Culture enters the medical discussion
Health-care providers wonder how far they should go to accommodate sometimes unorthodox needs of Canada’s increasingly diverse community, writes Tom Blackwell.
As the adolescent girl underwent gynecological surgery at a western Canadian hospital, a doctor stood by to perform an unusual function.
The physician was there, according to a source familiar with the incident, to sign a certificate verifying she remained a virgin — and was still marriageable in her immigrant community.
It was a stark example of an increasing preoccupation for Canada’s health-care system: accommodating the sometimes unorthodox needs of ethnic and religious minorities in an evermore multicultural society.
Hospitals grapple with requests for doctors of a specific sex or race; sometimes they disconnect fire alarms to allow sweetgrass burning, prolong life support for religious reasons and host clinics to treat fasting diabetics at Ramadan.
The gestures stem not only from the country’s growing diversity, but a generally more patient-focused system — and a recognition that treating solely physical ailments is not always enough.
“If we don’t engage in the (cultural) discussion, we won’t fully understand their health needs and they won’t get met,” says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children’s Hospital’s socio-cultural consultation and interpretation services. “So ultimately they will get sicker and be a greater cost to the health-care system.”
But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral — or even legal — line?
While a physician in the neonatal intensive care unit at Toronto’s Sick Kids hospital, Dr. Jonathan Hellmann was sometimes asked by fathers from “patriarchal” cultures not to discuss a child’s condition with the mother unless the husband was also present.
Agreeing to such a request not only raises ethical and practical questions, but might even violate Ontario’s Health-Care Consent Act — unless the mother explicitly agreed to the arrangement.
“It’s challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings,” says Hellmann. “Both equally have decision-making power, both should have information.”
Even hospitals that try to be sensitive to specific cultural groups, like Ontario’s Hamilton Health Sciences Centre, with its aboriginal patient “navigator,” can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.
And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a brain-dead patient on life support for days until he could be flown to his country of origin, the family’s culture rejecting the concept of neurological death.
Still, for every demanding request, there are dozens of positive incidents — even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.
Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient’s room temporarily so it doesn’t set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax.
Randi Zlotnik Shaul, director of bioethics at Sick Kids, said she’s aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with some parts of the proposal — and not interfere with other tiny patients — but a line was drawn at the proposal for a small, open fire, she said.
Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and sensitivity, like when someone asks that a patient’s bed face Mecca, she says.
“Some might respond very categorically, ‘Nope, in this place all beds face the same way,’” she says. “Someone oriented another way might say, ‘Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.’”
Serdynska says she knows of hospitals providing “mementos” of births to new mothers whose cultures traditionally require them to bury their placenta.
Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an innercity clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.
Her patients, however, happily embraced what they saw as the experience’s spiritual, invigorating benefits.
“It was an interesting challenge to my assumptions,” says Kiran. “My gut reaction was that fasting has negative impacts on health.”
In London, Ont., St. Joseph’s Health Centre runs a special clinic during Ramadan to help the city’s estimated 3,000 diabetic Muslims.
Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims.
But the system has generally made great strides, says Haffajee, who has addressed classes of nursing students on her faith’s practices.
“It’s about reasonable accommodation and understanding,” she says. “When people are ill, you’re dealing with very vulnerable people, so empathy goes a long way.”
Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal’s Serdynska.
Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of “capping,” or “coining,” a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements.
Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says.
“For some cultures who do not generally take pharmaceutical medication, this is very frightening.”
The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C.
Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.
“You’re dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community,” she says. “People (are) saying … ‘I want the two to work together.’ “
But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries?
Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province’s medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care.
Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.
Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school’s obstetrics and gynecology department.
More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race — typically Caucasians rejecting non-white workers in today’s multi-hued medical workforce — or want one of their own colour.
Ethicists at Toronto’s University Health Network (UHN) published a nine-page paper on how to tackle “discriminatory” requests of this sort, suggesting the affected health-care worker should often have the final say.
“It’s ugly, it’s unfair,” says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. “To … have someone say you’re not good enough because of the colour of your skin is offensive.”
How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners.
And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a “race-concordant” doctor can bring health benefits, especially for blacks and others who have historically faced prejudice.
In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient’s room.
“In some cultures … you have everybody there. You have all the aunts and all the uncles, and all the family members and friends,” says Dalhousie’s Simpson.
“For me, that’s been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there’s value to having your loved ones around you.”
It’s about reasonable accommodation and understanding. When people are ill, you’re dealing with very vulnerable people, so empathy goes a long way.