Attitudes of people to the truth-telling issue in Turkey

- Nermin Ersoy, M.D.
Kocaeli University, Medical Faculty
Department of Medical Ethics and Medical History,
Kocaeli, Turkey
Email: ersoyne@turk.net

Eubios Journal of Asian and International Bioethics 11 (2001), 68-74.


Like other human relationships, relationships within a profession also inevitably involve trust. Here, trust has special moral dimensions which are the foundations for professional ethics, what Barber has called "fiduciary relationship". Trust in the medical relationship shapes the ethical relationship between patients and physicians. In this sense, fiduciary relationship implies that the person trusted has explicitly or implicitly made a promise to act well with respect to the interests of the person trusted (1-3). For this reason, communication between physician and patients should be truthful, that is, statements should be in accord with facts (3) and deception, by stating what is untrue or by omitting what is true, should be avoided (3-7). The candid disclosure and discussion of information do not simply enable patients to make informed choices about health care and deal with what is happening to them, but also foster and help to maintain trust (1,2,7,8).

However, the issues of telling the patient the truth about his/her illness, or withholding it from patient, is closely related to cultural, social and also legal structure of a society, even to the different subcultures existing in the same society (i.e. values, norms, customs and expectations) (9). Cultural values appear to influence physicians' attitudes toward truth telling. For example, in one study, US physicians who reported that they commonly tell cancer patients the truth said that they did so in a way that was intended to preserve "hope" and "the will to live", both valued notions in USA society (8). The findings of another study suggested that gastroenterologists from southern and eastern Europe were less likely to be candid with patients than their North American counterparts (10). In another research, it was suggested that most (80%) of health care professionals in Spain think that information should be given only if the patient will understand and accept the situation (11). In another one, it was found that Greek doctors do not feel obliged to disclose the truth in the same way American or British doctors would. Moreover, they often take the view that patients do not really want to know and that often they waive the right to know (12). This findings show similarity with our previous research's findings in which most of the physicians (70%) did not believe that their patients wanted the truth (13). In Emirates, most of the physicians (59%) were asked what should happen if the patient specifically asked the doctors for information (14). Almost all of above researches indicated that most of patients or people wanted the truth (8,10-14). But in one study, a greater percentage of Korean-born patients preferred to be given less information than did US-born patients (8).

We considered that most of the patients seem to want the truth about their illness and condition. But we apparently do not have any knowledge about healthy people's expectations and attitudes related to this subject.

Recently improvements have been made in Turkish Law and in Turkish Medical Ethics Code involving truth-telling. The 46th Congress of the Turkish Medical Association accepted the Guidance of Profession Ethics on September 11, 1998. In the Item 26 it is said that "physician should tell the truth, but information should be compatible with patient's cultural, social and psychological condition" (15). Similarly, in the Status of Turkish Patient Rights it is stated that "patient has a right to obtain an information related to..........either verbal or written and information should be in accordance with patient's psychological condition and it should be given with a polite expression" (16).

For this reason, we aimed to obtain an opinion about the attitudes of people on truth-telling in Turkey. Thus, we hope to help developing the policies about the doctors' telling the bitter truth to patient, as well as finding out what kind of bad news people want to know.

Subject and Method

The study done between September 1996 and May 1997 in Kocaeli. Kocaeli is an industrial region of Turkey and is near Istanbul. The subjects were persons who attended the meetings related to health, social, cultural, historical and political issues at the Association of Kocaeli Higher Education. They were informed about the study, and afterwards the survey instruments were given to the persons who accepted to participate the study.

Survey development: The survey instrument adapted from the questionnaire was used by Dalla-Vorgia and his friends (12). After the survey was translated to Turkish, it was tested with a pilot study. The survey instrument including 13 items and had two parts. The first part included personal and sociodemographic variables such as; sex, age, occupation, marital or family status and whether the subject had suffered the loss of a beloved person. The second part of the instrument included three hypothetical questions related to three different situations:

Question 1- Do you believe that when someone is seriously ill and it is certain (almost 100 %) that he/she will die soon (for example, in a few months), the doctor should tell the truth to the patient?

Question 2- Do you believe that when someone is seriously ill and it very probable (for example, 50 %) that he/she will die, but not very soon (for example, in 5 years), the doctor should tell the truth to the patient?

