What "patient-centered care" requires in serious cultural conflict.

TL;DR: The author examines the tension that occurs when culturally sensitive patient-centered care disrupts the workflow of the service, requires acknowledging antithetical, unsupportable values, or entails discriminatory or ad hominem practices that constitute a personal insult or affront to the provider.

Abstract: The medical community has hailed the recent movement to provide patient-centered care as a progressive step forward in meeting the needs of the very diverse patient population of the United States. Stakeholders in all arenas of U.S. medicine-professional organizations, public advocacy groups, hospital administration, medical school leadership, insurance carriers, and nursing-have embraced the focus on patient-centered care. But, although the community universally endorses the ideal of patient-centered care, the ethical obligations it entails have only just begun to be explored. One of the most difficult circumstances in which to provide patient-centered care is when there is a deep cultural conflict-that is, when the values and priorities of the patient and his or her family are in direct opposition to those of the clinical team. Given the mandate to provide care that is "culturally and linguistically appropriate," the author asks what obligations providers have to meet patient demands when doing so is inconvenient, challenging, or, at the extreme, offensive and contrary to clinical values. The author examines the tension that occurs when culturally sensitive patient-centered care disrupts the workflow of the service, requires acknowledging antithetical, unsupportable values, or entails discriminatory or ad hominem practices that constitute a personal insult or affront to the provider. The strategy the author has invoked for this analysis is to search for common values that might provide a bridge between patients and providers who are in deep cultural conflict.

Summary

Introduction

• The recent movement to provide “patient-centered care” has been hailed as a progressive step forward in meeting the needs of the very diverse patient population of the United States.
• The patient has come to the ED with bleeding and abdominal pain.

Patient-Centered Care: The New Mantra

• The movement of “patient-centered care” is now embraced at all levels of American medicine: professional organizations, public advocacy groups, hospital administrators, medical school leadership, insurance carriers, and nursing schools all invoke the concept as a mantra.
• If patient-centered care requires attentiveness to patients’ needs that is culturally sensitive, the authors need to determine what obligations they have to meet those needs when it is inconvenient, challenging, or, at the extreme, offensive to mainstream values.
• Accommodating cultural or religious demands in these instances is not thought to slow down productivity or hamper the delivery of care.
• And while it is laudatory that the authors respect the value of this religious group, it is also the case that there are somewhere between two and five times as many American Muslims (the religious subgroup that might don a burqa) as American Jehovah’s Witnesses.

Otherness versus Commonality

• The women in the burqa and her husband seem to possess values incommensurate with those of the American mainstream.
• Part of why incommensurable values seem to create an unbridgeable chasm between individuals is that, in such conflicts, each person is regarded as radically “other,” too different for the kind of kinship that engenders empathy and understanding.
• The Universal of Autonomy So while an arranged marriage is by definition an oppressive institution according to mainstream American values, it is not an oppressive institution to those who view it as the most prudent way to assure a happy and long-term union, also known as A Focus on Commonality.
• Clearly there are grounds for fearing that she is not exerting any “patient autonomy” in this case, and the authors place high value on this species of autonomy.

A Focus on Commonality: the Universal of Informed Consent

• Reflective of their values, and legitimately endorsed.the authors.
• No one wants therapies or procedures done to them without either the patient’s knowing what they are and why, or the patient’s chosen “surrogate,” “advocate,” or “decision-maker” knowing.
• If the husband was not working towards a medical solution that safeguarded his wife’s health, then he would not have brought her in for care.
• Two essential elements of informed consent are “disclosure” – what has the decision-maker been told – and “understanding” – how much of that information has been adequately processed.

A Focus on Commonality: the Universal of Bodily Privacy

• Finally, the value that appears to be most at odds with contemporary American mores is bodily privacy.
• In every culture, there is a distinction made between the “public” and “private” body.
• The Burqa is the garment women often wear when they are living under Purdah.
• The nurse would instruct you to take off all of your clothes and come to the examining table, placing your feet in the stirrups.
• A powerful objection one might immediately raise to this thought experiment is that the two cases are not analogous: the experience of an American woman in a German gynecology practice is not the same as the experience of a Muslim woman living under Purdah in an American ED.

What Might Patient-Centered Care Look Like in This Case?

• Ideally she could be asked whether she wants to speak to the clinical staff without her husband present, but it is hard to imagine her saying “yes:” on either reading – that he is her oppressor or protector – she will be returning to this marriage when this healthcare crisis is past.
• I started this essay with three barriers to meeting patient-demands, namely, those that are not considered: 1) disruptive to the work-flow of the service; 2) illegitimate; or 3) ad hominem.
• My response to this objection (perhaps controversially) is that ignoring or dismissing the couple’s request request is tantamount to being complicit in a kind of psychological or emotional assault, so concerns about discrimination must yield here.

Summing Up

• Patient-centered medicine is not only a rejection of “my way or the highway” thinking about patient care: it is also a commitment to meeting patients on their own terms, respecting the values they come with to the clinic.
• He borrows the concept of ‘hospitality” from fellow bioethicist Laurie Zoloth.
• 4 Joint Principles of the Patient-Centered Medical Home.
• Introduction: Overview, History, Religious Texts, Organizational Structure (http://www.religioustolerance.org/witness2.htm).
• Hastings, J. Enclyclopedia of Religion and Ethics, Volume 6. J Patton, trans, also known as In.

