Cross-Cultural Geriatric Ethics: Negotiating our Differences

By Harry R. Moody

In the United States there is a long and tragic history of discrimination in healthcare based on skin color. On the one hand, this history should make us sensitive to the voices of minority ethnic groups (Jones, 1981). On the other hand, that very same history should make us skeptical about the idea of wholly different and incommensurable ethical concepts for people of different race or ancestry. To cite only one example of this point, authoritarian regimes in Asia, ranging from Singapore to Myanmar and China, have sometimes appealed to “Asian values” in their argument that universal principles of human rights provide no legitimate basis for criticizing their societies. Here, as has happened before, ethical relativism easily becomes a slippery slope leading toward acceptance of injustice. If we abandon standards of universal human rights, then what basis do we have, say in the case of Mrs. Chu, for insisting that a patient be truly and fully informed about the truth of a diagnosis? Do we have any basis for criticizing Mrs. Chu’s adult children if they maintain a conspiracy of lies? What if they try to implicate healthcare providers in the conspiracy?
The conventional “liberal” approach to dealing with patients of different cultural background is to insist on the primacy of “equal opportunity”: that is, recognition of ethnic diversity among elders (Gelfand, 1994), emphasis on accessibility and appropriateness of service delivery (Damron-Rodriguez, Wallace, and Kington, 1994), or the importance of translation (Haffner, 1992). But the “soft” liberal approach just described does not tell us what to do when confronting a situation like the case of Mrs. Chu. The dominant liberal view favors openness and truth-telling, but does it also require intrusion into family communication patterns if the family, and perhaps even the elderly Mrs. Chu, resist the Western style of cultural openness?
Perhaps a “hard” liberal version (i.e., a commitment to absolute universal human rights) would insist that liberal values prevail whatever the cost. But opponents of this kind of liberalism could point out that other values are at play here, not least of them filial piety and family solidarity. Filial piety in East Asian families is not simply a casual or customary practice but has deep historical roots in Confucianism (Okada, 1988). As a result of this rich and powerful tradition, understanding the elderly Asian patient requires appreciation of the Confucian background that has influenced cultural development in China, Korea, and Japan.
The case becomes even more complicated when we consider that not only ethics but systems of medical explanation may be involved in the case of Mrs. Chu. The family, after all, prefers to rely on traditional Chinese herbal remedies, and, here too, as in the Confucian tradition, we confront a major alternative tradition quite different from modern Western medicine.
What we see in both East and West is the rise of what is increasingly called “complementary” rather than “alternative” medicine. The semantic shift suggests not incommensurable systems but complementary approaches that can be used, pragmatically, in different ways as a specific case demands. Perhaps this pragmatic, complementary approach can also be applied to the resolution of ethical dilemmas when we face opposing imperatives, as in the case of Mrs. Chu. Western healthcare practitioners have become accustomed to seeing methods like acupuncture or herbal medicine as appealing to young adults or middle-aged baby boomers. But the elderly, especially immigrants from Asia, are likely to have grown up familiar with so-called alternative medicine. Among immigrants, the age profile of those who find alternative medical approaches appealing may be exactly the reverse of what we would see in the Anglo population.

