International Clinical Ethics & Veracity

The theme of the ASBH 2006 annual meeting was "Challenging Voices."  Hearing voices other than those that have dominated Western bioethics, and, to a lesser extent, the medical humanities, is, IMO, an absolute imperative as bioethics and the MH enter their second generation as formal "fields" of study.

I had the opportunity to attend some fascinating talks and presentations at ASBH, but I found one particularly compelling, and that was a panel presentation on international clinical ethics consultation ("CEC").  The panel featured Kazuto Inaba (Japan), Veronique Fournier (France), and Bert Molewijk (the Netherlands).  Mark Aulisio, of Case Western, also provided some context by discussing the state of CEC in the U.S.  Each had some fascinating insights on how CEC is practiced in their own cultures.  (Contextualizing CEC, perceiving that U.S. ways of practicing CEC are simply one possible way or ways of practicing CEC, rather than the way, strikes me as an important conceptual point, both for CEC, and for bioethics and MH in general).

Professor Molewijk sketched what he referred to as a hermeneutic, dialogical method of what he termed "moral case deliberation," as opposed to CEC.  He stressed practical approaches to cases, and I would suggest that his approach shows plain influences of medical humanities-type thinking on clinical ethics (this is because a hermeneutic, dialogical approach would not seem to naturally fit with some of the more analytic traditions of moral philosophy, though I want to stress I see nothing necessarily inconsistent between a dialogical approach and a more analytic, traditional approach to applied ethics problems).

Dr. Fournier briefly surveyed the activities and methods of the Centre Ethique Clinique.  What I found particularly fascinating was the fact that one of the three groups that participates in CEC is composed of volunteers from the community, otherwise unaffiliated with the hospital, who receive clinical ethics training. 

Professor Inaba discussed the state of CEC in Japan, including results of his research indicating that an overwhelming number of respondents wanted more formal assistance from ethics committees.  As my wife is Japanese, I have some interest in Japanese bioethics, and Professor Inaba's discussion reminded me of Tia Powell's excellent article (html; pdf) published recently in the open-access journal, Philosophy, Ethics, and Humanities in Medicine.

I was fortunate to have the chance to speak with Dr. Powell briefly after the panel presentation, and I mentioned how much I enjoyed her article, partly because I think it raises some fascinating cross-cultural and ethical questions.

Truth-telling is ranked fairly high on the U.S. medical value hierarchy, I submit.  The specter of a provider withholding information, particularly about prognoses, from a patient smacks of paternalism to many.  (The sources on this issue are legion; an ETHX search for "truth-telling" produced over 2000 hits.  This article, for example, presents some of the arguments against deceiving a patient).  The emphasis on truth-telling is a fairly recent concretion; Hippocrates himself advised physicians to be "economical with the truth" so as to ameliorate patients' anxiety.  Thomas Percival's Medical Ethics, as well as the original (1847) Code of Ethics of the AMA (pdf), both adopted perspectives on the importance of benign deception.

This intellectual current has come under serious attack over the last 30 years.  Obviously, a Kantian, deontological approach to ethics could and has been relied upon as grist for the mill on that point.  However, what I found so interesting about Dr. Powell's article was her exploration of the cultural limits to the value of truth-telling.  That is, what happens when the imperative of veracity is relied upon in a cultural setting where such truth-telling is both foreign and unwanted? Dr. Powell explains:

The emotional tenor of discussions about disclosure in Japan is reflected by surgeon and hospice advocate Fumio Yamazaki's best-selling book, Dying in a Japanese Hospital. Yamazaki gained notoriety as a disclosure advocate, arguing in his book that some patients, though by no means all, should be informed of their terminal diagnoses. Yamazaki painstakingly confronts the criticism that disclosure can be harmful to patients; he goes so far as to describe a case in which disclosure proved emotionally disastrous for both patient and physician. This case involved an elderly woman with extreme cancer-related pain, who demanded repeatedly and forcefully to be told her true diagnosis. Dr. Yamazaki did so, though without using the word cancer, in the presence of her daughter-in-law, who supported the patient with tearful embraces. Subsequently, the doctor describes the following events:

[The patient] didn't say a word to me or to the nurses for 24 hours after that. No matter how many times we spoke to her, she turned away and kept silent. Did she lose her speech because she was so shocked with knowing the truth? Or did she lose her speech because she was enraged with knowing how people she had trusted had betrayed her?