Question 3- Do you believe that when someone is seriously ill and has a relatively low probability (for example, 10 %) of dying, the doctor should tell the truth to the patient?

Possible answers were: Yes 'the truth should be told' , no 'the truth not should be told' , It depends, truth should be or not should be told according to patient's physical and psychological condition'. The participants had mentioned regularly in the pilot study that the answer would depend on the patientfs physical and psychological condition. "It depends" item corresponded to the changes in physical and psychological condition of the patient rather than gender, marital or family status, economical sufficiency, diagnosis or age (except in children).

Statistical analysis: Comparisons among the sociodemographic factors related to the hypothetical three questions were performed by using the Pearson chi-square test of independence. We considered the results as statistically significant if P _ 0.05.

Results

Table 1 provides basic sociodemographic data on the 550 Turkish subjects who participated. Among all participants, 54% were males and 49% were between the ages of 18-29. Most of them were married and were employed. Nearly one third of the working people were doctors (20.9 % ). The percentage of the persons who have children (49% ) and the persons who donft have children (51% ) are very close. 28% of the participants had an education of 8 years or less and 15 % were students at Kocaeli University. 48% were born in cities, 24% had lost their father and 15.1 % had lost their mother due to various reasons. More than half of them (54% ) had lost another beloved person (sister, brother, uncle, aunt, niece, nephew, friend) in the last five years.

Table 1: Participants' Sociodemographic Characteristics

Personal Characteristics

n

%

Sex
Male

296

53.8

Female

254

46.2

Age
- 29

269

49.0

30 - 39

189

34.4

40 - 49

81

14.8

50 +

11

2.0

Marital Status
Married

344

62.5

Unmarried

206

37.5

With children

271

49.3

Without children

279

50.7

Education
under 5 years

99

18.0

6 - 8 years

56

10.2

9 - 11 years

111

20.2

12+ years

284

51.6

Occupation
None

98

17.8

Physician

115

20.9

Other work

238

43.3

Student

99

18.0

Place of Birth
Rural

145

26.4

Semi-urban

143

26.0

Urban

262

47.6

Loss of Beloved Person
Mother Yes

83

15.1

No

467

84.9

Father Yes

130

23.6

No

420

76.4

Other Yes

296

53.8

No

254

46.2

TOTAL

550

100.0

Table 2 shows the distribution of subjects (in absolute numbers and percentages) by various sociodemographic factors, according to their reply to the first question.

29% of the participants said "no, the truth shouldnft be told, and a large number of them indicated that it was not right to make the patient unhappy at the end of his life. An important number of people who said "yes, it should be told (46%)" indicated that "this truth would give the patient an opportunity to realize something special that he/she always wanted to do" or "this would give the patient a chance to make sure that his/her family would not face economical problems after his/her death" to justify their choice. Some of the participants who had lost one of their family members (almost 20%) or another beloved person (54%) mentioned that the truth should be told even when the truth is cruel. Those people who had lost a family member stated that they felt bad for they had not told the truth to them. But, most of the participants (25%) suggested that the truth should be told to the patient considering the physical and psychological condition of him or after it was understood that the patient could tolerate the truth.

When we observed the relationship between the sociodemographic variables and the attitudes of the participants to telling the truth, we found out that variables such as; sex, age, marital or family status caused a statistically significant difference. More men than women (chi2=13.69;df=2; p:0,001), participants at the age of 20s more than the participants at the age of 30s (chi2=14.69; df=6;P=0,002), singles more than married people (chi2=30.09; df=2; p=0,0001), people with children more than people without children (chi2=26.4; df=2; p=0,0001) believed that this kind of truth should be told.

The difference education level caused was found to be statistically very significant. More than half of the participants (56%) who had 8 years of education or less notified that the truth should not be told (chi2=94.99; df=6; p=0,0001). It was also found that being employed caused a highly significant difference. While more than half of the unemployed persons (58%) (students not included) stated "no, it should not be told", 44% of the working participants indicated that the cruel truth should be told (chi2=95.80; df=6; p=0,0001), 63% of the students and 44% of the doctors agreed that the cruel truth should be told whatever the patient's condition is.

