Comparing the East and West using the individualism-collectivistism model

A contemporary ethical perspective views patients themselves as being best positioned to make decisions over the management they receive; this means the patient’s individual right to autonomy and privacy must be protected in order to allow them to participate fully in the decision-making process. From an East-Asian perspective, this is judged against cultural differences centred on collectivism, Confucianism and the family unit, where group autonomy and shared decision-making are emphasised over personal privacy.13 Under such a cultural milieu, families may choose not to inform and involve the patient with discussions pertaining to his/her medical condition as a manifestation of their duty to fulfil familial obligations within the family unit, for example by protecting the patient from potential suffering. This is in direct contradiction with the core tenets of patient autonomy and informed consent.

This raises a number of ethical dilemmas pertaining to informed consent, privacy and the role of the family in the patient-doctor relationship. Can informing family members first while bypassing the patients themselves be considered acceptable practice? What about withholding information from patients and seeking ‘informed consent’ from relatives instead (assuming the patient is fully competent and willing to be involved in the decision-making process)? In a collectivistic cultural milieu, the patient-doctor relationship is much more influenced by family opinions as compared with that in the West; for example, Cong found that most doctors in mainland China prefer to discuss with family members first on how much to inform the patient before informing the patient,14 while a proportion of doctors in Hong Kong found it ‘morally permissible’ to release bad news to family members without the prior consent of the patient.6 Such an approach would be seen as a gross violation of patient autonomy and right to privacy in a Western context. However, the individualism-collectivistim model characterises this dilemma as a fundamentally sociocultural issue, and Fan makes the argument that a Western medicoethical model emphasising individual autonomy is ethically relativist and incompatible with an East-Asian environment.12

This perspective is, however, an incomplete characterisation. The individual-collectivistic model does not delineate the extent to which cultural factors modify ‘universal’ standards defining good ethical conduct (if they exist at all), and where the line lies between cultural sensitivities and what Macklin describes as ‘universal character flaws’—arrogance, corruption, greed and indifference.15 Moreover, other influences continue to shape the patient-doctor relationship beyond a purely transcultural perspective; Macklin argues that the act of withholding information from patients, instead of being explained through a collectivistic lens of family determinism over the individual, may instead occur as a result of medical tradition (historical conduct of practice), class (doctors are better educated and occupy a privileged social strata) and paternalism (doctors command power over patients). In a similar vein, Ma notes that patients in Hong Kong are ‘submissive’ not because of the collectivistic culture, but because they are ‘less able to express themselves in front of powerful doctors’.16 We see that the presumption of the ‘family-unit’ modus operandi in an East-Asian context might not be as intrinsically linked with a sociocultural collectivistic perspective as is argued.

Similarly, the presumption that the individualistic interpretation of patient autonomy reflects fundamentally from the Western value system is also not entirely correct. The modern Anglo-American push for self-determination only originated in the 1950s precisely because of the lack of self-determination that existed previously (prior to this era, patients in the USA had little autonomy over the treatments they received) and after the horrors recounted in the Nuremberg trials after World War II.2 Macklin notes that

‘it is a mere 40 years since the concept of informed consent to treatment was introduced into the legal domain (in the United States) and probably only about 25 years since the practice of obtaining informed consent took root’. 15

She further argues that autonomy and family input are not mutually exclusive even in a Western conceptualisation, and there exists growing calls for change from within the Western cultural milieu for families to become equally relevant in the decision-making process.17

Finally, the fundamental argument of a distinctly ‘Asian’ sociocultural-political ideology has been hugely contested by various scholars including Amartya Sen, who has roundly disputed a ‘grand contrast between Asian and European values’18 and warns that such ideas are instead conceptualised to advance dogmatic political ideologies—in other words, there exists nothing particularly ‘Asian’ about ‘Asian values’.

It is clear that the individualist-collectivist perspective does not adequately explain the nuances shaping the standards underpinning patient autonomy within the patient-doctor relationship globally. However, we must not reject the argument that culture plays an integral role in defining the patient-doctor relationship.19 Thus, it is critical to tease apart the ‘culture’ aspect; culture-bound differences must be distinguished from grossly unethical practices less to do with intractable cultural differences and more to do with ‘universal character flaws’. In this view, Macklin argues the USA is simply better able to control these bad practices through laws, ethical norms and professional oversight of practice—in other words, good governance and regulatory control, aspects which can hardly be considered culture-bound.

