How To Discuss Ethics With Cultural Sensitivity?

[chronicconic]

Hi everyone. As the title suggests, I am unsure how to discuss ethics without sounding culturally biased.

 

For example, on the topic of circumcision in newborns, I see a violation of the infant's autonomy because the parent's decision is being enforced, which may or may not reflect the child's values. However, I understand circumcision also to be a culturally-based practice in some groups of people that should be respected. Therefore, what would be a culturally sensitive way to discuss the ethical dilemma?

[nick]

What a can of worms. I think that a medical professional cannot cast a blind eye to things s/he has found to be unethical simply because it's a cultural practice or "the way we've always done things." You might take the edge off it a bit by saying something like, "Values are changing and the world is getting smaller, so everyone, including myself, probably engages in some cultural practice that others find objectionable. In that light, everyone has to be open to reconsidering whether their traditional ways of doing things are compatible with modern values of universal freedom and equality." Other things might be to empathize with traditionalists ("they also want what's best for the child"), state that you're not in the position to judge cultures but to give advice/make decisions from a medical perspective, .... I dunno.

[_ _]

Don't say you would force someone to not circumcise a child because you aren't part of a culture that supports it. Leave you views out of it, it's not about your views. Cultural sensitivity is just like working with any other group of people different from yourself, for any reason, and that's the same way I would approach it in the MMI. 

 

I'm guessing you would never tell someone their cultural views were wrong in real life, so just treat this the same way. I think you might find it easier if you relax some of the 'ethical' framework of trying to classify everything into boxes of violations of specific principles, and simply explore the situations and the possible approaches, just explaining your thoughts more than you would in real life

[Bambi]

It is not your place to impose your views or to act in a paternalistic way making judgements. This is not the same as female mutilation. 

[nick]

It is not your place to impose your views or to act in a paternalistic way making judgements. This is not the same as female mutilation.

Isn't FGM an example of what OP is talking about? Medical ethics conflicting with cultural sensitivity?

[EM4me]

Don't say you would force someone to not circumcise a child because you aren't part of a culture that supports it. Leave you views out of it, it's not about your views. Cultural sensitivity is just like working with any other group of people different from yourself, for any reason, and that's the same way I would approach it in the MMI. 

 

I'm guessing you would never tell someone their cultural views were wrong in real life, so just treat this the same way. I think you might find it easier if you relax some of the 'ethical' framework of trying to classify everything into boxes of violations of specific principles, and simply explore the situations and the possible approaches, just explaining your thoughts more than you would in real life

 

     Is this always true? I mean, it was a cultural practice in 18th and 19th century America (and for a time, Canada) for people to own and trade slaves. The same thing was happening in ancient Greece for more than a thousand years. Slavery was accepted as a cultural practice in these societies; Aristotle claimed that slavery was natural and necessary in Greek society. But I think hardly anyone today would argue that slavery is ethical. Most people today would believe that, even though it was culturally accepted, it was still wrong. If we were asked a hypothetical question about modern-day slavery in another culture in an MMI would we be expected to concede to that accepted cultural view? Or do we lay down our ethical framework, and make an ethical decision about what's right and what's wrong, and then express an understanding for the sensitivity of the issue given that it is/was an accepted cultural practice?

     I know that slavery is an extreme example compared to circumcision, but I am just trying to make the point that just because it is culturally accepted does not necessarily mean that it is right. If someone could make the argument that circumcision in new borns is wrong because it doesn't respect the autonomy or values of the child (in much the same way slavery is wrong because it represents a lack of respect for persons), then aren't they free to express this during the MMI? If I was a physician and I was against circumcising babies, I think that I would refuse to participate in the circumcision of new borns. I agree that I would have no place to tell the parents of the child that their cultural views are wrong, and I would help the parents in finding another physician who was willing to perform circumcision, but I also don't think that it is fair to say that it is not okay to express my views. I might even state my opinions and discuss my concerns with the parents, and allow them to make an informed decision with considerations of safety, autonomy, and culture in mind. If they still decide to follow the cultural practice of circumcision, then that have every right to do so. I would not interfere, but I would also not set my views aside and perform the circumcision just because they said so.

[Bambi]

If I was a physician and I was against circumcising babies, I think that I would refuse to participate in the circumcision of new borns. I agree that I would have no place to tell the parents of the child that their cultural views are wrong, and I would help the parents in finding another physician who was willing to perform circumcision, but I also don't think that it is fair to say that it is not okay to express my views.

 

As an authority figure and as a physician, in my view, expressing your views without the parents seeking your views, is paternalistic and this is no place for a physician to go - unless requested.

[Bambi]

Isn't FGM an example of what OP is talking about? Medical ethics conflicting with cultural sensitivity?

 

The two are absolutely not to be compared. I believe FGM is a criminal act in Canada, at a minimum it is assault causing bodily harm if not grievous bodily harm.

[nick]

The two are absolutely not to be compared. I believe FGM is a criminal act in Canada, at a minimum it is assault causing bodily harm if not grievous bodily harm.

I totally agree with you that FGM is way more severe than circumcision and that one is legal while the other is a crime, but they are to be compared in the limited way that OP brought up: a conflict between universalist medical ethics and cultural practices.

[EM4me]

As an authority figure and as a physician, in my view, expressing your views without the parents seeking your views, is paternalistic and this is no place for a physician to go - unless requested.

 

Fair enough. Thanks for the help! But, is it okay to refuse to perform circumcision (or any other non-life-saving procedure) even if that means going against the parents' wishes? As long as the physician is not forcing his or her views onto the patient, and is willing to refer to another physician?

