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Nephrol Dial Transplant (2011) 26: 3838–3842doi: 10.1093/ndt/gfr630Editorial ReviewsThe impact of culture and religion on truth telling at the end of lifeClarissa de Pentheny O’Kelly1, Catherine Urch2and Edwina A. Brown31Imperial College School of Medicine, London, UK,2Department of Palliative Care, Imperial College Healthcare NHS Trust, London,UK and3Renal Department, Imperial College Kidney and Transplant Centre, Hammersmith Hospital, London, UKCorrespondence and offprint requests to:Edwina A. Brown; E-mail: [email protected]AbstractTruth telling, a cardinal rule in Western medicine, is not aglobally shared moral stance. Honest disclosure of terminalprognosis and diagnosis are regarded as imperative in pre-paring for the end of life. Yet in many cultures, truth con-cealment is common practice. In collectivist Asian andMuslim cultures, illness is a shared family affair. Conse-quently, decision making is family centred and beneficenceand non-malfeasance play a dominant role in their ethicalmodel, in contrast to patient autonomy in Western cultures.The ‘four principles’ are prevalent throughout Eastern andWestern cultures, however, the weight with which they areconsidered and their understanding differ. The belief that agrave diagnosis or prognosis will extinguish hope in pa-tients leads families to protect ill members from the truth.This denial of the truth, however, is linked with not losingfaith in a cure. Thus, aggressive futile treatment can beexpected. The challenge is to provide a health care servicethat is equable for all individuals in a given country. TheBritish National Health Service provides care to all culturesbut is bound by the legal principles and framework of theUK and aims for equity of provision by working within theUK ethical framework with legal and ethical norms beingexplained to all patients and relatives. This requires truthtelling about prognosis and efficacy of potential treatmentsso that unrealistic expectations are not raised.Keywords:autonomy; end of life; ethics; religionIntroductionDeath is an inevitable and frequent event in the renalsetting. Prevalence of end-stage renal disease (ESRD)in Europe in 2009 has risen to~932 per million popula-tion, carrying with it a 5-year survival probability of 48%. Furthermore, the incidence of ESRD is increased 3-to 4-fold in a number of ethnic minority groups . Thisdisproportionate burden of ESRD among ethnic minor-ities has in part been attributed to an increased incidenceof hypertension and diabetes, susceptibility to the devel-opment of diabetic nephropathy and to that of tuberculo-sis [3,4].London for example, typified by its multicultural soci-ety and population, has a resident non-UK born popula-tion of~40% . Almost two-thirds (63%) of all migrantLondoners are from BAME (Black, Asian and MinorityEthnic) groups; they also comprise one-fifth (22%) ofLondon’s UK-born population . Around 50% of pa-tients on renal replacement therapy in London are fromethnic minorities, predominantly South Asian . With