Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

To read about each commentator, click on the person's name; to read each piece, click on the title.

Common Sense

[Citation: Blackhall, LJ. Common Sense. Innovations in End-of-Life Care, 1999;1(2), www.edc.org/lastacts]

I was asked to write an article about cultural diversity, but as I began to write it, I realized that it was really about common sense. Common sense is the truth we do not question. When someone makes a statement and then says 'that's common sense,' they mean that there is no need for any further justification. It's self-evident. I guess you could say that doing research into cultural diversity has made me lose my common sense.

I am a hospice physician and a researcher who has lectured and published widely about the ethical and practical aspects of caring for dying patients. Several years ago my colleagues and I completed a large project called 'Ethnicity and Attitudes Toward Care at the End of Life'. ¹. This study looked at attitudes toward a variety of topics related to the care of dying patients (truth-telling, patient autonomy, advance care directives, withholding and withdrawing care) among elderly subjects from four different ethnic groups: Mexican American, Korean-American, African-American and white (European-American). In the first part of this study we interviewed 800 subjects, 200 in each group using a standardized questionnaire. They answered yes or no, agree or disagree, they picked from multiple choices. In this way we got a lot of information about our subjects' beliefs and values as well as about their demographic characteristics . We were able to do statistical analyses, to see how attitudes differed and if those attitudes differed by ethnic group or if that difference could be attributed to something else, like socioeconomic status, or religion. But because we recognized that attitudes about something as complex as the dying process can't necessarily be reduced to multiple choice questions, we went back the next year to talk to 10% of our original group in an in-depth ethnographic format. These interviews, conducted by anthropologists, got something more than answers, they got people's stories, their experiences and the meanings they made of those experiences.

I initiated this project because I was convinced that we in the bioethics profession were missing something. I was beginning to feel that many of the assumptions underlying attempts to improve care at the end of life were based on the experience of the mostly white middle class professionals like myself who did bioethics. We assumed, for example, that people are concerned with getting too much care at the end of life, and desire protection from over-burdensome care, perhaps in the form of advance care directives. Working at the LA County Hospital , it seemed unlikely that this was the major concern of the poor, mainly Latino patients I cared for.

The results of this study surpassed my expectations, but certain types of criticism stymied me. Were we just stereotyping? How could statistical information about the beliefs of a whole group help us with our encounters with individual patients? My greatest fear about our study was that the results would be reduced to a 4x4 index card in a medical student's pocket: Korean people: don't tell. Mexican-American: don't tell. White and African-American: tell. Then again, after lectures people frequently came up complaining that we had not mentioned the group they were most concerned with: Armenians, Hmong people, Russian Jews. Was the point of this work to study in detail the beliefs of every group in the United States? Was this possible, or even desirable?

I still knew that we and others in the field were doing something important, that if we didn't listen to these voices we would be missing something crucial. Then one day while standing in my office, reading a transcript, I had an epiphany. I was puzzling over a problem with the way our Korean-American subjects had answered some of the questions in our survey. The vast majority of them, close to 80% , agreed with statements like 'You should always keep a patient on life support, even if it appears hopeless, because there is always a chance of a miracle.' (Very few white subjects will agree with this statement, by contrast.) On the other had, very few of the Korean elderly we interviewed (only around 5%) wished personally to be put on life support at the end of their lives. What could this contradiction mean? No matter how I looked at it, I couldn't make sense of these results. So we asked our anthropologists, as part of their interviews, to bring up this issue with the Korean subjects they talked to. The first of these interviews, transcribed and translated, were now coming in. In the transcript I was holding, a patient we have called Mrs. Kim explained her views ². "I, myself would not want to be kept alive by life support," she said. "But I would be the dying patient, so it wouldn't be my choice. My children would decide, and they would have to keep me alive even one more day; that is the right behavior for children." She went on to tell us that if people heard that a child had decided to do anything else for their parent, they would regard it as "unfilial." Similarly, although she acknowledged that in the abstract it might be good to let a patient die sooner, with less pain, she would always ask the doctors to keep her aging parents or sick child alive even one more day. ³

Reading this, I suddenly realized that what seemed like a contradiction to me was only a contradiction because I was viewing the issue through the lens of patient autonomy. It seemed self-evident to me that the patient's wishes were of paramount importance in making a decision about life support. But to Mrs. Kim, her wishes were not the crucial factor. The relevant ethical principle was hyodo, filial piety. In the case of her illness it would be the duty of her children to care for her and the appropriate way for them to show their caring was to keep her alive, even one more day. Looking at these seemingly conflicting answers to our questionnaire through the lens of hyodo, the conflict dissolves. These elderly Korean-Americans do not want to be kept alive on life support and they think it is the right thing that people be kept on life support. Should their family members do any less for them, it would show a lack of caring that would shame the family, and perhaps, cause them to feel unloved.

