Cancer diagnosis has long been a divisive issue in Japan.

According to a health ministry study released in April, 140 hospitals across the nation stated that they told only 46 percent of terminally ill patients their true diagnosis. The same hospitals said, however, that they told nearly all families of the patients the diagnosis of the patients.

Japanese culture's emphasis on group harmony and mutual dependency is often cited as the reason doctors tend to inform families first. Some experts have slammed the practice, pointing out that it violates a patient's right to make an informed decision about his or her own life.

Ko Kawagoe, director of Home Care Clinic Kawagoe in Tokyo, says that he ultimately respects the wishes of their families, noting that 60 percent of his patients are informed. His policy is to tell families first, and if they don't want him to tell patients, he respects that wish -- though he will not lie if the patient asks him for the truth.

Even in such cases, though, he explains to the family the disadvantages of withholding a diagnosis, such as the patient's depression and growing distrust of people around them, Kawagoe said.

"In Japan, families must be involved. It's part of our culture and history," he said. "But, say, in the United States, people feel that it's 'my decision' to know the truth. In Japan, it's more 'our decision.' "

The key issue about diagnoses, however, is not whether to tell patients, but how, said Atsuko Fujita, founder of Chiba Prefecture-based Pure, a nonprofit organization that helps terminally ill patients get hospice care at home.

"The problem is that it's not clear what the diagnosis is for," she said. "Doctors should use the diagnosis to encourage patients, saying that even though the treatments might be extremely strenuous, they are necessary to keep you alive. We don't want it to be a death sentence."

Yoichi Hattori, lecturer of terminal care at Higashi Nippon International University in Fukushima Prefecture, agreed, saying that telling the truth requires strong communication skills.

"Instead of announcing, 'You have cancer,' doctors can say before a major exam, 'There might be bad news for you, depending on the results of the exam. In that case, do want to know the news?' ," Hattori said.

No matter the country, there is no single "right" approach and human emotions are much more complicated than pure logic, said Susan Orpett Long, professor of anthropology at John Carroll University in Ohio, who spent seven months of 1996 in Japan, researching the ways people here make end-of-life choices.

"I know some people in Japan say everyone should be told," Long said. "But I know that there are some people who really don't want to know, who feel more comfortable with their family making the decisions and handling things. And then there are certainly many, many people who do want to know and many people in between.

"If it's my choice and I don't want to know, then I'm conveying something about my values to the people around me. And that's normal." (T.O.)