truth telling - the medical students' perspectives

Truth Telling

Jesper BovéJetjun Chotikapukana

Truth TellingThe Medical Students’ Perspectives

Jetjun ChotikapukanaJesper Bové

Supervisor:Malene Gram

Aalborg University

Master’s Programme in: Culture, Communication, and

Globalisation

10th SemesterJune 12, 2006

Acknowledgements

We would like to express our utmost gratitude to those who have supported us in finding participants for the research of this thesis, as well as to those who have lent technical support throughout the entire duration of this the-sis:

Anni Airaksinen, Elaine Friis, Mona Bjørn, Pamela Amulaku, Amy Brathwaite, Klaus Munkhøj-Nielsen, Hong Li, Marie Jaegly, Malene Gram,

and

our families who have been patient and morally supportive and with whom we have spent too little time while writing this thesis:

Kornthita Mueanchit, Jessdank Chotikapukana, Passornrawan Chotikapu-kana, Chupoh Mueanchit, Rigmor Bové, Poul Bové, Somdet Bové, Claus Bové,

and

all the willing participants in Thailand, China, Singapore, Finland, and Denmark. Without them this thesis would not have been possible to mate-rialize

and of course all our friends.

Chapter 1

Introduction 101 Background Information 111.1 Problem Formulation 11 1.1.1 The Relationship between Cultural Beliefs and Truth Telling in Medical Context 11 1.1.2 The Ethical Perspectives of Truth Telling 131.2 Research Inquiries 151.3 Research Objectives and Scope of the Study 161.4 An Overview of Theories and Methodology 171.5 Chapter Overviews 18

Chapter 2

Methodology 202 Methodology 212.1 The Traveller vs. The Miner 212.2 Social Constructivism 232.3 The Semi-Structured Interview 24 2.3.1 The Interview Guide 24 2.3.2 Data Collection Process 24 2.3.3 Terminology 28 2.3.4 The Pilot Interview 29 2.3.5 The Interview Situations 32

C O N T E N T S

2.3.6 Limitations 332.4 Participant’s Background 34

Chapter 3

Theory 363 Theoretical Framework 373.1 Chapter Objective 373.2 Rationales behind Selected Theories 373.3 Categorization of Moral Theories 393.4 Utilitarianism 40 3.4.1 Understanding Utilitarianism 41 3.4.2 Criticism of Utilitarianism 453.5 Kant’s Ethics of Duty 46 3.5.1 Understanding Kant’s Ethics of Duty 463.6 Virtue Ethics 50 3.6.1 Understanding Virtue Ethics 51 3.6.2 Applying Virtue Ethics to Medical Context 53 3.6.3 Criticisms of Virtue Ethics 553.7 Moral Relativism 563.8 Summary of the Theories 583.9 Other Moral Theories 583.10 A Cultural Impact on the Physician-Patient Relationship 60

Chapter 4

Analysis 704 Analysis and Discussion 714.1 Chapter Objective 714.2 Participants’ Holistic Perceptions of Ethical Behaviour 734.3 Differences and Similarities in Perceptions of Truth Telling between the Asian and Scandinavian Participants 74 4.3.1 Themes from the Interviews 74 4.3.2 A Synthesis of Theoretical Considerations and Empirical Data 884.4 A Discussion of the Case Scenario 93 4.4.1 The Asian Participants’ Solutions 94 4.4.2 Concluding Remarks on the Asian Participants’ Solutions 98 4.4.3 The Scandinavian Participants’ Solutions 99 4.4.4 Concluding Remarks on the Scandinavian Participants’ Solutions 104 4.4.5 The Solution of Ruiping Fan 106

Chapter 5

Conclusion 1105 Conclusions 1115.1 Future Research Possibilities 117

Bibliography 120

Appendices 125Appendix 1 - Interview Guide, Medical Students 126Appendix 2 - Interview Guide, Young Doctors 129Appendix 3 - Symbols used in the Transcripts 132Appendix 4 - Interview Transcripts 133

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chapter 1

chapter 3

chapter 5

chapter 4

chapter 2

IntroductionThis chapter contains the following:

An Introduction to Truth TellingThe Research QuestionsThe Problem Formulation

•••

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Truth Telling - The Medical Students’ Perspectives

1 Background Information

Physicians encounter ethical dilemmas in their clinical practice, undoubt-edly almost daily. In the prevalence of ethical challenges faced by a medical professional, “truth telling” among other things, has perpetuated discus-sions about whether or not physicians should always tell their patients the truth in the face of patients’ fatal diseases.

As declared in the “Hippocratic Oath” (Wikipedia, 2005), the universal prin-ciples of the medical profession, physicians must save people’s lives within their utmost ability to do so and never deliberately do harm to anyone for anyone else’s interest (ibid). However, with respect to truth telling, giving honest professional opinions may conflict with the patient’s will and ulti-mately, however unintentionally, do harm for example, when the patient would rather not to know about the diseases, or the patient’s family does not wish the truth to be disclosed because the ‘truth’ is thought to be too painful to endure. Indeed, the patient’s willingness such not to be informed and the roles of the patient’s family in safeguarding him or her from the truth, as well as the relationship between physicians and patients (herein after is referred to as the “physician-patient relationship”) are influenced by cultural and religious beliefs (Ozdogan et al. 2004, Thanaprasertgorn 1997, and Fan 2000).

1.1 Problem Formulation

1.1.1TheRelationshipbetweenCulturalBeliefsandTruthTellinginMedicalContext

Recently, medical literature elucidates upon the cultural aspect of truth tell-ing, the so-called “cultural sympathy” (Surbone 2004), which in medical context refers to whether or not physicians should consider patients’ cultur-

Chapter 1 - Introduction

al backgrounds before revealing the diagnosis or prognosis1 of serious and potentially terminal illnesses, such as cancer and HIV/AIDS. Extensive stud-ies show that cultural sympathy influences physicians’ attitudes towards disclosure of truth inasmuch as it limits the medical professionals’ options and behaviors. In an attempt to justify physicians’ decisions in withholding or revealing the truth, ethicists try to provide answers to an apt inquiry of potential solutions for physicians to act rationally on both medical and cul-tural grounds. Surbone (2004) observes the family and community’s roles in shaping the physician-patient relationship. She defines these roles as the “family- and community-centered.” Take the Arabic culture, as an example: According to Arabs, it is not a decision of one person to decide whether the patient should be informed about the illnesses rather, all decisions will be made by the family, as dignity, identity, and security are bounded by be-longing to the family (Taboada & Bruera 2001:338).

Similarly, in some Asian countries physicians are likely to consult the family before revealing the truth to the patient. In Japan, for instance, physicians hold the “Hippocratic Oath” in high regard and consider themselves as the final decision maker regarding medical treatment of their patients. Never-theless, in special situations where the family is against the diagnosis dis-closure, physicians usually follow the family’s wishes. The same tradition is also evidenced in Egypt, where the patient is not to be involved whatsoever in decision-making. Likewise, Saudi Arabian physicians prefer to discuss medical problems with the patient’s family rather than directly with the pa-tient, even when the patient is competent (Mystakidou et al. 2003:148).

Back et al (2002) reveal a wide variation in patients’ willingness to discuss the diagnosis of growing cancer tumors, according to the patients’ ethnic back-grounds (in this research, participants’ ethnicity were European-American,

1 The prospect of recovery as anticipated from the usual course of disease or peculiarities of the case (http://www.m-w.com/cgi-bin/dictiona

ry?book=Dictionary&va=prognosis) September 23, 2005

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African-American, Mexican-American, and Korean-American). According to Back et al’s study, physicians have to take cross-cultural differences of the patients’ preferences into consideration before delivering bad news. More-over, even in contemporary China, Chinese physicians are committed to hiding the truth as well as lying if necessary in order to achieve what is, in the family’s view, the patient’s best interest; as Fan et al. (2004:180) put it: “If the family decides not to tell the truth to the patient, the physician must abide by that decision and hide the truth.” Fan et al. suggest that the physi-cians’ lies could actually be conceived as a humanitarian act so as to protect the patient from harm.

In Thailand, Thanaprasertgorn and Nilchaikovit (1997) conducted quantita-tive research on “Thai Physicians’ Attitudes towards Truth Telling.” They conclude that Thai physicians appear to be more open in terms of honesty in disclosure with their patients than those from other Asian countries, such as Japan and India, but less open than physicians from North American and Northern European countries. According to their study, the physician-pa-tient relationship in North America and Northern Europe emphasizes indi-vidualism, and patient autonomy, whereas in most Asian countries includ-ing Thailand, the physician-patient relationship is predominantly based on reciprocity and the patient’s cooperation. However, Thai culture stresses the importance of flexibility, thereby allowing an individual’s freedom more than other Asian cultures. This reason may explain why physicians’ atti-tudes towards disclosure in Thailand appear to be more truthful than their counterparts from other countries in Asia (ibid.).

1.1.2TheEthicalPerspectivesofTruthTellingTo more accurately comprehend the ethical perspectives of truth telling, it is essential to look closely into the four basic principles of medical ethics and their connections with truth telling. There is a growing body of literature including Ypinazar & Margolis (2004), Tai & Lin (2001), Surbone (2004), and

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Taboada & Bruera (2001) that refers to the four ethics of medicine2 as fol-lows:

1. Autonomy:Autonomy refers to patients’ right to choose or refuse the treatment, including to be informed and consent the treatment.

2. Beneficence: Beneficence literally means “do good.” In medical eth-ics, beneficence means that physicians have to respond to the needs of their patients and act in their patients’ best interest.

3. Non-malfeasance: Non-malfeasance or “above all, do no harm” (primum non nocere) is originally declared in the Hippocratic Oath. It conveys the ethical message to the physicians that they must not harm their patients in any case, even if they cannot help them ei-ther.

4. Justice: Justice concerns the distribution of scarce health resources, and the decisions of who receives what treatment, and according to which prioritization.

Autonomy, beneficence, and non-malfeasance are the keys to truth telling. Justice, although may be perceived as one of ethical facets to the medical world, is yet another moral challenge, which is not in a particular interest of this thesis.

Truth needs to be delivered to the patients because they have the right to be informed about the illnesses. However, sometimes the above principles conflict with each other, as truth disclosure (although for the patients’ best interest) might cause hopelessness and despair, clashing with non-malfea-sance, while non-disclosure could breach the principle of autonomy. Most of the time, telling a “white” lie is a way out, as witnessed in Fan’s (2004) study of Chinese society mentioned earlier. Furthermore, it is well worth noting that the patients have the right to request the doctors to keep the di-2 Definitions of each principle are referred to http://www.nationmaster.com/encyclopedia/Medical-ethics (October 5, 2005)

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agnosis in secret from the family. Oddly, the principle of justice also appears in this dilemma, for example in a case of a transplant patient. The doctor can either tell the patient that there is a very low chance of finding a suitable donor, or that there are other patients who need the transplant more than he or she does. Otherwise, the doctor could withhold that information from the patient3.

Thus, the dilemmas lie within what the physicians should do: hold on to the universal ethical values, such as beneficence and respecting the patient’s autonomy, or respect the pluralism of different cultures and ‘bend’ the rules accordingly.

1.2 Research InquiriesThe information relayed above leaves several gaps in relation, more specifi-cally, to medical students’ attitudes towards truth telling, namely:

These sub-questions all lead to one main concise research inquiry statement, guiding the content and presentation of the thesis, that is:

Whatconstitutestruthtellinginpatientdiagnosis/prognosis fromthemedicalstudents’perspectives?

3 A case example from Pamela Amulaku, a Red Cross/Youth HIV/AIDS volunteer

Whatarethedifferencesinperceptionsoftruthtellingamongmedical students with different cultural backgrounds?

How do patients’ cultural and religious backgrounds play a roleintruthtelling?

Whatarethegroundsofwhetherornotpatientsshouldbein-formedabouttheirfataldiseasesaccordingtomedicalstudents(as decision makers)?

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1.3 Research Objectives and Scope of the StudyThe study aims to explore medical students’ perspectives on and attitudes towards truth telling in medical practice, and to investigate the influences of cultures and religions on shaping these perceptions. The ultimate goal is to understand truth telling from different cultural perspectives. It should be noted that evaluating which theory is best is not the aim of this thesis, rather the researchers will apply theories as tools to clarify possibilities of per-ceiving truth telling differently. In this respect, theoretical considerations, where applicable, will be centrally incorporated into the interview results as justifications and for the researchers’ academic learning purposes.

Although previous studies have already been conducted within the same topic area, most were carried out by means of questionnaire surveys and concentrated only on the experienced physicians rather than medical stu-dents. In order to provide alternative and broader knowledge in the investi-gated area, this study intends to approach medical students who are study-ing to become doctors, as well as young doctors who have only a few years of clinical experience; as an old adage says “a young mind not yet affected by experience.” Presumably, interviews with medical students will manifest the influences of cultures and religions in shaping their attitudes towards truth telling, not yet swayed by full-fledged medical skill.

Following the qualitative research method, this study is unique from its predecessors in approach and thus will not merely produce the same re-sults as would have done by quantitative approach. In qualitative analysis, the participants do not represent entire cultural groups. Therefore, gener-alizability per se should not be expected, rather, the qualitative approach allows for much deeper and genuine understanding of attitudes towards truth telling in medical practice.

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1.4 An Overview of Theories and MethodologyFour ethical theories: Kant’s Ethics of Duty, Utilitarianism, Virtue Ethics, and Moral Relativism will be applied in this thesis. Kant’s Ethics of Duty aims to capture ethics at a universal level and provide justifications for “acting as duty requires.” The principle of Utilitarianism lays emphasis on both the ‘ends’ (the primary goal) of actions and the additional, or second-ary consequences occurring after actions have been demonstrated. Virtue Ethics, unlike the first two theories, stresses the underlying “virtues” of an agent and focuses on what makes a good person, rather than what makes a good action. Finally, Moral Relativism emphasizes ethical values that are relative to various individuals’ or societies’ thoughts.

Like the metaphoric statement says: “truth is relative,” and these ethical theories will be used as tools in the discussions around truth telling to pro-vide alternatives in perceiving ethics from different aspects. In order to un-derstand truth telling from different cultural contexts, Hofstede’s Cultural Dimension Index will also be applied in the analysis and discussion of the interview results. Although Hofstede’s Cultural Dimension Index has been perpetually criticized, the researchers find that his extensive cultural stud-ies cover all countries that are represented in this thesis and are therefore worth closer analysis. Moreover, there seems not to be another such thor-ough study that incorporates cultural dimensions into a medical context. The researchers bear in mind Hofstede’s known limitations, but maintain a strong belief that using his Cultural Index coupled with the four ethical theories and extensive literature on this investigated topic will yield fruitful results.

Regarding the methodological approach, an in-depth interview featuring open-ended interview questions will be conducted with medical students who are studying to become doctors, or may have some years of clinical

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experience. The participants hail from different ethnic backgrounds, and in-clude Danes, Afghan, Finns, Thais, Chinese, and Singaporean. The intend-ed number of the participants will be around ten. However, the proposed sampling method depends on the availability of the participants. Due to geographical constraints, some foreign participants will be interviewed by a Skype4 call via the Internet. All interviews will be audio-recorded and transcribed verbatim.

1.5 Chapter OverviewsThe second chapter following this introduction will provide the methodol-ogy employed throughout the study, with primary focus on the interview-ing methods used. Empirical data will be collected by means of qualitative interviews with medical students, from Denmark, Finland, Thailand, Chi-na, and Singapore. To provide a variety of cultural differentiation, medical students of non-Danish ethnic backgrounds studying in the Danish medical schools will also be invited to participate in the interviews.

To aid in the interpretation of the problem outlined above, the third chapter will present four theories of ethics. Over the course of the third chapter, four main concepts of perceiving ethics will be defined and elaborated upon.

In the fourth chapter, the Analysis will present empirical data from the in-terviews as well as highlight similarities and discrepancies amongst the perceptions of the ten participants. Finally, major findings will be deduced in the fifth chapter, the Conclusion, offering answers to the core research inquiry. The conclusion will as well offer some critiques of the results and speculations on future directions of study and practice in the same topic area.

4 Skype is an Internet based telephone connection that allows you to call all over the world at local telephone rates.

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chapter 1

chapter 3

chapter 5

chapter 4

This chapter contains the following:

The Social Contructivism ApproachThe Semi-structured InterviewThe Participant’s Background

•••

Methodologychapter 2

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2 MethodologyThis chapter starts with an elaboration on two contrasting metaphors for the interviewer, the “traveller” and the “miner” as construed by Kvale (1996). The purposes of this chapter are: first, to pinpoint how the role of the in-terviewer as “traveller” benefits data collection. Second, to briefly introduce social constructivism for a better grasp on the themes derived from inter-views. Last but not least, to substantiate the rationale behind the selected re-search method by thoroughly explaining semi-structured interviews, data collection process, and sampling procedures.

2.1 The Traveller vs. The MinerKvale (ibid) describes the different roles of the interviewer as “miner” and “traveller,” depending on methods of data collection and his or her theoreti-cal understanding of interviews. The first metaphor, of the “miner,” compre-hends knowledge as a valuable metal buried in the ground, and the inter-viewer as a miner who digs up this valuable metal. Some miners are digging for objective facts to be quantified, and others seek nuggets of important meaning, as Kvale puts it: “The interviewer digs nuggets of data or meanings out of a subject’s pure experiences, unpolluted by any leading questions.” (ibid).

The second metaphor called the “traveller,” illustrates the interviewer as a traveller on a journey collecting a story to be told upon returning home. The traveller explores the landscape of a foreign territory and enters into conversations with the people he or she encounters. The traveller investi-gates the many unknown areas of the country without restraints or maps. The traveller may deliberately look for specific sites or topics by following a method in order to accomplish his or her quest. In short, “the interviewer wanders along with the local inhabitants, asks questions that lead the subjects to tell their own stories of their lived world […]” (ibid). Importantly, Kvale further

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Chapter 2 - Methodology

explains that any traveller’s understanding of meanings in the original sto-ries are differentiated and disclosed through his or her subjective interpre-tations (ibid).

Both the traveller and the miner share the same goal: to search for valu-able information that enriches his or her understanding of the investigated subject. However, despite their common goal, the method employed in col-lecting data is different. The miner seeks to use quantified data that is not contaminated by the researcher’s own personal experiences and cultural background, whereas the traveller narrates the data qualitatively and accepts that his or her personal experiences may influence how factual information is interpreted. The traveller, therefore, reports the findings in accordance to his or her own [subjective] point of view.

Preferring the traveller’s point of view, the researchers of this project put forth their arguments for adopting the traveller’s method this way: on the one hand, one could undermine the truthfulness of interview findings by casting doubts on subjective interpretation. On the other hand, however, interpreting people’s life-experiences “creatively” (or “subjectively,” as some quantitative researchers may say) can generate knowledge that has not yet been introduced, or is merely taken for granted in the researchers’ society. Furthermore, the expressed goal of this project is to understand the mean-ings of truth telling from different perceptions that are considered subjec-tive meanings by nature. Thus, instead of seeking for objective data and sin-gling out subjectivity, the focus is shifted towards how to pose the interview questions that elicit truth and how to creatively interpret data that benefits the researchers’ (and by extension, their research communities) theoretical understanding.

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2.2 Social ConstructivismSocial constructivism holds the assumption that individuals seek under-standing of the world where they live and work. Therefore, they develop subjective meanings of their experiences, and associate the meanings with certain objects. According to Cresswell (2003), these meanings “are varied and multiple, leading the researcher to look for the complexity of views […]” (ibid). In order to capture the meanings of individuals’ experiences, social-science researchers strive to rely as much as possible on the participants’ own views of the situation that is being studied.

In an endeavour to obtain precise answers to their research inquiry, the re-searchers apply a concept of social constructivism with the interview meth-od and interpretation of data primarily because it enables both interviewers and participants to contemplate and co-construct the meanings of truth tell-ing. These meanings, according to Cresswell (ibid) are not simply imprinted on individuals, but are shaped through interaction with others, historical, and cultural norms that operate in individuals’ lives (ibid).

In conclusion, the role of the interviewer as the traveller and the social con-structivist approach share common assets that the researchers of this project are determined to follow. As mentioned earlier, the medical students’ per-ceptions of truth telling are constructed by their interactions with others in their societies, presumably with people of similar culture, values, and belief systems. Their perceptions are to be investigated, interpreted, and re-counted into new knowledge that perhaps uncovers some values taken for granted in the researchers’ society. The social constructivist approach aids the researchers to make sense of arguments and themes emerging from the medical students’ views on truth telling and the ethics related to this par-ticular subject. Findings from the interviews are qualitative by nature and thus yearn for the synthesis of these two particular approaches.

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2.3 The Semi-Structured InterviewThe purposes of the semi-structured interview are to allow the researchers to ask questions systematically and consistently, and yet maintain a flexible questioning sequence and format so as to capture the natural flow of the participants (Kvale, 1996:124). The semi-structured interview consists of the interview guide (see appendix 1 and 2 for a list of the interview questions) and the process of data collection as described below:

2.3.1TheInterviewGuideThe interview guide provides a frame on which the interviews shall be con-ducted. It contains two sets of questions: “research questions” and “interview questions”:

Research questions serve as a thematic foundation for the researchers to then build on theoretical concepts to investigate the issues and to analyze interview results. Interview questions are formulated in a conversational language in order to increase free-flowing dialogues and open dynamics of the relationship between the researchers and the participants during the interviews.

2.3.2DataCollectionProcessThe interviews systematically follow seven steps as illustrated in table 2.1.

The process of interviewing is inspired by Kvale’s seven stages of interview research. The detailed processes are more thoroughly narrated as follows:

Step 1: Thematizing: An interview theme was based on the researchers’ good grasp of previous qualitative interviews, coupled with the theoretical framework presented in chapter 3. The researchers conducted preliminary research on studies about medical ethics that focus on ethical morality and

Step1

Thematizing: The researchers formulated the topic by: First data collection:

• Conduct preliminary research on truth telling by collecting secondary data from a body of literature and;• Identify general questions and topics of interest• Find potential research areas

Step2 Designing:Designing the interview questions that will obtain the intended knowledge

Step3

Interviewing: Second data collection: Pilot interview with the first medical student

• Pilot the interview questions• Identify necessary improvements• Adjust/reformulate questions if necessary

Third data collection: Interviews with the remaining medical students

Step4 Transcribing: Transcribe the interviews verbatim

Step5Analyzing: Data processing and analysis

• Discover themes• Identify common/different themes (perceptions) existing amongst the medical students

Step6 Verifying: Verify the findings of the interviews

Step7 Reportthefindings

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attitudes towards truth telling of medical professionals. Later on, the re-searchers identified problematic areas and conceptualized research ques-tions.

Step2:Designing: This step involved the design of procedures for sam-pling and data collection. This study sampled ten medical students from different cultural and religious backgrounds. The participants were recruit-ed through random sampling. That is, the researchers sent out requests to potential participants (who are friends or colleagues of people related to the researchers) introducing the thesis topic and explaining reasons for the interviews. The interview questions were sent to the participants who ex-

Step1

Thematizing: The researchers formulated the topic by: First data collection:

• Conduct preliminary research on truth telling by collecting secondary data from a body of literature and;• Identify general questions and topics of interest• Find potential research areas

Step2 Designing:Designing the interview questions that will obtain the intended knowledge

Step3

Interviewing: Second data collection: Pilot interview with the first medical student

• Pilot the interview questions• Identify necessary improvements• Adjust/reformulate questions if necessary

Third data collection: Interviews with the remaining medical students

Step4 Transcribing: Transcribe the interviews verbatim

Step5Analyzing: Data processing and analysis

• Discover themes• Identify common/different themes (perceptions) existing amongst the medical students

Step6 Verifying: Verify the findings of the interviews

Step7 Reportthefindings

Table2.1DataCollectionProcess

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pressed interest in participating. It is worth noting that some potential par-ticipants withdrew their participation after reading the interview questions and unfortunately, there was no clear explanation for this. Presumably, the interview questions may have seemed too long and the interview prepara-tion too time-consuming.

All the interviews were conducted in English, including the interviews with the Danish and Thai participants. This fact may also prevent some people from taking part in this research because they did not feel comfortable be-ing interviewed in other languages than their mother tongue.

The criteria in selecting the participants were based on theoretical concepts: a diversity of participants from six cultural and ethnic backgrounds (Finn-ish, Danish, Afghan, Thai, Singaporean, and Chinese). An assumption be-hind this sampling is that the participants should reflect a diversity of at-titudes towards truth telling.

Step3:Interviewing: In this study, the researchers first conducted a pilot interview (see appendix 4) in order to test the interview questions for clar-ity and organization. The pilot interview was carried out with a medical student from Finland. The pilot interview followed the interview guide for the purposes of testing the precision and logical sequence of the questions. However, the interview questions were designed to be flexible enough to catch up with the participant’s responses. In the subsequent interviews, some questions were reformulated and fine-tuned in order to make them more concise and specific. Each interview was set to take roughly thirty minutes and was audio recorded.

Step4:Transcribing: All interviews were transcribed verbatim. The code “I” stands for the interviewers and “P” stands for the participants. Empty parentheses ( ) indicate the transcribers’ difficulty to hear what was said,

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due to bad telephone connection. Parentheses containing one or more words indicate words that the transcribers thought to be said despite lack of audio clarity. Underscoring “___” indicates some form of stress or emphasized statements. An equal sign “=”, one at the end of a line and one at the begin-ning, indicate interruptions in the dialogues. (See appendix 3 for transcrip-tion symbols).

All of the interviews were conducted in English although none of the par-ticipants were native English speakers. Therefore, the transcriptions in-cludedsomeoftheparticipants’ownphrasingandgrammaticalerrors.The researchers of this project chose to do this in order to stay as close as possible to the original meanings and thus avoid misunderstandings that may occur during translations. When necessary, the researchers attempted to explain what is being said in those quotations deemed to be unclear.

Step5:Analyzing:The interview results were analyzed according to their applicability to the ethical theories presented in this project. The analysis method follows the three approaches proposed by Kvale (1996): “Meaning Condensation, Categorization, and Meaning Interpretation.” That is, attention was placed on key words and these words were categorized into groups. In order to generate a more precise meaning of the key terminologies, the researchers divided the groups according to common values, and assigned a theme for each group.

For example, a theme called “virtues” consists of the attributes of “good” doctor qualities (such as, truthfulness, respectfulness, honesty, consider-ation, and compassion). When the meaning of any term was unclear, the researchers reiterated the questions or let the participant describe or give examples of what he or she actually meant. The same technique was also employed for other themes, such as a theme identified as “medical law” in-

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cluding points derived from the participants’ perceptions of truth telling from the perspective of a legal commitment that the doctor ought to reveal the truth to the patient to maintain his professional credibility. Another the-matic example “patient autonomy,” was for the most part composed of val-ues interpreted from the participants’ concerns about informed consent and individual rights when telling the truth to patients.

Furthermore, the meaning of the theme “doctors’s perception on patients from other cultures” was categorized from the participants’ reflections on manifes-tations of the patient’s cultural background, such as when his or her family demands the truth to be (or not to be) unfolded. Under the last two themes: “long term consequences” and “good intention,” the researchers gathered all pieces of information particularly relevant to justifications for revealing (or withholding) truth to (from) the patient.

Step6:Verifying: Although results of the interviews were limited and in terms of generalizability, the researchers tried their best to verify the results in order to meet with the criteria of qualitative research. Comparisons be-tween the interview results and studies about ethics and truth telling were presented afterwards in order to validate the findings.

Step7:Reporting: The researchers were aware that the final results should be as accurate and corresponding to the participants’ answers as possible. They presented the analysis with their utmost sincerity, striving to maintain openness and flexibility throughout the interview so as to adhere to the ad-vantages of qualitative interviews.

2.3.3TerminologyVerification: In qualitative research verification revolves around three con-cepts: “generalizability, reliability, and validity.” These concepts are elaborated in relation to quantitative research and are often used to refute the credibil-

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ity of qualitative methods.

Generalizability:Silverman (2005) has successfully answered how gener-alizability can be obtained in qualitative methods. One of his explanations is “purposive sampling” guided by time and resources. Purposive sampling demands that we think critically about the parameters of the population we are studying and choose our sample cases carefully on this basis (ibid). All participants are purposely invited to participate in the interview. This sam-pling choice significantly relies on the basis of theoretical framework, on the assumption that differences in perceptions towards truth telling are directly connected to the values and norms of a particular culture.

Reliability: Reliability refers to the consistency of findings. The interview-ers achieve this virtue by pre-testing the interview questions as designed in the interview guide, and by making the interview settings as similar to each other as possible. In other words, the reliability of the interview findings is addressed through standardized methods of interviews and transcriptions. Furthermore, all interviews are to be audio-recorded and transcribed me-ticulously; thereby open to further inspection by other researchers and the readers.

Validity: Validity is meant to demonstrate the “truthfulness” of findings. The truthfulness of interview results is determined by triangulation: comparing the interview findings with theories on the one hand, and on the other hand with other scientific works on the same subject area. With this in mind, the interview results (especially the case scenario) will be compared with the studies of Fan (2000), in chapter 4.

2.3.4ThePilotInterview The pilot interview allows researchers to test the interview process, have a trial interaction between the two parties (interviews and participants), prac-

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tice observation skills and interview techniques, and clarify their interview questions. The pilot interview of this study was conducted with a medical student from Finland who has not yet gained much practical experience but has attended ethical classes about truth telling during his medical educa-tion. This first participant received the interview questions a few days before his actual interview. In the subsequent interviews, the researchers decided to follow this procedure, sending the questions out prior to actual interviews to help the participant prepare his or her answers, as well as to familiarize him or herself with the subject. The interview was later conducted via the Internet by using Skype due to the geographical distance between the inter-viewers and the participants. This also allowed the researchers of this proj-ect to determine what method would be the most practical and would pro-duce the best quality of sound. The participant was first informed about the purpose of the study and how his contribution would benefit the research. The interview lasted for approximately half an hour. Due to technical prob-lems with the Skype connection, a minor interruption made it necessary to switch from the Internet telephone to normal telephone connection.

To a great extent, the pilot interview followed the pre-set sequence of inter-view questions. However, some improvements and changes were rendered necessary for the interviews that followed as illustrated below:

a) The clarity of the interview questionsSome questions needed to be reformulated in a more concise and specific way to enhance participants’ understanding. For example, in the subse-quent interviews, the question about telling “white” lie to the patient was made clear by first asking the participant to define a “white” lie. Adding this question was a good way to elicit any variations in comprehension accord-ing to the participant’s cultural background.

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Furthermore, when the pilot interview reached the stage of the case scenar-io, the participant first seemed not to be aware that the case was part of the interview, even though it was attached to the interview questions. There-fore, the researchers had to more explicitly inform the participants when sending out the questions that the case was also a part of the interview.

b) Breaks during the interviewThe pilot interview took place without any breaks, except for the unin-tended break due to technical difficulties. Both parties concentrated on the conversation and thus decided to go through the interview without any further interruptions. Since the interviews were conducted via the Internet telephone, having a break might not be necessary unless the participants request to do so.

c) Questions to be added in the subsequent interviewsAfter the pilot interview, the researchers added two more questions:

(i) “What is ethical behavior in your opinion?” This question acts as um-brella question to help the participants create an overall picture of perceptions of ethical behavior. Later on, the researchers posed a follow-up question about ethical behavior, especially pertinent to telling the truth.

(ii) “What is a “white” lie?” Apparently, this question was a rather provocative for some participants. However, the intention of pos-ing this question was to hear the participants’ opinions on telling a so-called “white” lie as definitions are varied depending on each person’s concepts of lie and truth. In a medical context, some doc-tors use a “white” lie in certain situations and for various purpos-es. The participants provided justifications for this act and their answers included professional condition, religious perspective, and personal point of view towards this question.

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Put succinctly, the pilot interview went smoothly although some small im-provements in the interview questions were determined to be necessary as well some technical difficulties needed to be rectified.

2.3.5TheInterviewSituationsThe majority of the interviews took place by using Skype calls. The research-ers were based in Copenhagen and this method, therefore, proved a neces-sity under the geographical circumstances. The Skype method of conduct-ing telephone interviews presented both advantages and disadvantages. For example, calling did not allow the researchers to observe the participant’s body language during the interviews. Obviously, the interviewers had no chance to notice non-verbally whether the participant clearly understood the questions or concentrated closely on the conversations. However, the positive side of this method was that the participants might have felt more comfortable expressing their responses without being interviewed in-per-son, especially those participants preferring a less obtrusive approach.

Another advantage of the process used was that sending out the questions in written form in advance of the interview gave the participants an oppor-tunity to have extra time to digest the questions and formulate thorough re-sponses if so desired. Finally this method allowed the researchers to include participants from countries far away, who would have been significantly more difficult to get in touch with otherwise.

Besides the eight interviews conducted via Skype, one interview was con-ducted face-to-face with a participant. The participant from Singapore did not want to participate in the interview but wanted to contribute her experi-ences with truth telling; therefore, she sent her responses to the interview questions via e-mail. Unfortunately, this did not allow the researchers to request elaboration on her answers. The researchers will only refer to the

33


source and not the specific line number when the Singaporean participant is quoted in the analysis.

