Bioethical Inquiry (2020) 17:337–344

https://doi.org/10.1007/s11673-020-09979-6

ORIGINAL RESEARCH

The Ethical Dilemma of Truth-Telling in Healthcare

in China
Zanhua Zhang & Xiaoyan Min

Received: 8 July 2019 / Accepted: 15 April 2020 / Published online: 11 May 2020
# Journal of Bioethical Inquiry Pty Ltd. 2020

Abstract Truth-telling is often regarded as a challenge Keywords Truth-telling . Ethics . Healthcare . China
in Chinese medical practices given the amount of clin-
ical and ethical controversies it may raise. This study
sets to collect and synthesize relevant ethical evidence
Introduction
of the current situation in mainland China, thereby pro-
viding corresponding guidance for medical practices.
In the past decades, the subject of ethics has seen dra-
This study looks into the ethical issues on the basis of
matic development. Along with this, healthcare profes-
the philosophy of deontology and utilitarianism and the
sionals have gained a relatively more comprehensive
ethical principles of veracity, autonomy, beneficence,
understanding of ethical issues (Hawley 2014). Ethics,
and nonmaleficence. Chinese philosophy, context and
as one part of philosophy, answers the question regard-
culture are also discussed to provide some suggestions
ing what is deemed right (good) or wrong (bad) in
for decision-making about disclosure in a medical set-
human behaviour (Kordahl and Fougner 2017). In the
ting. This study holds that, in order to respect the basic
medical sector, ethical codes of conduct for practitioners
rights to which critically ill patients are entitled, deci-
is a branch of philosophy that involves the analysis of
sions regarding truth-telling and their implementation
moral phenomena, moral language, and ethical founda-
should be carried out with thorough consideration,
tions and through which ethical decisions are made by
which can be achieved by critical thinking, well-
clinical practitioners (Fry, Veatch, and Taylor 2010).
developed and effective communication skills, the con-
Nowadays, medical practitioners are confronted with
sideration of cultural context, an understanding of indi-
an overwhelming amount of ethical conflicts during
vidual differences, and compliance with relevant laws
patient care, resulting in rather negative experiences
and regulations.
and impacts (McCrink 2008), especially when it comes
to truth-telling. In many cases, a patient’s family mem-
Z. Zhang bers are involved in clinical treatment and are subse-
Department of Emergency Intensive Care Unit, The Second quently involved in decision-making about truth-telling
Affiliated Hospital and Yuying Children’s Hospital of Wenzhou (Catherine et al. 2017; Fjose et al. 2018; Mu et al. 2014).
Medical University, 109 Xueyuanxi Road, Wenzhou 325000,
China The decision on whether to tell the patient about his or
e-mail: 505074846@qq.com her diagnosis and treatment options truthfully is
approached differently in different countries, partially
X. Min (*)
Department of Intensive Care Unit, The Second Affiliated due to which a global consensus on this matter has not
Hospital and Yuying Children’s Hospital of Wenzhou Medical been formed (Chen et al. 2018). This article mainly
University, 109 Xueyuanxi Road, Wenzhou 325000, China focuses on the ethical issues of truth-telling in China.
e-mail: 395566359@qq.com It is therefore necessary to look at the characteristics of
338
the relevant laws and of Chinese culture that may affect
medical practitioners and other involved parties’ atti-
tudes toward truthful communication with patients as
well as patients’ families. In the Tort Liability Law
rolled out in China, the patient is entitled to be informed
about the truth of their diagnosis. However, the latest
Law on Medical Practitioners released in 2010 declares
that medical practitioners are required to be aware of and
avoid adverse consequences that might be caused by
truth-telling. To reduce the possibility of adverse out-
comes, a “family consent for disclosure” method is
usually carried out (Liu et al. 2018). On top of that,
Liu et al. (2018) state that in Chinese culture “the family
prefers to hide cancer diagnosis from the patient in order
to protect him or her from perceived emotional harm”
(2174). The family members usually inform the physi-
cian not to disclose the diagnosis information directly to
the patient (Liu et al. 2018; Wei et al. 2016; Zhang et al.
