Indian people can emotionally stand the truth of cancer, a commentary on the study by Ranjan and Dua
- Noritoshi Tanida, M.D.
Department of Internal Medicine 4, Hyogo College of Medicine,
1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan.
Email: noritanida@pop07.odn.ne.jp
Eubios Journal of Asian and International Bioethics 10 (2000), 151-2.
The significant message of their study is that the emotional domain of quality of life (QOL) among cancer patients is not affected by truth disclosure in India. It has long been believed that truth disclosure harms the cancer patient and means a breach of the doctor's moral obligation of nonmaleficence. For example, a German physician, CW. Hufeland (1762-1836) emphasized the immorality of truth disclosure and strongly prohibited its practice. The Hippocratic Oath has enforced doctors not to share information with patients. Accordingly, concealing the truth from cancer patients was once a universal practice in medicine.
The breakthrough was first observed in the USA (1). Whatever the reason for this event, it has been welcomed by patients and the information appears to be beneficial in establishing satisfactory relationships and communication among patients, family and medical professionals (2). Observing the good outcomes in the USA, truth disclosure in cancer has spread to Australasia and Northwestern Europe (3). But doctors in most other countries still withhold the truth from cancer patients, because they fear that the truth would harm the cancer patient, particularly emotionally. It is true that the cancer patient meets a serious shock from the bad news when they are informed of the true nature of the disease, no matter whether in the Eastern or Western country (4). However, the patient has the capacity to cope with this serious situation. If the outcomes of truth disclosure had been worse than for concealing the truth, truth disclosure would not have been practiced so widely even if patients had wanted it in Western countries. Anyhow, maleficence by truth disclosure has never been proved except this initial distress.
India is a wonderland with a great diversity in every aspect. Like many other countries, cancer is considered to be a gigantic monster to which nobody can resist. Naturally, cancer patients are either kept seemingly happy in false hope or left in total despair being abandoned by doctors in India (5). Even in such circumstances, people can stand the truth in cancer emotionally as Ranjan and Dua have shown. The similar result was already shown in Japan that truth disclosure would not harm cancer patients physically or emotionally (6). In addition, virtually all cancer patients who were told the truth were satisfied with the disclosure (7). These studies and experiences suggest that truth disclosure did not exert negative influence on patient's clinical satisfaction and outcomes. The Indian result by this Ranjan and Dua's study is probably a finishing blow to a prudent attitude of doctors toward truth disclosure in cancer.
There is another important message in their study. Although there was no significant difference in the emotional domain of QOL, the physical well-being and ability domain and the sociability domain of QOL were worse in truth disclosed patients than in truth concealed patients. As they pointed out, these results may be consequences of insufficient supportive care of cancer patients. Under these circumstances, a lack of understanding and a stigmatized view are dominant toward cancer, which affects patients negatively resulting in loss of "confidence in treatment" in truth disclosed patients. These phenomena toward cancer were observed before in Western countries as well, and more or less these are on-going issues in any country or culture.
All these experiences indicate that basic human dreams, hopes, fears, and needs are the same, even if there is cultural difference (5). To understand and to overcome these problems surrounding cancer patients, issues of communication and supportive care should be incorporated into the education and training system for medical professionals. Proper understanding and good communication is the key to good quality of life of cancer patients.
References
1. Novack DH, Plumer R, Smith RL, Ochitill H, Morrow GR, Bennett JM. Changes in physicians' attitudes toward telling the cancer patient. JAMA 1979;241:897-900.
2. Centeno-Cortes C, Nunez-Olarte JM. Questioning diagnosis disclosure in terminal cancer patients: a prospective study evaluating patients' responses. Palliat Med 1994;8:39-44.
3. Thomsen OO, Wulff HR, Martin A, Singer PA. What do gastroenterologists in Europe tell cancer patients? Lancet 1993;341:473-476.
4. Miyaji NT. The power of compassion: truth-telling among American doctors in the care of dying patients. Soc Sci Med 1993;36:249-264.
5. Burn G. From paper to practice: quality of life in a developing country. The challenges that face us. Ann NY Acad Sci 1997;809:249-260.
6. Tanida N, Yamamoto N, Sashio H, et al. Influence of truth disclosure on quality of life in cancer patients. Int J Clin Oncol 1998;3:386-394.
7. Tanemura K. Telling the truth and telling the death to cancer patients. Terminal Care 1994;4:150-158 (in Japanese).
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