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Patient demographics are changing, not only  in Wisconsin but throughout the Midwest and the entire United States.   In   the   past,  one   talked about religious and racial diversity, but now the issues become more complex   with   cultural    diversity. The   ethnic  or   cultural   diversity in Wisconsin has grown impressively. Diversity is no longer limited to “white American,”  “African American,” or “Native American.” It now includes Asian, Eastern European, Sub-Saharan African, and Middle Eastern countries. Also, many states are experiencing considerable growth in their Latino populations.
This diversity not only leads to societal challenges, but also provides a very complex environment in dealing with the medical problems of people from many cultures and national origins.  With all patients, the physician, nurse, or other caregiver has an ethical responsibility to respect the values, priorities, and customs of those entrusted to their care. What may be acceptable or even expected in one culture may be problematic in another.
The issue is not simply one of an “American” caregiver dealing with a patient from another culture. It may be an American patient interacting with a physician, nurse, or other caregiver from another culture. How do you deal with a physician from an autocratic, paternalistic culture that now practices in this country where autonomy is of paramount importance?  Also, how do you get a recent immigrant to exercise his or her autonomy when they come from a paternalistic society? Who is “more correct”—the physician    from    another    country who was brought up with limited resources and consequently orders diagnostic  testing  very sparingly,  or the American-trained physician who orders every conceivable high-tech study at the “drop of a hat”? The situation can become even more  problematic  if  the  patient  is from an alien culture  and the care- giver  is from  a different  alien  culture, but both are interacting within American society. Physicians are expected to know what is best for their patients, and empowering the patient or the patient’s family to exercise their autonomy in the medical decision-making progress may be perceived by the physician as failing his or her “institutional duty.”

There are other trans-cultural issues that are potentially   sensitive. One must consciously be aware of them, even if there are no simple, easy answers.  How do you disclose medical errors or adverse outcomes when dealing with various cultures? How will 2 people from different cultures or religious groups interact in the United States when they may be in conflict back in their native lands?





The medical encounter can be viewed on several different levels: the clinical, the interpersonal, the societal or cultural, and the ethical.  One might also examine the religious aspects of a medical encounter.  The religious aspect is very often influenced by cultural issues, or the ethical and religious considerations are so intertwined that it is difficult to separate them. (One religious aspect, however, that seems to be totally free of ethical considerations would be the refusal of blood or blood products by a Jehovah’s Witness.)  Moreover, the encounter may have interactions on more than one level.
The effect of cultural issues influencing the clinical encounter can take many forms. A Hmong patient may refuse a cholecystectomy or any amputation because he wants to be buried intact with all his body parts. An Asian woman  may not  complain  of menopausal  “hot  flashes” because of diminished perception, a reluctance to complain,  or the undisclosed  use of  herbal  remedies  or  phytoestrogens from soy products. A Chinese patient may be reluctant to say “no” to a question for fear of being disrespectful   to   the   physician.     The Chinese patient may not ask for pain medication. Rather than asking if the patient has pain, a more appropriate response might be, “May I get you something for pain?”

Patients coming from a nation caught in civil strife may be suffering from Post Traumatic Stress Disorder. Also,  in dealing  with  patients  who have immigrated from another country, the physician  or other  caregiver must be sensitive to the fact that there may  be,  within  classes  of  people, drug   intolerances,   infection   (both usual and unusual), unique metabolic abnormalities, and iatrogenic  effects resulting from self-treatment remedies.

Clinical decision-making can often be influenced by cultural values. Segun Gbadegesin writes on the Yoruba concept of ikuyajesin. The Yoruba are a tribe in Nigeria. They feel that death is preferable to ridicule or loss of dignity.




Gbadegesin uses this concept to explain why a woman might refuse a mastectomy for breast cancer because it would leave her without a breast, or why a paraplegic man would consider suicide.

Serving on a clinical ethics consult service, as well as having discussions with both ethicists and clinicians, has demonstrated to me the tremendous range of interpersonal relationships in the patient-physician encounter. A middle-aged Bosnian woman has cancer, but the son insists that he will determine what is disclosed to his mother.  There is a comatose woman from Southeast Asia. The eldest son is not available. The youngest son is present but is uncomfortable asking questions or being assertive as the surrogate decision-maker. Finally, there is the elderly Jewish woman who is uncomfortable with the doctors and nurses dressed in white since they remind her of the concentration camp she was in as a child.