While place of birth and experience of loss of mother did not statistically make any significant differences in attitudes relating to telling the truth, the experience of loss of father (chi2=12,51; df=2; p=0,001) and the experience of loss of a beloved person in last five years (chi2=9,06; df=2; p=0,01) were observed to affect attitudes toward the truth-telling. Furthermore, persons who had lost their mother, father or a beloved person were observed to prefer the use of "It depends" item less (Table 2).

According to the answers of the participants to the second question "Should the doctor tell the truth to the patient who is seriously ill and it is probable to die (50 % ) for example in five years?" 24.7 % (136 people)of the participants indicated that the truth shouldnft be told because in this five year period the treatment of the illness might be discovered and there was no need to make the patient unhappy. Nearly half of them (47% ) said; "Yes, it should be told" because they believed that if the patient knew his illness, he wouldnft neglect his treatment. 28% of them indicated that it should be told according to the patientfs physical and psychological situation. They think that the truth should be told if the person is able to tolerate it (Table 3).

Attitudes toward this kind of truth did not differ statistically with gender (p=0.33), age (p=0.46), marital status (p=0.22) and having children (p=0.08). But, as in the first question, education was very statistically significant (chi2=37.77; df=6; p=0.0001). Most of the well-educated people indicated that this kind of truth should be told to the patient (Table 3).

The relation between the attitude of telling the truth and being employed (X=43.63;sd=6;p=0.0001) in the second question is contrary to the relation mentioned in the first question. Most of the unemployed people stated that the truth should be told to the patient who would probably die in five years time. While most of the doctors (46% ) thought that "It depends" item would be appropriate for this kind of situation, more than half of the students (52% ) said; "yes, the truth should be told" as in the first question (Table 3).

As in the first question, a relation could not be determined between attitude of telling the truth" and place of birth (village, town, city). In this case, it has been found that there is a statistical significant difference between the attitude of telling the truth and the loss of both the mother and the father (The loss of mother: x2=5.665; df=2; P=0.05; The loss of father: x2=8.93; df=2; p=0.01). In other words, it was observed that such an experience (losing a mother and / or a father) increased the number of choices made favoring attitude of truth-telling. The participants who had these experiences chose the item "it depends" less than the ones who did not have such an experience (Table 3).

Table 2: Distribution of subjects (in numbers and percentages) according to their reply to the question:

eDo you believe that when someone is seriously ill and it is certain (almost 100 per cent) that he will die soon (for

example in five months), should the doctor tell him the truth
?f, by various sociodemographic factors.

YES NO IT DEPENDS P

n ( % )

n ( % )

n ( % )

GENDER

Male

141 (47.6)

67 (22.6)

88 (29.7)

0.001

Female

112 (44.1)

91 (35.8)

51 (20.1)

AGE

- 29 years

129 (48.0)

75 (27.9)

65 (24.2)

30 \ 39 years

79 (41.8)

57 (30.2)

53 (28.0)

0.02

40 \ 49 years

42 (51.9)

18 (22.2)

21 (25.9)

50 + years

3 (27.3)

8 (72.2)

-

FAMILY STATUS
Married

140 (40.7)

127 (36.9)

77 (22.4)

0.0001

Unmarried

113 (54.9)

31 (15.0)

62 (30.1)

With children

106 (39.1)

105 (38.7)

60 (22.1)

0.0001

Without children

147 (52.7)

53 (19.0)

79 (28.3)

EDUCATION
5 years of schooling

39 (39.4)

56 (56.6)

4 (4.0)

6 - 8 years of schooling

18 (32.2)

30 (35.4)

8 (14.3)

0.0001

9 - 11 years of schooling

50 (45.1)

32 (28.8)

29 (26.1)

12 + years of schooling

146 (51.4)

40 (14.1)

98 (34.5)

OCCUPATION
None

36 (36.7)

57 (58.2)

5 (5.1)

0.0001

Doctors

51 (44.3)

16 (14.0)

48 (41.7)

Other work

104 (43.7)

79 (33.2)

55 (23.1)

Students

62 (62.6)

6 (6.1)

31 (31.3)

PLACE OF BIRTH
Rural

62 (42.8)

50 (34.4)

33 (22.8)

Semi-urban

65 (45.5)

38 (26.5)

40 (28.0)

NS*

Urban

126 (48.1)

70 (26.7)

66 (25.2)

LOSS OF BELOVED PERSON
Mother Yes

41 (49.4)