2.3.6LimitationsSince none of the participants are native English speakers, save the Singa-porean participant, they might have felt that language was a barrier to ex-pressing themselves. However, the researchers wished to conduct all inter-views in English in order to avoid misinterpretation. It is also noteworthy that a few students did not want to participate in the interviews because of language barrier.

Another research constraint prohibiting the researchers from allowing in-terviews to be done in other languages (such as Danish and Thai) and then translated into English was that the researchers were not professional trans-lators. This constraint would make it difficult for the researchers to correctly translate the interviews yet keep their original meanings.

Another stumbling block in recruiting participants for the interview was that the topic of truth telling might be perceived as controversial. Some medical professionals (and medical students) may consider that truth tell-ing depends on an individual case-by-case basis. Therefore, they might not be able to properly justify their reasoning in limited time, especially for the case scenario attached to the interview questions (see appendix 1 and 2). Some of the participants even mentioned that the case scenario was indeed difficult to answer even though they received it well in advance.

Furthermore, truth telling in a medical context is believed to be a sensitive area, since it involves the lives and futures of terminally ill patients, as well as their family members. Therefore, the researchers cannot be completely assured that what the participants said in the interviews would correspond with what they actually do when confronted with difficult situations of truth telling.

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2.4 Participant’s BackgroundIn order to provide the readers with an overview of the participants’ back-grounds, a brief profile of each participant is presented in Table 2.2. This ta-ble also exhibits how each participant was recruited for the interview. Some of them are already licensed doctors, but currently still studying to become more specialized in a certain field of medicine. Those participants will be called “medical student/doctor.” If they are studying to become a doctor and yet to have direct clinical experience, they will be called “medical student.”

Apparently, the Danish/Afghan participant’s religious background has an influence on his perspectives towards ethics, as clearly stated in the begin-ning of his interview. Religious conventions of other participants; however, did not have significant impact on their perceptions (at least none of them mentioned about their religion except the Danish/Afghan). Therefore, the researchers decided not to focus on this variable.

Participant Gender Background Recruitedthrough...Finnish 1 (Med. student) Male Beginning of education, no clinical

practice.…colleague of one of the resear-chers

Finnish 2 (Doc-tor) Male Full-time doctor. …colleague of one of the resear-

chersThai 1 (Med. student/doctor) Male Graduated 6 years ago, however still

studying to specialize. …friend of one of the researchers

Thai 2 (Med. student/doctor) Male Graduated 6 years ago, however still


Thai 3 (Med. student/doctor) Female Graduated 7 years ago, however still


Singaporean 1 (Med. student) Female Has clinical practice in the wards for

2 years as a medical student.…colleague of one of the resear-chers

Chinese 1 (Med. student/doctor)

FemaleSome years of clinical experience, however studying in Denmark to specialize.

…colleague of one of the resear-chers

Danish/Afghan 1 (Med. stu-dent/doctor)

Male

Born and raised in Denmark, but his family is originally from Afghani-stan. He practices Islam. Working as a doctor for 1½ year.

…friend of one of the researchers

Danish 2 (Med. student) Female One year left before graduation …friend of the researchers

Danish 3 (Med. student) Male One year and a half left before grad-

uation …friend of one of the researchers

35


Participant Gender Background Recruitedthrough...Finnish 1 (Med. student) Male Beginning of education, no clinical

practice.…colleague of one of the resear-chers

Finnish 2 (Doc-tor) Male Full-time doctor. …colleague of one of the resear-

chersThai 1 (Med. student/doctor) Male Graduated 6 years ago, however still


Thai 2 (Med. student/doctor) Male Graduated 6 years ago, however still


Thai 3 (Med. student/doctor) Female Graduated 7 years ago, however still


Singaporean 1 (Med. student) Female Has clinical practice in the wards for

2 years as a medical student.…colleague of one of the resear-chers

Chinese 1 (Med. student/doctor)

FemaleSome years of clinical experience, however studying in Denmark to specialize.

…colleague of one of the resear-chers

Danish/Afghan 1 (Med. stu-dent/doctor)

Male

Born and raised in Denmark, but his family is originally from Afghani-stan. He practices Islam. Working as a doctor for 1½ year.

…friend of one of the researchers

Danish 2 (Med. student) Female One year left before graduation …friend of the researchers

Danish 3 (Med. student) Male One year and a half left before grad-

uation …friend of one of the researchers

Table2.2Participants’Background and howtheywererecruited

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3 Theoretical Framework

chapter 1

chapter 5

chapter 4

chapter 2

Theory

chapter 3

This chapter contains the following:

Chapter ObjectiveA Rationale behind the Selected TheoriesA Categorization of the Moral TheoriesA Presentation of UtilitarianismA Presentation of Kant’s Ethics of DutyA Presentation of Virtue EthicsA Presentation of Moral Relativism

•••••••

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3 Theoretical Framework

3.1 Chapter ObjectiveThe purpose of this chapter is to present theoretical concepts relevant to truth telling in medicine, later to be applied to the analysis of empirical study from the interviews with medical students. In this chapter, four ethi-cal schools are presented, namely: Utilitarianism, Kant’s Ethics of Duty, Virtue Ethics, and Moral Relativism. The contents, discussions, and arguments for/against each theoretical tenet are based on a body of literature on philoso-phy of ethics as well as more specific works concerning medical ethics, with primary inspiration from MacKinnon (2001) and Hatab (2000). The reason for applying these two sources as major literature is because of their exten-sive studies that combine together ethics and medicine.

This theory chapter starts with an introduction of ethical theories. Later on, the second section gives an overview of cultural impacts on the physician-patient relationship as perceived in different cultural contexts. This section supplements Moral Relativism, in particular, in that the relationship between physicians and patients is determined by a variety of variables including the values, beliefs, and traditions of each culture. It is impossible to say that customs of one culture are any more right or wrong than another, in much the same way as a metaphoric statement says: “truth is relative.” Finally, the last section proposes some potential applications of these ethical theories to empirical data collected from the interviews.

3.2 Rationale Behind Selected TheoriesUtilitarianism, Kant’s Ethics of Duty, Virtue Ethics, and Moral Relativism are used as a theoretical framework based on the following grounds:

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Firstly, these theories capture four basic characteristics that mark modern ethical philosophy. The four characteristics, according to Hatab (2000), are (1) foundational, in claiming to find a unified explanation of what is mor-al and immoral; (2) decisive, in that the theoretical foundation supplies a decision-making procedure for a person to arrive at moral judgments; (3) action-guiding, in that these theories are confined mostly to rules and prin-ciples for justifying morality and providing guidance to a moral agent; and (4) subject-based, in that moral analyses are centered in the human subject and its decisions (ibid). More importantly, Utilitarianism and Kant’s Ethics of Duty are two of the most discussed theories in modern philosophical lit-erature. These two theories have had a deep impact on areas besides moral philosophy, for example in business ethics, health ethics, and last but not least medical ethics (Nyeng, 2000:33).

Secondly, the viewpoints of both ethics of duty and ethics of consequences naturally harmonize with medical ethics. That is, the desired consequences of medicine are to fight illnesses and to reduce suffering. However, at the same time the ethics of duty are indispensable, as being a doctor is to bear great responsibility and duty to save people’s lives. The realm of medical ethics inputs ethical contributions from both sides of duty and consequenc-es (Tranøy, 2005). The need for goal-oriented principles in medicine is crys-tal clear: to achieve what is best for the patients (ibid).

Lastly, “standards” of truths and lies are far more sensitive in medical ethics than in any other kind of ethics (ibid). This statement is commensurate with Moral Relativism. There are situations in medicine, just as in other walks of life, where information may be withheld but for good reasons (Higgs, 2001:436). When considering what brings “the best” for patients, lying can occasionally, be considered morally correct. A “white” lie is an example: tell-ing a “white” lie is not to delude the patient, but to make a judgment as to what might keep up the patient’s hopes. However, some justifications lurk-

39


ing behind “white” lies are too crucial to be abandoned, because in many countries lying to the patient is illegal according to laws of patients’ rights. Consequently, current evidence shows that withholding the truth was more common in earlier years than it is today (Tranøy, 2005:65). Nevertheless, the trend of withholding news to patients is still observed among Norwegian practitioners and depicted in laws and regulations of Norwegian medicine.In other cultures, telling a “white” lie may in fact still be a valid justification for some doctors, as noted by Higgs (2001:438) that in some countries “kind-ness” may be valued much more highly than “truthfulness.” For instance in China, medical ethics (even today), in both theory and in practice remain committed to hiding the truth as well as to lying when necessary to obtain the family’s view of the best interest of the patient. However, this procedure requires that the physician must inform a close member of the patient’s fam-ily, and then it is up to this relative to decide whether and how to tell the truth to the patient (Fan et al., 2004, Fan, 2000).

All in all, it is apparent that one selected theory supplements another, e.g. “Thou shall not lie” is one area Kant’s Ethics of Duty touches upon that is also deemed as a good virtue (Virtue Ethics). However, lying (to the patient) is not always morally considered an act of immorality if it may ultimately cre-ate greater benefit than harm (Utilitarianism). Yet doctors need caveats to rationalize their decisions, and such conditions coincide with various indi-viduals or societies’ thoughts (Moral Relativism).

3.3 Categorization of Moral TheoriesThere are two main streams of moral philosophy, “teleological” and “deonto-logical” ethics. The teleological theories ascertain the ethics of an act by look-ing on the likely outcome or consequences of a decision (the ends), which is why these theories are also named “consequentialist” moral theories. The term teleological derives from the Greek root “telos,” which means goal or

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end (Hartman, 2005:6 and MacKinnon, 2001:10). An example of a teleologi-cal or consequentialist theory is the Utilitarian theory.

On the other hand, deontological theories determine the ethics of an act by looking on the process of the decision (the means) (Hartman, 2005:6). Deon-tological theories are also called “non-consequentialist” moral theories. The term deontological originates from the Greek root “deon,” meaning duty (MacKinnon, 2001:10). Kant’s Ethics of Duty is the most discussed of the deontological theories.

Despite these two categorizations, making an objective classification of moral theories is rather difficult. For example, Aristotle’s Virtue Ethics can be classified in teleological ethics, where the contemporary Utilitarianism is included in a sub-category of teleological ethics. However, it is just as cor-rect to put virtue ethics in its own category, where the focus cuts across a distinguished line between consequentialism and ethics of duty. Thus, it is difficult to label each ethical theory, also because a particular way of think-ing in one theory may well include some aspects from another theory. An accurate and exhaustive classification is therefore an illusion. There are no absolute confirmed classifications of ethical theories, only comparatively appropriate distinctions (Nyeng, 2000:32).

3.4 UtilitarianismUtilitarianism:AnOverviewThe basic principle of Utilitarianism is called “the principle of utility” or “the greatest happiness principle.” In the early eighteenth century, the classic form of this theory was founded by Jeremy Bentham and John Stuart Mill and further elaborated by contemporary Utilitarian philosophers. Utilitarianism is often called “consequentialism,” in that the “right” thing to do is what pro-duces the best consequences for the greatest number of people. For Utilitari-anists, the best consequence for the human being is happiness, or the utility

41


of what maximizes pleasure and minimizes pain (Hatab, 2000:52). MacKin-non (2001) describes the best moral alternative according to the principle of utility as:

“[…] that which produces the greatest (or greater) net util-ity, where utility is defined in terms of happiness or pleasure.” More concisely, the underlying sentiment of Utilitarianism is that: “we ought to do that which produces the greatest amount of happiness for the greatest number of people” (MacKinnon, 2001:49).

The theory of Utilitarianism was originally geared towards public policy questions. In considering the inauguration of an action or policy, a Utilitar-ian must weigh the utility for all persons concerned and do what produces more happiness for the whole, rather than implement other alternatives. Subsequent versions of Utilitarianism have tended to define happiness in broader and richer ways than simply as the presence of pleasure and the absence of pain. In any case, the theory operates by way of quantifying units of utility and then calculating the totality that will provide a measure of right and wrong actions (Hatab, 2000:53).

3.4.1UnderstandingUtilitarianismTo start with, understanding the basics of John Stuart Mill’s principle of utility is necessary. Mill tries to create a principle uniting individual eth-ics with social ethics. In other words, Mill’s concept of utility is valid for people whose decisions have consequences for the lives of a large number of people, a good example of such people being politicians. However, in re-ality, the majority of all actions are steered by the desire to secure happiness for a limited group of people. With this claim, Mill complies with some of the prejudice against the concept of happiness maximization, namely; how does a person actually know how many people will be affected by their ac-tion? Mill claims that one should only take into consideration what one can

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cope with (Andersen, 2003:207pp). That is, one should not bear a responsi-bility for all people, but one ought to consider people who are affected by one’s act.

This principle of Utilitarianism lays emphasis on both the ends (the goal) of actions and the additional (and perhaps unintended) consequences occur-ring after actions have been demonstrated. In other words, a person ought to choose which action or practice is morally best by first considering all possible or actual consequences of his or her actions. Some philosophers call Utilitarianism as “universalistic” because it deals with the happiness or pleasure of all who are affected by an action or practice. Every person af-fected by such actions is to be counted equally, i.e. so our own happiness counts no more than that of others.

In order to calculate the greatest amount of happiness, many more elements must be determined than merely counting the number of people affected by an action. Therefore, Utilitarian thinkers devise that the greatest amount of happiness includes the following five elements: the net amount of pleasure or happiness, its intensity, its duration, its fruitfulness, and the likelihood of any act to produce it (MacKinnon, 2001:51).

The net amount of pleasure or happiness is to be gathered from almost all chosen alternatives that produce unhappiness and pain, and conversely happiness or pleasure for one and for others, as appears in John Stuart Mill’s quotation:

“[…] actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of hap-piness” (Mill in Andersen 2003:206).

Fundamentally and intuitively speaking, pain is bad and pleasure is good.

43


However, some minor acts that cause pain may be acceptable, in the event that they produce more overall pleasure than pain. For example, if painful effects of a punishment ultimately serve to prevent an unwanted action, then the punishment is acceptable, just as long as it hopefully produces happiness and pleasure in the long run. In a more medical sense, this can be compared with test subjects, who on a voluntary basis and under moni-tored conditions accept to be tested with new ways of treating a disease for the better of the majority in the future.

It is worth noting that Mill does not claim that, if all persons strive to achieve the greatest happiness possible for themselves as individuals, then the re-sult will automatically be the greatest happiness possible for the greatest number of people. According to Mill, the motive or the nature of the act is irrelevant to whether the act shall be judged as being ethically right or wrong. He asserts that it is essential to distinguish between the rule of ac-tion and the motive of action (Mill in ibid: 207).

Although Mill considers utility as the ultimate governing principle for all ethical questions, he takes into consideration pleasure both in degree of “quantity” and “quality.” He equates happiness with pleasure but suggests that “some kinds of pleasure are more desirable and more valuable than others” (Lloyd, 2003:237). To explain how certain pleasures are “higher” or consid-ered more valuable than others, Mill introduces the Utilitarian equation: moral superiority, or “intensity.”

Intensity.Moments of happiness or pleasure are not uniform. Some mo-ments are more intense than others, and thereby are more desirable/plea-surable. According to the principle of Utilitarianism, if all other factors are equal, in the scenario that a person has one gift to give away to his friends, he ought to give it to the friend who will enjoy it the most. Nevertheless, distribution of “pleasure” (which is, in contemporary principle of utility, es-

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Chapter 3 - Theory

pecially concerning social welfare, described as a “resource”) seems to be one of the major problems for which Utilitarianists fail to provide answers. Another drawback emerging from Utilitarianism is who is, or even how to possibly determine what sort of pleasure or happiness is the greatest for each individual. Mill argues that it is the individuals who have tried dif-ferent kinds of pleasure and who declare that the one kind of happiness pleases the person more than the other (Andersen 2003:208). Duration.Yet another factor that influences the greatest amount of happi-ness is the duration of the pleasure. That is to say that the longer the plea-sure lasts, the more desirable. As with the intensity factor, duration raises the question of whether the actual number of people made happy counts more or less in comparison to the total amount of happiness.

Fruitfulness.The success of experiencing pleasure or happiness depends on whether it makes a single person more capable of experiencing either similar or other kinds of pleasure or happiness in the future. In other words, fruitfulness depends not only on the instant pleasure but also on long-term pleasurable results. As previously intoned, immediate pleasure may bring pain later on, and conversely immediate pain may bring more pleasure in the future and thus avoid further pain (MacKinnon, 2001:52).

Likelihood. If an individual has the opportunity to decide between two alternative actions, one must estimate the likely results of each alternative before comparing their net utility. Ultimately, one may choose the acts with lesser rather than greater advantages if the chances of it actually happening are better - both the risk factor and the ultimate degree of utility is lower.

In summary, the five elements of happiness relayed above depict some jus-tifications for not always prioritising benefits of happiness to the greater amount of people. Some arguments may have been raised against this Utili-

45


tarian approach that, in reality, one cannot simply handle morality in the same way as mathematics. Today, Utilitarianism is still very vigorous and refined theories have been developed and proposed. The clearly defined assumptions of this theory and its connection to modern statistical deci-sion-making theory makes it appealing to doctors with their educational background lying within natural sciences (Wulff, 1995:21).

3.4.2.CriticismofUtilitarianismOne of the difficulties with Utilitarianism is comparing happiness among different people. Opponents of Utilitarianism, including Kant, argue that happiness of different people is incommensurable and thus to calculate hap-piness is impossible, even in principle (Cornman et al. 1992). Additionally, Utilitarianism has been criticized for leading to a number of conclusions that contradict “common sense” morality. For example, moral common sense dictates that one should never sacrifice another human for the happiness of other people. However, capital punishment is one such case that falls under defence of Utilitarianism. Under Utilitarianism, capital punishment is justi-fied if it prevents crimes or deters the would-be criminals.

Another weakness of Utilitarianism is its focus on the end results of an act, while intention and motives for an act are meanwhile neglected. Other ethi-cal schools are tempted to interpret Utilitarian thought to mean that an ac-tion intended to cause harm, but that inadvertently causes good results, would be judged equal to the result from an action propelled by good in-tentions. Further arguments against Utilitarianism have been put forward by one of the most renowned moral philosophers, Immanuel Kant, in his Ethics of Duty theory as will be presented in the next section.

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3.5 Kant’s Ethics of DutyAnOverview:Kant’sEthicsofDutyanditsCritiquesofUtilitarianismKant’s Ethics of Duty or “moral theory” originated from the German philoso-pher Immanuel Kant who is, at present day, regarded as a central figure of modern moral philosophies5. Kant’s ethics theory is also called “non-conse-quentialism” because it critiques the Utilitarian emphasis on consequence and happiness, whether referring to an individual or a collective outcome (Hatab, 2000:53). Kant argues that what brings happiness, unhappiness, pleasure, and pain, varies between and within individuals or groups. More-over, consequence is uncertain as it is always context or situational-depen-dent. Therefore, basing ethics on consequence is unreliable and produces misleading justifications for an ethical or unethical act (ibid). Instead of evaluating consequences, Kant emphasizes an agent’s moral intentions, by posing the inquiry “What ought I do?”

3.5.1UnderstandingKant’sEthicsofDutyFirstQuestion: “What gives an act moral worth?”One way to start examining Kant’s moral philosophy is to investigate plau-sible answers to the question posed above. In contrast to the principle of Utilitarianism, Kant believes that morality should be deontological, or duty-based, independent of consequences and interests of individuals or groups.

According to Kant, if one “intends” to do what one thinks is right, one ought not to be blamed for undesirable consequences that might follow, as the consequences of a person’s acts are uncontrollable and do not always mate-rialize as originally envisioned or desired. This line of thought is reflected in the contemporary cliché: “it’s the thought that counts.” That is, a person should not be blamed for the consequences his or her acts may lead to, pro-vided that the intention is conceived under the “right” motives. Thereby, it 5 There are four main characteristics of modern moral philosophies mentioned in the beginning of this chapter. There are four main characteristics of modern moral philosophies mentioned in the beginning of this chapter.

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is the intention that has moral worth: “[…] our motives are in our control. We are responsible for our motives to do good or bad, and thus it is for this that we are held morally accountable” (MacKinnon, 2001:67). Put concisely, individuals have control over the intentions behind their actions, but not over the ulti-mate ramifications of those actions.

This ethical reasoning based on moral intentions is referred to as having a “good will.” Without promulgating the “right” intentions, intelligence, wit, and control of emotions could conceivably be used for immoral purposes: “Having a right intention is to do what is right (or what one believes to be right) just because it is right” (ibid). Even though a person’s acts might ultimately produce positive results, if he or she was motivated to act for the “wrong” reasons, the outcome will be deemed to have no moral worth. Furthermore, it is not only the motive that is essential, but also the individual’s belief sys-tem. The act itself must also be morally relevant, according to society, which in Kant’s terminology is to “act out of duty,” and act as “duty requires.” With the “right” intention to act, one may ask the next logical question.

SecondQuestion:“What is the “right” thing to do?”In order to understand Kant’s rationale behind this question, it is necessary to study the difference between what he calls a “hypothetical imperative” and a “categorical imperative.”

To begin with, an “imperative” itself is merely a certain kind of statement that directs or commands us to do something, for example, “sit down nicely” and “open the window,” as well as more morally suggestive statements such as “You ought to open the window.”

Hypothetical Imperative: Some imperatives can be categorised as hypo-thetical imperatives in that they should be done in a given scenario. They require a person to exercise his/her own will in such a way that his or her

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Chapter 3 - Theory

needs will be fulfilled. In other words, hypothetical imperatives are com-mands in conditional, or hypothetical form (Johnson, 2004). For instance, “If person A wants to hand in this project on time, A ought to start studying now.” In this case, what A “ought” to do is a process of what A wants to hap-pen (namely to finish on time) by the means necessary to achieve this (start studying now). Furthermore, A can avoid the obligation to start studying now by changing his own goals. For example, A can decide that he does not want to finish the project on time. Then A does not need to start studying now.

According to Kant, the “oughts” are contingent on what a single person wants or needs, for example to please others or to harm someone. These “oughts” are subjective and individual meaning that each individual person “ought” to do different things from others. MacKinnon (2001:69) summa-rizes the “oughts” in the following statement: “If (or because) I want X, then I ought to do Y.”

MoralObligation:In contrast with the hypothetical imperative, the “moral obligation” is a mandate on individual personal experiences, as Kant states: “If there is something I morally ought to do, I ought to do it no matter what – whether or not I want to, and whether or not it fulfils my desires and goals or is ap-proved by my society” (ibid). “Moral oughts” are not individual but universal in nature and therefore, apply to all persons. Kant defines “moral oughts” as “categorical imperatives”: “[…] because they tell us what we ought to do no matter what, under all conditions, or categorically” (ibid). Thus, in Kant’s terminology, “moral oughts” are unconditional.

CategoricalImperative: Kant shapes a principle of what is right in the cate-gorical imperative, and that in turn, dictates certain actions as universal law (Hatab, 2000:53). He conveys justifications for what is “right” and “wrong” through categorical imperative, which consists of the two formulations rel-

49


evant to this research as follows:

TheFirstFormulation:“Act only on that maxim� that you can will as a univer-sal law” (MacKinnon, 2001:69).

A maxim, by definition, is a universal law justified by a rational being who, according to Kant, can only will something that does not contradict itself. For example, a rational person must not say incongruously that it is both raining and not raining at the same time because it is either raining or not raining here right now; both options are simply not possible at the same time (MacKinnon, 2001:70). The above maxim means that, whatever one consid-ers doing must be something one can accept that everyone else would do. Kant uses false promising as an example to test whether or not a maxim is considered against the backdrop of categorical imperative. That is, if every promise is false, there will become no such thing that can be believed to be a promise. Hence, Kant would argue that false promising is morally wrong because it cannot be universalised, and is a contradiction in terms.

TheSecondFormulation: “Always treat humanity, whether in your own person or that of another, never simply as a means but always at the same time as an end” (ibid).

Morality of the second formulation is centered on “[…] what constitutes proper treatment of persons as persons” (ibid). According to Kant, “proper treat-ment” is to treat all persons as individuals maintaining their own free will and autonomy.

Kant values a person as self-directing, rational, and self-imposing (Hatab, 2000: 54), as his saying claims: humans are autonomous and thus capable

6 A well-known phrase or saying, especially one that gives a rule for sensible behaviour (Longman, Dictionary of Contemporary English, A well-known phrase or saying, especially one that gives a rule for sensible behaviour (Longman, Dictionary of Contemporary English,

1995)

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of being self-ruled (from auto meaning “self” and “nomos”, meaning “rule” or “law”) (ibid). In this sense, autonomy differentiates a person from inani-mate objects. Since a person decides how he shall achieve his own goals, he should not be treated as a means to an end. On the contrary, achievements through utilization other human beings as though they are means or “ves-sels” purely at one’s own disposal and without respecting that they have a will of their own are not appropriate because this breaches the baseline freedom of a person as rational agent (ibid).

Consequently, this formulation implies that one ought to treat others as ends and not simply as a means to achieve ones own goal. Additionally, Kant believes that a person should be treated as having “intrinsic value” (value that is worth something in and of itself), and not just as having “in-strumental value” (value that is based on usefulness for a specific purpose) because: “People are valuable in themselves, regardless of, whether they are useful or loved or valued by others” (MacKinnon, 2001:70).

3.6 Virtue EthicsVirtueEthics:AnOverviewThe tradition of Virtue Ethics derives from the moral philosophy of the an-cient Greek philosophers Aristotle and Plato. The ultimate goal of Virtue Ethics is to achieve “eudaimonia,” roughly translated to “flourishing,” that leads to a good, happy, and fulfilled life (Gardiner 2003:298). Virtue ethi-cists believe that to better explain why a person behaves morally or not, it is necessary to consider a philosophy that delves into the nature of a “moral agent.” Therefore, theoretical discussions of Virtue Ethics focus the moral agent’s character and resonate upon a human being’s emotional responses, rather than the perceived “rightness” of an action.

According to Aristotle, a person has practical wisdom to lead a good life, if

51


he or she fulfils the purpose and function of being a human. Their practical wisdom, or rationality is a unique function that sets a human apart from other living creatures (ibid). To “flourish” and to lead a good life, one has to develop positive virtues that enable one to behave well. However, it is not sufficient just to possess such virtues, a person must also know when and how to exhibit them with rationality. Therefore, in order to make “right” choices in acting well, the virtues must become integral to a person’s char-acter (ibid: 297).

The methods of Virtue Ethics are in stark contrast to the dominant methods of Kantian and Utilitarianism described above, which focus solely on guid-ing principles for actions, that allow a person to decide how to behave in any given situation.

Virtue Ethics, alternatively, focuses on what makes a good person, rather than what makes a good action. As such it is often associated with the more holistic , teleological ethical system - one that seeks to define the proper “telos” (goal or end) of the human person.

3.6.1UnderstandingVirtueEthicsIn order to understand this philosophy of virtue ethics, a brief description of the concept “virtue” is necessary. A virtue is a good character, such as honesty or loyalty. The opposite of a virtue is a vice7. MacKinnon (2001:88) describes a virtuous person as a morally “good”8 person, and virtues as the good traits such a person would represent. Under the theoretical tenets of Virtue Ethics, living a moral life is directly related to the development of a good overall character. Thus, it can be concluded that Virtue Ethics focuses on the question “What should I be?” rather than “What should I do?” Further-more, an individual has to determine his/her overarching ideals for human 7 A bad or immoral quality in someone’s character: e.g. the vice of greed (Longman, Dictionary of Contemporary English, 1995). A bad or immoral quality in someone’s character: e.g. the vice of greed (Longman, Dictionary of Contemporary English, 1995).

8 “Good” and “bad”, in this sense are subjective terms

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life and then try to embody these ideals. For example, if one considers truth-fulness to “a virtuous” ideal, one must try to become a consistently truthful person (ibid).

According to Aristotle, there are two different kinds of virtues: “intellectual virtues” and “moral virtues.” The “intellectual virtue” is the ability to under-stand, reason, and judge well. These qualities are fundamental catalysts of behaviour learned from teachers, parents, and other role models. Alterna-tively, a “moral virtue” is a characteristic encouraging a person to act well. Moral virtues are not learned through intentional or systematic teaching, but instilled through repetition. For example, by practicing truthfulness or honesty a person naturally becomes more truthful and honest in character over time (MacKinnon, 2001:89). Moral virtues are comparable to refining skills in arts or handicrafts, as Aristotle puts it:

“[…] we learn by doing them, e.g. men become builders by build-ing and lyre-players by playing the lyre; so too we become just by doing just acts, temperate by doing temperate acts, brave by doing brave acts” (Aristotle in Singer, 1994:27).

The virtue has, in other words, become habit or second nature to the per-son. The same thing happens with the opposite of virtues: vices. Vices are regulated through repetition of misbehavior. For example, a person who lies over and over again finds it increasingly easier to lie and more difficult to tell the truth. A person can have both “bad” moral habits (vices) as well as “good” moral habits (virtues). However, like ordinary bad habits, vices are difficult to change or break (MacKinnon, 2001:89).

Aristotle listed and classified a number of virtues, such as: courage, self-control, generosity, magnificence, high-mindedness, gentleness, friendli-ness, truthfulness, wittiness and modesty. He claimed that each virtue is a mean that could be construed as a level of “balance” between extremes.

Area Defect (vice) Mean (virtue) Excess (vice) fear and confidence cowardice courage recklessness pleasure and pain insensitivity self-control self-indulgence material goods stinginess generosity extravagance expenditures niggardness magnificence vulgarity deservedness pettiness high-mindedness vanity honor unambitious unnamed ambitious anger apathy gentleness short temper interrelationship grouchiness friendliness obsequiousness honesty self-depreciation trustworthiness boastfulness relaxation & amusement boorishness wittiness buffoonery shame shamelessness modesty bashfulness (Mintz, 199�:830)

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Area Defect (vice) Mean (virtue) Excess (vice) fear and confidence cowardice courage recklessness pleasure and pain insensitivity self-control self-indulgence material goods stinginess generosity extravagance expenditures niggardness magnificence vulgarity deservedness pettiness high-mindedness vanity honor unambitious unnamed ambitious anger apathy gentleness short temper interrelationship grouchiness friendliness obsequiousness honesty self-depreciation trustworthiness boastfulness relaxation & amusement boorishness wittiness buffoonery shame shamelessness modesty bashfulness (Mintz, 199�:830)

Table3.1AristoleanMoralValues

“Courage”, for example, lies between “callousness” and “indulgence” (Gar-diner, 2003:298). As such, a lack of “truthfulness” is self-depreciation, while too much is considered boastfulness (MacKinnon, 2001:89, Mintz, 1996:830). Ideally, one should be neither overly truthful nor overly untruthful. The de-gree of honesty is dependent on what that is appropriate for the individual person and for the particular circumstances he or she faces at the time. The other virtues of Aristotle’s other moral virtues are summarized in table 3.1.

3.6.2ApplyingVirtueEthicstoMedicalContextsGardiner (2003:297) incorporates Virtue Ethics into a physician’s moral de-cisions and stresses that although most moral dilemmas in medicine are an-alysed with some ethical considerations derived from Kant’s Ethics of Duty and Utilitarianism, these frameworks fail to fully address the attitudes and emotional reactions of a person. Furthermore, it is not always clear how to judge which consequences are the “best”, or most “advantageous.” To justify his arguments, Gardiner uses a classic case of the “Jehovah’s Witness”9 faith, 9 A group of r A group of religious members who insist on strict moral codes and refuse blood transfusion.


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laying out a moral dilemma when a patient requests a course of treatment that contradicts his doctor’s professional judgement.

According to Virtue Ethics, a virtuous doctor examines the facts of the case and identifies his or her emotional responses to the patient’s request sum-marized as follows:

Compassion:A compassionate doctor understands that his or her profes-sional judgment is rejected and the patient may die unnecessarily. However, if the patient is deemed competent to make decisions about his health, he is therefore competent to make decisions about his spiritual faith (ibid: 299). A compassionate doctor, thus, understands that this patient is prepared to risk death because of devotion to his faith.

Trustworthiness:The patient confides his private vulnerability to the doc-tor by disclosing his profound faith to his religion. If the doctor insists on blood transfusion, the patient will find it difficult to trust the doctor again, and may not trust the medical practice in the future (ibid).

The doctor recognizes his or her emotional attachments to the patient and decides to accept the patient’s request. The doctor’s decision may sound inhumane and what is more, contradicts with his/her medical ethics (i.e. the Hippocratic Oath) to save people’s lives. A tragic dilemma unfolded in a case such as this, however, can rarely be solved to the complete satisfaction of all parties (ibid).

It is likely that Utilitarianism would result in the doctor’s insistence to save the patient’s life, as this seems to be the best consequence one would have imagined. However, debate revolves around how to define what’s best and for whose interest. The patient demonstrates his strong and unwavering will that he does not want blood transfusion and accepts the risk of death.

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Hence, saving his life by giving blood is apparently against his will. In contrast, the Kantian system ad-heres to living by the “right” principles - believing that it is more virtuous to act well on principle of duty, even if one is not predisposed to do so (ibid: 298). There is clearly a theoretical dilemma regard-ing the nature of morally “right” principles in this case example.