Mostly I have not changed my own beliefs about how I would like to be cared for at the end of my life. But I have stopped believing that the good death I envision for myself is a death that would seem good to someone else. I have come to distrust the idea of 'common sense.' When we say that something is common sense, we mean that it is an idea that makes so much sense to us that we have never examined it; perhaps it is the idea that was so ingrained in us from earliest childhood, so reinforced by our culture that we cannot think to question it. Almost all of our subjects, whatever ethnic group they are from, think dying people know they are dying. To the African-American and European-American subject, it is 'common sense,' therefore, that you can tell them that they are dying. Why hide the truth since they already know it? But to our Korean-American and Mexican-American subjects, it is 'common sense' that for this very reason you do not need to tell them. Why cause them more pain?

Common sense is the lens through which I see the world, the lens I have worn so long that I have forgotten that it is a lens. Doing this study allowed me to see that I do wear a lens, a straight white girl from Schenectady lens. And it allowed me for a few moments here and there to take off my lenses and try on someone else's. The subjects in this study enlarged my vision, and for that, I will be forever grateful.

Endnotes

1. Gelya Frank PhD, Sheila Murphy PhD, Vicki Michel JD and Stan Azen PhD. [Return to International Perspectives]

2. I have paraphrased her words here. [Return to International Perspectives]

3. A longer and more thorough discussion of this case can be found in Frank G., Blackhall L., Michel V., Murphy S., Azen S., Park K, "A Discourse of Relationships in Bioethics: Patient Autonomy and End of Life Decision Making among Elderly Korean Americans" Med Anthro Quart 12 (4): 403-423 1998. [Return to International Perspectives]

Cancer Disclosure and Family Involvement with Japanese Patients in the US:
An Interview with Dr. Michael D. Fetters

Dr. Michael D. Fetters is a family physician and director of the Japanese Family Health Program, in Ann Arbor, Michigan, where he cares for many Japanese expatriates. Dr. Fetters has lived in Japan for almost three years. As a Fulbright scholar, he conducted research on the topic of physician disclosure to patients and families of cancer diagnoses. This experience, and his fluency in Japanese, have provided him with a particular expertise and a lens for identifying dilemmas that can arise when caring for Japanese patients in the United States. Here he first describes the knowledge that his research on family decision making and cancer disclosure in Japan offered him as a practicing physician. Then he provides a case example that illuminates the complexity that such knowledge adds when the two relevant cultural, linguistic, and legal systems lead to contradictory, or at least distinct, paths of action. What follows are edited comments from Innovations' interview with Dr. Fetters. [Citation: Fetters M. Cancer Disclosure and Family Involvement with Japanese Patients in the US: An interview with Michael Fetters, by AL Romer, Innovations in End-of-Life Care, 1999;1(2), www.edc.org/lastacts]

I first went to Japan as a teenager through AFS (American Field Service, an exchange program) and have been there many times since. As a Fulbright scholar, I conducted research on end-of-life decision making there. Prior to conducting this research, I was familiar with the idea that it was common not to disclose a cancer diagnosis in Japan. However, when I got to Japan, I observed that the family took on what seemed to be a very different role in decision making from that in the United States. This different ethic of cancer disclosure was like a light through a cracked door, so to speak, that led me to a new place. It was an invitation to reexamine family decision making and how families are much more the unit of care in practice in the Japanese setting than in the American setting.

Here in Ann Arbor, Michigan, I'm a family physician, and so I'm involved with the care of patients across the lifespan, from babies to geriatric patients. While end-of-life care is a small percentage of my practice, I am involved in the care of dying patients. A large number of my patients are Japanese: anywhere from 70 to 80 percent most clinic days, and some days as much as 100 percent, because I'm one of the few physicians in the area who speaks Japanese. We have a large Japanese population because of the automotive industry and because of research and other academic opportunities at the University of Michigan.