DIGNITY, ETHICS, AND AGING

A major goal of healthcare ethics is to treat patients with respect and dignity, and this ideal is reflected in policies favoring patient autonomy and privacy. Thus, hospitals try to provide privacy for patients by limiting visiting hours or prohibiting visitors from sleeping overnight. In contemporary bioethics we tend to believe that autonomy is best served when individuals make decisions for themselves without undue influence from others, even on the part of their own families. But curtailing visiting hours or separating a patient from family decision-making can actually be a profound assault on patient dignity. Many non-Anglo families would much prefer more “family friendly” sleeping accommodations. Privacy and autonomy, however admirable as ideals, may clash with what families, especially elders, deem to be ethically appropriate treatment.
Over the past generation, a revolution in healthcare ethics in the United States has occurred. Because of its influence, we tend to take for granted the idea that telling patients the truth about terminal illness is always the right thing to do. Yet most cultures around the world make the exactly opposite assumption. Talking openly about death could be a profoundly disrupting, even disrespectful thing to do. In the case of Mrs. Chu, her adult children make just such a claim.
The ideal of dignity and respect for age is a powerful, if often neglected, dimension in the field of aging, as a recent volume (Disch, Dobrof, and Moody, 1998) reminds us. Yet, a concern about dignity can itself become a major problem inhibiting doctor-patient communication and therefore damaging care of elderly patients. Galanti (1991) cites the case of a 64-year-old Chinese woman in the hospital after an acute heart attack. The physician at discharge urged her to return after two weeks for follow-up, and the patient agreed but never did so. What probably happened is that the patient did not want to offend the doctor by refusing to his face and causing dishonor. By agreeing, then not following through, she spared everyone embarrassment, though perhaps put her life at risk.
Some blunders in cross-cultural communication are so absurd as to be laughable. For instance, in traditional Chinese culture it is common to think of numbers as “lucky” or “unlucky.” Failing to understand the meaning of numbers can cause big problems. In New York, an ethics advocacy group developed a new outreach program on advance directives for Chinese elders and publicized it with a call-in telephone number. Time went on but no one ever called the number. Finally, someone informed that outreach group that the telephone number used in Chinese signified “sudden death.”
Another point where courtesy and dignity become an issue is when saying “no” really means saying “yes” and vice-versa. Here cultural norms governing politeness may cause serious misunderstanding. For example, it is not unusual for Middle Eastern or Asian patients to say “yes” in order to avoid the embarrassment of contradicting a health professional and thereby showing disrespect. When cultural norms in favor of politeness or compliance are overlooked, the result can be disastrous. Imagine the case of asking a recent Asian immigrant patient whether a specific painkiller seems to be working. The elderly patient says yes, and the nurse or doctor goes away blithely assuming the dosage is correct.
Galanti (1991) cites the case of Mr. Ling, a 68-year-old Chinese man with second degree burns over his body who persistently refused any pain medication, despite evidence of severe pain. His refusal made worse an associated cardiovascular problem resulting in seriously high blood pressure. In this case the attending physician tried to get the patient to accept pain medication to lower the blood pressure. But Mr. Ling, along with his family, refused, and the nursing staff felt they had to uphold his right to refuse treatment. The difficulty here goes back to a stoic attitude to pain widely shared in Chinese culture. With Asian patients, it may be best for health professionals to anticipate needs for pain medication and not simply wait for a formal request. If there is good reason to be concerned about pain, then patients can be told that the doctor has ordered the medication, and patients may be less likely to refuse because of courtesy. Even if patients do refuse, as in the case of Mr. Ling, there may be ways to negotiate with them and persuade them to accept more aggressive palliative care.
The case and intervention strategy just cited may strike some readers as an example of outright paternalism. But it is not. Negotiation with a patient is not the same thing as overriding that patient’s decision. On the contrary, as I have argued elsewhere (Moody, 1992), at the initial level, “negotiated consent” involves advocacy and definition of choices that patients themselves may have given up because of “surplus compliance.” An aggressive advocacy stance, therefore, may well involve challenging a patient’s “spoken choice” if that choice is compromised by factors that inhibit it, such as fear or pervasive cultural habits like reluctance to communicate.
Above all, negotiated consent means calling a patient’s reasons into the light of day through dialogue. What happens through that dialogue is not known in advance. If Mr. Ling’s (cultural) stoicism proves more powerful than his (cultural) deference to authority, then he still exercises his right to refuse pain medication, and the medical staff must oblige. But we should not opt for silence and blind acceptance of spoken choice as the sole preferred mode of showing respect for patients unless we have compelling reasons to do so (sometimes we do, of course).
The real point is that any dialogue with Mr. Ling, or Mrs. Chu, or members of their families, will be a dialogue not only between individual agents (professionals and patients) but also a dialogue across cultures. We need not reify culture or stereotype “Asian patients” but we can recognize cultural tendencies and recurrent barriers to communication. From the standpoint of negotiation and communicative ethics, cultural differences become an occasion for communication and clarification, not a trump card that cuts off debate about right and wrong, as would be the case for simplistic versions of cultural relativism and, ironically, also with an abstract and impoverished notion of patient autonomy.
