultural differences in truth telling and medical ethics in general. It is one thing to acknowledge that in China today medical professionals routinely withhold information about terminal illness from patients and usually inform family members only. It is another thing to assume or claim that telling truth about terminal illness is culturally alien to China or unknown in the “Middle Kingdom” until recently. As already indicated, the cultural differences at stake here are far more complex and rich and thus far more intriguing than anything implied by a crude dichotomizing schema: open disclosure in the West versus nondisclosure or indirect disclosure through family members in China.
Though little known inside and outside China today, and rarely acknowledged even by Chinese medical ethicists and historians of medicine ethics, a well-established tradition of medical disclosure existed in China (Nie 2011: chapter 6, 7, 2012). Primary historical sources in China, including the biographies of ancient medical sages and famous physicians from various dynasties, reveal that the story of open and honest disclosure by Yi Huan recounted earlier was not isolated. Anticipating contemporary Western practice by more than 2½ millennia, well-known Chinese practitioners took truthful and direct disclosure about terminal illness for granted. Besides Yi Huan, they include Yi He (c. sixth century BCE), the “father of medicine” Bian Que (c. ﬁfth century BCE), the “sage of medicine” Zhang Zhongjing (c. second century AD), and the “father of surgery” Hua Tuo (c. second century AD). The biographies of nearly 1,400 famous physicians recorded in A Collection of Ancient and Modern Books: Medicine (an ofﬁcial and authoritative seventeenth-century publication, 520 volumes in the original format) demonstrate time and again that Chinese physicians almost always honestly and directly told their patients of the diagnosis and prognosis of terminal illness. Moreover, the story of Yi Huan also indicated that patients expected physicians to tell them the truth about their medical conditions however unfavorable the outlook. Primary historical and literary sources from Imperial China offer further evidence that this expectation of honest and open disclosure by laypeople was widespread. Furthermore, important ethical rationales for doing so were offered or presumed. The Confucian moral outlook mandates truthfulness as a basic ethical principle and a cardinal social virtue which physicians ought to take as their guiding star.
Therefore, historically and culturally speaking, in striking contrast to the tradition of concealing truth in the West, the norm and practice in China was for physicians to disclose truthfully and directly to patients. Ironically, the apparently “authentic” or “representative” Chinese practice – nondisclosure or indirect disclosure – was probably a result of the development and inﬂuence of Western biomedicine in China from the eighteenth and especially nineteenth centuries. In China today, a shift is occurring to open disclosure, driven by reform-orientated patients and medical professionals. This change appears to be similar to that which began in the West in the 1960s. However, the current shift in China is not so much imitation of Western (and thus foreign) ways as it is a return to a long but forgotten indigenous tradition.
The Philosophical Basis Of Truth Telling
Though the importance of truthfulness in sustaining human society is evident, its value in healthcare can be expressed in a variety of ways. Trust is essential to sustaining an effective practitioner–patient relationship, and trust requires honesty. An honest relationship leads to better health outcomes for several reasons, one of which is that it enables the patient to contribute personal knowledge of her condition and her goals – i.e., her knowledge of what would be harmful or beneﬁcial to her – to the decision-making process. Considered this way, truthfulness may be said to be important because it follows from the principles of beneﬁcence and non-maleﬁcence. As already noted, truthfulness is also often related directly to the value of autonomy. Though the meaning and scope of autonomy remains a matter of contention, it is broadly agreed that it means affording competent patients the right to make decisions about whether to accept or refuse treatments that are offered and to exercise some degree of control over the course of treatment. In order to help patients make such decisions, it is necessary to provide them with certain information as accurately as possible. The amount of information that is required will vary from patient to patient (as discussed below), but it typically would include information about the illness, how it will develop, what treatment options there are, what these treatments involve, what is likely to happen if no treatment is given, and so on. In making such decisions, a person is attempting to align her hopes, plans, and expectations with a true projection of her future, and hence from her perspective, the quality of the decision depends in many ways on the truth of the information. Thus, if the doctor knowingly provides false or misleading information, she/he is undermining the patient’s autonomy.