There's enormous heterogeneity in the roles that families assume when they are caring for a loved one or making decisions. That's true in this country and it's also true in Japan. So one of the very difficult things in making cross-cultural comparisons is that there's always the risk of stereotyping. One of the things that medical anthropology has taught us to do is to really look at the details and to look at the rich diversity that exists within cultures. And so on the one hand, I'm a bit hesitant to say, "This is the way it is in Japan, and this is the way it is in the United States." But one can still step back and say there are some very different patterns that emerge about the roles that families play in the United States and the roles that families play in Japan. And the other thing, obviously, about culture is that culture is dynamic, and there are lots of changes occurring in Japan at this time.

Different Approaches to Patients from Different Cultural Backgrounds

I didn't realize I was doing anything differently in terms of my approach to American patients and Japanese patients until I had medical students with me, who asked me questions about why I was taking a particular course of action. At one level, what underlies my approach is the same for all patients, in the sense that I'm really trying to understand what the patient's motivations for health care are, what his or her own concerns are, what sorts of explanatory models the patient is using, and what his or her own view is about what's causing the illness. Then I try to figure out how I can integrate the care that I provide to that patient with his or her own explanatory model. So I really try to take that approach with everyone.

At the same time, I do know quite a bit about Japanese culture, and that puts me at a different starting point when I interact with Japanese patients. I think that understanding a lot about a particular patient population can give you a better starting point for finding out where it is that patients are on particular issues and where they want to go. But that knowledge can also complicate things when it is used in a cross-cultural setting.

Ambiguous Disclosure

Akira Akabayashi, Todd S. Elwyn, and I have a paper forthcoming in the Journal of Medical Ethics about ambiguous disclosure. Ambiguous disclosure is a concept that comes out of our research on cancer disclosure and one pattern of how Japanese physicians interact with patients. What it boils down to is that it's very easy in Japanese to give a vague sense of what's going on. Ambiguity is a standard part of the language. In other words, in everyday life, conversation is less direct. If conversation is customarily vague, you don't feel as though someone is intentionally trying to deceive you.

Around the issue of cancer disclosure, for example, it's natural to speak rather vaguely about what sorts of things have been found, regarding the physical examination or laboratory work-up using blood tests or the sorts of findings present on x-rays. This ambiguous disclosure then, we argue in this forthcoming paper, really becomes an invitation to the patient to determine how much he or she really wants to know about a particular topic. In this sense, ambiguous disclosure then allows the listener a choice about how to proceed. The patient can then, in theory, take control and say, "This is something that doesn't make sense to me. You're not painting a completely clear picture. There's not a lucid picture of what's going on here. Give me some more details on that." However, what's complicated is that the patient may worry about breaking social norms if he or she inquires too directly in response to ambiguous disclosure. Again, this depends on the circumstance and the approach that a particular physician takes.

Sociolinguistics and Cultural Knowledge

Clearly, another important difference between interactions taking place in English and those in Japanese, whether here or in Japan, has to do with the Japanese language, in which there are hierarchical structures embedded in the language itself. There is a variety of terms to use for expressing the "self"; there is also a variety of terms used for expressing the pronoun "you." The selection of specific terms may humble the speaker or elevate the person whom he or she is addressing.

These linguistic structures provide important cues that influence where the discussion can or should go. Furthermore, there are honorifics that make a discussion either more formal or less formal. And there are different verbs that one can use, which again, would reflect hierarchical differences. So it gets tricky, especially for someone who is grounded in a different culture, even if "fluent" in Japanese. Understanding the meaning of a conversation on a delicate subject becomes quite dependent on sociolinguistic and cultural knowledge as well as on the assumptions of each speaker. On the one hand, physicians could try speaking at a very familiar level, but patients might then take that to mean, "This is an informal doctor who isn't a good doctor just because he or she is not very doctor-ish." There are lots of judgment calls about how to address others.

Within Culture Heterogeneity: How Much Do Patients Want to Know?

I actually experienced this in the United States as I was building my practice of Japanese patients. I was well-versed in issues of ethics and respect for patient autonomy, and I had theories that the reason that patients were not exercising autonomy was because they just weren't being given the opportunity in Japan. And I soon learned that that was true for some people. I've actually been amazed by the number of questions that my Japanese patients have about their health. Sometimes they have even more than I would expect from my English-speaking patients. This experience is very interesting because it was quite common for me to hear Japanese physicians say that patients really don't have any questions, end of story. In contrast, I've found that patients are frequently very inquisitive. And yet, there is a lot of heterogeneity. Some of my Japanese patients do sound like what Japanese physicians would predict -- basically they want to follow my advice. When I offer them several treatment options, "Well, we could do this or that," then they'll come back and say, "Well, which do you think I should do?" Others really want to know everything.

