pp. 107-109 in
Bioethics in Asia
Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute
Copyright 2000, Eubios Ethics Institute
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3.2. Truth Telling to the Patient: Cultural Diversity and the East Asian Perspective
Rice University, Texas, USA (and China)
In an Editorial of the Journal of the American Medical Association, the well-known American physician bioethicist, Edmund Pellegrino, argues that truth telling to the patient is not a cultural artifact (1992). Instead, it is morally required in the general sense, because, "human capability for autonomous choices cannot function if truth is withheld, falsified, or otherwise manipulated" (p. 1734). Only at the situation in which offering the truth to the patient has a significant probability of causing harm, for example, emotional damage or suicide, does the physician have the therapeutic privilege of withholding the truth. For Pellegrino, "autonomy is a valid and universal principle because it is based on what it is to be human" (p. 1735).
This presentation intends to argue that Pellegrino fails to recognize that there are different moral understandings of truthfulness and autonomy as well as different metaphysical assumptions regarding what it is to be human. It is true that all cultures have a sense of truthfulness. Most people agree that we should tell the truth insofar as we can. However, people disagree on the ambiguous but substantial problem of when to tell how much of what truth to whom. The fact is that different cultures practice truth-telling differently and incommensurably. This makes Pelligrinofs assertion that truth telling is not a cultural artifact trivially true. It is trivially true because all cultures agree that we should generally tell the truth. It is substantively useless because cultures disagree about when to tell the truth, when to withhold the truth, and when to tell lies.
In particular, this presentation argues for the following three theses. First, lying is inherent part of most substantive conceptions of truthfulness. As some has pointed out, truth telling is morally overrated. "When deceiving is publicly condemned, it is privately practiced by almost everybody" (Nyberg, 1993, p. 7). If a lie is simply defined as "believing (or knowing) one thing and saying (writing, or expressing) another" (Shibles, 1985, p. 31), then everybody lies (Ford, 1996). All of us can point to numerous occasions in our experience in which we felt that the choice to deceive was morally appropriate. Someone has identified more than forty reasons for why we tell lies (Shibles, 1985, pp. 129-134). Such reasons range from expedient considerations such as being polite, through selfish motivations such as fishing compliments, to altruistic deliberations such as helping people who are in trouble.
There has been one moral theory, i.e., Kantian deontology, that requires that one should always tell the truth. However, under most moral and cultural conceptions of truthfulness, it is morally justifiable and even obligatory to tell lies in certain circumstances. I will simply assume that Kant is wrong in his claim on truth telling without offering any argument, for this assumption does not affect the controversy involved in this essay. Thus the question whether it is ever acceptable to use deception is out of our scope in this essay. Our crucial concern is when it is morally appropriate to withhold the truth or even tell a lie. Evidently, different cultures and different moral theories offer different answers to this question. Notice that there used to be stereotypes about various nations concerning their propensity to lie. For instance, a French anthropologist commented: gThe Asians, the Japanese, the Chinese, the Siamese, show bad faith, and are much disposed to make deceitful promises when they struggle with the English and the Germans. It is necessary to add that they can be of good faith when they feel that they are not threatenedh (Larson, 1931, P. 51).
The fact is, however, that every culture recognizes some lies to be malevolent and morally problematic, and some other lies to be benign and morally appropriate. In this respect, there is no contrast between the Asians on the one side and the Europeans on the other. In all societies, there are good reasons for not lying all the time, but there are also strong reasons for lying some of the time. For example, for ancient Chinese military philosopher Sun Zi, the art of warfare is simply based upon deception. For most people, it is all right to tell white lies and humorous lies. It is even morally admirable to tell altruistic lies. Most people would think it morally wrong to tell the Nazi Gestapo the truth that your friend hidden at your home is a Jew. In this sense, lying can be considered as inherent part of the conception of truth telling in most cultures. Most substantive conceptions of truthfulness do not require always to tell the truth. Instead, they allow and even require lying in certain circumstances.
The second thesis I want to argue is that different cultures hold different and incommensurable substantive conceptions of truthfulness. These distinct conceptions stand underlying peoplefs different ways of exercising truth telling in particular societies. As Alasdair MacIntyre points out, Lutheran priests brought up their children to believe that one ought to tell the truth to everybody at all times, whatever the circumstances or consequences, and Kant was one of their children. Traditional Bantu parents brought up their children not to tell the truth to unknown strangers, since they believe that this could render the family vulnerable to witchcraft. In our culture many of us have been brought up not to tell the truth to elderly great-aunts who invite us to admire their new hats. But each of these codes embodies an acknowledgment of the virtue of truthfulness" (1984, pp. 192-193).
In addition to such cultural differences in the subjects and objects of lying, substantive conceptions of truthfulness also vary in other ways. For instance, J. A. Barnes illustrates several aspects concerning lying in which cultures differ from each other. First, some untrue statements may not be taken as lies at all in one cultural code, but they are interpreted as offending lies in another cultural code. Second, there are cultural differences in the extent to which lying is considered justifiable. Finally, cultures differ also in how entirely benign social lies are constituted (1994, pp. 66-67). In short, different cultures shape and practice their respective conceptions of truthfulness. They are truthful in different ways.
