Reflections by Marc Tunzi
Poor Ana. While she and her baby received state-of-the-art treatment in many ways, her care really didn't go so well in others-and it's not exactly over yet…
No one in this case - patient, family, or staff-did anything particularly wrong, but many of them certainly could have done a number of things "more right." What makes this case challenging is the fact that those involved probably thought they were doing the right thing.
Ana and her husband assuredly wished to stay in the U.S. and wanted their baby to be born here and become a U.S. citizen. Avoiding prenatal care was simply one aspect of avoiding any kind of "official institution" that might increase the risk of job loss or deportation. Like many who have immigrated to the U.S. in search of a better life (nearly all of our families at some point…), they were willing to make sacrifices to secure their future.
Ana was probably born and raised in a small, rural Oaxacan village, where she never went to school and which she never left before coming to the U.S. Like many of my own Oaxacan patients, she may be very bright-just uneducated. Personally, I like to think of education as a "reverse onion" with layers added on as we learn more; larger layers can only be added on if the smaller and intermediate layers have been built up first. It is impossible to teach anyone anything new if the learner does not have the foundation on which to understand it. Ana had probably never seen a physician nor been in a hospital anywhere before the day she arrived bleeding and in pain at East Valley. C-section? NICU? Can you imagine even trying to obtain informed consent from her with such a combination of language, education, and experience barriers?
But to suggest that she "doesn't seem really to care about her baby" is another thing. Without knowing for sure whether people from her particular Mixteco culture are generally a little stoic-many of my Oaxacan patients are-we can assume that she must have been incredibly frightened. Most likely, she was also acutely depressed, wondering what this meant for her personal future, her baby's future, her relationship with her husband, etc.
The staff at East Valley took care of Ana in the same way, with the same standard, that they would take care of anyone. They followed a very traditional physician-centered, Western medical model, doing what they thought was best. What else could they do? They couldn't talk directly with Ana and there was no obvious surrogate decision-maker; they had to do what they believed was in Ana's and her baby's best interests. The staff's shortcoming was not in their initial emergency care; it was in what followed.
There are two commonly used clinical approaches to cases with cultural conflicts or misunderstandings. One is the LEARN pneumonic 1:
Listen to your patient's perspective (and remember that sometimes you have to elicit it actively…).
Explain your perspective as a medical professional.
Acknowledge the differences.
Negotiate a mutually acceptable plan of action.
The other is a standard set of questions meant to engage and "draw out" a patient's understanding of what is going on 2:
What do you think has caused your problem (or illness or circumstance or situation)?
What do you call the problem?
Why/how do you think it started?
What do you know about it? Do you know others who have it?
How serious is it? How worried are you about it?
What do you believe the treatment should be? What do you think is going to happen?
What is the main problem this situation has caused for you?
What is your greatest fear about this problem?
The first step in using either of these approaches, however, is to recognize the disconnect between doctor and patient or between health care team and family to begin with. It is impossible to see things from someone else's different perspective if you don't actually see that the perspective is different.
And that's what the staff failed to do here. Like most of my own errors, the staff's shortcomings were not acts of commission but acts of omission. It was not what they did; it was what they failed to do.
An analysis of this case from the "principles" approach of Beauchamp and Childress3 would focus primarily on a failure of the principle of respect for autonomy, honoring an individual's right to control his or her own body and health care decision making. The East Valley staff did not appear to obtain informed consent from Ana or her husband at any step of her or their infant's treatment. Staff may have provided information, and Ana and her husband may have signed consents, but even if they did, it was assuredly an automatic process. It is not clear that independent, thoughtful decision making based on real dialogue between the healthcare team and the patient and family took place. The other three major medial ethics principles-beneficence (doing good), nonmaleficence (avoiding harm), and justice-also apply, but less strongly.
Another approach to analyze this case is the "4-box" method, developed by Albert R. Jonsen et. al.4 This method presents medical indications, patient preferences, quality of life concerns, and contextual features as four distinct domains that clinicians must carefully examine. Real life decisions for action result from how these "four boxes" come together as a whole. The last of these "boxes" is particularly relevant to Ana's situation, focusing in on a failure to understand this patient's and this family's special cultural context.
Did staff try to contact a Mixteco interpreter so that they could really talk to Ana and her husband? Did they ask more explicitly about what "cleaning with an egg" would mean? Did they seek out a social worker or other professional from outside their institution to learn about Mixteco culture, habits and beliefs? While hospital staff do not typically do such things, this was not a typical case. The small amount of extra time and money for these efforts pale in comparison to the time and cost of a c-section and several weeks in the NICU.
Should the staff have known better? If this were the first time they had encountered such a case, maybe not. I've made similar mistakes; I suspect we all have. The East Valley staff did what they knew, and several of them made true extra efforts. Let's hope Ana taught them well for the next time. And let's also hope that they've shared their new-found knowledge and skills with those who are caring for Ana and her baby now.
1Berlin E, Fowkes W. A Teaching Framework for Cross-Cultural Health Care: Application in Family Practice. Western Journal of Medicine, 1983; 139:934-938.
2Kleinman A, Eisenberg L, Good B. Culture, Illness and Care. Annals of Internal Medicine, 1978; 88:251-258.
3Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 5th edition. New York: Oxford University Press, 2001.
4Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 6th edition. New York: McGraw-Hill, 2006.
MARC TUNZI, M.D., is associate director of the Family Medicine Residency Program at Natividad Medical Center, Salinas, Calif., and is associate clinical professor of family and community medicine at the University of California, San Francisco, School of Medicine. After graduating from Santa Clara University, he received his medical degree from the University of California, San Diego, School of Medicine and completed a family medicine residency with the University of California, San Francisco, Fresno-Central San Joaquin Valley Medical Education Program. He holds a Certificate in Health Care Ethics from the University of Washington and has served on the Natividad Medical Center Bioethics Committee for fifteen years.