Caring for Patients in Cross-Cultural Settings

Abstract

In our multicultural society, cross-cultural encounters are becoming increasingly common in the health care setting, often leading to distinct ethical and interpersonal tensions. Members of different cultures cannot take for granted a common catalog of recognized diseases; a understanding of their ascribed causes and usual treatments; or similar attitudes toward sickness, health, death, particular illnesses, and accidents. Although value differences also exist among different groups within a shared culture - across class, caste, gender, age, religious, and political line - cross-cultural conflicts may be more deeply rooted, for such differences embody not just different opinions or beliefs, but different ways of everyday living and different systems of meaning.[1] The difference between intra- and intercultural disagreements in health care may fall along a continuum, with intercultural tensions often appearing more striking and all encompassing. To illustrate this, consider the case of a Western patient diagnosed with carcinoma of the breast who disagrees with a Western physician's recommendation to undergo a mastectomy. The patient prefers instead to preserve the breast and treat the cancer with lumpectomy. In reaching her conclusion, the patient may stress the value she places on bodily integrity, physical wholeness, social attractiveness, and sexuality. Although the physician shares the patient's goal of preserving quality of life, the physician may place greater stress on curing disease. The physician may therefore reach a decision after consulting survival rates for the two procedures for patients at a similar stage of the disease. Despite the different concerns the patient and physician entertain, they are likely to share many of the same ethical concepts and principles. Thus they may articulate their differences in terms of a common moral vocabulary, for example, in terms of a tension between competing values of autonomy and beneficence. Or their discussion may refer to the relative priority of maximizing the quality versus the duration of the patient's life. This conceptual repertoire is likely to assist in reaching a treatment decision. By contrast, intercultural disagreements in health care often involve the clash of different dominant social understandings. For example, consider the case of a Navajo patient who expresses to a Western physician a preference for a traditional healing ceremony to cure disease. Both the patient's and the physician's ideas about healing seem ordinary and natural within the context of their respective cultures. In attempting to communicate their respective orientations to each other, however, each will refer to practices and traditions, concepts and values, and systems and methods of knowledge that appear unusual from the other's perspective. Thus, cross-cultural debates often seem to introduce moral anarchy because people lack cultural standards or vantage points from which to communicate and resolve value differences. There are at least two distinct ways in which cross-cultural differences may become especially striking in the clinical setting. First, a health provider may come from a dominant cultural group and the patient may be a representative of an immigrant or refugee group or of a historical ethnic minority. Alternatively, health professionals themselves may be members of immigrant, refugee, or ethnic minorities and patients may be from the mainstream of society. In this paper, we address the first sort of paradigm case. Background and Context Although individuals with culturally distinct identities exist across many different subgroups in society, cultural differences among dominant and minority ethnic groups have become especially pronounced in recent years. The influx of immigrant and refugee populations has meant that today physicians are more likely than ever before to encounter patients from diverse cultures in their daily practice, and the need for ethical analyses has increased. …