Introduction

The request of a patient or family member that a physician behave in ways that depart from what is normative and sanctioned by broadly accepted standards of practice is always potentially jarring for the physician. When the request appears to be founded in honorable intentions and deeply held convictions, this situation can become a perplexing dilemma. A careful consideration of the foundational principles of both the physician's and the patient's/family member's views and values is necessary in order to properly evaluate the possible courses of action and their implications and consequences for all concerned. Only when such an evaluation is undertaken can the physician make an informed decision about how best to respond. Ms. Watanabe's urgent and earnest request that her father not be told of a diagnosis of cancer poses such a dilemma for the sensitive and responsive physician. Her appeal to the traditional values of her father's native culture as the justification for her request must be taken seriously if she and her father are truly to be treated with respect and caring concern.

Everything that is developed in societies and learned through social channels of both formal and informal teaching is a product of culture,¹ and is shaped by particular cultural worldviews and mores. This includes "technologies and canons of knowledge, authority structures and behavioral rules, laws and the principles that undergird them, definitions of normalcy and acceptability, assumptions about propriety and necessity, expectations and their rationales, and the values by which knowledge and expectations are applied to specific situations."² All are cultural creations. All encode certain preferences and options, and exclude or reject others.

Cultural influences affect health professionals - physicians, nurses, bioethicists, and others - as much as they do patients. Although health professionals are often inclined to believe that "culture" enters the clinical interaction with patients (or only with some patients), this assumption is demonstrably false. Whenever we feel outraged or upset at a suggestion or an action, feel relieved or pleased by an outcome, or feel that patients or family members or physicians should or should not behave in particular ways, we are putting our cultural values into play.

Because we assume that the tenets and norms to which we ourselves are acculturated are "right," or are simply "the way things are" (which members of all cultures assume), our own culture is often invisible to us in daily life. By contrast, the cultural norms and expectations of others are made conspicuous to our attention when they contrast or conflict with our own. By virtue of the very fact that they differ from what is customary to us, these contrasting norms and values may seem to be somehow "inherently" strange, incorrect, or even indefensible. The "invisible" but profound normative sense of the propriety of what we have been taught to do and how we have been taught to do it (again, a sense which members of all cultures share) can generate confusion and strong feelings when it is challenged.

One very good way to identify important cultural influences in a clinical interactions is to ask and discover what is customary or expected, and what meanings things have, for all parties to the interaction (patients, family members, physicians, nurses, ethicists, chaplains, etc.).³ For example: what does the particular diagnosis or treatment recommendation mean to each participant? how does each participant define appropriate roles for health professionals and for family members in caring for the patient, or in defining what constitutes the patient's best interest? what things does each participant consider important or essential for making the remainder of a patient's life good and satisfying? It is most helpful to make these (usually tacit) expectations and meanings explicit, so that everyone involved can see where everyone else is "coming from."

Although the field of bioethics has been developed with careful attention to identifying and applying principles that transcend the dictates of specific cultural or religious systems, it is nevertheless itself a product of culture, and reflects particular forms of cultural shaping. This is inescapable, for all ethical first principles are cultural products, arising from culturally furnished moral codes and views of what is good and desirable in human interaction. Bioethics as we know it in the United States today derives specifically from Western cultural systems, elite and formal intellectual traditions, a Judeo-Christian moral framework, and concerns arising in conventional medical professional practice (itself strongly shaped by Anglo-European and middle-class values).⁴ This does not mean that central bioethical principles cannot be applied across cultures, but it does mean that the ways in which they are applied, and the rationales that support specific applications, can differ strikingly from culture to culture. For example, in American bioethics, attention is directed to patient rights, whereas in Japan bioethics focuses on patient protections. In Mr. Watanabe's case, the principles of patient autonomy and physician beneficence which the issue of truth-telling entails are centrally important both to the physician and to Mr. Watanabe's daughter. What differs between the two viewpoints represented here is the interpretation of what each of those principles means and the participants' views of how they should be applied for the best interest of the patient (and in what that best interest consists), and on what basis priorities among principled courses of action are to be established in this specific set of circumstances.⁵

