Imagine: You are a physician about to reveal to your patient that he has been diagnosed with metastatic cancer. Your patient, an individual of the same ethnic origin as you, leans nervously on the arms of the chair in front of you. Because of your common ethnicity, your patient may expect you to disclose the details of his life-changing diagnosis in a manner that is culturally sensitive; to do so, you may have to conceal some facts. However, as a physician in the United States, you are legally bound to tell your patient the truth about his condition. As the clock ticks rapidly in your office, you find yourself caught in a dilemma of cultural versus legal considerations. What should you do: tell the culturally sensitive truth or the legally justified truth?

This scenario is commonplace today in doctor's offices across the U.S. Patients often choose their physicians with certain cultural expectations in mind, and physicians in turn must deliberate between conforming to their patient's cultural traditions or to medical law. In such cases, it is difficult to determine what a physician should do. The legal arena mandates patient autonomy, but this is often not consistent with a patient's cultural modes of handling medical information. Cultural values are embedded in a patient's scheme of life to the same degree that legal considerations are inseparable from a physician's occupation. In order to better understand truth-telling situations where law and culture are opposed to one another, each argument must be evaluated individually.

One of the main issues that arises is why a physician should tell the whole truth to patients as advocated by medical law. In Resolving Ethical Dilemmas [1] manifold reasons are cited to explain why physicians should avoid misrepresenting medical information to their patients. First of all, it is suggested that lying to a patient is morally condemned since it debases the patient [1]. A lying doctor often betrays patients' trust. Furthermore, lying infringes upon the fiduciary physician-patient relationship [1]. Patients expect the physician to provide the best possible evaluation and treatment of their medical conditions. Because the patient depends upon the physician acting for him in his best interests, lying on the part of the physician desecrates this relationship [1]. In addition, truth-telling is generally advantageous to the patient because a patient who fully understands his condition is better able to make decisions and participate in his care [1].

Another important reason why a U.S. physician should avoid medical misrepresentation is that it is illegal. The U.S. mandates the policy of patient autonomy, which states that a patient has the right to be completely knowledgeable about his medical situation [2]. According to this standard, the role of a physician is to provide his patient with the best possible understanding of his illness, so that the patient can make informed decisions about treatment, taking into consideration the pros and cons of his various options [2]. The Patient Self-Determination Act, an ordinance implemented in December 1991, dictates patient autonomy by providing patients with the right to refuse or accept medical care [1]. Furthermore, this act bestows upon patients the right to determine their power of attorney in making medical decisions [3]. Thus, the U.S. legal system mandates that patients receive complete access to his health information.

However, despite the benefits of patient autonomy, this policy also creates several problems. For example, patient autonomy fails to consider that a patient may be emotionally incapable of coping with his diagnosis [1]. Moreover, this statute overlooks family integrity, as it does not directly address the requests of the patient's well-wishers [2]. In practice, patient autonomy often fails to address values that are important to patients of certain ethnic origin [2]. Thus, in the U.S., patient autonomy often unintentionally trespasses upon the ideas that different cultural groups have about how their medical information should be handled.

Culturally speaking, the U.S. houses a vast array of ethnic groups with different views on medical truth-telling. A recent study conducted by Blackhall et al. [2] supports this idea. In this study, 800 African, European, Mexican and Korean Americans were surveyed about their views on medical truth-telling situations [2]. The researchers determined that Mexican Americans and Korean Americans were less inclined to support patient autonomy and complete truth-telling to the patient than the other groups surveyed. Instead, these two groups were strong proponents of completely informing the patient's family about the truth of the patient's medical conditions while providing the patient with a more sensitive version of the truth [2]. These groups also opted for placing the power of decision in the family's hands [2]. As this study concludes, culture clearly impacts an individual's beliefs in the medical sphere.

The Italian Deontology Code, originally enacted in the 1970s [4], is another example of how cultural differences can affect views on truth-telling. In Italy, this code dictates that a physician must inform the patient of his condition depending on the patient's cultural beliefs and ability to cope with the situation [4]. Accordingly, it is justified for a physician to misrepresent the truth to his patient if he believes that the patient is incapable of handling the truth or if he is aware that complete truth-telling does not adhere to the patient's cultural values. However, at the same time, this code mandates that a responsible guardian must be aware of the patient's true condition and aid the physician in providing the patient with the best possible care [4]. In contrast to U.S. law, the Deontology code takes greater consideration of cultural values in truth-telling situations.

Evidently, medical truth-telling is a gray area in which cultural and legal considerations are constantly in flux. In scenarios such as the one presented at the beginning, a physician must carefully weigh the compelling arguments presented by both of these sides before speaking to his patient. The study performed by Blackhall et al. suggests that an effective way for physicians to resolve such dilemmas is to ask their patients about how they wish to handle their medical information [2]. Doctors in the U.S. have effectively practiced what Blackhall suggests by using the legal front to bolster the cultural argument and having patients provide written and oral consent for their cultural decisions about truth-telling [5]. For example, U.S. physicians sometimes ask patients to designate an attorney who will receive the complete truth about their medical condition, while the patient himself will only receive the culturally sensitive truth [5]. Working through medical law to respect a patient's cultural wishes is an effective course of action for all parties involved because it acts in support of the patient's interests while ensuring that the physician will not be subject to legal liability for misrepresentation.

Ultimately, it is good communication between the physician and patient that will resolve truth-telling dilemmas. A physician should make every attempt to respect his patient's autonomy in both the legal and cultural realms. It is only then that these two different worlds can be brought together and be in balance with one another.