2015). Overall, the patient’s right to be informed of the
diagnosis, the medical practitioners’ obligation to be
mindful of adverse consequences, and family members’
preference in regard to truth-telling all combine to place
Chinese medical practitioners in a confusing situation in
dealing with particular situations, exposing contradicto-
ry and conflicting needs in applying ethical principles in
medical practice in modern China (Bharnthong 2012).
Within this context, this study discusses the ethical
issues that emerge from a scenario involving typical
issues of medical disclosure based on the current situa-
tion in mainland China. These issues are looked into
critically and taking into account ethical principles.
Scenario: Mr. Chen is a seventy-one-year-old mar-
ried man with two sons and three daughters who has
been diagnosed with advanced lung cancer. Based on
the severity of his condition, the doctor deemed that
there were only six months left for the patient and
suggested that the only treatment that might prolong
the patient’s life was chemotherapy. Mr. Chen was treat-
ed with regular chemotherapy in the pneumology de-
partment. However, his children, in order to protect their
father from deep anxiety and depression, and to not lose
heart when fighting the cancer, chose to tell him that it
was a regular therapy for pneumonia. They figured that,
even in the worst scenario, where their father dies of
cancer, he would not be suffering episodes of emotional
torture but leave the world in a peaceful mind. The old
man was optimistic about his recovery until he over-
heard about his diagnosis from a couple of nurses’
chatting and found out the depressing truth. A few days
Bioethical Inquiry (2020) 17:337–344
later, he passed away, for which the nurses who
disclosed the prognosis were blamed.
In China, the presented scenario is common in nurs-
ing practice. As stated by Liu et al. “A total of 124 pairs
of patients and their family members were analysed. Of
the 124 patients, 47 (37.90%) patients knew about their
cancer diagnosis and 77 (62.10%) patients did not know
about their cancer diagnosis before chemotherapy” (Liu
et al. 2018, 2173). Whether to tell the truth or not is an
ethical dilemma, which is partially due to the challenges
inherent in balancing clinical effect, ethical principles,
and human rights. With this in mind, and taking into
account a review of the literature, the analysis on the
ethical dilemma will be carried out using the philosoph-
ical theories of deontology and utilitarianism, as well as
the ethical principle of veracity, autonomy, beneficence,
and nonmaleficence. Finally, several ethical recommen-
dations are proposed for healthcare practice in future
cases where healthcare professionals encounter similar
conditions.
Ethical Judgment of Disclosure
In compliance with the ethical principle of veracity, health
workers should be as honest, straightforward, and truthful
as possible (Hawley 2014). In other words, the practi-
tioners, as an essential part of healthcare provision,
should at all times disclose the diagnosis-related facts
and prognosis to the patients, along with the risks and
benefits that possibly can be brought by the treatment to
be implemented (Kuwano, Fukuda, and Murashima
2016). Diagnosis disclosure is considered a patient’s right
and an important practice in western countries (Liu et al.
2018). In the western ethical tradition, providing truthful
information to patients is given great value. Medical
practitioners are obliged to answer the patient’s
diagnosis-related questions in a truthful manner
(Zolkefli 2018). However, in situations where a prognosis
is quite discouraging, telling the truth is still deemed a
tricky matter by healthcare providers. This is even more
of a challenge in eastern countries under the influence of
eastern philosophy (Beyraghi et al. 2011). In China,
family members tend to conceal cancer diagnosis from
the patient in an effort to soften the potential emotional
depression that the patient may suffer (Liu et al. 2018). As
Jiang Yu et al. point out, more often than not, the objec-
tion to disclosure is a consensus reached by the Chinese
family members collectively (Jiang et al. 2007).
Bioethical Inquiry (2020) 17:337–344
In many eastern countries, family members usually
hold that telling patients about a poor prognosis may
have potential harm on the patient’s quality of life and
his or her attitudes in facing the disease, including
possible frustration and depression. However, “patients
and their family members had different preferences
toward diagnosis disclosure. There were more patients
than family members who wanted the patients to be told
the diagnosis of terminal illness” (Liu et al. 2018, 2176).
Liu et al. also conclude that patients who are informed of
the truth do not appear to have higher distress level
compared with those who are not. With this evidence,
and supported by the fact that patients have autonomy
and the right to be informed about the condition of their
disease and to make an informed decision, the
healthcare workers should not hide the truth from the
patients.