Dual Identity Offers More Degrees of Freedom

I think the first thing I bring to the interaction is that I'm not Japanese. So my patients are allowed to change the rules a bit. The boundaries, all of a sudden, are no longer clear. There is an expectation that I am a Japanese-speaking doctor, who is the director of the Japanese Family Health Program at a clinic where the nurse is Japanese, the receptionist is Japanese, and the other doctor is Japanese. So there's a relatively high expectation that this clinic is Japanese-centered. But at the same time, I'm not Japanese, so the boundaries are ambiguous; one has to explore a bit, I guess, and say, "Where do we draw the lines?" Patients, too, can explore how much they want to participate or how much they are encouraged to participate in decisions about their health care.

Clinical Tool to Elicit Preferences: Advance Directive for Disclosure

Because of the issue of nondisclosure of cancer diagnoses in Japan, when working with Japanese patients who appeared to be seriously ill, I began using an "advance directive for disclosure." Since I started this practice, others like Atsushi Asai, for example, have published written versions. ¹ I think it says something about the validity of this concept of an advance directive for cancer disclosure when it crops up in several places.

This document basically asks the patient for his or her preferred level of participation in decision making. Actually, the document has evolved even since I started using it. Now I try to find out both to what degree a patient wants to participate in decision making, and how much information the patient wants to know. There is research coming out suggesting that physicians in the United States overestimate the degree to which patients want to participate in decisions and they underestimate the amount of information that patients want to know about their condition. Working on that assumption, I'm raising the questions that this form elicits with all of my patients, not only Japanese patients, to get both a sense for how much patients want to participate in decisions and how much information they actually want to know.

My original document is in Japanese, in the form of a questionnaire because it was originally a research questionnaire. The conclusion that I have come to is that the written form is much less important than the opportunity that the questions create for a dialogue with the patient. The document allows for an opportunity to explore, "Where is this person coming from? In what direction does he or she want to go?" Now I usually use an oral advance directive for disclosure with patients.

Case Example:
A Japanese Man Who Presents as Gravely Ill at a Japanese Clinic in the United States, Accompanied by His Wife - Which Culture's Rules Should Be Followed?
The indented text tells the story of what happened. The full-page text describes Dr. Fetters' internal dialogue as he balanced different expectations and ethical principles in this interaction with a Japanese patient and his wife. Dr. Fetters presented this case at the American Society of Bioethics and Humanities meeting. ²

A middle-aged Japanese man came into my office with his wife complaining of a lump in his stomach. His skin was yellow, and he was losing weight. Within the first thirty seconds of the interview, it was clear that he had a very serious problem. Any clinician would look at this person and say, "There's something very serious here; the fact that he is complaining of this hard mass is virtually diagnostic of his having some sort of cancer."

In this case I found myself trying to process all of the information that I had about how different cancer disclosure attitudes are in the United States and Japan. In Japan, there is a tendency to tell breadwinners of the family if they have cancer. And then there's the fact that he's living in the United States. And there are other considerations. So the question becomes, To what degree am I obligated to follow U.S. expectations and rules versus Japanese expectations for disclosure? And what exactly would those be, in this situation?

I have to tell you, it was really quite difficult. I thought I was really prepared for the time when a cancer patient would walk through my door because of all the research I'd done in Japan, especially if the patient were Japanese. Yet all of a sudden, when the rubber hit the road, I realized again how difficult it all is, despite all the scholarly work I had done. Luckily, the physical examination can be a time-generating opportunity to think.

I proceeded to ask him his preferred level of involvement in things, and he quickly said, "Well, I want you to tell me everything."

Now this is a helpful question, but it alone does not make the doctor's job easier. When a patient says, "Tell me everything," how much does that really mean? How fast? Should one just dump the whole can of worms here? Should the physician use time as an element to warm up the patient to the diagnosis? Remember, I had no previous relationship with this person. His wife was also with him at the time. They both appeared really very concerned. He was obviously very sick, and I was almost certain he had cancer, and probably at a very bad stage of the disease.

What I decided to do represented a compromise. I was more explicit than ambiguous disclosure would require, but perhaps less explicit than the American norm.

I gave him a differential diagnosis. It could be hepatitis. (He had had a history of a different kind of hepatitis.) It could also possibly be cirrhosis, since he was a fairly liberal user of alcohol. I mentioned in passing at the very end of the interview, that well, this could also be a cancer. When I said "cancer," his face dropped. His chin almost hit the floor.

