No Easy Answers in Bioethics Podcast
Comparing Chinese and American Bioethics: Cheng and Tomlinson - Episode 4
December 14, 2017
This episode features Dr. Guobin Cheng, Adjunct Associate Professor with the Center for Ethics and Associate Professor at Southeast University in China, and Center Director and Professor Dr. Tom Tomlinson. Freshly back in East Lansing from the annual meeting of the American Society for Bioethics and Humanities (ASBH) held in Kansas City, Missouri, they sat down together to discuss differences and similarities observed in American and Chinese bioethics. Based in part on work they presented at the ASBH meeting, they discuss specific case examples as they relate to patient autonomy, family and individual identity, and the patient’s right to know or right not to know diagnosis and prognosis.
This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.
Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s guests are Dr. Guobin Cheng, Adjunct Associate Professor with the Center for Ethics and Associate Professor at Southeast University in China, and Center Director and Professor Dr. Tom Tomlinson. Freshly back in East Lansing from the annual meeting of the American Society for Bioethics and Humanities held in Kansas City, Missouri, they sat down together to discuss differences and similarities observed in American and Chinese bioethics. Based in part on work they presented at the ASBH meeting, they discuss specific case examples as they relate to patient autonomy, family and individual identity, and the patient’s right to know or right not to know diagnosis and prognosis.
Tom Tomlinson: Hello everybody my name's Tom Tomlinson. I’m the Director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University. And today we're joined by Dr. Guobin Cheng from Southeast University. Guobin say a few things about yourself.
Guobin Cheng: Hello everyone I’m Guobin Cheng and I’m the Director of the Department of Medical Humanities, Southeast University, Nanjing, China. It's my pleasure to join you and we can discuss something about medical ethics.
TT: Yes. So, Guobin was a visiting professor with us for a year from March 2015 to March 2016. And on frequent occasions during that year, he and I would sit down and just talk. And talk about our clinical experiences, because of course he is trained as a physician and has a number of clinical experiences himself in that role. And I have been involved in clinical ethics consultation with some of the hospitals near Michigan State University. So we both had experiences of various kinds and we would then compare notes with one another. And that's kind of what we're going to do today. This is based in part on the panel that he and I did at the recent meetings of the American Society for Bioethics and Humanities in Kansas City. So Guobin why don’t you start with, say something about that case of Mrs. Yuan.
GC: Okay. Let’s begin with this case. This is the real case where I was a surgical resident. So Mrs. Yuan is my patient. She is a 70-year-old woman. With an advanced colon cancer. So the case will start with an interview between us, and one year before the interview she got operation to remove the tumor. But as you know, the doctor on the case and the family member didn’t tell her the truth about her diagnosis and prognosis. So usually in China when a patient got diagnosis of cancer, the doctor will tell to the family member and will not tell anything about that to the patient themselves. But this is the problem. So in this case before Mr. Yuan came to my office is to get some recommendation about a new surgery. Because she got some other disease, but because she don’t know that she already has advanced cancer. And the doctor and her family members thought okay you have advanced cancer, so maybe you cannot live very long and the new surgery maybe do not give her much more benefit.
TT: But they didn't say that to her.
GC: Yeah because he didn't tell her the truth at the beginning, so I think this is the common problem the Chinese doctor and especially Chinese doctors have to face, because if you don’t tell a patient the truth, so when the patient about to make a new decision, they cannot make the right one. But the dilemma is why should the doctor tell them all the things.
TT: So why didn't, so why didn't the family want to tell her?
GC: Yeah. Actually the family members think the bad news will be, do some damage to the patient’s metal health or other things.
GC: The most common reason is they believe the very bad news will destroy the people, the patient’s hope to fighting the disease.