Philosophy of Deontology
According to the philosophy of Kantian deontology
(Misselbrook 2013), a strict observance of truth-telling
is recommended. Kant argues that some actions are
intrinsically wrong, and no anticipated good results
can be achieved by implementing these actions which
compromise moral integrity (Kant 1797). Lying is sim-
ply wrong with or without good will behind it. Lying
undermines human dignity and implies lack of respect to
both the person who lies or the person being lied to. In
other words, being dishonest will have a negative effect
on the self-esteem of the person who lies as well as the
counterparty’s dignity. The good consequences intended
cannot justify a lie regardless of the motivation behind
it. Moreover, the relationship between the two parties is
at risk of being corrupted. What this philosophical the-
ory holds is that people should tell the truth, nothing but
the truth at all times, even when it comes to bad news. In
addition, according to the British Columbia College of
Nursing Professionals, the patient’s dignity, autonomy,
and privacy should be respected in a positive nurse–
client relationship, and the nurse who violates a bound-
ary in terms of disclosure can negatively impact the
nurse–client relationship (BCCNP 2019). To this end,
medical practitioners in clinical practice often find it
hard to have a healthy relationship with the patient when
concealing diagnostic facts. Moreover, those medical
practitioners are more likely to find themselves in an
embarrassing situation and are likely to suffer moral
distress (Bharnthong 2012). However, Kant’s moral
339
philosophy has been criticized for its absolutism and
lack of exception for any moral obligation of benefi-
cence. According to Jiang Yu et al. (2007), “it is recom-
mended that truth telling should depend on what the
patient wants to know and is prepared to know” (934).
After all, if there’s proof, either direct or indirect, show-
ing that the patient is not ready to or wishes not to be
informed of the truth, the disclosure could be a potential
harmful activity which may destroy the patient’s confi-
dence in fighting the disease (Aaron 2016).
Philosophy of Utilitarianism
In contrast, utilitarianism (Mill 1863) focuses on the
moral consequences of actions. The utilitarian assumes
that the rightness or wrongness of lying is determined by
the consequences of lying, which is compatible with the
argument that it is acceptable to deceive the patient
about any discouraging prognosis, so that the patient
may die in peace. Utilitarianism advocates the view of
promoting happiness for the greatest number based on
Epicurus’ theory. According to utilitarianism, the
greatest happiness can be procured for the greatest num-
ber based on efficiency, effectiveness, and cost-benefit
analysis (Borjalilu et al. 2018). In the words of Francis
Hutcheson, quoted in Guha and Carson (2014) “in equal
degrees of happiness, expected to proceed from the
action, the virtue is in proportion to the number of
persons to whom the happiness shall extend” (Guha
and Carson 2014, 160). From this viewpoint, whether
or not the nurses decide to tell the truth should be
decided in favour of the majority’s well-being and
should minimize the possible suffering of the greatest
number. Based on this, as the patient’s family members
consist of the greatest number involved in decision-
making, medical staff should make a decision that hon-
ours the family members’ will rather than the patient’s.
This is to say, disclosing the diagnosis to the patient is
unacceptable if it fails to benefit the majority of the
members involved in the scenario. However, there is
something vague in the theory of utilitarianism. For
instance, what exactly does the greatest happiness of
the greatest number entail (Savulescu, Douglas, and
Wilkinson 2018)? Moreover, different groups tend to
have different views on happiness. On top of that, the
measurement of happiness or suffering is rather uncer-
tain as people’s feeling is a subjective matter. It is
difficult and sometimes impossible to predict the conse-
quences of each action that have been done or are to be
340
done (Smart and Williams 1973). As mentioned above,
medical practitioners are obliged to consider the possi-
ble consequences resulting from the disclosure and act
upon on it. In the cases where the patient is facing a poor
prognosis, whether it is damaging or beneficial to dis-
close the truth to the patient is also influenced by the
patient’s personal traits and experiences. It’s also worth
noting that utilitarianism is full of arguments in itself.
From one viewpoint, utilitarianism holds that, if needed,
one should sacrifice one’s own happiness for the greater
good/pleasure of the greatest number (Kahane et al.
