Modules

Cross-cultural communication

Part 1

Introduction

This case is about the Exantus family and the physicians who looked after them. Betsy, Dani and their three children came to Canada from Haiti 12 years ago. Betsy and Dani have a busy restaurant in Toronto. Maxon is in the navy and away most of the time; Elsi is married with two children; and Mado is a secretary, sometimes helps in the restaurant, and lives with Betsy and Dani. Betsy speaks some English but Dani speaks only Creole. They are very proud of their success in Canada. Betsy has been complaining about pain in her back for the past four months. She initially attributed this to lifting heavy barrels of cooking oil and other food supplies, but the pain has not gone away. She has been noticeably uncomfortable lately. On the day our story begins, Betsy was getting supplies off a shelf, suddenly cried out and fell to the floor where Dani found her, unable to get up. One of the customers called 911 and Betsy was taken to the emergency room. Here are the physicians who became involved with Betsy during her illness:

  • Dr. Bolden, an emergency room physician
  • Dr. Tyson, a family medicine resident doing an internal medicine rotation
  • Dr. Riel, an oncologist
  • Dr. Harrell, a senior resident in internal medicine
  • Dr. Tyson: Hi, I’m Kim Tyson, and I am a family physician on staff.

    I recently had an experience that was very difficult when I was doing a rotation in internal medicine.

    I had a family that came in through emergency because the mother had fallen and she was suffering from severe back pain. Well, we discovered that she had advanced lung cancer that was affecting her spine. I had a lot of trouble communicating with her because, well, the whole family is Haitian, both she and her husband didn’t speak English very well. So, I had to communicate with her through her children because we didn’t have a professional Creole translator available.

    The family had some expectations about her care that I had learned about, but I had never encountered before.

  • Betsy(moans and calls out in Creole; she is obviously in a lot of pain) I’m in pain… Help me… It hurts…

    Dr. Bolden: Do you speak English?

    Betsy: No… it hurts… it hurts… (continues to speak in Creole)

    Dr. Bolden: Is there anybody here with you that speaks English? (Transition to Betsy and family with Dr. Tyson)

    Dr. Tyson: Hi I’m Dr. Tyson.

    Mado: Well, it’s about time…

    Dr. Tyson: You’re her son?

    Mado: Yes.

    Dr. Tyson: Do you speak English?

    Mado: Of course.

    Dr. Tyson: Your father?

    Mado: No, my dad speaks Creole.

    Dr. Tyson: Okay, so you speak English… did you see what happened? Mado: No, I wasn’t there, my father was there… she just fell down at the restaurant and she’s in a lot of pain… I don’t understand…

    Dr. Tyson: Well, it’s indicating that she has a problem with her spine. She can’t move her legs very well. The x-ray shows that there’s an abnormality on her spine…

    Mado: An abnormality?

    Dr. Tyson: Yes, an abnormality on her spine and so we hope to have her in for a few of days, run some more tests, and, uh, I’d like…

    Mado: A few days? More tests? What are you talking about?

    Dr. Tyson: Well, she’s definitely in a lot of pain.

    Mado: I can see that, obviously. (interrupting Dr. Tyson)

    Dr. Tyson: And we need to make sure that there’s, you know, no serious damage…

    Mado: Can you just give her some pain medication? It can’t be that serious…

    Dr. Tyson: We are going to give her something for the pain, but you have to understand… she can’t walk… so, if you can just explain to her that we’re going to run some more tests, and we’ll be admitting her to Dr. Mayer’s service up on the eighth floor…

    Mado: Look, I don’t think it’s gonna go well, okay? But I’ll try to explain to her. (Speaks in Creole to his mother) (Betsy moans, Mado speaks in Creole to her)

    Mado: The doctor wants you to stay here. She wants to run some tests to see what is going on.

    Betsy: It hurts… I want my family… help me…

    Dani: Don’t worry…

    Mado: You have to stay here.

    Betsy: No… I want to go home.

    Mado: She doesn’t want to stay. Can’t you just give her some pain medication? I will take her home. Look, we wasted so many hours here already.

    Dr. Tyson: We’re definitely going to give her something for the pain. We want to make her comfortable of course, but we need to make sure that we run all the tests that are necessary to find out…

    Mado: Look, it’s not good enough. She wants to go home to take care of her business so do something.

The immigrant and the health care system

Commentary on part 1

First impressions are important. Based on the part of the encounter between the Exantus family and the physicians in the emergency room you saw, how do you think the interaction influences the impression the physicians and the patient and her family have of each other? What constitutes patient-centered behaviour in an emergency room? Is it possible? Review your own experience.

