Reflections by Doha Raik Hamza

We are presented in this case with a classical confrontation between Western medical ethics and Muslim culture. The interaction described in this case study is unfortunately common between clinicians and Muslim families. The case highlights two important issues when it comes to providing care to Muslim patients: informed consent and the use of family members as interpreters.

From the moment the family senses something is terribly wrong with the long anticipated baby, they insist on shielding the patient from the bad news for fear of its harmful impact. Dr. Fox, on the other hand, is a firm believer in Mrs. Ansari's right to know what is wrong with her baby. Hence he reluctantly talks to the husband first, then single-handedly and in a dramatic scene decides to inform the patient of the grave situation, after interrupting her prayer.

It is important to note that the notion of "One does not tell bad news, period" is as essential to Muslims who embrace it as is the notion of "Every patient has a right to know" to many health care practitioners in U.S. clinical settings. That is why this clash is quite severe: It is a clash between what we as humans have deemed to be basic assumptions, i.e. unequivocal truths of life that are rarely challenged, if ever.

But what could have been a more amicable resolution to two seemingly contradictory courses of actions? I believe clinicians have to come to terms with the fact that "the patient's right not to know" is as valid as "the patient's right to know." In the case scenario, we only need to ascertain Mrs. Ansari's voluntary consent to her right not to know.

One is especially frustrated by Dr. Fox's attitude and insistence on "fixing" the situation, totally neglecting that:

1. After being discharged, Mrs. Ansari will continue to live within her culture and interact with her family.
2. Dr. Fox may not even remember Mrs. Ansari's name six months from the incident.
3. If Mr. Ansari were in a similar situation himself, Mrs. Ansari would probably try to shield the grave news from her husband in an effort to avoid any harmful emotional impact.

In addition to neglecting the patient's right not to know as an aspect of her informed consent, Dr. Fox extensively relies on family interpreters. He does this despite the presence of several warning signs, such as Mrs. Ansari's and her family's limited English, and the nature of the news that Dr. Fox intends to relay to the family. Where language is limited, the use of family interpreters is advantageous when it comes to ascertaining simple requests such as whether the patient is having pain or not. It becomes risky, however, when it comes to relaying grave news for the following reasons:

1. Naturally, family interpreters are emotionally involved with the patient. For the purpose of ascertaining the patient's informed consent, they therefore may not be the most accurate or reliable.
2. Medical interpreting requires being familiar with medical terminology. This may not be the case for many family interpreters. This is especially true for those who may not have had formal training in the English language-such as immigrants-or in the language they try to interpret. This latter situation is often true of immigrants' children who tend to learn their parents' language informally, as they speak it at home, and who thus usually have limited vocabulary.
3. In this case, Dr. Fox creates an unneeded tension between the Ansari family and Mrs. Ansari's friend by asking her to translate the grave news. While Dr. Fox continues to see patients, Mrs. Ansari, her family, and her friend will continue to deal with the ramifications of his decision.

It is important to note here that we cannot describe the behavior of Mrs. Ansari and her family as "typical Muslim" behavior. Muslims differ in their level of adherence to Islamic teachings, in their degree of acculturation to the societies in which they live, in their levels of education, and in myriad other ways that make the experience of each Muslim patient and his/her family unique and shaped by very particular life experiences.

A culturally astute clinician cannot be expected to know every detail about Muslim cultures, details that sometimes influence the way people behave to a greater extent than the religion of Islam itself. It is helpful then to equip oneself with some practical tools and attitudes that could be useful in navigating crucial issues with the Muslim patient-or any patient for that matter:

1. The health-care team must show flexibility and exhibit willingness to learn and understand, in the best possible sense, the cultural and religious values that are shaping the patient's and his/her family's behavior.
2. Health-care personnel must be keenly aware of their own cultural values in order to avoid imposing their own views of health and decision making on their patients. Dr. Fox's sincerely-intentioned effort gently but firmly to relay to Mrs. Ansari the grave news likely stems in part from his wish to be informed of his own medical condition should he ever find himself in a similar situation.
3. The clinician needs to rely more frequently on the health care team personnel and mobilize resources that can be of great value specifically when dealing with critical issues like those in the Ansari case. A social worker might have been a very helpful resource here for navigating the dynamics of decision making within this family and for understanding the cultural values that are shaping family members' behavior. Interpreter services may not have had a Dari/Farsi speaking person but might have arranged a phone conversation or an interpreter specifically to come speak to Mrs. Ansari and her family. A chaplain might have been of assistance in explaining simple matters, such as the fact that the Islamic prayer takes only five minutes to perform, or that an Imam ought to be called since the family seems quite devout and might need religious guidance with such a crucial decision.
4. Little actions can culminate in a mega impact. What experience teaches us is that an outcry like the one at the end of this case is rarely the product of a single event, but rather the natural result of many small actions that went wrong. It is this series of small actions that makes the reaction of some patients and/or their family members so powerful. First Dr. Fox relies heavily on the patient and her family for interpretation; then he refuses to wait until the husband does a five minute prayer; then he relays some very heavy news to the husband, interrupts the patient while she is praying and gives one final blow by insisting on flatly telling the patient all the details. He does this only to face a response from the patient and her family for which hospital security might be needed. Had the doctor shown more accommodation of the simple and reasonable requests from the patient and/or her family from the beginning, he might have received a more agreeable response. Minimally, he might have been able to discuss calmly what could be done, what would be in the patient's best interest, and which measures she could voluntarily agree to.

The case study again teaches us that cultural competency is not about remaining in one's own comfort zone and merely applying empty rules and regulations. Rather, it is about a creative interaction between human beings of differing experiences and backgrounds that could, if honestly sought and correctly harnessed, become an exhilarating learning experience for all involved.

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

Doha Raik Hamza served as the Muslim volunteer coordinator at the Spiritual Care Services at Stanford Hospital from 2003-2007.