Ethics and cultural sensitivity

The American College of Graduate Medical Education requires residents to demonstrate mastery of 6 competencies, the constituent parts of which include a vast array of technical, intellectual, and interpersonal skills. Two particularly important skills, ethics and cultural sensitivity, though generally acknowledged to be central to the rendering of appropriate care, are not taught as easily and applied (a Master’s degree in Bioethics typically takes a dedicated 2-year course of study) as others, such as medical knowledge or surgical skills, which were at the heart of medical pedagogy at the time that many of today’s professors were completing their own residencies decades ago. However, the Association of American Medical Colleges has advised that, “A cultural competence curriculum cannot be an add-on to the present medical school curriculum. If issues such as culture, professionalism, and ethics are presented separately from other content areas, they risk becoming de-emphasized as fringe elements or of marginal importance.”

Although medical ethics is a rich and diverse field that can enhance the professionalism of young trainees, its depth, language, and scope of knowledge can make mastery a challenge for an overburdened house officer. Given those realities, it is not surprising that many trainees opt for or are only provided with the “Cliffs Notes” (Houghton Mifflin Harcourt, Boston, MA) version of applied ethics. Reduced to its most basic heuristic, medical ethics becomes 4 principles (autonomy, beneficence, nonmaleficence, and justice), which in a pinch are boiled down to a single overarching theme: autonomy takes precedence. Although this approach clearly is oversimplified and not universally accepted, there are respected ethicists who would agree with its essence (ie, the premise that autonomy usually should be given rank above the other principles of ethics).

Gillon has made just such an argument, positing that, “Ethics needs principles—and respect for autonomy should be ‘first among equals.’” A joint statement on professionalism by the American Board of Internal Medicine, the American College of Physicians-American Society of Internal Medicine, and the European Federation of Internal Medicine echoes that sentiment by listing respect for autonomy, along with the primacy of patient welfare and social justice, as 1 of the 3 pillars of professionalism. However, even if one were to concede the moral correctness of that position (and many ethicists would not), it would not be a reliable guide to appropriate ethical action in all cases. In some circumstances, respect for cultural differences seemingly can challenge the place of autonomy at the pinnacle of ethical care.

Cultural sensitivity requires an understanding of the importance of cultural differences, respect for those differences, and minimization of adverse consequences of those differences. In some instances fulfilling these mandates can require something as simple as getting a translator for a clinic. However, cultural differences extend beyond language and diet and can include a culture’s unique approach to ethics. Thus, while Western medical ethics gives deference to autonomy, other societies may build their ethical life around a different set of core tenets or moral domains. Haidt and Shrewder have contrasted the deification of “autonomy” (“based on moral concepts such as harm, rights, and justice, which is designed to protect individuals in pursuit of the gratification of their wants”) by Western societies with the place of autonomy in other cultures in which, at best, autonomy holds rank with other equally important moral domains, particularly community (“based on moral concepts such as duty, hierarchy, and interdependency, which is designed to help individuals achieve dignity by virtue of their role and position in a society”) and sanctity (“based on moral concepts such as natural order, sacred order, sanctity, sin, and pollution, which is designed to maintain the integrity of the spiritual side of human nature”). In some societies, “self” may not be as revered as “group.” Research has shown that, when westerners are asked to complete the phrase “I am,” they are likely to insert occupations (eg, a doctor) or sentient states (happy), although people in Eastern societies are more likely to state a relationship (eg, I am a son). The primacy of relationships in those societies can seem alien to Americans.

Conflicts between autonomy and cultural sensitivity

The resident who cares for the patient in the story that was mentioned earlier found it difficult to reconcile her sense that Ms X had not freely exercised her autonomy with her (the resident’s) desire to be culturally sensitive. What that resident must appreciate is that moral domains are not prioritized in identical ways across the globe and that respect for autonomy does not conflict necessarily with acceptance of other cultures’ beliefs about the importance of community (eg, autonomy [self-rule] would allow an individual to willingly accept their “role” within a family). Although the resident might believe that Ms X’s case is alarming because it appears to her that a woman (the individual with whom the physician has a fiduciary obligation) was not free to exercise her own autonomy, the resident’s definition of autonomy in this case may need to be more expansive. Even though she may believe that only a choice to deliver immediately and to start chemotherapy could possibly reflect “true autonomy,” she may need to consider that the fullest expression of a patient’s autonomy may be in giving agency to her place in the family. The resident must at least consider the possibility that the woman believes that her obligations within that family (ie, the moral domain of community) are more valued (to her) than is her own well-being. Thus, her decision to delay delivery and therapy may in fact be proffered freely and truly reflect her autonomy. Indeed, “scholars have critiqued traditional notions of autonomy, which presuppose a self-sufficient, independent self, threatened primarily by intrusion from others, highlighting instead the importance of social relationships and dependence.”

However, it is important to draw a clear distinction between determining who makes a decision in a clinical situation and a physician’s obligation to act on that decision. There is no requirement that the resident accept or participate in any treatment plan so long as it is grounded in a patient’s cultural beliefs. In fact, although a physician’s reservations about a woman’s choice cannot override that woman’s right, as in this case, to refuse treatment (“negative” autonomy), it can allow physicians to opt out of the care that is requested by a patient (“positive” autonomy) if the requested care is believed to be unethical or futile.

Unfortunately training in ethics and training in cultural competency often are taught separately, giving no consideration to the potentially critical interaction between the two. As Paashe-Orlow has written, “Virtually absent from the literature on cultural competency is any discussion of the role of ethics.” The failure to integrate these subjects may leave residents trying to treat each with equal deference and to respect any or all requests that may be couched in the language of cultural sensitivity, even if those requests seemingly mean ignoring those ethical principles that, in other contexts and lessons, they are taught should be paramount. Faculty members who teach ethics in class or on rounds must supplement those education sessions with discussions of how cultural diversity can modify the prism through which ethics are considered. Otherwise, residents and all clinicians may wonder in such situations which mandate trumps the other.