Full text

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1
What “Patient-Centered Care” Requires in Serious Cultural Conflict
Autumn Fiester, PhD
Dr. Fiester is the Associate Director of the University of Pennsylvania Center for
Bioethics and the Director of Graduate Studies in the Department of Medical Ethics at the
University of Pennsylvania School of Medicine.
Autumn Fiester, PhD
Center for Bioethics
3401 Market Street
Suite 320
Philadelphia, PA 19104
Phone: (215) 573-2602
Fax: (215) 573-3036
fiester@mail.med.upenn.edu
No external funding to report.

2
Abstract
The recent movement to provide “patient-centered care” has been hailed as a
progressive step forward in meeting the needs of the very diverse patient population of
the United States. The focus on patient-centered care has been embraced at all levels of
American medicine: professional organizations, public advocacy groups, hospital
administrators, medical school leadership, insurance carriers, and nursing schools. But
while the ideal of patient-centered care is universally endorsed, the ethical obligations it
entails have only begun to be explored. One of the most difficult circumstances in
which to provide patient-centered care is in deep cultural conflict, where the values and
priorities of the patient are in direct opposition to those of the clinical team. Given the
mandate to provide care that is “culturally and linguistically appropriate,” the author asks
what obligations providers have to meet patient demands when it is inconvenient,
challenging, or, at the extreme, offensive and antithetical to mainstream values.
Bariers are examined that patient-centered care in such cases is disruptive to the
work-flow of the service, requires acknowledgement of illegitimate values, or entails
discriminatory practices that constitute a personal insult or affront to the provider. The
strategy invoked for this analysis is a search for common values that might provide a
bridge between patients and providers in deep cultural conflict. The author concludes by
responding to these important barriers to providing patient-centered care.

3
What “Patient-Centered Care” Requires in Serious Cultural Conflict
Consider the impasse between the patient and the clinician in the following case:
A male radiologist is called by the ED to perform an evaluation for an
intra-uterine pregnancy. The patient has come to the ED with bleeding and
abdominal pain. The patient's beta-HCG is around 250. When the radiologist
arrives in the patient’s room, he finds her covered in a burqa, and the patient's
husband explains that she needs to remain covered and that the male radiologist
will not be allowed to perform the necessary exam. The patient says nothing.
There appears to be no language barrier.
In the context of the recent movement to provide “patient-centered care,” cases like this
one present a serious challenge to the clinical team: what the patient – or at least the
person speaking for the patient – considers necessary for her values to be protected is in
direct conflict not only with the standard of care, but with the standard operating
procedures in contemporary US medical settings. The standard of care in a suspected
ectopic pregnancy is a diagnostic vaginal ultrasound, and the standard operating
procedure is that the clinician assigned to the case (of whatever gender) does the exam
and the exam is performed in a hospital gown. Against the backdrop of the already
almost unmanageable clinical load in US emergency departments, what type of attention
and accommodation does “patient-centered care” demand when that effort threatens to

Frequently asked questions

Q1. What are the contributions in "What "Patient-Centered Care" requires in serious cultural conflict" ?

The recent movement to provide “ patient-centered care ” has been hailed as a progressive step forward in meeting the needs of the very diverse patient population of the United States. One of the most difficult circumstances in which to provide patient-centered care is in deep cultural conflict, where the values and priorities of the patient are in direct opposition to those of the clinical team. Given the mandate to provide care that is “ culturally and linguistically appropriate, ” the author asks what obligations providers have to meet patient demands when it is inconvenient, challenging, or, at the extreme, offensive and antithetical to mainstream values. Bariers are examined that patient-centered care in such cases is disruptive to the work-flow of the service, requires acknowledgement of illegitimate values, or entails discriminatory practices that constitute a personal insult or affront to the provider. The strategy invoked for this analysis is a search for common values that might provide a bridge between patients and providers in deep cultural conflict. The author concludes by responding to these important barriers to providing patient-centered care. 

Q2. What is the default position of the American Muslim community?

Given the American commitment to religious pluralism and tolerance, if one religious orcultural belief or value is deemed legitimate and worthy of respect, then their default position must be that they all are. 

Q3. What is the objection to ignoring or dismissing the couple’s request?

My response to this objection (perhaps controversially) is that ignoring or dismissing the couple’s request request is tantamount to being complicit in a kind of psychological or emotional assault, so concerns about discrimination must yield here. 

Q4. What does it mean to protect a woman’s privacy?

Protecting her need for a high level of bodily privacy means working with her tominimize the amount of bodily exposure she has and controlling the gender of the providers she comes in contact with. 

Q5. What is the third feature of the cultural differences that the authors routinely accommodate?

The third feature of the cultural differences that the authors routinely accommodate is thatthey are not (3) ad hominem with regard to the provider: the requests do not discriminate against certain categories of providers by race, gender, sexual orientation, etc. 

Q6. How many American Muslims do not wear a burqa?

And while it is laudatory that the authors respect the value of this religious group, it is also the case that there are somewhere between two and five times as many American Muslims (the religious subgroup that might don a burqa) as American Jehovah’s Witnesses. 

Q7. What is the lesson to draw about the ability to meet patient needs in cases of cultural or religious?

So one lesson to draw about their ability to meet patient needs in cases of cultural or religious difference is that when demands are relatively novel, they may cause interruption in a way that they might not, once a standard method for handling them is developed; the authors can’t refuse accommodation merely because a system for accommodating that request hasn’t yet been worked out. 

Q8. What is the second feature of the patient-demands the authors routinely accommodate?

The second feature of the patient-demands the authors routinely accommodate is that theyare not considered (2) illegitimate, but are implicitly sanctioned as worthy of thataccommodation. 

Q9. What do you want to say about the three values that Kant claims are universal?

I want to look at three values that The authorwill claim are universal and merely instantiated (or cashed out) differently: autonomy, informed consent, and bodily privacy.