The impact of culture on the patient-surgeon relationship.

Abstract

Practicing surgery in a multicultural setting poses numerous ethical challenges. Informed choice processes can be frustrated by cultural practices that locate decision-making authority in someone or some group (for example, family, brother, uncle, paternal grandmother) other than the patient, even when the patient has the capacity to make choices about treatment. Differences in meaning systems associated with the patient’s culture and life experiences can frustrate disclosure and understanding of the relevant information on which the patient is to make an informed decision to choose or refuse an operation. This can be exacerbated in the presence of language differences and when translation is needed. In some cases, information from the surgeon is screened and altered by a family translator before it reaches the patient, because, for instance, cultural values hold that it would be wrong to frighten the patient. Sometimes cultural norms can prevent the patient from telling her family translator intimate details of her medical concerns, so a different story is told, leaving the surgeon with an inaccurate account of the medical problem to be solved. In many cultures, patients are not told the truth about cancer diagnoses or terminal prognoses. Surgeons can be asked not to disclose such information to patients or even to lie to patients, sometimes even to patients who directly ask about their diagnosis or prognosis. Surgical procedures considered standard of care by the surgeon are sometimes refused on the basis of values and beliefs not shared by the surgical profession. Alternatively, surgical procedures are sometimes requested that violate the surgeon’s standard of care. Not abiding by standard-of-care recommendations can result in consequences that the medical profession and the dominant culture have difficulty accepting. These and other cultural components of patient-surgeon relationships can challenge the values and standards on which the surgeon feels obliged to practice good patient care. Further, they can affect the success of the patient-surgeon relationship and the health outcomes for the patient. For these reasons, surgeons must attend to the cultural components of the patient-surgeon relationship and find ways to respond to them in an ethically and medically responsible manner. This article tackles the issue, for surgeons, of “operating” with cultural sensitivity. We address this problem first by stepping back to review the nature of culture and why culture is important at all. Then, through case examples and discussion, we address several of the ethical challenges that surgeons can experience when they and their patients come from different cultures. For ease of discussion, we assume a United States context in which surgeons belong to the dominant American culture that accepts most “Western” values and norms. The patients in our discussion belong to a nondominant culture within American society. Although many surgeons in the United States belong to, or share membership with, nondominant cultures, in their capacity as surgeons, surgeons are expected to abide by the expectations of a medical profession imbued with the values of the dominant culture. Hence, the dominant culture always comes to bear on encounters with patients. Although our case examples draw attention to the cultural traditions of at least some Japanese Americans, Hmong immigrants, and refugees from Somalia, it is important to realize that culture is not something unique only to people coming from “exotic” locales. American culture, with its particular beliefs, feelings, and behaviors, poses its own ethical challenges for American surgeons. An alternate set of case examples could well tackle issues related to operating on children and adolescents with trisomy-21 to make their faces look No competing interests declared.