The attitude toward truth telling of cancer in Taiwan

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Abstract

Objective

This study examined a group of Taiwanese subjects at a medical university hospital regarding their attitudes toward truth telling of cancer.

Method

Self-report survey with convenience sampling of 195 participants admitted for a 3-day comprehensive health examination in a medical university hospital in Taiwan. Three instruments used to collect the data included the Brief Psychiatric Symptom Rating Scale (BPSRS), Chinese Health Questionnaire (CHQ), and the Attitude Toward Truth Telling of Cancer List.

Results

Once diagnosed with cancer, 92.3% of the participants preferred being told the truth about their diagnosis and 7.7% did not. Age, education, and employment were found to differ between disclosure and nondisclosure groups. The latter group also tended to have higher depression and hostility scores on the BPSRS and higher minor psychiatric morbidity scores. A total of 62.6% of the participants preferred that doctors tell a relative the truth about their cancer diagnosis, while 37.4% preferred that doctors not tell a relative the truth. The distributions of demographic data and mental status did not significantly differ between disclosure and nondisclosure groups if a relative was to be the cancer victim.

Conclusions

A majority of subjects in Taiwan would prefer to know the truth if victimized by a cancer disease, despite the supposed influence of Chinese culture. Furthermore, attitudes toward truth telling of cancer differed between relatives of patients and the patients themselves. Relatives of cancer patients were more likely to follow to the principle of beneficence, whereas the patients themselves were more likely to follow to the principle of autonomy.

Introduction

Of all fatal diseases, cancer has had the highest mortality rate in Taiwan since 1982. In many cultures, cancer has been considered the fatal disease so frightening that physicians often try to protect their patients by refusing to disclose or acknowledge a diagnosis of cancer. Hippocrates argued that as a matter of principle, physicians in clinical practice should not give patients any autonomy over their health care [1]. Oken [2] suggested that most physicians believed that disclosure of a life threatening illness would be followed by fear and despondency, which might progress into overt depressive illness or even culminate in suicide. However, scientific and technological developments in oncology have improved the prognoses of patients with cancer; thus, physicians often believe they can offer their cancer patients more hope of survival. Furthermore, many more patients request information about cancer out of desire for increased self-management of their health care. The principle of respect for patient autonomy and rights has received greater scrutiny since the American Hospital Association Statement on a Patient's Bill of Rights in 1972 [1]. What people with cancer are told is controlled not only by law, but also by a medical ethos of respect for individual responsibility and autonomy. More recently, it has been reported in a considerable number of western studies that most people (cancer victims or not) would prefer being informed of a cancer diagnosis [3], [4].

Although surveys in the western world consistently show that patients want to know about their cancer diagnosis, in other countries, e.g., Saudi Arabia [5], Japan [6], [7], [8], Southern Europe [9], Greece [10], Italy [11], and Poland [12], cancer patients either do not ask questions about cancer (even when they become suspicious about such a diagnosis) or are simply not informed of such a diagnosis. In western countries, respect for individual autonomy might be a central doctrine; while in other countries, the best interests of both patients and families, based on the principle of beneficence, seem to predominate [13].

The judgment as to whether giving bad news will be to the patient's advantage is a complex one. A doctor's decision whether or not to reveal a cancer diagnosis is determined by various factors, including the age, intelligence, emotional stability, personality, psychological support from friends and relatives, and the desire of friends and relatives to protect the cancer patient from the diagnosis [12], [13]. Of these, the patient's personality was identified as the most important factor by 74% of physicians in Greece [10]. From the psychiatric perspective, the patient's mental status should also affect the decision. Unfortunately, the medical literature has thus far neglected this important dimension of diagnostic disclosure. In addition to mental status and background, cultural variables should be considered as well, such as cultural differences between orientation towards the family (e.g., most Asian, Arab, and African countries) versus orientation towards the individual (e.g., Anglo-Saxon and North European countries). Attitudes regarding medical decision making differ between ethnic groups often because of cultural rather than demographic variables [14]. A belief held by many Chinese is that the sick are entitled to be treated as children and deserve protection [15]. Cancer connotes certain death, and there is a strong negative image of death in Taiwan. Many hospitals or hotels in Taiwan avoid naming a “fourth” floor because “four” and “death” have similar pronunciation in Mandarin. Confucius once said, “I have not known life well enough yet, so how can I know death?”

The purposes of this study were to explore preferences regarding truth telling after a diagnosis of cancer and to identify the characteristics of subjects who preferred that the truth be withheld. In addition, we explored preferences regarding who should bear the news of a cancer diagnosis, as well as the implications of cancer according to subjects undergoing a 3-day comprehensive health examination in Taiwan.

Section snippets

Methods

A descriptive method of investigation was implemented. Participants in this study were convenience samples recruited from the Center of Health Examination at a medical university hospital in Kaohsiung, Taiwan. The purposes of the research were provided in written form to 230 potential participants. The participants were informed that they were free to withdraw from the study at any time and that the decision to withdraw would not adversely affect them in any way. Participants were told that

Results

One hundred and ninety-five subjects volunteered to participate in the investigation. The participants ranged in age from 18 to 75 years; 59.5% were males, 54.4% had more than 9 years of education, 74.9% were employed, 54.4% were Buddhist, and 83.1% were married and living with a spouse.

If diagnosed with cancer, 92.3% of the participants preferred being told the truth about the diagnosis and 7.7% preferred not being told the truth. The reasons for preferring nondisclosure to self were emotional

Discussion

This study found that 92.3% of the participants preferred to be told the truth about a cancer diagnosis, which is close to the 93% rate reported by Shen [22] in a previous study in Taiwan. According to a 1961 JAMA report, 90% of the doctors surveyed had declined to inform patients diagnosed with cancer [2]. In 1977, 97% of the doctors told the truth about cancer in principle [4]. This change reflects the changes in biomedical ethics in American society [1]. More information about diagnosis and

Acknowledgements

This study was supported by a grant from the National Science Council, Taipei, Taiwan. We are particularly indebted to the participants of the study.

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