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The Ethics of Cultural Competence

Paasche-Orlow, Michael MD, MPH, MA

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Dr. Paasche-Orlow is assistant professor of medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.

Correspondence and requests for reprints should be addressed to Dr. Paasche-Orlow, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 91 East Concord Street, Suite-200, Boston, MA 02118; telephone: (617) 414-5868; fax: (617) 414-4676, e-mail: 〈mpo@bu.edu〉.

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Abstract

Cultural competence curricula have proliferated throughout medical education. Awareness of the moral underpinnings of this movement can clarify the purpose of such curricula for educators and trainees and serve as a way to evaluate the relationship between the ethics of cultural competence and normative Western medical ethics. Though rarely stated explicitly, the essential principles of cultural competence are (1) acknowledgement of the importance of culture in people's lives, (2) respect for cultural differences, and (3) minimization of any negative consequences of cultural differences. Culturally competent clinicians promote these principles by learning about culture, embracing pluralism, and proactive accommodation. Generally, culturally competent care will advance patient autonomy and justice. In this sense, cultural competence and Western medical ethics are mutually supportive movements. However, Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. Specifically, if the values of cultural competence are thought to embrace ethical relativity, inexorable conflicts will be created. The author presents his view of the ethics of cultural competence and places the concepts of cultural competence in the context of Western moral theory. Clarity about the ethics of cultural competence can help educators promote and evaluate trainees’ integration of their own moral intuitions, Western medical ethics, and the ethics of cultural competence.

Virtually absent from the literature on cultural competence is any discussion of the role of ethics. For example, the June 2003 issue of Academic Medicine, which was largely devoted to articles on cultural competence, is typical in this regard.1 This is an unfortunate gap in current medical education and may reflect insufficient attention to ethics and moral development by cultural competence educators. Although the absence of explicit evaluation of ethical issues is consistent with prior literature on cultural competence, I maintain that at least two important contributions from ethics should enter the discourse and pedagogy of cultural competence.

There should be (1) a clarification of the underlying moral agenda of cultural competence, and (2) an explicit development and evaluation of the relationship between the moral agenda of cultural competence and the moral consciousness of medical trainees. A third topic relating to culture-specific knowledge of ethics and a fourth topic regarding the skills of cross-cultural ethical deliberation will not be dealt with here, as they are simply additional domains of the well described multicultural/categorical and cross-cultural approaches.2 In this essay, I present my views about the first two topics and place them in the context of Western moral theory.

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Defining the Ethics of Cultural Competence

Cultural competence has had a largely unarticulated moral agenda. An important starting point is to clarify the values of cultural competence. Examination of the literature reveals a strong mandate, for example, to remove barriers of access to medical care and to eliminate health disparities. Underlying these views of culture and medicine there are three essential principles:

* Principle 1: Acknowledgement of the importance of culture in people's lives

* Principle 2: Respect for cultural differences

* Principle 3: Minimization of any negative consequences of cultural differences

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The Ethical Response to Principle 1 (Acknowledgement of the Importance of Culture)

Within the context of the patient–physician relationship, application of the first principle yields the notion that for doctors and patients to understand each other, clinicians must learn to appreciate the broad influence of cultural factors in their patients’ lives. This is a warm and embracing vision of medical care that is itself based on a philosophy of personal in-depth engagement. A narrowly biomedical vision of disease cannot suffice.3

Clinicians have a responsibility to develop a deep understanding of their patients to ensure they provide high-quality care. A common obstacle, for example, relates to the notion of having an asymptomatic chronic disease, like hypertension. Many patients have a health belief-system that associates disease with feeling sick and is oriented around brief episodes of illness. While this may seem like a mundane example, that particular health belief-model puts many hypertensive patients at risk for worse health outcomes; such patients may be less likely to take medically warranted actions (e.g., exercise, weight loss, salt restriction, and medication) since they feel perfectly well.

Detached mastery of particular cultures is never, in and of itself, the goal of cultural competence.4 Instead, the physician's essential purpose in learning about patients’ cultures is to develop tools for insight and improved working relationships with each particular patient.5 Normative conceptualizations of a given culture's health beliefs and folk illnesses can be useful tools, but they cannot substitute for good communication. It would be ludicrous, for example, to assume that all Haitian patients believe in Voodoo or that all white U.S. patients will only pursue allopathy. Ultimately, knowledge about a patient's own preferences should guide decision making.

While increased culture-specific knowledge is a common curricular objective, the lack of knowledge in cultural norms is not the largest barrier to achieving personalized and detailed insight in the values and health beliefs of each patient. The main impediment is our tepid embrace, as physicians, of patient-centeredness.6 The process of enthusiastic engagement with the human beings who are our patients will facilitate culturally competent medical care.

