Exploring the Ethical Dimensions of Cross-cultural Patient Care

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Clinical Scenario

You’re seeing a patient who’s new to your practice, a 68-year-old female immigrant from a Middle Eastern country. The patient is dressed in the traditional manner of her native country, and she’s accompanied by her husband, neither of whom speak English. She has been referred to you for an evaluation of a lower neck mass that has been steadily enlarging over the past three months, as well as for progressive hoarseness and a cough.

Owing to the patient’s language, you access a telemonitor-based interpreter before entering the room; you’re accompanied by one of your resident physicians. It has been your custom to greet patients with a handshake, but you’re uncertain whether to do so with this patient. You proceed with the introductions via the interpreter on the video monitor. You note a series of long exchanges between the interpreter and the husband, rather than the patient, and the interpreter’s responses to you in return are rather brief. Obtaining a history turns out to be a drawn-out affair of long exchanges during a three-way dialogue.

When you finally get to the examination portion of the evaluation, the patient seems rather reluctant to be touched by you or your resident. The patient clearly has a weak voice, which you suspect is due to a paralyzed vocal fold, as well as a large, firm unilateral neck mass, likely thyroid in origin. As you request to be allowed to perform a fiberoptic trans-nasal laryngoscopy and explain the procedure, you see that the patient looks to her husband for permission. Describing the procedure and answering questions via the interpreter takes a fair amount of time. You explain your concerns about the neck mass representing a neoplasm of the thyroid gland with an attendant paralyzed vocal fold. You again recommend the fiberoptic laryngoscopy, as well as a fine needle aspiration biopsy, followed by a series of diagnostic scans, and seek the patient’s agreement to proceed with the endoscopy. After considerable information exchange using the interpreter, the husband decides that he will need time to consider the diagnostic plan and requests a return appointment in the future to further discuss the procedures. You agree to this plan, but caution that time is of the essence and excessive delay wouldn’t be in the patient’s interest.

How can you ensure that ethical patient care and communication are maintained while navigating cultural differences? read further for discussion.