25 (30.1)

17 (20.5)

NS

No

212 (45.4)

133 (28.5)

122 (26.1)

Father Yes

62 (47.7)

49 (37.7)

19 (14.6)

0.001

No

191 (45.5)

109 (26.0)

120 (28.5)

Other Yes

149 (50.3)

87 (29.4)

60 (20.3)

No

104 (40.9)

71 (28.0)

79 (31.1)

  • non-significant

  • Statistically non-significant
  • According to the replies of the participants for the third question "Should the doctor tell the truth when someone has a serious illness and will probably die in low probability (e.g.: 10 %); almost half of the participants indicated that informing the patient about the truth was appropriate so that the patient would not behave carelessly and would take good care of herself/himself. Compared with the first two situations, more participants (30%) were found to have said "no, it should not be told" and stated that it would not be right to make the patient worry unnecessarily. 22% of the participants expressed that it was suitable to tell the truth by considering patient's condition (Table 4).

    It was observed that there was no significant difference caused by sociodemographic characteristics (such as age, gender, place of birth, marital status, having children) in attitude to telling the truth in this situation. Having lost the father or another beloved person was not found to influence the answer to this question to a significant degree. However, the loss of the mother influenced the answer to a low statistically significant degree (x2=5.84; df=02; P=0.05). Most of the participants who had experienced the loss of the mother had stated that the truth should not be told in this situation.

    Both the education level (x2=15.8; df=2; P=0.05) and being employed (chi2=12.28; df=6; P=0.05) were found to make a significant difference of low degree in the attitude of telling the truth to the patient with a low probability of death in a long period of time. However, this relation is contrary to the situation in the first and second questions. Most of the participants who had an education of less than eight years preferred the truth to be told for the third question.

    Discussion

    We believe that we have an opinion of the attitudes of our people about the subject on truth telling to the patients who have life-threatening illnesses. It was determined that almost half of the participants showed their preference in telling the truth to the patient in three different cases contrary to commonly held opinion of "fatal illnesses do not want to know the reality". However, the attitudes toward telling the cruel truth were found to be influenced by gender, age, marital status, education level, being employed and the loss of a beloved person (Table 2, 3, 4).

    Table 3: Distribution of subjects (in numbers and percentages) according to their reply to the question:

    eDo you believe that when someone is seriously ill and it is very probable (for example 50 per cent) that he will die, but not very soon (for example in five years), should the doctor tell him the truth?f, by various Sociodemographic factors.

    YES NO IT DEPENDS P

    n ( % )

    n ( % )

    n ( % )

    GENDER

    Male

    137 (46.2)

    65 (22.0)

    94 (31.8)

    NS*

    Female

    121 (47.6)

    71 (28.0)

    62 (24.4)

    AGE

    - 29 years

    131 (48.7)

    74 (27.5)

    64 (23.8)

    30 \ 39 years

    81 (42.9)

    39 (20.6)

    69 (36.5)

    0.008

    40 \ 49 years

    41 (50.6)

    17 (21.0)

    23 (28.4)

    50 + years

    5 (45.5)

    6 (54.5)

    -

    FAMILY STATUS
    Married

    156 (45.3)

    97 (28.2)

    91 (26.5)

    0.04

    Unmarried

    102 (49.5)

    39 (18.9)

    65 (31.6)

    With children

    123 (45.4)

    78 (28.8)

    70 (25.8)

    NS

    Without children

    135 (48.4)

    58 (20.8)

    86 (30.8)

    EDUCATION
    5 years of schooling

    42 (42.4)

    42 (42.4)

    15 (15.2)

    6 - 8 years of schooling

    28 (50.6)

    17 (30.4)

    11 (19.6)

    0.0001

    9 - 11 years of schooling

    57 (51.4)

    29 (26.1)

    25 (22.5)

    12 + years of schooling

    131 (46.1)

    48 (16.9)

    105 (37.0)

    OCCUPATION

    None

    49 (50.0)

    39 (39.8)

    10 (10.2)

    0.0001

    Doctors

    47 (40.9)

    15 (13.0)

    53 (46.1)

    Other work

    110 (46.2)

    64 (26.9)

    64 (26.9)

    Students

    52 (52.5)

    18 (18.2)

    29 (29.3)

