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Response by Lin and Hicks

The decision issues in this study are more likely to be about whether to choose dialysis or an alternative therapy when Taiwanese patients with endstage renal disease (ESRD) are facing treatment choices. Our study lends support to the supposition that culture influences decision-making. As described in our paper, uremia is interpreted by people in Taiwan as “poison” and dialysis is misunderstood as “washing kidneys.” This false representation toward the illness and its treatment consequently influenced study participants’ decision behaviors. In contrast to much of western culture, people in Taiwan believe that alternative therapies, such as Chinese medicine, have the potential to cure their uremia. This belief motivates patients with ESRD to try a variety of alternative therapies before dialysis. In other words, in the initial stage of ESRD treatment decision making, their attention is focused on whether or not to choose dialysis treatment, rather than a particular type of dialysis (i.e., hemodialysis, continuous ambulatory peritoneal dialysis). Many patients therefore delayed their dialysis treatment and were subsequently admitted to the emergency room due to complications caused by the delay. In Taiwan, the options for treatment of ESRD are the same as that in the U.S., including hemodialysis, continuous ambulatory peritoneal dialysis, or kidney transplantation. There might be differences in selecting these three treatment options because of the cultural contexts. According to the Taiwan nephrology medicine association, most patients (94%) selected hemodialysis as their treatment of ESRD, only 6% of patients selected CAPD. This great difference between these two treatments may be attributed to the preference of the physician. In Taiwan, the physician is usually regarded as an authority figure. People in Taiwan facing treatment decisions tend to submit to an authority figure. Patients are thus more likely to follow their physician’s opinion for their treatment option. Health care providers in Taiwan often regard the patient as a passive agent, who may not necessarily be able to care appropriately for the CAPD. The physician usually encourages ESRD patients to select the modality of hemodialysis for their ESRD treatment. In other words, patients make decisions about their treatment based on their physician’s recommendation, rather than their own personal preferences. Another difference between Taiwan and U.S. culture in making