“A” is of course the best answer in all of these situations. Practically, however, there is rarely a professional interpreter available at the time and for the language required. The question then is: What is the next best option? Sometimes the “culturally sensitive” and the “ethically correct” are in conflict.
Professional, or cultural, interpreters are more than translators. They have been trained not only to convey as precisely as possible what is said by interviewer and patient, but also to interpret non-verbal behaviour and to be a “culture broker” between them. They are aware of cultural taboos and usual practices, adjusting their language with the patient when necessary. They can inform the interviewer of a patient’s values and belief systems. They are also trained in medical terminology and the principles of ethical health care, including confidentiality. For these reasons, working with such an interpreter is preferable and is certainly culturally sensitive. It also seems ethically correct in that it affords the best chance to obtain accurate information from the patient and to accurately convey the diagnoses, treatment options and other information. If professional interpreters are not available, can a health care institution be said to be providing adequate care? The answer is not clear cut. Hospitals and other health care systems must balance finite resources against the needs of the population served.
Volunteer (non-professional) interpreters (scenarios 2, 3, and 4)
Most health care institutions keep a list of all bilingual or multilingual employees. They may or may not have had training in being an interpreter. Their educational level and linguistic abilities are quite variable. If the ethnic community is small, they may know the patient. They may be thrust into very emotional situations, as in scenario 3.
Is it ethical to ask a young inexperienced kitchen worker to translate? Unfortunately, this question is rarely asked. In such cases, the translator may be emotionally traumatized and the patient and family may receive incorrect or poorly conveyed information.
In scenario 2 there is a community worker who is presumably a member of the patient’s ethnic group. Could this be a problem? While this person certainly seems to know the cultural values of the patient, could this lead to bias? Is there a limit to cultural sensitivity if the wishes of the patient conflict with best (western) medical practice?
When dealing with a sensitive case that can possibly have legal repercussions, it is best to seek guidance from the medical regulatory authority in your jurisdiction. They will confirm how certain matters, such as requests for female circumcision, are handled within the jurisdiction. For example, if you are practising in Ontario, the policies of the College of Physicians and Surgeons of Ontario state that any physician performing a female circumcision or referring a patient to such a practitioner is subject to a charge of professional misconduct. It further states that any child in this situation must be referred to the Children’s Aid Society.
If you asked the community worker to translate, how would you know if your statements were being correctly conveyed? Finally, if a patient and translator are from the same small community, the patient may not wish to reveal embarrassing or sensitive information.
In scenario 4 we observe the problems that can arise if a non-professional attempts to interpret in a psychiatric interview. Psychiatric interviewing is perhaps the most culture-laden and language-dependent of all areas of communication. Use of language is critical in eliciting information, for instance, the translation of “depression” into some languages may not result in obtaining information about that diagnosis as the language might not have a word that means what it does in English. If psychotic symptoms are intermittent, a simple direct question like “Are you hearing voices” might miss the mark and the interpreter might say that the patient does not hear voices.
Family as interpreters
This is the most frequent interpreter issue we face as health-care workers. This issue often occurs in highly charged situations such as sudden death, end-of-life or delivering bad news. A family can be drawn together, or torn apart, depending upon how the issue is handled. Three common situations are portrayed in these scenarios and in the case involving Elsi and Mado.
In scenario 1 the patient evidently has deferred to her husband to provide information and to make decisions on her behalf. This is customary in some cultures. However, some ethicists raise the question that, given the choice, would the woman want this? Here again there is a potential conflict for the physician between being sensitive to the patient’s culture, and not only respecting the individual (in a western sense) but also respecting basic human rights.
Read Waiver of Informed Consent, Cultural Sensitivity, and the Problem of Unjust Families and Traditions, by Insoo Hyun.
In scenarios 2 and 3, a child is placed in the position of having to translate emotionally charged information. In both scenarios, this may traumatize the child. As well, the child may be unable intellectually to convey the information correctly. In other situations, children provide valued services as family interpreters, of which they are justly proud. It all depends upon the context.