Cross-Cultural Medical Ethics

To the Editor:—We welcomed the recent contribution of Feldman, Zhang, and Cummings ¹ to the growing literature about cross-cultural medical ethics. The authors surveyed Chinese and American internists and found significantly different beliefs about professional ethics. American internists were more likely to disclose to patients a cancer diagnosis; Chinese internists, to honor family wishes over patient wishes about care.

We add three observations. First, culture is the values, beliefs, and behaviors, transmitted from generation to generation, by which a people interpret their experiences. Understanding a culture requires grasping as much as possible the cultural insider's viewpoint. We commend the authors for taking great pains to choose seemingly universal clinical ethics issues about critical patients, to translate and backtranslate the vignettes, to pretest the questionnaire in both countries, and to use presumably culturally savvy interviewers to survey subjects on-site in China and the United States. Nonetheless, we suspect that whether primarily Chinese or Americans designed the study, practitioners from the other country might identify different ethical issues as important in their practices or resolve such issues differently from the ways expressed in the questionnaire. The high rate of “other” responses that could not be classified into the questionnaire's predetermined fixed responses reinforces our suspicions. For that reason, we favor preliminary, qualitative work that allows subjects to express their ethics concepts in their own words.²

Second, all cross-cultural descriptive studies, including our own, suffer a common drawback: They cannot answer the question, What should be done when cultural values conflict? Although defining the diversity of values is important, we urge social scientists, philosophers, and practitioners alike to tackle also the difficult questions, Are ethics precepts valid across cultures? If so, what are these precepts? and How should they apply to concrete cases?

Finally, the article shifts from presenting data on cultural differences among physicians to discussing cultural differences between physicians and patients. For that reason, it misses an opportunity to demonstrate that even a highly formative bioscientific medical education does not erase deep cultural beliefs.³ Physicians from different cultures who practice bioscientific medicine may have significant ethical differences. Such differences may create conflicts with their colleagues. We predict those conflicts will increase in number and impact as physicians collaborate ever more often across cultural boundaries. For that reason, the article by Feldman, Zhang, and Cummings should alert physicians to the possibility of important cultural differences with colleagues that may escalate into conflicts and require great sensitivity to resolve.