To date, it has never been customary in Japan for physicians to tell patients that they have cancer. Although the attitudes of both physicians and the public on this matter have been undergoing change since the early 1980's, as of 1994 no more than 13% of Japanese physicians told patients either their cancer diagnosis or their prognosis. It is unclear to what extent this degree of disclosure is confined to those cancers that have high probabilities of cure, or to those situations in which the prognosis favors either cure or many years of relatively symptom-free life (i.e., there are some optimistic counterbalances to the bad news).⁶ The common practice is for family members to be informed of the diagnosis, prognosis, and treatment plan - typically quite straight-forwardly - and for the family to make the decision about whether and to what extent to inform the patient. Most are still not told, or at least not told in a direct manner.^6-9 When physicians discuss their patients' illness with them, it is not uncommon for euphemistic terms ("infection," "unclean tissues") or a substitute diagnosis (ulcers, pneumonia, or a "precancerous condition") to be used.⁹ Physicians commonly accept the guidance of the family if the issue of whether or not to tell a particular patient his or her cancer diagnosis arises,⁶ and (self-appointed) family surrogacy in treatment decision making is the norm with cancer patients. ^6,9,10

Ethnographic interviews and surveys carried out across Japan in the early 1980's revealed that nearly 100% of respondents would not personally want to be told that they had cancer or that they were going to die. In the same studies, physicians nearly universally indicated that telling a patient s/he had cancer would violate the physician-patient covenant and the doctor's duty to keep their patients living and hopeful.⁷ Tanida's surveys a decade later indicated that as many as 60% of the general public would want to be told the truth themselves if they had cancer. However, only 30% believed that the truth should be told to cancer patients directly, and no more than 19% thought that they would tell a family member with cancer the truth.⁶ In the growing hospice movement in Japan, 30-50% of whose patients have cancer, informing patients of their diagnosis remains neither the general norm nor a requirement for patients' eligibility for hospice.¹⁰

These findings show that, although attitudes are changing with respect to how individuals feel about their own desires for and ability to handle disclosure, traditional norms and values continue to guide their thoughts about how cancer patients in general - and their own family members in particular - could best have their interests served. Governmental and medical bodies are similarly divided. In 1989 the Government Task Force for Terminal Care of the Ministry of Health and Welfare recommended that truth disclosure to cancer patients be made standard practice, and outlined principles to guide the decision and disclosure processes. One year later, the Bioethics Council of the Japan Medical Association concluded that "truth disclosure should be strictly limited to very exceptional cases."⁶ The first court case to rule on any aspect of this issue was heard in the Japanese Supreme Court in 1995. The justices found in favor of a hospital sued by the family of a patient who died after deciding against surgery for what she was told were gallstones (the true diagnosis was gall bladder cancer). It was the opinion of the Court that doctors are justified in concealing from patients that they have cancer; that the physician's responsibility to the patient had been fulfilled by his advising her that surgery was necessary; that doctors' decisions have superiority over patients' decisions; and that the patient, having followed her own decision rather than that of her physician, was responsible for the outcome. The justices found rendering a substitute diagnosis in the case of cancer acceptable, with the caveat that physicians must not, in so doing, dimish patients' sense of the severity of their illness.¹¹

Personhood and the interconnected self. The Japanese sense of self is rooted in familial and social relationships; interdependence and interconnectedness with others are highly valued. ^8,12 There is no counterpart to the willful, independent, and highly individuated self so prized in American society, which in the context of Japanese culture would be interpreted not as mature and capable, but as isolated or asocial and unable to function in a connected ("normal") way. In particular, unity and interconnectedness of the family are valued and sought after.^2,13 Central to the Japanese psychological makeup is the concept of amae: the urge (seen as "natural") to an inherent closeness with others that allows one confidently to presume on their benevolent identification with one's own needs and wishes in the expectation that they will respond "in a manner favorable to oneself."¹⁴ Highly prized are "intensely emotional intimacy relationships, high levels of receptivity to others, [and] strong identification with the reputation of the family and others."¹⁵

In this framework, episodes of illness "function to test and strengthen human relationships."⁸ Taken from this point of view, the reciprocity of the desire of others to protect patients from having to grapple with a difficult truth themselves, and the willingness of patients to be protected in this manner and to indicate by their demeanor that others' efforts on their behalf are successful,⁷ assumes very different implications from those that would attach to the same behaviors when evaluated from an American macro-cultural perspective.

Role of the family in patient care. It is expected that family members will assume a central role in the care of patients, even when the patients are hospitalized. It is customary for family members to attend to the hospitalized patient many hours a day, or even around the clock, taking care of their personal needs, furnishing and laundering their personal clothing (worn in preference to uniform hospital gowns), providing their meals and favorite foods (provided in preference to hospital food), and receiving visitors - who come in great numbers, usually bearing gifts.⁸ This pattern is considered to be in the best interests of both the patient and the family, for it maintains social bonds at a time when these have heightened importance to the well-being of all.

Filial responsibility. Dependence of elders on their children for financial, emotional, and physical needs is considered normal, and indeed regarded as desirable.⁷ The confidence of elders that their children will care for them properly (cf. amae) is an aspect of interdependence as well as a privilege of age and an enshirnement of the highly valued concept of respect for elders. The desire and willingness of children to care for their elders in this way are expressions of these same values.