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The Ethical Response to Principle 2 (Respect for Cultural Differences)

To respect the cultural differences encountered in clinical medicine, providers will need to develop a level of comfort with patient autonomy. At times, physicians have been slow to allow cultural practices that come in conflict with Western medical practice. The choices of patients who are Jehovah's Witnesses, for example, have needed to be upheld by judicial intervention. However, to seek a legal remedy requires time and money, and many patients are not lucky enough to come from a cultural group that has achieved sufficient organization or power to be able to protect its members.

The value of respecting other cultures requires that health care providers embrace an essentially pluralistic perspective that allows for cultural differences. Through pluralism, clinicians can allow a range of different views and refrain from assuming that their patients share their own perspectives. Conditions for successful pluralism include that the people involved have sufficient self-awareness and security with their own viewpoint to not be threatened by alternative points of view. Medical training is a period of moral uncertainty for many people.7,8 As medical trainees are at different stages of acculturation to the iatroculture (the culture of physicians), pluralism may be a challenging concept. Explicit awareness of the medical community as a doctor culture is an important element of cultural competence education and may facilitate the student's exploration of pluralism.9,10

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The Ethical Response to Principle 3 (Minimize Negative Consequences of Differences)

The values of cultural competence dictate that health care providers should alter their practices to facilitate better medical care. Whenever possible, the burden of adaptation should not be placed on patients. Without accommodation, quality health care will not be accessible to many patients who, for example, may not speak English.

Maneuvering through health care environments can be confusing and scary. Facilitating health care is complex enough for patients who are interacting in their primary language and do not need to adapt to different social conventions or bureaucratic procedures. To provide culturally competent care, clinicians need to think proactively so the health and social burden of being different does not consistently fall on their patients.

Language barriers are obvious examples, but accommodation has far-reaching and complicated ramifications and requires an ongoing learning process and flexibility. As patients from diverse backgrounds move through the health care system, it takes a special effort for culturally appropriate options to exist at all times. Additionally, a well-practiced mechanism to allow exceptions must be imparted. This can be a complicated and expensive process. To make members of different cultures feel welcome in an institution requires attention to the intricacies of diversity. Nutrition and architecture, color schemes, even the conceptualization of time or the idea of rationality, are common examples of what may have to be adapted to cultivate a culturally competent health care environment.11

Learning about disparities in health outcomes should institute a cascade of events to determine the barriers experienced by patients and the types of accommodation needed to ameliorate the health burden due to cultural difference. This type of evaluation should explore the range of corrective actions needed, from the removal of frank bias to the discussion of health beliefs and negotiation of a shared model of care.

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Ethics of Cultural Competence and Trainees’ Moral Consciousness

In what ways are the ethics of cultural competence in harmony with or in tension with the ethics of medical trainees? Does the development of “cultural humility” lead to the embrace of cultural relativity? Does cultural competence endorse cultural relativity?

Most writing on cultural competence has depicted its purpose exclusively in utilitarian terms. For example, Kagawa-Singer and Kassim-Lakha pose the question “Why attend to cultural differences?”12 Their answer essentially is restricted to the idea that culture influences health. Similarly, the National Center for Cultural Competence presents a utilitarian justification. Their Web site states that cultural competence is important:

* to respond to current and projected demographic changes in the United States;

* to eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds;

* to improve the quality of services and health outcomes;

* to meet legislative, regulatory, and accreditation mandates;

* to gain a competitive edge in the marketplace; and

* to decrease the likelihood of liability/malpractice claims.13

An alternative answer is that it is a matter of basic ethics: Culturally competent care is a moral good that emerges from an ethical commitment to patient autonomy and justice. In this sense, cultural competence and Western medical ethics are largely mutually supportive movements.

The principles of cultural competence, however, are conditional. Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. For example, what is the culturally competent response to a patient's request of a clitorectomy for their child?

Figure 1 depicts the four main movements in Western moral theory and where medical trainees may feel ethical tension when encountering cultural competence curricula. Absolutism holds that moral truths are self-evident and extend beyond the confines of place or time. Fundamentalism is the view that all cultures endorse certain shared fundamental principles (e.g., human rights), which are specified in various ways and upheld across cultures. Multiculturalism is the view that different cultures have different moral systems, and postmodernism asserts that each person's views have equal moral worth.

Figure 1
Figure 1
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An essential tension appears to exist for the ethics of cultural competence, mainly between the claims of fundamentalism and multiculturalism, as indicated in the figure. To practice culturally competent medical care, I maintain that health care providers must advance the three principles outlined earlier in this essay. Such behavior is no longer optional or supererogatory, as was the case in the 1980s when practitioners who promoted these principles were thought to be culturally sensitive. Cultural competence goes beyond cultural sensitivity and must replace it. However, how can pluralism be morally obligatory for medical providers? This is an internally contradictory notion, whereby cultural competence seems to endorse both a fundamentalist or even absolutist rule (all providers must fulfill this set of principles) while advancing the multicultural principle of ethical relativity to respect all the various and sundry views of patients.

