e-Ethics September 2002
Easier Said Than Done: Ethical Issues in Medical Interpretation
|
Anxious to discuss recent
tests and arrange a surgical consult,
Dr. Cheron remembers that
her patient, Mrs. Kim, speaks only
Korean. Mrs. Kim's teenage niece,
Hana, drove her to today's
appointment. Dr. Cheron knows
from Mrs. Kim's chart that Hana
has interpreted in the past, but is
hesitant to include her in a complex
and possibly emotional conversation.
A secretary in the ER is
Korean, and Dr. Cheron wonders
whether it would be better to ask
her to assist. Immediate access to
a professional medical interpreter
would be ideal, but there is not
one on staff. What should Dr.
Cheron do?
Discussion
This predicament occurs daily
throughout the country. Although
use of family or untrained staff as
medical interpreters is common
practice, it raises serious ethical
concerns.
Dr. Cheron's discomfort over
using Hana to interpret is appropriate.
Communicating patient
information to family and friends
without the patient's consent is a
serious breach of confidentiality.
But can Dr. Cheron obtain genuine
permission under these circumstances?
Mrs. Kim may be reluctant
to express her real feelings
about having Hana present, particularly
since Hana would most likely
translate that request. Hana
herself may feel torn between a
desire to help and feelings of inadequacy or embarrassment that are
difficult to express. Dr. Cheron
intends no coercion, but the situation
itself places a chilling effect
on Mrs. Kim's voluntary choice,
and introduces a role for Hana that
under other circumstances would
be highly improper.
Family interpreters may not
appreciate the importance of confidentiality
regarding conversations
to which they have been privy, and
may convey to others what they
learn. These difficulties would not
be entirely avoided by asking the
ER secretary to interpret. Since
she is not directly involved in Mrs.
Kim's care, she normally would
not have legitimate access to Mrs.
Kim's medical information without
the patient's permission. While all
employees in health care should
understand the importance of confidentiality,
those who do not work
directly with patients or patient
records on a daily basis may not
fully understand its primacy in
respecting and protecting patients.
Apart from these aspects of
informed consent and confidentiality,
there are other matters about
which Dr. Cheron should be concerned.
The fact that Hana is bilingual
does not mean that she can
interpret medical terminology.
(The same would be true of many
bilingual employees.) If Hana
becomes stressed, the accuracy
and completeness of her interpretation
could suffer, and Mrs. Kim
could be deprived of information
crucial to decisions about her care.
Sometimes family interpreters
omit or soft-pedal distressing information.
They may also alter
patient-to-physician communications
because of their own preferences
or opinions about what
course the treatment plan should
take, particularly if they have a
position of decision-making
authority in the family. The result
could be omission of tests or procedures
a patient really wants, or
initiation of treatment the patient
prefers to avoid. While these interpretive
errors may reflect good
intentions, they directly affect medical
treatment and may undermine
a patient's trust in the physician,
the medical team, and the institution
at which care is provided.
Professional interpreters are
trained to balance the highly
nuanced and seemingly contradictory
roles of conduit and advisor.
They must, on the one hand,
translate completely, not deleting,
adding, condensing or altering
information. This task requires
interpretive skill and a professional
demeanor in which the interpreter
acts as a neutral participant. At
times, however, the interpreter
must step out of that neutral conduit
role and advise a physician
like Dr. Cheron of cultural traditions
or beliefs that bear on what
is being said and heard. Professional
interpreters know to indicate
when they are moving from
one role to another so that patient
and physician will correctly attribute
advisory communications to the translator
and not to each other, but it
would be rare for family or untrained
staff acting as interpreters to understand
this dynamic.
When staff members double as
informal interpreters, an important
organizational repercussion is often
overlooked. Employees who interpret
on an ad hoc basis have a sincere
desire to help, and are understandably
appreciated by colleagues like Dr.
Cheron. Clearly, Mrs. Kim's care
would be compromised if there were
no interpreter. But the secretary's
absence from the ER could also
decrease the quality of patient care—
particularly if the department is short
staffed. Someone must cover her
workload, perhaps for a considerable
time, while she assists Dr. Cheron.
While a one-time absence may not
carry serious consequences, repeated
requests for assistance draw an
employee away from the job for which
she is primarily responsible, and her
absences may lower morale in her
area.
Having thought through the drawbacks
of asking Hana or the ER secretary
to interpret, Dr. Cheron is still left
with the question of what to do when
professional interpretation services are
unavailable. Perhaps there are options
beyond those she has considered.
Most hospitals have policies on
communication assistance, including
information about in-house and community
resources. Social services staff
should be able to assist in arranging
alternatives like telephone interpretation.
Anticipating the need for translation,
some hospitals make available
key documents (pain scales, advance
directives, etc.) that have been translated
into languages frequently spoken in
their communities. Increasingly aware
that problems arise when family members
or ad hoc staff volunteers interpret,
some facilities have identified
employees who are willing to serve
formally as volunteer interpreters
when needed. Giving them in-service
training about the interpreter's role,
confirming their language skills with
standardized tests, and coordinating
their efforts in order to respect their
time, results in a better alternative than
family or informal staff interpretation.
Periodically circulating a list of these
employees enables providers like Dr.
Cheron to receive help when needed in
a manner that is responsible and fair to
patients and colleagues. Although Dr.
Cheron was caught unprepared today,
learning more about the services at her
hospital may lessen her frustration in
the future and help her provide the
excellent, ethically sensitive care to
which she is committed.
|
|
|
|
|
|
|
To view other Publications, click
here.
|
|
|
To view other issues of e-Ethics, click
here.
|
|
|
|
