CROSS CULTURAL MEDICAL ETHICS

1. CROSS CULTURAL MEDICAL ETHICS Manfred Maier, MD Chairman, Department of General Practice & Family Medicine Head, Center for Public HealthMedical University of Vienna Dept. of General Practice, Medical University of Vienna

2. 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. Dept. of General Practice, Medical University of Vienna

3. OVERVIEW • ethics introduction • cultural influences on health and behavior • - diet • - gender • - pain • - medication • - psychiatry • - epidemiology of diseases • communication • other examples • ethically sound decisions Dept. of General Practice, Medical University of Vienna

4. 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 Dept. of General Practice, Medical University of Vienna

5. 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 Dept. of General Practice, Medical University of Vienna

6. INTRODUCTION TO MEDICAL ETHICS • 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, …) Dept. of General Practice, Medical University of Vienna

7. INTRODUCTION TO MEDICAL ETHICS • 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) Dept. of General Practice, Medical University of Vienna

8. INTRODUCTION TO MEDICAL ETHICS • 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 Dept. of General Practice, Medical University of Vienna

9. MEDICAL ETHICS • access • beneficience - non maleficience • equality – justice / disparity (resource allocation ) • autonomy – informed consent • truthfulness (interpreter) Dept. of General Practice, Medical University of Vienna

10. JUSTICE - EQUALITY • The principle of justice requires that all people be treated equally. Dept. of General Practice, Medical University of Vienna

11. EQUALITY Dept. of General Practice, Medical University of Vienna

12. ACCESS Dept. of General Practice, Medical University of Vienna

13. ACCESS Dept. of General Practice, Medical University of Vienna

14. AUTONOMY • Autonomy of the patient means respect • for his / her self – determination. Dept. of General Practice, Medical University of Vienna

15. 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) Dept. of General Practice, Medical University of Vienna

16. DEFINITION OF CULTURE • The sum total of a set of shared beliefs, values and practices. • Collins English Dictionary Dept. of General Practice, Medical University of Vienna

17. CULTURE AND DIET • 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) Dept. of General Practice, Medical University of Vienna

18. DIETARY CULTURE AND HEALTH / DISEASE • malnutrition • rickets • anaemia (Asians) • overnutrition • cancer Dept. of General Practice, Medical University of Vienna

19. CULTURE AND GENDER • 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 Dept. of General Practice, Medical University of Vienna

20. CULTURE AND PAIN • response to pain (private - public pain) • pain perception and pain tolerance • Communication / presentation of pain • response to pain behavior Dept. of General Practice, Medical University of Vienna

21. CULTURE AND PAIN (2) • 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 Dept. of General Practice, Medical University of Vienna

22. CULTURE AND MEDICATION • 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) Dept. of General Practice, Medical University of Vienna

23. RITUALS • “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 Dept. of General Practice, Medical University of Vienna

24. CULTURE AND PSYCHIATRY • 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 Dept. of General Practice, Medical University of Vienna

25. 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 CULTURAL FACTORS IN EPIDEMIOLOGY Dept. of General Practice, Medical University of Vienna

26. 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 Dept. of General Practice, Medical University of Vienna

27. 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 Dept. of General Practice, Medical University of Vienna

28. INFLUENCES • interaction with patient • understanding, accuracy, completeness • trust • compliance • health care outcome Dept. of General Practice, Medical University of Vienna

29. INTERVIEWING APPROACHES • Arthur Kleinman’s tool to elicit health beliefs • L-E-A-R-N module • strategies for clinical cultural assessment and interaction Dept. of General Practice, Medical University of Vienna

30. 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. Dept. of General Practice, Medical University of Vienna

31. L-E-A-R-N MODELOF 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. Dept. of General Practice, Medical University of Vienna

32. INTERPRETERS • ad – hoc interpreter • family, neighbors, friends, practice staff,… • professional interpreter • legal situation ? Dept. of General Practice, Medical University of Vienna

33. INTERPRETERS • their role( interviewer- translator- interpreter) • code of ethics • tips and guidelines for interviews involving interpreters Dept. of General Practice, Medical University of Vienna

34. 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 Dept. of General Practice, Medical University of Vienna

35. 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?” Dept. of General Practice, Medical University of Vienna

36. 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. Dept. of General Practice, Medical University of Vienna

37. RELEVANT EXAMPLES • in medicine and health care • - prevention, diagnostics, therapy,... • - genetic counseling • - reproductive medicine, abortion • - (stem cell) research • - medicalisation • - transplantation • - euthanasia • - allocation of resources Dept. of General Practice, Medical University of Vienna

38. 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 Dept. of General Practice, Medical University of Vienna

39. RELEVANT EXAMPLES • in general practice • - certificates • - advice • - prescriptions • - unconventional methods • - truth telling • - autonomy • - secrecy - confidentiality • - equity - justice • - request of patients Dept. of General Practice, Medical University of Vienna

40. 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 Dept. of General Practice, Medical University of Vienna

41. 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 Dept. of General Practice, Medical University of Vienna

42. 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? Dept. of General Practice, Medical University of Vienna

43. USEFUL LINKS • www.diversityrx.org • www.xculture.org Dept. of General Practice, Medical University of Vienna