When the family of an elderly Chinese patient insisted she not be told about her diagnosis of metastatic cancer, her physician felt he had an obligation to inform the patient.
"As the result of an ethics consultation, the physician agreed to ask the patient if all diagnostic information and treatment options should be shared not with the patient, but with her eldest son," says Paul Hofmann, DrPH, FACHE, president of Hofmann Healthcare Group, a Moraga, CA-based consulting firm specializing in health care ethics, and a former hospital CEO. The patient concurred — an outcome which respected the values of the physician, patient, and her family, says Hofmann. Here are some obstacles to patients receiving culturally competent care:
Providers may believe that ethical obligations are met as long as there is competent language translation.
"But cultural competence is not achieved solely through having a translator in the room, with the goal of the patient agreeing to the proposed treatment plan," says Margaret R. McLean, PhD, director of bioethics at Markkula Center for Applied Ethics at Santa Clara (CA) University. Culture is far more than language, she explains — it shapes how patients think about illness and death, and how they perceive and describe pain and other symptoms.
"For the most part, hospitals provide competent language translation," says McLean. "But they need to support provider cultural competence by encouraging that culture brokers be part of the care team."
Providers’ ethical obligation stretches beyond providing language interpretation, says Karen Peterson-Iyer, PhD, a lecturer in the Department of Religious Studies at Santa Clara (CA) University. "Patients need to be understood and empowered within their own specific cultural contexts," she underscores.
If a patient embraces a culturally based belief that direct conversation about death is considered taboo, for instance, it is incumbent upon providers to respect those cultural leanings.
"This might involve, for example, uncovering whether a patient would like to have those sorts of conversations directly or through the intermediary of a designated close family member," says Peterson-Iyer.
Some physicians, nurses, and other healthcare professionals have not received adequate education on culturally competent care during their academic training.
"It is not enough to have know-ledge of different cultural beliefs and practices," says Rosalind Ekman Ladd, PhD, a visiting scholar in philosophy at Brown University in Providence, RI. "One must be able to assess one’s own unconscious biases, cultivate a sensitive attitude, and develop a communication style that elicits trust."
In many cases, there is a wide gap between the ethnic and socio-economic status of physicians and patients.
"The experience of medical students with people unlike themselves is limited," says Ladd. "Thus, without some deliberate effort and education, they do not know how patients of diverse backgrounds approach medical decisions."
Hospitals fail to make culturally competent care a higher priority.
Hofmann criticizes hospitals for failing to recruit and appoint staff members as culturally diverse as the communities they serve. "Unless and until these problems are addressed, significant progress will not be made," he says. Time constraints and inadequate resources are common barriers or obstacles, but they are also "convenient rationalizations for the failure to make improvements," Hofmann says.
Bioethicists can teach and support
Hofmann says bioethicists "can and should perform a pivotal role by using actual cases to teach and to support providers in giving more culturally competent care."
Cultural context should be brought up in the discussion of every case, urges Ladd, whether hypothetical ones or actual cases referred to the ethics committee.
Providers must adhere both to accepted ethical practices in Western medicine, and the equally important moral mandate to honor and respect a patient in the context of his or her specific cultural beliefs and practices, says Peterson-Iyer.
"It is a mistake for a provider unquestioningly to assume that U.S. practices of delivering information or discussing sensitive topics are always the right’ way to do so," she underscores.
Simple awareness on the part of a provider that an individual patient may not share these Western assumptions goes a long way toward attaining a higher level of cultural competency, adds Peterson-Iyer.
"As the United States increasingly becomes a diverse land, our health care system will need to come to grips with, and fund, these needs, if it is to avoid a dangerous — not to mention unethical — level of health stratification," says Peterson-Iyer.
- Paul B. Hofmann, DrPH, FACHE, President, Hofmann Healthcare Group, Moraga, CA. Phone: (925) 247-9700. E-mail: email@example.com.
- Rosalind Ekman Ladd, PhD, Visiting Scholar in Philosophy, Brown University, Providence, RI. E-mail: firstname.lastname@example.org.
- Margaret R. McLean, PhD, Director of Bioethics, Markkula Center for Applied Ethics, Santa Clara (CA) University. E-mail: email@example.com.
- Karen Peterson-Lyer, PhD, Department of Religious Studies, Santa Clara (CA) University. Phone: (408) 551-3188. E-mail: firstname.lastname@example.org.