TT: Yeah, right. So, you know I think that there are similar kind of thinking in the U.S. often. There is a lot of concern about whether or not patients will lose hope especially patients—with some advanced metastatic cancer for example—will lose hope if they're told, they may be told their diagnosis but there is often some reluctance to tell them what their prognosis is, about how much longer they have to live. Because of a concern that if you do that they will lose hope and their last months will then be much more distressing than they could have been, if you had kept that from them. So you know remember we talked a lot about the situation I described of a lady who had metastatic ovarian cancer, had gone through numerous treatments that produced only very temporary remission and was in a phase three clinical trial. She remained optimistic. Thinking that so long she was a fighter she was going to beat the disease and her oncologist had not spoken directly to her about her prognosis. And she showed little interest actually and never asked him about it. But her husband and children approached him asking that he not tell her because they are worried that she would in fact just be decimated, if she were to find out. And he agreed so long as they understood that if she asked him directly he would have to tell her the truth. But if she didn't ask he wasn't going to tell. So that sounded, seemed to me like a situation that's not uncommon in the U.S. but kind of like the case that you just described.
GC: So I think we could find that the reason, actually it looks very similar between the U.S. and China. So I think we can find some questions in this situation. The first one is: Does the patient themselves want to know everything, even the very very bad prognosis. I have little worry about that. So for my experience, I find some patients actually they did not want to know everything. Maybe they want to know the diagnosis but I think it’s a little hard for the doctor and the families to tell them you only have one month to live. So I don’t know they are any surveys about how the patient’s wishes about that.
TT: So in the U.S. there are if you when you survey patients or the general public about whether they want to know these things the great majority say yes. That they want to know everything. About their illness including the prognosis, including bad news. On the other hand, one of the other things that they tend to say is that they want to be asked first. So there is a bit of a tension there, which because it, what that suggests is that they might want to be able to say no. They might want to be able to shield themselves from the news. But what's significant about it is they want to have control, of whether or not they're going to get that that news or not. And that's then produced as practice that I think was reflected in the case that I described, where the recommendation is before you share bad news you have to basically get permission from the patient. So there's this idea that patients have a right not to know in the U.S. And so that ends up then producing a situation where patients aren’t told, that is similar to the situation in China although maybe the origins of it or the reasons for it are different.
GC: So I will focus on a point that in the U.S. the patient have the right to know or not know. Okay?
GC: So but in China the situation is a little different. Because most of the family members and the doctor, I have to say they did not very concerned about the patient’s individual rights. They pay more attention on the some cancer patient’s best interest. So the logic is they believe that bad news will damage to the patients and so to keep the patients’ best interest we will keep secret from them and it’s right. The patient’s right, individual right to be informed is out of the picture. Okay. Another thing is… Please let me go back to a little. What is the meaning of “everything?”
TT: Well what is the meaning of everything?
GC: Should it be include diagnosis, of course. But will we talk about prognosis, I think does “everything” mean you have to tell them you will be dying one month later or just to give them some different options at the end. You maybe have a chance to die one month later and you maybe have chance to live a little more longer. So what’s the meaning of everything?
TT: Well I think so this, so one way to put the question is, what kind of information do I have an obligation to the patient. I have an obligation to provide the diagnosis but how much of an obligation or what kind of obligation do I have to give the prognosis. And I think the answer to that question may connect up with another difference. I think in the U.S. it's going to be the patient so long as there are competent, it's going to be the patient who's going to be making decisions about what treatments they get. They'll have to give their permission for a surgery for example or their permission to enter another research trial, you know to see whether this new treatment might help them or not. It won't be the family that’s asked and so if it's the patient who's going to be making decisions about their treatment. Then the information that's even more important than a diagnosis is the prognosis. Because if the patient, for example, if the patient really understands that even with treatment they may not live very long, they will have a, they may have a very different attitude toward getting further treatment. They may decide you know what I'd rather feel better and not suffer the effects of my chemotherapy and have my last months more comfortable, that's what I prefer. So if it's the patient, so that's what the concern is about the patients not knowing in the U.S. not knowing that they have terminal limited prognosis, is that they can't really exercise their individual autonomy about whether to be treated or not. But is it different in China?
GC: Yeah, I think the Chinese doctor and family members maybe pay not attention on the patient’s best interest, okay let me use this word, and so they really not very care about individual autonomy. Usually people used to negatively asses the patient’s reaction of the bad news. And also negatively asses the patient’s capability to make decision when they are old and very sick.
TT: So they didn’t think the patient would be able to take the news? Or make good decisions?
GC: Yeah. So the second reason is about the capability. So that give the doctor and the family members excuse to make me think okay I can keep this secret because the patient seems to don’t have the capability to do that decision making.
TT: Hm, okay.
