Cultural Issues in Ethical Decision Making

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Cultural Issues in Ethical Decision Making

• James Hallenbeck, MD
• Assistant Professor of Medicine
• Stanford University
• Director, Palliative Care Services, VA Palo Alto
  HCS

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Ethics
Culture
CONFLICT
Decision making
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What is Culture?
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CultureMore than EthnicityMore than Beliefs
and Practices

• Family role
• Gender
• Sexual orientation
• Age/generation
• Role in healthcare
• Illness role
• Cancer
• HIV
• Dementia etc.

• Ethnicity
• Religion
• National Origin
• Nationality
• Urban/Rural
• Socioeconomic status
• Education
• Occupation
• Community role

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Culture as a Verb

• Means of communication
• Language
• Contextual
• Non-verbal
• Spatial/temporal
• Human relations
• Trust mistrust
• Power Powerless

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Culture Dynamic Processes

• History/evolution
• Example Changes in how become ill, age and die
  force cultures to change and adapt
• Tensions within cultural groups

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Example Japanese and Truth-telling

• Stereotype Japanese do not tell patients they
  are dying. Family makes decisions
• Tension Japanese often will say, We Japanese
  do not tell people that they are dying However,
  a majority will also say they personally would
  like to know if they are dying

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The Cultural Representative

• Useful in exposing others to perspectives of
  representative group
• Problems
• Representative may or may not be content expert
• Risk of stereotyping, despite admonitions to
  contrary
• Emphasis on cultural others not ones own
  cultures
• Educational focus on attitudes, not more
  generally applicable skills

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Culture of BiomedicineTensions

• Individualism
• Autonomy
• Disease in the individual
• Consumerism
• Egalitarianism
• Health care as a right

• Mechanistic/technologic
• Reductionist
• Paternalistic
• Bureaucratic
• Capitalism
• Health care as commodity

Lacking in modern biomedicine Focus on suffering
as object of medicine Inclusion of concept of
life-force in model Understanding illness as
something transcending the individual
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Culture of Western Bioethics
Emphasis on

• Abstract principles
• Individualism
• Rights based
• Self-determination
• Egalitarianism ethics committees
• Rules- policies, regulations, laws esp. United
  States part of corporate culture

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Major Principles of Medical Ethics
Autonomy
Interdependence
Beneficence
Nonmaleficence
Justice
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Medical Ethics and Advance Directives
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Problem How does one act autonomously, if unable
to make decisions?

• Answer others will represent wishes using
  substituted judgment in a process of surrogate
  decision making

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Advance Directives the Problem

• Few Americans filled out advance directives
• Doctors didnt seem to pay much attention to them
• Bad things were happening to people at the
  end-of-life

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The Solution Patient Self-Determination Act of
1990

• Requires health care facilities to raise the
  issue of advance directives with patients on
  admission
• Big questions
• How effective were or are advance directives in
  improving healthcare outcomes?

So, how are we doing...
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SUPPORT STUDY

• 4804 Seriously ill patients
• 569 had Advance Directives (12)
• 36 contained special instructions
• 22 of these had recommendations to forgo
  treatment as applied to the patients actual
  situation
• In only of these 9 cases was care consistent with
  specific instructions

Teno, J Am Geriatr Soc, 1997
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Why?
Death Denial
Culture
Educational deficiencies
Stubborn, cold-hearted doctors
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Advance Directives not bad, but

• Argument for use and implementation not
  anthropologically based
• May not be as important as advocates thought as a
  vehicle to improved healthcare outcomes
• System issues now appear more important

Lynn, J., et al., Rethinking fundamental
assumptions SUPPORT's implications for future
reform. Study to Understand Prognoses and
Preferences and Risks of Treatment. J Am Geriatr
Soc, 2000. 48(5 Suppl) p. S214-21.
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Pseudo-ethicsConflicting ethics not always the
underlying cause of disagreements

• Misunderstandings and miscommunication
• History Lack of trust
• Knowledge deficits
• Lack of competencies /skills
• Lack of options or knowledge of options

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Example Truth-telling
Don't tell gramma!
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A Narrowly Defined Ethical Dilemma

• Importance of autonomy
• The patient has a right to know
• Pending decision (chemotherapy, DNR, hospice
  referral) requires informed consent

Ethics Consult!
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Dealing with Issues of Truth Telling

• Statement of respect
• Why has this request been made?
• Where does the patient stand?
• Statement of own values
• Prepare/permission to negotiate
• Set ground rules
• Talk with patient

To defer ones autonomy can be an act of autonomy
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Explanatory Model Questions

• What
• Do you call the problem?
• Do you think the sickness does?
• Do you think the natural course of the illness
  is?
• Is it you hope for/fear?
• Why
• Do you believe this problem occurred?

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What, Why, How, Whocontinued...

• How
• Do you think the illness should be treated?
• Who
• Should one turn to for help?
• Should be involved in care and decision making?

Kleinman, A., Culture, illness and cure clinical
lessons from anthropologic and cross-cultural
research. Annals of Internal Medicine, 1978. 88
p. 251-258.
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Summary

• Ethics are important, but cannot exist in a
  vacuum
• Approaching all disputes as representing ethical
  dilemmas reflects a Western cultural bias
• Culture permeates everything we do
• Most difficult is appreciating our own cultural
  biases
• Skill training, especially in cross-cultural
  communication can go a long ways in resolving
  disputes peacefully