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Commentary.

Doing the right thing in clinical medicine, always a challenge, is even more complicated when providers and patients are from different cultures. Our ability to consider this case in an informed and thoughtful manner may be hindered by our lack of knowledge of Mien culture generally and Ying Saeto's local world particularly. Mutual unfamiliarity, of course, is paradigmatic of cross-cultural encounters. Nonetheless, we can raise several points to consider when addressing moral conflicts in cross-cultural settings.

One is that the meaning we assign to various ideas and concepts is culturally based. For example, in the Hippocratic tradition physicians are admonished to benefit patients, or at least do no harm. This seemingly straightforward maxim is rendered ambiguous in the cross-cultural setting precisely because abstract concepts like benefit and harm take on meaning only in the context of culture, and in the give and take of peoples' everyday lives, relationships, and experiences. What a Mien person considers beneficial or harmful may differ profoundly from Western biomedical notions of benefit and harm.

Not only may people from different cultures attach different meanings to similar concepts and principles, but additionally unfamiliar--even unimaginable--concepts and principles may be a central feature of the moral landscape. For example, an important concept in traditional Navajo culture is hozho, which is approximated in meaning by combining the Western notions of beauty, harmony, order, good, and happiness. There is no equivalent concept in Anglo-American culture. Conversely, in traditional Navajo culture there is nothing comparable to the Western concept of risk, an idea that fundamentally shapes and permeates Western medicine. The broader point here is that Western biomedicine too is a cultural system, reflecting a particular set of concepts and principles and a unique way of construing the world. Confronting that which appears strange and different invites refection on that which is familiar; both exist and can only be appreciated in context.

The fact that the patient in this case is a child complicates matters further. Some providers may be comfortable with the idea of respecting cultural differences when the patient is a competent adult, but with children they may be unwilling to tolerate decisions that result in what they perceive to be compromised care or harm, even when these decisions make sense in the context of a particular culture. There is certainly precedent for this distinction in American law, most notably in cases involving Jehovah's Witnesses and Christian Scientists. Yet one might ponder in what sense we truly respect another culture if we interfere with its transfer to the next generation.

Mapping unfamiliar moral landscapes and interpreting foreign moral vocabularies may benefit from an ethnographic approach. Ethnography positions itself at the interface of different traditions and different systems of meaning, and may be useful for: (1) identifying the culturally relevant values, principles, and concepts of a particular group; (2) discerning the meaning(s) the cultural group assigns to those principles and concepts; (3) gaining insight into the culturally appropriate way of doing things; and (4) beginning to understand the social, political, and historical forces that constitute the larger context in which individual cross-cultural relationships are embedded. This information is crucial to determining what the ethical course of action is when providers and patients do not share a common cultural background.

An ethnographic approach to ethics in the cross-cultural setting need not result in a strict ethical relativism. One can be respectful of cultural differences and recognize that there are atrocities and violations of fundamental human rights which agents from diverse perspectives would judge as morally unacceptable. Here the perceived degree of harm is critical: if great enough it may outweigh our duty to respect cultural differences.

In deciding "how far to go with cultural sensitivity," ethical limits should be set only after a careful, thoughtful, and imaginative effort to understand and interpret, in context, that which appears strange and problematic. This decision should be accompanied by a sincere and critical reflection on one's own position and its historical add cultural underpinnings. Attention should also be given to who is at the table and which perspectives are represented when decisions are made about the fundamental rights and principles to be respected.

Finally, Western physicians caring for non-Western patients should acknowledge that in the cross-cultural setting they are representatives of a dominant culture and thus may have the power to impose and enforce their views in ways their patients do not. Health care providers must therefore be sensitive to inequities of power and manage them responsibly.

In the case presented, the physician's first response to Ms. Saeto should not be to educate her, thereby disabusing her of her "folk beliefs." Rather, the physician's effort should be directed primarily to understanding Ms. Saeto in the context of her world, and to explaining the physician's perspective to her. Interpretation in both directions is required.

A cross-cultural ethical conflict, like ethical dilemmas in other settings, may not have a single, ethically correct resolution, but many possible resolutions, each with ethical costs and advantages. However, which resolutions are ultimately considered will depend on which voices are included in the moral dialogue--and in the cross-cultural setting more than one voice must be heard.
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Title Annotation:on Culture, Healing, and Professional Obligations, p. 15, in this issue
Author:Carrese, Joseph
Publication:The Hastings Center Report
Date:Jul 1, 1993
Words:856
Previous Article:Culture, healing, and professional obligations.
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