GC: So I’m not just ignore the autonomy. I didn’t give him the information because he can’t use the information to make decision.
TT: Because I have an excuse, I have an excuse now for not asking the patient because I assume that the patient is not able to make the decisions. If I didn’t assume that, if I assumed that the patient was able to make decisions, then it would be a much more difficult decision to take that power away from the patient, than it is if I assume the patient can't decide. Well then someone else has to decide and that someone else should be the patient, I mean should be the family and the doctor.
GC: Yeah, yeah. Usually the Chinese doctor and the family assume that he patient didn’t have the capability. And so if we go to the hospital in the real clinical context we will find if the patient is really strong willing and they always be in charge of the family before they go to the hospital, he can express their own idea very clearly and strongly and ask strong the doctor and patients to do something to inform themselves the diagnosis, they will get the news. So it depends on the patients. Okay, sorry. But we will not put the autonomy on the first level. We have to make an assessment of the patient’s situation and to find out why they could got that capability.
TT: Mhm, right. So, so in China the very assertive patient, the patient who demands to be told, is probably going to be accommodated. You know the people will then-- okay so the patient will make the decisions. But I want to go back to this, this idea that the assumption that supports the family taking on this role, is the assumption that the elderly patient or the patient who is, who is very sick with that with a bad prognosis isn’t able to exercise their right of autonomy. Suggests that the difference may be the difference between the U.S. and China is not so much whether the individual person has a right of autonomy. It’s a, the difference is the assumption about the fact. So the assumption in China is that patients who are in certain situations don't have the capacity to make the decision. Not that they don't have a right of autonomy, but they don't have a capacity. Where in the U.S. it tends to be the reverse. And if that's true then we should remember in the in the U.S. side that it wasn't all that long ago, not until into the 1970s, where it was a very common practice in the U.S. not to tell the patient with cancer even their diagnosis for fear that they would not be able to take it and to turn to the family instead to give them decision making authority. And the reasons that supported that historically in the west are very similar I think to the reasons in China.
GC: Okay I think the situation in China is also changed in last decade years. And more and more patients the doctors and family members accept the concepts of the individual’s right to be informed and the patient’s rights such kind of the concepts. And there are some survey to show more than 60% the patients want to know everything, even the bad news. But actually in the clinical practice I think the patients is only no more than 40%.
TT: Okay, okay.
GC: The patient could get the news. So I think I should give some tips to the autonomy. Actually I don’t think Chinese did not accept the idea of autonomy, as you said. They just focus on the fact, why the patient can’t use their autonomy to make a good decision. So they actually put more attention on the outcome of the decision. So I don’t know why that. My understand is right, so I think in U.S. if the patient have the competent to make decision, we have -- make sure the patient have the capability to do that. So why the, any kind of the decision they made will we accept that.
GC: But in China little different. We have to make assessment of the decision itself. If it the decision is a good one, depends on some shared value we will say okay.
TT: If it's a decision, if it's a decision that we agree with.
GC: Yeah. Yes that’s okay. But if the decision is a bad one we will consider, does the patient have the capability, so yeah.
TT: Yeah, yeah. Well okay. So you know in the U.S. the legal some legal presumption is that every adult has the ability to make decisions for themselves. So if we have concerns about a particular patient in the hospital, say, and we're thinking well maybe we should or should we be looking to this person to the patient to make decisions or should we ask the family or someone else to make decisions for them. The very first thing we have to do is to evaluate their capacity. So there's an assumption that the patient has the capacity and now it's our responsibility to show that they don't. And it's only after we've shown that they don't, that from a legal point of view it's okay for us not to ask them any longer, but to ask family or ask somebody that they may have appointed to represent them or whatever it might happen to be. So there is much stronger protection legally I think for the patient’s autonomy perhaps in the U.S. On the other hand we are most concerned about whether the patient has capacity, if they are making decisions we think are wrong. So if the patient's making a decision that everybody around them thinks is a bad decision to make, we will be looking much more carefully at their capacity than we would otherwise. If they're agreeing with us, well they're fine. We're not going to dig any deeper. It’s when they're disagreeing with us that we get alarmed and we begin to look more closely because we want to make sure that if they're going to make a bad decision, it's their bad decision. And will be their responsibility and they'll have to bear the consequences. Because one of the ideas about autonomy is that I have the freedom to make bad choices and then it's my responsibility if that's what happens.
