Introduction
Patients seeking healthcare in the U.S. now come from a variety of cultures, countries, ethnicities, races, and religions. Patients from these diverse backgrounds can have different values and traditions than those of the provider, and sometimes these differences can result in conflicting health care expectations.
To what extent should these differences be taken into account in order to provide optimal healthcare? Controversy exists over how far patient expectations should be accommodated by providers if in the provider’s opinion the quality of healthcare is compromised.
Such topics in “multi-cultural,” “trans-cultural,” or “cross-cultural” medicine have received increasing attention in recent years. The word “culture” is used because culture consists of the shared beliefs, values, and traditions of a group of people.
A popular view is that culture is the common beliefs and traditions of a society, a community of people. It seems the grouping could also be based on a common ethnicity or race. An “ethnicity” is a group of people with a common geographic origin, language, or set of traditions. “Race” often refers to biological commonality but may include other factors such as beliefs and practices. All such grouping factors may need to be considered.
How Culture Influences Health Care
What is relevant to healthcare is that the shared beliefs, values, and traditions of a group of people may include or produce expectations and assumptions about such matters as health, disease, and appropriate relationships and behavior. Culture may shape a patient’s understanding of the meaning and importance of health, how to interact with healthcare professionals, how to cope with illness, how decisions are made, how rigorously to follow the provider’s treatment plan, the meaning and appropriate attitude toward death, and the role of the family. Failure of healthcare professionals to account for these group-based factors may result in misunderstandings, patients being offended and insulted, and poor healthcare outcomes.
Diverse cultures may have very different beliefs and traditions, so for the American healthcare professional it’s not as simple as just learning how “non-Western” cultures think. Because there are so many cultures, information about patients from a particular culture should be as specific as possible about that culture. Some healthcare institutions have developed fact sheets on particular cultures, ethnic groups, and nationalities.
Here are some examples of differing traditions that may affect healthcare. Patients:
- May not speak or understand English well.
- May be suspicious of Western medicine and avoid seeking healthcare when ill or pregnant.
- May have a different kind of diet.
- May think they should try to heal naturally before seeking treatment, or let God heal them, or seek alternative cures, or seek religious healers. Illness may be thought of as punishment by divine forces. Any prescribed medicine may interact with natural medicines already prescribed by an alternative medicine practitioner. In any event, the patient may self-adjust the dosage of the prescribed medicine.
- May not be rigid about schedules, whether for appointments of medications. The concept of a rigid timetable may not be familiar.
- May be shy about removing clothes or being touched. Either sex may feel uncomfortable in front of the opposite sex. Women may desire female providers.
- May be reluctant to have surgery because of a desire to keep the body whole. Organ donation might be avoided for this reason.
- May avoid eye contact with the provider and others. The patient may be quiet, avoid asking questions, and nod rather than talk. This may be out of politeness or an unquestioning attitude to authority.
- May prefer direct eye contact because it implies sincerity.
- May be suspicious of signing paper forms.
- May think that when the provider explains risks, he or she is wishing them on the patient.
- May not take women healthcare professionals seriously.
- May not take anyone other than the doctor seriously because the physician is the authority figure.
- May go home to very different sanitary conditions than the provider assumes.
- May be guided by religion in making decisions.
- May be guided more by family than self in making decisions. The family may expect to be told everything, even before the patient knows. The family may desire to make the decision for the patient or keep the patient in the dark.
Suggestions to Accommodate Cultural Differences
Hospitals and large medical practices may be able to call upon extensive resources to help providers care for patients from other cultures. Translation services may be available for non-English languages common in the surrounding community. (Using a patient’s relatives as translators should be done only with caution because they may interpret or filter information instead of just translating.) Fact sheets may be developed to help providers understand specific cultures and their traditions. Informed consent forms may be made available in a variety of languages. Community health workers may be available (local clergy from the patient’s community also may be able to help). In recent years attempts have been made by healthcare institutions and medical and nursing schools to develop courses or workshops to train in how to be “culturally competent” or at least culturally sensitive.
It’s worth noting that a patient’s specific religious or other views may not match the “official” or mainstream version of the religion or culture. The provider may have to go beyond the information available and discuss specific beliefs and interpretations with the individual patient and family.
Ethicists generally recommend that healthcare providers accept and work with the beliefs and traditions of patients from other cultures out of respect for patient autonomy. The idea is that the patient has a right to his or her beliefs. The patient comes to the medical office seeking healthcare services rather than guidance, judgment, and condemnation of their cultural heritage.
The provider-patient relationship is ideally a fiduciary one – based on a trust the patient has in the provider. It is easier for a patient to trust the provider if the patient does not feel the provider is ignoring, challenging, or rejecting the patient’s cultural traditions.
Limits on Accommodating Culture
Tense confrontations may arise when the parents and provider have radically different understandings of the nature of disease. The provider subscribes to the scientific assumptions and theories of Western medicine, with a germ theory of disease in which microorganisms are the cause of disease and the illness of the patient. The patient may believe the disease has other causes in the spiritual or social realm.
The use of cultural resources in the patient’s community or the use of hospital or government social workers may help clear up communication problems, but in the end it may come down to a clash of worldviews. If the patient is rejecting the best that Western medicine has to offer, one may wonder why the patient was seeking healthcare from a Western provider in the first place, but of course perhaps he or she was not familiar with typical Western treatments.
Cultural traditions can give rise to the following difficult situations:
- The patient rejects the course of treatment recommended by the provider.
- The patient (or the patient’s family) demands a specific intervention from the provider that is medically inappropriate or futile.
- The patient is a child and the patient’s family rejects needed treatment.
Patient rejects course of treatment: If the provider recommends a course of treatment or other medical intervention and the patient from another culture refuses, that is the patient’s moral right and the provider ultimately should respect their autonomy. Most thinkers recommend the provider first seek to find out the specific reason for the patient’s refusal and perhaps alleviate any miscommunication or clear up any misunderstanding or misplaced fear or anxiety. Sometimes a simple change, for example in the way a medication is administered, will solve the problem. But the provider needs informed consent to proceed, and the patient has a right of refusal.
Patient demands inappropriate intervention: The patient’s right of refusal does not mean the patient has a legitimate right to demand a specific treatment or intervention from the provider. The provider is under no obligation to provide care he or she thinks will harm the patient or be of no benefit; it just doesn’t matter that the patient wishes the treatment for cultural reasons. However, the provider could be sensitive to the reasons for the patient’s or patient family’s wish.
Parents reject treatment for a child: If a parent objects to treatment for a minor child, and the treatment is needed to prevent or cure a life-threatening condition, ethicists commonly argue that the provider needs to consider his or her obligation to the patient as primary. From the provider’s perspective it is morally wrong to let a child die when the child could have easily been saved with an available intervention. The principles of non-maleficence (do no harm) and beneficence (provide benefit for the patient) would ordinarily be considered here to override any obligation to respect the wishes of the parent. Physicians have gone to the courts to allow treatment in such situations.
For situations not life-threatening, the situation is less clear. This is more likely to be seen as a conflict between competing moral principles – obligations toward the child patient conflicting with the need to respect the rights of the parents – with no obvious winner. Legally, though, for such matters as elective surgery or vaccinations, the provider will probably not be able to obtain authorization from the court to proceed if the parent does not consent, even if the physician thinks such intervention is in the best interests of the child.