3.6.3CriticismsofVirtueEthicsDespite attempts to bring forward the “good” traits of a virtuous person, Vir-tue Ethics have been criticized on the theoretical difficulty to find the nature and balance of virtues, as exemplified in the case study above. MacKinnon (2001:89) argues that a contemporary list may be both similar to and differ-ent from Aristotle’s list. For example, we could include loyalty as a virtue, as a mean between two extremes. However, is there such a thing as too much or too little loyalty? Not all virtues may rightly be thought of as a mean be-tween two extremes. Consider, justice, for example. If it was to be listed as a virtue, then could there be such a thing as being too just or too unjust?

It is also vital to note that different people, cultures and societies often have vastly different opinions on what constitutes a virtue. In an intercultural context, a virtue is subjective and can hardly be conceived in a similar man-ner. Beliefs and perceptions around virtues also tend to vary and change over the course of time. For example, Thai culture would have once consid-ered a virtuous wife to be quiet, servile, and obedient to her husband. Such notion of “wifely” virtues no longer holds true in modern Thai society.

A theory that captures the relativity of moral behaviour is thus essential. Moral Relativism consequently comes into the picture, a more widely en-compassing conceptualization that better fulfils the theoretical require-

Jehovah’s Witness

“A male patient of Jehovah’s Wit-ness faith loses a massive amount of blood. He refuses blood transfu-sions for religious reasons, but asks for alternative treatment with non-blood products and surgery. He ac-cepts the substantial risk that sur-gery without blood transfusion is much less likely to save his life than surgery with blood transfusion.”

(Gardiner, 2003:298)

Case Scenario

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ments of the project.

3.7 Moral RelativismMoral Relativism derives originally from the ancient Greek philosophers; however, the 18th century enlightenment philosopher David Hume is in several important respects, known as the father of Moral Relativism. He is famous for denying any objective standard for morality, and for suggesting that the universe is indifferent to our preferences and our troubles.

In short, Moral Relativism or “ethical relativism” emphasizes ethical values that are relative to various individuals’ or societies’ thoughts. This notion means that ethical values are a function of, or are dependent on, what indi-viduals or societies actually believe. More concisely, Moral Relativism can be described as briefly as is stated in the following citation: “According to ethical [moral] relativism, there is no objective right and wrong” (MacKinnon, 2001:24).

Moral Relativism consists of two basic yet variant perspectives. The first form is called “individual ethical relativism”- dealing with ethical judgments, beliefs, and attitudes of individual persons. According to “individual ethical relativism”, each person has his or her own ethical views and none of them are more correct or more errorneous than those of the others. The individ-ual’s distinct lens are formed through a different background of a person, explaining why he or she holds a particular attitude or view. Therefore, it is not possible to claim that the attitudes one person holds are moral or im-moral: “[…] because to do so would assume some objective standard of right and wrong against which we could judge their correctness” (ibid). Precisely, judging one’s views and attitudes is not coherent to Moral Relativism, as there exists no absolute right or wrong attitudes.

The second form of Moral Relativism is called “social” or “cultural ethical rel-

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ativism.” Cultural ethical relativism states that ethical values differ from one society to another and that the basis for moral values lies in the prevailing social or cultural views of each society. In order to decide what is “right,” a person from a specific society or culture must act in accordance to the norms of that society. Though people in a specific culture are likely to be-lieve that their culture and values are universally correct, a cultural ethical relativist knows that no culture or society’s views are necessarily better than any other. That is, the standards of moral issues are relative to unique indi-viduals and diverse societies: “[…] different individuals and different societies accept different moral beliefs or standards and thus disagree about the answers to moral questions” (Carson et al. 2001:1). Furthermore, the diversity of culture does not essentially imply that two people who disagree on the answers to a particular moral question cannot agree on their basic moral views.

“Individual ethical relativism” and “social ethical relativism” are the two ma-jor forms of ethical relativism. Nevertheless, there are some other types of ethical relativism construed under the same philosophical constructs, for example: “Normative relativism” holds that different basic moral require-ments apply to different moral agents, or groups of agents, due to dissimi-lar objectives, desires, or beliefs among such agents or groups: “[Normative] relativism states that the moral requirements binding on a person depend on, or are “relative to,” her intentions, desires, or beliefs (or the intentions, desires, or beliefs of people in her society)” (Carson et al. 2001:2). Normative relativism takes a number of forms, but two of the most common and noteworthy are: “Indi-vidual normative relativism” contends that: “[…] an action is morally obligatory for a person if and only if that action is prescribed by the basic moral principles accepted by that individual person” (ibid). In contrast to “individual normative relativism,” the second form, “social normative relativism” purports that: “[…] an action is morally obligatory for a person if and only if that action is prescribed by the basic moral principles accepted by that person’s society” (ibid). Consequently, a person who belongs to any society must act in accordance with funda-

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mental moral principles and beliefs of that society.

“Metaethical relativism” proposes that no moral judgment is true or false, and therefore it is possible for different individuals and societies to hold conflicting moral judgments without any of them being mistaken. Accord-ing to metaethical relativism, the truth behind moral judgment is all rela-tive. This means that what might seem ethically correct to one person or society might not necessarily seem correct to another (ibid). For example, it might seem acceptable for society X to tell the patients the truth about his/her fatal disease, whereas for society Y to do so would be met with severe disapproval: “some cultures expect that their doctors may not be telling the truth: some doctors feel that proper patient care may sometimes require untruths” (Higgs 2001:433).

3.8 Summary of the TheoriesIn order to summarize the ethical principles and theories described in the preceding chapters, an outline shall be presented in Table 3.2 with the in-tention of giving the readers a concise overview.

3.9 Other Moral TheoriesOther possible theories were contemplated for use but then discarded be-cause although relevant to the field of study, they were deemed not inclu-sive, or as useful as the four ethical theories presented earlier. Briefly, some of these other theories are:

“Ethical Egotism” - an ethical belief which holds that, what is right and wrong is based on individual self-interest (Hatab 2000:52). Egotism prescribes that individuals take actions that further their self-interests, as opposed to being compelled to act in the interest of others or by duty (ibid). This theory was discarded due to its fundamental premise of self-interest, which naturally conflicts with medical ethics.

Utilitarianism Kant’sEthicsofDuty VirtueEthics MoralRelativbism

PracticalReasoning “How do I get what is good?”

“How do I de-termine what is rational?”

“What habits should I devel-op?”

n/a

CentralQuestion“What ought I to do?”

“What ought I to do?” (Motive & Action focus)

“What is the best kind of person to be?”(Agent focus)

n/a

PrimaryFocusofEvaluation “Consequences” “Motive & Ac-

tions”“People” (Agents) “People” (Agents)

BasicNotion “Maximum Happiness”

“Right Motiva-tion &Do the right thing”

“Developing good character”

“No objective right and wrong”

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Utilitarianism Kant’sEthicsofDuty VirtueEthics MoralRelativbism

PracticalReasoning “How do I get what is good?”

“How do I de-termine what is rational?”

“What habits should I devel-op?”

n/a

CentralQuestion“What ought I to do?”

“What ought I to do?” (Motive & Action focus)

“What is the best kind of person to be?”(Agent focus)

n/a

PrimaryFocusofEvaluation “Consequences” “Motive & Ac-

tions”“People” (Agents) “People” (Agents)

BasicNotion “Maximum Happiness”

“Right Motiva-tion &Do the right thing”

“Developing good character”

“No objective right and wrong”

Table3.2OverviewofEthicalTheories

“John Rawl’s Theory of Justice (Social Contract or Contractarianism)” – is geared primarily towards political justice and social welfare (ibid). According to Rawl, justice is the first virtue of social institutions, just as truth is the first virtue of the scientific system. This theory attempts to capture the prioriti-zation that human rights and other individual freedoms should have been in a society. Although the concept of justice and human rights is relevant to ethics of medicine (justice in medicine concerns the distribution of scarce health resources, and the decisions of who receives what treatment, while human rights concern the principle of patient’s autonomy), the theory itself neither leans towards medicine nor touches upon the characteristics of a moral agent. This is opposed to the theme of this project, which is interested in capturing more about individual persons than the welfare of society.

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3.10 A Cultural Impact on the Physician-Patient Re-lationshipThis section gives an overview of the physician-patient relationship per-ceived in Western and Eastern cultures. The segment starts with a brief ex-planation of patients’ autonomy in the Western countries employing Den-mark and The United States as two key examples. Following the Western concept of patient autonomy is a narration of some Asian views that are distinctly more “familistic10 or community-centered,” focusing on the roles of the patient’s family in Thailand, Japan, and China.

Later on, an analysis of national culture is briefly introduced based on Hof-stede’s Cultural Dimensions. Despite the fact that Hofstede’s dimensions of national culture have been consistently cited in the intercultural studies field (Sondergaard 1994, Yoo and Donthu 1998), his work also receives extensive critique, especially regarding its framework and method. One of these cri-tiques is on the generalizability of the research findings, because the sample is drawn from just one large multinational company (IBM). Sampling that is limited to a single source raises questions as to whether the cultural differ-ences may be confounded by homogenizing influence of a corporate culture transferred across national boundaries (Shackleton and Ali 1990, Schwartz 1994). In addition, Yoo and Donthu (1998) suggest that Hofstede’s resulting dimensions of national culture could have been a product of the period of the study. Nevertheless, Hofstede’s model is used in this project, as it ren-ders comprehensive cultural values and is particularly relevant to the given countries under study. Furthermore, the model depicts the fact that the cul-tures are typically varied in many ways.

Autonomy:WestandEast

Several studies such as Taboada and Bruera (2001), Mystakidou et al. (2004), and Fan (2000) conclude that the relationship between physicians and pa-10 Technical term used by Fan (2000)

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tients in the West is greatly influenced by “autonomy” and “individualism.” Generally, physicians and patients mutually respect each other and both sides are well aware of patient rights and self-determination to consent for treatment. The patient, who has a right to accept or decline treatment based on the information he or she is provided, makes decisions individually. Unlike the West, autonomy is not taken for granted in the East, but rather overwhelmed by “familistic, or community-centered” traditions. Truth is not to be revealed to the patient unless his or her family agrees that the patient is emotionally capable of dealing with trauma after the truth is released. Hence, doctors usually consult the family first before discussing their prog-nosis or diagnosis with the patient. Furthermore, according to the Eastern cultures, patients respect and accept doctors as the embodiment of kindness and mercifulness, for what it is worth. They tend to oblige to doctors’ judge-ments with feelings of gratitude and lack of awareness around autonomy. Briefly speaking, the Western and Eastern perspectives towards the relation-ship between doctors and patients result in incongruous notions of truth telling and the morality of “telling a white lie” to patients (Fan 2000:92).

DenmarkDenmark was chosen as one of the Western countries to illustrate the physi-cian-patient relationship principally because Danish society is well recog-nized for its individualism and homogeneity (Kastrup in Okasha et al (ed.) 2000:68). For “outsiders,” Denmark may not be reminiscent of any harsh controversies in medicine compared with the United States, or even with other European countries. Needless to say, this thesis focuses on a compara-tive study of Danish and other Western and Asian cultures.

Individualism, solidarity, independence, and self-determination are among the characteristics of Danish culture that have featured in the Danes’ percep-tions of patient autonomy and the physician’s mandate of telling the truth, as highlighted by the Danish Medical Association 1989 (Kastrup in ibid).

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Back in 1989, the Assembly of Representatives adopted the latest revision of the Danish ethical regulations (Danish Medical Association 1989). These regulations aim to strengthen good medical practice, confidence, and coop-eration between doctors and patients (Kastrup in ibid:71). Furthermore, the policies view medical secrecy as the most valued criteria and at the same time they emphasize the patient’s right to discretion. According to the regu-lations, a doctor ought not to force information on his or her patient who clearly does not want to receive it.

The official Danish interpretation of patient autonomy clearly states that the patient has a right to make decisions about his or her treatment without any interference from family or health professionals. In this context, form-ing an alliance between the doctor and the patient’s family seems meaning-less (Kastrup in ibid:79), since medical professional standards prioritize the patient’s autonomy over a relationship with the patient’s family.

TheUnitedStates“The United States is a country where individual freedoms are exercised with few, if there is any, restriction” (Alarcon in Okasha et al (ed.) 2000:89). The indi-vidual’s freedom is ubiquitous and deeply profound in every social class, in any walk of life, even in the practice of medicine. Blackhall et al. (2001) affirm this notion by concluding that in the US, patients seem to hold a strict belief that information about their bodies is theirs to know. Their conclusion is derived from in-depth interviews with patients of different nationalities (European-American, African-American, and Korean-American).

According to Blackhall et al.’s research, European-American and African American patients bear attitudes towards truth telling that link to empow-erment and rights, while Korean-American patients rarely mention the no-tion of wanting “rights” to the truth and are more likely to see truth telling as cruel and potentially harmful (ibid: 62). American medicine has witnessed

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ethical challenges caused by conflicts be-tween physicians’ professional opinions and the patient’s family every now and then. An example of such challenges is de-scribed in the hypothetical case scenario about Mrs. C and Dr. P (Fan, 2000:87).

As Fan (ibid) puts it, Dr. P can decide to respond to the daughter’s request by tell-ing her that while her point is well taken, he cannot follow her request as in his stan-dards of professional practice, he must talk to the patient first. This plausible solution leads Fan to question whether physicians should rather take a culturally sympathet-ic response in such case. To confront with the difficult situation, Dr. P has to choose either to prioritize the patient’s au-tonomy even though his action is considered rude and unsympathetic, or to comply with the daughter’s request and thereby act against his standards of practice. Even if Dr. P chooses to communicate directly with the daughter, the question of whether he should also deceive Mrs. C about her diagnosis remains. Obviously, doing so only leaves him open to another dilemma of violating the patient’s autonomy and potentially risking the reputation of his professional practice. The researchers of this project found this case sce-nario interesting and decided to ask the participants to come up with their suggestions as to how Dr. P could resolve the situation. These solutions will be included as a part of the Analysis chapter.

OtherWesternCountriesMaking a universal consensus on truth telling is impossible, especially when culture is factored into doctors’ consideration. Even among those health

Case Scenario

“Mrs. C was an 80 year-old-Chinese woman who came to visit her daughter in the United States. With little knowledge of English, Mrs. C was sent to a hospital because she experi-enced loss of appetite and rapid weight loss. While Mrs. C waited in one of the examina-tion rooms, her daughter made a request to Dr. P and emphasized her view that if Dr. P concluded that her mother had a life-threat-ening disease, he should not directly reveal such information to Mrs. C. The daughter explained that in the Confucian tradition, it is considered rude and unsympathetic for a physician to give such information to an el-derly, seriously ill patient. Instead, this infor-mation should be given to the patient’s family members. If the family members believe that it is appropriate to share medical bad news with the patient, the family members and not the doctor should do so.”

(This hypothetical case is presented in an article by Ruiping Fan, B.M. PhD in H.E.C Magazine 2000; 12(1): 87-95)

Mrs. C and Dr. P

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care professionals from European countries, a variety of perceptions to-wards truth telling has persisted for years. For instance, in the beginning of the 1980s, while most doctors in northern Europe and in other Anglo-Saxon countries were already revealing diagnoses both to the patient and (with the patient’s permission) to the spouse. Meanwhile, in Southern and Eastern Europe, doctors maintained an attitude of truth concealment (Mystakidou, et al: 148), and likewise, the same attitude existed in Greece where a major-ity of doctors withheld the truth about diagnosis from their patients. Ap-parently, attitudes toward truth telling gradually changed over the course of time between the 1980s and the present-day early 21st century. Recently, a study in Italy indicates that patients are more informed compared to the past; similarly in Ireland, the majority of health care professionals make their decisions on truth telling according to the patient’s wishes (ibid).

AsianCulturesandCommunity/Family-CenteredTraditionsExamples from Thailand, Japan, and ChinaThe traditional values of togetherness and unity in Asian cultures are deep-ly rooted within family or community. In Asia, a sense of togetherness is closely connected with ethics as, for example, described by Moore (1967 in Okasha et al. 2000), in the East, ethics are not just simple principles that govern human nature. Moore cited Japan as one example of a society where individuals are bound together by ethics since there exists “[...] a pattern of social living, without absolutes or universals, except for the one basic ethical principle of duty-loyalty to the group” (ibid: 14). For Asians, ethics determine each individual’s loyalty to their group, while religion creates peace and harmony in the societies. Without having both ethics and religion, the soci-eties cannot be stabilized. Indeed, two of the most powerful religions and philosophies that have had a great impact on Asian civilization are Confu-cianism and Buddhism. Thailand and Japan, for example, are two countries that represent the Buddhist and Shinto (a sect of Buddhism) while China represents the Confucian society.

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In Thailand, “Ban” literally refers to a house or a place where people live. However, in many cases “Ban” translates more broadly to function as an extended family and its decisions on a person’s life. As Hofstede’s Cultural Dimensions indicate, the Thai society is collectivist. This is manifested in a close long-term commitment to the member group, or to the extended fam-ily or relationships. Loyalty in Thai society overrides most other social rules and regulations. In other words, the society fosters strong relationships where everyone takes responsibility for fellow members of their groups (Hofstede, 2005a).

For Japanese, “Taiwa” is the grand harmony, which maintains its integrity through proper status of individuals within the group (Liu in Okasha et al (ed.) 2000:134). At the individual level, there has long been an assumption that an individual needs to be submissive to authority. This assumption has been described as essential for understanding Japanese thoughts and inter-personal relationships.

Both social obligation and an individual’s submission to authority explain Thai and Japanese’s natural tendency to depend on others for help. This propensity also explains why patients are submissive to their doctors’ au-thority and expect them to make an appropriate decision on behalf of the community or the family.

In Japan and Thailand, patients believe that they are asking their doctors for a favour when they encounter medical problems. The formality of so-cial interactions between doctors and patients in the two countries is well-documented. Hoshino (1997:14) reveals that Japanese patients tend to not question their doctors’ decisions as he describes, “They […] try to be as good an obedient patient as possible…[and generally] do not care much about their civil rights.” Some patients even go as far as rejecting physicians’ attempts to explain conditions and medical treatments in detail, believing that they

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should not be burdened by such information and that all decision-making that are doctors’ responsibility. Hoshino (ibid) calls this attitude as “manaita no ue no koi,” a Japanese proverb which means that a patient is resigned to his or her fate.

Thus, in most cases, the truth about diagnosis is not revealed to patients, with more than 90% of doctors in Japan hiding the diagnosis from their pa-tients (Mizushima et al. 1990). Hoshino elaborates on this circumstance that the doctors’ duty: “is perceived without any thought that they might be infring-ing upon the patient’s right to autonomy, self-determined, and privacy” (Hoshino 1997:17).

Unlike Japanese society, Thanaprasertgorn and Nilchaikovit (1997) assert that Thai society is relatively flexible (“Yued-Yun” in Thai) as compared with Japanese and Chinese societies. The open attitudes towards truth tell-ing of Thai people allows doctors and patients to cooperate in the “middle way”: patients respect doctors’ decisions yet they are not submissive to their doctors’ authority or unaware of their rights to autonomy. Therefore, pa-tients are free to hear the truth about diagnosis and to request their doctors to either unveil or withhold the truth from their family if thought to be too harsh to endure.

As mentioned earlier, Confucianism is a core philosophy that has nurtured Chinese society with its disciplines, morality, and order for centuries. Con-fucianism or “The Religion of Confucian” is:

“An East Asian ethical and philosophical system originally de-veloped from the teachings of the early Chinese sage Confucian. It is a complex system of moral, social, political, and religious thoughts which had tremendous influence on the history of Chi-nese civilization down to the 21st century.” (Wikipedia, 2005a).

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Confucian ethics interpret autonomy and self-determination in a much dif-ferent way from the Western world. In a society where family is the center of all attention, autonomy becomes more collective rather than individu-alistic (Tai M. 1997: 61). According to Confucian ethics, the focal point of each person’s life is not himself or herself, but the family. Thus, autonomy can only be spoken of as collective right rather than an individual privilege. Taking the Confucian autonomy into account, when a patient is diagnosed with a terminal disease, the first person to be notified is often not the pa-tient himself, but the head of the family, such as the father or the husband. This practice is normal in the cultures greatly impacted by Confucianism, namely, Chinese and Taiwanese (ibid: 52). The head of the family will then confer with other family members to see what course must be taken. It can be said that doctors overtly keep close connections with the patient’s fam-ily and thereby, doctors’ withholding information from patients or telling “white” lies are acceptable and morally appropriate, as Fan (2000) narrates: “[…] all societies have good reasons for lying some of the time.”

The concept of autonomy is nothing new to the East, but various cultures mark different interpretations of autonomy in accordance with philosophies and religions that govern a person’s life. Despite the fact that autonomy is one of the basic principles of medical ethics, its concept and deeper mean-ings may be greatly varied between cultures.

The idea underlying autonomy is that a person’s freedom to information and consent ought to be respected. Therefore, most Western medical pro-fessionals believe that sharing the truth about diagnosis, prognosis, and treatment options with the patients will generate the basis of this freedom. However, truth telling is not: “[…] just the opposite of lie, not just the sum of correct statements, but a reciprocal state on the physician-patient relationship.” (Surbone 1992:62). This remark subtly simplifies that cultural backgrounds of patients should also be taken into consideration in the physician-patient

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relationship, whereby doctors and patients collaborate during the course of treatment in order to reach their mutual equilibrium of truthfulness.

Now that the four ethical models most relevant to this thesis have been in-troduced and thoroughly deliberated, the foundation has been created for the application of these theories to a practical situation: gaining the under-standing of truth telling in different cultural contexts by means of qualitative interviews. The next chapter will present the findings of the interviews.

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chapter 1

chapter 2

chapter 1

chapter 3

chapter 4

chapter 5

AnalysisThis chapter contains the following:

Chapter ObjectiveAn Overview of the Participant’s Per-ception of Ethical BehaviourA Discussion of Themes from the In-terviewsA Discussion of the Case Scenario

••

•

•

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4 Analysis and Discussion

4.1 Chapter ObjectiveThe main target of this analysis is to bring in empirical evidence acquired from interviews to aid in answering the research questions. Moreover, in order to further illustrate varied realizations of truth telling, findings and theoretical considerations will be synthesized.

As set out from the introduction, the aim of this thesis is to explore medical students’ perspectives on and attitudes towards truth telling, and to inves-tigate how cultural influences shape these perceptions. In order to achieve this goal, the four theories of ethics presented in the preceding chapter will be centrally incorporated into the results.

To begin with, responses from the first interview question: “what is ethical behaviour?” will be put forward. This question represents as an umbrella inquiry rendering the participants’ broad and holistic impressions of ethical behaviour. It should be noted that the Danish/Afghan student was the only participant who mentioned that his religion (Islam) has great impact on his behaviour, and on how he perceives and handles truth in both his private and professional lives. For this reason, his quotations relevant to religious influences will be deliberately highlighted.

In the second part of this chapter, seven themes distilled from the inter-views will be discussed, contextualized, and divided into categories accord-ingly to their characteristics and attached meanings. In the last section, the participants’ solutions for the case scenario posed at the end of the interview questions will be introduced. The case scenario exhibits potential conflicts between professional medical opinions and patient rights. These conflicts are substantially induced by a range of cultural perceptions of individual rights that might interfere with a doctor’s decisions in revealing or with-

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Finnish 1 (Pilot interview

)-N

ot applicable- (This question w

as not used in the pilot interview)

Finnish 2“I think it’s ethical practice like w

hat you, as a therapist would do to yourself, like to treat the patient like

yourself.” (L4)

Danish/A

fghan 1

“I think my view

point is different from som

e other people, because I have strong basis in my reli-

gion, and the religion that I practice is Islam. A

nd there are some rules or som

e guidelines; some sayings

of how to deal w

ith people on a comm

on level, and then in some specific situations how

to do and what to do,

and what not to do. I have com

bined that with different courses that I had regarding com

munication, and

how to deliver, eh, deliver the hard m

essages, like telling some people that they had a cancer or som

ething like that, so. But in general ethical behaviour is treating others the w

ay that you want to be treated yourself.”

(L2)

“There’s a tradition or saying of the Prophet Moham

ed that: “treat each other that yourself would like

to be treated.” I think this is a comm

on principle, not just in the religion, but as a moral foundation of every

people who have som

e kind of interactions, because in a civilization people need to interact in a correct way or

else the comm

unication will be lost.” (L12)

Danish 2

“I think when you are a doctor first of all your patients have to have, erh... They have to believe you and as a

doctor you have to pay respect to them and you have to be truthful, and respectful in your inform

ation. And

you have to take into opinion, where the patients are, or w

hat the patient’s situation is, and how em

otional they are, and how

much inform

ation you can give them w

ithout them breaking, w

ithout their whole w

orld breaking dow

n. So you have to be very careful and still you have to be truthful and respectful to the patient.” (L4)

Danish 3

“I think ethical behaviour is when you respect the people and you respect its opinions and you try to

treat them in the best w

ay possible for that specific patient.” (L5)

Thai 1“I think it is about sharing about bad new

s to the patient such as cancer or something like that. A

nd the second is to (deal) w

ith some problem

s such as HIV to his or her spouse, and the third thing is about

the knowledge of the treatm

ent.” (L2)

Thai 2“Ethical behaviour according to m

y opinion is behaviour that concerns rationale, emotion or feelings of

other people. It also includes truth and not telling lies.” (L8)

Thai 3“I think it som

ething about truth, about how to tell the truth to the patient in appropriate tim

e and you have to judge if the patient is w

ell prepared or not to receive the news or som

ething like that.” (L9)

Chinese 1

“I think that ethical behaviour in my opinion is w

hen I treat the patient. The patient has a right of informed

consent and otherwise the patient needs, or has the right of self determ

ination.” (L2)

Singaporean 1“Ethical behaviour in m

y personal opinion is where I stick to m

y own m

orals and principles, on top of the ethical guidelines set by the Singapore M

edical Council. For exam

ple, proper informed consent

should be obtained from patients before any treatm

ent or procedure is initiated.”

Table4.1Q

uestionno.1:W

hatisethicalbehaviourinyouropinion?

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Finnish 1 (Pilot interview

)-N

ot applicable- (This question w

as not used in the pilot interview)

Finnish 2“I think it’s ethical practice like w

hat you, as a therapist would do to yourself, like to treat the patient like

yourself.” (L4)

Danish/A

fghan 1

“I think my view

point is different from som

e other people, because I have strong basis in my reli-

gion, and the religion that I practice is Islam. A

nd there are some rules or som

e guidelines; some sayings

of how to deal w

ith people on a comm

on level, and then in some specific situations how

to do and what to do,

and what not to do. I have com

bined that with different courses that I had regarding com

munication, and

how to deliver, eh, deliver the hard m

essages, like telling some people that they had a cancer or som

ething like that, so. But in general ethical behaviour is treating others the w

ay that you want to be treated yourself.”

(L2)

“There’s a tradition or saying of the Prophet Moham

ed that: “treat each other that yourself would like

to be treated.” I think this is a comm

on principle, not just in the religion, but as a moral foundation of every

people who have som

e kind of interactions, because in a civilization people need to interact in a correct way or

else the comm

unication will be lost.” (L12)

Danish 2

“I think when you are a doctor first of all your patients have to have, erh... They have to believe you and as a

doctor you have to pay respect to them and you have to be truthful, and respectful in your inform

ation. And

you have to take into opinion, where the patients are, or w

hat the patient’s situation is, and how em

otional they are, and how

much inform

ation you can give them w

ithout them breaking, w

ithout their whole w

orld breaking dow

n. So you have to be very careful and still you have to be truthful and respectful to the patient.” (L4)

Danish 3

“I think ethical behaviour is when you respect the people and you respect its opinions and you try to

treat them in the best w

ay possible for that specific patient.” (L5)

Thai 1“I think it is about sharing about bad new

s to the patient such as cancer or something like that. A

nd the second is to (deal) w

ith some problem

s such as HIV to his or her spouse, and the third thing is about

the knowledge of the treatm

ent.” (L2)

Thai 2“Ethical behaviour according to m

y opinion is behaviour that concerns rationale, emotion or feelings of

other people. It also includes truth and not telling lies.” (L8)

Thai 3“I think it som

ething about truth, about how to tell the truth to the patient in appropriate tim

e and you have to judge if the patient is w

ell prepared or not to receive the news or som

ething like that.” (L9)

Chinese 1

“I think that ethical behaviour in my opinion is w

hen I treat the patient. The patient has a right of informed

consent and otherwise the patient needs, or has the right of self determ

ination.” (L2)

Singaporean 1“Ethical behaviour in m

y personal opinion is where I stick to m

y own m

orals and principles, on top of the ethical guidelines set by the Singapore M

edical Council. For exam

ple, proper informed consent

should be obtained from patients before any treatm

ent or procedure is initiated.”

holding truth from the patient.

4.2 Participants’ Holistic Perceptions of Ethical Be-haviourAccording to the interviews, Scandinavian participants perceived ethical behaviour as “treating others the way one wants to be treated,” whereas Asians focused not completely dissimilarly on “being rational and considerate.” In addition to these two characteristics, the Chinese and Singaporean men-tioned “informed consent” as one example of ethical behaviour. A summary of each participant’s response is illustrated in table 4.1.

Special attention should be paid to the second Finn’s (Finnish 2) and the Danish/Afghan’s answers - their opinions happened to be relatively close to one of Kant’s propositions: “to act only on that maxim that one can will as a universal law.” Alternatively, the Danes’ replies could be associated with Virtue Ethics as they articulated some key characteristics of a “good” doctor as being “truthful” and “respectful.”

Parallel examples of Virtue Ethics were also noticeable in the Thais’ com-ments. They perceived ethical behaviour as resembling a virtuous doctor: rational, considerate, truthful, and competent in envisioning probable out-comes of revealing the truth to the patient. The Chinese’s student percep-tion was somewhat different: she leaned towards Kant’s Ethics of Duty, as she mentioned patient rights, informed consent, and self-determination. The Singaporean also touched upon the basics of Kantian philosophy. She intended to adhere to her moral principles, on top of the ethical guidelines imposed by the Singapore Medical Council. According to the Chinese and Singaporean participants’ answers, it is plausible to conclude that their sim-ilar cultural background plays a role in shaping their corresponding per-ceptions.

AllinterviewswereconductedinEnglishandquotedverba-tim.Languagemistakes in the quotationswerenotchangedinorder to keep originaldata.

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Chapter 4 - Analysis

From theoretical aspects, the participants’ answers can be classified into Kant’s Ethics of Duty and Virtue Ethics. It is interesting to discover that Utilitarianism was not mentioned in their perceptions of typical ethical be-haviour. Nevertheless, Utilitarianism will doubtlessly be manifested gradu-ally through answers to subsequent interview questions.

4.3 Differences and Similarities in Perceptions of Truth Telling between the Asian and Scandinavian Participants

4.3.1ThemesfromtheInterviewsSeven themes were derived using Kvale’s qualitative interview approaches: “meaning condensation, categorization, and interpretation” (please refer to the Methodology chapter).

The seven themes are listed below: 1. Virtues2. TheRoleofthePatient’sFamily3. TheDoctor’sPerceptionofPatientsfromanotherCulture4. MedicalLaw5. PatientAutonomy6. Long-termConsequences7. GoodIntention

1.VirtuesThis theme encompasses virtues as originated in the question: “what would you do when you are confronted with ethical dilemma about truth telling?” The researchers employed this question with the intention to clarify how par-ticipants would solve the dilemma of telling the truth (about diagnosis) to the patient and/or to the patient’s family. In their responses to this question,

75


participants referred to various virtues, namely truthfulness, honesty, respect, trustworthiness, sincerity, compassion, sympathy, kindness, consideration, and advocacy. Some of these virtues were quoted directly from the participants’ statements while others were extrapolated from the researchers’ own under-standings of the participants’ meaning (See table 4.2 next page). It should be noted that these virtues may have overlapping meanings across cultures. For instance, it is possible to match the term “straightforward” (as mentioned by the Thais) with being “truthful” or “direct,” qualities mentioned by the Scandinavians. In practice, the participants might use different words car-rying the same attached meanings, as depicted in figure 4.1 below.

TruthfulnessDirectness

Straightforward

KindnessSympathy

ConsiderationTrustworthiness

BeneficenceSupportiveAdvocacy

CompassionSensitivity

HonestyRealisticSincerity

Respect

Figure4.1VirtuesfromtheInterview Ques-tion:

“What would you do when you are confronted with an ethical dilemma about truth tell-ing?”