    PLACE OF BIRTH
    Rural

    67 (46.2)

    43 (29.7)

    35 (24.1)

    Semi-urban

    64 (44.8)

    41 (28.7)

    38 (26.6)

    NS*

    Urban

    127 (48.5)

    52 (19.8)

    83 (31.7)

    LOSS OF BELOVED PERSON
    Mother Yes

    42 (50.6)

    26 (31.3)

    15 (18.1)

    0.05

    No

    216 (46.3)

    110 (23.6)

    141 (30.2)

    Father Yes

    66 (50.8)

    40 (30.8)

    24 (18.5)

    0.01

    No

    192 (45.7)

    96 (22.9)

    132 (31.4)

    Other Yes

    149 (50.3)

    76 (25.7)

    71 (24.0)

    No

    109 (42.9)

    60 (23.6)

    85 (33.5)

    0.04

    * Statistically non-significant

    In the first question, about death being almost certainly imminent in a short period of time, some differences associated with sociodemographic characteristics were found telling the truth. For example; males, people in their forties, unmarried participants, participants not having children, and people who had lost a beloved person were found to prefer the truth be told to the patient with such a grave prognosis more when compared respectively with females, people younger than forty or older than 50yrs, participants with children and people who had not lost a beloved person (Table 2).

    Some results of our study resembles the studies in Greece (12) and United Arab Emirates (14). However, in our study the effect of gender to telling the truth was shown but in Greece and UAE did not have this feature. Some of the male participants even wrote footnotes in the questionnaire such as "it must be told absolutely", "I have to make some plans for my family so that they would not have any problems when I am gone". These kind of footnotes seem compatible with the commonly held opinion of a man has the duty of earning a living for his family in Turkey.

    In our study, the attitude of people in their forties showed similarity with the attitudes of the younger people in the study made in Greece. The attitudes of younger people was suggested to be due to the fact that they view death from a distance and therefore show more courage (12). In the light this assessment, we think it would be reasonable to suggest that people in their forties want to be in control of their own lives more, since they may have a family or /and may have experienced the loss of a dear person.

    The effect of marital status in telling the truth both in our study and the study in Greece are similar. In both studies, majority of the unmarried people and the people without children favored the attitude of telling the truth. Some of the participants having both of these described properties have expressed their feelings with sentences such as "Who is he/she going to tell but me?" "How can I be cured if he/she does not tell me?". We think that these expressions are descriptive of the tendency of these people to know the truth.

    Table 4: Distribution of subjects (in numbers and percentages) according to their reply to the question:

    eDo you believe that when someone is seriously ill and has a relatively low probability (for example 10 per cent) of dying,, should the doctor tell him the truth?f, by various Sociodemographic factors.

    YES

    NO

    IT DEPENDS

    P

    n ( % )

    n ( % )

    n ( % )

    GENDER

    Male

    143 (48.3)

    83 (28.0)

    70 (23.6)

    NS*

    Female

    123 (48.4)

    82 (32.3)

    49 (19.3)

    AGE

    - 29 years

    130 (48.3)

    77 (28.6)

    62 (23.0)

    30 \ 39 years

    91 (48.1)

    57 (30.2)

    41 (21.7)

    NS

    40 \ 49 years

    39 (48.1)

    26 (37.1)

    16 (19.8)

    50 + years

    6 (54.5)

    5 (45.5)

    -

    FAMILY STATUS
    Married

    164 (47.7)

    113 (32.8)

    67 (9.5)

    Unmarried

    102 (49.6)

    52 (25.2)

    52 (25.2)

    NS

    With children

    125 (46.1)

    93 (34.3)

    53 (19.6)

    Without children

    141 (50.5)

    72 (25.8)

    66 (23.7)

    EDUCATION
    5 years of schooling

    55 (55.6)

    31 (31.3)

    13 (13.1)

    6 - 8 years of schooling

    32 (57.2)

    13 (23.2)

    11 (19.6)

    0.05

    9 - 11 years of schooling

    54 (48.6)

    33 (29.8)

    24 (21.6)

    12 + years of schooling

    125 (44.0)

    88 (31.0)

    71 (25.0)

    OCCUPATION
    None

    55 (56.1)

    30 (30.6)

    13 (13.3)

    0.05

    Doctors

    48 (41.8)

    38 (33.0)

