The Markkula Center for Applied Ethics has a major research focus on culturally competent care; that is, health care that is sensitive to the differing values and needs of cultural subgroups within our pluralistic society. This section of our Web site provides articles, cases, and commentary emerging from this research.
This project required the development of a unique process of case writing and commentary. Center Bioethics Director Margaret R. McLean conceived of a process that begins in the relevant community by asking people to describe their health care encounters and ethical challenges. Personal interviews are conducted with health care professionals who work with non-majority cultures. On the basis of these interviews, case studies highlighting common and thorny issues are composed. The cases are then sent back to members of the relevant community for commentary. Finally, Center Program Specialist in Health Care Ethics Karen Peterson-Iyer writes an ethics commentary.
The United States is among the most ethnically diverse nations on the planet. By the year 2010 it is expected that 35 percent of the U.S. population will consist of people ordinarily categorized as ethnic "minorities." This diversity itself translates into a social and cultural richness of immense proportions. Yet such diversity also provides occasion for a multitude of challenges in terms of the provision of satisfactory medical care. Not only do many racial/ethnic minorities suffer from inferior health on a number of standard health indicators; in addition, many patients from non-majority ethnicities and/or cultures frequently experience misunderstanding, mistreatment, or marginalization in clinical health care settings. Providing patients with health care that is sensitive to the values that emerge out of their particular ethnic or religious backgrounds can be referred to as "culturally competent care."
It is incumbent upon us to ask not just how access to the health care system in general could be made more equitable for ethnic and cultural minorities-though that is indeed an excellent question. We must also ask how specific cross-cultural clinical interactions-that is, interactions between patients and health care professionals, in hospitals, medical clinics, and doctors' offices-potentially contribute to the social devaluation and marginalization of members of racial/ethnic minority groups. Because each patient is not just a physical body, but rather a unique social individual with a rich set of cultural, personal, and religious expectations and practices, the degree to which health care professionals can be sensitive to and accommodate these expectations and practices will determine, in part, the success of patient medical care.
The provision of such culturally competent health care is partly a utilitarian matter, since health care dollars can be used most effectively only if patients and health care professionals are not working at cross-purposes or otherwise misunderstanding each other in clinical encounters. Culturally incompetent care ultimately translates into numerous practical problems, such as decreased patient compliance, the impossibility of obtaining truly informed consent, and an increased risk of liability for malpractice. Yet it is also a matter of justice that health care should be designed to meet the needs of all society's members and groups, not simply those who belong to the ethnic and cultural majority. In a diverse nation, if health care is to be just, it must respect, accommodate, and be informed by that diversity. Moreover, justice requires that the social and health burden for improving culturally discordant clinical encounters fall not just to patients, but also to health care professionals and institutions themselves.
Culturally competent care, by attempting to minimize miscommunication that characterizes and exacerbates culturally dissonant medical encounters, will help to reduce racially based health disparities where they exist. But clearer communication by itself is not enough. Culturally competent care means not only seeking to listen to and make accommodation for patients' diverse beliefs and practices; it also means that clinicians must become aware of their own assumptions-including those related to the "culture" of medicine-and attempt a posture of cultural humility and respect toward those who hold different and perhaps conflicting assumptions from their own. At times they may even need to reconsider the belief systems and values which underlie Western clinical practices and perhaps rethink them, in light of patients' beliefs and values.
Hence, part of providing culturally competent care means that we must challenge our own ethical assumptions and constructs, asking whether they are in fact appropriate for all people and not simply those belonging to the majority culture. Many U.S. bioethical practices-such as informed consent or patient privacy-are based on an anthropological model emphasizing human individuality over communal or family connection. These practices may be difficult to apply in quite the same ways in the case of patients who operate out of a strong sense of family and/or communal identity versus individual identity and personal liberty.
At the same time, it is neither obvious nor automatic that respect for cultural diversity requires us to abandon long-treasured Western bioethical values. In fact, as Ruth Macklin has pointed out, a conception of justice in which equality holds a prominent place challenges the idea that it is always necessary to respect all of the beliefs and practices of every cultural group. She writes, "We ought to be able to respect cultural diversity without having to accept every single feature embedded in traditional beliefs and rituals." Further, no culture is monolithic, and every individual is a complex interplay of identities, including cultural and religious identities.
Hence, it is tricky to determine the weight to accord to particular cultural or religious practices. We need not arrive at a general answer here to these sticky ethical questions. But it is helpful to keep them in mind as we approach more specific clinical encounters.
Karen Peterson-Iyer is a program specialist in health care ethics at the Markkula Center for Applied Ethics.
