Olomouc 2012 Dept. of General Practice, Medical University of Vienna CROSS CULTURAL MEDICAL ETHICS Manfred Maier, MD Chairman, Department of General Practice

Olomouc 2012 Dept. of General Practice, Medical University of Vienna

CROSS CULTURAL MEDICAL ETHICS

Manfred Maier, MD

Chairman, Department of General Practice

& Family Medicine Head,

Center for Public HealthMedical University of Vienna


STANDARDS FOR ACCREDITATION OF MEDICAL EDUCATION PROGRAMS

LCME, September 2003

ED-21. The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.


OVERVIEW

• ethics introduction• cultural influences on health and behavior - diet - gender - pain - medication - psychiatry - epidemiology of diseases• communication• other examples• ethically sound decisions


OBJECTIVES

participants should be able to

• deduce the influence of cultural context on health and illness

• estimate the consequences of the cultural background for the prevalence of illness / disease

• explain various ways to communicate efficiently in a cross cultural medical encounter


INTRODUCTION TO MEDICAL ETHICS

Terminology• (professional) ethos

- moral conviction of a person, group, society, epoch- contained in principles of values and attitudes- develops historically upon reflection- forms the standardized basis of interaction between individuals or groups

• (medical) ethics- philosophical science of ethos/morality- critically reflects on human behavior/actions/ professional

charters as to good or bad- rationalizes behavior/actions of individuals/institutions- aims at how to act



Terminology• values/attitudes (in health care)

- general (gratitude, loyalty, advocacy, decency, respect, compassion, empathy, integrity, competence)

- personal (material possessions, high income,

avoidance of blood transfusions,...)

- professional (primacy of patients welfare, respect of

patients autonomy, promotion of social justice,

commitment to competence, honesty, confidentiality,

professional responsibility, …)



Historic development

• Hammurabi’s code of laws (c. 1780 b. c.) • Hippocratic oath (400 b. c.)• Prayer of Moses Maimonides (12th century)• Medical Ethics (Thomas Percival, 1803)• physicians charter (ACP-ASIM-ABIM, 2000)



What is medical ethics?• a systematic effort, to account for goals of and

methods used in medical actions (by medical professionals)

• It is based on

- factual medical knowledge

- moral medical practice/action• Ethical considerations are an intrinsic

constituent of any medical action


MEDICAL ETHICS

• access• beneficience - non maleficience• equality – justice / disparity (resource

allocation )• autonomy – informed consent• truthfulness (interpreter)


JUSTICE - EQUALITY

The principle of justice requires that all people be treated equally.


EQUALITY

Characteristics of Primary Care Physicians According to Visits by White and Black Medicare Beneficiaries

Characteristic of Physicians Visits by White Patients

Visits by Black Patients

P Value

Race - % (no. of pairs)WhiteBlackAsianOther

85.3 (35,824) 0.7 (370) 11.2 (3939) 2.7 (1067)

59.7 (1947)22.4 (650)15.7 (483) 2.3 (98)

<0.001

Location of practice - % (no. of pairs)UrbanRural

73.0 (34,256) 27.0 (7289)

72.9 (2744)27.1 (467)

0.99

Provide some charity care each mo - % (no. of pairs)

YesNo

78.8 (31,317) 21.2 (10,228)

83.4 (2452)16.6 (759)

0.06

Board certification - % (no. of pairs)Board certifiedNot board certified

86.1 (36,570) 13.9 (4822) )

77.4 (2644)22.6 (559)

0.02

Source: N ENGL J MED 2004;351(6): 575


ACCESS


ACCESS

Primary Care Physicians’ Perceptions of the Quality of Care Provided in Relation to the Race of Patient

Index of Quality of Care Visits by White Patients

Visits by Black Patients

P Value

Access to high-quality specialists - % (no. of pairs)

AlwaysNot always

82.1 (33,271)17.9 (8189)

76.0 (2437)24.0 (774)

0.04

Access to high-quality diagnostic imaging - % (no. of pairs)

AlwaysNot always

83.4 (34,443)16.6 (7082)

75.6 (2449)24.4 (762)

0.003

Access to non emergency hospital admission - % (no. of pairs)

AlwaysNot always

63.0 (23,414)37.0 (13,946)

51.5 (1613)48.5 (1261)

<0.001

Able to deliver high-quality care to all patients - % (no. of pairs)

AgreeDisagree

80.7 (32,588)19.3 (7960)

72.2 (2398)27.8 (688)

0.02

Source: N ENGL J MED 2004;351(6): 575


AUTONOMY

Autonomy of the patient means respect

for his / her self – determination.