Indirection and reserve in communication. Restraint and reserve are regarded as essential components of artful and proper communication; indirection, subtlety, and minimization are therefore valued, and bluntness is considered crass and rude. Non-verbal communication is common,¹⁰ and its various forms are expected, practiced, and understood to a degree that would be confounding (even infuriating) to the average American. Dutiful enactment of proper role expectations - on the part of patients, physicians, and family members alike - is a common form of non-verbal communication^7,8 of love, devotion, concern, respect, and commitment.

Fiduciary relationship of doctors to patients. Physicians and patients construe their relationships in terms of personal, as well as professional, ties.^7,8 Physicians have a sovereign duty to preserve their patients' lives and well-being and to protect them from harm; in this context, divulging a cancer diagnosis or a terminal prognosis are seen as cruel and inhumane, and as violations of the physician's duty and the patient's trust. In the spirit of interconnectedness and reciprocity characteristic of Japanese cultural norms, physicians impart optimism to patients by their words and omissions, while conveying the depth of their concern in more subtle, non-verbal ways; patients in turn "avoid discussing their cancer, as this threatens the doctor's image as a healer."⁷

Respect for authority. Japanese social relations are highly structured, and organized in a vertical pattern of status relationships. Individuals are acutely aware of their relative superior or inferior standing with respect to others in all social interactions, and gauge their behavior accordingly. Persons of superior status and persons in positions of authority (e.g. physicians) merit respect, and are presumed to be beneficent with respect to those of lower status (e.g., patients) with whom they interact^6-9,10 (another corollary of amae).

Views of cancer and of death. While death is a subject that arouses strong emotions in Japan, it is not, in itself, a subject that cannot be discussed under any circumstances, nor necessarily one that invariably arouses horror. Indeed, there are many forms of voluntary death that are sanctioned and even romanticized in Japan, such as the suicides in service to their country of the kamikaze pilots of the second World War or of Japanese soldiers who preferred the honor of suicide to the dishonor of capture; the seppuku suicide of the samurai tradition; or the double suicide of true lovers prevented by legal or social dictate from marrying. These deaths are considered aesthetically beautiful, in part because the individuals involved retain a special honor and purity, and remain in control of their own fates until the last moment.⁸ Death from cancer is another matter altogether.

Cancer carries the connotation in Japan of inevitable death, in the face of which one is helpless.^6-10 Cancer itself is seen metaphorically as a sort of "stealthily growing ogre which suddenly appears and devours its prey."⁷ Its perceived internal and clandestine character and its sudden, devastating manifestation give cancer a strong association with pollution and decay, both of which are reviled in Japanese values.^7,8 Death from cancer is not only presumed inevitable, but also conjures images of wasting, debility, deterioration, contamination, and loss of control; it is the cruelest and most horrible of deaths.^6-10 It is this extreme degree of horror, revulsion, and fear that make cancer unique among diseases as a diagnosis that cannot be discussed without its very mention believed to cause harm: deep distress, fear, hopelessness, resignation, and more rapid disease progression as a consequence of these.

Japanese physicians who routinely tell patients that they have other diseases from which they may well die⁹ commonly report a worry that patients who are told they have cancer may even kill themselves in their desperation and distress, although few, if any, can report known instances of this happening.⁷ This concern may seem paradoxical in a culture that admires and even makes cultural institutions of some forms of suicide, but it is quite in keeping with the same value system: a suicide of honor is quite a different thing than a suicide prompted by terror or loss of emotional control.

Cultural belief systems are not determinative: they influence different individual members in varying ways. It is important to gain knowledge about the cultural systems in which individual patients and family members (and health professionals) were brought up, but equally important to remember that knowledge of the cultural repertoire of a particular identity group does not provide a sound basis on which to predict the beliefs and values of individuals. What knowledge of an individual's cultural background does do is furnish important background information that both provokes specific questions and provides a possible interpretive framework for understanding that individual's actions and responses. Each individual person (like each particular set of circumstances in which ethical dilemmas arise) needs to be assessed and understood: does this person, at this time, believe x or desire y?

