e-Ethics October 2002
The Cultural Context of Complementary and Alternative Healing Practices: Seeking Cooperative Healing
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Delivering the standard array
of healthcare services to increasingly
diverse populations requires
understanding and responding to
a wide range of cultural beliefs
about health, illness, and treatments.
Many people subscribe to
such health-promoting and healing
practices as herbal medicine,
acupuncture, homeopathy, massage,
chiropractic interventions,
bioelectromagnetics, and folk
medicine. Patients often seek out
such interventions, labeled complementary
or alternative medicine
(CAM) by proponents of mainstream
medicine, even as they participate
in more conventional
biomedical care. Given ethical
commitments to respect patients
as persons, seek to do good and
prevent harms, and promote clinical
excellence, conventional
healthcare professionals may
encounter significant ethical questions
involving the healing practices
of cultures that do not have a
biomedical foundation.
S is an 18-year-old Hmong
woman with a history of hemodialysis
treatment for end-stage renal
disease and hypertension. She is
compliant with treatment, but her
parents are uncomfortable with
their daughter's medical care and
her need for continued hemodialysis.
Hmong cultural health prac-tices
are based on the belief that
spirits cause illness and spiritual
healing is necessary to remove
their harmful influence. Without
notifying her nephrologist, her
parents have begun a series of
treatments with a folk medicine
healer—a shaman—well known in
their community.
Recently S was admitted to the
hospital after becoming febrile.
Unfortunately, her dialysis line had
been infected with Staphylococcus
aureus, and a chest X-ray revealed
a complete opacification of her left
chest. A chest tap revealed a
hemothorax with old, thickened
blood surrounding her left lung. A
consultant suggested immediate
surgery to clear out the blood and
possibly restore function to the
lung. S asked that her father make
all healthcare decisions for her.
Communicating through a translator,
he initially agreed to the
surgery, but soon rescinded his
consent.
Guided by their paradigm of
health care, S's family saw the
accumulation of blood as the
result of inappropriate care by her
physician and believed that the
hospital wanted to use the surgery
to destroy the evidence. They
pressed strongly for shamanic
intervention to treat her lung.
Some members of the treatment
team considered S's father
"difficult" and "superstitious."
Other team members supported
the proxy's right to refuse treatment.
They were less sure that the
hemothorax was surgically treatable,
since the blood had been
present for quite some time and
might have damaged the lung permanently.
Others suggested inviting the Hmong shaman to provide
"alternative" treatment at the hospital,
in hopes that the family
could be persuaded to continue
dialysis and perhaps reconsider
surgery. The attending physician
requested an ethics consultation to
review all parties' concerns and
possible options.
S was too ill to participate in
the conference. The committee
invited her father, as proxy decision
maker, and the translator to
attend. In the past, when medical
professionals insisted that a
Hmong family accept biomedical
treatments and avoid using traditional
folk medicine, the result had
been an adversarial relationship.
That outcome typically destroyed
any trust between caregivers and
family and effectively ended the
relationship. In this case, by
involving the family in the ethics
conference, the committee wanted
to demonstrate respect for the
patient's and family's values and
preferences while seeking the best
outcome for the patient consistent
with clinical excellence.
One committee member noted
that, for many people, Western
biomedicine is "alternative
medicine." Another observed that
when patients and their families
refuse interventions that are relatively
benign in nature, healthcare
professionals rarely raise an ethical
eyebrow. The greatest difficulties
occur when patient or family
are unwilling to accept a life-sustaining biomedical intervention
and want a scientifically "unproven"
intervention. When patients choose
CAM treatments and avoid well documented,
effective medical treatments
for serious conditions, clinicians may
feel torn between a desire to respect
the patient's preference and a duty to
prevent harm. Ideally, culturally
respectful approaches should enhance
the quality of care. But what if such
respect leads clinicians outside the
scientific paradigm of medicine?
In this case, two factors seemed
significant: the questionable value of
the surgical intervention and the family's
skepticism about the biomedical
explanation and treatment of S's condition.
The ethics committee concluded
that supporting the family's spiritual
and medical practices and honoring
the refusal of surgical intervention
would serve the greater good. They
hoped that this recommendation
would help restore the therapeutic
relationship, so that the family would
continue their daughter's ongoing dialysis.
The committee accepted a degree
of harm—the potential loss of S's
lung—in the hope that she would continue
to receive life-sustaining dialysis.
As a result of the ethics consultation,
the attending physician agreed to
discharge S home, where she would
receive shamanistic treatment. The
family agreed to a follow-up meeting
in three days to air additional concerns
and develop a further plan of
care. Ten days later, S received a
repeat X-ray. To the surprise of many,
the hemothorax had completely
resolved. Supported by her family, S
continued her dialysis appointments,
and a successful first discussion was
held about the possibility of renal
transplantation.
Medical skepticism about CAM
interventions is based on a perception
that these treatments are unproven,
and a corresponding concern for
patient well-being. Interestingly, some
commentators argue there is a very
fine line between conventional biomedical
interventions and CAM, as much of
Western medical care is based more on
tradition than carefully validated scientific
studies. Wherever one draws that
line, CAM and biomedicine share at
least two central values: a commitment
to the patient's well-being, and a recognition
that trust is vital to the therapeutic
relationship.
Clinicians should assess the cultural
background of each patient and
inquire about cultural values that may
affect health care. Recognizing the
biomedical culture in which they
themselves participate, clinicians
should become aware of specific
beliefs and practices of the populations
they serve—and should always
inquire whether an individual patient
adheres to those cultural beliefs. The
art of medicine requires that practitioners
ask their patients about the
use of CAM and learn enough about
CAM interventions to support the
patient's goals, working always to
minimize harm and maximize cooperative
healing.
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