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Attention should be paid to the virtue quoted by the Chinese: “beneficence.” Beneficence, according to this participant’s understanding, means to do what is “the best” for the patient. However, determining what is “best” in any given scenario could involve the doctor’s decision, the patient’s con-sent, and perhaps as the most important figure for the Chinese student- the patient’s family. In theory, beneficence, therefore, could be classified into

Virtues: Quotations:

Sympathy “But in practice I can tell the truth and I can say at least very sympathize.” (Finnish 2: L65)

Straightfor-wardSincerity Compassion

“I have to stay calm and try to be compassionate to the patient, and let the patient feel I’m being sincere. And then, I will just go straightforward.” (Thai 3: L7)

Trustworthi-nessRespectTruthfulness

“They have to believe you and as a doctor you have to pay respect to them and you have to be truthful.” (Danish 2: L4)

Beneficence“I think the principle as a doctor; the most important thing is the principle of benefi-cence, the principle of beneficence for patients of course.” “It means, what’s the best for patients” (Chinese 1: L63, 66)

DirectnessSensitivityRealistic

“We say it directly to the patient, but we try to be as much sensitive as it is possible, but we are realistic about chances.” (Finish 1: L17)

Honesty

Kindness*

Consider-ation*

Advocacy*Supportive*

“You have to tell the truth in whenever it’s possible without harming anybody or make their (the patients) lives miserable.” (Danish 3: L20)

“I believe that one needs to be honest about things. “If you yourself are open and hon-est about everything, you get the best response.” (Danish/Afghan 1: L241, 264)

“You have to take into opinion how much information you can give them without their whole world breaking down.” (Danish 2:L6).

“I would make sure the relatives know that the patient has a right to know. Further-more, it is usually inevitable to let the patient know the truth as the disease progresses. Thus, it would normally be better for the truth to be told to the patient by the relative, with the doctor playing an advisory role.” (Singaporean 1)

* The researchers’ interpretation

Table4.2Answers to thequestion:

“What would you do when you are confronted with an ethical dilemma of truth telling?”

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one of Utilitarian elements: pleasure or happiness of people involved in an act. That is, the doctor has to do what he or she believes to be the “best” for the patient, which at the same time also complies with what the family thought to be the “best” for the patient.

Another example of virtue was drawn from one of the Danish participants (Danish 2). She pointed out that the doctor should “respect” the patient’s feelings and be “truthful” about all information given. It seemed that her definition of “respect” was similar to the meaning of “considerate” since she formulated her answer:

“[...] you have to take into opinion, where the patient is, or what the patient’s situation is, and how emotionally they are, and how much information you can give to them without their whole world breaking down.” (Danish 2: L 6).

In addition to their overlapping definitions, these virtues might also be sub-ject to cultural interpretations. For example, according to the Asian partici-pants, a “good” doctor ought to be “compassionate” and “sincere” (Thai 3), whereas according to the Scandinavians, he or she should be “direct,” “hon-est,” and “realistic” (Finnish 1 and Danish/Afghan).

As to reasons why some doctors might try to avoid the dilemma of truth telling, the Danish/Afghan recounted from his experience that:

“[…] because doctors today, and generally many people they have a problem with death, they don’t even think about the death, so when they are finally confronted with it, they don’t know what to do and how to react. A patient may come and ask a doctor. What will happen now, I have three weeks, what then? What should I do? A doctor would be in confusion, even more than the patient. So I think the problem comes because the doctors didn’t adjust themselves or acquaint themselves with thoughts about death and the life hereafter and these things. And this is why, they don’t hide the truth, but they try to step away from it and let somebody else do the job.” (Danish/Afghan 1: L270).

Virtues: Quotations:

Sympathy “But in practice I can tell the truth and I can say at least very sympathize.” (Finnish 2: L65)

Straightfor-wardSincerity Compassion

“I have to stay calm and try to be compassionate to the patient, and let the patient feel I’m being sincere. And then, I will just go straightforward.” (Thai 3: L7)

Trustworthi-nessRespectTruthfulness

“They have to believe you and as a doctor you have to pay respect to them and you have to be truthful.” (Danish 2: L4)

Beneficence“I think the principle as a doctor; the most important thing is the principle of benefi-cence, the principle of beneficence for patients of course.” “It means, what’s the best for patients” (Chinese 1: L63, 66)

DirectnessSensitivityRealistic

“We say it directly to the patient, but we try to be as much sensitive as it is possible, but we are realistic about chances.” (Finish 1: L17)

Honesty

Kindness*

Consider-ation*

Advocacy*Supportive*

“You have to tell the truth in whenever it’s possible without harming anybody or make their (the patients) lives miserable.” (Danish 3: L20)

“I believe that one needs to be honest about things. “If you yourself are open and hon-est about everything, you get the best response.” (Danish/Afghan 1: L241, 264)

“You have to take into opinion how much information you can give them without their whole world breaking down.” (Danish 2:L6).

“I would make sure the relatives know that the patient has a right to know. Further-more, it is usually inevitable to let the patient know the truth as the disease progresses. Thus, it would normally be better for the truth to be told to the patient by the relative, with the doctor playing an advisory role.” (Singaporean 1)

* The researchers’ interpretation

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He also added that some doctors might need time to ponder about telling the truth, especially when he or she might have emotional attachments to the patient. In fact, the Danish/Afghan participant indicated that he had handled this dilemma in the past by discussing openly with the patients. This was reflected in his answer in the above table 4.2.

One can conclude that the above mentioned virtues are essential for doctors to demonstrate their moral intentions, no matter to whom the truth might eventually be revealed (the patient and/or the patient’s family). This finding corresponds with Kantian tenets that promulgate one’s “good will” to act on what one believes to be “right.”

2.TheRoleofthePatient’sFamilyThis question highlighted the contrasts between the Asian and Scandina-vian participants’ perceptions. In relation to the question “what is ethical behavior?” mentioned earlier, a follow-up inquiry was employed. That is, possible rationales behind a doctor’s decision, to reveal the truth directly to the patient, or to let the family convey the information and decide when (or whether) the patient should be informed, were explored.

The Asian students were obviously concerned about family involvement in that all of them stressed the importance of including the patient’s family in the procedure of truth telling. As is a normal practice in their countries, they described how a doctor would usually open with “small talk” with the family before discussing with the patient. On the contrary, this information was rarely found in the Scandinavian participants’ answers:

“In our country, the process of telling the truth to the patient is quite complicated. First, we have to talk with the family first, and then we have to ask the consent from the relatives that we can tell to the patient.” (Thai 2: L23).

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“Because it’s very serious talking about cancer or a tumor so be-fore you tell the patient directly you normally will talk with the family about this, about the diagnosis.” (Chinese 1: L39).

According to the Asians in the study, doctors should immediately tell the truth to the family or the next of kin of the patient. They accentuated strong ties and extended-family values dominating Asian societies. The Thai and Singaporean participants reasoned that doctors must consult with the pa-tient’s family before the patients themselves because:

“Many times, I have considered telling the truth to the patient is cruel. That’s why I have to talk to the relatives first. The relatives know how to tell the patient.” (Thai 2: L58).

“If the doctor violated cultural conventions and insisted on tell-ing the truth to the patient, the family might lose their trust in the doctor and thus, the doctor lost the support of the family in the treatment of the patient.” (Singaporean).

Unlike the Asian participants, the Scandinavian participants would prefer to have an open discussion with the patient mainly because they were aware that doctors are legally obliged to do so.

“You can’t tell things about your patient to the patient’s family without the patient’s permission.” (Finnish 1: L89).

However, the situation depended on a condition whether or not the patient was prepared to hear the truth, as the Danes hypothesized:

“Doctors tell relatives to also help the patient to accept the situa-tion so the family can support the patient even more. If I see that the patient is close to falling apart and doesn’t want to speak at all with any doctors or nurses and so on, then maybe I believe that it’s more helpful to bring in the relatives without having the permission of the patient.” (Danish 2: L81, 42).

“Depending on who the patient is, is it a child, is it a psychotic ill person? Can the person bear to hear the truth? If it’s a five-year-

TheSingaporeanquotationsdonotincludelinenumbers.Theparticipantsenttheanswersinwritingandwasnotinterviewed.

80


old child who has, or is going to die from cancer in maybe half a year, I don’t think it would be fair to tell the child.” (Danish 3: L9).

Yet for the second Thai participant, his decision to reveal the truth to the patients was based on the following grounds:

“I would have to know the background of the patient first, about the education, about the social economy, and about the general health.” (Thai 2: L56).

The other Thai participants postulated that whether the patient or the pa-tient’s family would firstly hear the truth was not considered a major issue because the patient would always be eventually informed:

“It is not important to tell the patient first or tell the family mem-bers first, but it is important to tell the patient.” (Thai 1: L186).

“Maybe just tell the relatives and postpone the news [to the pa-tient] or something like that.” (Thai 3: L119).

The Chinese participant remarked that informing the patient was not ac-tually a normal medical practice, as doctors would review the truth with the family before delicately delivering “not complete” information to the pa-tient.

“Normally, we will tell the family the truth and then we discuss together how to tell the patient the truth.” (Chinese 1: L56).

“If the disease is not serious, of course we can tell the patient all of the information if they want to know. But if it is very, erh, very...you know some diseases like cancer tumor is not good, so normally we tell the patient the general information, not com-pletely.” (Chinese 1: L74).

In summary, involvement of the patient’s family in truth telling depends on individual cases. Findings indicated that the family had more influence

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on the Asian participants’ decisions than on the Scandinavians’ opinions. The essential roles of patients’ families in Asian societies correspond with a study completed by Fan (2000) further elaborated in section 4.4.

3.TheDoctor’sPerceptionofPatientsfromanotherCultureThis theme particularly related to the question: “In your opinion, is the pa-tient’s cultural background important for physicians to make a decision when they have to tell the truth?”

Cultural aspects were discussed liberally during the interviews. Answers from all participants showed that culture played an important role in their decision drivers. In fact, culture might directly affect the treatment that the doctor will perform on the patient, for example:

“With regards to treatment, caution should be practiced. For example, Muslim patients should not be given, or should be in-formed first before being given certain medicines that have an alcoholic component, or that use alcohol in the manufacturing process.” (Singaporean 1).

The Singaporean also reflected an interesting point on the sometimes irre-spective influence of a culture on truth telling, as she elaborated:

“While the cultural background does play a part in the way and the means of telling the truth, the decision as to whether or not the truth should be told is irrespective of culture.” (Singaporean 1).

The second Danish participant would respect the patient’s cultural conven-tion, even though she might not all the time agree on it:

“I think you have to respect the culture. This old woman grew up with this [Chinese] culture and maybe it’s the only culture she has known.” (Danish 2: L157).

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The Danish/Afghan participant claimed that he treated patients without bearing any stereotypical assumptions towards them:

“I didn’t feel that I could classify people as behaving in one direc-tion if they were from Asia or from another in another way. I (felt/found) different kinds of patients in both cultures [Danish and Is-lamic] or in different cultures, so there was no specific stereotype kind of way that people behaved.” (Danish/Afghan 1: L70).

The first Thai participant expressed his feelings towards some fatalistic Muslim patients who held a strong belief that illnesses were caused by God’s intention, trusting in fate even to the extent of living and dying. He was sometimes caught in a moral dilemma:

“They don’t want their doctor to help them because they think that they should die, because their god wants [them] to.” (Thai 1: L17).

[…] You can’t do anything because they [the patients] have the right to deny the treatment.” “I will need to give them all infor-mation about the prognosis of the treatment, if they want me to treat them. Yes, I will do it.” (Thai 1: L39).

To investigate how the participants experience any different opinions to-wards truth telling from their colleagues of other cultures, a follow-up question was inquired. Surprisingly, none of the participants anticipated serious problems with this subject, even though some of them had attended an ethical class and had touched upon truth telling before. Perhaps, culture does not fundamentally alter the degree of cultural sensitivity in the medi-cal profession, at least as discovered from this study.

4.MedicalLawThe researchers construed this theme based on answers to the question: “Do you follow medical standards of practices when telling the truth to the pa-tient?”

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According to the Scandinavian participants, doctors were obligated by medical law encompassing patient autonomy, i.e they must respect patients’ decision on receiving or withholding from the truth. The Danish and Finn-ish participants heavily stressed that the law imposes doctors to reveal the diagnosis and prognosis directly to the patient, as the first Finn contended that:

“In Finnish law, you must tell the truth directly to the patient, so there are not so many services to make.” (Finnish 1: L36).

The Danes in this study also expressed similar opinions, as each of them cited:

“According to the law, you are not allowed to tell the relatives at all.” (Danish 2: L40).

“I need to inform the patient about everything according to the rules. And if they deny that they want to hear anything, I have to respect that as well.” (Danish/Afghan 1: L145).

“If the patient is not a child, honestly, I have to get the permission from the patient, is it OK that I talk to your family about your illness.” (Danish 3: L55).

As presented in the above quotations, doctors have to communicate directly with the patient, unless the patient is under age or otherwise emotionally or physically incapable of making decisions (such as if the patient has de-mentia or is unconscious). Hence, a categorical statement can be formu-lated from the Scandinavians’ answers: mandatory telling of the truth to the patient (who is capable of making decisions) unless the patient requests otherwise.

The Scandinavians’ answers much associate with one of ethical character-istics of a moral agent Kant put forth: autonomy, which will be discussed more thoroughly in the upcoming theme.

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Unlike the Scandinavian, the Asian participants vaguely commented on medical law. The Thai students only noted that the patient must be eventu-ally informed about his or her diagnosis/prognosis. However, according to their interviews, they did not clearly explain whether telling the truth to the family was allowed because it was stated in the law, or merely because it was considered a general practice or “norm” in Thailand.

“In our country, the process of telling the truth to the patient is quite complicate. First, we have to talk with the family first, and then we have to ask the consent from the relatives that we can tell to the patient.” (Thai 2: L23).

The Chinese participant pointed out that Chinese doctors often have a dif-ficult time to tell the truth directly to the patient. She referred to desiring a law about truth telling, as there currently is no specific law in China about telling the truth to the patient and that has made it problematic for doctors to make routinized decisions:

“I want some day that we have law so that it is easy for the doc-tor. (Chinese 1: L160).“[…] In China [we] need to complete our medical law […] so that it is easier because the doctors can follow the law.” (Chinese 1:L157 and L165).

5.PatientAutonomyThe interview results signified that the Scandinavian students valued pa-tient autonomy relatively more than the Asian students. While the Asian students tended to communicate with the patient’s family, the Scandina-vians aimed to openly discuss with the patient. One of the Danes in this project contended that she would not provide only the truth but also moral support to the patient:

“I don’t think my job stops at telling them the truth and then my job is done, I believe I have to be available with my knowledge but also as a person, as a human being. That’s my goal as a doc-tor, also to be available emotionally for the patient.” (Danish 2:L110).


In fact, none of the Asian participants placed their emphases on patient au-tonomy. The second Thai student clearly stated that: “As a doctor, you have to tell all information to the relatives.” (Thai 2: L72). The Singaporean also con-firmed that “most of the decisions to inform the patient are made by the doctor after consulting with the family.” (Singaporean).

In accordance with theoretical perspective, answers from the second Dane seemed to demonstrate a “moral obligation.” This obligation, as put forward by Kant, is a mandate on one to “act out of duty,” because one feels morally “ought” to do so.

6.Long-termConsequencesThis theme was deduced from the question “Have you ever considered truth telling is cruel?” Answers to this question were systematically separated into two categories: participants who said “No” because they thought truth would relieve the patient from any doubt or anxiety about what had hap-pened, and those who said “Yes” because they were concerned about the emotional effects of telling the truth to the patient.

NO- “Not really. In the long run, it is better for the patient to know the truth and to face it. The method of truth telling can help to ease the process.” (Singapore 1).

NO - “It is better to talk about that [the truth] and not leave the patient in uncertainty.” (Finnish 2: L69).

NO - “It can be really cruel for the patient to experience the truth at first. But I believe in the long run, it’s the best for the patient.” (Danish 2: L103).

NO- “If I told you, you have one day to live in. You know, today you would use your time very very meticulously about some dif-ferent things you know. You would make up with some contacts if you had some quarrels with anybody, you would try to resolve them.” (Danish/Afghan 1: L216).

YES - “A lot of old people are very, erh, they are very sensitive

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for their mental you know, if they know they have cancer probably they will lose their confidence for life for (…) and that’s not good for treatment.” (China 1: L105).

YES - “Yes. It is indeed, and again in the situation with the child, a young child. To tell the truth that you have this disease and it’s just getting worse and worse and maybe in half a year you won’t be able walk anymore and another one or two years you might die. It could be quite cruel to tell the truth.” (Danish 3: L61).

The above answers can be correlated to the principles of utility. That is, an ethical decision should be determined on the principle of greatest happi-ness of all concerned people, and by the same token, pain is acceptable if it serves to cause good consequences in the future. Nevertheless, long-term consequences are sometimes difficult to foresee, as one of the Finnish par-ticipants remarked:

“It depends on the patient’s condition. I think that it’s important for doctors to give some hope to the patient because we don’t know that in any case the patient will die. Intensive care and so on can help the patient to recover.” (Finnish 2, L52).

7.GoodIntentionTo elicit the meaning of “good” in this theme, two questions were used: “What is a “white” lie?” and “Is it morally acceptable to tell a “white” lie to the patient, considering your professional ethics?” Findings showed that a “white lie” could be found acceptable (even though most participants believed it was morally wrong), if it was committed through “good” inten-tion.

The purpose of posing this question was to illustrate how two people from the same culture might not perceive a moral issue in the same way. As shown in table 4.3, the second Danish and the first Thai participants accepted that a “white” lie might shed a glimpse of hope for some patients, while the other Thai students completely dismissed the idea of accepting a “white” lie.

Finnish 1 (Pilot inter-view)

-Not applicable-The question was not used in the pilot interview.

Finnish 2 “I don’t like a lie, or a white lie. Maybe there’s some kind of a good white lie but I will put it in a scientific way.” (L71)

Danish/Afghan 1

“A white lie to me is something which wouldn’t matter, which wouldn’t have any consequence on the patient’s life.” “I found many doctors telling a white lie but from a religious point of view I’d never tell a lie. You know if I tell a lie in this life, I would have to answer for it on the here after.” (L225, 233)

Danish 2“A white lie must be something that cannot hurt a person. Actually, if you have to see it truthfully, a lie is a lie, but I also believe that sometimes you have to help a person through a situation by telling a white lie.” (L125)

Danish 3 “It’s no good to tell a white lie. An example of a white lie is like telling the patient, just to make them feel good.” (L77, 84)

Thai 1 “Sometimes it is important to tell a white lie because some patients cannot accept the truth.” (L135)

Thai 2 “A lie - not tell truth, the opposite of telling truth. What could be white, I don’t know. ” (L69)

Thai 3 “If you say morally there is no white lie. A lie is just a lie.” (L117)

Chinese 1 “The white lie I understand is a lie but it’s good for the people. It’s a lie but our goal is to try to help people.” (L98)

Singaporean 1 “As a professional, it is wrong to tell a lie, whether it is “white” or not.” (Singaporean 1)

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Finnish 1 (Pilot inter-view)

-Not applicable-The question was not used in the pilot interview.

Finnish 2 “I don’t like a lie, or a white lie. Maybe there’s some kind of a good white lie but I will put it in a scientific way.” (L71)

Danish/Afghan 1

“A white lie to me is something which wouldn’t matter, which wouldn’t have any consequence on the patient’s life.” “I found many doctors telling a white lie but from a religious point of view I’d never tell a lie. You know if I tell a lie in this life, I would have to answer for it on the here after.” (L225, 233)

Danish 2“A white lie must be something that cannot hurt a person. Actually, if you have to see it truthfully, a lie is a lie, but I also believe that sometimes you have to help a person through a situation by telling a white lie.” (L125)

Danish 3 “It’s no good to tell a white lie. An example of a white lie is like telling the patient, just to make them feel good.” (L77, 84)

Thai 1 “Sometimes it is important to tell a white lie because some patients cannot accept the truth.” (L135)

Thai 2 “A lie - not tell truth, the opposite of telling truth. What could be white, I don’t know. ” (L69)

Thai 3 “If you say morally there is no white lie. A lie is just a lie.” (L117)

Chinese 1 “The white lie I understand is a lie but it’s good for the people. It’s a lie but our goal is to try to help people.” (L98)

Singaporean 1 “As a professional, it is wrong to tell a lie, whether it is “white” or not.” (Singaporean 1)

Table4.3Question16:

“In your opinion, what is a “white” lie?”

A “white” lie, as such, was believed by some to be harmless, inoffensive, and even falling within conventions of their culture. The Chinese respondent, for example, thought that although a “white” lie was still indeed a lie, it could be used for good purposes, such as to help people (in this case, the pa-tient). Her answer corresponded with a study by Fan (2004), who revealed that some Chinese doctors may use a “white” lie in order to hide the truth (p.180).

It should also be kept in mind that while the participants could say what-ever they thought people ought to do ideally, in reality they might behave

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oppositely themselves. Thereby, some participants, although adamant that they did not approve of “white” lies, might use them unintentionally or even unconsciously in other situations (including those not necessarily related to medicine). For some participants, the answers to this question were also in-fluenced by a religious perspective. For example, from the Danish/Afghan’s point of view, all lies are black, as he said: “I’d never tell a lie. You know, if I tell a lie in this life, I would have to answer for it in the [life] hereafter.” (Danish/Afghan: L225).

4.3.2ASynthesisofTheoreticalConsiderationsandEmpiricalDataFirstofall, the researchers would like to give their thoughts on the Chi-nese respondent’s quotations about “beneficence,” or in other words what is “best” for the patient. In principle, patients count on a doctor’s professional opinion of what is “best” for his or her treatment. With respect to truth tell-ing, the doctor may consider hiding the truth if he thinks that it is “best” for the patient. Hence, deciding what is best for the patient is entirely up to a doctor’s individual judgment. Some patients might want to hear the truth, but some would not, as the Chinese student revealed:

“In China, actually a lot of patients they don’t want to know the truth.” (Chinese L121).

Answers from the Danish/Afghan reaffirm this point, in adding that he thought foreign patients expected that they would be treated the same as they received in their home countries:

“You know, this is of course a truth with modifications, gener-ally speaking… People coming from different countries they have some sort of traditional way of being treated by their doctors, and when they come to another system and they get treated in a differ-ent way, they behave differently.” (Danish/Afghan 1, L115).

Utilitarianism plays a major role in explaining this point, since the theory

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suggests that the right thing to do is whatever produces the best conse-quences for the greatest number of people. Nevertheless, findings of this research have proved that deciding what is “best” for patients is up to in-dividual standards, customs and tradition, education, religion, and other sorts of influential factors that might affect one’s value judgment.

Secondly, after carefully examining the above findings, the researchers have deductively reasoned that the perceptions of truth telling from the Asian participants’ perspectives were considerably influenced by “familistic” or “collectivistic” values, while the Scandinavians in the study leaned towards “individualistic” values and were more concerned about individual rights. This finding corresponds with Hofstede’s CulturalDimensionIndex:“In-dividualism Index (IDV).”

Scandinavian countries such as Denmark rank higher on the “individualism index” thereby fostering individual rights more) than in Asian countries, such as China, where a lower “individualism index” illustrates a more col-lectivist society. The average cultural dimensions index is presented in table 4.4 below.

Despite the relevance of Hofstede’s cultural index to this finding, the re-searchers do not, by any means, intend to generalize their findings to the entire population. Hofstede’s cultural index is applicable in the sense that it helps to distinguish the participants’ perspectives, and it consequently points out one of the major cultural differences between these two regional groups. Hofstede’s model is used in this project because it renders com-prehensive cultural values and is most relevant to the given countries used here as examples. Furthermore, the model depicts the fact that all cultures are both similar and different in many ways.

Provided that the sampling size was bigger, this research could possibly


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yield different results, either within the same culture or again across cul-tures. It could also be a sheer coincidence that Hofstede’s index, although produced from a business perspective, is applicable to other walks of life, such as medicine. Though similar criteria are not yet available in medicine, Hofstede’s index seems to be a dependable source to link the findings at hand to the theoretical foundation of cultural analysis.

Third, looking back to Kant’s Ethics of Duty, pressure to “act as required by

Table4.4ComparisonofHofstede’sCul-turalDimensionIndex and Defi-nitions

Power Distance In-dex (PDI):

Focuses on the degree of equality, or inequality between people in the coun-try’s society. A high PDI indicates inequalities and wealth of people within the society.

Individualism (IDV):

Indicates the degree the society reinforces individual or collective inter-personal relationship. A high IDV means that individuality and individual rights dominate in the society. According to Hofstede’s survey from 1967-1973, most western countries, especially the United States, and Scandina-vian countries have a high IDV index.

Masculinity (MAS) Concentrates on the traditional masculine work role model of male achieve-ment, control, and power.

Uncertainty Avoid-ance Index (UAI):

Indicates on the level of tolerance for uncertainty and ambiguity within the society.

Long-Term Orien-tation (LTO)

Focuses on the degree the society embraces, or does not embrace long-term devotion to traditional thinking values. High long-term orientation indi-cates the country respect for tradition, which is ordinary for almost Asian countries.

(Hofstede: February 20, 2006b)

(Hofstede: February 20, 2006a)

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duty” seemed to make sense in some situations arising, such as when the participants referred to medical law, or when some of them quoted with regards to ethical behaviour that they would: “treat patients like yourself.” This was because, for the purpose of this research, ethics was taken from a universal point of view and the theory itself aimed to benefit people at a macro versus a micro level.

At a micro level, of course, people are all unique and one can or does not al-ways treat the other as if him or herself, especially when it comes to individ-ually-held conventions, such as religion and culture. Further to this point, the findings reaffirmed that to “act out of virtues” should be considered (such as when the Danes in this study said that many doctors broke their societal rules by talking to the patient’s family first, in case where they thought that the patient was not prepared to know the truth). To some extent, answers from the interviews indicated that participants sought to contextualize ethi-cal behaviour, especially truth telling on an individual case-by-case basis depending on each patient’s conditions. For example, for many questions, respondents answered “it depends on the patient.” This statement is strongly connected to MoralRelativism, in that it stresses the uniqueness of each individual and emphasizes that ethical values are relative to various indi-viduals or societies.

Insummary, findings from the interviews reaffirmed that the Scandinavian participants’ decisions were influenced by a “duty” (the law), and their de-cisions can be categorized as reflective of Kant’s Ethics of Duty. According to the Scandinavian students, it was a doctor’s duty to inform his or her patients of the truth, although these consequences may not be desirable for the family. The Scandinavian respondents pondered that despite its flaws, this act of truth telling appeared justifiable.

Table4.4ComparisonofHofstede’sCul-turalDimensionIndex and Defi-nitions

Power Distance In-dex (PDI):

Focuses on the degree of equality, or inequality between people in the coun-try’s society. A high PDI indicates inequalities and wealth of people within the society.

Individualism (IDV):

Indicates the degree the society reinforces individual or collective inter-personal relationship. A high IDV means that individuality and individual rights dominate in the society. According to Hofstede’s survey from 1967-1973, most western countries, especially the United States, and Scandina-vian countries have a high IDV index.

Masculinity (MAS) Concentrates on the traditional masculine work role model of male achieve-ment, control, and power.

Uncertainty Avoid-ance Index (UAI):

Indicates on the level of tolerance for uncertainty and ambiguity within the society.

Long-Term Orien-tation (LTO)

Focuses on the degree the society embraces, or does not embrace long-term devotion to traditional thinking values. High long-term orientation indi-cates the country respect for tradition, which is ordinary for almost Asian countries.

(Hofstede: February 20, 2006b)

(Hofstede: February 20, 2006a)

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On the contrary, the Asian participants were more concerned about keep-ing the patient’s family involved. In this culture, Utilitarianism seems to be most applicable, in the sense that the ends come to justify the means (the Asian students’ decisions were based on an outcome of the family consen-sus). To put it more simply, the Asian respondents were influenced by the extended-family value. Hence, they laid emphasis on achieving a maximum utility, which in this case results in a benefit for both the patient and the relatives or the family.

Ultimately, the analysis of the participants’ answers can be boiled down to the analysis of a doctor’s virtuous acts, where Virtue Ethics proved its indispensable role of capturing the characteristics of a “good” doctor (such as being truthful, respectful, trustworthy, and sincere), according to each participant’s perception. This is a major reason why incorporating Virtue Ethics was necessary, in order to analyze the participants’ answers that fo-cus on an agent rather than a moral act.

Last but not least, the interviews illustrated that truth telling can be con-ceptualized variously as ethical or unethical, based on individual contexts, culture, and customs in a society. The Asian participants perceive truth tell-ing as a matter of group-oriented activity, whereas the Scandinavian par-ticipants perceive it as an individual right. Thereby, Moral Relativism rein-forced that perceptions of truth telling are culturally bound and that truth telling is much more sophisticated than simply judging whether telling the truth is “just” or “unjust.”

The last section of the analysis to be examined and presented as a finale of the chapter is the case scenario, which also continues the synthesis of theo-retical considerations and empirical data.

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4.4 A Discussion of the Case ScenarioAs a part of the analysis, the researchers have decided to include the participants’ thoughts and ethical considerations re-garding the case scenario about Mrs. C and Dr. P which was also presented ear-lier.

The case scenario was presented to the participants with the aim to illustrate potential conflicts between professional medical opinions and patient rights, as well as the influence of the patient’s fam-ily in truth telling. The question posed by this case scenario is: “should doctors follow the patients’ culture in revealing the diagnosis to the relatives of the patient, even though doing so may jeopardize their legal obligations to the patient?”

Obviously, there is no objectively right or wrong answer to the case scenario. However, original solutions given by Ruiping Fan (2000) shall be revealed afterwards in order to reflect on the participants’ varied answers. It should be noted that none of the participants are from the U.S. where the case sce-nario occurred. Thus, the participants in this study may not be aware of American medical law, specifically of informed consent. The majority of participants expressed that this scenario was complicated. A concrete solu-tion, however, was not expected, as much as desire to see how they would react to such situation and to investigate their thoughts and comments on solving this case.

Allparticipantsreceivedthecasescenariotogeth-erwiththeinter-viewquestionspriortothein-terviews,allow-ingthemtimetopreparein-depthresponses.

Case Scenario

“Mrs. C was an 80 year-old-Chinese woman who came to visit her daughter in the United States. With little knowledge of English, Mrs. C was sent to a hospital because she experi-enced loss of appetite and rapid weight loss. While Mrs. C waited in one of the examina-tion rooms, her daughter made a request to Dr. P and emphasized her view that if Dr. P concluded that her mother had a life-threat-ening disease, he should not directly reveal such information to Mrs. C. The daughter explained that in the Confucian tradition, it is considered rude and unsympathetic for a physician to give such information to an el-derly, seriously ill patient. Instead, this infor-mation should be given to the patient’s family members. If the family members believe that it is appropriate to share medical bad news with the patient, the family members and not the doctor should do so.”

(This hypothetical case is presented in an article by Ruiping Fan, B.M. PhD in H.E.C Magazine 2000; 12(1): 87-95)

Mrs. C and Dr. P

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4.4.1TheAsianParticipants’SolutionsThai1

“… in my opinion I will discuss to the family member first, be-cause if I say something to the patient he or she will have some conflict with the family members…” (Thai 1: L163).

According to the first Thai participant, the doctor ought to take the fami-ly’s wishes into consideration when informing them about Mrs. C’s disease. This Thai participant understood the family’s desires clearly, as he stated that a conflict with the patient’s family could arise if he revealed the truth to the patient directly. According to his understanding, it was not important whether the patient or the family was informed first: “It’s not important to tell the patient first or tell the family member first, but it is important to tell the patient […]” (Thai 1: L185, 186).

A Utilitarian approach, therefore, seemed to be adapted by this student as he sought to secure happiness of the family under this particular circum-stance. The same participant explained further that if the doctor refused to follow the daughter’s request, he or she might be confronted with another probable dilemma: a conflict between his or her decision and the patient’s cultural beliefs. In any case, this student chose the Utilitarian alternative that produced maximum happiness for both the patient’s family and the patient.

Thai2“I will tell the information to the relative, but I want to know what is the relationship between the patient and the relatives, the son, the brother, the sister, or the daughter. Sometimes there are many people involved.” (Thai 2: L92-94).

The second Thai participant argued that he had to explore closeness be-tween the patient and his or her family members: “…and then tell the truth to the closest family member, like the son, brother or sister of the patient.” (Thai

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2: L96). He further commented that this particular circumstance was in fact an ordinary case in Thailand, where the patient’s relatives demand doctors not to reveal the diagnosis to the patient. He reaffirmed that: “It has to be the daughter who tells the truth to the patient.” (Thai 2: L104). However, when confronted with the interviewers’ extended question on whether Mrs. C. had the right to know the truth or not, he contended that:

“Before the daughter asks the doctor not to tell the truth to the patient, she [the daughter] should talk with her mother first, like “I have to talk to the doctor and I’ll tell you. You don’t have to talk to the doctor.”” (Thai 2: L106-108).

This participant would leave the decision on revealing the truth in the hands of the daughter. He trusted that the daughter would communicate with her mother before the diagnosis. Provided that Mrs. C consented to pass her rights to the daughter, it should be the daughter who would then inform the doctor about her mother’s wish. Yet, it could happen that the daughter did not seek her mother’s consent but still insisted that the doctor should not tell the truth to her mother.

The above ramifications manifest trust between the family and the doctor as well as suggest specific medical procedures in China, where doctors would likely to consult the patient’s diagnosis with the family before the patient him or herself. This participant clarified that he must evaluate the patient’s general backgrounds (such as age, education, and presumed knowledge about the disease) before he could reveal the diagnosis to patient.

“I will add information about the disease and tell the patient (in-directly), like… how many days he has to stay in the hospital […]” (Thai 2: L45-46).