The principles just mentioned – beneﬁcence, non-maleﬁcence, and autonomy – are three of the four principles discussed by Beauchamp and Childress in their inﬂuential work The Principles of Biomedical Ethics (now in its sixth edition). These are sometimes described as the “Western” principles of biomedical ethics, the implication being that they are only applicable to Western sociocultural contexts and that non-Western cultures have different ethical principles. In particular, it is widely debated whether the principle of autonomy – perhaps the most common ethical, legal, and political justiﬁcation for truth telling – is transcultural due to its alleged individualistic orientation. Yet, the points made above about the problems with dichotomizing and why it is wrong to draw a broad line between “Eastern” and “Western” values are equally applicable here. While these values have been articulated by ethicists working in a Western context, they have become part of global ethical discourse and have been both accepted and debated in many different cultural contexts. Even if the principle of autonomy were not transcultural, promoting good and preventing harm are universally held to be important norms in medical ethical traditions of different cultures. This is not to say that their meaning and application is unambiguous and unaffected but cultural factors; the point is simply that they are intelligible as global values. They are referred to here to indicate some of the typical ways that truthfulness is justiﬁed.
If truthfulness is related to beneﬁcence, non-maleﬁcence, and autonomy in the ways just outlined, then its scope and weight as an ethical norm and the manner in which it is related to particular situations will depend on how we understand these underlying ethical concepts. If, for example, it is thought that the practitioner’s primary duty is to promote the well-being of the patient (one conception of beneﬁcence), then a practitioner may not be obliged to tell the truth to patients in circumstances where she/he is sufﬁciently sure that doing so would be contrary to the patient’s well-being (perhaps also presuming that well-being is conceived only in terms of emotional stability). A corollary to this view might be that autonomy is valued only in so far as it promotes the patient’s well-being. Such a position may be derived, for example, from utilitarian or consequentialist moral theories. Alternatively, if autonomy is paramount over well-being, then the practitioner may be obliged to tell the truth to the patient irrespective of the effect this may have on, say, her/his well-being (however conceived). This view is expressed by classic Kantian moral theory. Kant famously argued that it is always morally wrong to lie to another person, irrespective of the perceived consequences, including the effect this may have on her happiness. This is because for Kant the capacity to act autonomously is the source of human dignity and moral value and this value must always have priority over other values. On this view, it is preferable to be autonomous (and to have the self-respect that comes from being autonomous) and miserable, than to be comforted by falsehoods or – more precisely – to derive pleasure from “heteronomous goods” at the expense of one’s capacity to act autonomously. Equally, it is better to allow a person to make an autonomous decision even if that decision may turn out to be contrary to her/his well-being, than to try to protect her by undermining her ability to act autonomously.
The different justiﬁcations for truthfulness just outlined could be related to the historical and literary examples referred to earlier in various ways. Such examples provide a different kind of insight to that provided by philosophical argument, and it is perhaps better to hold the two alongside each other rather than attempt to assimilate one to the other. That at least shall not be attempted here. Rather, some further questions that need to be accounted for in addressing this matter shall be highlighted; questions that are particularly evident in the practical contexts in which the questions ﬁrst arise.
The Practice Of Truth Telling And The Need For Skilled Judgment
As one considers whether or not it is right to tell the truth to patients, one must also consider what “telling the truth” means in particular circumstances. This is partly an epistemic problem, in that much that is “known” in healthcare is a matter of probability and hence is inherently uncertain. It is also a problem of scope, as it may not be immediately clear how much information one is obliged to deliver in order to have performed one’s duty to be truthful. Finally there are questions about the manner in which the information is provided and whether the provider is obliged to ensure that the patient understands the information that has been given. These issues have been explored extensively in the literature on informed consent. A brief discussion of what they each involve will be given here.