The main error in this formulation of cultural competence is that it is based on a one-sided evaluation that focuses on patients and ignores the moral consciousness of the providers. This can be seen, for example, in Crandall's adaptation of Bennett's enthorelativism; Crandall presents the highest developmental phase of cultural competence to be one where the “clinician lacks strong cultural identification and has the ability to unconsciously adjust to a wide range of cultural beliefs.”14

Cultural competence, like ethical relativism, opposes the imperialism of clinicians’ enforcing their views on others.15–18 Cultural competence educators are themselves cultural agents engaged in the training of students to their new culture. However, in doing so, cultural competence cannot require ethical relativity. Such a move would inextricably place it at odds with mainstream Western medical ethics.

Ethical conflicts in clinical medicine will arise, and most of the time mutually agreeable options can be explored.19 Nevertheless, when true ethical conflicts emerge, clinicians cannot be forced to embrace the full spectrum of cultural relativity. Many Western ethical norms are codified in law and standards of practice, and in most situations, clinicians can resign without significant detriment to their patient from cases where they experience unavoidable conflicts.

Cultural competence curricula will force many trainees to wrestle with the deep-seated ethical tension between their own emergent ethical commitments and ethical relativity. Medical trainees are at heightened risk, as they are often in a period of moral clarification and adjustment.7,8,20 It is important to clarify how practitioners may maintain their own values and concurrently pursue the values of cultural competence.

What logic does a teacher use to explain to trainees that he or she would not accommodate a patient's request for their daughter's clitorectomy? How does the teacher justify asserting his or her moral system and disregarding the moral system of such a patient? Cultural competence educators must be comfortable discussing this tension to help their trainees process their own feelings on these topics.

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Summing Up

Explicit evaluation of the role ethics may play in cultural competence curricula has been lacking. The ethics of cultural competence involves (1) learning about culture, (2) the embrace of pluralism, and (3) accommodation. While these activities will largely advance patient autonomy and considerations of justice, they will inherently be limited because of the tension between cultural relativism and human rights. If educators do not differentiate between cultural competence and ethical relativism, trainees may experience conflicts between their own values and what they perceive to be the values of cultural competence curricula. Cultural competence educators should be able to help trainees clarify their own moral intuitions and evaluate trainees’ capacity to integrate their values, Western medical ethics, and the ethics of cultural competence.

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Acknowledgment

The author acknowledges the guidance and mentoring of Holly A. Taylor, PhD, MPH, from the Department of Health Policy and Management and the Phoebe R. Berman Bioethics Institute, The Johns Hopkins University, Baltimore, Maryland.

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References

1. Acad Med [set of articles on cultural competence]. 2003;78:547–604.

2. Betancourt JR. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med. 2003;78:560–9.

3. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251–8.

4. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9:117–25.

5. Galanti GA. An introduction to cultural differences. West J Med. 2000;172:335–6.

6. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.

7. Wear D. Professional development of medical students: problems and promises. Acad Med. 1997;72:1056–62.

8. Branch WT Jr. Supporting the moral development of medical students. J Gen Intern Med. 2000;15:503–8.

9. Taylor JS. Confronting “culture” in medicine's “culture of no culture”. Acad Med. 2003;78:555–9.

10. Kagawa-Singer M, Wellisch DK. Breast cancer patients’ perceptions of their husbands’ support in a cross-cultural context. Psychooncology. 2003;12:24–37.

11. Davidhizar R, Bechtel G, Giger JN. A model to enhance culturally competent care. Hosp Top. 1998;76:22–6.

12. Kagawa-Singer M, Kassim-Lakha S. A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Acad Med. 2003;78:577–87.

13. Why is cultural competence important? 〈http://www.georgetown.edu/research/gucdc/nccc/faqs.html〉. Accessed 25 September 2003. Washington, DC: The National Center for Cultural Competence.

14. Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588–94.

15. Baker R. A theory of international bioethics: multiculturalism, postmodernism, and the bankruptcy of fundamentalism. Kennedy Inst Ethics J. 1998;8:201–31.

16. Macklin R. A defense of fundamental principles and human rights: a reply to Robert Baker. Kennedy Inst Ethics J. 1998;8:403–22.

17. Baker R. Negotiating international bioethics: a response to Tom Beauchamp and Ruth Macklin. Kennedy Inst Ethics J. 1998;8:423–53.

18. Beauchamp TL. The mettle of moral fundamentalism: a reply to Robert Baker. Kennedy Inst Ethics J. 1998;8:389–401.

19. Nie J-B. The Plurality of Chinese and American Medical Moralities: Toward an Interpretive Cross-Cultural Bioethics. Kennedy Inst Ethics J. 2000;10:239–60.

20. Patenaude J, Niyonsenga T, Fafard D. Changes in the components of moral reasoning during students’ medical education: a pilot study. Med Educ. 2003;37:822–9.

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