As mentioned in his above quotation, this participant would indirectly pro-vide additional information about the disease to the patient by informing

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him or her the length of stay at the hospital. This indirect approach could be viewed as one element of high-context culture prevailing in some Asian countries, where: “[…] one is expected to be sensitive to subtle contextual cues and to not assume that critical information will always be verbalized.” (Ferraro, 1998:53). Ferraro further states that: “This cautious approach can be seen in the general suppression of negative verbal messages. As a result, politeness and the desire to avoid embarrassment often take precedence over the truth.” (ibid).

Thai3“It’s hard to tell the bad news to the patient, because anyway she can’t understand English, so you have to tell the relatives.” (Thai 3: L143-144).

“I think it depends on the status of Mrs. C. […] I mean you have to judge that Mrs C. is well prepared or not, if she is prepared and you think that her condition is OK I think you can tell her […] I think it’s an individual problem.” (Thai 3: L150-153).

The last Thai participant would consider primarily the patient’s emotional condition. She premised her solution on the doctor’s professional opinion on judging whether or not Mrs. C was well prepared to hear the truth, regard-less of the daughter’s request. If Dr. P’s professional judgment proved that Mrs. C could handle the truth, then he would reveal it to Mrs. C. This jus-tification was also observed in answers from other Thai participants when they were enquired whether the patient has a right to know the truth:

“I would have to know the background of the patient first, about the education, about the social economy, and about the general health.” (Thai 2: L56).

Chinese1 “If I were doctor P […] I would probably agree with her daughter [Mrs. C’s daughter]. The first reason, the patient is an 80 years old Chinese woman. I don’t think she will get enough education […] in China actually a lot of patients they don’t want to know the truth.” (Chinese 1: L119-122).

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“Sometimes, of course at the beginning they want to know some-thing. But some of them don’t want to know the completely truth.” (Chinese 1: L124-125).

However she further stated:

“[…] if the patient really wants to know the truth I will think about it.” (Chinese 1: L127).

But her final conclusion to the case scenario was:

“[…] after Dr. P. talked with her daughter [Mrs. C’s daughter] I guess I probably won’t tell if the diagnosis is very serious, prob-ably I won’t tell the lady about her disease.” (Chinese 1: L129-130).

The interviewers reminded the Chinese participant that American medical law did not allow Dr. P. to directly discuss the diagnosis with the daughter without Mrs. C’s consent. However, she did not perceive her solution con-flicted with legal medical obligations, because: “We [don’t have] some law about this [in China] […]” (Chinese 1: L136).

She clarified that medical law (especially of truth telling) did not have a substantial impact on Chinese doctors and that doctors were likely to avoid telling the truth directly to the patient. This medical practice is ordinary in China. She also referred to the term “therapeutic privilege11” which provides doctors with special rights to perform treatment: “[…] against the patient’s rights of informed consent.” (Chinese 1: L154).

Singaporean1“Dr. P. could tell the family that with a life threatening, disease, it is often impossible to withhold the truth forever. He should en-courage the family to take the responsibility of breaking the bad news to the patient and to show their support for the patient. It

11 The therapeutic privilege allows a physician to legitimately withhold information, based on a sound medical judgment that divulging the The therapeutic privilege allows a physician to legitimately withhold information, based on a sound medical judgment that divulging the

information would be potentially harmful to a depressed, emotionally drained, or unstable patient. (Beauchamp et al., 2001:84).(Beauchamp et al., 2001:84).

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should be made clear that the patient has a right to know, and that if the patient should ask the doctor directly about her condition, the doctor has the responsibility to tell her the truth.” (Singapor-ean 1)

4.4.2 Concluding Remarks on the Asian Participants’ Solutions The above answers contemplated by the Asian participants resemble Hof-stede’s Cultural Dimensions. In Asian countries sampled in this study, peo-ple tend to exhibit long-term commitments to their family members and close friends. Their societies also foster strong relationships in a community where everyone takes responsibility for fellow members. These collectivis-tic attributes could be the reason why Asian participants, without hesita-tion, would almost spontaneously tell the daughter of Mrs. C’s diagnosis. Undoubtedly, they are familiar with decision-making that accommodates the family’s wishes.

When the case scenario was presented, they grasped the situation instant-ly and did not conceive any ethical problems in giving the information to the daughter. Their answers also correspond with the following statement: “[…] the Eastern pattern of medical decision making is “familistic.” Typically the entire family, rather than the patient, makes medical decisions for the patient.” (Fan, 2000:89). Thus, illustrating the illness of a family member is a family matter.

It should be noted that although the case scenario occurred in American so-ciety, the Asian participants could easily relate to their own culture, synony-mous with that of Mr. C. They seemed to be accustomed to the daughter’s request and Mrs. C’s situation. One of the Thai students commented on this particular situation that:

“We have many cases like this in Thailand too. The relative doesn’t want the doctor to tell anything to the patient.” “It has to be the daughter who tells the truth to the patient.” (Thai 2, L101-104).

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In connection with the four ethical theories, the Asians’ solutions fall into Moral Relativism postulating that an ethical act is led by societal values. It is acceptable in Asian societies (Thailand, Singapore, and China) that doctors let the patient’s family decide when/whether the truth should be revealed. However, such practice can be disapproved in Scandinavian societies (such as Denmark and Finland). In order to argue how the Asian participants would have acted in a more morally relativistic manner, one could suggest that a modified case scenario featuring an Asian doctor and a Western pa-tient should have been applied.

It should also be noted that Kant’s Ethics of Duty and Utilitarianism may not be as applicable to the Asians’ responses as clearly as Moral Relativism. This condition is due to the fact that both Kant and Utilitarianism target an agent and consequences of an act respectively, instead of the morality of culture. The Asian participants did not perceive truth revelation to the patient’s fam-ily an ethically incorrect practice. Therefore, their answers do not belong to Kant’s maxim or to the Utilitarian greatest happiness principle.

4.4.3TheScandinavianParticipants’SolutionsFinnish1

“I would tell it to Mrs. C because, in fact it is illegal not to tell. (Finnish 1: L100-101).

This Finnish medical student was the most persistent of all participants, as he insisted that the doctor must tell the truth directly to Mrs. C because the law obliged him to do so. However, if there is no specific law on truth telling, he would consider the daughter’s request. Otherwise, he could not break the rules:

“But the law is that you must tell to Mrs. C. In ethical ways it’s much more complicated.” (Finnish 1: L105-106).

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This Finnish student supported Kant’s moral obligation, especially in Kant’s declaration: “If there is something I morally ought to do, I ought to do it no mat-ter what – whether or not I want to” To be more concise, without any legal obligations, he was in fact willing to accommodate the daughter’s wish: “I wouldn’t consider it unethical to tell to the daughter.” (Finnish 1: L115). In theory, this participant may find himself caught in a dilemma of what he was legally obliged to and what he thought to be ethically correct under this specific situation.

Finnish2“I don’t see any problem that to tell the results to the daughter […] In many cases that the patients can’t understand the medical terms it is quite often that they want help from their daughter or son and we will speak with the daughter or the son […]” (Finn-ish 2: L94-98).

“It’s not a problem for me considering that the patient’s back-ground may be a problem for the doctor to talk with the patient. In some cases, the family may not be good to the patient and they ask that the doctor should not tell anything to the patient. But we have to ask before hand whether the patient wants the information being shared with some family members or somebody else and we will put this request in the medical records that the patient wants the information to be shared with family members.” (Finnish 2: L100-108).

The second Finnish participant emphasized that he would take the fami-ly’s desires into consideration whenever: “[…] it will be good for the patient.” (Finnish 2: L113). Thus, he strongly illustrated the Utilitarian approach, up-holding the consequences of an act and what makes the most people happy under a certain situation.

The second Finnish participant’s answer was not as similar to that of the first Finnish participant as the researchers anticipated, although they bear no cultural and educational differences. Their answers could prove that

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Kant’s moral obligation would not always be applicable and universal, as he proposed. Even if medical law did not allow them to communicate with the daughter without Mrs. C’s permission, both participants were willing to bend the rules in order to perform their best.

From an Utilitarian’s perspective, the daughter’s request is not considered in conflict with the doctor’s ethical standard. However, the only problem that remained was that the daughter did not wish her mother to be informed by the doctor in any case. This proved that culture can overrule doctors’ pro-fessional judgements, which Utilitarianism has yet been able to refute.

Danish/Afghan1“[…] I would first of all require a translator. And then I would ask the permission of the family because I think you need to respect the family as well and their traditions. One cannot just overrule them by that. And then try to explain the family that I as a doctor need to speak with the patient in seclusion, in a room, one by one. And when I would be with the patient and the translator would be present as well, I would go step by step and I would say that we need to speak about something seriously, I have a request from one of your family members because of your traditions that you practice in your home country, that if there is something seriously that we wouldn’t or shouldn’t tell you this. Do you agree with that.” (Danish/Afghan 1: L313-322).

There might be a chance that the patient would interpret the doctor’s dis-course negatively, if he or she mentioned: “we need to speak about something serious.” However, Mrs. C was from China and she was not familiar with di-rect communication from the doctor; therefore explaining why the daughter did not want Dr. P to approach her mother. As stated earlier by the partici-pant, he would not in fact inform the patient directly, if “there is something seriously […] we shouldn’t tell you this.” At the present stage the doctor had not examined Mrs. C yet. However, he would like to confirm with the pa-tient that if something appeared to be wrong, he should inform Mrs. C’s daughter and not Mrs. C herself.

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The Danish/Afghan participant clearly adopted a Moral Relativistic point of view in his attempt to solve this case scenario, as he stated:

“[…] I think you need to respect the family as well as their tradi-tions. One cannot just overrule them by that.” (Danish/Afghan 1: L314)

This participant leaned towards the cultural-ethical relativism placing an emphasis on ethical values varying from society to society, and on the moral values of individual basis. However, a Kantian approach may also be no-ticeable in this participant’s answer. He tended to follow medical law by accepting the patient’s decision on how she wanted to be informed about her diagnosis.

Danish2“I think you have to respect the culture, because this old woman has grown up with this culture […]. And maybe it’s the only cul-ture she has known. I think it’s important to respect the culture and then maybe I will try to persuade the daughter in telling her mother just something about the situation so the old woman isn’t without any clue at all. […] I believe first of all that old people or the elderly they have some kind of instinct. They can feel when their time is running out. So I think I will try to persuade the daughter in telling her mother that it’s a bad situation and where it might lead her to. But I will take a long talk with the daughter.” (Danish 2: L157-164).

The second Danish participant expressed her moral commitment to satisfy the daughter’s desire: “I think you have to respect the culture.” Her clarification corresponded with what Kant calls “moral obligation,” where he states: “If there is something I morally ought to do, I ought to do it no matter what – whether or not I want to, and whether or not it fulfils my desires and goals or is approved by my society.”

In fact this medical student was willing to push medical law aside in order

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to comply with the desires of the patient’s family, although from a legal perspective, the society may not approve it as a legal act. Therefore, from a pragmatic point of view, Kant’s moral obligations are not completely ap-plicable in real life. Moreover, in accordance with the Danish/Afghan par-ticipant, the elements of Moral Relativism can also be traced in the second Danish participant’s response:

“[…] this old woman has grown up with this culture […]. And maybe it’s the only culture she has known. I think it’s important to respect the culture […]” (Danish 2: L157)

Consequently, by this statement she concurred that it is necessary to accept Mrs. C’s cultural background making the situation more comfortable for Mrs. C and her family.

Danish3“[…] maybe I would be a little bit […] smart, and I would not di-rectly talk to the daughter, but I would use the daughter to trans-late to the mother.” (Danish 3: L1�0-1�2). “I would have to do it that way. You can always say afterwards that, OK I didn’t talk to the daughter; I just used the daughter as a translator. […] The overall idea of saying this is, I would have to tell. I would have to talk to the patient. And in this case I would use the daughter.” (Danish 3: L164-165 & 167-168).

One might question if this participant adopt the view of Kant’s categorical imperative, stating that: “one should never treat humanity simply as a means but always at the same time as an end.” It seems that this participant was us-ing Mrs. C’s daughter as a means to translate his conversations in helping her mother. One should be able to distinguish this answer from that of the Danish/Afghan participant. The Danish/Afghan participant would require a translator, so in this sense, he did not really exploit the daughter as a means. Furthermore, one might ponder whether the daughter would not be biased since she was a family member of the patient. This assumption

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was of course a decision for the doctor to make based on his or her profes-sional opinion. Even though the third Danish participant required Mrs. C’s daughter to act as a translator, it was with his final end in aiding Mrs. C and her family. The veracity of this student was expressed in the following statement:

“I’m a doctor and I have to do good to people, I have to help the people and then maybe I can help this old lady, that I would have to use any possible ways, and meaning that I would talk to the daughter, and make her translate to the mother.” (Danish 3: L172-175).

The above response further highlights his intentions to help Mrs. C even though he had to exploit the daughter as a means. Therefore, the rationale behind his exploitation of the daughter can be categorized into Utilitari-anism: an ultimate intention to do good to people. Another ramification for this student’s solution could be that he intended to protect himself (by requesting a translator) if questioned why he informed the daughter simul-taneously, which can potentially be perceived as breaking the law.

4.4.4 Concluding Remarks on the Scandinavian Participants’ Solu-tionsThe majority of the Scandinavian participants agreed that the situation pre-sented in the case scenario was very difficult and complicated. They re-quired more time to reflect on solutions than the Asian participants. Even though they were aware of the conflicts of whether Mrs. C could be in-formed directly or not according to the medical law, most of them decided to take a cultural sensitivity approach to solve the situation. Only the Finn-ish student decided to directly inform Mrs. C directly regardless of the po-tential ramifications of his actions.

Although as mentioned earlier, he was willing to talk to the daughter if the

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law did not prevent this act. The implication could be that, even though the law insisted that the doctor informed Mrs. C directly (or at least obtained her consent to reveal the diagnosis to the daughter), he was likely to recog-nize the importance of culture and adhere to the family’s wishes. In general, the Scandinavian participants were more concerned about the law in order to do what they believed was right for Mrs. C and her daughter. This find-ing could of course indicate that they focused greatly on the legal implica-tions of their acts, instead of the culture to which Mrs. C belongs.

Combining all participant responses, it should be highlighted that cultural issues actually play a pivotal role in this situation. As indicated in some of the participants responses, Utilitarianism can be applied only at a limited level - meaning it will only provide maximum happiness to a limited num-ber of people at a time. This is because each human being is unique and as in the case scenario, what produces the highest amount of happiness to Mrs. C may not necessarily be applicable to all other patients of Dr. P.

Thus, applying the theory of Utilitarianism as a universal rule still leaves much to be desired, especially when dealing with patients in a fragile state of their lives. These patients need extra care in regards to their personal needs and desires. Some of the participants also expressed their concerns in their responses to the case scenario:

“I think you have to respect the culture.” (Danish 2: L157).

“I think you need to respect the family as well and their tradi-tions. One cannot just overrule them by that.” (Danish/Afghan 1: L314)

However, as mentioned in chapter 3 about Utilitarianism: “[…] in most cases the majority of all actions will be steered by the happiness for a limited group of people.” This limitation of Utilitarianism is precisely what this project’s re-

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searchers are referring to. As a result, in order to apply the Utilitarian per-spective to patients in similar situation as Mrs. C, the doctor needs to find out what actions will lead to the happiness for this limited group of people, or in this case, for Mrs. C and her daughter. The second Finnish participant summed it up in the following statement:

“You have to find out with the patients first whether they want their information to be shared because in Finland we have a law. Some cultures or countries may have their own ideas about what they want and how they want to be treated and so on. And if we are aware of their wants and try to go the same way, it will be good for the patient.” (Finnish 2: L110-113).

Furthermore, the results indicated that all participants took a culturally sen-sitive approach in solving this case, indicated by their willingness to aid the patient, despite being in conflict with medical law; the only exception was the first Finnish respondent, who strongly reiterated his commitment to the law. The essence of the participants’ responses was covered by Moral Rela-tivism in that: the differences in culture do not necessarily imply that two people who disagree on the answers to a particular moral question cannot agree in their basic moral views.

4.4.5TheSolutionofRuipingFanNow that the participants have shed light on how they would cope with the situation, it is finally time to reveal how Fan (2000) presented a solution to the case. It is important to note that the article was written with the inten-tion of focusing on the ethical perspectives.

One way Dr. P could respond is according to his standard of practice in his home country, the U.S. He could say to the daughter of Mrs. C:

“[…] this is America. I must follow my standard of practice. Your mother is competent and knows some English. So I must speak with her directly and obtain her consent to treatment.” (Fan, 2000:88).

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This approach does not demonstrate cultural sympathy and nor does it take into consideration the cultural perspectives of the patient, and perhaps oth-er approaches should be made available in such situations. For instance Dr. P could also have said:

“I understand that in your culture your daughter is supposed to take care of you in this situation. I should speak with her about your disease and treatment. Do you want me to do that, or you want me to speak with you directly? Either way is good for me. So would you please make a choice?” (Fan, 2000:88).

This situation allows Mrs. C. to make the decision herself. She can then appoint her daughter as her advocate and thus allowing her to make medi-cal decisions on her behalf. In this way, Dr. P. complies with the medical laws of his home country and, at the same time, takes the patient’s cultural background into consideration while permitting the family to follow their cultural beliefs. For Dr. P, who has a Western cultural background it may be difficult to understand the reasoning of the Chinese family. However, for Eastern cultures, this familistic pattern of medical decision-making is not viewed as depriving the patient’s rights to make health decisions. More-over, the patient often welcomes the involvement of the family because the family relieves the burden from the patient; therefore, also the burdens of listening and providing consent to the doctor (Fan, 2000:89-90).

Furthermore, as the Chinese participant also stated: “[…] in China actually a lot of patients they don’t want to know the truth.” (Chinese: L119-122). The reason why they do not want to hear the truth is due to the fact that: “[…] when a fatal diagnosis or prognosis is made, the Chinese believe that it is unsym-pathetic to provide such information directly to the patient.” (Fan, 2000:90). This has indeed been a practical ethical rule in China for centuries, that the doc-tor does not directly inform the patient about his or her fatal diagnosis or prognosis, but instead speaks directly to the relatives. Fan suggests that Dr. P takes the culturally sympathetic approach in response to Mrs. C’s daugh-

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ter’s request. Therefore, if the Chinese family agrees with this approach, the American culture and law has been abided, as Mrs. C herself has appointed her daughter as her decision maker and Dr. P would not violate the stan-dards of medical practice in his home country.

However, Fan (2000:91) adds that: “Of course the physician has the right to maintain his or her moral integrity.” For example, in instances where the doc-tor finds that the family has not made decisions in the best interest of the patient, then he or she can refuse to act on that decision. One final option is, to simply consult the patient directly. The same response also came from the second Finnish participant who stated:

“In some cases, the family may not be good to the patient and they ask that the doctor should not tell anything to the patient. But we have to ask beforehand whether the patient wants the information being shared with some family members or somebody else and we will put this request in the medical records that the patient wants the information to be shared with family members.” (Finnish 2: L104-108).

In summary, Fan’s approach incorporates Kantian, Utilitarian, and Moral Relativistic reflections forming a holistic approach of how to handle the situation; demonstrating that the four ethical theories can be applied differ-ently, according to the perspectives of the doctor who may or may not be culturally sympathetic to his or her patients.

The studies of Fan (2000) and Fan et al. (2004) mainly focus on justifications of how Western physicians obtain informed consent from Asian patients (especially those of Confucian conventions). His research theme is set out in order to investigate an impact of Confucianism on medical professionals in taking patients’ cultural background into consideration and simultaneously following medical laws in the US. Although this project is cross-examined with Fan’s studies, it has produced a variety of findings that he has not en-compassed, both in terms of themes and research subjects.

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First of all, this thesis not only concentrates on medical students, but also applies an alternative approach by seeking to put forth the participants’ perceptions of a cultural sensitivity and the obligations to medical law.

Second, this study aims at a comparison of perceptions between Asian and Scandinavian medical students as well as their views related to their own beliefs in ethics of truth telling.

In fact, the present study also reveals that the Chinese medical student de-sired for stricter medical laws in China, especially in the area of informed consent, with the intention to provide doctors with clear guidelines when they need to inform the patient about his or her disease. Although only one Chinese participant was interviewed, this new finding has not yet been mentioned in other studies, including that of Fan (2000). Nevertheless, find-ing this discrepancy does not necessarily mean that Chinese patients, such as Mrs. C and her family, would agree on such change in the law, as it may conflict with the Confucian traditions valuing the prominent roles of the patient’s family members in truth telling.

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chapter 1

chapter 3

chapter 4

chapter 2

chapter 5

ConclusionThis chapter contains the following:

Conclusions to the Research Ques-tionsConclusions to the Problem Formula-tionFuture Research Possibilities

•

•

•

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5 Conclusions

As is so often the case in qualitative research, there does not appear to be precise and objectively right or wrong answers to the question about peo-ple’s perceptions. However, through the investigation of participants from both Asia and Scandinavia, this project can propose that perceptions of truth telling are differentiated between the two regions. This finding has been substantiated by primary data from interviews, together with theoreti-cal concepts about cultural dimensions and ethics, and through a literature analysis.

Throughout this project, truth telling has been applied as a research subject to examine how and what differences exist in people’s perceptions. Find-ings indicate that generally the Asian participants believe that truth telling is a family decision, whereas the Scandinavians typically perceive it as an individual matter. Why do they think differently and what influences their perceptions? The time has finally come to provide conclusive answers to these research questions.

Researchquestionno.1: Whatarethedifferencesinperceptionsoftruthtellingamong

medical students with different cultural backgrounds?

KeyWords: Group/Individual-Oriented Decisions, Collectivism, and Indi-vidualism

For the Asians in this study, truth telling was perceived to be determined based on family consensus rather than an individual decision. Their percep-tions are driven by “familistic” or “collectivistic” values. This finding is forti-fied by responses from the Asian participants manifesting some primary

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Chapter 5 - Conclusion

traits of collectivism, such as: the family knows the patient best (Thais) the family provides moral support to the patient

(Thais) the family would be the one who takes care of the pa-

tient (Chinese) most of the decisions to inform the patients are made

by the doctors after consulting the family (Singapo-rean)

it would be better for the truth to be told to the patient by the relatives, with the doctor playing an advisory role (Singaporean)

It should be noted that the Asian participants neither emphasize the impor-tance of medical laws, nor prioritize the patient’s rights. Thisfindinghigh-lightstheunderlyingdifferencebetweentheScandinaviansandAsians.Namely that, Western law usually requires consent directly from the patient, so long as the patient is competent. As findings in this project illustrate, this is not what the Asians (in this project) perceive as a normal practice. How-ever, this does not mean that the Asian subjects disregard individual rights. From the interviews, it seems that while they do not prioritize individual rights, they tend to examine medical ethics on a more personal level by re-flecting through a relationship between the doctor and the patient’s family. That is, a doctor must ensure that the family is aware that the patient has a right to know, even though the family may decide not to reveal the truth to the patient. Thus, their answers with regards to revelation of truth follow the chronological direction shown below:

Thedoctorconsultswiththefamily.Heorsheensuresthatthefam-ily is fully informed about the diagnosis and the patient’s right to know the truth about diagnosis. Then, the family makes a final decision

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onwhetherornottorevealthetruthtothepatient.Ifthefamilydecidesthat the patient should not know, the doctor will be obliged to follow thefamily’swish.Inthecasewherethepatientexpressesthatsheorhewishes not to know, the doctor has no obligations to inform her or him

On the contrary, perceptions of the Scandinavians in the study seem to re-flect more “individualistic” conventions. They place emphasis on medical laws and accentuate patient rights. Their point of view consists simply of a relationship between the doctor and the patient, not considering the pa-tient’s family. The majority of the Scandinavian participants’ responses, ex-hibiting key traits of individualism, reaffirm this finding:

medical law holds doctors liable if the patient does not give informed consent (Finns)

the doctor is not allowed to discuss the diagnosis with the family without the patient’s consent (Finns and Danes)

the patient is self-reliant and capable of making deci-sions unless his or her ability to render decisions is interfered by diseases, such as dementia, or in a case of young patients under age (Finns and Danes)

Thus, the Scandinavians’ answers pursue the following route:

Thedoctorobtainsinformedconsentfromthepatient. Thedoctorinformsthepatient.Basedonprofessionaljudgments,truthisconveyedtothepatientwithsupportfromthefamily.

In summary, findings from the interviews, in conjunction with review and analysis of the theories, reinforce that the perceptions of the Scandinavians are subject to individual bias and lean more towards duty oriented behav-iour than to group conformity. This finding marks the most important dif-

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ferenceinperceptionsbetweentheAsiansandtheScandinavianswhocomprisedthestudy.

Researchquestionno.2: How do patients’ cultural and religious backgrounds play a role

intruthtelling?

KeyWords:Cultural and Religious Conventions

According to medical students, patients’ cultural and religious backgrounds have strong influences on both medical treatment and truth telling.

MedicalTreatment: Influences on how patients should be treated.From the medical students’ point of view, doctors have to pay special at-tention to some cultural and religious conventions that may conflict with medical treatment. The influence of religion that appears most prominently within this project is that of Islamic teachings. For instance, it is crucial to inform a Muslim patient if medicine used in treatment contains alcohol. Patients sometimes also refuse treatment altogether because of their reli-gious customs, as happened in the case of some fatalist Muslim patients in Thailand whose religious beliefs associate causes of diseases with God’s will. Under such scenario, any kind of treatment must be consented from the patients and doctors cannot just force patients to accept therapy if it is against their will. Nevertheless, the conflict between religious beliefs and medical treatment has still remained a controversial subject and is not a main focus of this study.

TruthTelling: Influences on who (the patient or the patient’s family) should be informed about the patient’s diagnosisRegarding how to inform the patients of their diagnosis, the Asian partici-pants would not hesitate in leaving it to their family members to decide

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how the patients should be informed. This was adeptly illustrated in the case scenario where a Chinese elder is admitted to a hospital in the USA and her daughter requests the doctor to follow Chinese medical practice that directs any available information about the patient’s diagnosis to the family members. The Asian participants do not see it as a problem to inform the daughter about her mother’s diagnosis and then have the daughter pass on this information to the patient or conversely choose not to tell the patient at all [which was contended by the Chinese participant and supported by Fan (2000)]. On the contrary, the Scandinavian participants tend to follow “the rules,” in spite of certain deviations. Some of them would request a transla-tor, or use the daughter as translator in order to keep direct communication with the woman. However, some of them would not object to following the daughter’s request if confronted with the scenario described above.

It appears difficult to justify whether the doctor should respect the patient’s cultural background or follow medical laws in telling the truth directly to the patient. Most of the participants are inclined to apply a cultural sym-pathetic approach (to respect the patient’s culture). Only one Finn would reportedly strictly follow the rules.

Researchquestionno.3: Whatarethegroundsofwhetherornotpatientsshouldbe

informedabouttheirfataldiseasesaccordingtomedicalstudents (as decision makers)?

KeyWord:Informed Consent

The practicalities of these questions indicate that the decision of whether or not to reveal the truth is entirely based on each patient’s conditions, in other words, it is “context-specific.” According to medical students, the doc-tor must evaluate conditions of the patient both physically and mentally,

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consider education (in some cases in Asia, patients’ education has an impact on how much the doctor will inform them), age, occupation, and presumed knowledge about the disease. Some patients may want to become familiar with all available information about their disease, while others would want to know only the best way to cure it.

The most direct answer to the third question, however, is on the grounds of informed consent. All participants agree that if the patient demands informa-tion, the doctor must willingly provide it, regardless of any other factors mentioned above. Therefore, informed consent is the primary rationale be-hind medical students’ decisions in disclosing the truth to their patients.

Now that all of the sub-questions are answered, the time has come to an-swer the overarching thesis question:

Whatconstitutestruthtellinginpatientdiagnosis/prognosis fromthemedicalstudents’perspectives?

KeyWords:Culture, Ethics, Religion, Medical Law, and Family

Culture,ethics, religion,medical law,and family are all major determi-nants of overall perceptions of truth telling. These key words appear to con-cisely convey the meanings of truth telling from medical students’ perspec-tives.

To some degree, culture shapes Asian medical students’ perspectives to-wards truth telling, as mentioned above. The influence of culture is reflect-ed through values of group-conformity and the important role of extended family. The Asian participants do not hesitate to include the patient’s family when revealing the truth, as the prevailing belief is that the family knows the patient best. These acts manifest a trait of group-oriented decision-mak-

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ing. The key reasoning behind the acts is status quo - this is the way to deal with truth telling in Asian countries. Medical law does not seem to influ-ence the Asian participants when considering how to tell the truth to the patients.

The distinction between the Scandinavians’ and Asians’ perceptions is vis-ible, not only in terms of their decisions on revealing truth, but also due to their concern about medical law. From the review of analysis, it is reason-able to conclude that Scandinavian participants tend to adhere to rules and guidelines, which marks another notable difference between the Asians’ and Scandinavians’ perceptions. However, where there is some doubt about cultural practice or ethical acts, medical law seems to overrule. One Chinese participant stated that she would actually like the Chinese medical law to be more specific on this exact subject thus indicating a desire for more spe-cific medical law and stricter guidelines regarding truth telling.

Delicate ethics come into the picture when the participants are in doubt whether truth should be revealed, especially when truth is thought to be too painful to endure. However, the medical students would evaluate each patient on a case-by-case basis considering the above-mentioned factors as well as the patient’s individual wishes.

5.1 Future Research PossibilitiesThis project has employed qualitative interviews with a limited number of participants. To be properly generalized and applied to a larger group of population, the samples would need to be greatly expanded, both in terms of cultural diversity and sheer quantities. Therefore, with this limitation in mind, this project can provide some suggestions for future studies within this theme, such as:

Combining quantitative research with qualitative research. This

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method has some advantages in that it would provide more gener-alized findings by featuring a much larger sample size. Thus, find-ings would become more valid and applicable to a larger population. A future study on the same subject area could be conducted by the means of a questionnaire survey and a focus group study.

Considering that Denmark continues to have a growing number of immigrants, it could be interesting to invite more medical students of varying ethnic backgrounds to participate in future research. Moreover, it would be interesting to find out how these participants reconcile their different cultural issues with simultaneous respect of the medical laws in Denmark.

Another interesting topic pertinent to the previous point, and was

actually mentioned by one Dane in the present research, is regarding the notion that medical students should be more educated in how to best deal with patients of various cultural backgrounds, bearing in mind that Denmark is becoming a culturally diverse society and cultural sensitivity is a key competency for the health profession, among many other fields.

There could also be a study about the morality of telling the patient a “white” lie. As reaffirmed in this thesis, in some Asian countries such as China and Thailand, telling a “white” lie is acceptable if it can help in nurturing the patient’s hope when facing a life threatening illness. Potentially, a future study could be conducted in order to render de-tailed evidence or lack thereof for this suggestion.

A comparative study between newly educated doctors and doctors with several years of clinical practice could be conducted. Such a study would be interesting since it might reveal a difference in these

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two groups’ attitudes towards truth telling.

A last observation would be to conduct a study by collecting data from within European countries to compare characteristic percep-tions among people from different regions, such as Eastern, Southern, and Northern Europe. This could also be interesting in comparison with other regions, for example studying deviations within Asia.

The above suggestions will remain just that until further studies can be con-ducted. Ideally, at least a much larger sample size would be an asset in or-der to shed more light on medical student’s perspectives.

Truth telling is a very complex matter, and it will probably never be easy for doctors to inform their patients that they might only have little time left to live. However, situations like those presented in this thesis will continue to materialize on a regular basis for the medical students interviewed, as well as for all their colleagues. It is easy enough to read about ethics and how one should deal with truth telling according to text books, however it will ever remain an ethical challenge to convey difficult information in real life.

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List of Appendices:

Appendix 1 Interview Guide, Medical StudentsAppendix 2 Interview Guide, Young DoctorsAppendix 3 Symbols used in the TranscriptsAppendix 4 Interview Transcripts

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Appendices

Appendix1

InterviewGuide,MedicalStudents

ResearchQuestions InterviewQuestions

I.IntroductoryQuestions

1 What is ethical behaviour accord-ing to your understanding? (ask for some examples)

2 During your medical education, did you receive specific ethical courses?

3 What kind of ethical challenges have you discussed in the class?

4 Could you please give us some examples of ethical cases you dis-cussed in the class?

5 In ethical class, have you dis-cussed truth telling?

II. Thematic & Dynamic Questions

What are the differences in perceptions of truth telling among medical students with different cultural backgrounds?

6 Did the ethical course incorporate cultural aspects?

7 Could you give us some exam-ples?

8 Do you have experiences with col-leagues from another culture who have different views on ethical di-lemmas (truth telling) and treatment of patients?

How do patients’ cultural backgrounds play a role in truth telling?

9 In your opinion, is the patient’s cul-tural background important for phy-sicians to make a decision when they have to tell the truth?

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(If yes) Could you describe or give us some examples/ why do you think it is important?

(OR)

(If no) Why do you think it is not important?

10 What could be the reasons that are more important/necessary for physicians than cultural background before telling the truth to the pa-tient?

What are the grounds of whether or not patients should be informed about their fatal diseases ac-cording to the medical students (as a decision maker)?