Finally, I intend to argue that there is a particular East Asian perspective of truth telling to the patient which is shaped by the East Asian principle of autonomy. Pellegrino argues that, in North America, truth telling to the patient is a necessary corollary of the principle of autonomy (1992, p. 1734). This claim is not accurate, because there is not a universally-accepted principle of autonomy. A more accurate expression needs to include a qualification to the principle of autonomy. Indeed, it is the Western principle of autonomy that requires the way of truth telling to the patient practiced in North America. But there is at least another substantive principle, the East Asian principle of autonomy, that is different and incommensurable from the Western principle of autonomy (Fan, 1997). The East Asian principle of autonomy underlies the East Asian pattern of truth telling to the patient in contrast with the Western manner.
The Western principle of autonomy is an individual-oriented principle. It requires that the patient, as long as being competent, have the final authority to make clinical decisions for himself. It is his own desires, preferences, and opinions of the good life that serve as basis for his decision making. The principle promotes the value of individual differentiation and independence from the family, the physician, and the cultural group (Fan, pp. 313-315). Under this principle, the physician must disclose diagnosis, prognosis, and treatment options directly to the patient, no matter how harsh the information is. The exception is only justifiable either when substantial evidence shows that offering the truth will severely harm the patient or when the patient clearly expresses that he does not want to know the truth.
In contrast, the East Asian principle of autonomy is a family-centered principle. The principle implies that the entire family, rather than the individual patient, should have the final authority over clinical affairs. The familyfs decision should be made for the best interests of the patient in accordance with the objective conception of the good life adopted by the local cultural group. And it is the value of harmonious dependence between family members, rather than individual differentiation and independence, that this principle upholds (Fan, pp. 315-319). Indeed, with the guidance of this principle, the clinical practice in East Asian areas is characteristic of a strong familialist feature. Physicians usually do not offer medical information to the patient directly. Instead, they offer information to a family representative and leave the family to decide whether to tell the patient the truth or not. This is certainly more so when severe diagnoses or fatal prognoses are involved.
This familialistly-characterized East Asian understanding of autonomy has been shaped by the long-standing Confucian tradition. The Confucian metaphysical doctrine concerning what it is to be human differs from the modern Western individualistic conception as embodied in the Western principle of autonomy. Confucianism holds a particular theory of the nature of the family and human individuals. For Confucianism, there is moral significance that every individual is arranged by transcendent Heaven (tian) to be born to a family, to be brought up in a family, to possess special relations with other family members, and to live onefs life inseparably from the family. Confucians believe that one should take onefs family as an autonomous unit from the rest of society, flourishing and suffering as a whole. Hence, the medical problems of one family member are taken as the problems of the entire family. A sick family member should be taken care of by the rest of the family. He should not sustain the burden of listening to a strange physicianfs information or be burdened with directly signing a consent form. Instead, a family representative should arrange all matters with the physician.
Indeed, most East Asian people do not think that the patient should be informed of the diagnosis or prognosis of a terminal illness. They believe that telling such truth to the patient is unsympathetic to the unfortunate situation of the patient. It is isolating the patient from his family and placing unnecessary burden on his shoulder. It is against the value of the harmonious function of the family as an autonomous whole. In short, it is causing harm to the patient and the family. On the part of the patient, pushing hard for the truth does not make good sense, except in some special conditions (for example, the patient might really need to know how much time is left to him so that he can re-arrange something very important). On the part of the rest of family members, they must make every effort insofar as they can to do the best to the patient. This general belief is even held by East Asian communities living in other areas of the world, for example, in North America (Blackhall, et al., 1995). This is also more or less believed and practiced by some European nations (Surbone, 1992).
Certainly, many issues remain to be investigated and studied regarding the East Asian way of truth telling to the patient. For instance, what percent of patients who are not told the diagnosis or prognosis know it anyway? Is there any difference in the interaction between patient and family when the patient is the head of the family? Is there any difference between male patients and female patients? Most importantly, can family be justified to refuse treatment on behalf of a competent patient without consulting the patient? Nevertheless, it is important to recognize that the East Asian perspective of truth telling to the patient differs from its contemporary Western notion directed by the Western principle of autonomy.
Barnes, J.A.: 1994, A Pack of Lies: Towards a Sociology of Lying, Cambridge University Press.
Blackhall, L.J. et al.: 1995, 'Ethnicity and attitudes toward patient autonomy,' JAMA 274: 820-825.
Bok, S.: 1989, Lying: Moral Choice in Public and Private Life, Vintage Books, New York.
Fan, R.: 1997, 'Self-determination vs. Family-determination: Two Incommensurable Principles of Autonomy,' Bioethics 11: 309-322.
Ford, C.V.: 1996, Lies! Lies!! Lies!!! The Psychology of Deceit, American Psychiatric Press, Washington, D.C.
Larson, J. A.: 1932, Lying and Its Detection: A Study of Deception and Deception Tests, University of Chicago Press.
MacIntyre, A. 1984, After Virtue, University of Notre Dame Press.
Novack, D.H. et al.: 1989, 'Physicians' attitudes toward using deception to resolve difficult ethical problems,' JAMA 261: 2980-2985.
Nyberg, D.: 1993, The Varnished Truth: Truth Telling and Deceiving in Ordinary Life, The University of Chicago.
Pellegrino, E.: 1992, 'Is truth telling to the patient a cultural artifact?' JAMA 268: 1734-1735.
Shibles, W.: 1985, Lying: A Critical Analysis, The Language Press, Whitewater.
Surbone, A.: 1992, 'Truth telling to the patient,' JAMA 268: 1661-1662.
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