    29 (25.2)

    Other work

    114 (47.9)

    76 (31.9)

    48 (20.2)

    Students

    49 (49.5)

    21 (21.2)

    29 (29.3)

    PLACE OF BIRTH
    Rural

    74 (51.0)

    48 (33.1)

    23 (15.9)

    Semi-urban

    60 (42.0)

    48 (33.6)

    35 (24.5)

    NS

    Urban

    132 (50.4)

    69 (26.3)

    61 (23.3)

    LOSS OF BELOVED PERSON
    Mother Yes

    30 (36.1)

    31 (37.3)

    22 (26.5)

    0.05

    No

    236 (50.5)

    134 (28.7)

    97 (20.8)

    Father Yes

    57 (43.8)

    45 (34.6)

    28 (21.5)

    NS

    No

    209 (49.8)

    120 (28.6)

    91 (21.7)

    Other Yes

    145 (49.0)

    95 (32.1)

    56 (18.9)

    NS

    No

    121 (47.6)

    70 (27.6)

    63 (24.8)

    * Statistically non-significant

    Table 5: Replies of people to questions about truth- telling (N: 550) (%, n)

    Situations in Questions:

    Tell the truth

    It depends

    Do not tell the truth

    If the patient certainly will die in soon

    46.0 (253)

    25.3 (139)

    28.7(158)

    If the patient very probably certainly will die in not very soon

    46.9 (258)

    28.4 (156)

    24.7(136)

    If the patient low probability will die in long time

    48.4 (266)

    21.6 (119)

    30.0 (165)

    Consistent with the results of the studies both in Greece, UAE and Turkey. There was a very strong effect between the attitudes of telling the truth and the education level (12,14). In fact, in Turkey and UAE higher educated people showed greater tendency for the attitude of telling the truth whereas the lower educated people in Greece had the similar attitude.

    Having an occupation shown to affect attitudes in favor of truth-telling both in Greece and in our country.

    Our results about the attitude of doctors in the first situation differ from the results of other two studies. While most of the doctors in Greece and UAE said "it must be expressed according to the patient's condition, most of the doctors in our study said "yes, the truth should be told". Although the attitudes of doctors and people were observed to be significantly different in both studies, there is no big difference between doctors and people in our country. The similar attitude of our doctors showed us the increasing tendency of fulfilling their duties to the people in the last decade. Because, in our previous study which was performed almost ten years ago, there were significant differences between the attitudes of patients and doctors about telling the truth ( chi2=104.83; sd=2; p_0.0001) (13).

    The other feature differing in the study in Greece is the effect of loss of mother and place of birth. Greek people born in urban areas want the truth to be told whereas in our study, neither the place of birth nor the experience of loss of the mother was shown to make a difference in the attitude (12). But, the experience of loss of the father was found to make a significant difference in our study. This result made us think that the experience of loss of the father is more effective on developing such an attitude due to the important role of the father in maintaining the existence of the family in our country.

    In the second question; half of the people stated that the truth should be told to the person who has a serious probability of dying (not quickly but for example in five tears) and it was observed that these attitudes had been affected by some personal and sociodemographic characteristics. For example, although a significant difference caused by gender, having children, birth in village or city was not observed, it was found that age, marriage, education level, having an occupation and loss of beloved person affected this attitude.

    In our study, attitudes of people in their forties are similar in the first and second questions. Their attitude show resemblance with the attitude of the younger Greek people, as well as with the attitudes of university students in our study.

    According to both conclusions of our study and the conclusions of the study in Greece (12), married people are not in favor of telling the cruel truth. However, some of the unmarried people in this study are in favor of telling the truth. Because, they believe they might neglect their medical treatment if they are not told about the truth. This indicates that living alone affects the attitudes of telling the truth in this way.

    In our study, most of the people who had an education level of more than five years are in favor of telling the truth. This is similar with the conclusions of the study done in Greece (12). But these results are not similar with the conclusions of the study done in the United Arab Emirates, because most of the people in the UAE are not in favor of telling the cruel truth (14).

    Most of the unemployed participants were found to prefer attitudes favoring truth- telling for situations in second and third questions which is contrary to their attitude in the first question.

