Health care providers are subjected to a lot of ethical and professional matters which are too numerous and create a great number of unanswered questions. One of the areas under discussion that has brought a universal concern is the debate on truth telling specifically in cancer field. Cancer is associated with a number of potentially unfavorable events, including debilitating and/or disfiguring treatment, pain, loss of function, and death (Parker, 2001). Regardless of the cultural diversities all over the world and encroachment in the cancer therapy, most people perceived it as a stigma and directly related to the death, from the moment an individual experience change that may be associated with malignancy, to the diagnosis, treatment, fear of relapse after the cure or end stage palliative care, many complex ethical issues can raised. (Surbone,A 2006) Cancer diagnosis disclosure can be defined as verbalizing the full information ,clarifying desired or undesired facts to others , which may be voluntarily or in compliance with legal regulations ,polices or workplace rules. Therefore, cancer diagnosis disclosure to the patient is considered one of those important ethical issues in oncology that poses a difficult judgment for physicians and nurses in order to decide whether to inform the patient about the diagnosis or not.
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The purpose of this paper is to discuss the various cultural and ethical issues in relation to truth -telling and disclosing cancer diagnosis to patients .Moreover, to analyze the situation using the ethical values, theories and principles that affect on ethical decision making. In view of the fact, although breaking the bad news of cancer diagnosis is known as stressful task, few people believe that telling the truth to the patient may harm them and lead to suffering .On the other hand, majority strongly believe that disclosing cancer diagnosis to the patient themselves is of a great importance because of several reasons, especially if the physicians break such bad news in a supportive manner, with specific communication practices and at the appropriate time.
Altering the approach of truth telling
Ever since the early history of medicine, breaking bad news has been an issue of dilemma, with the considerations of Hippocratedes proposing hiding of any information that could cause desolation and deteriorate the patient’s condition. This state was established in the first ethical code in medicine in 1847 that directed doctor not to tell bad news to the patients due to the possibility of restricting their lifespan. Moreover, Many Asian societies believed that it is unneeded to honestly inform a patient of a cancer diagnosis. Accordingly, this approach become a worldwide by avoids harm through keeping the patients unaware of their condition. Conversely, people who received such adverse information will consistently be expressively unfavorable has never been proved. (Kumar et al, 2009).
In the past, the norm in all the societies was not to tell the truth to the patients regarding their terminal disease (Hallen and Arnold.2007). This approach has been change significantly throughout the past decades. Kazdaglis et al (2010) in their study they revealed that in 1961 90% of the doctors in the United States of America (USA) stated that they favoured not to tell the cancer patients their diagnosis. On the other hand, after 20 years, 97% of the doctors were telling a diagnosis of cancer to the patients .This shows a entire change of approach in the USA. Nevertheless, telling the truth to the terminal cancer patient is still not accepted in some cultures, such as Spain, Italy, Greece, Turkey, Egypt, Singapore, China and Japan. Even though in these cultures there is a trend to tell the truth more frequently than in the past, full discloses is still not a general practice.
Among different countries there is different approach in regard to revealing the truth to terminal cancer patient. As early mentioned in USA most of patients are informed about their diagnosis. The same approach is perform in England, Canada and Finland .As a result of the resent laws and policies that in these counties that obligated the doctors to give full information, they don’t have choice to withhold the information. Where in Japan, the doctors disclose diagnosis of cancer to the family member as they have a vital role in deciding whether to tell or not to tell the truth to the cancer patient .Subsequently, in Japanese culture few of doctors (13%) tell their cancer patient about their diagnosis. Similar approaches are practice in Arab and Islamic societies. In Turkey a significant number of cancer patients did not know their illness (44%).In Lebanon, where laws permits not telling the truth , almost half of doctors tell the patient about their diagnosis of cancer . where in Kuwait and Saudi Arabia majority of doctors favoured to discuss the information with family members instead of the patients themselves ,moreover, they withhold the truth if the relatives asked them to (Kazdaglis et al , 2010). Furthermore, doctors have similar approach in Spain, Italy, Greece, Egypt, Singapore, and China, as family member are accountable for the decision-making for the patients. (Sheu and- Mu, 2007).
Possible explanation for not telling the truth
This assumption is basis on telling the truth is more probable harm the patients than help them as the patients may have severe emotional suffering (Danial 2006 ) .Furthermore, by revealing the truth, there is possibility of shocking a patient’s hopes . Hope is an important mechanism for dealing with cancer and it can be risk by knowing the truth. Moreover, even though it is difficult to imagine that withholding the truth will enhance patient care, telling the truth might be considered improper, therefore in some cultures the truth must be informed to a family member. (Kazdaglis et al ,2010).perspectives
Possible explanation for telling the truth
In analyzing the assumption of disclosure of diagnosis to cancer patients these principles needs to be taken in to considerations. Autonomy enforces respect for the patients as independent individuals who have the right to information and to make own medical decisions (Surbone,A 2006). It takes us to the fact that it is an obligation for physicians to share full information in regard to cancer patients’ diagnosis and prognosis where the patients and physicians come into a true therapeutic, trusting relationship. Moreover, telling the truth defend the autonomy of patients who require this information for decision making and contribution in treatment. In addition, undergoing many diagnostic procedures and even main treatments in cancer field such as chemotherapy and radiation-therapy is not possible without the provision of formal informed consent, which is difficult when the diagnosis has not been disclosed. Also with additional information about disease prognosis and treatment side effects patients have the ability to refuse ongoing treatment as their right.