The physician needs to understand and appreciate patients' perspectives concerning   their   illness and what they want and expect in their treatment. Only then can you determine and set up a therapeutic goal that is in keeping with patients' wishes and values, thus respecting their right of self-determination or autonomy. The patient may opt for conventional treatment, or may opt for conventional   treatment    combined    with some form of alternative therapy,  or may opt for no treatment  at all.






The ancient Greeks questioned whether virtue could be taught, or whether it needed to be inherently present in a person and simply be developed.  Renee Fox raises the same issue with cultural competence. “It is commendable that   the authors who address these attributes think of them as professional abilities that can be taught and implemented in clinical training, rather than primarily as virtues associated with moral character.”

Trust is essential for a good doctor-patient relationship.  Trust, however, is not infrequently lacking. Studies have demonstrated that African Americans were more likely than whites to report low trust in health care professionals.   One can only conjecture   how much of an issue this might be with patients from other countries or cultures as well.

The concepts of beneficence, non-malfeasance, autonomy, and justice are often considered the cornerstone of American bioethics.   Beneficence (i.e. to do good, help others, and con- tribute to their well-being) and non-malfeasance (i.e. to not injure, harm, or wrong someone) are not unique to American clinical ethics. It would be hard to argue that there are cultures or societies where the physician routinely disregards the well-being of his patients. Autonomy, on the other   hand, does not have the same critical importance   or role in other cultures or nations that it does in the United States.

Autonomy does not simply involve the concept of self-determination, the right to accept or refuse treatment. It is also involves other is- sues such as disclosure and the degree of disclosure, privacy and confidentiality, and veracity or truthfulness. While  veracity  and  honesty  are  of tremendous importance  in American medicine  today,  veracity  has  traditionally   been   ignored   by   various codes of  medical  ethics.  It was not until 1980 that the American Medical Association’s Principles of Medical Ethics recommended that physicians “deal honestly with patients and colleagues.”

In American society, truthfulness and respect are very intimately connected.  It is difficult to show true respect for a person while directly lying to them. Truthfulness is essential for informed consent. A patient has a right to the truth regarding diagnosis, prognosis, procedures, risks, alternative treatments, etc.  Without this truthfulness, a patient could not make an informed decision and, thus, exercise his or her autonomy.

While    truthfulness,   disclosure, and self-determination are crucial in American medicine, other cultures may look upon things differently, and actually consider these elements harmful.  The Chinese culture places tremendous importance   on family and tradition. There is less emphasis on individual feelings. Family members,  rather  than  the  patient,  may make the health  care decisions,  and might even  withhold   the  truth  for fear of worsening the patient’s condition.

The family plays a central role in other Asian cultures as well. For example, in the Vietnamese culture, the eldest male is usually the family spokesman. In the Unified States, however, this role may be assumed by the person with the best command of English. Discussion with the patient or the family will usually clarify the identity of the family spokesperson. There may be, however, decisions left to the collective decision-making of the family members, rather than just 1 individual, such as removal of life support.  Variability in Vietnamese religious practices may also affect how medical issues are addressed. Most Vietnamese are Buddhist, but others may be Catholic, Evangelical Protestant, or Chinese Confucian.




Just as there may be considerable variability   among   Asian   cultures, there may be considerable diversity among the various Latino cultures. Family involvement is very important,   and   family   decision-making may be more important than individual autonomy. The Latino culture highly values respect. Consequently, older patients often prefer to be addressed formally, rather than by their first name.

Cultural, religious, and ethical issues and values may all converge in the clinical setting. This seems to be especially true in dealing with patients from the Jewish and Islamic faiths. End of life choices and the Jewish law (Halacha) are addressed by Daniel Eisenberg, MD, who writes that “the Jewish person contemplating using a power of attorney may name their Rabbi to be their legal proxy, ensuring that any issues of Jewish law will be dealt with appropriately.”  While the tendency  is to treat  rather than withhold treatment, there is a prohibition  about  “touching  a  moribund patient  (goses) who  is  estimated  to have less than 3 days to live,” according to the code of Jewish Law.  This may therefore pose some difficulty in rendering comfort care to such a patient as he or she approaches death.

Addressing health care issues, especially   end-of-life   decisions,   can be especially problematic in dealing with Islamic patients.  Apart from the fact that there are several different sects of Islam, many Islamic customs are directed by national or cultural norms rather than by religious directives. Simple examples of this are the prohibition of women driving cars or the necessity for a woman to cover her face in public.  These customs may apply to one Islamic country but not necessarily to others.  While discussion with the patient or family is essential, in complex situations involvement of an Imam can prove invaluable. Modesty and touch are often critical issues in dealing with Muslim patients. Some Muslim women will want to remain covered during a physical exam. Other women will want a female physician to examine them. If the physician is a male, then the woman may very likely want her husband present during the exam.

