Hanisch, 1

A Method to Facilitate Effective Cross-Cultural Interaction in Western Medicine

One of the largest challenges of 21st century medicine involves addressing
cultural variation. The way in which health care professionals facilitate cultural
inclusion and promote compromise between different parties will ultimately
determine whether or not Western medicine rises to meet patients health goals. In
order to account for cultural variation, the Western model of medicine must remain
founded on the core bioethical principles of autonomy, beneficence, and justice.
Adherence to these principles will facilitate the long-term goals of patient-centered
care and moral equality in the health care system.
In this paper I will argue for a three-pronged approach of translation,
legislation, and negotiation for Western medicine in order to address cultural
variation. I will then apply this method of facilitating effective cross-cultural
medicine to the Deaf culture and highlight issues that arise when deaf parents
desire deaf children. Finally, I will evaluate the moral obligations of health care
professionals with respect to their engagement with cultural differences.
In his paper Clinical Cultural Competence and the Threat of Ethical
Relativism, Insoo Hyun argues for the presence of the over-arching principle of
moral equality in Western medicine. According to Hyun, the inclusion of this
principle allows for cross-cultural respect. He does, however, acknowledge the
hardship of translating the blanket term moral equality into clinical practice. In a
multicultural society such as ours, tolerating others differences can be a challenge.
Sometimes we are not sure what to do when faced with the different practices of
another culture, especially when they offend our moral sensibilities and run counter
to our own moral norms. Many of us may attempt to explain away cross-cultural

Hanisch, 2
ethical differences by pointing to peoples unreflective superstitions or false
assumptions. Unfortunately such an approach is not always possible or effective. [1]
Hyun believes health care professionals can bridge the gap between effective
patient care and cultural variation through the respect of ethical customs founded
on the recognition of moral equality. He concludes, For a clinician to ignore the
need to understand patients culturally embedded ethical beliefs related to health
and healthcare would be at least as bad as his or her ignoring the need to elicit and
understand patients explanatory models of health and disease. [1]
Hyuns argument for moral equality leading to cross-cultural competence is a
great starting point upon which to propose more concrete interventions that have
direct applicability to Western medicine. A three-pronged approach of translation,
legislation, and negotiation will lead to increased levels of understanding and
compromise between health care professionals and their culturally diverse patients.
First, physicians and patients must be able to communicate effectively with
one another. This requires the ability of a competent translator to relay information
between the two parties. Translation does not start in the exam room. It starts in the
waiting room*, or even in the ambulance on the way to the hospital. Health care
offices must employ multilingual signs according to the common languages of the
region. Additionally, office staff must be trained to interact with multicultural
patients, using methods such as universal hand signals to communicate basic
information until a translator can be summoned. Patients receiving prompt and
effective language services will experience a positive impression of the health care
system. Translation provides the first vital step towards a patient-centered, morally
equitable approach to Western medicine.

Hanisch, 3
Second, legislation must specify protocols for treatment of all patients in a
morally equitable manner. The three principles of bioethics (autonomy, beneficence,
and justice) must provide the foundation for such legislation, and social situations
such as poverty should also be taken into account. Programs such as Medicare and
Medicaid are valuable in combating monetary difficulties for patients, but do little to
assuage the alienation many culturally diverse patients feel when entering a
hospital or clinic. Instead, programs such as CLAS (culturally and linguistically
appropriate services) attempt to facilitate the needed cultural inclusion in the health
care setting through federal standards.[2] For example, CLAS standard 5, accessed
on the US Dept. of Health and Human Services Office of Minority Health website,
states, health care organizations must provide to patients/consumers in their
preferred language both verbal offers and written notices informing them of their
right to receive language assistance services. [2] The goal behind CLAS is to provide
a regulatory mechanism that homogenizes and heightens the level of moral equality
while promoting strict adherence to the principles of bioethics in the national
sphere. Additionally, we can use the existing program as a model for the expansion
and revision of future government services in the health care setting.
The third area in which Western medicine can address cultural variation
involves negotiation between parties to avoid what Anne Fadiman calls cultural
collision. This method is almost identical to Arthur Kleinmans recommendation to
look at a model of mediation and decide whats critical and be willing to
compromise on everything else.[3] To avoid situations where patients feel
threatened or manipulated by the health care system, health care professionals
must maintain an attitude of openness and tolerance towards cultural differences.
They must understand that their culture (Western medicine) has a system of

