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The American University of Beirut (AUB) was established in the last decade of the 19th century and is the only one of three current medical programmes in Lebanon to adopt American curricular standards and English as a language of instruction. A formal course in medical ethics was introduced in 1994, which instructs students in the third year on issues such as truth-telling to patients, within the context of the “paternalism versus autonomy” debate.1–4 Changes of attitude toward cancer disclosure following the introduction of that formal course were measured serially in the same class of AUB medical students as they moved from the first to the fourth medical years. In that four-year interval, students graduated from theoretical courses to clinical contact with patients.
Seventy students (median age 21, 23% females) were first interviewed in 1995, of whom 65% were available for a second interview in 1998. The same questionnaire was used both times, and assessed students' general preference regarding disclosure of cancer diagnosis to the patient (“prefer to tell or not to tell”). A list of patient variables was proposed, and students had to indicate whether they felt a particular variable to be important in deciding whether to disclose for a specific patient. Finally, four statements measuring personal attitudes and perceived norms regarding disclosure were also assessed.
A large majority (84%) of those surveyed in 1995 preferred to disclose the cancer diagnosis to the patient directly, and that proportion remained high (86%) as they moved to their fourth year. Patients' characteristics thought at both points to be important in adopting a disclosure decision were mostly related to emotional stability, expressed desire to be told the truth, and expected survival time. Characteristics which were not important at both measurements were social status and gender. None of the students perceived patients' religious beliefs to be important at baseline versus 11.5% at follow-up (p=0.02). At baseline, 74% thought that patients' medical awareness was important versus 57% at follow-up (p=0.10).
The proportion of students who believed that cancer patients consider deception as beneficial decreased from 60.5% to 31% (p=0.005). Those who expect their physician to deceive them if they were cancer patients decreased from 48% to 18% (p=0.002). Those who believe they would know what is in their “patient's best interest” and act accordingly decreased from 78% to 57% (p=0.033). Finally, the proportion of those who perceived physicians to resort to deception “often” with their patients increased from 16% to 54% (p<0.001).
In Lebanon, paternalistic attitudes favouring concealment of serious diagnoses have prevailed among physicians. Both physicians and the public at large traditionally assumed that direct disclosure of cancer diagnosis to the patient might be detrimental. Recent studies have challenged those assumptions and indicated that expectations may be changing in Lebanon as they have elsewhere.5,6 In this brief report, we show that as medical students mature they become more able to put aside their, usually negative, prejudice about the patient's own view of what is best for him or her, when deciding whether to disclose or not. This may indicate that over time students become more aware of the psychological turmoil which accompanies cancer disclosure, where objective knowledge is less important than coping strategies. The increasing realisation that patients do not always perceive deception to be beneficial, that physicians cannot alone determine the best interest of the patient, and that a large number of practising physicians still resort to deception are interesting findings. They show that this generation of young Lebanese graduates is turning away from the real or perceived paternalistic attitude of more senior physicians and adopting attitudes more respectful of the patient's autonomy, needs and right to know. It will be important to evaluate how much of this nuanced “pro-disclosure” attitude carries over into their “real-life” professional practice in the future.
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