When I saw my patient's shock, I became enormously uncomfortable. On the one hand, I felt, "I've really gone too far here. This is the first time that I've met this person." On the other hand, I felt I was deceiving the patient. I think that this is something that clinicians oftentimes are not honest about with themselves. I had intentionally tucked the possibility of his having cancer all the way at the very end, trying to deemphasize it, using that as a tool for trying to acclimate him to the idea that there could be something very serious here. Strictly speaking, I was honest. I didn't really know for certain what he had. I was conveying to him that he had something quite serious. But I did not disclose the full range of my thinking. I did not say "I really think that you have cancer."

With an American patient, I might have been more candid about the fact that I had a strong suspicion that this was cancer. So really, again, this comes down to the question of whether a physician should do things differently with patients from a different cultural and linguistic background or not.

In Japan, physicians will often divulge a cancer diagnosis to family members first and ask the family whether the diagnosis should be shared with the patient. Consulting with families is seen as appropriate. In fact, physicians are expected to take families' preferences into account. My own unpublished research on the use of advance directives for disclosure showed that virtually everyone who said that they would not want to be told themselves about an advanced stage of cancer said that they would want their spouse told. So data that I had collected among this same population (Japanese expatriates visiting a Japanese-centered clinic in the United States) had told me that the more likely it was that a patient coming for cancer lab tests actually had a worse stage of malignant disease, the less likely it was that that patient would want to be told that he or she had cancer. And in that circumstance, the person whom he or she would want to be told was the wife or husband.

In light of this research, one of the things I did was to talk with this patient's wife while he was changing his clothes and it was natural for us to leave the room. I said, "You know, I think there's a pretty good chance this is cancer, and if it is, do you think it's appropriate to tell him?" And she said, "Absolutely not! Don't tell him. You can't tell him; he would never be able to handle it."

So here is a situation, where I tried to put my research findings into practice. I had asked the wife her opinion on disclosure and received an unequivocal response: "Absolutely don't tell him. It'll kill him. He'll get worse." Yet I am an American physician, practicing in the United States, and the patient has told me to tell him everything.

So I reviewed the differential diagnosis and suggested that he needed to be hospitalized so that we could do the usual diagnostic tests and try to figure out what he had. I explained that they would then come back to the office to talk about the results with me. The patient was then admitted to our university medical hospital.

As it happened, I knew the attending physician on the service, as well as the resident. Because of the size of our institution, it is actually unusual for this to happen. It was the best possible circumstance for taking a coordinated approach that would take into account his cultural background. You can't go against the flow if you don't know the people on the inpatient team.

In this case, I was able to say, "We're not going to dump everything out on him while he's in the hospital. This is a very sensitive and delicate issue, and I think it's probably best for me to handle his test results in the outpatient setting." All the physicians agreed, given the circumstances, that this was the way to go.

He had a CT scan of the abdomen, and he was having some diarrhea as a complication of the malignancy, so they did a workup on that. Basically these tests only took about a day, and so the hospital staff prepared to discharge him that evening.

As is often the case in American hospital settings, there was too little doctor-nurse communication about the patient, and the nursing staff apparently hadn't been involved in the decision to hold off on the disclosure of test results. As a result, the discharge nurse dutifully pulled out her standard institutional form that lists a series of questions to be answered, namely: "What's the patient's name? What are his or her medications? What's the diagnosis? What did the test results show?" Well, she wrote the answers, as she's supposed to, on the form, including "There's a 12 cm mass in your liver." After getting his discharge instructions, the patient reported that she said, "You are all set, you can go home now." At this point, it was fairly late at night. The patient took the form, walked into the parking lot with his wife, and broke into tears.

This man had two daughters; it was the birthday of, I believe, his older daughter. So he's in the hospital getting a CT scan to show that he's got cancer, and his daughter's supposed to be having her birthday party. I'm not criticizing the nurse here. In fact, one could blame us, the doctors, for not including the nurses in our plan. However, I see it as an indictment of the whole system. The nurse was doing her job: writing down the diagnosis and giving it to the patient. That's informed consent. That's ethics in practice in the United States.