Hanisch, 4
principles through which patients of other cultures may feel intimidated. In these
cases, health care professionals must bridge the gap of misunderstanding by falling
back to the principle of patient autonomy to facilitate patient-centered care.
Although the care received may be sub-optimal in terms of the principles in the
culture of Western medicine (a patient who needs chemotherapy refuses it and
elects to have a shaman perform a ritual instead), the competent adult patient
remains free to choose his or her way of life, or death. There are obviously
situations where sub-optimal care according to the patients wishes is
contraindicated, such as parental refusal of a childs treatment or a mentally
incompetent patient. In these situations the treatment decisions must take into
account health care power of attorney, parental autonomy, and Dena Daviss model
of a childs right to an open future. By understanding that Western medicine is a
culture, health care professionals are better equipped to negotiate the potential rift
between a patients culture and proper treatment decisions.
Now that we have a model to address cultural variation, let us attempt to
understand the status of deafness in terms of cultural differences. Deaf people
possess a physical dysfunction in the inner ear that usually leads to an altered form
of interaction with the general population. Therefore, deafness remains one of the
few conditions that Western medicine considers both a physical disability and a
social disability. Most deaf people, however, would argue that deafness is not a
disability, but a neutral condition that does not correlate to a lower quality of life. [4]
Additionally, the deaf culture can be described as inclusive and vibrant, offering
many social and high-level educational opportunities. [4} This inclusion can be
witnessed in documentaries such as Sound and Fury, where deaf families eat
together, help each other, and send their children to the same school and

Hanisch, 5
extracurricular activities. The documentary presents a stark concept: most deaf
families consider themselves in it together and are fiercely proud and protective
of their unique way of life.
The varying definitions of deafness from two different cultures lead to a
potential fallout. Western medicine must rely on the principles of bioethics and in
some cases, a childs right to an open future to forge a morally equitable approach
for providing health care to deaf people. In her book The Spirit Catches You and You
Fall Down, Anne Fadiman quotes social worker Francesca Farr, who depicts Western
medicine in the phrase, our view of reality is only a view, not reality itself. [3] This
insight supports my argument that when dealing with cultural differences, Western
medicine cannot solely focus on the notion of treating the patient to species-typical
functioning. Instead, it must recognize that certain cultural practices may not align
with Western conceptions of health and healing. For example, the health care
professional would obviously want to apprise the patient of his or her treatment
options with the goal of restoring species-typical functioning, but ultimately the
decision must lie with the patient. Some culturally diverse patients may refuse to
undergo treatments due to certain beliefs, and this must be respected. This cultural
mediation recognizes that the goals of Western medicine may not be the goals of
the patient. What happens, however, when a parents reality conflicts with a childs
future reality? In the example of deaf parents desiring deaf children through
methods such as IVF, we must add a caveat to our three-pronged model to address
cultural variation.
Dena Davis addresses the concept of a childs right to an open future in terms
of creating deaf children in her book Genetic Dilemmas. When the shaping takes
the form of a radically narrow range of choices available to the child when she

Hanisch, 6
grows upwhen it impinges substantially and irrevocably on the childs right to an
open futureI maintain that liberalism requires us to intervene to support the
childs future ability to make her own choices about which of the many diverse
visions of life she wishes to embrace.[5] Our model for Western medicine to address
cultural variation is built upon the principle of autonomy. In the case of deaf parents
wanting deaf children, the model indicates that parental autonomy should take
precedence. A deaf child would represent mediation between cultures, as Western
medicine understands the parents desire to raise the child in the Deaf culture, and
helping to create a deaf child through fertilization techniques. This mediation,
however, does not take the childs best interests in to account. In this instance,
cross-cultural medicine must yield to the childs right to an open future and strongly
discourage the couple from engineering a deaf child. Although the Deaf culture
arguably offers an inclusive society in which to live, there are still aspects of societal
interaction offered by the hearing world that deaf people cannot participate in.
Engineering a deaf child effectively closes career, marriage, and other societal
opportunities for the child before he or she can even understand the meaning of
deaf.[5]
Conversely, deaf parents can give birth to a child (naturally or through IVF)
who not only learns ASL and interacts with the Deaf culture, but has the ability to
hear and interact with hearing culture. In this way, the child learns and develops as
a member of both cultures. Also, the childs inner ear is physically normal and all
possible social opportunities associated with the ability to hear remain intact. This
line of reasoning can be extended to the use of cochlear implants for an already
deaf child, with or without deaf parents. If we are to say that protecting a childs
right to an open future is a moral obligation involving the contraindication of