2015). However, utilitarianism is rather unreasonable
in that it requires saint-like behaviour; that is, people
are supposed to always be ready to make the choice that
will maximize utility. In this process, utilitarianism fails
to give enough allowance for human nature by saying
that people should place everyone else’s interest equally
with their own (Montgomerie 2000).
Principle of Beneficence and Non-Maleficence
Deontology and utilitarianism, which underpin the bio-
medical principle framework of B&C, can be applied to
guide decision-making regarding truth-telling. Benefi-
cence is one ethical principle that underpins nurses’
obligation to do what’s best for patients. To further
explain the principle, healthcare givers should provide
medical treatment and nursing care in a way that will
impose no harm, diminish existing harm, and promote
the best interest of patients (Beauchamp 2009). Non-
maleficence is a sister to beneficence. But the two are
different. According to non-maleficence, a treatment
that may cause more harm than good should be ruled
out. This stands against beneficence, where every single
viable treatment should be considered and ranked in
terms of preference (James 2016). Taking the above
scenario as an example, from a beneficence point of
view, by telling Mr. Chen that he was receiving a regular
therapy for pneumonia, both he and his family would be
more at ease and the patient would be more confident,
which may be conducive for the treatment result. How-
ever, non-maleficence will highlight the potential risks
of concealing the fact from the patient: 1. Mr. Chen
would not be mentally and physically ready for the
coming chemotherapy. 2. The shock to Mr. Chen by
accidently learning the truth would be dramatically larg-
er than it would have been if he had been told initially, to
a point that could cause serious damage, 3. A healthy
nurse–client cooperation could be corrupted, which
Bioethical Inquiry (2020) 17:337–344
could have a negative effect on treatment results. This
study is not intended to answer the question of whether,
in the modern healthcare environment, avoiding harm
should be prioritized over doing something beneficial or
vice versa. However, it is perceivable that combining
non-maleficence and beneficence can give us a more
comprehensive view of a medical scenario. Therefore,
the two are worth considering when tackling an ethics
scenario in a medical setting, so as to strike a balance
between the benefits and risks that can be brought by
truth-telling.
Principle of Autonomy
Since the twentieth century, autonomy, as an important
ethical principle, has significantly shaped modern med-
ical mentality (Sarafis et al. 2014). Autonomy implies an
intrinsic respect for people’s rationality, meaning there is
an entitlement to personal liberty to determine or direct
one’s own actions based on one’s will, thought, and
actions. It indicates that rational people can decide, think
and act upon their thoughts and reasoning (Beauchamp
and Childress 2015). The dignity and rights of the
patients are given decent respect when patients are treat-
ed as independent individuals, regardless of their cultur-
al and ethnic background, gender, age, sexual orienta-
tion, nationality, illness, and disabilities (NMC 2018). In
the healthcare sector, the principle of autonomy is influ-
enced by the patients’ capacity to be autonomous, which
is associated with the internal and external constraints
relevant to the patients. The internal factors affecting
patient autonomy include mental ability, age, disease
condition, and level of consciousness, while the external
factors include treatment circumstances, nursing re-
sources, economy ability, and the amount of disclosed
information (Cranmer and Nhemachena 2013). In terms
of the truth-telling issue, the principle of autonomy
holds that clients are entitled to make choices indepen-
dently without any interference from medical profes-
sionals or family members. In order to fulfil the right
of autonomy, clients should be informed with sufficient
information regarding the illness situation, so as to
support sound decision-making. The information should
include diagnosis, prognosis, advantages and disadvan-
tages of the therapeutic methods involved, influence on
functionality and quality of life, expenditure and effec-
tiveness, and other information associated with the in-
dividual (Rosveh et al. 2017). The clients can only make
decisions about appropriate treatment options when the
Bioethical Inquiry (2020) 17:337–344
medical caregivers provide them with sufficient infor-
mation (Zolkefli 2018). In American and European
countries, truth-telling is considered standard practice,
meaning telling a discouraging truth is less likely to
cause a conflict. The principle for autonomy has been
given enough respect even to the extent that the princi-
ple of beneficence can be compromised (Pojman and
Tramel 2009). There is a legal requirement for medical
staff to inform the patients of their states and options and
the side effects of the treatment, with the only exception
being emergency cases in most western countries
(Patuzzo and Pulice 2017). For instance, Canada has
rolled out comprehensive rules in regard to the princi-
ples of informed consent which require physicians to
gain a patient's informed consent prior to undertake a
treatment (Du and Rachul 2013).
