Markkula Center of Applied Ethics

Cancer: A Failure to Communicate - Reflection by Doha Raik Hamza

The primary issue that presents itself vividly in this case is that of interpretation, and the central role communication plays in our lives. While the health care setting today boasts numerous creative innovations that have saved the lives of many, there are certain aspects of the provision of U.S. healthcare that remain quite primitive, although they are crucial to patient well-being. Language interpretation is one of these. Here, the hospital had three days to gather Mr. Tabrizi's complete history, which could have been arranged through the use of phone interpretation services or through an interpreter from an agency. Yet it instead relies on the availability of the son to translate.

Mr. Tabrizi's reluctance to share facts about his personal or familial medical history could be a manifestation of his lack of trust in the medical team. His trust only deteriorates as he remains adamant about consuming a minimum amount of hospital food for fear of the presence of pork products. An effort to provide details on the nutritional ingredients of the hospital meals, which can generally be obtained from nutritional services, might have been a simple gesture that could have helped gain Mr. Tabrizi's trust and facilitated his cooperation with the medical team. If we try for a moment to see the world from Mr. Tabrizi's eyes, we will probably see a 69-year old isolated male who speaks no English, in an unfamiliar hospital setting, sick, and anxious for test results. It all indicates a very vulnerable and fragile person with an exacerbated sense of helplessness and frustration for lacking the ability to relay his own basic needs and wishes. One empathizes with the medical team and the many procedures and quality of care that need to be provided equally to all patients, but it is little gestures like these-providing culturally competent interpretation, ensuring the patient is aware of the food ingredients, providing reading material in the patient's native language, etc.-that could very well have bridged the gap between the patient and the medical team and provided an avenue for culturally competent communication.

Yet, despite the warning signs, Dr. Looke, having received the test results, proceeds to tell Mr. Tabrizi the grave diagnosis through his son. If we analyze the conversation, we will note the following cultural packaging of news that the son remarkably accomplishes, in spite of tremendous stress:

Dr. Looke Mr. Tabrizi's son
Mr. Tabrizi has extensive small cell lung cancer. The doctor believes that Mr. Tabrizi is very sick.
Mr. Tabrizi most likely does not have long to live. [There is no indication that the son translated this statement.]
There are basically "two possible treatments" available for this cancer: chemotherapy and radiation; The doctor says he must do two things to care for himself: eat well and get more rest.
Dr. Looke strongly prefers beginning with the first (chemotherapy). Mr. Tabrizi could take some "strong medicines" which would most likely help him to get better.


                                                           
As the encounter above clearly shows, what the son does, given the grave diagnosis, is to filter out any terms that could cause emotional distress to his father, a choice of action that we can say is generally present among Muslim patients. What is puzzling about the difficult conversation that Dr. Looke has with Mr. Tabrizi and his son is that each party does what is culturally expected of it to do. Per hospital and ethical mandates, Dr. Looke makes sure fully to inform the patient of his diagnosis. The son, on the other hand, makes sure to shield his father from the emotional impact of bad news, perceived to cause a negative impact tantamount to or more severe than the diagnosis itself-especially given how sudden and grave the news is.

Many Muslim patients seem to cope better with a culturally-sensitive packaging of grave news, and that almost always also implies a gradual disclosure of a negative prognosis, an approach that may not be available to Dr. Looke, given the other patients he has to see and the limited time he can spend with Mr. Tabrizi and his family. After such a stressful encounter as the one described here, one would hear the sad lamentation, "They just do not understand us!" from some Muslim patients and their families. Dr. Looke as well as the Tabrizi family would have been in a better position if the doctor had sought to ascertain whether or not Mr. Tabrizi wished to be fully informed of his medical condition. If the patient had forfeited his right to know, the family could then have chosen to disclose the information as gradually as it wanted to.

The issues described in this case are not easy to resolve, since for all parties involved, they revolve around what is perceived as crucial to a patient's wellbeing, i.e. to be fully informed of the medical condition (Dr. Looke's position), and not to be told bad news for fear of its impact (the Tabrizi family's position). Perhaps the answer lies in a resolution as described above, one that could clear the clinician of any ethical impropriety and nevertheless respect the patient's cultural requests. Such resolution might bring the clinicians out of their comfort zone as they are asked to respect cultural values that they may not necessarily embrace.

Finally, Mr. Tabrizi's case highlights the crucial need for more collaboration between hospitals and their local Muslim communities, or on a national level between the healthcare communities and the U.S. Muslim umbrella organizations. The fruit of such collaboration could be community outreach programs, devised by both entities and focused on Muslim patients' needs and issues such as: patient autonomy, explanation of Muslim patients' rights and responsibilities, advance healthcare directives, palliative care, and organ donation. In fact, the discussion of such important topics is almost non-existent in many Muslim communities, yet Muslims, as patients, continue to face them every day when a loved one falls sick, and they often struggle to find satisfactory answers alone. Such a preemptive program could provide an open forum for discussion of sensitive topics, with the involvement of concerned individuals, such as Muslim religious scholars, physicians, and patients. Such discussions are sure to raise awareness and generate practical and helpful recommendations for the healthcare organizations and for Muslim patients.

This collaboration could also prove very helpful in identifying local Muslim individuals who are willing to provide support to their co-religionists in cases of emergency. These individuals, such as local Imams, chaplains, or trained Muslim volunteers, could act as a bridge between the medical team and Muslim patients, which would have been invaluable in the case of Mr. Tabrizi.

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.

February 2008