AUTONOMY

the cultural background of a patient may influence

• his / her way of living• His / her understanding of health / illness• His / her authority over his / her own life

(informed consent)


DEFINITION OF CULTURE

The sum total of a set of shared beliefs, values and practices.

Collins English Dictionary


• classification of food / non food (frogs – cats – dogs)• sacred food – profane food (forbidden)

– Hinduism (cows, animals)– Islam (pork / pig; fish with fins, ritually slaughtered-

halal)– Judaism (pork / pig; fish with fins, kosher)– Sikhism (beef ; pig, jhatka)

• parallel food classifications– hot – cold (symbolic value)– medicines as food

• social food (ritual aspects, social status, group identity)• infant feeding practices (breast feeding)

CULTURE AND DIET


DIETARY CULTURE AND HEALTH / DISEASE

• malnutrition• rickets• anaemia (Asians)• overnutrition• cancer


• components of gender (genetic, somatic, psychological, social)

• gender cultures / sexual behavior• medicalization (stress, menstruation, old age)• health (male- female)• reproduction and birth culture• fertility / infertility

CULTURE AND GENDER


CULTURE AND PAIN

• response to pain (private - public pain)

• pain perception and pain tolerance• Communication / presentation of

pain• response to pain behavior


• pain behavior– beliefs about meaning and significance– context in which it occurs– emotions associated with it

• social aspects– reaction to pain behavior– pain – “bad behavior” – guilt – attitudes shaped by society

CULTURE AND PAIN (2)


response to medication may vary

• total drug effect (attributes, recipient, prescriber, setting)

• placebo effect (culture bound)• abuse and dependence (alcohol, smoking,

psychotropic drugs)• sacramental drugs (rituals, social interactions)

CULTURE AND MEDICATION


• “aspects of prescribed and repetitive formal behavior, which have no direct technological consequence and which are symbolic”

• types of ritual– calendrical rituals– rituals of social transitions– rituals of misfortune

RITUALS


• normality – abnormality

• mental disorders (biological, social labeling or combined approach)

• somatization (vague, particular organ)

• culture bound psychological disorders (amok, hsieping, susto,..)

• family role in the cause and cure of mental disease

• prevalence in migrants

CULTURE AND PSYCHIATRY


CULTURAL FACTORS IN EPIDEMIOLOGY

• economic situation• family structure• gender role• marriage pattern• sexual behavior• pregnancy/birth practices• child rearing practices• body image alterations• diet• dress

• personal hygiene • housing arrangements• sanitation arrangements• occupation• religion• funerary customs• culturogenic stress• leisure pursuits• domestic animals• self / lay treatment


COMMUNICATION

there are differences between

• what you think you are going to say and what you actually say

• what you said and what the patient understands• what the same word means in your or another

individual’s context / culture / language• doctor’s and patient’s perspective


CROSS – CULTURAL - ENCOUNTER

• in your native language• in a foreign language which you speak /

understand• in a foreign language which you don´t speak /

understand


INFLUENCES

• interaction with patient• understanding, accuracy, completeness• trust• compliance• health care outcome


INTERVIEWING APPROACHES

• Arthur Kleinman’s tool to elicit health beliefs• L-E-A-R-N module• strategies for clinical cultural assessment and

interaction


KLEINMAN‘s TOOL

• What do you call your problem? What name does it have?• What do you think caused your problem?• Why do you think it started when it did?• What does your sickness do to you? How does it work?• How severe is it? Will it have a short or long course?• What do you fear most about your disorder?• What are the chief problems that your sickness has caused

for you?• What kind of treatment do you think you should receive?• What are the most important results you hope to receive from

the treatment?