Reflective exercise 2

The “Reflective exercises” focus on the ethical, communication and cultural objectives. There are no absolutely right or wrong answers but some options are better than others. Read the options and any questions arising from them and watch the videos (videos are available for only three of the four options). Use the questions associated with each option to guide your decision-making. After completing the exercise, you can read the commentary on each choice and consult resources.

If you were the physician in this situation and were asked “not to tell,” how would you respond? What would you do?

Option 1

You tell Elsi that it is impossible to keep information from patients in a hospital setting.

  • Do you think this is a:
    • valid,
    • reasonable and
    • realistic argument?
  • Did hospitals in which you have worked have any policies about such issues?
  • If you were a hospital administrator, what would be your position?
  • Dr. Tyson: I’m sure you think that’s best for your mother, but believe me, patients know. They know when something’s wrong, they figure it out by what they hear from the nurses and the techs, and then they draw their own conclusions. Then, they start playing these games with the staff and the family and then everyone avoids either talking to the family or to the patient. And then the patient gets isolated… well it’s just not good for anyone.

    Elsi: Playing games? What kind of hospital is this? Doesn’t your staff know what’s appropriate to say to patients and their families? What do they do, spend their days gossiping in the hallways? I thought that only happened on TV. Look, I’m sure if you explain the situation to your staff, they’ll understand.

    Dr. Tyson: No, I’m afraid it’s not quite that simple. With everything that’s going on here all the time, we simply can’t control what a patient sees and hears.

    Elsi: Unbelievable!

Option 2

You tell Elsi that experience shows that most patients want to know the truth, no matter how bad it may be.

  • Do you agree with this assertion?
  • Is there a difference between lying and not telling the whole truth?
  • What ethical principle(s) is Dr. Tyson invoking in this instance?
  • Dr. Tyson: I’m sure you think that’s best for your mother, but most people want to know about their condition. Have you thought about how she might feel if we lie to her?

    Elsi: No, no. I’m not asking you to lie, just don’t mention anything, just don’t mention anything about cancer, or dying. She just won’t cope.

    Dr. Tyson: Well actually, most people find it better. That way they don’t have to play this game with their family of not knowing. They find it comforting that they can actually talk about it. And, she will have to… you know, take care of her affairs. She has a business, so she will have to make some decisions with that, won’t she?

    Elsi: You sound as if she’s going to die tomorrow.

    Dr. Tyson: No, not tomorrow, but… And she’ll have to have some treatments, what if she asks about those?

    Elsi: The treatments aren’t a problem. That’s not an issue, she’ll do those. Her English isn’t that great so you can always go through us. We’ll facilitate that. Look, she just can’t find out about having cancer, she won’t be able to manage.

    Dr. Tyson: She just has to hear that one word: cancer, and understand it, and she’ll know. And we’ll have to get consent forms signed… What if she asks what those are for? I mean, I can’t lie to her. That would be deceptive to the patient.

    Elsi: Look…

    Dr. Tyson: I wouldn’t do that, she wouldn’t trust me.

    Elsi: You’re not getting it. She can’t find out. It’s not the way we do things. She can’t find out.

    Dr. Tyson: Well, what if she asks me what’s going on? What am I supposed to say?

    Elsi: Figure it out.

Option 3

You ask for the reasons behind the request and then temporize with a suggestion for further communication later.

  • How well do you think Elsi and Dr. Tyson understand each other’s position?
  • In choosing this option, can you think of any possible negative repercussions?
  • In a situation of possible conflict within a family, where does the physician’s duty lie?
  • Dr. Tyson: I’m sure you think that’s best for your mother, but could you help me understand why? Because when families ask us to do this sometimes, it doesn’t work out very well.

    Elsi: Well, she’ll be really upset if she finds out, and she’ll turn her face to the wall, and she’ll give up.

    Dr. Tyson: Well, actually, more often that’s how we think that they are going to feel, but that’s not necessarily how the patient feels. So why don’t you tell me a little bit more about your mother, and help me understand why you think she’ll react that way.

    Elsi: Well, we’re Haitian. She’s from Haiti, and the way we do things in our culture is that the patient never finds out about their condition. We don’t want to disturb them with those kinds of details so the family takes care of everything. And, you know what? I think it’ll be better for both of our parents that way. Dad just wouldn’t know how to handle things if mom knew.