Furthermore, the principle of beneficence can also be used to justify disclosure. Even if prognosis going to be poor, the patients may need to know it in order to take care of uncompleted business by organizing finances, cure affairs or doing other events that might offer a sense of finishing to their life’s work. Full disclosure may let patients to alter their attitudes in life, put new goals and work on achieving them in their remaining life.
The theory of utilitarianism is one of the ethical theories in which actions are classified as morally right or wrong based on their consequences. It tends to promote actions that construct the best outcomes. It is considered a modern effort to combine the strengths and minimize the weaknesses of egoism, altruism and rational paternalism (Beauchamp, 2008).
The decision of disclosing cancer diagnosis to the patients was taken based on utilitarianism. Breaking such news to the patients themselves will produce a lot of beneficial consequences that will help them in several ways. Firstly, many patients are being suffered psychologically from their suspicion of having this the disease or not. Therefore, telling them the truth will help in making for peace of mind and decreasing their worries. Consequently, this will lead to enhance their understanding their illness and make the patients more aware of the seriousness of their disease condition. This will aid planning medical care smoothly through enhancing their treatment compliance, improving self determination and helping them to obtain medical attention when they should to prevent further deterioration. Moreover, not telling patients the full truth about their conditions can mean deceiving them and thus, being honest with them will enhance the bond of trust between doctor, nurses and patient and increase the public’s faith in the medical profession as well. Last but not least, disclosing the diagnosis of such life threatening disease will offer the patients an opportunity to shape their life as they see fit. For all of these advantages of cancer diagnosis disclosure and based on the theory of utilitarianism, it is now obvious that breaking such news is of a great meaning for the patients that should not be withhold.
One of the areas in medical profession that has brought up a lot of ethical dilemmas is the field of cancer .The word “cancer” often accompanies feelings like fear of death, loss of hope, pain and suffering and thus cancer diagnosis disclosure to the patient is considered one of those important ethical issues in oncology that poses a difficult judgment for physicians and nurses in any clinical setting. However, all the way through studies it was significantly noticed that large number of individuals expressed the desire of getting full information regarding their disease conditions. In addition, there was general revealing on this matter as one of the patients’ rights. Therefore, in order to support patients in such drastic situation and avoid insensitive handling of breaking bad news various strategies have been recommended. Finally, to tell the truth is not to deny hope. Truth and hope are all part of an ethics and caring.
There are several recommendations made in the literatures intended for telling the truth to cancer patients about their diagnosis in a way that considers patients’ psychological reaction and optimizes their satisfaction. These suggestions can facilitate the task of disclosing cancer diagnosis for both patients and health professionals in a variety of ways. First, it should be practiced by qualified health team members with special knowledge and training in communicating such news and based on a standardized policy and protocol. Additionally, written policies must be available in critical units, including oncology for the sake for regulating the procedures of either tell or not to tell the truth, when, how, to whom, and by whom.
indeed, patients appear to be varied
in their information requirements.
Full, uncensored disclosure, which is insist upon by one patient, may be utterly undesirable to another . It can be argued that it is important
to take into account the individual needs of every patient, recognizing that full information disclosure may not necessarily
be desired or helpful for some patients at a specific time, even though the situation could change later.
It is important to consider the ethical
issue of truth-telling from both perspectives.
In Asia and south-east Europe,
where revealing the diagnosis is difficult
because of cultural issues, health professionals should be more willing to answer patients’ questions truthfully when they indicate a preference to know, even if they do not express it verbally. In the USA and the UK, in contrast, health professionals should perhaps adopt a more cautious attitude. Respect for the patient should include identification of those who wish to know less and complying with their choice. Finally, all health care professionals, in whatever country, should bear in mind that ethnic
minorities with different cultural backgrounds and different attitudes to disclosure are present in almost every society around the world.
Rather than trying to guess patients’ preferences, a possibility would be to ask them well before any diagnosis is made. Just as patients are asked for their preferences
about resuscitation should it became necessary or asked to give consent
before surgery, they could similarly be asked to indicate their preferences about information disclosure. A question
of this type should be addressed as a matter of course to all patients, not only the ones with possible cancer. Although this idea is not currently easy to put in practice, it is an alternative that deserves further consideration.
This article has explored the dilemma
of how to always satisfy the 2 ethical principles of veracity (truthfulness) and beneficence (doing good). There is no answer that “fits” all patients in all countries,
but it is valuable for health professionals
to have a broader understanding of the issues and to treat each patient as an individual.
In addition, according to Statement on a Patient Bill of Rights that has been kept by American Hospital Association; the patient has the right to get full recent information from his physician in regard to his diagnosis, treatment and prognosis and to give informed consent prior to the start of any procedure or treatment. Also the patient has the right to every consideration of his privacy concerning his own medical care program and those not directly involved in his care must have the permission of the patient to be presented or informed (Davis et al, 2009).
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