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Communication through Interpreters in Healthcare:
Ethical Dilemmas Arising from Differences in Class, Culture, Language, and
Power
Joseph M. Kaufert and Robert W. Putsch
J Clin Ethics 1997, 8(1)71-87)
This article, published in the Journal of Clinical
Ethics in 1997, examines the triadic relationship between providers, patients
and interpreters in multilingual medical practice. Even when patients and
providers are educated in the same language, the unstated assumptions of
the medical profession and health care institutitons often lead to distortions
and miscommunications between the two parties. When patient and provider
come from different cultural and linguistic backgrounds and an interpreter
is assigned to serve as intermediary, additional practical and ethical problems
arise. The authors critique theories that emphasize the 'neutrality' and
'accuracy' of interpreters without considering the fallacy of impartiality
in medical interpretation or the power inherent in the interpreter's role.
The role of the interpreter:
The authors note that, in many health care institutions,
language and culture are treated as 'barriers' to effective care. In a traditional
model, clinicians surmount these barriers by choosing a more culturally-appropriate
approach to communication; in this model, the interpreter is seen as an
instrument of the clinician's will, whose purpose is to bridge the linguistic
and cultural gap between patient and practitioner and to make their motives
transparent to each other. This model is evident in the codes of health-care
interpreter ethics the authors have drawn from more than 20 institutions
and organizations, most of which emphasize the 'objective, neutral' role
of the interpreter. Most of the codes were derived from the codes of interpreting
in use in legal settings such as courts and business negotiations. The (adversarial)
legal model imposes severe constraints on the practice of medical interpretation
and on the doctor-patient relationship as mediated by an interpreter. "Medical
discourse has, as a basic goal, mutual understanding," the authors
write; "it is not normally adversarial."
Through a series of case studies, the authors describe
how the model of the neutral, objective interpreter is exceeded or subverted
in actual practice. In one case, an interpreter first asked additional questions
during a history, and then sought to elicit consent for a surgical procedure
without offering a back- translation of her remarks for the physician.
Terminal illness and end-of-life issues
In cases where the interpreter acts as cultural
broker, even with the physician's awareness and consent, they may find that
the patient's cultural background proscribes not just the matter to be communicated,
but the act of communication itself. In the case of terminal illness, US
medical practice uses the device of informed consent to validate difficult
decisions on whether to pursue treatment that can be painful and ultimately
futile. Death and dying are culturally-defined processes, however, and the
way they are discussed is culturally-defined as well. Thus in two case studies,
the authors present patients whose families forbid doctors to discuss a
terminal prognosis directly with the patient. In one of the cases, the family
members themselves refused to hear the prognosis, and asserted that they
want 'everything to be done' to save the patient without engaging in the
specific discussions of treatment alternatives necessary for meaningful
consent as defined by hospital practice. At the same time, a trained medical
interpreter refused to help the doctor communicate the prognosis and the
futility of invasive treatments directly to the patient because it was against
the expressed wishes and cultural practices of the family. Ultimately, the
caregivers chose to withhold all but palliative care on the grounds that
the family were not truly consenting to more invasive alternatives.
In the second case, bilingual family members refuse
to allow a trained medical interpreter from outside the family to assist
in the case, and controlled the decision-making process in their father's
illness through their control of interpretation. Because the bilingual son
and daughter refused to inform their father of his prognosis or of the risks
of treatment, the attending oncologist was unwilling to initiate chemotherapy
for the patient's acute T-cell lymphoma on the grounds that he was unable
to consent. Only after the son and daughter signed the consent agreement
as proxy decision-makers did the oncologist begin the (ultimately successful)
regimen. In both cases, the family members felt that communication of the
prognosis and discussion of treatment alternatives would harm the patient.
Conclusion
The authors conclude that the ethical codes presently
guiding medical interpreters fail are frequently inappropriate given the
nature of medical interaction. Instead, they argue, interpreters' codes
should recognize their roles as actors rather than simply as witnesses in
cross-cultural communication. In particular, models of interpretation should
consider the particular function of interpreters in situations where not
only substantive medical issues (e.g., whether and how to treat an illness)
are contested, but structural matters (e.g., how to convey to the patient
that they are ill) as well.
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