11 When you are confronted with a dilemma of truth telling, how would you react to the situation?

12 Do you follow some medical standards of practice when telling the truth to the patient?

If so, what did you do? OR What do you think you would do if you had to tell a patient about the diagnosis of a fatal disease?

Justification for telling the truth to the patient:13 What would you consider before telling the truth to the patient?

14 How much information does the patient want to know concerning their diagnosis and treatment?

15 Do you discuss directly with the patient before going through diag-nosis and obtain his or her consent of discussing the result with the family?

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Justifications for not revealing the truth to the patient

16 Have you ever considered truth telling as cruel to the patient?

If so, what could be the alternatives to telling the patient the truth?

17 In your opinion, what is a “white lie”?

Is it morally acceptable to tell a “white lie” to the patient, consider-ing your professional ethics?

18 What is the harm when doctors violate cultural conventions and insist on telling the truth to the patient? (If patient is from another culture)

What could be the rationale behind physicians’ decisions in disclosing the truth to their pa-tients, according to the medical students?

19 What factors most commonly influence decisions to inform the patient?

20 If you were a patient, would you want to be fully informed?

IIIEndingQuestions&AScenario

21 Do you have anything to add about truth telling?

22 Case Scenario:

“Mrs. C was an 80 year-old-Chinese woman who came to visit her daughter in the United States. With little knowledge of English, Mrs. C was sent to a hospital because she experienced loss of ap-petite and rapid weight loss. While Mrs. C waited in one of the examination rooms, her daughter made a request to Dr. P and emphasized her view that if Dr. P concluded that her mother had a life-threatening disease, he should not directly reveal such information to Mrs. C. The daughter explained that in the Confucian tradition, it is considered rude and unsympathetic for a physician to give such information to an elderly, seriously ill patient. Instead, this information should be given to the patient’s family members. If the family members believe that it is appropriate to share medical bad news with the patient, the family members and not the doctor should do so.”

What could be a solution for Dr. P?

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Appendix2:

InterviewGuide,YoungDoctorsResearchQuestions InterviewQuestions

I.IntroductoryQuestions

1 What is ethical behavior accord-ing to your opinion? (ask for some examples)

2 How long have you practiced?

3 Have you experienced ethical di-lemmas of truth telling during your practice?


What are the differences in perceptions of truth telling among medical students with different cultural backgrounds?

4 During your practice, are there any situations where you have to consider the patient’s cultural back-ground before making decisions (about treatment, the patient’s fam-ily involvement, etc)

5 Could you give us some exam-ples?

6 Do you have experiences with col-leagues from another culture who have different views on ethical di-lemmas (truth telling) and treatment of patients?

How do patients’ cultural backgrounds play a role in truth telling?

7 In your opinion, is the patient’s cultural background important for physicians to make a decision when they have to tell the truth?

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(OR)


8 What could be the reasons that are more important/necessary for physi-cians than cultural background be-fore telling the truth to the patient?

What are the grounds of whether or not pa-tients should be informed about their fatal diseases according to the medical students (as a decision maker)?

9 When you are confronted with a dilemma of truth telling, how would you react to the situation?

10 Do you follow some medical standards of practice when telling the truth to the patient?


- Justification for telling the truth to the patient:

11 What would you consider before telling the truth to the patient?

12 How much information does the patient want to know concerning their diagnosis and treatment?

13 Do you discuss directly with the patient before going through diag-nosis and obtain his or her consent of discussing the result with the family?

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- Justifications for not revealing the truth to the patient (white lie)

14 Have you ever considered truth telling as cruel to the patient?

15 If so, what could be the alterna-tives to telling the patient the truth?

16 In your opinion, what is a “white lie”?

17 Is it morally acceptable to tell a “white lie” to the patient, consider-ing your professional ethics?

18 What is the harm when doctors violate cultural conventions and insist on telling the truth to the patient? (If patient is from another culture)

What could be the rationale behind physicians’ decisions in disclosing the truth to their pa-tients, according to the medical students?

19 What factors most commonly influence decisions to inform the patient?

20 If you were a patient, would you want to be fully informed?

IIIEndingQuestions&AScenario

21 Do you have anything to add about truth telling?

22. Case Scenario:

“Mrs. C was an 80 year-old-Chinese woman who came to visit her daughter in the United States. With little knowledge of English, Mrs. C was sent to a hospital because she experienced loss of ap-petite and rapid weight loss. While Mrs. C waited in one of the examination rooms, her daughter made a request to Dr. P and emphasized her view that if Dr. P concluded that her mother had a life-threatening disease, he should not directly reveal such information to Mrs. C. The daughter explained that in the Confucian tradition, it is considered rude and unsympathetic for a physician to give such information to an elderly, seriously ill patient. Instead, this information should be given to the patient’s family members. If the family members believe that it is appropriate to share medical bad news with the patient, the family members and not the doctor should do so.”


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Appendix3:SymbolsusedintheTranscripts

I :Interviewer.

P :Participants.

[…] :Some parts of the quotations are omitted for more concise an-swers.

( ) :Empty parentheses indicate the transcribers’ inability to hear what was said, due to bad telephone connection.

(X/Y) :Parentheses containing one or more words indicate words that the transcribers thought was being said due to lack of audio clarity.

A :Underscore line indicates stress or emphasized statement.

= :Equal sign indicates interruptions in the dialogues.

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Pilot Interview with a Male Finnish Medical Student (1): Finnish 1

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I: You told me that you also had some discussions about ethics in your medical class, right? P: Yes, we have had a course about ( ) I: And what did you discuss about, like can you tell me a little bit about it? P: We have been discussing about how the doctor basically ( ) so what a doctor I: So you said something about communication, do mean, how the doctor can communicate

with the patient? I: We are talking about communication between patient and doctor. Can you give me some

examples? P: In what situations ( )? I: Yes exactly, I mean in what situations the doctor should pay attention, when he or she

communicates with the doctor. P: Basically, basically we have talked about the problem between the communication is that

the doctor is not actually listening to the patient, because I have read that it’s about 15 seconds that the doctor lets the patient talk. So we have studied that the doctor has to listen more to the patient, and not so much talking.

I: OK, yes, I see. OK, and how about when a doctor has to tell bad news to the patient. P: Yes, we have talked about that also, like if you ( ) say it directly to the patient, but we try to

be as much sensitive as it is possible, but we are realistic about chances. You had a case of cancer here and, in cancer case for example we will tell realistic chances of surviving and something like that, so we try to be as sensitive as possible, but speak directly to the patient.

I: So, so basically it’s in that situation the doctor has to tell the truth to the patient. P: Yes. I: No matter what! P: Yes, yes. It’s the law actually (laugh). I: OK, and eh, could it be, I mean for example, if before the doctor and the patient go through

the situation and the patient asks the doctor that, if there is something happening, he or she doesn’t want to know. Then how would the doctor deal with the, eh, this kind of request?

P: Eh, I don’t really know because that’s a very complicated situation. I think it’s very rare in Finland, that kind of situation. I haven’t heard about that kind of situation.

I: OK. I just ask you because we have read about that kind of situation in other countries, so we would just like to compare. But since you say, it’s very rare in Finland, then, then it’s fine. And. So, let’s get back to the truth telling. So in your opinion, do you think that the patient’s cultural background is important for the doctor to consider, or to take into account before telling the truth?

P: Eh, eh, of course you have taken the cultural background, you have to think about it, but in Finnish law you must tell the truth directly to the patient. So there is not so many services to make, but you can do it more sensitively.

I: OK, yeah, and eh, OK. Suppose that you are in the situation that you have to tell the truth to the patient. What would be the, eh. What would you consider before you tell him or her. Like for example, if you have a patient with cancer, and your patient is an old woman, would you consider that the age might play a role in this situation, for example if you just go

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directly and tell the truth to your patient, do you think that it would hurt her feelings? Do you understand my question?

P: Yeah, yes, let me see. You think about that, if the patient is old and the age, and he won’t be living much in any case. Do you mean that?

I: Yes. P: I think if the patient is very old, in that situation the options (bad connection, not clear what

he said) I: And what is the difference, like if you have a patient who is a child, then would you

consider to tell the parents instead of telling it to the child? P: I think first to the parents, I think telling it to the child when the child is very young is not

necessary to tell directly and of course you have to tell that he is very ill but not the exact ( ) cancer is not that important in that situation.

I: So although there are rules, but still there are some situations = P: = Eh, no no, but when the child is under a certain age, it’s not that simple, because the

parents take care of the child. But if the child is independent so that he can speak about things he can, but it’s not about age I think. But if the child is independent, he can call independently to the hospital, and the parents, if the child wants ( ) and hear about his healthcare. He can ( ) and call.

I: OK, and eh, since you’ve mentioned that before the doctor tell the patient, then the doctor has to do it in a very ( ) because it’s a sensitive issue so he has to do it in a nice way, but in that situation, do you think that to tell the truth is like, is eh, is cruel or is mean because it will hurt the patient’s feelings, I mean in your opinion?

P: No, I think the cruelest is to not tell the truth. I: OK, yes, that’s very interesting. (giggle). OK, and, so. (12) So, now let’s talk about in the

opposite way, if you were a patient yourself, would you like to be fully informed about what happened to you?

P: Yes, yes. I would like to. Very important. I: OK, and do you also want the patient to tell the truth to your family, or you just want to keep

it between the patient and yourself? P: Eh, you mean, if you are a doctor, ( ) that is, you mean if I was a doctor in that situation? I: Ahh, yes. Both, yeah, OK. P: Eh, so should the doctor tell to the family, or should the patient tell it to the family. If you

mean that? I: Yes. P: Eh, I think that the patient, that’s the patient’s choice. He can, he or she can choose if the

doctor tells it or the patient himself. I: So, do I understand correctly that the patient should choose himself, whether he wants the

truth to be told to the family and? = P: = Yes. = I: = And, if he wants to do so, then if the patient would tell the family, not the doctor?

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P: Eh, eh, I think that’s really the patient’s choice, so the patient can choose if the doctor tells it to the family, or the patient can choose to tell himself to the family.

I: OK. P: Or he can choose not tell anything. I: OK. So in your opinion, the patient has fully right to do whatever he or she wants? P: Yes. Yes. Yes. Exactly. I: And the doctor has to respect that right? P: Yes, yes. Of course and eh, and I think it’s even illegal to tell. ( ) You can’t tell things about

your patient to the patient’s family without the patient’s permission. = I: = OK. = P: = You can’t do it. Yes, it’s illegal. I: OK, and eh. So can we talk a little bit about the case in the end of the questionnaire, if

you’ve read the case scenario? P: What scenario? I It’s in the end of the questions, I don’t know if you have the questions at hand right now? P: Yes I have. I: You want me to summarise what the situation is? = P: OH YES. Yes, yes yes. I have it. OK. The case scenario. OK I: So. P: (skimming through the case scenario) ( ) I would tell it to Mrs. C because. In fact it is illegal

not to tell. = I: = OK. = P: = But in ethical ways, if there wasn’t any law about that, eh, I would be discussing this thing

with the daughter, and eh, I would be searching about the best solution in this case in ethical ways. But the law is that you must tell to Mrs. C. In ethical ways it’s much more complicated.

I: Yeah, yes you’re right. So you think that if in that case Dr. P. tells the truth to the daughter then you would think it’s unethical, according to medical professional standards? Is that what you ( ). = 110

P: = Eh, if Dr. P. tells to the daughter it would be illegal. I: OK. Illegal! But, do you think it would also be unethical to tell the truth to the daughter

instead of to tell to Mrs. C.? P: I don’t know about that. That’s a complicated situation, but eh. I can say it’s unethical

because the cultural background ( ) is so complicated. But I (would/could) tell it directly to Mrs. C. because, I would tell, but I wouldn’t consider it unethical to tell to the daughter.

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I: OK, yes. And, I’m just wondering, do you have the same, like, case scenario that you discussed in your class about ethics or something like that?

P: Eh, we have discussed about things, but not this kind of case scenarios. Not such big things we have discussed. (giggle) We have discussed about truth telling, the truth telling, but there would be some ( ) much more some legal things we have discussed. We had some discussions about for example, there was some real cases where. This was a dentist, and he

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had accidentally done some cutting in the mouth and eh, ( ) stitches, I don’t know the word, sew you with the needle and eh =

I: = To sew? You mean to sew? P: Yeah, yes I mean that. Yes. He did that wound ( ) (bad connection, not clear what he said) I: OK, malpractice. So in that case it’s eh, it’s the doctor’s fault? P: Yeah, yes it actually was. But we discussed about that, if it’s so bad to tell about that, but of

course it is. (laugh). I: Well in that kind of truth telling, do you remember if there is any cultural ethics you’ve

discussed in class or?= P: = We actually discussed about this ( ) because I think the Middle East ( ) They do not tell

the truth to the patient.I: So what did you? Did you agree with the practice in the Middle East, or do you think that

they should by all means follow the practical standards, eh, the standard of practice? Because since you mentioned that, eh it’s different in different cultures.

P: Yes it is, but eh. I don’t know about how the people in that culture think about this, but I would be very disappointed if this kind of things happened in Finland or in any Western countries because I have a very (legal) opinion and that everybody should have the truth about their medical situation, not something, eh, false. And, I understand that it’s very much easier to live if you don’t know about your situation, but it’s also very cruel or very mean, not to tell.

I: OK. So maybe you just, they just, eh. There’s a difference between the Western Culture and the Eastern Culture and they look it from different perspectives and =

P: = Yes I think so too = I: OK, yes, so I understand you correctly. Can I ask you the last question? Do you have

anything to add about truth telling? P: Eh, no. But I can tell you that in Finland the truth telling is very much the law is demanding

to tell the truth. Doctors they have actually no (self) they have to tell the truth. And I also think that truth telling directly to the patient is a very good thing in Western culture because the people have ( ). They think that they will hear the truth always and, eh. I can say it very nicely, eh, but it’s hard to explain. OK.

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Interview with a Male Finnish Doctor (2): Finnish 2

I: We would like to interview you about truth telling in medical context. P: OK I: What is ethical behaviour in your opinion? P: I think it’s ethical practice like what you, as a therapist would do to yourself, like to treat

the patient like yourself.5

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I: How long have you practiced? P: About 30 years I: Have you experience ethical dilemmas about truth telling during practice? P: Ah…Not directly. Of course, there are some times about not telling the whole truth to the

because of the patient. But sometimes maybe the treatment or the choices are the patient’s. I mean, how I will go on the choice depends on something like it could be a little bit of long but not so much pain. It is also maybe very very expensive for the patient and so on. In those cases there are some ethical aspects but usually not so much.

I: Have you even been confronted with a situation where you have a patient who has terminal disease like cancer or HIV/AIDS and you have to tell the truth to the patient?

P: About that he or she has cancer or he or she will die soon, something like that you mean? I: Yes, exactly. P: I’m a cardiologist and treating a patient with hearth disease. So, not very related to cancer.

But of course, most of my patients, they will die because of heart disease most. But I cannot say to them that they will die in certain circumstances. I don’t think I have ethical problems. Of course, the most difficult part is to tell the patient that he will die sooner or later. But most of the patients know that, it also depends on the course of treatment. They can die after one week or one month. All I can do is to give them some hope as long as they live to help to live a little bit longer. So, it’s not in my practice that I treat the patient who is dying like they are diagnosed with cancer.

I: Do you have experience with colleagues from other cultures who have different views of ethical dilemmas and treatment of the patient?

P: Typically, I have colleagues who are from other fields of medicine. So, I don’t think so, because in Finland most of my colleagues are Finnish, especially in our clinic. So, I don’t know if all the doctors think the same. It’s quite uncommon to hire other doctors that are not Finnish because of the language. You know Finnish language is very difficult to talk. So…There are some colleagues come from Estonia but they can speak quite good Finnish. There was one time that there are some doctors from Spanish and English speaking countries. But they learn how to speak Finnish because most of the patients are Finnish and all the treatments are in Finnish. Of course, I don’t mind treating patients from other countries. But in daily work life, we are not much different in terms of culture and practice.

I: Have you ever had a patient from other culture, for example, from Asia? P: No. 99% of the patients are Finnish. Few are from the US and some patients are Vietnamese

but they are in other clinic. If the patient cannot speak English, like some patients are from

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Africa, there will be someone to help him or her to the doctor what is wrong with the patient. Or the patient can choose young doctors who can speak English and so on. I don’t think culture is a problem in treatment. Of course, there might be some kind of different view but in general I think it’s not a problem. But actually, I don’t have that much experience.

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I: I ask you about culture because I would like to relate it to the next question. Supposed that you are in the situation, which you have to tell the truth to the patient what she or he will not have much time left. What would you consider before telling the truth to the patient?

P: It is very different from case to case. If I know that the patient has special hearth disease that they will not have much time left according to the prognosis, if the patient asks about the prognosis I can say that according to the prognosis the patient will die after 6 months or after 1 year and so on. But it’s depends on the patient’s condition. If there are still some hopes that we can improve the condition, I think that it’s important for doctors to give some hope to the patient because we don’t know that in any case that the patient will die. Intensive care and so on can help the patient to recover. So, I will try to the truth that of course…I can’t promise anything but the situation can change and there may be some hope and the possibility of improving situation.

I: Would you talk to the patient directly or would you talk to the patient’s family? P: Usually, it’s the patient. It also depends on the patient’s condition if he can understand what

I talk to him. If he can accept then I will talk directly to him, quite often that the patient wants the relatives or someone to be with him, which is okay. Most of the cases, the patient wants information by himself and discuss with the doctor. It depends on what the patient wants.

I: As a person, and as a doctor, have you ever considered that to tell the truth to the patient that he or she doesn’t have much time left is cruel?

P: No…But of course in certain aspects, I can imagine a situation that it is very hard and very difficult shock and it may be not good for the patient. But in practice I can tell the truth and I can say at least very sympathized, like there is some kind of hope for the patient, and if the patient knows quite a lot of the disease and now that it seems to be the time that the patient should know. It’s better to talk about that and not leave the patient in uncertainty.

I: We have been talking about the truth, now we will talk about the opposite of truth, which is a lie. Do you think that it is morally acceptable for the doctor to tell a “white lie” to the patient, considering your professional ethics?

P: I don’t like a lie, or a white lie. May be there’s some kind of a good white lie but I will put it in a scientific way. So that I know that this was based on scientific research. In individual basis, I don’t think it is a lie but of course, I can put it in a positive way. So I would not say that I’m lying. If the patient wants very direct answers, I can say that (the truth) you have disease and can’t live long because of many things, but if the patient has cancer or something like that, in my opinion you should say that it is cancer, not other diseases. It’s

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better not to deny the condition that this is cancer. Sometimes I can say that it is cancer but there is treatment and the prognosis depends on the treatment. So, not telling the lie about the disease. If we see the diagnosis we can say something about what are the results of the treatment. I think you should warn the patient about the results before hand that there might be some kind of results and not positive answers. The patient should know before hand. So, it’s quite normal that you can say before hand what are the results from treatment.

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I: If you were a patient, would you want to be fully informed about the status of the disease? P: Yes, yes of course I would. As a doctor, I know the fact and I can get the fact out of the

medical record. So nobody can tell me a lie. If there are some diagnosis or special kind of treatment or some answers, nobody can lie me about what is the answer. Of course, they can put it in a better way like saying a little bit soft. I can understand that it is a good or bad but just say it in a better way. But I think the patient should be told directly, in a positive way. Not saying that you will die immediately in one month or two month. You cannot say that.

I: Did you read the case scenario at the end of the questions? Do you remember or would you like me to summarize it?

P: OK, I will read it… I think what would be the solution of Dr. P I could answer that. I don’t see any problem that to tell the results to the daughter and in this case if the patient can’t understand English. In many cases that the patients can’t understand the medical terms it is quite often that they want help from their daughter or son and we will speak with the daughter or the son of the patient about the patient. I don’t see any problem of telling the results to the daughter in this case. It’s not a problem for me. We can tell the daughter about the disease and she can tell her mother. It’s not a problem for me considering that the patient’s background may be a problem for the doctor to talk with the patient. If the patient can’t speak English, we have to ask the daughter but there is no reason to believe that this daughter will lie to the doctor that her mother can’t speak English. The daughter is not the enemy of her mother. In some cases, the family may not be good to the patient and they ask that the doctor should not tell anything to the patient. But we have to ask before hand whether the patient wants the information being shared with some family members or somebody else and we will put this request in the medical records that the patient wants the information to be shared with family members.

I: It’s quite interesting to hear your professional opinion. P: You have to find out with the patients first whether they want their information to be shared

because in Finland we have a law. Some cultures or countries may have their own ideas about what they want and how they want to be treated and so on. And if we are aware of their wants and try to go the same way, it will be good for the patient. In Finland, we have discussion about diagnosis of a young girl who came from Africa and they have some kind of special operation for young girls, which is not in the Finnish culture to do with the young girls. So this is some kind of ethics and culture and should this Finnish doctor who thinks that this is torture for a child so it should be done by a Finnish doctor because they (in

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Africa), they are not doing in professional way. This kind of problem maybe (ethical dilemma) but it is not in my practice.

I: Last question, do you have anything to add about truth telling in general? 120

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P: I don’t think so. I hope that you can get something out of my answers. But at least I can say that in Finish culture, it’s not something that absolute truth or absolute lie. But it’s something a bit grey.

I: OK. Thank you for your time.

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Interview with a Male Danish/Afghan Doctor (1): Danish/Afghan 1

I: What is ethical behaviour according to your opinion, in general? P: In general speaking? I think my view point is different from some other people, because I

have strong basis in my religion, and the religion that I practice is Islam. And there are some rules or some guidelines, some sayings of how to deal with people on a common level, and then in some specific situations how to do and what to do, and what not to do. I have combined that with different courses that I had regarding communication, and how to deliver, eh, deliver the hard messages, like telling some people that they had a cancer or something like that, so. But in general ethical behaviour is treating others the way that you want to be treated yourself.

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I: Yeah. Is that according to Islam or is it a combination between your professional practice and your religion?

P: I think both but, specifically there’s a tradition or saying of the Prophet Mohamed that: “treat each other that yourself would like to be treated.” I think this is a common principle, not just in the religion, but as a moral foundation of every people who have some kind of interactions, because in a civilization people need to interact in a correct way or else the communication will be lost. So I think people by some way they found out that this, by experience I think. Trial and error.

I: So have you met any conflicts between your religious background and the medical standards in Denmark for example?

P: On the contrary. On the contrary. Actually I felt that a lot of ways have been opened because of my strong background, and especially because in this country, the history of the Danes. And I myself was born and raised in Denmark. But the history of the Danes, when you look retrospectively, there has been, they have a different approach to religion and to Christianity in general. It’s like a taboo subject even now. But, I felt a lot of ways opened for me, how they felt that I was as a person in the hospitals I’ve been, and the way that I am with the patients as well.

I: OK, so just one short question. How long have you practiced as a medical, or a doctor? P: I believe in one and a half year by now. I graduated for one and a half year ago. I: OK. So have you experienced any ethical dilemmas of truth telling during your practice? P: What do you mean by truth telling? I: It’s like if you had to, eh, tell a patient that he or she had a fatal disease like cancer, and how

did you deal with the situation? P: Like whether I told the truth or not? I: No. P: How much did I give them the truth? And what do you mean by ethical dilemmas? I: Well, if it was difficult for you as a person or with your background or anything to tell the

patient? P: You men that if I stood in a situation where I seriously considered, should I do it or should I

not, and how much should I conceal of the message?

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I: Yeah exactly. 40

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P: No, actually not. In each conversation with the patient I try to take the pace of the patient, to let the patient decide how much should be told in the beginning. And then I just follow that and. You know for example, a patient may ask. Eh, I may come with something. We’ve made some investigation, we made an X-ray of the chest or we took some blood samples which shows that there is some cancer. And then I go to the patient and I said, eh. And the patient typically has been in the hospital for a couple of days or weeks, or it might even be the first time that I see him in the clinic. So I always start with: “We took some tests, and we have the results of them.”

I: OK, and then you reveal the news to the patient? = P: = I wait. = I: = You wait. = P: = And then I let the patient say: “So, what did they show?” “They showed that there was

some seriously going on.” And then I wait, and let them ask, because I discovered some people. You know they have in the background that they already know from the beginning that this is, that they have cancer for example. And they don’t want to hear a lot about it, they just want to know, just to come and, just to have it confirmed. So I don’t give too much information because it may be overwhelming for the patient. And some other times I have patients, they want to know everything in detail, to know what did the newest research or the newest treatment show. So I try to follow the pace of the patient.

I: So this is something you’ve learned from your ethical classes during your education, or is it something from your communication classes?

P: This is from the communication course. I: From the communication course. OK. Is that the part of the medical education or? P: It’s part of the post-graduate programme. I: Extra courses you took? P: Yes. I: OK, I see. And eh, you mentioned that sometimes it’s different what the patient wants. And

is it, eh. Patients from different backgrounds, for example from Asia or Danish patients, or it’s just difference as a person and nothing relevant with the culture?

P: Actually it’s been, eh. I know exactly what you are pointing at, eh. But I didn’t feel that I could classify people as behaving in one direction if they were from Asia or from another in another way. I (felt/found) different kinds of patients in both cultures or in different cultures, so there was no specific stereotypic kind of way that people behaved.

I: OK. P: But one could imagine that it would be so, but I didn’t experience that. I: OK. So do you have any experiences with colleagues from another culture who have

different views on ethical dilemmas? P: I did.

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I: You didn’t? P: I did.80

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I: You did? P: Yes. I: Can you give some examples? P: It might be, eh, always when I was in the medical department, eh, you know they always

start with the morning conference. And at the morning conference usually the procedure usually is that people, or the doctor, who has been on duty, he goes through the patients that came in, eh, that came in to the hospital in the previous 24 hours. So he tells about the patients one by one. And one morning I was there, and he told about a patient. And actually it was quite a sad story, about a patient who experienced some difficult things. I don’t remember the details about what actually happened, but you know, I found the doctor making a joke of it, and all the other doctors, they kind of laughed. And it was a sad story, and it was seriously, it was quite serious. And I found myself in a situation, you know. I didn’t know why people laughed, so I stood up. You know, I as a young doctor, and all of the big, elder doctors and I said I don’t find the funny in this. What’s funny about that? And some people they tried to say, oh there is no need to react in this way and everything. But I told them that. Imagine that the patient was here himself or some relatives of the patient. If they heard this story you know, they would be outraged. And I imagine myself I was being the patient. If I was, came in to the hospital and some people talked about me like that or made a joke about a serious problem, it would hurt me a lot. So, in the following couple of days I discovered that some doctors, they might do this to keep an order, or to keep a distance to the problem, but I believe there is a problem somewhere. I myself I didn’t find the solution was to make jokes with everything and in this way keep it away, you know there are some foundational things that needs to be developed in each human being, which may be lacking in those people that does like that. This is one example.

I: Do you have an example, for example let’s say, you are Muslim, is it correct? And your colleague may be Christian, and sometimes do you find that there is a difference in your opinion regarding how much, eh, regarding truth telling. Have you ever discussed that?

P: Eh, I didn’t discuss it and eh, with people because I didn’t find there’s some sort of coincidence that a Muslim tells the truth more than the Christian (laughs) No, on the contrary, I think, you know people are so different so I didn’t find any eh, anything there.

I: So, do I understand you correctly that the patient’s cultural background. You didn’t consider a patient’s eh. You treat the patient as a patient but you didn’t have some stereotypical opinion that they are from Asia so maybe they need different treatment. Do I understand you correctly?

P: In some way. You know this is of course a truth with modifications, generally speaking. This is not just people from Asia but also people from Germany as well. People coming from different countries they have some sort of traditional way of being treated by their

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doctors, and when they come to another system and they get treated in a different way, they behave differently, like for example in some of the Asian countries and in Germany as well and some other countries, you know people they give, or the doctors they administer antibiotics for example, very freely. In Denmark there is a very restricted policy in giving antibiotics. They only give it if it’s necessary. But you might find some people from a different culture coming. You know, you examine them, you listen to their ( ) you find out there is no reason to give antibiotics at all because it’s virus infection. And virus infection doesn’t need antibiotics, only bacterial infections. But still there is some sort of demand of the patients, that they need to have the antibiotics because they went to the doctor, and they need to go back from the doctor with something in their hand, a prescription. And, you know, I found this in some incidences.

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I: OK. So in some incidences the patient’s cultural background has an influence on your, eh. = P: = No, no. They don’t influence me. I found that they want to, you know they have a

different way, but they wouldn’t influence me, because if I from a medical point of view, if I find that there is no reason to give antibiotics, I wouldn’t give it. Even if they take a club and hit me in the head with it I wouldn’t give it.

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I: OK, so if we talk about truth telling if you know there is a patient from a different cultural background and you know. I don ’t know if you learned about it in medical school that these patients might not like to hear the truth directly, how, have you ever had any experience with that or?

P: Could you give me a specific example, just to relate to it? I: If for example the patient, like in the case scenario we have here in this interview that, there

is a patient from China, and they are not used to getting the news straight, but you should tell it to the family instead, how would you deal with that? Because in Denmark for example it’s like you have to tell it straight to the patient right? =

P: There are some rules actually. = I: = According to the law or. = P: = You’re right, you’re right. I need to inform the patient about everything according to the

rules, or how much, you know, how much they would like to. And if they deny that they want to hear anything I have to respect that as well. And I can only tell something to their, or I can only tell about the patient to different people, to the relatives, with the patient’s consent.

I: OK, with the patient’s consent. = P: = Yes, so it’s quite a dilemma, I just skimmed the case scenario, what do you actually do in

that situation is difficult to say. And I think, every doctor looking at this case, you know, would scratch his head to find out what one would do in that case. A way to come out of this would be if the patient had any sort of dementia [demens] or was confused or psychiatrically ill or something like that. Then you could tell the relatives without, or to let the relatives determine, what should be done and what should be said.

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I: Yeah, how about if it’s a child under age of 18 or something, here in Denmark. P: Then you have. You have to have the parents’ consent. I: OK. And if it’s an old person who is like you mentioned = P: = Dementia? = 160

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I: = Yeah, then you should tell the relatives of that person? P: Yes. Because you know, I had one dement person, patient with dementia in the hospital

when I was in Aabenraa, and eh, you know, she came in to the hospital, and it was because of diarrhoea, and eh, I spoke with her and I found out that she had a severe dementia. I asked her what year it was, and she answered, I don’t know. Do you know what place this is, that you are admitted to? She said, I don’t know. So I told her, look around. What do you see? So she looked around, she couldn’t really describe. She didn’t know where she was. So I asked her, do you think this looks like Tivoli, a funfair. So she said, yes, it looks like a Tivoli. (laughs). You know, when I told her it was a hospital, she laughed. But you know, the sad part of the story was. One minute after. Exactly one minute after. I tried the same thing and the same scenario repeated itself. I said, is it Tivoli, and she said yes it is, and I said it was a hospital, and she laughed again. You know, some people in this situation, you know you cannot give them any information because they will never believe them. So in this case, you need to rely on the relatives.

I: OK. So you said there are some rules according to truth telling and it’s important that doctors have to follow those rules, is that correct?

P: Mmm, that’s correct. I: OK. P: But there is no moral code that they need to follow. There are some rules that you need to

abide by the rules, if you don’t abide by the rules you can get, eh. You won’t get prosecuted in Denmark but you can get what they call a nose. You know, you can have a strong [påklage]

I: Sorry. = P: = en påklage, man kan få en påklage. I dont know what [påklage] is in English. I: A kind of complaint or something like that. A strong complaint. P: Yes. I: Is there anything. What would you consider before telling a truth to a patient, about a fatal

disease.P: I wouldn’t consider the patient itself. I would evaluate the patient to see what kind of person

that he or she is. How much he or she can handle. Whether there should be family present or not. And then I would ask the patient if, eh. That we have something seriously to think about, that I suggest that the family should be present if she or he agreed upon it. I would consider the time lapse from telling. I could give a warning shot, like we need to sit together and discuss this more thoroughly. Maybe we could meet after one week or a couple of days if. Medically if I had the time to it. And I would evaluate the situation, the surroundings of

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me in the hospital. In the room. Other patients present or not. And the surroundings in their home, you know are there any nurses helping them in their homes if I tell them this story, who would be able to take care of the patient when they leave the hospital because in the hospital, they are you know, I have them. I can take care of them. I have the nurses. I have everything that I can handle around with. But if I send them. Eh, the moment they are out od the hospital, you know, I don’t have anything to do with them anymore. Who will take of them as well. So, this is some of the things one needs to consider. And of course also the disease itself. You know. How much time is left. Is there any cure available or.

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205I: OK. And if there is not much time left, would that make you. Would it be easier for you to

make a decision that you’d better tell the truth right now instead of prolong = P: = I would always tell the truth, but I would let the patient know when the truth should be

told. You know, if I found that it’s more beneficial to postpone telling the truth a couple of days when the family should be present as well, I would suggest it, but I would always let them know if you like us to speak about it now, then we begin.

I: OK. And also regarding the patient’s quality of life afterwards, for example it would probably. If they didn’t know they had a cancer, would it make you consider. OK this patient has half year to live and it’s probably better not to tell, right now, and just let the person enjoy the last half year or something?