The most important point to be made in the case of Mr. Ling is the most obvious point of all: It is a case of pain management, for good or ill. In fact, the American healthcare system does a very poor job of pain management, as project SUPPORT and other empirical studies have recently shown. In a system that does a poor job of managing pain, does it really make sense to encourage patients to “freely” disregard options for palliative care? A hollow concept of patient autonomy that is independent of culture and history is likely to lead to perpetuation of injustice and mindless preservation of the status quo. Oppressed people will sometimes “freely” make choices that reflect the limited alternatives available to them in concrete circumstances. The alternative is not arrogant paternalism, but a serious dialogue that recognizes, and crosses, the cultural differences that are part of our global society today.
With these considerations in mind, we can return to the case of Mrs. Chu and make certain concluding observations about the case.
First, respect for Mrs. Chu’s dignity and position in the family is a prima facie ethical imperative. Such a prima facie imperative can be rebutted and overcome, but we are wise to proceed cautiously in communicating with Mrs. Chu, and we should certainly not disregard family members. The medical profession’s admonition “First, do no harm” means to think carefully before intervening in a family’s customary or culturally sanctioned form of life. The nurse’s suggestion that the healthcare team should inform Mrs. Chu directly, no matter what the family may say, is wrong.
Second, we should reject the doctor’s “hands off” claim that, once having informed the Chu family, he has fulfilled his duty in the matter. Contrary to what he says, what happens next is very much his responsibility. There is actually a Chinese saying that maintains that should we save the life of another person, we then become responsible for that person ever after. Whatever that saying may ultimately mean, it reminds us that life-and-death interventions invoke ongoing responsibilities that cannot be lightly disregarded.
Third, we should be skeptical of the social worker’s proposal to “balance risks and benefits” in the utilitarian manner. It may prove very difficult to reach such a conclusion in cases where cultural expectations lead to different experiences of what a “benefit” may actually be. The power of an ethics of rules and principles is to give us guidelines for action instead of trying to predict outcomes or calculate risks and benefits in obscure ways.
As for the healthcare team member who advocates “telling the truth” by obfuscation (“You have neoplastic disease”), we can only dismiss this as a self-serving rationalization. From a legal point of view, if Mrs. Chu is receiving healthcare within the United States, then she is subject to the laws of this jurisdiction, not her country of origin or citizenship. When the healthcare team grasps at straws in this way, it is surely a sign of failure to come to grips with the underlying ethical conflict.
The preferred solution in the case of Mrs. Chu is to adopt a posture of “negotiating our differences” – an approach endorsed by those who favor mediation in medical ethics. But “mediation” doesn’t mean simply “splitting the difference.” On the contrary, the process of mediation, like communicative ethics more broadly, is an ethical enterprise. Negotiation means holding out for certain ethical ideals–such as patient autonomy–while at the same time recognizing competing values, such as family solidarity in the Confucian tradition. To negotiate does not mean to abandon one’s own values, but it means acknowledging that one is not in a position to enforce those values at the cost of competing claims. In Mrs. Chu’s case, a culturally sensitive approach to her condition might mean acknowledging a complementary role for herbal medicine in her treatment plan. Even in the matter of truth-telling, compromise is possible. There are forms of communication that can gradually convey to Mrs. Chu the truth of her diagnosis without disrupting communication patterns within the family.
Having recommended negotiation and mediation in the case of Mrs. Chu, it is now time to utter a final word of caution. The practice of negotiation does not stand alone. Among some immigrant groups the idea of “negotiation” may be more associated with the marketplace than with medical settings, where traditional paternalism (“Doctor knows best”) tends to prevail. If we are to avoid the perils of the new American medical marketplace (with the rise of managed care and other changes) while also escaping the dangers of traditional paternalism, then we will need recourse to powerful ethical ideals. Here, I fear, even “negotiated consent” is not enough. Negotiation needs to be balanced by greater priority to ideals of dignity and demands of social justice rather than individualized autonomy or truth-telling, particularly when autonomy or truth-telling proves incompatible with dignity and self-respect.
The emphasis on social justice reminds us that, even within the framework of “principlism,” conflicts between beneficence and autonomy do not stand alone. Just as individual liberty and equality need to be balanced by fraternity, so conflicts between individual beneficence and autonomy need to be balanced by consideration of the wider historical and cultural context. Concern about ethnicity is precisely such a consideration. But the danger of “ethnic ethics” lies in the prospect of cultural fragmentation and relativism in which universal rights and principles simply vanish from sight–truly, a “night in which all cows are black,” where no protest or intervention on behalf of justice is even possible.
To avoid moral darkness, we need to keep in mind what diverse ethnic groups share in common–a concern for the dignity of elders–and also what all groups face under America’s increasingly chaotic and ethically opaque healthcare system. This is a key point and one that helps us avoid the danger of “diversity” becoming a slippery slope leading toward fragmentation and interethnic conflict.
Today, more than ever, groups divided by color or language or cultural ancestry need to make common cause around ideals of justice and the common good: a reminder of the unity that transcends our differences. This reminder is in the spirit of the ancient Chinese saying that when the Tao (Spiritual Truth) disappears, morality remains. When morality disappears, law remains. When law disappears, force remains. When force disappears, then chaos rules all. In a world where chaos and force are all too evident, the appeal of law and morality must be embraced by a unity in which our differences do not disappear but are reconciled by all that we hold in common.

REFERENCES

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By Harry R. Moody
Harry R. Moody, Ph.D., is director of the Brookdale Center on Aging of Hunter College, New York
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