Patients with LEP likely to experience worse outcomes
Informed consent is primary ethical issue
Ethical issues related to caring for patients with limited English proficiency (LEP) are "a particularly complicated area," says Ellie Andres, MPH, a former senior research associate in the Department of Health Policy at the George Washington Univer-sity School of Public Health, Washington, DC.
Patients with LEP often cannot communicate directly with their providers. In the best situations, patients with LEP see bilingual providers who can speak their language or rely on trained medical interpreters.
"But often patients with LEP 'get by' in medical encounters with the help of family members or other medical care staff serving as ad hoc interpreters, or even using their own limited second language skills to communicate with their providers," says Andres.
When patients with LEP do not have access to bilingual providers or trained interpreters, says Andres, "care may be compromised."
Consent may not be truly informed
Patients with LEP may fail to understand important medical information, such as informed consent conversations or end-of-life care.
"Health professionals have a fundamental responsibility to ensure that patients understand what we are proposing to do to their bodies — whether it's a surgical intervention, a medical treatment, or a diagnostic test," says Matthew Wynia, MD, MPH, director of the American Medical Association's Institute for Ethics and an assistant clinical professor at the University of Chicago (IL) Hospitals.
This responsibility is rooted in pragmatism, since ill-informed patients are less likely to adhere to treatments and get better. "But it's also rooted in the basic human right not to have someone act on you without your informed consent," says Wynia. "And, of course, informed consent is also a legal requirement."
Patients with LEP are at much higher risk of not providing truly informed consent, says Wynia, especially if their doctor doesn't speak their language fluently or doesn't have a trained interpreter on the team.
Practitioners need to do their best to understand what messages make sense to each patient, how to help them succeed in self-care, and how best to capitalize on their social relationships to improve their health status, says Wynia.
"We can't do any of these things very well if we don't speak the patient's language, or if we don't have a qualified interpreter on the team," says Wynia.
Social justice issue
Providing equal quality care for patients with LEP is "clearly a social justice issue," says Mary Anderlik Majumder, JD, PhD, an associate professor of medicine in the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, TX. "Those of us working in the field of medical ethics have been accused of neglecting issues of social justice, and with some justification."
Patients who face language barriers often experience worse outcomes than English-speaking patients, says Majumder. Psychiatric patients with LEP are more likely to receive a diagnosis of severe psychopathology, and pediatric asthma patients are more likely to be intubated. In general, patients with LEP have higher rates of hospitalization and drug complications.1
"Language barriers may compound other sources of disadvantage, and complicate efforts to provide comprehensive, compassionate support in challenging contexts, such as the critical illness of a family member," Majumder says.
Majumder says bioethicists can use these approaches to ensure ethical care:
Remind others that hospitals and other health care facilities have legal obligations under Title VI of the Civil Rights Act of 1964.
"The webpage for the HHS Office for Civil Rights provides information on the nature of these obligations, and access to resources to help facilities meet these obligations," she notes.2
Be aware of the perils of relying on an "ad hoc" interpreter, such as a family member or a hospital employee who is not a trained interpreter, to help with a crucial conversation.
"A recently published set of recommendations is very helpful in this regard," she says.3
Are providers' own skills sufficient?
Physicians who speak additional languages should be tested, if possible, to ascertain what their ability level actually is, says Wynia, before they start practicing medicine in a foreign language.
"We need to be alert to clues to help us recognize when it is safe for us to use our second language skills, and when we are out of our depth," says Wynia.
Just as clinicians rely on certain criteria to determine when they need to call in a specialist, criteria can alert a provider to the need to bring in a trained interpreter when the provider is using his or her own non-English language skills to provide patient care.4
"Today, most providers have at least some knowledge of a second language," says Andres. "Often, interpreters are not readily available in all health care settings, particularly smaller practices."
It can be tempting for providers to try to "get by" with their own language skills when a trained interpreter is not immediately available to help.
"However, this presents an ethical issue," says Andres. "The provider may be compromising care by communicating in a way that is not fully understood by the LEP patient, and this could lead to medical errors."
While LEP patients have a right to language access, they may not feel comfortable asking for an interpreter. Instead, they may go along with the provider without fully understanding the encounter.
"It is very important for bioethicists to encourage providers to have access to interpreters whenever possible, and to be trained on how to access and use interpreters in the clinical setting," says Andres.
Should providers find themselves in a situation in which they are tempted to use their own skills, it is essential that they understand their skill level and whether it is appropriate for them to use their own skills.
"Hence, bioethicists should recommend provider language skill assessments before any use of one's own language skills is permitted," Andres says.
- Flores G. Language barriers to health care in the United States. N Engl J Med 2006;355:229-323.
- Office for Civil Rights, U.S. Department of Health and Human Services, Limited English Proficiency (LEP), http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep.
- Regenstein M, Andres E, Wynia MK, for the Commission to End Health Care Disparities. Promoting appropriate use of physicians' non-English language skills in clinical care: A white paper of the Commission to End Health Care Disparities with recommendations for policymakers, organizations and clinicians. American Medical Association, Chicago, IL 2013.
- Regenstein M, Andres E, Wynia M. Appropriate use of non-English-language skills in clinical care. JAMA 2013;309:145-146.
- Ellie Andres, MPH, a former senior research associate in the Department of Health Policy at the George Washington University School of Public Health, Washington, DC. E-mail: firstname.lastname@example.org.
- Mary Anderlik Majumder, JD, PhD, Associate Professor of Medicine, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. Phone: (713) 798-3511. E-mail: email@example.com.
- Matthew Wynia, MD, MPH, Clinical Assistant Professor, Department of Medicine, University of Chicago (IL) Hospitals. Phone: (773) 702-2710. E-mail: firstname.lastname@example.org.