Reflections by Abdelmalek Yamani

"Verily the creation of any one of you takes place when he is assembled in his mother's womb; for forty days he is as a drop of fluid, then it becomes a clot for a similar period. Thereafter, it is a lump looking like it has been chewed for a similar period. Then an angel is sent to him, who breathes the ruh (spirit) into him. This Angel is commanded to write four decrees: that he writes down his provision (rizq), his life span, his deeds, and whether he will be among the wretched or the blessed."

This is one of the sayings (Hadith) of the Prophet Mohammad that Muslim Scholars cite whenever there is an issue related to a fetus in the womb of the mother. According to this text, a fetus becomes fully human by the end of the first 120 days or the first four months or by the end of the 16th week of pregnancy, and thus it becomes a crime, according to the Islamic law (or sharee'ah) to abort a pregnancy for no reason. Moreover, even when there is a reason such as the one given in this case, Muslim scholars have specified conditions by which a woman can terminate her pregnancy, such as doing all possible to make sure there is no mistake in identifying that the fetus is not viable. In keeping with that condition, a trustworthy Muslim doctor should validate the diagnosis and give his/her affirmation to terminate the pregnancy.

From a cultural perspective, most women would choose not to terminate their pregnancies for fear that they would be negatively judged by the entire community. In this regard, while religion may permit termination, culture often inhibits women from this decision. In such a case, a woman who contemplates abortion may be treated as if she doesn't accept the will of Allah (God) despite knowing that the fetus will not be viable or will live under severe conditions.

In the case at hand, Leyla and her entire family may not know about the Islamic ruling, but they are all aware of the cultural stand with regard to their fetus. Under the circumstances of the case, there is no way the family will accept terminating the pregnancy. The question then becomes: If a doctor is sure of the medical diagnosis, how can he or she convince this family to accept his or her suggestion?

Before answering this question, let us first look at the data we have:

1. The country of origin and the primary language indicate that the doctor is in the presence of a very devout Muslim family, which is also well rooted in Afghan culture. This means that any treatment or decision should take both religion and culture into consideration.
2. Because of the above, the family is expecting Leyla to be treated humanely and emotionally well. In fact, given the circumstances, the doctor/patient relationship is not intellectual but rather emotional. The family is expecting Leyla to be treated softly and with love, respect, and deep understanding. Also, by taking this step and visiting a hospital, the family seems to indicate that it is desperate for a doctor who will act wisely and patiently, as a caretaker, a savior, and a friend.
3. The presence of the husband, mother, aunt, children, and a friend show that Leyla enjoys the full support of her family. It also means that any decision should be made collectively with the consent of all the family members.
4. Mrs. Ansari already has three daughters. Thus, to the mind of this family, there is a good chance that this fetus is a boy, whether or not there is any scientific basis for such a belief. In fact, starting with the first child, the family has been hoping for a baby boy. This desire grew bigger with the birth of the second and the third daughters. A baby boy, in this case, means a second man of the house, a caretaker when parents reach old age and most importantly a protector for his three sisters. In a sense, he will be key to all future hope and goodness.

Does Dr. Fox keep the above items in mind? It seems clear that he does not.

Instead, Dr. Fox commits the following mistakes:

1. Dr. Fox does not take the time to get to know the family and acquaint himself with each member. Because he does not do so, Dr. Fox is not able to surmount the psychological obstacle between himself and his patient and her family, and thus he is unable to find himself a place in the heart and the mind of this family.
2. Dr. Fox is not relaxed and thus not welcoming. Coming from a tribal background, each member of the family would be well-versed in reading one another's faces to deduce meaning. It is probably easy for them to discern that there is something wrong going on and that Dr. Fox is not bringing glad tidings. This contributes to a sense of resentment and rejection of anything Dr. Fox says.
3. Dr. Fox does not listen to Mr. Ansari when he asks him to talk outside, which indicates that he does not understand the negative dynamics he has already helped to create.
4. Dr. Fox wrongly insists on his own timing. Instead he should have tried to make the husband feel comfortable by encouraging him to go and pray.
5. Dr. Fox is too blunt and too unconsidered in the way he delivers the news to the husband. At this moment, Mr. Ansari is likely driven completely by his emotions. Instead, a soft, slow, and brief introduction could have paved the way for his news.
6. Dr. Fox interrupts the communication/argument between the husband and his mother-in-law. Instead, he should have waited until they had finished. The husband would likely have translated without Dr. Fox asking him to do so.
7. Dr. Fox should have listened to Mr. Ansari's request and let him tell his wife and deal with the entire situation instead of Dr. Fox. Dr. Fox should not have assumed the validity of his own assertion that "such a choice is not yours to make." In the mind of the husband, only two people can make that decision: Mr. Ansari and his mother-in-law.
8. Dr. Fox breaks the laws of respect and intimacy by invading a woman's space without the consent of her husband. According to Islamic tradition, a man should not enter a house or a place where a woman is without asking permission first. He also interrupts her prayer.
9. Dr. Fox forces the friend to get involved without asking whether it is ok to include her and share the news with her or not.
10. Dr. Fox shows no mercy in telling the news and does not care about the outcome.