Mr. Watanabe is isei, the first or "arriving" generation in any family of Japanese immigrants to the US. He came to the US as an adult, which suggests that his culture of origin provides his primary framework of beliefs and values, of what feels "right" and "natural" to him. His statements to the physician, prior to his diagnostic procedure, that he would like his daughter to be fully informed of his results and prognosis, and that he trusts in her knowledge and character to act on his behalf, seem to reflect Japanese traditional values and customs regarding the role of family members as patient caretakers and decision-makers. Jean Watanabe, having grown up in the US, may have developed a more "hybrid" set of values, reflecting both Japanese and American cultural influences. It seems clear from the urgency and sincerity of her requests to the physician, however, that among the Japanese cultural values she has internalized are those defining beneficence as protecting patients from the harm and cruelty of knowing that they have cancer, and those defining the proper role of a daughter in protecting and providing succor for an elder parent and in carrying out an elder's wishes.

These assumptions, reasonable on their face, should be regarded as hypotheses, to be tested and evaluated in conversation with Mr. Watanabe and his daughter. If they are borne out, then Mr. Watanabe and his daughter will be shown to be acting appropriately with respect to all parties - each other, themselves, and the physician - in congruence with the Japanese cultural values outlined above.

The primary ethical principles involved in Mr. Watanabe's case are those of autonomy and beneficence, together with their corollary concerns of what constitutes Mr. Watanabe's best interest and who is qualified to decide this matter. It may justifiably be argued - especially in the case of a physician's unfamiliarity with the accepted cultural values and norms of a patient - that persons closest to the patient and sharing in the same cultural worldview are best qualified to define the patient's best interest in terms that are consonant with how the patient him- or herself would experience it. Although the norms of Mr. Watanabe's native culture place little value on individual autonomy, vesting value instead in interdependence and familial identity and reciprocal responsibilitiy, Mr. Watanabe may still properly be viewed as an autonomous person, on grounds that autonomy inheres in personhood, however else personhood is defined.

Autonomous persons are entitled "to use their autonomy as they see fit - even to delegate it" when they so choose.⁵ It is a proper exercise of Mr. Watanabe's autonomy for him to determine what degree of information he wants to have regarding his diagnosis and prognosis, for although American bioethics recognizes patients' right to complete information as a condition of their autonomy, there is no justification for any insistence that it is a patient's duty or responsibility to be so informed; indeed, it may accurately be said that patients have an equivalent right not to know, if that is what they freely choose.¹⁶ It is likewise a proper exercise of his autonomy for Mr. Watanabe to delegate receipt of information and authority to make decisions on his behalf to his daughter (or to whomever he may nominate). The only condition on this form of exercise of autonomy is that the patient must have the capacity to make such decisions in the clear knowledge of what they signify; there is no indication in this case that Mr. Watanabe lacks such capacity.

The principle of beneficence in bioethics is construed in the American cultural context as requiring physicians to disclose diagnostic and prognostic information to patients, as a necessary condition to their informed treatment decision making. Beneficence in the Japanese context, both in bioethics and in the daily life of laypersons, is contrued as the obligation to protect patients (and others for whom one has resonsibility) from harm; harm, in turn, is seen to include revelation of dire information, such as a diagnosis of cancer or an unfavorable or terminal prognosis. Dire information, in itself, is understood to have devastating and injurious potential. To the extent that patients' rights are involved, from the Japanese point of view, it is their right to be protected from injury - including psychological or emotional injury - that has primacy here. This is not dissimilar to the American view of how disclosure of these facts should be modulated in the case of children,¹⁷ or to the recognition that there are circumstances in which the "infliction" of truth is burdensome, rather than beneficent.⁵

If it can be ascertained with reasonable certainty that Mr. Watanabe, having decisional capacity, is choosing to exercise his autonomy by declining to be informed of the details of his condition or treatment recomendations, and by appointing his daughter as his proxy recipient of information and as his decision maker; and if it is clear that both he and his daughter feel that this is a beneficent course of action; then it is both ethical and culturally appropriate to accede to his wishes, since doing so recognizes and respects his autonomy as a person and meets the requirements of beneficence as they are defined by both American and Japanese accepted cultural standards.

As the cultural diversity of the United States population continues to expand, physicians will increasingly be called upon to respond to ethical dilemmas in patient care in the context of cultural values they may not share, or with which they may be unfamiliar. The ability to respond thoughtfully and appropriately, to take patients' beliefs and values seriously into account, to themselves make informed ethical decisions in these circumstances, can no longer be regarded as an "extra" credential of physicians; rather, it is an essential clinical competency. Cultural competence does not consist in mastering a set of "facts" about particular cultural heritage groups and "what they believe;" it is not a form of "snapshot anthropology." Cultural competence is that set of knowledge of self and others and of the variability of viable systems of values; of attitudes of accommodation and respect for persons; and of skills in both assessing the basis of values conflict and negotiating its satisfactory and ethical resolution, that will enable physicians to deliver the highest quality of care, and the profoundest quality of caring, to all patients, whatever their background or beliefs.

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