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P: I would never do that. I: You wouldn’t do that? P: Never. Because if I told you, you have one day to live in, you know. Today you would use

your time very very meticulously about some different things you know. You would make up with some contacts if you had some quarrels with anybody you would try to resolve them. If you were angry on your wife or your wife were angry at you, you would try to become united again. You know, I would never do something like that, like waiting.

I: OK, eh. Do you think it’s morally acceptable to tell a white lie to the patient considering professional ethics?

P: No. I: No. P: Not the least. Because. And this is. Now, I found many doctors telling a white lie but from a

religious point of view, I’d never tell a lie. You know, if I tell a lie in this life, I would have to answer for it in the here after. (laughs).

I: Can I ask one question? P: Sure. I: How do you understand a white lie? I just want to know if we understand it in the same way. P: Mh. It’s quite. I think it’s nice that you put, eh. That you mention it because, always we

speak about things but, the disagreements come because we don’t understand the fundamental issues. A white lie to me is something which wouldn’t matter. Which wouldn’t

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have any consequence of something. It wouldn’t have a consequence for the treatment, it wouldn’t have a consequence on the patient’s life. That’s what I think of a white lie. 235

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I: OK, so for example if there is one doctor who diagnose a patient, his patient or her patient and he found that he or she has cancer, but then he just tells the patient that, oh there is nothing serious, just to comfort the patient’s feelings, and in that case, a white lie is not. In that case it’s unacceptable in your opinion?

P: I wouldn’t define it as a white lie even. You know, on the contrary I always experience that if you yourself is open, and honest about everything, you get the best response. I had one patient in the hospital, which had. When she came inside, she had never been in the hospital before, she was in the age of 77 or something like that. And she came in because of weight loss. So I wasn’t the first to see her, but there were a couple of doctors before me, and she had been admitted to the hospital for approximately one week when I saw her. And they had made a::ll kinds of investigations, all kinds. You know they made first investigations, they found she had some kind of tumour in her stomach. They didn’t know if it was good tumour or a bad tumour so they needed to make some more investigations. So they made complete investigations, and they even took some samples out of this tumour and they checked the rest of the body, and they found out that she had, what you call disseminated cancer. You have cancer in all over your body. You know it has spread. It’s a couple of weeks before you go away. And, when I had to do the house round [stuegang] at that point, eh, I was astonished that no doctor before had been telling the patient, we suspect it could be this, we need to take some samples to confirm or to say it’s not that. I didn’t find any doctor doing that at all. So I had all the results and I had ( ) the diagnosis that she had disseminated cancer. And I went inside, I tried to let her decide the pace, I told, and you know and we came about everything, and when I was finished with the patient. It took about one hour, I went outside. And you know who started crying? The nurse. So I said, why do you cry? She said, I never in my 30 years as a nurse seen anyone who could speak to a patient in that way. You know, you really gave her hope. She had three weeks left this poor patient. She said, you really gave her hope despite of these three weeks, and you know, I was so astonished. You know, this assignment wasn’t even meant for you. It was meant for the senior doctor [overlægen] who should take care of this, but now I’m so happy that you did this. So I believe that one needs to be honest about things, this is the way that becomes the most, you know. And today, not just in the hospital environment with even people in front of each other, they are so false, they tend to be somebody that they’re not. Or they tend to hide something within themselves instead of being honest.

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I: So all these doctors who didn’t say anything, they were, like trying to hide the truth for her, or? Is this a common practice in hospitals in Denmark or? =

P: = Not trying to hide the truth but I think that a common thing, that I have noticed is that people have, eh. The hardest thing is to tell someone about something seriously. Because then it means that doctors themselves, they need to take a stand to death. What will happen

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in death, what will happen afterwards? Does anything happen? And because doctors today, and generally many people they have a problem with death, they don’t even think about the death, so when they are finally confronted with it, they don’t know how to do and how to react. A patient may come and ask a doctor. What will happen now, I have three weeks, what then? What should I do? A doctor would be in confusion, even more than the patient. So I think the problem comes because the doctor didn’t adjust themselves or acquaint themselves with thought about death and the life hereafter and these things. And this is why, they don’t hide the truth, but they try to step away from it and let somebody else do the job.

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I: OK, so. That’s interesting. Very interesting. So they don’t learn anything about this at medical school like. Well, I know it’s difficult to learn something like this with death, but a way to take an approach like you’ve done sometimes, like you told about the communication, like normally it’s not a practice at medical school to learn about this or?

P: They have, they’ve started something in the medical schools now, in the universities about how to handle the communication with people, but in this extent, that you speak with the patient about death. I think this a lesson for life and not something that can be taught in the university. And in reality it is a difficult thing, a difficult subject. You know if you asked yourselves now. Did you take a stand to death? Or what would happen, you know. Now you’re together, and you will have a, hopefully a nice life. And you’ll have some children, you will have a big house and a nice sports car (laughs). And you’ll make a lot of money writing good books. (laughs).

I: About truth telling. (laughs) P: But then you know, then you have the grand children, and then what? When you die, then

what? It’s a difficult thing to answer. I: If you were a patient, would you want to be fully informed? P: Sure, sure. I would, because then I know how to react. I: Yeah, like you said before you could plan your. = P: = Yes, if I had one month or three months to live, I would do what I felt was necessary in

those three months. I: OK. Eh, do you have anything to add about truth telling in general or? P: No, not. I don’t have anything in mind at the moment. I: No? Eh, let’s just finish off with this case scenario here. Do you have any suggestions could

be a solution to doctor P? P: Now you put me to the wall. (laughs) I: Or we just want some thought and to hear your opinions. P: It’s a very difficult case I must admit that. This 80 years-old Chinese woman, does she have

any kind of dementia? I: No. P: Is she psychiatrically ill or something like that, that she doesn’t understand? I: No, she just doesn’t speak very well English.

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P: OK. I’m trying to find a way out. (laughs). It’s quite difficult, eh. If we example, or if we imagine that this is in Denmark, I would first of all require a translator. And then I would ask the permission of the family because I think you need to respect the family as well and their traditions. One cannot just overrule them by that. And then try to explain the family that I as a doctor need to speak with the patient in seclusion, in a room, one by one. And when I would be with the patient and the translator would be present as well, I would go step by step and I would say that we need to speak about something seriously, I have a request from one of your family members because of your traditions that you practice in your home country, that if there is something seriously that we wouldn’t or shouldn’t tell you this. Do you agree with that, then the case would be solved. I wouldn’t tell her anything, I would tell the patient about it and the laws in Denmark would be fulfilled as well. I wouldn’t break any law. If she said, no I insist on knowing what is wrong, you know, then any law, any tradition needs to go back. It doesn’t mean I don’t care about a tradition, but it means that in this case when an individual has a problem and wants to know about his or her own disease, and really, this is something very essential for each human being. I would respect that more than the tradition. Not meaning that I don’t respect the tradition but I would do that and then I would say, OK this is the case we made the investigation and it showed out that you have so, and so, and so.

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330 I: OK. P: I think I would in that case like that. But difficult. I: It’s very interesting to hear your arguments and point of views.

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Interview with a Female Danish Medical Student (2): Danish 2

I: So, can you tell me what do you think is ethical behaviour according to your opinion? P: In giving information to the patient? I: Yes. P: Erh, I think when you are a doctor first of all your patients have to have, erh. They have to

believe you and as a doctor you have to pay respect to them and you have to be truthful, and respectful in your information. And you have to take into opinion, where the patients are, or what the patient’s situation is, and how emotional they are, and how much information you can give them without them breaking, without their whole world breaking down. So you have to be very careful and still you have to be truthful and respectful to the patient.

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I: OK. Respectful, you mean you have to be respectful to the patient’s consent, is that correct? P: In respectful I mean, you have to take, erh. You have to show your patient that you respect

them as a human being and you respect them because. Erh, it’s quite difficult to explain exactly what I mean. But when you have a patient who is critically ill, that patient is emotional out of balance and you have to take that into consideration when you tell the truth that maybe this patient will die within three months. So in a way you have still been truthful, you have to. Yeah, do you know what I mean?

I: Yes I understand, so except for the patient’s condition for example like you mentioned the patient is very ill so you have to be considerate before you tell the truth to the patient. And except for that, do you think that the patient’s cultural background has influence on the decision?

P: Erh, I think they have because it’s ( ) but still as a doctor usually you don’t know the patients very well if you are taking care of them at the hospital. Maybe you have only seen them a few times. So you have to, it’s with patients that I don’t want to know how many months or how many years I have left. You have to respect that and say, well we know that with this condition you have, you might not live for very long but you don’t have to set a time schedule or set a time day or within three months you might be dead. Just say that, with this condition you’re most likely to. You won’t live for that long.

I: OK. And in the class when you. Have you discussed about truth telling in your ethical class? P: We have some, but not that much. But in the group where we wrote this exam, we had some

discussions about it. I: OK, and during the discussion have the topic touched upon the cultural aspect. For example

if you are a doctor and you have to treat a patient for example from Asian countries. And in that case there will be a family of the patient involved in the process, have you discussed about these issues?

P: Erh, not in that aspect we haven’t discussed it but we have discussed about how much you are allowed and how much you can decide to tell the relatives in any circumstances. Erh, yeah that’s really it.

I: OK, so could you please tell me how much you as a doctor are allowed to tell the relatives about the disease?

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P: Erh, according to the law you are not allowed to tell the relatives at all. 40

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I: Oh, OK.= P: =Actually. Erh, but usually doctors tell relatives to. I don’t know maybe to also help the

patient to accept the situation so the family can. They know what situation the patient is in, and then support the patient even more. But you are not allowed as a doctor to tell the relatives at all.

I: OK, and I believe that it’s like a standard of practice in Denmark, is it? P: That you tell the relatives? I: Erh, no that you are not allowed to tell the relatives. P: Yeah, it is by law, it is. But many doctors don’t obey that law, so they tell the relatives. I: OK, so if you are a doctor which you will be in the near future.= P: =Hopefully yes, (laughs) I: Oh yes, I believe. What would you consider before telling the truth to the patient? P: Erh, depending on what information I have to give the patient. If it’s just to tell them that

you don’t suffer from anything life threatening and so on, I would tell the whole truth. But as soon as the aspect about death and mortality comes into. I would be quite careful and I would really consider what words I used to tell the patient. And also what environment, erh. How the room is that we are in, so it’s as cosy as possible so the patient feels comfortable in that situation.

I: OK, and will you tell the whole truth to the patient or will you tell just bit by bit and, so that the patient?

P: In the beginning also, not knowing the patient, I will tell bit by bit and then later on in the conversation if I feel that the patient can handle=

I: Yes= P: =All information, I will tell all the information. And also, if the patient asks questions about

his or her situation, and they are quite specific then I will answer truthfully as I can but still, I will take into consideration what the patient is like and then yeah….It depends on the patient. But overall, I will tell the whole truth.

I: OK, I see. If the patient doesn’t want to know or, if you see that the patient cannot handle the truth because it will affect his or her mentality, or the truth will cause depression, will you tell the family or you just wait until the patient gradually becomes better, in terms of his or her emotion then you tell the truth to the patient? Do you understand my question?

P: Yes I do. If the patient doesn’t want to hear the whole truth I believe that I will ask the patient, can I tell your relatives how the situation is or you and then if the patient agrees I will talk to the relatives and tell the whole situation, and then maybe they can help the patient to come to the realisation of his or her situation.

I: So if I understand correctly, the family of the patient will be involved in this process only if you ask the patient for his or her permission that you can talk with the family first. Is that correct?

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P: Yeah, it. I would like to say that I would do that in the future, erh, but I think as a doctor you have to take into consideration again, what is the patient like, what is the situation of the patient. If I see that the patient is close enough and doesn’t want to speak at all with any doctors or nurses or families and so on, then maybe I believe that it’s more helpful to bring in the relatives without having the permission of the patient.

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I: Does it also depend on the patient’s age or education background before you tell the truth? P: I will take into consideration how strong mentally the patient comes across to me. I think it’s

very individual depending what patient you are confronting with this information. I will try to analyse the patient as well as I can before telling anything. I believe.

I: OK. Do you have classmates from other countries? P: Yes I have some classmates from Sweden, Norway, Iceland, and the ( ) and the ( ) parent’s

came as immigrants or refugees to Denmark. I: And when you have discussions about truth telling do you experience some different

opinions according to. I’m sorry, do you experience some different opinions from your class mates from different countries?

P: Not from different countries, just as we are individual people, individuals. And then also I believe to have experienced that there is a big difference between men and women. So that. ( )

I: Would you please tell me what do you mean by big difference between men and women? P: Erh, in my class, we women, we tend to be more considerate of the feelings of the patients.

Of the future patients. And I think it’s the nurturing instinct we have in, that the boys don’t have in the same extent. So there’s a big difference.

I: If you are a doctor, and again I believe that you will be. (laughs) Will you consider that truth telling is mean or it is cruel to the patient?

P: It can be really cruel for the patient to experiencing the truth at first. But I believe in the long run it’s best for the patient to be aware of his or her situation to deal the very best with it. So, maybe if, again if it’s a terminal patient then maybe they can make arrangements for their family and if they have children and so on. But I also believe that it’s my job as a doctor to be available, to help them further on in the process of accepting their situation if they questions about how they will be in a few years or in a few months then I will have to also lead on when I have more experience then I can tell them more truthfully how I believe their situation will be further on. So I don’t think my job stops at telling them the truth and then my job is done, I believe I have to be available with my knowledge but also as a person, as a human being, to be able to see them as a person and be able to, for them to have these feelings and it’s. And they are allowed to cry and be upset and I will not run away because of that. Still handling and taking care of them in this situation where they can be upset and then try to calm them down and to comfort them the best I can. Maybe in a way taking over the role of the nurse. I don’t know. (laughs) But that’s my goal as a doctor, also to be available emotionally for the patient.

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I: OK, I see. Is it morally acceptable to tell a white lie to the patient, considering your professional ethics?

P: Again it depends on the situation of the patient, I believe. And also of the situation. If I’m confronted with a patient who is very very emotionally out of control and on the brink of a depression that can cause them to shorten their lives with a ( ) or a year. Maybe it’s alright to tell a white lie.

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I: What is a white lie in your opinion? P: That’s a difficult question. (laughs) I think a white lie must be something that cannot hurt a

person or the person’s, or the people close to this person. I think that’s the best definition I can give.

I: I would like to know because, you know to define a white lie. Defining a white lie is very different from person to person and from culture to culture and we have experienced some people that say there is no such thing called a white lie, because if it’s a lie, then it’s a lie.

P: Yes, but it’s true. Actually if you have to see it truthfully then a lie is a lie but I also believe that sometimes you have to help a person through a situation by telling a white lie for this person to come to the realisation of his or her situation maybe. It’s quite difficult but I won’t tell a lie if it in the end can hurt the patient though, or people close to this person, I believe. It’s quite difficult because I haven’t had that much experience with patients yet.

I: So if you were a patient, would you be, would you want to be fully informed? P: Me personally? I: Yes. P: Erh, I would like to know if I had a terminal disease or a life threatening disease I believe I

would like to know what this disease does to my body and how long I have to live still. And what I can do to make the situation better and may prolong my life and then what the doctors believe they can do to help me.

I: OK. Did you see the case scenario at the end of the questions? P: Yeah I did, but I must tell the truth I can’t remember it that well. I: Oh it’s OK I can just give you the summary right now. P: OK, that sounds good. I: It’s about an old woman who is Chinese and she came to visit her daughter who lives in the

United States. And this woman has little knowledge of English and she was admitted to the hospital. And then the daughter came to talk with the doctor that no matter what happened, no matter the diagnosis turn out to be the doctor has to talk with her. And under no circumstances that the doctor should tell the woman, this old lady about the disease, because it is considered cruel that the doctor tells the truth to an old lady. So this doctor was caught in the middle between not to tell the truth to the patient and yet he respect the cultural difference of the patient and the family. So if you were in the in the same situation as this doctor, what would you react or what would you think would be a solution for the doctor?

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P: Erh. First of all I actually think it’s quite, quite. Erh. What is it? I’m just lacking a word here. (laughs) I think you have to respect the culture. Because this old woman has grown up with this culture and she shows. And maybe it’s the only culture she has known. I think it’s important to respect the culture and then maybe I will try to persuade the daughter in telling her mother just something about the situation so the old woman isn’t without any clue at all. I believe that. I believe first of all that old people or the elderly they have some kind of instinct. They can feel when their time is running out. So I think I will try to persuade the daughter in telling her mother that it’s a bad situation and where it might lead her to. But I will take a long talk with the daughter.

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I: OK, I understand. And last question. Do you have anything to add about truth telling? P: Erh. Still just show respect to your patients. I think that’s the most important thing you can

be, because people can feel when you’re not true. When you are not telling the truth. And yeah. Respect your patients and their relatives. I think that’s quite important.

I: OK so yes. We’ve covered all the questions in the interview and thank you very much for your help.

P: You’re welcome, you’re welcome. I hope you can use some of my answers.

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Interview with a Male Danish Medical Student (3): Danish 3

I: OK, so first of all could you please tell me what is ethical behaviour according to your understanding?

P: With that question do you mean what is good ethical behaviour? I: Yes. P: I think ethical behaviour is when you respect the people and you respect its opinions and

you try to treat them in the best way possible for that specific patient. And erh, yeah. 5

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I: And if it’s about truth telling, then what do you think is ethical behaviour? To tell the truth, or the opposite way?

P: I mean depending on who the patient is, is it a child, is it a psychic ill person or is it. Can the person bear to hear the truth, if it’s a five year old child who has, is going to die from cancer in maybe half a year I don’t think it would be fair to tell the child that.

I: OK. During your medical education, did you receive any specific ethical courses? P: Yes we did. We had actually a few, I think about three. And its norm.. Unfortunately it’s in

the very start of the, in the very beginning of the study that we have it. Because now when we, at this point where we are now, graduating in two years there is a lot of tough stuff we have to learn so there is not enough time to take all these more, what do you call it, light education like communication and ethical problems. But we had a lot of practice in it before. We have also done a report in a theme we could choose ourselves.

I: OK, and in ethical courses, have you discussed about truth telling in the class? P: Yes, we have. And that’s I think. Or my opinion is that you have to tell the truth in,

whenever it’s possible without harming anybody or making their lives miserable. And, erh, I mean it’s no good in telling a little child that you are going to die in a short period of time.

I: OK. So in that case you have tell it to the parents instead of.= P: =Yes of course, that’s also what we discussed, you know you can always discuss with the

parents or the family or who you might have there. Talk with them you know. But it’s not so easy because sometimes it’s not allowed that you go and talk to the family and the parents before you talk to the patient. And the patient has to say to the doctor yes it’s OK, you can tell my family. But I would say in any possible way you should always tell the truth.

I: OK. How about if the patient is from a different culture and according to the patient’s cultural background the patient would prefer that you talk to the family?

P: It’s erh, in this kind of matter I wouldn’t make any difference, if they were a different culture as Danish. Only in matters, for example like abortions and stuff like that. But I mean about telling the truth it doesn’t make any difference for me if you are Moslem or if you are German or Swedish.

I: OK, do you have experience from classmates or from your colleagues from another culture that, who has different views on ethical dilemmas on truth telling?

P: We have of course a lot different cultures in my studies, Swedish, Norway, and we also have people from Moslem countries. And I don’t feel a big difference actually. In their opinion. The problem is more like how to act as a doctor when we make different examinations and

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perhaps some of the Moslem girls. If you know, have to take the clothes off a man for example. That’s a big problem. Not according to telling the truth. I don’t see a big difference there.

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I: OK. So suppose that, if you are confronted with a dilemma of truth telling, how would you react to the situation?

P: Depending on what situation. You know I have to look at the patient and I have to make my own picture of the situation. How would this patient react on the truth? Would the person be able to live afterwards, you know without killing themselves? Some medical questions are so hard to take for the patient, that the patients they kill themselves. In that case it would be bad to tell the truth. And then of course you always have the family you can discuss it with.

I: So if you determine that the patient is not ready to hear the truth then in that case you will discuss with the family first? Do I understand you correctly?

P: Yeah. I would do that if the matter was so serious I would have to do that. I: And in that case do you still have to ask for the patient’s consent before you talk to the

family or you just talk with the family directly?= P: =It depends on if it’s a child. I can just go and talk to the family. But if it’s not a child

honestly I have to get the permission from the patient. But I mean it shouldn’t be so hard you can always just ask the patient, is it OK that I talk to your family about your illness. And I mean, who would not give the promise to do that.

I: OK. How much information does. Oh, I’m sorry maybe this question may not be applicable to you. Have you ever considered that truth telling is cruel to the patient?

P: Yes. It is indeed. And again in the situation with the child. A young child. To tell the truth that you have this disease and it’s just getting worse and worse and maybe in half a year you won’t be able walk anymore and another one or two years you might die. It could be quite cruel to tell the truth. But I mean you also have to tell the child something, you have to tell the child that it’s very important this (decision/disease).

I: OK= P: =It might not stop ( ) Its very difficult and you have to be in the situation to actually know

how you’re going to react. I: Erh, is it morally acceptable to tell a white lie to the patient considering your professional

ethics.P: No I: OK.= P: =No I don’t think so. It’s erh. I mean in the overall answers you have to. If it’s possible in

any way to harming the patient too much, you have to tell the truth. And I mean if you as a doctor should be able to live with yourself afterwards. You can’t just go around lying all the time.

I: OK. So what is a white lie according to your understanding?

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P: An example of a white lie? Is like telling the patient, just to make them feel good, it’s not so bad, it’s probably going to be much better, and knowing that it’s just going one way and the patient is going to die. But I mean it would be so much easier for the doctor just to say to the patient to make them happy, just to say ( ) it would be well.

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I: OK, but still in that case, it is morally acceptable if the purpose of telling a white lie to the patient is because the doctor does it because of he has to do good intention?

P: Hmm, yeah but still it’s no good of telling a white lie. I mean if the situation is in a way that it’s not good for the patient to know the truth. I mean you shouldn’t tell a lie but. No way.

I: OK= P: =Just tell the patient, you know, you don’t have to tell the patient, OK you are going to die.

It’s not good of course, but you can tell the patient it’s not good you are very very ill, and the chances of getting cured are very small. In that way. You can never, you can never tell a lie in the patient. And maybe something will work out in the future and maybe you will be cured. You can never, never lie to the patient about the ( ) it’s no good. You can maybe keep some information back. So the patient don’t know about that he or she maybe is going to die. But you can’t lie, it would be wrong.

I: Yeah but erh, considering if the doctor keeps information from the patient, then would it be considered not to tell the truth and therefore it would be unethical according to your opinion?

P: Erh, could I get that question one more time? I: Yes, erh. You said that it’s not acceptable to tell a lie to the patient.= P: =No ( )= I: =Yeah. But sometimes if you don’t tell the truth, for example you keep some information.

So in this case. In this case, keeping information from the patient would be unethical or ethical according to your opinion?

P: OK that’s ( ). Erh, in some cases I don’t think it will be unethical, and I don’t think it would be lying not to tell the whole truth. But if telling the truth means a terrible life for the patient and if the patient only has like half a year, a year back to live, it’s not erh. Of course you have to tell the patient that it’s very serious and you are not going to get well again but. I mean it’s not good for any people to know that you are going to die in half a year maybe. You can’t, you can’t continue living a normal life and you just have to. Think about it all the time I think.

I: OK, so it’s different between telling a lie or keeping some information from the patient, it’s two different things? Is it correct?

P: Yes, I think it is.= I: =OK= P: =Because you’re not lying actually. You are just not telling everything, you know. I: OK, OK. Yeah. Erh, have you ever experienced ethical dilemmas of truth telling during your

practice?

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P: Actually we’re spared for that kind of, of, what do you call it, jobs on the education. I had erh, ( ) another doctor and telling a patient that they have discovered a cancer for example. And, erh, we told, or the doctor told the truth there ( ) And it went all well. I mean it’s not, telling somebody they have cancer it’s like somebody that you are probably going to die or maybe have 50% of risk of dying. And then you can tell the patient what options they have and to do, and to comfort them and tell them it’s not sure you are going to die. But it’s erh. I haven’t done it myself yet. It won’t. I don’t think it will happen before I graduate. We are spared for that kind of information. ( )

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I: OK. I don’t know if you. If you were a patient, would you like to be fully informed about the disease?

P: Of course I would. I think most people would. But I mean it’s. In this case it’s quite hard about me, because I know a lot of diseases, and I know the outcome of a lot of diseases. You know, the worst kind of people to treat, it’s doctors. Because they know too much.

I: OK (Giggles) P: (Laughs) Quite a lot of doctors, if they get some kind of diseases and they know how bad it

is, they take something to kill themselves. Because they know it’s not worth it and, it’s no good anyway.

I: Yeah. What factors most commonly influence decisions to inform the patient? P: What, common what? I: For example, if you are a doctor, and you have to tell the truth to the patient. What would

you consider before telling the truth to the patient. For example the patient’s age, which of course you already mentioned, but are there other factors you would consider?

P: I would consider also, what good would it do to this patient, knowing the truth. Could it maybe be reasonable. I mean if it’s a patient that maybe has, erh. If it’s a patient who is going to die, there is a lot of stuff the patient needs to take care of. I mean in that way it could be reasonable. But of course an adult or normal person I would always tell the truth. I mean there should be some kind of special case if I would not, you know, not tell a white lie, but, you know, not tell them everything. Not give them the bad dark perspective of the future.

I: OK. Erh, have you read the case scenario at the end of the questions? P: No, I have actually not. I: It’s OK, I can just summarize the case now. P: It’s this old Chinese woman? I: Yes. Erh, the old Chinese woman travels from China to visit her daughter in the US. And

then she got admitted to the hospital, and she has little knowledge of English. So the daughter came to talk with the doctor that no matter what happened to her mother, the doctor has to talk with the daughter, not with her mother, because it is cruel for the. Erh, according to the Chinese culture that the doctor will tell the truth to the patient who is an old woman. But the problem is, in the U.S. you can not talk to the family before you have the

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patient’s consent. So what would you do if you are in the same situation as this doctor, hat would you react, or what do you think would be a solution for this doctor?

P: Erh, it’s a quite tough one.= I: =Yeah. P: You can’t talk to the patient because she only speaks Chinese. Erh, maybe I would be a little

bit, what do you say, smart, and I would not directly talk to the daughter, but I would use the daughter to translate to the mother.

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I: OK. P: So I mean, I think I could. I mean, I would have to do it that way. You can always say

afterwards that, OK I didn’t talk to the daughter, I just used the daughter as a translator. 165

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I: OK. (giggles). P: But I mean the overall idea of saying this is, I would have to tell. I would have to talk to the

patient. And in this case I would use the daughter. I: OK= P: =Allowed or not allowed. I: OK. P: Because, you know I would have to. I’m a doctor and I have to do good to people, I have to

help the people and then maybe I can help this old lady, that I would have to use any possible ways, and meaning that I would talk to the daughter, and make her translate to the mother.

I: OK P: But you can’t help, you can’t help this old lady. You probably can’t help her without talking

to her. So. I: OK. So, last question, do you have anything to add about truth telling in general or do you

have any truths to tell us? (laughs) That you haven’t told us yet. (Laughs) P: (Laughs) No, I would just say, in any way it’s possible, any time, a doctor should tell the

truth to the patient. I mean, it’s only in very special cases. And also, never tell a white lie. I: OK. P: You can keep some information back if you think it would harm the patient, but overall you

have to tell the truth as a doctor. Because you know a lot of stuff and you know a lot of things about how the body works, and you must expect that they don’t know anything about it. So they have to trust on you completely. Therefore you have to tell the truth.

I: OK. So it’s also a matter of trust between the doctor and the patient, and that is why you have to be truthful to the patient?

P: Exactly. I mean it must be a terrible situation sometimes because they don’t know anything. They can only trust what the doctor tells the.

I: OK. So I think we have covered all the questions of the interview. Thank you very much. P: You are welcome, it’s been nice talking to you.

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Interview with a Male Thai Medical Student/Doctor (1): Thai 1

I: What is ethical behaviour according to your opinion? P: I think it is about sharing about bad news to the patient such as cancer or something like

that. And the second is to (deal) with some problems such as HIV to his or her spouse, and the third thing is about the knowledge of the treatment.

I: OK. How long have you been working as a doctor? 5

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P: Nearly six years. I: So, when did you finish your education? P: 1999. I: OK, so you have some years of experience with patients and = P: = Yes. I: So, during your practice have you experienced any ethical dilemmas of truth telling? P: Yes. I: Yeah? Can you give some examples? P: Erh. When I worked in southern Thailand- Most of the population is Muslim ( ). You know

about the Muslim ( )? I: Yeah. P: And they have some believes that ( ) is about their God, so if they die, they don’t want their

doctor to help them because they think that they should die, because their God wants to. And they will take the patients to their home and they die in their home, or something like that. And so that, when I am the doctor I need to tell about, or I need to tell to the patient or to the family member that it is very important to treat this patient, because if I treat, they will be better or sometimes they will recover from the illness, but sometimes the family members or the patient don’t want the doctor to do it. So they will go home and then let them die.

I: So, did you have to say anything to the patient like, erh, that the patient is very ill. Did you tell it directly to the patient or?

P: Erh, yes but in the ( ) most of them don’t ( ) don’t know what happened to them. The most important thing you need to say, should say to their family member, because the family member is very important and it is very difficult to deal with.

I: Yes, can I just add one question? P: Yes. I: You said that you have to talk with the family member about the patient and then you have

to tell them that it is necessary to treat the patient. Do you think that there is a conflict with their religion because they believe that if they some kind of illness and if they have to die then it’s the God’s will to die, and if you insist that this patient has to be treated do you think that in a way it conflicts their cultural believes and their religion’s practice?

P: Yeah, yes. Most of them I remember and this is, erh, most difficult to dealing with ( ) this situation because most of the patients (insist) they will take the patient to go home. But if the patient or the family member insist about this, you can’t do anything because they have the

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right to deny the treatment. But I will need to give them all other information about the prognosis or the treatment I have to give them, if they want me to treat them. Yes. 40

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I: OK. Do you have any experience with colleagues from another culture who have different views on ethical dilemmas of truth telling for example and the treatment of patients?

P: Erh, yes, yes. Because this is an individual case because ( ) sometimes they are OK, I will let you go home or something like that but sometimes I ( ) you know that in the case that the family member deny the treatment you can’t do ( ).

I: OK. But is it only with Muslim people that you have experienced this or is it also with Thai people that in general that you, if you want to tell the patient about an illness of the patient if it is a fatal disease like HIV or cancer, how do you deal with truth telling to people from Thailand in general or Thai people.

P: Erh, I will discuss with the close family members first, but if the patient has a fully conscious ( ) I will talk to the patient first because I think that it is the right of the patient to know everything, what happened to them, because it’s the patient’s body not the family members’ OK? So that they have the right to know about the disease.

I: OK, and could you give an example of you could disclose the information to the patient, would you say it directly to the patient or try to tell it with. In what way would you deal with it?

P: Ahh, OK. I will, I will. The first thing that I would know about the background of the patient first. About the education, about the social economy, and about the general health. And then, if I have assessed that the patient can accept about this bad news, I will give, I will have with some (coupling) first that, erh, I just give them the situation that, erh, such as HIV, I will give them the true (signification) and then (ask/answer) them again. After that I will ask them that, if you had HIV infection, what would you do? Or if you are not infected, what would you do? And then I will (accept/assess) the answer. If the answer is OK that they can manage with their lives, I will tell the truth to the patient, but if not I will have time to (talk) to them first, not tell the truth in the first meeting, I will make another meeting and then gradually tell about the truth to the patient. Most of them can accept in the future.

I: OK, so you let the patient decide the pace more or less? P: Pardon. I: You let the patient decide, well, you let the patient or you see how the patient reacts to some

information in general first, and then you talk to the patient later on. P: Yes, yes. I: Do you have any other reasons that are more important or necessary for a doctor than the

cultural background of the patient before you tell the patient the truth? P: Hmm, other things than cultural background? I: Is there anything you consider in general when you need to talk to the patient about=

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P: =Erh, yes about the patient’s mental status ( ) level, about their education and their social economy. I will need to know all of this and then to ask them again before I tell the truth to the patient.

I: OK. When you are confronted with a dilemma of truth telling how would you react to the situation?80

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P: Erh. Sometimes I will ask about their education first as I said to you and then I will give an introduction about the content of the disease first, and then I will ask them about their reaction of the patient and the family members ( ) and then I will give them some of the, gradually, give them gradually more information. And then I will make another meeting and then gradually give them more information, yes.

I: So do you follow any medical standards of practice? P: Yes, I do. I: This is the normal way in Thailand? Did you learn to do it this way in medical school? P: Yes I: You had some medical classes of ethics? P: Yes. I: How much information does the patient normally want to know about the diagnosis and the

treatment. P: Most of the patients wants to know all of the disease. Especially, will they be cured or will

they be in recovery or will they die or something like that. I: So they are very interested in knowing, like what are their chances to survive and= P: = Yes = I: = And what kind of treatment is possible for them and. P: Yes, yes. I: And how would you tell them if the disease cannot be cured? P: OK. Erh. I will introduce first the general knowledge of ( ) first and then I will ( ) them that

this disease can’t be cured but I can do something to make you feel better ( ) or sometimes I will give them the hopes that now there is no treatment but in the future. Erh, I will give them the information that now there is no treatment but in the future can we have the management that can give them cure.