What could Dr. Fox have done to deal with the situation? Following is one possible scenario:

Dr. Fox has never dealt with a Muslim or Afghani family, and has no knowledge of the religious or cultural directives to follow in order for him to work effectively in this case. Knowing the gravity of the news he is bringing to the family and the impact that such news may have on Mrs. Ansari, he decides not to act randomly. Instead, he calls a knowledgeable Muslim friend and asks him to tell him about the basics of Islam, the Afghani culture, the family structure and the role of gender in everyday life and particularly in decision making.

Armed with the necessary information he needs, he takes his time, composes himself, puts a nice smile on his face, and knocks at the door of the room where Mrs. Ansari is waiting. The husband welcomes him warmly. He shakes his hand and invites him in. Without looking around, Dr. Fox looks Mr. Ansari in the eye, briefly asks him about what he does in life, about his family, the health of his children, the neighborhood where they live, and even about the last time he visited Afghanistan. Once he feels that Mr. Ansari is relaxed and that the family welcomes him, Dr. Fox turns gently to the mother-in-law, then to Mrs. Ansari's girlfriend, and greets them without shaking their hands or looking at their faces for a long time. Finally, Dr. Fox smiles and greets Leyla, asks her a few questions about her health, praises her family members for their support, and assures her that everything will be fine. Then he asks permission to talk to the husband outside and in private.

Once outside, he alludes to the fact that he is about to tell the husband something very important and that if he wants to, he can ask his mother-in-law to join them. (In most cases like this, it is the mother-in-law who should be consulted first or in the company of the husband. She should not be left out, for she is a key member of the family). Mr. Ansari thanks Dr. Fox, goes back and returns with his mother-in-law. Dr. Fox asks them to follow him to his office. Once they sit comfortably, he pulls out the images of a healthy fetus. He goes through a small explanation of what a fetus should look like; then he pulls out the actual pictures and shows how an ill fetus looks, and what the future baby's life may be like if the pregnancy continues. Dr. Fox talks about the danger and the risk (if any) that a pregnant woman may undergo. He also describes how many women who have chosen to terminate pregnancies have been able to live happily and have more children.

By now, the husband and the mother-in-law already know that something is not right and that the doctor is about relay negative news about either Leyla or her fetus, or both. Their eyes become wide and they pay full attention to what Dr. Fox is saying. Calmly, Dr. Fox tells them about the conditions of their fetus, about the fact that this baby may not be able to live, and that they may consider terminating the pregnancy now, before it potentially impacts Leyla's health and wellbeing. Without waiting for their answer, Dr. Fox shows them his sympathy and understanding and asks them not to make any decision at the moment. He advises them to get together and pray for guidance from Allah.

In summary, there are many unspoken religious and cultural values that come into play in this case (as it originally is written), values that remain unspoken and unexpressed. Leyla and her family are not part of Dr. Fox's cohort group. Thus, there are no commonalities to connect him to their religious and cultural values. He assumes many things about the family and as such he fails in his mission to convey very important medical information to the family. His main failing is his inability to express the universal value of respect.

Return to the case
Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Muslim Patients

Abdelmalek Yamani holds an M.S.E.E., an M.A. in psychology, a Ph.D. in linguistics, and is a PhD. candidate in psychology. Currently, he is working as a software engineer at Cisco Systems and is a professor of Arabic at the University of San Francisco.