Hanisch, 7
engineering a deaf child, then we must also say that health care professionals have
a moral obligation to ensure that deaf children have access to cochlear implants.
Cochlear implants currently represent the best method of restoring hearing to a
deaf person, and if implanted early enough in a childs life, they can allow the same
ability to interact with both deaf and hearing cultures. [6] For example, the crosscultural interaction facilitated by cochlear implants in Sound and Fury allowed a
young female to take part in many opportunities that promoted self-confidence and
maturation, such as playing on the school basketball team. Additionally, she was
able to seamlessly interact with her parents at home using ASL and with her friends
and teachers at school through the English language. The use of cochlear implants
in deaf children allows a broad range of new opportunities, and ensures that a
childs right to an open future is respected.
Thus, health care professionals have a moral obligation to ensure moral
equality through the recognition of the principle of patient autonomy in cases of
competent, adult patients; yet a childs right to an open future must also be
recognized and acted upon to ensure the ability of the child to maximize his or her
future opportunities concerning societal interaction in a variety of forms including a
career, marriage, and religion. Health care professionals must strongly encourage
the use of cochlear implants in deaf children. In some instances the parents may
not be convinced that cochlear implants will be beneficial for their child, and
physicians must use their best judgment to determine when this is the case and
facilitate a compromise. Cochlear implant technology is not perfect, and until it
improves to the point where hearing is completely restored, this argument will
continue. The obligation to uphold a childs right to an open future trumps parental

Hanisch, 8
autonomy, and must be considered an important caveat to the model of
approaching cultural variation in Western medicine.
An objection to the three-pronged model would question the authority of
physicians to disregard the engineering of deaf children and to promote the use of
cochlear implants in all deaf children. Some might adopt an expressivist stance and
say that the bias against selecting for children with disability discriminates against
people with disability. Others such as Francis Murphy, a leading disability rights
advocate, say If choice of embryos for implantation is to be given to citizens in
general, and if hearing and other people are allowed to choose embryos that will be
like them, sharing the same language, characteristics, and culture, then we
believe deaf people should have the same right. Of the small minority of deaf
couples who want a deaf child and choose to attempt to create via costly
reproductive techniques instead of adopting, few succeed [9]. The financial costs and
small likelihood of success associated with creating a deaf child causes many deaf
couples who wish for a deaf child to opt for adoption

[9]

. However, there still are

couples who wish to engineer a deaf child, and to deny them the right to do so while
allowing and even promoting other embryo trait modification procedures appears to
discriminate.
First, it must be stated that the ultimate choice rests with the physician. If a
physician feels that it is a moral wrong to engineer a deaf child, then he or she
should refuse to perform the procedure and request that the couple find a new
doctor. This should only occur after a thorough discussion about adoption, the
benefits of raising a hearing child, and the risks and costs associated with such a
procedure. The physician should make a strong case to the parents that raising a
hearing child could enhance their own lives through the experiences the child has

Hanisch, 9
with the hearing culture. Compromise is vital. For example, a physician may agree
to help engineer a deaf child providing that the child receives cochlear implants at a
certain age. Although this situation is by no means ideal for the child, the solution
balances the parents desire for a deaf child and the moral obligation to respect the
childs right to an open future. Again, this situation should be avoided until all other
alternatives such as adoption and natural procreation have been thoroughly
discussed, as the solution resides in the gray area between parental autonomy and
the childs future autonomy.
As the societal trend of equality progresses and technology improves, one
must assume that with the right to select for certain traits in a child comes the right
to select against certain traits such as hearing. If this is the case, then physician
discretion becomes the last line of defense for the principle of the childs right to an
open future. To navigate the complex situations regarding engineering a deaf child
or cochlear implantation, physicians must look to the principles of bioethics and ask
Who is this procedure for? Do they wish for it to happen? Who will this procedure
benefit? If the procedure will not benefit the child, or if it is impossible to determine
whether they wish for it to happen, then the procedure is morally wrong and should
be avoided in the same manner that the Supreme Court ruled against the denial of
a blood transfusion for a child of Jehovahs Witness parents. It is far more beneficial
to preserve a childs hearing and allow him or her to interact with both the hearing
culture and the deaf culture through ASL and spoken language than to engineer a
deaf child and restrict momentous life opportunities. Physicians must recognize the
lifelong implications for the deaf child and act accordingly by convincing couples to
adopt or to procreate and let nature decide the childs traits.