    Dr. Tyson: Well, there’s obviously a lot of people who disagree with whether a patient should be told their diagnosis and what’s going to happen so… I don’t want to make this harder for your family. So, I won’t say anything specific to her now, okay? Unless she asks, okay? I mean, I’m going to be truthful with her if she asks. Now, I know this has been a shock for you, and I don’t want to make this harder for you or your family so why don’t we just take some time and think. Tell me, how is your father coping.

    Mado: Well, dad is very upset, but he won’t tell mom, and you know what Elsi? Maybe mom wants us to do it this way. She should know. We should tell her. She’s not stupid, she’s going to know.

    Elsi: I know she’s not stupid. Your way would be better for us, but for mom and dad, I don’t think so. They just won’t know how to handle this.

    Dr. Tyson: I see.

Option 4

You decide that Elsi’s request is unrealistic and that you must talk to Betsy about her condition and ask her how much she wants to know. You decide to call in a professional interpreter. Should you seek the family’s permission first? Would doing so without seeking permission be deceptive? What might be the repercussions of such an action?

Commentaries

  • Dr. Tyson: Well, as you can see, I didn’t know how to respond to Elsi’s request that I don’t tell Betsy about her condition. And Elsi seemed to be speaking on behalf of the whole family. Now, I didn’t want to make a judgment on their cultural traditions, but my understanding of optimum patient care was in conflict with their wishes. We are taught to respect other cultures, so the best course of action here was to try and understand what their request was, even if it went against what I thought was best. There really wasn’t a correct response.

Commentary on option 1

Many problems and errors in the complex field of health care are not caused by any one individual’s actions but by a “systems error”: an important lab report gets lost in a pile of paper; the nurses in the hallway are not talking about Betsy but they are right outside her door so she thinks they are.

In this response to Elsi’s request, the physician may very well be right. It is difficult to keep information, or misinformation, from hospitalized patients. Dr. Tyson may not be able to control every interaction between her patient and numerous health care workers but she can control what she does and says. Does invoking a “systems problem” — blaming others — absolve the physician from responding to Elsi’s request? How should she respond to Elsi’s complaint about gossip?

Most hospitals have policies or codes of conduct about confidentiality and similar issues. Dr. Tyson is a resident, which means she may spend a variable period of time in any one institution. She should be aware of the policies of any institution in which she works, but practically, she may not be.

Which, if any, of the four possible responses to Elsi’s concern would you use, assuming that Dr. Tyson agrees to Elsi’s request not to tell Betsy about her cancer?

  1. “The people who work here are all professionals. They won’t say anything inappropriate to any patient.”
  2. “I will speak to the ward manager and ask her to tell everybody not to speak to your mother about her condition.”
  3. “This hospital has a confidentiality policy. I will get a brochure on it for you to read.”
  4. “I will give you the contact information of the hospital’s patient advocate whom you can call to discuss your concerns.”

Commentary on option 2

In this option, Dr. Tyson gives the standard “truth-telling” response she learned in ethics classes. There is considerable literature supporting this position. There are many studies showing that patients want to know about their condition and that “not telling” results in isolation, poorer response to treatment and poorer quality of life. Sometimes families get it wrong and think that their family member would not want to know, when in fact they do. Sometimes the patient goes along with the deception in order to spare his or her loved ones the distress of talking about an impending death.

However, most of those studies were conducted in western patient populations, usually American. Studies involving patients from non-western cultures sometimes tell a different story. This depends, however, upon the patient’s acculturation to the local culture (see option 3).

Some ethicists feel that there is no difference between lying and not revealing the whole truth because the intent is the same, that is, to deceive the patient. Both instances have the same result: the patient cannot be a fully informed decision-maker. Others feel that lying is a worse decision in that, if found out, trust in the physician would be destroyed, whereas with failure to provide relevant information, the resulting decisions made by the patient would be their responsibility. It may also have something to do with the fact that for most of us, we have been taught from childhood that lying is wrong. We should at least realize that failure to reveal, even if done with beneficent intention, is not necessarily benign.

Commentary on option 3

Here, Dr. Tyson is trying to obtain information about Betsy’s beliefs and values. How should she interpret the information Elsi gives her? Are we getting information about Betsy or about Elsi and how she thinks about things? By including Mado and Dani in the discussion, Dr. Tyson is certainly trying to find common ground between her medical beliefs and those of the family. But which set of values and beliefs should take precedence? Should she follow the medical view that in almost all cases, it is best for patients to be told of their conditions or should respect for others’ cultural values prevail? Should she accept Mado’s or Elsi’s assessment of the intergenerational differences in approach to truth-telling? If Dr. Tyson tells Betsy about her diagnosis in spite of the family’s objection, is she behaving with respect for patient autonomy or paternalistically in deciding herself what is best? For instance, if she agrees not to tell Betsy, is she denying her the opportunity to decide what to do with her life? Perhaps she might not accept treatment, believing that her condition is not so serious. If she is told, what might be the consequences of angering her family? What additional questions should Dr. Tyson ask that might be helpful in determining Betsy’s wishes?