Source: Arthur Kleinman: Patients and Healers in the Context of Culture. The Regents of the University of California. 1981.


L-E-A-R-N MODEL OF CROSS CULTURAL ENCOUNTER,

GUIDELINES FOR HEALTH PRACTITIONERS

• Listen with sympathy and understanding to the patient’s perception of the problem

• Explain your perceptions of the problem• Acknowledge and discuss the differences and

similarities• Recommend treatment• Negotiate agreement

Source: Berlin EA. & Fowkes WC,Jr.: A teaching framework for cross-cultural health care -- Application in family practice, In

Cross-cultural Medicine. West J. Med. 1983; 139 (12): 93-98.


INTERPRETERS

• ad – hoc interpreter– family, neighbors, friends, practice staff,…

• professional interpreter• legal situation ?


INTERPRETERS

• their role( interviewer- translator- interpreter)• code of ethics• tips and guidelines for interviews involving

interpreters


CODE OF ETHICS

• confidentiality• accuracy• completeness• conveying cultural frameworks• non – judgmental attitude about the content to be

interpreted• client self- determination• attitude towards client (trust, respect, discretion,

equality, dignity,…)• acceptance of assignment• compensation; professionalism


TIPS FOR INTERVIEWS INVOLVING ad hoc INTERPRETERS (1)

• Be more directive; insist on literal interpretation.• Use clear, specific, unambiguous language.• Ask that the interpreter identify remarks as either his or

her own or the patient’s.• Consider questions or comments to patient or interpreter

that explore their relationship; for example, “Your son is worried about you. He thinks that you have heart trouble. What do you think?”


TIPS FOR INTERVIEWS INVOLVING ad hoc INTERPRETERS (2)

• Some questions are best asked twice, once to patient and once to interpreter; for example, “Are there any remedies that your family uses for this trouble?”

• Use humor and empathy to avoid being intimidating.• Remind both parties that a hospital interpreter may be

scheduled in advance if required for follow-up.


RELEVANT EXAMPLES

• in medicine and health care- prevention, diagnostics, therapy,...- genetic counseling- reproductive medicine, abortion- (stem cell) research- medicalisation- transplantation- euthanasia- allocation of resources


DIFFERING VALUES IN HEALTH CARE

• physician – colleagues / institutions– specialist – generalist (GP / PM)– hospital care – ambulatory care– private health care – public health care– theoretical knowledge – practical knowledge– experience / opinion – evidence based medicine– cultural / ethnic competence – incompetence– biomedicine – complementary medicine –

integrative medicine– research orientation – teaching orientation


RELEVANT EXAMPLES

• in general practice

- certificates

- advice

- prescriptions

- unconventional methods

- truth telling

- autonomy

- secrecy - confidentiality

- equity - justice

- request of patients


METHODS TO REACH ETHICALLY SOUND DECISIONS

• deontological ethics (Kant)

- „a moral persons must always do her duties regardless of the consequences“

- „everybody should act like this“• teleological ethics (consequentialism, utilitarianism)

- are the consequences more beneficial or more

disadvantageous ?

- associated with social pleasure


METHODS TO REACH ETHICALLY SOUND DECISIONS

• the four principles (Beauchamp, Childress)

- beneficence, non-maleficence, respect of autonomy, justice

• the structural integrity (Europe)

- an action is good, if all elements are good

- elements are: goal and methods, aim,

circumstances and consequences

- practical intelligence/conscience are central


METHODS TO REACH A DECISION

• ethical questions

- whom am I dealing with?

- who will be affected?

- what are the goals?

- who has an interest in the goal?

- what are the risks in reaching the goals?

- how can the risks be judged?


USEFUL LINKS

• www.diversityrx.org• www.xculture.org

Documents

Olomouc 2012 Dept. of General Practice, Medical University of Vienna CROSS CULTURAL MEDICAL ETHICS Manfred Maier, MD Chairman, Department of General Practice