![]() “Do you prefer to make medical decisions about future tests or treatments for yourself, or would you prefer that someone else make them for you?” “Some people want to know everything about their medical condition, and others do not. In the United States, this protection may include deliberately not translating diagnosis and treatment information to patients, 16 a situation that is less likely to arise with appropriate use of a translator ( Table 2). In Hispanic, Chinese, and Pakistani communities, family members actively protect terminally ill patients from knowledge of their condition. Many African and Japanese physicians, when discussing cancer with patients or family members, choose terms such as “growth,” “mass,” “blood disease,” or “unclean tissue,” 15 rather than specifically describing a potentially terminal condition. Physician strategies commonly employed to minimize direct disclosure include using terminology that obscures the seriousness of a condition or communicating diagnostic and treatment information only to the patient's family members. Outside the United States, health care professionals often conceal serious diagnoses from patients. The consumer movement, legal requirements, an emphasis on patient informed consent, and reduced physician authority have contributed to health-related “truth telling” in the United States. Many Asian and Native American cultures value beneficence (physicians' obligation to promote patient welfare) by encouraging patient hope, even in the face of terminal illness. ![]() 11 Cultures valuing nonmaleficence (doing no harm) protect patients from the emotional and physical harm caused by directly addressing death and end-of-life care. These non-Western cultures believe that communities and families, not individuals alone, are affected by life-threatening illnesses and the accompanying medical decisions. Other cultures, however, de-emphasize autonomy, perceiving it as isolating rather than empowering. In the United States, legal documents such as advance directives and durable powers of attorney are strategies to prolong autonomy in situations in which patients can no longer represent themselves. 9, 10 Although many patients in the United States value autonomy, other cultures emphasize beneficence. Principlism, a well-established ethical framework for medical decisions in the United States and Western Europe, highlights cross-cultural differences that occur along four dimensions: autonomy, beneficence, nonmaleficence, and justice. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physician- and family-based decision making among some cultures. ![]() Similarly, with regard to decision making, the U.S. In contrast to the emphasis on “truth telling” in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of “bad news” locus of decision making and attitudes toward advance directives and end-of-life care. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. ![]() model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Ethnic minorities currently compose approximately one third of the population of the United States. ![]()
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