Ethical decision making and patient autonomy - A comparison of physicians and patients in Japan and the United States

Background: Patient-centered decision making, which in the United States is typically considered to be appropriate, may not be universally endorsed, t hereby harboring the potential to complicate the care of patients from othe r cultural backgrounds in potentially unrecognized ways. This study compare s the attitudes toward ethical decision making and autonomy issues among ac ademic and community physicians and patients of medical center outpatient c linics in Japan and the United States. Methods: A questionnaire requesting judgments about seven clinical vignette s was distributed (in English or Japanese) to sample groups of Japanese phy sicians (n = 400) and patients (n = 65) as well as US physicians (n = 120) and patients (n = 60) that were selected randomly from academic institution s and community settings in Japan (Tokyo and the surrounding area) and the United States (the Stanford/Palo Alto, CA, area). Responses were obtained f rom 273 Japanese physicians (68%), 58 Japanese patients (89%), 98 US physic ians (82%), and 55 US patients (92%). Physician and patient sample groups w ere compared on individual items, and composite scores were derived from su bsets of items relevant to patient autonomy, family authority, and physicia n authority. Results: A majority of both US physicians and patients, but only a minority of Japanese physicians and patients, agreed that a patient should be infor med of an incurable cancer diagnosis before their family is informed and th at a terminally ill patient wishing to die immediately should not be ventil ated, even if both the doctor and the patient's family want the patient ven tilated (Japanese physicians and patients vs US physicians and patients, p < 0.001). A majority of respondents in both Japanese sample groups, but onl y a minority in both US sample groups, agreed that a patient's family shoul d be informed of an incurable cancer diagnosis before the patient is inform ed and that the family of an HIV-positive patient should be informed of thi s disease status despite the patient's opposition to such disclosure (Japan ese physicians and patients vs US physicians and patients, p < 0.001). Phys icians in both Japan and the United States were less likely than patients i n their respective countries to agree with physician assistance in the suic ide of a terminally ill patient (Japanese physicians and patients vs US phy sicians and patients, p < 0.05). Across various clinical scenarios, all fou r respondent groups accorded greatest authority to the patient, less to the family, and still less to the physician when the views of these persons co nflicted. Japanese physicians and patients, however, relied more on family and physician authority and placed less emphasis on patient autonomy than t he US physicians and patients sampled. Younger respondents placed less emph asis on family and physician authority. Conclusions: Family and physician opinions are accorded a larger role in cl inical decision making by the Japanese physicians and patients sampled than by those in the United States, although both cultures place a greater emph asis on patient preferences than on the preferences of the family or physic ian. Our results are consistent with the view that cultural context shapes the relationship of the patient, the physician, and the patient's family in medical decision making. The results emphasize the need for clinicians to be aware of these issues that may affect patient and family responses in di fferent clinical situations, potentially affecting patient satisfaction and compliance with therapy.