GC: So I think actually the situation in both side is much more similar than I think, than I thought okay. Okay on one hand is a patient’s individual autonomy to make any decisions they want to make. On the other hand there are always some others will be assessed the decision is good or bad. So I think the difference is, how can I say, when the patient make a bad decision, the family is right to join decision-making. The family members’ role that played in the decision making is a little different. I think the Chinese family member played much more stronger role in the process but in U.S. sometimes they may be out of the pictures.
GC: Okay. But the whole logic is much more similar. And if we have to find some difference I think actually I think the Chinese people more and more accept the idea of the individual, individual’s rights and the individual’s freedom. And we also affect by the very traditional idea about the person live first as part of the family. The first level identity of a patient is he or she was member of a whole family.
TT: Mhm. Was shaped by family that they were, that they grew up within a family. They were shaped by their family.
TT: They for those reasons have obligations to their family.
TT: And not just to themselves.
GC: Yeah so she should, in my case, she should not to do something absolutely different from her family members’ wishes. They even thought the patients have the duty to not against the family’s wishes. But if the conflict is very strict, for such a, in my case, Mr. Yuan wanted to extra operation to remove a new small tumor to release her some suffering and the family members think that is a bad decision. But after a home meeting when the family members understand why she want to do that operation is because she believe the suffering is much bad than prolonging her life. Because, the word is a little difficult, it’s frequent urination.
TT: She had urinary incontinence. She couldn’t control her urination because of this other tumor, and as I remember the case, the situation from the family's point of view was that, no is there's not really any point in doing this because they knew that she had this terminal illness. But the patient, they didn't really appreciate how much distress this caused the patient. If she, this urinary incontinence, and that's why she wanted the surgery.
GC: Yeah, she think the situation destroy her identity as a person.
TT: As a person. Right. And dignity.
GC: Yeah, but usually the family members did not consider it about that. They focus on physical benefit. They focus on how long they will live and they focus on the, some other things, we call subjective.
TT: Yeah the subjective or psychological, rather than the physical.
GC: Yeah, but at the meeting when the family members know Mr. Yuan is hard to understand his situation. How to, how much she want to protect her own identity. She understand, they understand her decision. And they receive the operation at last.
TT: Yeah, they agreed.
GC: They agreed.
TT: Well, so actually Goubin and I have another case that we discussed at ASBH that, it was a comparison between China and the U.S. with respect to the patient's desire to make decisions not just for themselves but also for their families. I don't know if we, we don’t have time to talk about all the cases. But I'll just maybe conclude by saying and I’ll ask you to make comments too. That you know I think, Goubin, that in this conversation we just had about this case, things came out that hadn't come out before. [Both laugh] And that's been my experience in talking with you. Is that we've talked about these cases many times or different or related cases many times, and every time we talk something new surfaces. It may be a new difference that we hadn't recognized before. It may be a new similarity that we that we didn't recognize before. And this is just evidence of how interesting and complicated these kinds of comparisons are going to be.
GC: Yeah actually I made some notes about these discussions but when we began I almost struck all of those and we always can find something new we discuss. And I think people from different culture want to understand each other. They have some different approach, we can just from the theoretical ones, we can find some terms that can describe how diverse we are, very simple.
TT: At a very abstract level.
GC: Yes. For example, Americans is individualism, and Chinese is familyism or collectivism. Such as like that. Another approach is we can go into the real world to find the facts, how to affect the clinical decision-making or clinical behaviors.
TT: Yeah if we get down to the closer to the ground and not so high up, if we get down closer to the ground, then I think we can have much more informative conversations that help us get beyond stereotypes. Cultural stereotypes.
TT: Well so this is been, you know this is why it was such a pleasure to have you with us for that year and I know I look forward to our continuing conversations and collaboration.
GC: Of course, it's my hope, it’s also my pleasure to do that. And I also hope I can, we can find more opportunity to involve, to more and more people joining us, to make this discussion more how can I say…
GC: Yeah richer.
TT: Yeah I hope so too. I’m sure we will. So thanks a lot Guobin.
GC: Thank you Tom.
LM: Thank you for joining us today. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.