There are several ways that health information can be uncertain. There may simply be a lack of evidence regarding the treatment being offered. It may be that there are signiﬁcant differences between the patient being treated and the subjects of the trials from which the evidence comes. The healthcare professional may not be up-to-date with the latest evidence or may be unsure about how the evidence should be interpreted (indeed, interpretation can be a matter contention even among specialists). Many patients will ﬁnd evidence difﬁcult to understand and will simply have to trust what the provider says. This indicates further complications, as the trust a patient places in the provider often extends beyond the reliability of the information to the treatment decision itself. A patient may also be seeking conﬁdence, reassurance, and guidance from the provider about the decision and so place considerable weight on whatever the doctor says – or appears to say – about the risks or beneﬁts of the treatment. The provider needs to be aware of these relational dynamics as she/he communicates her/his uncertainty to the patient and avoid generating both false assurance and undue fear. This means that while truthfully informing the patient of risks associated with a procedure, the provider might also need to help the patient manage her/his anxiety about such risks. The provider may attempt to reassure the patient by contextualizing the risk (by comparing it to other risks) and by mentioning ways that the risk can be managed. However, given the uncertainty, the provider cannot honestly promise the patient that the feared outcome will not happen.
The problem of scope arises from the fact that there is an indeﬁnite amount that can be said about a given illness, treatment, and options for treatment, and different patients require different levels of information. In many jurisdictions, the standard for determining the appropriate level of disclosure has evolved from a “reasonable practitioner” standard (upheld in the 1957 Bolam vFriern Hospital Management Committee case (1 WLR 582) case), according to which a practitioner is obliged to tell patients what most practitioners would tell a patient in a relevantly similar situation, to an “individual patient” standard, whereby practitioners are expected to disclose additional information in response to concerns or questions that are raised by the patient. The latter position was upheld in the Rogers v Whitaker case of 1992 (175 CLR 479). In this case, the defendant had offered and performed a surgical procedure intended to correct the appearance of one of the plaintiff’s eyes. After the procedure, she developed a condition called “sympathetic ophthalmic,” which rendered her nearly blind. She maintained that the defendant failed in his duty by not informing her of the risk of this happening and that if she had known, she would have not gone ahead with the procedure. The estimated chance of it happening was 1 in 14000, and the defendant said that he regarded the risk so unlikely that it never occurred to him to mention it. If we think generally about the volume of information that should be given to patients, we may think that such low probability risks should not be routinely mentioned and that this is not a requirement of truthfulness. However, it is also the provider’s duty to make a reasonable attempt to ﬁnd out how much information each patient needs and to disclose accordingly. The view of the court in the Rogers v Whittaker case was that the plaintiff had given sufﬁcient indication to the defendant that she needed to know the risks of this nature and that he therefore failed in his duty to adequately disclose all relevant information.
The issue of patient understanding also involves the nature of the communication between the doctor and the patient. Truth is only useful to a person in so far as it is comprehensible to that person, and our conception of truth telling as an ethical norm in healthcare must take account of this. It would not be reasonable to expect healthcare providers to ensure that patients sufﬁciently understand the information that is given to them as understanding is unpredictable and necessarily requires some effort on the part of the patient. However, it is reasonable to expect that providers endeavor to make the information comprehensible to the patient, for example, by modifying the language that is used and by allowing sufﬁcient time for the patient to process the information and ask questions if required. The provider can also check understanding by engaging the patient in discussion and by asking questions. This helps patients to realize what they do not understand and to frame their own questions accordingly. Training in communication is now included in medical school programs around the world, and doctors are expected to be competent in the relevant communication strategies. So, while we cannot expect providers to ensure that patients understand, we can expect them to do a certain amount to enable understanding.
Harms, Benefits, And Hope
As noted at the outset, and as illustrated through the examples described, health information can have a profound and potentially harmful impact on the person receiving it. As discussed, concern about these effects was a primary factor in historical practices of not truthfully informing patients. While contemporary ethical and legal standards reject such practices, the underlying concern cannot be simply ignored, no matter how convincing one ﬁnds the ethical reasons for being truthful. Indeed, indifference to these harms would indicate a dangerous lack of compassion. So, while respecting the patient and her/his right to truthful disclosure, a good healthcare practitioner must also remain aware of and responsive to the impacts of the information that is given and attempt to understand and support the patient in so far as she/he can. There are several factors involved in this.
The ﬁrst important factor is the manner and timing in which information is given. The same words can be either cruel or kind depending on how they are communicated. Just as skill is required to make health information easily comprehensible, skill is also required to see that information is delivered in a caring manner. Allowing the hearer time to process what is being said supports her ability to accept and understand and conveys care and support from those communicating the information (see Evans 2008, pp. 198–199). Moreover, if a patient is allowed time to “arrive at the truth” for herself, she maintains a sense of agency, which can mitigate the painful shock that bad news can generate. By contrast, to communicate all relevant information at once (sometimes described as the “full disclosure model”) before it is wanted is arguably not serving autonomy, as it disregards what the patient wants to hear.
