This article is the last in a series focusing on ethical issues in cancer care, prepared by researchers at Northwestern University. The articles highlight selected ethical issues, place the issues in the context of relevant literature, and comment on their significance in oncology practice. These issues are discussed in greater depth in Ethical Issues in Cancer Care (Kluwer, 1999).
ABSTRACT: This article is the last in a series focusing on ethical issues in cancer care, prepared by researchers at Northwestern University. The articles highlight selected ethical issues, place the issues in the context of relevant literature, and comment on their significance in oncology practice. These issues are discussed in greater depth in Ethical Issues in Cancer Care (Kluwer, 1999).
Nearly all health care providers in the United States today care for at least some patients who come from a different cultural background than their own. Accordingly, health care providers have become more aware of cultural issues in the clinical setting. When it comes to the care of cancer patients, cross-cultural issues are especially important.
Cancer patients, who are undergoing extreme emotional distress as a result of their cancer diagnosis, must be able to clearly understand diagnoses and treatment options, and make cooperative decisions about their care. The provider, patient, and patient’s family must maintain constant and open communication for the patient to understand these issues and take an active role in treatment. For patients and providers who are from different cultural backgrounds, this kind of communication can be challenging.
Tod Chambers, PhD, assistant professor of medical ethics and humanities and of medicine, Northwestern University, explores cross-cultural relations between health care providers and patients with cancer in the third chapter of Dr. Peter Angelos’ book Ethical Issues in Cancer Patient Care (Kluwer Academic Publishers, 1999).
In his chapter, Dr. Chambers outlines the effect of cultural issues on medical ethics and the need for health care providers to be attentive and responsive to patients’ cultural backgrounds so as to effectively resolve conflicts that may arise from differences in language, worldview, values, and ethos. Dr. Chambers provides techniques that health care providers can use to prevent and resolve such conflicts and ultimately improve the quality of patient care.
Cross-cultural issues become especially important in light of the disparities in cancer incidence and mortality among ethnic minorities in the United States. Improving the quality of care for ethnic minorities may help to alleviate these gross inequalities. Providers have the potential to drastically improve patient care for ethnic minorities by setting aside commonly held stereotypes, familiarizing themselves with patients’ cultural backgrounds, and becoming sensitive to cultural differences.
One of the first steps to improving patient care and preventing and resolving cross-cultural conflicts is awareness of one’s own cultural identity. As Dr. Chambers points out, health care providers who are members of the majority population often assume that they themselves have no ethnic identity, which can lead them to see their own beliefs as "self-evident and natural."
It is important to recognize the biases of one’s own cultural beliefs and attitudes, and to be aware of the dangers of imposing those beliefs and attitudes on others. Developing the techniques and skills to communicate well with patients from other cultures is ultimately rooted in this self-awareness.
In the clinical setting, providers often see cultural issues as barriers that need to be overcome in order to obtain informed consent from patients for procedures. Rather than perceiving culture differences as a kind of intrusion into the clinical setting, culture can be viewed as a context within which people live and make decisions.
Dr. Chambers warns against the temptation to make assumptions or predictions about behavior based on cultural identity. Knowledge and familiarity with a particular culture, however, can provide understanding about patients’ behavior, prevent misunderstandings and problems, and help the provider and patient arrive at meaningful decisions together.
With some effort on the part of the provider, patient care can be dramatically improved, and, in the long run, precious time can be saved.
Speaking the Patient’s Language
Patients are burdened with tremendous emotional distress when they are diagnosed with cancer. This burden is multiplied for the patient who does not speak the provider’s language or share his or her cultural background.
Such patients may be unable to clearly communicate fears, problems, and symptoms to the health care provider, and may not be able to follow instructions and recommendations. In addition, the provider may not be able to make an accurate assessment of an individual’s physical and mental state.
In one case related by Maria Die Trill in her article, "Cross-Cultural Differences in the Care of Patients with Cancer," psychiatric consultation was requested to address depression and "histrionic" complaints of pain in a Hodgkin’s lymphoma patient. Once the patient was evaluated in his own language, however, he was found to have a central nervous system involvement of herpes.
Even at times when it seems unnecessary, a third-party translator can be employed to avoid common mistakes such as this. Dr. Chambers points to the value of professional as opposed to nonprofessional translators.
Nonprofessional translators (ie, a volunteer or family member) are more prone to mistranslation of biomedical concepts and omission of critical details.
Professional translators are indispensable in understanding symptoms, providing an accurate patient history, communicating instructions about medications, and discussing diagnoses and treatment options. A professional translator who is considered an active part of the medical team may also be able to translate subtle cultural information as well as words.
Nonverbal language can also be a barrier to communication between patients and providers who do not share the same cultural background.
Body language varies widely among cultures. A touch on the shoulder can be comforting and welcome to one person, while to another it may seem like an invasive gesture. Lack of eye contact may sometimes be interpreted as a sign of depression, disinterest, or inattention, although it may be intended as a sign of respect.
Perceptions of comfort with regard to physical distance between persons also varies from culture to culture. To assess the desired physical distance between persons, providers may look for nonverbal cues when meeting with new patients and follow their lead.
Ethos, or "the character of our daily lives," as Dr. Chambers puts it, is another source of cultural differences that health care providers may experience. For instance, issues of individual patient autonomy may differ among patients. Some patients may come from a more group-oriented culture and view the family as an extremely vital aspect of their cancer care.
Providers may inquire of their patients if someone in the household is consulted in decisions about health and whether the patient would prefer to have that person present during medical visits. Involving the family can be a powerful way to alleviate some of the stress and pressure patients feel when making important cancer treatment decisions.
According to certain cultural beliefs, illness can be attributed to both natural and supernatural causes, and these cultures tend to emphasize the spiritual aspect of illness. It may be tempting to discount the significance of patients’ spiritual beliefs. In many cases, however, these beliefs can be a powerful tool for helping patients and their families cope with a cancer diagnosis and potential end-of-life issues.
Respect for different languages, values, worldviews, and ethos can bring the health care provider a greater understanding of individual patients. By examining their own cultural biases and learning about the influences of cultural beliefs on patients, health care professionals can open new lines of communication that will benefit both themselves and their patients.
"Development of communication skills should start from personal conviction and effort," Maria Die Trill wrote in her article about cross-cultural differences. "Our patients are our best teachers, and sometimes what we learn from them is more than the help we can give them. It is our responsibility to take advantage of our professional experience to improve the overall medical support they deserve."
1. Institute of Medicine: Committee on Cancer Research Among Minorities and the Medically Underserved: The Unequal Burden of Cancer. Washington, National Academy Press, 1999.
2. Chambers T: Cross-cultural issues in caring for patients with cancer, in Angelos P (ed): Ethical Issues in Cancer Patient Care. Norwell, Mass, Kluwer Academic Publishers, 1999.
3. Rothschild SK et al: Cross-cultural issues in primary care medicine. Disease-a-Month 44(7):293-319, 1998.
4. Die Trill M et al: Cross-cultural differences in the care of patients with cancer: A Review. General Hospital Psychology 15:21-30, 1993.
5. Torrecillas L et al: Communication of the cancer diagnosis to Mexican patients. Ann NY Acad Sci 809:188-196, 1997.