Scene: A Japanese patient goes to a clinic complaining of abdominal pain and trouble eating. In the waiting area, a strange man greets him and tells him a story. "I know a man who had stomach cancer," he says. "He had terrible stomach pain." The patient's face pales as he hears this. "He had black stool that smelled terrible." The patient shudders and looks away. "They told him it was just a stomach ulcer. He could eat whatever he wanted as long as it wasn't too rough. He died a few months later."The patient is called into the office where he is told that he had he only has a stomach ulcer and he can eat whatever he wants, as long as it isn't too rough. He looks the doctor in the eye and says "is it cancer? Tell me if I have stomach cancer!" The nurse keeps her head low and scurries away. Another doctor cannot meet his gaze.
Implicitly, he knows what this means and resigns himself to his fate.
/end scene
This is a scene from Ikiru, where a dying bureaucrat decides to spend the remainder of his life building a playground.
Why didn't a doctor disclose the cancer diagnosis to his patient? He outright LIED to the patient who was under considerable distress. This scene bothered me a lot when I saw it for the first time. Then I learned a little bit more about the Japanese cultural aspects that made this behavior acceptable. It's still something I'm not comfortable with, but at least I know what they are thinking now.
In traditional Japanese culture, a terminal diagnosis is not disclosed to the patient. It is thought that this knowledge of an impending death only brings stress and consternation for the patient, who would have otherwise died in a happier state. So instead of telling the patient, the Japanese doctor tells the family. They decide what is best for the patient in what has been termed "family autonomy."
Japanese people have a more interdependent construal of self. They are more prone to say things indirectly to avoid conflict and confrontation. They want everyone to get along.
An important Japanese value is amae. This is "indulgent dependency," or "the accepted perogative of the individual to depend on the benevolence of another." It is tolereated by Japanese people, but it might seem like spoiled whining to Americans. The way I'd interpret it is something along the lines of:
"Please help me, I cannot help myself, I need someone to take care of me!"
This type of pleading puts responsibility of care into the hands of a loved one, boss or someone else that's of a higher position.
Still, this runs at odds with everything I'd want from a doctor. Paternalism, the feeling that "doctor knows best" is an idea we've abandoned for about 40 years now. It is starting to be discarded in Japan as well, as more and more people expect the truth from their physicians, no matter how painful the news may be.
Resources
Fetters, Michael. “The Family in Medical Decision Making: Japanese Perspectives” Journal of Clinical Ethics. Summer 1998. 9(2)132-146.
Powell, Tia. “Culture and Communication: Medical Disclosure in Japan & U.S.” American Journal of Bioethics. 6(1):18-19, 2006.
Posts
This happens with traditional Chinese families too. When my grandfather was diagnosed with stage 4 lung cancer, it was my uncle, the eldest son, who made all the decisions.
ReplyDeleteThey withheld the diagnosis from the patient out of concern. It was a frightening concept and they did not want to lose my grandpa earlier than expected.
They told my grandpa eventually, but only after he had realized, and accepted, that something was very wrong and that he was not going to get better.
:-)