    The doctors' attitude on the matter of telling the truth to the patient who has a serious risk of dying in five years shows similarity with the conclusions of the study done in Greece (12). In both studies, most of the doctors say that the decision of whether to declare the truth or not should be made according to the physical and psychological situation of the patient, which makes us think that doctors' attitudes concerned with telling the truth are similar in both countries. In the UAE this situation seems to be completely different. Because, the great majority of the doctors in the UAE have said that the truth should not be told to the patient in this situation (14).

    The participants whose parents or beloved ones had died prefer the truth to be told to the patient. Most of them use expressions like "the truth was not told to my mother, father or relatives", "I am regretful for not having told them the truth", "Maybe they would do or say something they wanted and I did not give this chance to them. So I am still very sorry". For that reason they believe that the cruel truth should absolutely be told to the patients. It makes us think that these sorts of biting experiences affect the development of the proper attitude. However, this experience causes an opposite attitude to be adopted for the Greek people. They are not in favor of telling the truth to the patient.

    The third question was on the matter of telling the truth to the patient who will be able to live for a long time and has a low risk of dying. It is seen that the attitudes for this sort of situation are affected less by personal and sociodemographic features (Table 4). It is also seen that both the attitudes of our people and Greek people do not have a significant relation with gender, age, place of birth and loss of parents. But the educational level and having an occupation or not affect the attitudes of the people of either community. Moreover, it is indicated that marital status creates a difference on the Greek people's attitudes (12). Most of the married or unmarried individuals or the ones with or without children are seen to be in favor of telling the suffering truth to the patients. However, we observed that marital status or having a children did not make a statistically significant difference in attitudes for the third question in our study.

    It was found that the educational level also had an effect in telling this sort of truth, as in the attitudes relating to telling the truth in the other two situations. However, contrary to the findings belonging to the other two questions, most of the people who have a five year education and most of people who have who had an eight year education are in favor of telling the truth. However, it is seen that among Greeks who had an education of more than eight years announced their preference in favor of telling the cruel truth.

    Conclusion

    We suppose that the conclusions of our study give an idea about our people's expectations, thoughts and attitudes relating to telling the cruel truth. However, it seems difficult to say whether our people want to know the truth relating to a serious illness or not, based on the conclusions of this study. Because, it has been observed that the attitudes relating to telling the truth to the patient who will certainly die in a very short time, to the patient who will die after a while in high probability or to the patient who might die after a long time in low probability do not differ from each other (Table 5).

    The fact that the item "it depends, it should be told considering the physical and psychological condition of the patient" is an important criteria for the physician to fulfill his duty of telling the truth.

    The attitudes or expectations belonging to three different situations relating to the cruel truth show differences according to sociodemographic features of the individual. This makes us think that these conclusions will be useful to guide doctors on the issue of telling the truth.

    For example; in a situation like telling the truth to the patient who will die in a short time (in five months), most males, people in their forties, unmarried people, the ones without children, the ones having an occupation and high educated (12 years +) people and the ones of lost beloved person (especially a father) show an attitude favoring truth- telling.

    People who prefer that the truth should be told to the patient who is seriously ill and who will very probably die (for example in five years) tend more to be in their twenties and forties, unmarried, without occupation, persons who lost their beloved persons (especially a father) and those who had a middle-level education (6-11years).

    Most of the people who show an attitude preferring the truth to be told to the patient who will die in ten years in low probability (10%) are those who have no occupation, those who have a low education (elementary) and especially the ones who did not lose his/her mother.

    The doctors' attitudes relating to telling the truth show similarity with the persons who have an occupation and are highly educated. This attitude of the doctors makes us think that doctors will be more successful in fulfilling the expectations of the patients who have an occupation and are higher educated.

    Although those conclusions are significant for us, we believe that studies with larger numbers of participants should be done on the issue of telling the cruel truth to the patients, in order to develop national policies on this issue. Because, attitudes aiming to withhold information from the patients, deceive or lie to them frequently end up as suits in Turkish courts (17). Moreover, such news reaching the large masses through the press causes the confidence in medical science to be shaken. According to the regulation of the Patient's Rights issued on 1st August, 1998, the doctors' duty on explaining the truths to the patient about himself or herself is quite obvious (16). In addition, we also believe that by developing the doctors' ethical sensitivities and efficiencies with the ethical educational programs after the graduation, it will be possible to lessen the occurrence of potential ethical problems.

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