There are three key ethical issues relating to palliative and end of life care in Turkey: difficulties around disclosure of prognosis, that arise because the Turkish people tend to avoid openly discussing diagnosis and the progress of their illness; problems of communication with patients at the end of life and acceptance by the medical professionals; and fears about use of opioids, that can lead to low usage and potentially increased suffering at the end of life.

In terms of issues around disclosure of diagnosis and problems of communication there is a strong ethos in Turkey of keeping a diagnosis from the patient, largely because a cancer diagnosis, in particular, is still regarded as a death sentence. Also, Turkish culture has tended towards a ‘paternalistic attitude’ in the physician.⁷¹ There are signs that physicians’ and public attitudes are changing, along with changes in legal responsibility towards patient’s rights and autonomy; and that these changes are essential in order to encourage a greater openness. ^72,73,74 Medical oncologist, Deniz Yamac explains:

‘Turkey is a little different from Europe, people know about end of life but they don’t say it, about half can talk about it, about cancer, but some don’t want [to hear] the name of cancer. You can act according to the patient which is in front of you. You must feel it, you must have the information before you and be open. I ask my patients, “what do you know about your disease, your illness, what do you need?” So I can see my way how to act, how to talk, but I don’t think that all Turkish doctors [who] are concerned with cancer know that, so I do the workshops in communication. Not to know – how to tell. They [the patients] should know; it’s their life. I try to tell it but not to break their heart. They must know their future. But doctors run away in order to prevent themselves from hurting. Doctors are afraid of palliative care and [often] don’t want to be involved.’⁷⁵

Yasemin Oguz et al. suggest that an important ethical issue is a lack of acceptance of the end of life by healthcare professionals, which requires the creation of a ‘treatment philosophy’ that acknowledges and provides for the needs of people at the end of life:

‘To create this new treatment philosophy, Turkish physicians will have to accept death and dying patients as a natural life process for which medicine in its caring and comforting role has an important role.’⁷⁶

There are ethical concerns about the continuing widespread fear of opioids, a fear which pervades the perceptions and practice of the public at the end of life and the healthcare professionals who care for them. The problem about the practice of euthanasia and assisted suicide of people suffering severe under-treated pain has fuelled considerable debate in medical ethics since the mid 1970s.⁷⁷ The point is made that improved training would result in better pain management and thus mean less suffering and consequently less call for euthanasia and assisted suicide.⁷⁸ For example, in 2003, Turkish oncologists at Akdeniz University Hospital demonstrated a significant improvement in quality of life for cancer patients who were receiving opioids.⁷⁹ There is a strong ethical dimension to the national campaign conducted by Serdar Erdine to educate both the public and healthcare professionals about the efficacy of appropriate opioid usage in alleviating cancer pain.⁸⁰