None of these questions are easy to answer but thinking them through is necessary before taking action. Broadening the discussion to include other physicians or an ethicist might be helpful.

Commentary on option 4

Many would say that this is the best course of action. We have no evidence that Betsy has ever discussed how she would like information to be handled if she became sick, and it would appear that Elsi is making assumptions based on what she thinks she would want. Dr. Tyson’s responsibility is to the patient first, even if this might anger the family. A number of studies have shown that physicians are poor judges of patients’ desire for and need for information and that the best thing to do is to ask directly. However, as in this case, there may not be an available interpreter and, as we saw, using a family member might not provide the information required. Also, one must keep in mind that even if asked directly, a patient might defer to family out of concern for them, feeling the family could not cope with discussing such issues with their loved one. Finding out what a patient really wants to do in these situations requires tactful exploration of their values and relationships, and cannot be accomplished with a few brief questions.

For more information on working with interpreters, see the “Working with interpreters” section of this module and “Cross-cultural interviewing.”

Final comments on reflective exercise 2

Elsi has made her request while she herself is under stress, having just heard of her mother’s diagnosis. This may not be the best time to make such a request nor to agree to it. If there is time (e.g., no imminent danger of death), everyone should think through the issues and possible consequences. This should be viewed as an ongoing process and not a final decision. The family, the physician and the patient may all change their minds during the course of the illness. It is important that they all understand that and do not feel bound by a previous decision.

At what Bennett level is the physician in each option? What would have to occur for the physician to attain a higher level?

Other types of truth-telling

While breaking bad news about a diagnosis is perhaps the most often cited form of truth-telling dilemma, there are others. The informed consent process is closely related, as we saw in “Consent and confidentiality.” The distinction often is that a treatment or procedure may not be offered. Some physicians feel that they do not need to give patients potentially troubling information if nothing can be done, but in fact, evidence shows that patients want to have information regardless. Not to do so would deny the respect due to persons as autonomous beings.

Exceptions to truth-telling

There are few exceptions:

  • Clearly, in the case of the unconscious or incompetent patient, the substitute decision-maker would be told the truth.
  • If the patient really indicates a desire not to be told. The physician should be cautious about becoming the decision-maker in these instances. Some form of dialogue should occur with the patient or other family member (see the articles on decision-making).

Therapeutic privilege

Truth-telling is a process and the timing and degree of disclosure can be adjusted to circumstances, as in option 3. If the physician truly has good reason to believe that the patient might come to harm from being told something, then a temporary waiver of revealing the truth might be appropriate. Such instances are rare and legally the courts take a dim view of therapeutic privilege.

Cross-cultural interviewing: What do we need to know?

  • Dr. Riel: Hello.

    Dr. Tyson: Hi, Dr. Riel?

    Dr. Riel: Yes, speaking.

    Dr. Tyson: Hi, it’s Dr. Tyson. I just wanted to talk to you about the Exantus family.

    Dr. Riel: Oh, yes.

    Dr. Tyson: Well, you’ll be meeting the mother Betsy soon to talk to her about her lung cancer.

    Dr. Riel: Oh, yes.

    Dr. Tyson: … well, her family doesn’t want her to know about her condition, and I don’t really see how we can keep it from her and properly inform her about what her treatment options are.

    Dr. Riel: So, the family doesn’t want her to know that she has cancer?

    Dr. Tyson: No.

    Dr. Riel: Well, it will be difficult but we’ve had cases like this before. You know, in many cultures the family believes that it’s better for the patient if they’re unaware of their condition. It does make it a bit awkward for us sometimes, but you do understand that you are under no obligation to lie to her?

    Dr. Tyson: Yes, I told them that and I think they understand, but how do we make sure that Betsy understands enough that she can make an informed decision? She doesn’t speak English very well and we don’t have a hospital interpreter available who speaks Creole.

    Dr. Riel: Well, usually when we don’t have a hospital interpreter the best solution is to ask the family to do so, to translate for us. Do you know if any of them speak English well enough?

    Dr. Tyson: Yes, her children, but how do I know that they will tell her what she needs to know when they don’t even want her to know what her condition is?

    Dr. Riel: Well, do you have any reason to believe that they won’t cooperate, or won’t act in her best interest?