Attitudes about end-of-life decisions are not only necessarily different when comparing American attitudes with Asian or Middle Eastern, but, according to Rubulotta, may be surprisingly different from our Western European counterparts. Surveys have found “major differences in the behavior of clinicians practicing in northern versus southern European countries.” In dealing with trans-cultural issues, you must often strive for compromise and attempt to pursue a mutually agreeable treatment plan. Hopefully with this approach we can shift the discussion from paternalistic “compliance” to one of “adherence.”

The bioethical  concept  of justice as it pertains  to cultural  diversity  is more  difficult  to address  compared to the other  3 principles  of bioethics: beneficence, non-malfeasance, and autonomy. According to Robert Veatch, justice can be looked at in 2 different ways, going all the way back to Aristotle. Justice in the broad sense is synonymous with “the right course of action.”   Justice in the narrow sense refers to fairness in distribution. While it is unlikely that anyone would argue against doing what is right for the patient, the concept of fairness in distribution is more problematic.

The public media and public discourse have focused on immigration, especially “illegal immigration,” and its strain on the health care system and health care resources in this country.  The problem goes well beyond whether or not someone is “illegal.” What about the millions of uninsured or under insured people who also happen to be “legal”? These problems necessitate that our country and government develop a comprehensive, rational, fair, and sustainable health care delivery system.




How do you therefore deal with multicultural health care? While there is no easy solution, there are several steps that at least provide a starting point.

First of all, you need to be sensitive to the issue. If you are not aware of the issue, you cannot address it or deal with it. Expanding your knowledge base is helpful. This can be done by talking and interacting  with people of different cultures. While books and journals are informative, the Internet is proving to be especially valuable in this area. Educational sessions and lectures are helpful, but only if you attend. Through personal experience,  I  have found  it  both amazing  and discouraging  that even when  a  hospital  or health  care system offers a presentation on cultural diversity and health care, attendees consist of people from many different departments and services, but not physicians.

Of tremendous importance is an honest, respectful dialogue or communication with the patient and/or family members to develop a knowledge,   sensitivity,   and   appreciation of their customs, values, hopes, perceptions, and expectations.  This can help establish trust, which in turn can hopefully improve health outcomes as well as patient   satisfaction.   A meaningful discussion with a cleric, elder, or other   respected   member of the patient's community can also prove very helpful.

Cultural   diversity in health care will continue to grow in the United States. Procrastination or denial will not make it disappear. The longer we wait to address the issue, the more difficult it will become.




Florida Home Bound MHA, Inc. [FHB] employees abide by all state, federal, and agency policies, procedures, and regulations which govern their duties and responsibilities.
FHB employees strive to provide only the highest quality care and services, and graciously accept evaluations of their work.
FHB employees strive to upgrade their skills and competencies with a personal and professional growth plan.
FHB employees strive to be honest, forthright, and accountable in all their dealings with physicians, clients, coworkers, and the agency.
FHB and its employees will not discriminate on the basis of race, color, age, religion, sex, national origin, disability, communicable disease, physical or mental handicap, or any other legally protected status.
FHB employees are receptive to guidance and counseling services to help improve their work performance.
FHB employees attend staff development seminars and in-service training programs to keep current in the latest development in their fields of specialization.
FHB employees accept only those assignments which are position-appropriate for them.
FHB employees are confidential concerning both client and agency information entrusted to them.
FHB employees are actively involved in helping to improve standards of care and in helping to control health care costs.
FHB and its employees will not knowingly misrepresent their services.
FHB employees will strive to ensure the safety of those clients entrusted to their care, and will immediately report any incident of patient abuse or suspected abuse, neglect or exploitation according to law.
FHB employees will safeguard the property of the agency used in the performance of their duties.
FHB employees will not engage in any conduct detrimental to the best interest of their patients, coworkers, or the agency.
FHB employees will promote a positive working climate and good public relations.
FHB and its employees are good citizens and supportive of their local communities.
FHB and its employees strive to conform to the highest level of ethical behavior in their educational, admission, discharge, and billing practices.
FHB and its employees interact honestly and ethically with other health care providers, educational institutions, and payers.
FHB and its employees clearly inform any patient referred to another organization, service, or individual of any financial benefit to the referring organization, service, or individual.
FHB, its employees and clients, have ready access to the agency's Ethics Committee.



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