Recharacterising patient autonomy: ‘respect for persons’ first and foremost

Can we propose an alternative conceptual framework to reconcile the dichotomy between cultural relativism and the quest for some form of commonality in patient autonomy? Macklin argues for a more fundamental approach: she believes that while values such as ‘privacy’ (as part of patient autonomy) might be culture-bound, the first-level moral principles which underpin these values are far less culturally relative—what Macklin refers to as ‘respect for persons’, the fundamental respect for the wishes and values of the individual patient.

If the conceptualisation of patient autonomy is realigned instead as a means through which we maximise ‘respect for persons’ rather than as an end in itself, what would such an interpretation look like in an East-Asian ‘collectivistic’ setting? First of all, respect for individual privacy within the family context need not be absolute—indeed, many patients themselves would prefer that their family take over significant portions of what is traditionally constituted as under the domain of ‘patient autonomy’ in an individualistic setting (it should be noted, however, that family privacy remains a different matter entirely). This does not contradict the best interest of the patient, nor does it indicate a violation of ‘respect for persons’ if and only if this aligns with the patient’s individual wishes. ‘Respect of persons’ must entail a minimum standard of individual patient autonomy, including the right to make informed decisions over their own care: this is logical as it may be impossible to know what a patient truly wants without discussing medical care issues with them directly, and in order for the patient to then make decisions in accordance with their wishes, they must be adequately knowledgeable of their own clinical condition.

An example of such an approach is found in Hong Kong, which Chan argues lies in the middle of a cultural continuum between the USA and mainland China, by retaining a strong family presence with aspects of individual autonomy in what Chan refers to as ‘moderate familism’.6 Within the context of breaking bad news, he delineates the ‘special role’ of family in ‘vetting information and preparing the patient’, while abiding by several core principles:

• All patients have the right to be informed of bad news

• Not lying to the patient

• Telling the truth to the patient eventually.

We see that in this conceptualisation, respect to patient autonomy is enshrined even though the family maintains a significant role in information-sharing and patient care and could even be notified of medical developments before the patient him/herself. The ‘respect for persons’ is protected as the patient remains adequately informed of his/her medical condition, and thus is able to exercise a minimum degree of self-determination. In such a scenario, while the family plays a highly involved role in patient care, family insistence cannot override the individual right to information and autonomy. Indeed, Chan argues that the principal issue is not whether bad news is delivered to the patient (depriving patients of their autonomy), but rather who is best positioned to deliver the news, how it is done and when it is most appropriate to do so (maximising beneficence).

With the family’s role clearly acknowledged within the patient-doctor relationship in a collectivistic culture, doctors acting in the best interest of patients may choose to involve family consultation within the decision-making process, including disclosing information to family members without the patient’s consent, so long as this is believed to be in the spirit of ‘respect for persons’ and in the patient’s best interest. If the patient objects to family participation (reasserting his/her right to autonomy), or if the doctor views such an approach as not in the patient’s best interest (protecting his/her right to beneficence), this assumption of family oriented care immediately ceases and is instead replaced with a more Western model emphasising individual consent and autonomy. This fundamentally places the gold standard of the patient-doctor relationship on the patient’s best interest, safeguarding the first-level principle of ‘respect for persons’.

The Hong Kong approach does not contradict the individualistic approach; rather, it proposes a context-specific characterisation of the patient-doctor relationship fundamentally compatible with modern standards of medical ethics, rebuffing the argument for ethical relativism. This conceptualisation grants the culturally aligned freedom for a collectivistic interpretation of patient autonomy, maximising beneficence and trust within the patient-doctor relationship while preserving the original spirit of patient autonomy as the Western model was originally conceptualised to protect. It is not within the scope of this essay to argue about the practical challenges of applying this approach in clinical practice or even to arrive at a normative judgement as to whether any particular approach claims moral superiority—rather, it is simply a demonstration that the central principles underlying a bioethical concept as fundamental as patient autonomy can be applied in cross-cultural settings. So long as the patient-doctor relationship upholds fundamental respect for the patient’s best interests, additional cultural modification that takes into account the importance of family input in collectivistic cultures based on the patient’s value system should not be seen as contradictory to a Western interpretation of the practice of medical ethics, but instead as an opportunity to further strengthen the patient-doctor relationship in different socio-cultural milieus in being simultaneously morally ethical and culturally aligned.