Another important factor determining the effect that health information has is the patient’s hopes. Hope is essential to the resolution of suffering as it supports the effort required to endure the adversities associated with illness and dying (McMillan et al. 2014). A person with hope retains a sense of purpose and is thereby able to retain “wholeness” despite whatever she/he is enduring. Hope, however, may be grounded in a variety of ways, and the effect given information will have on hope will differ accordingly depend on how that hope is grounded. For example, hope can be orientated toward a particular kind of outcome and based on a certain understanding of the probabilities involved. Alternatively, it may arise from a more general expectation that “something good” will happen and be somewhat independent of any given epistemic claims. The former kind of hope is likely to be signiﬁcantly affected by relevant kinds of information, whereas the latter is not. When a person’s hope is grounded in a particular outcome, there is a risk that the hope will be lost if that outcome is said to be impossible or when it ultimately does not eventuate. A healthcare provider may be reluctant to dismiss a particular hope entirely, given the broader therapeutic value that hope can have. At the same time, pursuing a “false hope” can leave the patient worse off than she/her would have been otherwise as the patient may later regret the investment that has been made in pursuing this hope (consider, e.g., a patient enduring a difﬁcult surgical procedure which fails to cure the illness). Many responsible healthcare providers would see it as their duty to protect patients from such an outcome by steering them away from false or unrealistic hopes and may therefore become concerned if a patient expresses, say, a hope for substantial recovery when the probability of this happening is very low. Thus, it can be difﬁcult for a provider to know how far to press certain information, especially given that one cannot always say deﬁnitively whether or not a hope is in fact “false.” In some cases, a provider may decide that it is better to allow a person to hold onto hope, irrespective of how the provider views the basis of the hope (different models of autonomy support different approaches to these kinds of situations). In short, the duty to truthfully disclose must be somehow integrated with the overarching therapeutic goal and be executed with sensitivity to the changing needs of each patient. This again requires considerable skill.
The art of healing and the art of truth telling are inherently interconnected. Drawing on primary historical, sociological, and literary sources from the West and China, it is evident that the cultural differences in medical truth telling are more complicated than often supposed. Also, as outlined above, there are different ethical justiﬁcations for truth telling and practical challenges of telling the truth in a manner in keeping with the therapeutic goal of healthcare. In conclusion, in spite of the striking and persistent cross-cultural differences and the possible exceptional cases for nondisclosure in particular clinical contexts, truth telling in general ought to be considered an essential ethical norm for healthcare and global bioethics.
There are several further issues that arise in relation to truth telling which have not been addressed here. Firstly, the role of family has been widely identiﬁed as a major non-Western and Western cross-cultural difference in healthcare and bioethics around medical truth telling. Nevertheless, the difference may not be so radical and dichotomous as it appears because truth telling to the individual patients and the active support from family members are not mutually exclusive. As insightfully portrayed in Tolstoy’s novella, secrecy and lying can alienate the patient from other family members. In such difﬁcult time as the Chinese saying “yiren xiangyu, mandang bule” (the whole family suffers if a single member is in pain) expresses, truth telling can help avoid the patient’s feeling of abandonment, offer better support to the patient, and strengthen, rather than weaken, the bonds of love and interdependences among family members. Secondly, there are questions about whether and when healthcare providers are obligated to disclose information to third parties. For example, when a patient is diagnosed as HIV positive, should this be conveyed to the patient’s sexual partner(s)? If so, should the disclosure be discretionary or compulsory for the health providers? Thirdly, there is an issue of patients who prefer not to know. To impose upon these patients any unwanted truth would not be ethically justiﬁable from the principles of respecting autonomy and non-maleﬁcence. Fourthly, there are debates around when and how medical errors should be communicated. Finally, there are questions regarding the duties of truthfulness when caring for patients who are incompetent or incapacitated due to age, injuries, dementia, or mental illness.
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