So the patient did follow up with me the next day and told me what had happened. Again, he had a very serious, downtrodden look, and his wife looked the same way. So I reviewed what I understood his preferences to be for disclosure. This conversation is all occurring in Japanese, with me saying, "In the United States, we tell patients virtually all the information about their care... as much of the information as they want to know, whereas in Japan, that's not always the case, and because I'm familiar with the traditions in Japan, I just want to make sure that we're doing things the way you want to have them done." And he said, "Well, I want to know everything." And he seemed to be very resolute in that. There was no trepidation, per se, in his voice. So then I told him that it was cancer. And he said, "Well, I thought so."

This case example only got more complicated. Through a negotiated process with the patient, the patient ended up bringing his boss to meet with me. The patient then asked me to disclose his diagnosis and all the details of his case to his boss. Believe me, this was really uncomfortable given how much respect for patient confidentiality had been driven into my head. Interestingly, this dialogue with his boss actually facilitated his return to Japan. This experience made clear to me how murky these questions about decision making are. How do you determine what patients want? What do families want? Who decides what, and who is included in decision making? In the end, this patient was able to return home to Japan expeditiously in part because he brought his boss into my office. Including his boss in the decision making was good for his situation. Once in Japan, his disease was treated more aggressively than it would have been in the United States, where palliative care would likely have been the recommended route.

His wife kept up with me after his death and reported that she felt he died sooner than he needed to, because of those aggressive, curative efforts. She was happy for him, though, because he wanted to have treatment because he wanted to have a chance to live. All in all, I'd like to think I created a positive opportunity for his wife to participate in his care. She was consulted in the same way she would have been in Japan. I hope that including elements of both Japanese and American approaches to care gave her and the patient, her husband, some sense of normalcy.

The Take-Home Messages of This Case

In sum, in this example, I found myself grappling with how to integrate my knowledge of Japanese culture and medical practice into my practice in this cross-cultural setting. This example makes transparent how current principles in ethics fall short in their capacity to guide action on the part of a physician who is operating across two quite different cultural worlds. Which culture's rules should hold? There's more to autonomy than just talking directly with the patient. My definition of respect for patient autonomy is robust, and that really means taking into account the patient's preferences, and that means you include family members and others if the patient wants them to be involved.

Without stereotyping, there's a trend for more Japanese physicians to talk about making decisions based on a variety of elements and not making decisions based strictly on principles. In the United States, physicians often turn to principles of autonomy to buttress their decisions - for example, "Well, it's their right to know" or "The patient has to know; it's the patient's decision."

I would say that there is a place for the use of philosophical principles in medical decision making, but there's also a place for narrative ethics and putting the patient in context and really weighing all of the different factors. Where we really experience difficulties is where these different approaches lead to different conclusions. However, the assumption is that there's lots of room under the rubric of "patient autonomy" to respect all the kinds of issues that narrative ethics, feminist ethics, or a cross-cultural perspective might make more salient. That's not true. That is not the clinical reality. You come to very different conclusions depending on what approach you take. We really haven't developed a mechanism for understanding where one principle ought to outweigh others. That's the real difficulty.

I take home several key points from this experience.

1. It is crucial to know where the patient is coming from. Nondisclosure, ambiguous disclosure, or more gradually timed disclosure of cancer or other potentially terminal diagnoses may work better than 100 percent immediate disclosure of all the facts for some patients, particularly those coming from cultures where nondisclosure is common and where principles of patient autonomy hold less sway.
2. However, in the United States hospitals are not geared to accommodate to doing things differently. The systems in place fit with the patient autonomy model as it has evolved here in the United States, and attempts to modulate care to fit other cultural models may come into conflict with those systems, as mine did with the nurse writing the diagnosis on the discharge note, which is the customary way of doing things in this country.
3. I believe it is essential to build a relationship with a patient, especially new ones, before communicating everything. Communication must occur within the context of a relationship; and yes, building this relationship takes time.
4. Patients from different cultures have very different boundaries about who are important decision makers to them - as in this case, for example, this patient's wish to have his boss come to my office and hear the diagnosis from me, immediately. Being sensitive to these differences requires a kind of flexibility on the part of clinicians that can come into conflict with our U.S. notions of confidentiality. But if it is the patient who is requesting that we speak with others, it makes sense to comply, even if we might be surprised by who the patient wants to include in these discussions.

References

1. Asai A. Should physicians tell patients the truth? Western Journal of Medicine. 1995; 163:36-39. [Return to International Perspectives]

2. Fetters MD. November 1998, Can US medical culture tolerate non-disclosure of the cancer diagnosis? First American Society of Bioethics and Humanities Meetings, Houston, Texas. [Return to International Perspectives]