Hanisch, 10
A final critique to the three-pronged model would address the heavy
emphasis on patient autonomy and the ambiguous phrase of moral equality.
Some might say that an over-emphasis of autonomy does not lead to an
atmosphere of patient-centered care. Rather, it further alienates the patient from
Western medicine. A patient might ask, I came to be examined and treated, so why
am I not being persuaded into making a treatment decision? It can be argued that
patients view physicians as beings of higher educational authority whom are better
equipped to make a treatment decision instead of offering impartial advice. [7] Also,
in situations of extreme duress patients may be mentally competent, but unrealistic.
For example, a man with a wife and a young child doesnt want to be intubated to
alleviate a dangerous buildup of fluid, even when his life is at stake. If a physician
respected only autonomy in this case, a child would grow up without a father.
Doctors should respect autonomy, but be willing to assume a more paternalistic
attitude when necessary.
Furthermore, autonomy does not necessarily lead to moral equality. This can
be seen through Erik Parenss schmocter problem and other situations where the
physician functions only as an avenue to procure a medication based on the
patients desires for physical enhancement, not necessarily treatment. According to
Parens, the schmocter problem can exacerbate existing inequalities between
various demographics by only allowing patients that can afford treatment to
receive it.[8] This is a far cry from the moral equality that the three-pronged model
for cultural variation dictates. Instead, a patient-centered model seems to promote
the very thing it seeks to inhibit: social injustice and ineffective communication
between Western medicine and various cultures.

Hanisch, 11
If we look at the model to address cultural variation in Western medicine from
a nurture perspective, claims of moral ambiguity and the abuse of patient
autonomy negate themselves. The concepts of translation, legislation, and
negotiation are designed to facilitate interactions between patients and health care
professionals that neither force treatment decisions nor promote complete
neutrality, but guide the patient toward the most beneficial treatment decision
based on the circumstances. Moral equality is realized when a physician uses his
education, experience, and the guiding principles of the existing model to facilitate
the best possible outcome. In this situation, patient autonomy remains a vital part
of the physician-patient interaction and does not promote inequality, as there is an
expectation of mutual respect. The physician recognizes when to adopt a more
paternalistic approach with distressed patients while still upholding autonomy. This
aspect of social medicine is one of the most important ways to facilitate patientcentered care, allowing the respective realities of Western medicine and the
patients culture to synchronize and coexist as the physician pursues the best
avenue of treatment in-line with the patients beliefs and wishes.
In this paper I have outlined a model which allows Western medicine to
address cultural variation. Founded on the principles of patient autonomy and moral
equality, the three-pronged approach of translation, legislation, and negotiation
ensures a patient-centered experience in which the culture of Western medicine and
the patients culture do not collide, but coexist. Additionally, the model must take
into account a childs right to an open future and in instances where a childs future
opportunities are threatened, the childs future autonomy supersedes parental
autonomy and a compromise must be sought. This caveat has implications in Deaf
culture, where children should be given the opportunity to traverse both the deaf

Hanisch, 12
and hearing worlds. Finally, it is a health care professionals moral obligation to
facilitate cultural inclusion in practice while upholding the principles of bioethics
with respect to moral equality and a childs right to an open future. This allows the
concept of patient-centered care to remain a core value in the nations health care
system.
*

As I write this in this in the waiting room of a clinic while a family member finishes a
procedure, the office staff is attempting to communicate with a group of Vietnamese
women that their translator will be thirty minutes late. It is good to see the
application of the principle of translation, even if it does not always run on time.

Works Cited
[1] Hyun, Insoo. "Clinical Cultural Competence and the Threat of Ethical Relativism."
Cambridge Quarterly of Healthcare Ethics 17.02 (2008): 160-61. Print.
[2] OMH Content. US Department of Health and Human Services Office of Minority
Health, 12 Apr. 2007. Web. 15 Nov. 2012.
<http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2>.
[3] Fadiman, Anne. The Spirit Catches You and You Fall Down. N.p.: United States:
Farrar Straus and Giroux, 2002. 261-276. Print.

Hanisch, 13
[4] Sparrow, Robert. "Defending Deaf Culture: The Case of Cochlear Implants*."
Journal of Political Philosophy 13.2 (2005): 135-52. Print.
[5] Davis, Dena S. Genetic Dilemmas: Reproductive Technology, Parental Choices,
and Children's Futures. New York: Routledge, 2001. 82. Print.
[6] "Cochlear Implants." Cochlear Implants. N.p., 21 July 2001. Web. 15 Nov. 2012.
<http://www.nidcd.nih.gov/health/hearing/pages/coch.aspx>.
[7] Gawande, Atul. "Whose Body Is It, Anyway?" Complications: A Surgeon's Notes
on an Imperfect Science. New York: Metropolitan, 2002. 220-21. Print.
[8] Parens, Erik. "Is Better Always Good? The Enhancement Project - The Hastings
Center." The Hastings Center. N.p., 1 Apr. 2010. Web. 15 Nov. 2012.
<http://www.thehastingscenter.org/Publications/SpecialReports/Detail.aspx?
id=1362>.
[9] Turley, Jonathan. JONATHAN TURLEY. N.p., n.d. Web. 15 Dec. 2012.
<http://jonathanturley.org/2007/12/24/engineering-deaf-babies-for-deafcouples-us-and-britain-debate-the-selection-of-deaf-embryos-and-adoptedchildren/>.