When the patient's oldest son visited the hospital later that day, he attacked the doctor for breaking a promise to the family and telling his mother the truth. Dr. Yamazaki's pain in this encounter, and his sense of having tried and failed to act as an ethical physician by disclosing the patient's diagnosis is palpable.

It seems difficult to argue but that truth-telling in this instance caused profound harms to the physician, the patient, and the family.  (Yes, I am aware this is a consequentialist perspective, and that there may be deonotological good that arises from truth-telling even where the consequences are destructive, but I admit I do not find that contention convincing in this case).

Dr. Powell concludes:

In sum, full disclosure does not rise to the level of a universal norm. It was not the accepted standard in medicine for the past thousands of years, and is not currently the standard in most of the world. Nondisclosure is ethically appropriate for some patients, partly because of culturally shaped norms. Fuller disclosure is best for other patients because of their individual culturally shaped preferences.

Fascinating, truly.  If this is correct, and I see much merit to Dr. Powell's argument, one has to wonder how the importation of U.S. and Western values as to clinical ethics may be helpful to cultures whose practices reflect profoundly divergent understandings of the importance attached to certain values.

Thoughts?

Comments

[Giskin]

I am often taken aback at the divergence present in a class of medical students on the issue of truth-telling. It seems that in some Medical Schools at least, this important issue is left to the individual to decide on a policy of disclosure without much (or any?) interrogation of the underlying ethics. Personally, I feel the value is underestimated of asking the patient outright how much they would like to know about their condition. Trying to second-guess patients' feelings in this regard is unlikely to be as successful.

Research in science communication has shown conclusively that an honest admission of uncertainty is always preferable to unwarranted confidence in diagnoses or prognoses. People do tend to cope with uncertainty much better than is generally given credit for. However, the right to choose not to know is also eminently defensible. I think it should be the patient's choice though rather than the doctor deciding unilaterally what is in the patient's best interests, no matter how well intended.

[Daniel Goldberg]

I agree wholeheartedly. The wisest course of action is simply to ask the patient how much disclosure they would like, but even the asking of that question ought, IMO, to be undertaken with a cognizance of the notion that the patient's particular values and cultural beliefs inform their wishes to a greater or lesser extent.

I do think that Western bioethicists should be considering the problems posed by cross-cultural questions with far more scrutiny than I see in the literature, though there are some positive signs on this point.

Amy Chua's excellent book, World on Fire, surveys the problems posed by attempting to export democracy to cultures and places where democracy was previously unknown. Her point is not at all that democracy is undesirable; quite the opposite, in fact. Her point, as I see it, is that the introduction of Western capitalistic and individualistic values that attend Western conceptions of democracy has worked much mischief in a variety of places for a variety of reasons.

I think her argument is germane to these cross-cultural questions of bioethics and MH, too. I think the danger is the assumption that values will necessarily translate cross-culturally is exceedingly dangerous.

This, of course, is not to say that a provider ought to feel abashed about preferring certain values over others, but simply that the provider ought to understand the idea that their preferences are just that, and are not necessarily shared by some persons who identify as members of different cultures.

I guess part of my thinking on this subject is colored by the fact that I tend to find persuasive Quine's argument on the indeterminacy of translation. If that's so, one would properly expect me to be skeptical of any claim that values (such as those on deception) ought to govern for persons whose beliefs are shaped by some very different cultural predilections and backgrounds.