Current Situation in China
As discussed above, autonomy is associated with the
concept that patients should be empowered to make
independent decisions about their medical treatment.
The principle of autonomy has also been reflected in
Chinese law: the principle of informed consent has been
included in a wide range of legal documents. For in-
stance, chapter 7 of the Tort Law of the People’s Re-
public of China introduced in 2009 explicitly regulates
that medical staff must clearly explain the diagnosis and
relevant treatment to the patients. In cases where a
medical practitioner fails to gain informed consent and
a patient’s interest is thereby harmed, the medical insti-
tution should be held accountable (Du and Rachul
2013). However, being able to honour the patient’s
autonomy requires consistency with the principle of
beneficence and non-maleficence (Asghari et al. 2011),
which complicates the problem. As analysed above, the
well-nuanced distinctions between beneficence and
non-maleficence need to be balanced. When a medical
practitioner feels uncertain about revealing the truth, the
conflict often lies between the advantages and disadvan-
tages resulting from respecting the patients’ autonomy.
In particular, when it comes to a Chinese medical set-
ting, the uncertainty is very likely to be emphasized due
to the critical rule that a patient’s family members play in
the decision-making process. People who support truth-
telling argue that disclosure is an act that respects pa-
tients’ independent rights over decision-making, pro-
tects patient–doctor relationships, and empowers pa-
tients’ adherence to therapy (Ahalt et al. 2012;
341
Kazdaglis et al. 2010; Zolkefli 2018). For those who
stand against truth-telling, one of the arguments is that,
in some cases, the severity of a patient’s illness condi-
tion can reduce his or her capacity for autonomous
decision-making (Sarafis et al. 2014). Moreover, it
should be taken into account that patients often lack
comprehensive knowledge relevant to the medical con-
dition; respecting patients’ autonomy unconditionally
may lead to an abdication of the doctors’ responsibility
(Zolkefli 2018). That is, the idea of autonomy empowers
clinicians to inform patients of all viable options, then sit
back and follow the patients’ choices, which is referred
to as the “simplified understandings of respect for au-
tonomy that emphasize the value of independence” by
Liu et al. (2018, 2179). In conclusion, it’s safe to say that
medical workers in China are facing a crucial challenge
in balancing the requirements of Chinese law, ethical
codes, and conduct regarding respect for patients’ au-
tonomy, as well as the characteristic of Chinese culture
where, statistically, most family members would choose
not to reveal discouraging truth to the patients.
In regard to this dilemma, paternalism, which stands
against autonomy, is quite a common practice in a
Chinese context (Xue, Wheeler, and Abernethy 2011).
Paternalism is characterized by the attitude of
disregarding someone’s autonomy for the sake of that
person’s own good. In a medical setting, paternalism
refers to situations where decisions regarding medical
treatment are made for the patients or where certain truth
about discouraging prognosis are deliberately hidden
from the patients, thereby producing, ideally, a better
treatment result or bringing other benefits, such as stress
reduction, to the patients (Beauchamp and Childress
2015). Chinese philosophy, with a history of several
thousand years, has many differences to western philos-
ophy (Hawley 2014). One of the differences lies in the
view of a clan. Patients and medical staff in China are
inevitably influenced by the most commonly known
philosophy concepts: Confucianism and Buddhism
(Hawley 2014). Supported by such philosophies, Chi-
nese perspectives to depressing news such as serious
cancer, fatal prognosis, and limited life expectancy give
more consideration to a human’s feeling, and, partially
due to the closeness of the relationships of a traditional
Chinese family, family members or relatives are often
given more power in decision-making relevant to an
individual in the family (Hoseynrezaee,
Kordikarimabadi, and Jahani 2017). In addition, the
responsibility of family members to the patient is
342
emphasized. In contrast with western culture, Chinese
culture is strongly grounded on family values (Xue,
Wheeler, and Abernethy 2011). Most family members
consider it an obligation to protect the patients from
being hit by the upsetting news. In this situation, it is
quite common that the entire family members agree to
withhold the diagnosis information from the patient.