    Dr. Tyson: Well…

    Dr. Riel: Do they seem dysfunctional as a family?

    Dr. Tyson: Her husband is always by her side, and the children do seem genuinely concerned for her health, so…

    Dr. Riel: Then I would say that if they understand the treatment options and what we need to do to treat her, then you ask them to translate for you.

    Dr. Tyson: Okay, great. Well that’s what I’ve been doing… Thanks for your help. I really wasn’t sure what the best way was to handle this, so I appreciate it.

    Dr. Riel: No problem. Bye-bye now.

    Dr. Tyson: Bye.

  • Dr. Tyson: Could you please tell her that I have come to talk about treatments, and that I’ve asked you to interpret.

    Elsi: Sure. (Elsi and Betsy converse in Creole)

    Elsi: The doctor wants to talk to you about treatments and I will translate.

    Betsy: I want to go home.

    Elsi: She said she wants to go home.

    Dr. Tyson: Oh, of course, but we do have to get the urine and the back problem sorted out, so could you tell her that? And ask her if she would like to get the information directly, or to you, or what. (Elsi and Betsy converse in Creole)

    Elsi: The doctor is going to tell us what you have to do to get better. You just need to rest for now.

    Betsy: My back hurts. What is the problem? I want to go back to work.

    Elsi: The doctor is going to give you some medication and you will be able to go back to work.

    Mado: Elsi, you can’t say that…

    Elsi: Shhh, shut up, Mado… (turns to Dr. Tyson) She said to go through us, whatever you need.

    Dr. Tyson: Okay… I will call a surgeon and an oncologist to meet with you all, but I would think it’s especially important that your mother be at the meeting as well, okay?

    Elsi: Sure. (Afterwards, in the hallway)

    Dani: Mado! Elsi!… what is going on? I’m confused.

    Elsi: Nothing, papa. It’s nothing. Go back to mom.

    Dani: I want to know what is happening…

    Elsi: Papa, I assure you. It’s nothing. Please, go see momma. (Dani returns to the room)

    Mado: Elsi, we’ve got to tell her. I mean, who’s going to take care of the restaurant?

    Elsi: You’re going to take care of the restaurant.

    Mado: Me? You are crazy?

    Elsi: What’s your excuse?

    Mado: Elsi, I cannot handle that on my own! We’re talking about a business Elsi…

  • Dr. Tyson: Well, that didn’t go as well as I’d hoped, and I’m not really sure that Betsy really understood the treatments I was suggesting… and then Mado, well, he got upset with something that Elsi said, and there seemed to be this family fight happening… I think I should have tried harder to get an interpreter after all. I guess this has been an important learning experience for me. I need to learn more about how to work with an interpreter and how to communicate with families in conflict.

    See “Cross-cultural interviewing.”

Reflective exercise 3

Reflective exercise 4

  • This exercise is not directly related to this module but can be used to reflect upon the issues of working in a cross-cultural medical environment, specifically when working with interpreters.

    Read the following scenarios, answer the questions and submit the answers in order to read the commentaries.

  • 1. A recent immigrant brings his wife to the clinic saying that she does not speak English and he will interpret for her. He says she is pregnant but healthy. She is dressed in traditional clothing and stares at the floor. The physician notes that the husband answers the questions put to her and does not address his wife. When asked about this behaviour, he states that they have discussed it all before coming.
  • 2. A Senegalese woman brings her 12 year old daughter to the community clinic. She speaks little English, but brings with her a note from the community worker who speaks her language. It says that the woman needs to have her daughter circumcised. It explains that this is very important in their culture and that the whole family would be ostracized and would suffer significantly if the procedure was not performed. It further requests that if no one at the clinic can perform such an operation, that the mother and daughter be referred to someone who can do it. The physician asks the child, who has been going to school in English, if she knows about this. The girl looks frightened and states her mother says she must have it.
  • 3. An Egyptian taxi driver is brought to the emergency room, having been stabbed by a drug-seeking passenger. In spite of efforts to save him, he dies. Shortly after, a police officer brings the taxi driver’s wife and three children to the hospital. The woman speaks little English. The oldest child is nine and is fluent.
  • 4. A Spanish-speaking patient is sent for psychiatric assessment. His wife says he has been hearing voices and accusing her of trying to poison him. She fears for her safety. A secretary from the records department is asked to translate and, during the interview, indicates that the patient is rational and denies any symptoms of psychosis.

Comments on Reflective exercise 4

“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 interpreters

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.


 

Next: Part 2

Continue