Among a variety of end of life issues that give rise to ethical debate in Thailand, two topics under the umbrella of patient autonomy have attracted widespread interest: diagnosis disclosure and informed consent.

Diagnosis disclosure

Adherence to the principle of patient autonomy might convince a physician that patients should know their diagnosis and generally understand its implications in order to make informed decisions about their continuing care and approaching death. Within Thai culture however, this seemingly straightforward decision is rendered more complex by the patient’s position within – and deference towards – the extended family. Temsak Phungrassami:

‘The principle of autonomy means we have to tell every patient their diagnosis, but Thailand is not like a Western country where autonomy is the first priority. We consider the patient as a member of the family. So when we evaluate, we have to evaluate both the patient and the family. I did some research about cancer disclosure in radiotherapy patients. The result is interesting because the disclosure rate is getting higher and higher, but there are still some patients that don’t want to know. Yet these patients cooperate in their treatment; they plan for their future; they prepare themselves for their funeral. So they accept their approaching death; they just don’t know they have cancer.

‘The Lord Buddha said something about truth telling, which is helpful here and I quote it in my papers. He said that the truth we have to tell needs to be told at the proper time, when it will benefit the person who receives it. So we can use this principle in handling this kind of cancer disclosure. If the patient doesn’t want to know but co-operates with their treatment and also prepares for the future, I don’t think we need to tell them their diagnosis.’⁷²

This accepting approach of adults towards their own death contrasts sharply with that of parents wanting to explore every avenue to extend the lives of their children. In this scenario, the appropriateness of disclosure is a contested issue. Srivieng Pairojkul:

‘Concerning children, the difficult issue is the grief of the parents and it’s very severe. I think they accept that dying is part of the circle of life; but as a parent they still want to fight, every minute, to get their children to live. It’s still there. So I think the idea that children should know they are dying is a challenging issue. From my interviews with parents, I think they don’t want their children to know they are dying. So they hide it and ask the doctor, ‘Don’t tell the children’, and they don’t tell them. I think this is part of the paternalistic pattern of Thai culture: parents tell you what to do. Most children don’t have a right to say anything; they just listen to their parents. But I think they should have some sort of communication and we are trying to explore this problem, to see what we should do to encourage the parent to tell the child.’⁷³

Informed consent

New legislation introduced in March 2007 addressed the issue of the patient’s right to die in accordance with pre-recorded wishes that exclude interventions such as cardio-pulmonary resuscitation. During the Bill’s consultation stage, Mettanando Bhikkhu, a former physician and Thai Buddhist monk, tried to rally opposition to the proposals on the grounds of insufficient weight being given to the experience of ‘living wills’ in countries such as America, and the inability of patients to appoint agents or proxies. He writes:

Section 10 [now 12 in the legislation] has apparently left out these rights and puts too much emphasis on a mere piece of paper, the ‘living will’, which has not received good reviews in Western countries. In a country like Thailand, where people have low knowledge of medicine and their own legal rights, and where paternalism of physicians and informal relationships dominate medical professionalism, Section 10 of the bill can easily serve as a license to kill for some ill-minded physicians … Each bill should be debated over and carefully drafted, for example, on the nature of informed consent, advance directive, their pros and cons as well as legislative protection of the rights of individuals with utmost consideration before they are passed into law.⁷⁴

Mettanando Bhikkhu raised these points with members of the Hospice Foundation of Thailand but found little support for his views.