The effect of this deed in Chinese culture can be per-
ceived positively. According to Jue et al., there is no
doubt that with paternalism some potentially negative
effects on a patient, such as negative mind state, psy-
chological distress, fear and anger, uncertainty, and loss
of hope can be cancelled to a certain extent by blocking
discouraging news (2015).
Conclusion
In cases where a prognosis is severely upsetting or has
great uncertainties, whether to disclose the truth or not
can become an even harder decision to make (Sarafis
et al. 2014). Apart from that, even when it comes to
similar scenarios, there are many different nuances,
various aspects of ethical conflicts, and a range of
influencing factors to be considered in decision-making.
In this regard, any absolutism attached to truth-telling is
liable to bias and is unlikely to produce a viable solution
to address the given ethical conflict in a proper manner.
According to the International Council of Nursing
(2002), nurses have responsibilities and accountabilities
for promoting health, preventing illness, restoring
health, and alleviating suffering. In the medical sector,
practitioners’ respect for human rights is valued greatly.
The rights refer to cultural rights and dignity, as well as
the power of making one’s own choice and living one’s
own life with self-esteem (Melia 2013). In China, dis-
closure or non-disclosure is still an ethical issue with
many concerns attached (Jiang et al. 2007). Many med-
ical staff hold that, according to professional codes of
conduct, they should provide the patients with sufficient
genuine information even if the resulting outcome could
be counterproductive. From some family members’ per-
spective, it is considered beneficial to protect the pa-
tients from certain hard facts, unless truth-telling is
absolutely necessary due to medical-related reasons or
needs. In addition, what cannot be ignored during the
decision-making process is the autonomy and dignity of
the patients, while judiciously balancing the principles
of beneficence and non-maleficence. Moreover, how
Bioethical Inquiry (2020) 17:337–344
and when to inform the patients about their diagnosis
and prognosis need more comprehensive discussion and
critical thinking based on the particular situation and the
selective application of the theories discussed above.
Recommendation
According to the Munich Declaration published by the
World Health Organization (WHO) (Büscher and
Wagner 2005), nurses and midwives are an essential
force to meet the contemporary challenges faced by
healthcare organizations around the world, including
China. It is safe to say that nurses and midwives consti-
tute the largest group of healthcare professionals and fill
an essential role in delivering and promoting best quality
healthcare. This means that, among all the medical
practitioners, nurses and midwives form the biggest
group that is confronted with the dilemma of concealing
or revealing bad news (Bumb et al. 2017). The Nursing
and Midwifery Council (NMC) Code of Professional
Conduct (2018) states that truth-telling should be valued
fully in healthcare. However, the dilemma of whether to
follow a non-disclosure decision made by a patient’s
family members or to inform the patient in respect of
his or her autonomy appears to be a tough call for
medical practitioners to make due to the complexity of
real-life scenarios. Besides, the manner of communica-
tion in the process of truth-telling also carries significant
effect on not only the patients but also medical profes-
sionals (Narayanan, Bista, and Koshy 2010). In China,
considering the big role that paternalism has played,
truth-telling in the medical sector should reasonably
attempt to balance autonomy and paternalism (Dive
2017); before bluntly telling the truth regarding a poor
prognosis, it is suggested that practitioners gather more
information and evaluate the factors that may impair the
patients’ interests. Achieving this goal includes atten-
tively asking the patients about their attitude to disclo-
sure and non-disclosure and improving the communica-
tion skills and critical thinking ability of nurses and
other general medical stuff, so as to empower them to
make a more reasonable and ethical judgement (Alfaro-
LeFevre 2008). As China is a family-centric community,
paternalism is a dominant element in truth-telling, and
patients often prefer their family to know about the
information and keep the relevant information to them-
selves; medical workers should take into account cul-
tural diversity and respect the patients’ attitudes toward
Bioethical Inquiry (2020) 17:337–344
truth-telling (Tang 2019). As well as focusing on wheth-
er to carry out truth-telling, medical practitioners should
pay more attention to when, how, and to whom the truth
is told based on the nuances in different cases (Yoon
et al. 2015). On balance, in order to reach a case-specific
and ethical judgment in terms of truth-telling, critical
thinking, effective communication skills, cultural con-
text, patients’ individuality, codes of professional con-
duct, and rules and regulations should all be taken into
account (Hawley 2014).
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