CROSS CULTURAL MEDICAL ETHICS

Mutiara Budi Azhar

Faculty of Medicine Sriwijaya University

Cross-Cultural Medical Ethics

OVERVIEW

• key terminology• recent data • patient autonomy• epidemiology of disease

Dr MBA

Cross-Cultural Medical Ethics

OBJECTIVES

Students should be able to• recall key aspects of medical ethics• deduce the influence of cultural context on

the autonomy of the patient• to estimate the consequences of the

cultural background for the prevalence of illness / disease

Dr MBA

Cross-Cultural Medical Ethics

MEDICAL ETHICS

• access• beneficience - non maleficience• equality – justice/disparity (resource

allocation )• autonomy – informed consent• truthfulness (interpreter)

Dr MBA

Cross-Cultural Medical Ethics

Fragment of the Hippocratic Oath on Papyrus from the Third Century.

Courtesy of Wellcome Library, London.

Dr MBA

Cross-Cultural Medical Ethics

EQUALITY

Characteristics of Primary Care Physicians According to Visits by White and Black Medicare Beneficiaries

Characteristic of Physicians Visits by White Patients

Visits by Black Patients

P Value

Race - % (no. of pairs)WhiteBlackAsianOther

85.3 (35,824) 0.7 (370) 11.2 (3939) 2.7 (1067)

59.7 (1947)22.4 (650)15.7 (483) 2.3 (98)

<0.001

Location of practice - % (no. of pairs)UrbanRural

73.0 (34,256) 27.0 (7289)

72.9 (2744)27.1 (467)

0.99

Provide some charity care each mo - % (no. of pairs)

YesNo

78.8 (31,317) 21.2 (10,228)

83.4 (2452)16.6 (759)

0.06

Board certification - % (no. of pairs)Board certifiedNot board certified

86.1 (36,570) 13.9 (4822) )

77.4 (2644)22.6 (559)

0.02

Source: N ENGL J MED 2004;351(6): 575

Dr MBA

Cross-Cultural Medical Ethics

JUSTICE - EQUALITY

The principle of justice requires that all people be treated equally.

Dr MBA

Cross-Cultural Medical Ethics

ACCESS

Primary Care Physicians’ Perceptions of the Quality of Care Provided in Relation to the Race of Patient Index of Quality of Care Visits by White

PatientsVisits by Black Patients

P Value

Access to high-quality specialists - % (no. of pairs)

AlwaysNot always

82.1 (33,271)17.9 (8189)

76.0 (2437)24.0 (774)

0.04

Access to high-quality diagnostic imaging - % (no. of pairs)

AlwaysNot always

83.4 (34,443)16.6 (7082)

75.6 (2449)24.4 (762)

0.003

Access to nonemergency hospital admission - % (no. of pairs)

AlwaysNot always

63.0 (23,414)37.0 (13,946)

51.5 (1613)48.5 (1261)

<0.001

Able to deliver high-quality care to all patients - % (no. of pairs)

AgreeDisagree

80.7 (32,588)19.3 (7960)

72.2 (2398)27.8 (688)

0.02

Source: N ENGL J MED 2004;351(6): 575

Dr MBA

Cross-Cultural Medical Ethics

ACCESS

Dr MBA

Cross-Cultural Medical Ethics

AUTONOMY

Autonomy of the patient means respect for his/her self – determination.

Dr MBA

Cross-Cultural Medical Ethics

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)

Dr MBA

Cross-Cultural Medical Ethics

• classification of food / nonfood (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)

CULTURE AND DIET

Dr MBA

Cross-Cultural Medical Ethics

CULTURE AND DIET. Cont’

• parallel food classifications– hot – cold (symbolic value)– medicines as food

• social food (ritual aspects, social status, group identity)

• infant feeding practices (breast feeding)

Dr MBA

Cross-Cultural Medical Ethics

DIETARY CULTURE AND HEALTH / DISEASE

• malnutrition• rickets• anaemia (Asians)• overnutrition• cancer

Dr MBA

Cross-Cultural Medical Ethics

• 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

CULTURE AND GENDER

Dr MBA

Cross-Cultural Medical Ethics

CULTURE AND PAIN

• response to pain (private- public pain)

• pain perception and pain tolerance

• communication/presentation of pain

• response to pain behavior

Dr MBA

Cross-Cultural Medical Ethics

• 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

CULTURE AND PAIN

Dr MBA

Cross-Cultural Medical Ethics

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)

CULTURE AND MEDICATION

Dr MBA

Cross-Cultural Medical Ethics

• “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

RITUALS

Dr MBA

Cross-Cultural Medical Ethics

• 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

CULTURE AND PSYCHIATRY

Dr MBA

Cross-Cultural Medical Ethics

PERCEPTIONS OF SOCIAL BEHAVIOR

controlled

„normality“symbolic inversionsreligious statesculture – bound -syndromes

abnormalnormal

uncontrolled

„bad“ „mad“

Dr MBA

Cross-Cultural Medical Ethics

CULTURAL FACTORS IN EPIDEMIOLOGY

• 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

Dr MBA

Cross-Cultural Medical Ethics

STANDARDS FOR ACCREDITATION OF MEDICAL EDUCATION PROGRAMS

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.

Dr MBA

Cross-Cultural Medical Ethics

STANDARDS FOR ACCREDITATION OF MEDICAL EDUCATION PROGRAMS

Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.

Dr MBA

Cross-Cultural Medical Ethics

STANDARDS FOR ACCREDITATION OF MEDICAL EDUCATION PROGRAMS

A medical school must teach medical ethics and human values, and require its students to exhibit scrupulous ethical principles in caring for patients, and in relating to patients' families and to others involved in patient care.

Dr MBA

Cross-Cultural Medical EthicsDr MBA

Cross-Cultural Medical Ethics

Thank you very much for your kind attention

Dr MBA