I: OK, and although you know that maybe the patient will die do you think that you just give them some hope, is that what you are saying?

P: Erh, it depends on the ( ) of the patient. If they will die in the next two or three days or in the next two or three months I don’t give them some hope, but I will give them the best management or I will give you the best treatment to you, to make you feel better. But because of most of the patients, you know, sometimes you, they can’t accept about ( ) it is very important for them to know about the disease what will happen to them in the nxt two or three months, yes, in the future.

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I: Yes, and erh, if for example, if in case that they know that this disease cannot be cured and then die eventually, and they deny to receive the treatment, then how would you deal with that situation?

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P: Erh, you mean that how would I say to the patient if? Can you explain more about the question?

I: Yes. I mean that, if the patient deny and say that, I will die anyway so I don’t want any treatment, I just wan to go home and die with my family. Then in that case will you insist on the treatment or will you let the patient decide whether he or she wants to continue with the treatment.

P: Ah, OK. I can give them the whole information that what will happen if I treat you and then give you, I will give them everything, such as the ( ) of the treatment about the ( ) and in the case of if you are treated how long will you survive or if you are not treated how long will you survive then, and then I will give you ( ) if they insist that they don’t want a treatment I ask them ( ) But I will give them some urgent information first before they have the decision.

I: Erh, have you ever considered that truth telling might be cruel to the patient? P: Erh, no. Because I think that most of them keep fear when they don’t know or don’t

understand what will happen to them. So I think that to tell the truth will get them to relieve some of the anxiety.

I: And what do you think about telling a white lie to the patient? Is it considered in your professional ethics or is it morally acceptable to tell a white lie to the patient?

P: Erh, sometimes, yes. I think that sometimes it is important to tell a white lie because some patients (can accept that this is first) But then. I will give you some examples. If the patient could not accept that, perhaps have some mental illness such as psychosis or something like that so I will tell the ( ) that I will give you some ( ) or some supplemented nutritional or something like that to give you have a better health or something like that because that if you say that I will give you the medication that will kill you, the patient will not accept your treatment. But then I tell the lie that if the patient accept this medication then the disease will be in recovery then they will have the insight that, OK I accept that ( ) Yes. Sometimes it’s very important to do this.

I: OK. Then how would you define a white lie according to your experience or according to your opinion?

P: If I will say some white lie, I will tell the truth to the family member, because I would like the family member or someone who care about the patient to know that what I will in the future to this patient. Yes. And then I need some cooperation from the family member too, to dealing with this difficult patient, yes.

I: OK, so in this case, please correct me if I’m wrong. So you will go and talk with the family first before you talk to the patient, is it correct?

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P: If I decide to tell a white lie yes, I will discuss with the family members first before to tell the patient. Yes.

I: In what case was it you would tell the family first, was it if the patient had dementia or something or when was it? 155

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P: Oh yes. I will ask them about the mental status first. If they can(‘t) accept about the treatment so that I will talk to the family members first.

I: OK, I see. If you were a patient would you like to be fully informed? P: Yes. I: If you had a fatal disease? P: Yes, I think that people fear the most, if they don’t know what happen to them. I: OK. Do you have any suggestions or any ideas or opinions about this case? P: Hmm, in my opinion I will discuss to the family member first, because if I say something to

the patient they will have some conflict with the family members and then my treatment will be ( ) because I will discuss with the family members first about the information that I will talk to the patient. If they accept what I say, everything is OK, but if it’s not I will explain about the reason that if I don’t tell the information to them, what will the patient have of ( ) such as anxiety or a depression and then I explain some of the reasons or I talk to the family members like this. Most of my case will substance to tell the truth to the patient.

I: So you will talk to the family first in this case= P: =Yes.= I: =Even though the patient is not mentally ill or something or. P: Yes, because in the wrong term of the management the family member is the important key

that ( ) to the treatment, because if you don’t have the cooperation from the family member you can (choose) the patient too.

I: Do we have, erh, I’m sorry, do you have any rules or ethical standards that insist that no matter what the doctor, the doctor has to tell the truth to the patient first, if the patient is capable of making a decision, do we have this kind of rules?

P: Yes. Yes because it has the ethical standards ( ) if the patient can make a decision by themselves, erh can do the decision by themselves however they have the mentally status that ( ) or mentally condition or the dementia so that I will give the information to the closest family members, yes.

I: But if the patient is able to make a decision him or herself then you have to tell it to the patient first?

P: Erh, it is not important. It’s not important to tell the patient first or tell the family member first, but it is important to tell the patient, yes, if they can make a decision by themselves.

I: OK, so in this case scenario, if the doctor insist. I’m sorry, if the doctor decide to talk with the family member first. So according to the Thai medical practice, this action does not conflict with the ethical standards, do I understand correctly?

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P: Erh. What I mean that, if the patient can make a decision making, the doctor should tell the truth to the patient, but it’s not important that you will say to the patient in the second or say to the patient in the first. But eventually you need to tell the truth to the patient.

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I: OK. Do you have anything to add about truth telling in general? P: Erh, I think that truth telling is individual, you can’t use this erh. Even if the patient has the

same disease, erh, but you can’t use the same strategy to the other patient, because this is really hard to do this. So it’s very very delicate situation. It depends on everything such as background of the patient and the background of the family members or something like that. Sometimes you can say that the doctor is correct or the family member is correct, sometimes there is ( ) or something like that.

I: OK, thank you very much. 200

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I: We are doing a project about truth telling and ethical standards and perceptions of medical students. We made this interview guide about truth telling which we will go through together now. You can just take your time. OK?

P: OK I: Do you have the questions? 5

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P: Yes, I do. I: That’s fine. Let’s start then. What is ethical behaviour according to your opinion? P: Ethical behaviour according to my opinion is behaviour that concerns rationale, emotion or

feelings of other people. It also includes truth and not telling lies.I: Do you have any examples from your work? P: Yes,….such as if I have a patient that has AIDS or cancer and he will die soon, I will talk to

the relatives of the patient, but talk little by little not so fast, not like “you father will die very soon” But you have to see how much they know. I will start like “how much do you know about your father?” Something like that, but not tell lie like “your father will be better soon.”

I: How long have you been working as a doctor? P: I graduated for 6 years now. This is my sixth year of work. I: Have you experienced any ethical dilemmas about truth telling during your practice? P: Yes, I have, quite often. Most of the cases are when the patient will die soon. I: How did you deal with the situation like that? If you have a patient, who is fatally ill, or who

has cancer or AIDS and you know that the patient is going to die, how did you deal with the situation…like telling the truth to the patient?

P: In our country, the process of telling the truth to the patient is quite complicate. First, we have to talk with the family first, and then we have to ask the consent from the relatives that we can tell to the patient. We also have to see if the patient is educated or how he or she is feeling, see if (s)he has some hope, then we can talk to the patient. But if we talk with the hopeless patient, we have to talk with the relatives first. In my experience, the relatives want the doctor to tell the truth to the patient. It also depends.

I: Do you have any experience from colleagues from other culture who have different opinion on the ethical dilemma of truth telling, or the treatment of the patient?

P: No, because in Thailand…the doctors I’m working with are Thai and we have the same culture.

I: OK. So, you are from the same culture? P: Yes. I: If you confront with the ethical dilemma of truth telling, how would you react to the

situation?P: I will do the best I can and try to see how much the patient knows and then add some

information to the patient. You have to know the background of the patient. I: Do you need to know the background of the patient in general, or..

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P: Yes, in general….how much the patient knows and we will add. 40

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I: Do you ask the patient about how much do they want to know in general? P: Yes, how much they know about the disease. I: Then, what would you do afterwards? If you know that they know about the disease, how

would you continue? P: I will add information about the disease and tell the patient (indirectly), like…how many

days he has to stay in the hospital, or if he can go back to work, something like that. I: Do you follow some medical standards? P: Yes, we have to follow the standard of practice. I: Is this the standard of medical practice in Thailand? We would like to know that the

situation you just explained about how you tell the truth to the patient is a standard of medical practice in Thailand.

P: Yes, this is the standard we have. I: How much information does the patient want to know, concerning the diagnosis and the

treatment? P: It depends very much on the patient’s education. If the patient has high education, he wants

to know all.I: Have you ever considered that telling the truth to the patient is cruel? P: Yes, I have. Many times. That’s why I have to talk to the relatives first. The relatives know

how to tell the patient (how the patient can handle the truth).I: So, in many cases, the family members have influence on your decisions, for example how

you are going to tell the patient. So, it is not only the communication between the doctor and the patient, but also between the doctor and the family. Do I understand correctly?

P: Yes, yes. You understand correctly. In Thailand, we have to confirm with the relatives. I: Do you think that sometimes it is morally acceptable to tell a “white lie” to the patient? P: No, you always tell truth. You don’t tell lie. I: Even if it’s a white lie? P: What is the white lie, I don’t understand well. What is the white? A lie is a lie. I: What is a white lie in your opinion? P: A lie—not tell truth, the opposite of telling truth. What could be white, I don’t know. I: Perhaps, it could be not to tell the whole truth, to withhold some information? P: To withhold information. I told you. It depends on the relatives. Sometimes the relatives

have to tell the patient. But as a doctor, you have to tell all information to the relatives. I: Do you think that it should be the doctor who should tell the truth to the patient, because the

doctor has professional capabilities to tell information about the disease? P: It depends. If the patient has good education and ask for the truth, you have to do what the

patient asks. But if the patient has no idea, or don’t know about the disease, you have to discuss with the relatives first.

I: If you were a patient, would you want to be fully informed about your disease?

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P: Yes, I do, also because I’m a doctor. If I have to become the patient, I want to know the whole thing.80

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I: OK. Have you read the case at the end of the questions? P: Yes I: Do you have any suggestions about the situation or any idea what could be done, or what

would you do if you were in the same situation as Dr. P? P: Oh! I have to read the case again. I will read quickly because I can’t remember the question. I: OK P: In this situation, do I understand right that the family members want me to tell the truth to

the patient?I: The situation is…this old woman from China came to visit her family. She doesn’t speak

English. If you were in the same situation, how would you react? She doesn’t speak your language. And the daughter of the patient insisted that the information should be revealed to the relatives.

P: I will tell the information to the relative, but I want to know what is the relationship between the patient and the relative, the son, the brother, the sister, or the daughter. Sometimes there are many people involved. You have to talk with different kind of people, many times.

I: So, first you have to find out whether how close the relatives to the patient right? P: Yes, and then tell the truth to the closest family member, like the son, brother or sister of the

patient.I: But in this case, the daughter of the patient insisted that no matter what the diagnosis will

be, the doctor, or you in this case have to talk to the daughter because according to Chinese culture, telling the truth to an old, woman patient is not acceptable.

P: OK, I understand. We have many cases like this in Thailand too. The relative doesn’t want the doctor to tell anything to the patient.

I: So, what would you do? P: It has to be the daughter who tells the truth to the patient. I: Does the patient have right to know? P: Umm… I understand. This is quite difficult to the doctor too. Before the daughter asks the

doctor not to tell the truth to the patient, she should talk with her mother first, like “I have to talk to the doctor and I’ll tell you. You don’t have to talk to the doctor. But in Thailand, many patients ask their doctors many questions too.

I: Do you have anything to add about truth telling. P: In general, it is like what I have talked to you. It depends on the relatives, the patient, and

the patient’s education. If the patient has high education, or the patient wants to know the cause of disease, we have to tell the patient. But in many cases, the patient does not ask the doctor; we have to talk to the relatives first. If the relatives allow us to tell the patient, we will tell. If the relatives do not want us to tell the patient, then we don’t. But if the patient wants to know, we have to talk to the patient and we always tell truth, not tell lie.

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I: OK. Thank you very much for your participation. P: You’re welcome.

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Interview with a Female Thai Medical Student/Doctor (3): Thai 3

I: We are going to record the interview I hope it’s OK with you? P: OK I: Because we have to write about it later. So I don’t know if you have the questions or you

read the questions already? P: Erh, I read some of them, the first page. 5

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I: Yeah OK. We just take it nice and easy and then we see what happens. OK? P: OK I: So, what is ethical behaviour according to your understanding? P Erh, I think it something about truth, about how to tell the truth to the patient in appropriate

time and you have to judge if the patient is well prepared or not to receive the news or something like that.

I: OK. And how do you evaluate if the patient is well prepared or not? P: Erh, you have to judge by the patient’s status, and sometimes you to see if what is the inside

of the patient. Like what he is thinking he’s got. His psychological background or something like that. If he’s depressed or something like that.

I: OK, and erh. During your medical education, did you receive any ethical courses or something like that?

P: Yes, a short course yes. I: A short course only or? P: Erh, not a full course, just some, a few hours of lecture. I: OK. So you got some basic ideas of to deal with patients and, in difficult situations? P: I think some yes. I: Have you had any ethical challenges that you have discussed in class? P: Erh, actually not many but I have ever experienced something like difficult situations.

Mostly can get with it, not difficult situations! I: So you haven’t had any difficult situations? P: Not any serious ones, not difficult ones. I: What situations have you discussed in class? P: Mostly like some patient perhaps with some kind of cancer or HIV results, where you have

to tell the patient he has cancer or he has HIV or something like that? I: OK, and how would you approach a patient with cancer. By the way, what year are you

studying at now, how many years have you studied? P: Well, I have practiced for seven years I have graduated already for seven years. I: OK, so can you give us some examples of how you would approach a patient who had

cancer or HIV? P: Erh, how to approach, you mean after checking the examination or you already have the

results?I: Yeah, if you have the results of the disease from the patient, a specific disease, and then you

have to tell the patient like what. How would you tell the patient about this?

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P: I think before I take any kind of laboratory examinations or give the patient any kind of examination I have to tell the purpose to the patient. Like, what am I doing, so that he or she may have some kind of prepared, before he is going to hear the bad or good news later.

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I: OK. P: And then after I got the results. I may, I have to stay calm and maybe I have to be

compassionate with the patient and just tell him the truth. I: OK. So you just tell the patient if the person, if the patient knows something about the

illness in advance, you tell the person about it? P: I have to judge the patient first. If her or she is well prepared or he has a ( ) or not. If they

don’t want to hear the truth, that is another question, but if he or she thinks they can accept that I just tell them.

I: OK. And if you decide that this person or if you evaluate that this person is not prepared to hear the truth, how would you deal with it then?

P: Maybe I get them a little bit more time, or maybe I can tell it to their first degree relatives or something like that.

I: OK P: Well, sometimes you have to ask the patient if he or she wants me to tell their relatives or

not, because some patients don’t want me tell about his disease to other people, even his own family.

I: OK. So sometimes you tell the patient’s relatives and not the patient him or herself? P: If the patient is not in the condition that he or she can receive the news or something like

that.I: OK. In this ethical course or during your practice, have you experienced any ethical or

cultural aspects that had been different when you had to tell the truth a patient if the patient was from a different cultural background or something?

P: No, they didn’t stress in that part too much, and I never had any kind of different cultural background of the patient. Most of my patients are Asian. Chinese or Thai, and there is not much difference.

I: So, have you ever talked to other colleagues, like other doctors or physicians from other cultures who have different perspectives on the ethical dilemmas of truth telling for example?

P: Yeah, I’ve been in the States and I don’t think there is much difference between how we tell the truth to the patient.

I: So it’s basically the same way they approach the patient? P: In point of view, yes I think it’s the same. I: So, when you are confronted with a dilemma of truth telling for example, how would you

react to the situation or how would you deal with the situation? P: You’re asking about my feeling or how am I going to act with the patient? I: Yeah how would you act with the patient?

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P: I have stay calm and try to be compassionate to patient, and let the patient feel I’m being sincere. And then I just go straight forward. 80

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I: OK, so you just tell it straight forward. P: Yeah, but this will happen only if the patient’s status is well prepared to receive the news. If

they are not ready or they are not well prepared I, perhaps I’m not telling them at that time. I: OK. So you want to wait or you would tell the patient later or? P: Maybe something like that when he or she is more prepared. I: OK. And the way you deal with this, is this the medical standard of practice in Thailand or is

it the way you learned to do it in ethical class or during your education or how is it? P: Hmm, well. I think I learned it from my own practice and my experience after observing

some other senior doctors doing it or something like that. I learned it by myself, I don’t think that I do it more, I learned it more in my medical years.

I: OK. So you. Of course it’s easier when you have some practice and you saw other people, so you learned it by that way?

P: Yeah. Something like that. I: Is there anything you would consider to do before telling the truth to the patient? Like you

told before about the information or something? Is there anything else you would do? P: Well, perhaps I try to give him another round of physical examination or asking about his

illness history and perhaps I ask that, what he or she thinks he had. Or what is the plan after he or she received. What is he thinking about the plan to do, or something like that. And I will try to explain about the results I have and what is the prognosis, and what is the treatment, or something like that.

I: Yeah, and if you know there is no treatment for the disease how would you tell the patient about that? Or if it is very difficult and the chance for the person to not survive, or something like that, how would you do that?

P: Erh, maybe I will tell them that, there are some other way of treatment that can make he or she feel more comfortable in this time he or she has left, or something like that. And try to make the time some more, good quality of life or something like that in the time left, or something.

I: So do you discuss directly with the patient before going through the diagnosis and obtain his or her consent of discussing the result with the family?

P: Yes. I: OK. Have you ever considered that truth telling is cruel to the patient? P: No. (laughs) I have never experienced that. I: OK, maybe you thought that, OK, of course it’s not very nice to tell something like this. P: Well, it’s not nice but I’m fortunate I have never met any kind of difficult patients. I: OK. Do you think it’s morally acceptable to tell a white lie to the patient? I mean

considering your professional ethics?

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P: I think. This is a hard question. If you say morally there is no white lie, a lie is just a lie. But if he or she hears the bad news and hear he or she will suddenly get worse you shouldn’t tell him. Maybe just tell the relatives and postpone the news or something like that.

I: Yeah. So sometimes you mean it could be OK to make the patient to feel better and then tell the relatives instead?

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P: Yeah, maybe. Or maybe just, instead of you’re going to tell him that he got a liver cancer you just tell him that he got a liver disease or something like that. Sometimes they don’t ask much that how bad it is or something like that.

I: OK. Talking about white lies, how would you, what would you. Or what do you think is a white lie?

P: A white lie is something that. A lie that you just tell the patient and you just lie to make him feel not so bad, or something like that.

I: OK. So if you were a patient yourself, would you like to be fully informed yourself? P: Yes. I: About your diseases or? P: Yes, now it’s yes, but I’m not sure if that time really comes, will my decision change. I: Of course it’s always difficult when you’re a doctor. You might know yourself what it could

be, right? P: Yeah, (laughs) I: (Laughs) So you can do the diagnosis yourself maybe, I don’t know? But anyway, let’s hope

it won’t be a question. But have you read the case scenario at the end of the questions? P: Yes. I have read it. I: Do you have any ideas or any opinions of how to deal with this situation? P: Well, I think the patient here Mrs. C, is very old. From this I’m not sure. The patient cannot

speak English? I: Yeah. P: It’s hard to tell the bad news to the patient, because anyway she can’t understand English, so

you have to tell the relatives.I: So you would tell the relative of the? P: Yes, but in my point of view I will not tell the patient directly, and leave the decision on the

relatives, that they want to tell their parents or not.I: Even though it’s in the US for example, and you’re not allowed to tell others than the patient

first? For example, if you are not allowed to tell other people. P: Not allowed to tell other people but. Well. I think it depends on the status of Mrs. C. if she

can handle with the. I mean you have to judge that Mrs C. is well prepared or not. If she is prepared and you think that her condition is OK I think you can tell her about. I think it’s an individual problem. But she. If her status is not good she is under bad coma, an oxygen mask, you can’t tell her anyway.

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I: Yeah. OK, do you have anything to add about truth telling in general? Is there anything you want to tell us about or we should know about?

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P: No. Nothing. I: Any truths that you didn’t tell us, and you want to? P: No (laughs). I already told you more than I know. (laughs) I: You told us more than you know? (laughs) P: Yes. (laughs). I: That’s great. OK, but I think we went through all the questions now already. And it’s very

good to hear your opinions I think. Thank you very much.

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Interview with a Female Chinese Medical Student (1): Chinese 1

I: What is ethical behaviour according to your understanding? P: Actually it’s a good question. I think that ethical behaviour in my opinion is when I treat the

patient. The patient has a right of informed consent and otherwise the patient needs, or has the right of self determination or something like that. But sometimes it’s a ( ) of my doctor so that’s a ( ). 5

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I: Can you explain self determination, what do you mean by self determination? P: Erh, determination for the patients. They have rights to make their self determination for

their disease, but as a doctor who also has a ( ) determination, but yes it’s a different determination.

I: OK. And during your medical education did you receive any specific ethical classes? P: About what? I: About in general. P: Well sure. I: Could you give me some examples? We mean about the ethics. P: OK, so if I have a patient who has a very serious disease like cancer or some tumour it’s

hard to tell the patient the truth directly. That’s a very difficult situation as a doctor. I: OK, and did you discuss that difficult situation in the class? P: Erh, what’s your question? I: I mean, like you said, it’s a very difficult situation for the doctor to tell the patient who has a

terminal disease, the did you discuss solutions within the class about what the doctor should do?

P: With another doctor or? I: Yes, with another doctor. P: Yes, normally we would do that. I: And these classes were they in China or here in Denmark? P: In China! I: OK. I: So what was the consensus that you reached? P: Erh, what do you mean, for the patient or? I: I mean, after you did that with the other doctors, whether or how should you tell the patient,

then what were their opinions? P: Well, after I talk with a colleague or a senior doctor normally we have to talk with the

patient’s family. I: OK, and why? P: Why? Because, erh. Yeah, of course the first step, after that we’ll talk with the patient but.

How can I explain? It means, first we have to judge what kind of patient, you know. It means, if this patient has HIV AIDS or if he get a good education or if he can accept some bad news, or something like that, if he is active if he is a positive ( ) or something like that.

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I: OK, and. So in this case it’s. It depends patient’s background, like education? P: Ja. I: OK. Have you experienced any difference from Denmark and China then in this respect? P: Oh, actually I’m in Denmark just for the research, not to work on the clinic. But in China

I’m a clinic doctor. I: OK. I see. But have you heard anything or experienced anything while you were here about

these situations, that they might look a bit different from China or something like that? P: No, sorry, not really. I’m just doing research. I: OK, no problem. P: So actually in China it’s really common. I: It’s common practice? P: Yes, I mean we always talk with the family and another doctor before the patient. I: Yeah, and can I ask what happen if you consult with the family, I’m sorry, if you tell the

family. Is it the family who will tell the patient or is it the family who decides that the doctor should or should not tell the patient?

P: I think you are right. Normally we’ll tell the family the truth and then we discuss together how to tell the patient the truth. Normally ( ) family just if the patient need to know then the doctor will tell the patient directly.

I: OK. So, when you are confronted with a dilemma of truth telling. For example if the family said that the patient should not know, and then what would you do because on the one hand the patient has the right to know and on the other hand if the family ask you to hide the truth from the patient, then what would you do?

P: For me, I think the principle as a doctor; the most important thing is the principle of beneficence, the principle of beneficence for patients of course.

I: OK, and what does it mean? P: Ah, it means, what’s the best for patients. I: OK. But in this case it is the family who decides, not the patient? P: Erh, well think about the families’ suggestion, of course, well. Well, think if it’s good for

the patient. The patient is the most important. I: OK. But you always talk to the family first before you tell the patient then? P: Aha, yes. I: And in general, how much information does the patient want to know concerning their

diagnosis or their treatment? P: If the disease is not serious, of course we can tell the patient all of the information if they

want to know. But if it is very, erh, very. You know some diseases like cancer tumour is not good, so normally we tell the patient the general information, not completely.

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I: OK. Can I just go back to my last question about. If the patient, no sorry, if the family of the patient decided that the patient should not be told, then as a doctor how would you tell the patient what is happening with his or her body?

P: Well, it depends on the different patients, we’ll make different decisions, not totally decided by the family, not totally.

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I: OK, could you give me some examples? P: For example if the patient really wants to know the truth and he has a good education he can

understand, he can accept the truth, or something like that. So, probably we can tell the patient directly.

I: OK, and if the patient, if it is on the opposite way, the patient doesn’t have much education then would you tell a white lie to the patient?

P: Mmh, depends on the disease. I: OK. Could, you give some examples, where it could be good to give the patient a white lie

or something? P: Yeah, we have some patients who has a tumour in the eye ball and normally, this patient is

very young, and not so old, a teenager or something like that, so normally we would talk with the family first if it’s good for a teenager to, tell them about the tumour or something. Yeah. So, normally the family don’t want the patient know the truth so at that time or that moment I think I would do some white lie.

I: OK, and so, can you please tell me, what is a white lie according to your understanding according to your opinion.

P: The white lie I understand is a lie but it’s good for the people who, how do you explain? It’s a lie but our goal is to try to help people.

I: OK, so if I rephrase it, that is a lie that doesn’t harm the patient?= P: =Yeah right. ( ) I: OK. Have you ever considered that truth telling can be cruel to the patient? P: Sure. I: Especially if the patient is old or?= P: =is old or, especially in China yeah, a lot of old people are very, erh, they are very sensitive

for their mental you know, if they know they have cancer probably they will lose their confidence for life for ( ) and that’s not good for treatment.

I: OK. If you were a patient, would you want to be fully informed? P: If I am a patient? I: Yes. P: Of course I want to know the truth completely to. That’s different because I’m a doctor, I

know all kinds of medical knowledge and I have enough knowledge to judge myself. So I’m not ( ) to with confidence for the future because that’s different.

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I: OK, so let’s say if, erh. Do you think there are other alternatives to telling the truth to the patient? For example instead of telling the truth then you prolong the truth until, for some time, or maybe other alternatives?

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P: Yes, I think I would do that some times. I: OK. Regarding the case scenario what do you think should be the solution? P: If I were doctor P, If I was him or her I would probably agree with her daughter. The first

reason. The patient is an 80 years old Chinese woman. I don’t think she will get enough education for ( ). So, another reason is if the patient wants to know the reason, in China actually a lot of patients they don’t want to know the truth.

I: Yes, why, why don’t they want to know the truth. P: Sometimes, of course at the beginning they want to know something. But some of them

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I: OK, so as a doctor= P: =yes if the doctor, if the patient really wants to know the truth I will think about it. I: OK, P: Then after I talked with the or after Dr. P. talked with her daughter I guess probably I won’t

tell if the diagnosis is very serious, probably I won’t tell the lady about her disease.I: OK, and, erh. Well in that case do you think that it’s against the practical standard of the

doctor, for example in some countries it says in the laws that no matter what, you have to tell the truth to the patient and let the patient decide, whether he or she wants to know the truth or not. But in this case if Dr. P. goes and talks to the family before the patient, do you think that it is against the practical standard?

P: Not really. We are not ( ) some law about this ( ) that’s very important we know that of course. But there are some specialties we can privilege this right in an emergency or some ( ) or in the public interest or what is called the therapeutic privilege. Do you know what I talk about?

I: Erh, I don’t understand about therapeutic.= P: Therapeutic privilege? I: Yes, erh, could you explain? P: It means, if you are a doctor if you are a reasonable decision standard doctor ( ). Do you

know this word? I: Erh, I’m sorry I’m not familiar with this term. P: It means, of course if you are a real doctor there are some standards to judge if you are a

doctor.I: OK. P: It’s called reasonable decision standard to judge if you are a real doctor or something like

that. So the doctor has some privilege. I: OK. P: We call it therapeutic privilege.

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I: OK P: So we have some special power to. Erh, against the patient’s rights of informed consent. We

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I: OK. And erh, last question. Do you have anything to add about truth telling? P: Yes, I think in China we need to complete our law. Medical law because the law is not so.

It’s not good enough to. For details. Do you know what I mean? I: Yes. P: So we need to. Yes I want some day that law ( ) so that is easy for the doctor. I: Since you mentioned about the law. If I understand correctly you mean that there is not

specific laws about truth telling and sometimes it is difficult for the doctor to make a decision.=

P: = Right, right. I: But if there is a law, then it is easier because the doctors can follow the law. P: Right, right. I: OK. So I think we covered all the questions, and thank you very much.

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Written Answers from the Singaporean Medical Student

I. Introductory Questions

What is ethical behavior according to your opinion? (some examples) Ethical behaviour in my personal opinion, is where I stick to my own morals and principles, on top of the ethical guidelines set by the Singapore Medical Council. For example, proper informed consent should be obtained from patients before any treatment or procedure is initiated.

How long have you practiced? I have been in clinical practice in the wards for 2 years as a medical student.

Have you experienced ethical dilemmas of truth telling during your practice? No. Most of the decisions to inform the patients are made by the doctors after consulting the family.


During your practice, are there any situations where you have to consider the patient’s cultural background before making decisions (about treatment, the patient’s family involvement, etc) Not really.

Could you give us some examples?

Do you have experiences with colleagues from another culture who have different views on ethical dilemmas (truth telling) and treatment of patients? In terms of truth telling, there is not much difference. However, with regards to treatment, caution should be practiced. For example, Muslim patients should not be given, or should be informed first before being given certain medicines that have an alcoholic component, or that use alcohol in the manufacture process.

In your opinion, is the patient’s cultural background important for physicians to make a decision when they have to tell the truth? While the cultural background does play a part in the way and the means of telling the truth, the decision as to whether or not the truth should be told is irrespective of culture.


(OR)


What could be the reasons that are necessary or more important than cultural background before telling the truth to the patient? If the patient is unable to take the bad news, thus affecting his prognosis.If the next of kin explicitly refuses to let the patient know the news. However, it should be made clear to the next of kin that the patient has a right to know and if the patient asks the doctor, the doctor cannot

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withhold the information.

When you are confronted with a dilemma of truth telling, how would you react to the situation?

I would make sure the relatives know that the patient has a right to know. Furthermore, it is usually inevitable to let the patient know the truth as the disease progresses. Thus, it would normally be better for the truth to be told to the patient by the relative, with the doctor playing an advisory role.

Do you follow some medical standards of practice?

Yes. Withholding important information makes the doctor potentially liable.


What would you consider before telling the truth to the patient?

The patient’s state of health (Both mental, emotional and physical aspects). Consultation with the next of kin if necessary.

How much information does the patient want to know concerning their diagnosis and treatment? It varies from patient to patient. Some patients just want to know what the doctor thinks is the best option, while others want to know all the options available, as well as all the information about the diagnosis.

Do you discuss directly with the patient before going through diagnosis and obtain his or her consent of discussing the result with the family? Not in all cases. Most of the time the patient is involved in the discussion. However, the immediate relatives are often also involved in the discussion as they play an important supportive role. While it is necessary to obtain consent from the patient before telling the family, this normally applies to more sensitive issues like where abortion, contraceptive use, or other terminal illnesses. Exceptions include HIV, where recently a law has been passed in Singapore that the spouse must be informed if the patient is diagnosed to have the disease, as the spouse is at risk.

Have you ever considered truth telling as cruel to the patient? Not really. In the long run, it is better for the patient to know the truth and to face it. The method of truth telling can help to ease the process.

If so, what could be the alternatives to telling the patient the truth?

Is it morally acceptable to tell a “white lie” to the patient, considering your professional ethics? As a professional, it is wrong to tell a lie, whether it is ‘white’ or not. The patient has a right to know.

What would you define a “white lie”, according to your opinion?

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Appendices


What is the harm when doctors violate cultural conventions and insist on telling the truth to the patient? (If patient is from another culture) The family might lose their trust in the doctor and thus, the doctor loses the support of the family in the treatment of the patient.

What factors most commonly influence decisions to inform the patient? Patient factors include age, education level, health, and the family. Other factors include the disease, where the certainty of the diagnosis, the outcome of the disease, and the treatment play a part.

If you were a patient, would you want to be fully informed? Yes.

III Ending Questions & A Scenario

Do you have anything to add about truth telling? Nope.

Case Scenario:

“Mrs. C was an 80 year-old-Chinese woman who came to visit her daughter in the United States. With little knowledge of English, Mrs. C was sent to a hospital because she experienced loss of appetite and rapid weight loss. While Mrs. C waited in one of the examination rooms, her daughter made a request to Dr. P and emphasized her view that if Dr. P concluded that her mother had a life-threatening disease, he should not directly reveal such information to Mrs. C. The daughter explained that in the Confucian tradition, it is considered rude and unsympathetic for a physician to give such information to an elderly, seriously ill patient. Instead, this information should be given to the patient’s family members. If the family members believe that it is appropriate to share medical bad news with the patient, the family members and not the doctor should do so.”


Dr. P could tell the family that with a life threatening, disease; it is often impossible to withhold the truth from the patient forever. He should encourage the family to take the responsibility of breaking the bad news to the patient, and to show their support for the patient. It should be made clear that the patient has a right to know, and that if the patient should ask the doctor directly about her condition, the doctor has the responsibility to tell her the truth.

truth telling - the medical students' perspectives

Documents

participants background

asian participants solutions

chapter objective

willing participants

chapter overviews

understanding virtue

criticisms of virtue

interview guide