[SunAndMoon]

I totally agree with you that FGM is way more severe than circumcision and that one is legal while the other is a crime, but they are to be compared in the limited way that OP brought up: a conflict between universalist medical ethics and cultural practices.

the extent to which a cultural practice can be accepted would depend on such factors. and so i would agree that the two should not be compared.

 

if i were to answer that question i would balance the importance of practice X in community A with the conflicting values in our community + the health risks of practice X.

 

Then i would look at the consequences of prohibiting practice X (people would do it in unsafe environments, certain communities may feel like they are unfairly treated), the consequences of allowing/encouraging practice X (if there are risks to those who undergo it and/or their families).

 

ultimately acknowledge the complexity of the issue and concede that the physician should def. not decide about whether a given practice should be allowed or not (only decide if HE feels comfortable doing it given that its permitted) and defer to other authorities which can shed light on the issue (lawmakers, gvt, religious authorities, community leaders, etc.).

[Bambi]

Fair enough. Thanks for the help! But, is it okay to refuse to perform circumcision (or any other non-life-saving procedure) even if that means going against the parents' wishes? As long as the physician is not forcing his or her views onto the patient, and is willing to refer to another physician?

 

Absolutely, just refers the parents to another physician willing to do it.

[Bambi]

I totally agree with you that FGM is way more severe than circumcision and that one is legal while the other is a crime, but they are to be compared in the limited way that OP brought up: a conflict between universalist medical ethics and cultural practices.

 

I would agree with you on a theoretical, philosophical level, but not on a practical level, i.e., not in real life.

[nick]

I would agree with you on a theoretical, philosophical level, but not on a practical level, i.e., not in real life.

Thanks for clarifying. So we have a pretty common scenario, theory and practice not lining up. Which should be changed to avoid charges of hypocrisy? Should we change practice, and ban medical professionals from performing ritual circumcision, or change theory, and, for example, decide that Jewish and Muslim babies just have fewer rights than all other babies (to be clear, I think this is racist and indefensible, but it's a way of resolving hypocrisy)? The medical profession not living up to its own standards is a precarious position to be in.

[SunAndMoon]

I honestly dont see how one could agree with the statement above on a theoretical, philosophical level. The two are clearly distinct in terms of intentions and outcomes. It would be best to be better documented on both male and female circumcision prior to discussing it and equating them, or considering them to be comparable on one ground. 

 

If they are different, then there is no discrepancy between theory and practice

[nick]

I honestly dont see how one could agree with the statement above on a theoretical, philosophical level. The two are clearly distinct in terms of intentions and outcomes. It would be best to be better documented on both male and female circumcision prior to discussing it and equating them, or considering them to be comparable on one ground.

 

If they are different, then there is no discrepancy between theory and practice

They are definitely different in intention and outcome, these are two ethical principles used to answer the same question. The two types of ritual infant genital modification are similar in that they ask the same question (which OP asked), about how to resolve conflicts between universalist ethics and tradition.

[SunAndMoon]

They are definitely different in intention and outcome, these are two ethical principles used to answer the same question. The two types of ritual infant genital modification are similar in that they ask the same question (which OP asked), about how to resolve conflicts between universalist ethics and tradition.

Are medical ethics universalistic?

[nick]

Are medical ethics universalistic?

To my understanding, yes. It's something like "autonomy, benificence, non-maleficence" (sp?), not "autonomy, benificence, non-maleficence, except for Jewish babies." (If anyone's curious why I keep bringing up Jews, it's cause I'm a Jew and I feel less likely to be misunderstood as racist when I'm discussing my own people.)

[SunAndMoon]

To my understanding, yes. It's something like "autonomy, benificence, non-maleficence" (sp?), not "autonomy, benificence, non-maleficence, except for Jewish babies." (If anyone's curious why I keep bringing up Jews, it's cause I'm a Jew and I feel less likely to be misunderstood as racist when I'm discussing my own people.)

These four principles (the three you stated + justice) are universal, but their interpretation is not. Principlism leaves room for different interpretations of beneficence and non-maleficence based on background.

[nick]

These four principles (the three you stated + justice) are universal, but their interpretation is not. Principlism leaves room for different interpretations of beneficence and non-maleficence based on background.

So we agree decisions regarding male infant circumcision should be made on the basis of what is best for the baby (understanding that cultural context might or might not be relevant in specific cases)?

[SunAndMoon]

So we agree decisions regarding male infant circumcision should be made on the basis of what is best for the baby (understanding that cultural context might or might not be relevant in specific cases)?

who decides what is best for the baby in situations where that decision would not significantly impact his health? the parents, society, the justice system?

[CalgStudent]

The circumcision issue is not quite so ethically complex. Circumcision is not recommended in Canada unless otherwise indicated. Thus, although a physician should acknowledge and respect cultural practices involving circumcision, they would be going against practice guidelines by actually performing them. It would be like having a patient who wants to get annual mammograms when the screening is not indicated. The role of the physician in this case, I think, is to explore the practice with the patient and indicate that the procedure is not benign The physician can then explain the risks and that they no longer perform circumcisions unless necessary for other reasons.

[_ _]

     Is this always true? I mean, it was a cultural practice in 18th and 19th century America (and for a time, Canada) for people to own and trade slaves. The same thing was happening in ancient Greece for more than a thousand years. Slavery was accepted as a cultural practice in these societies; Aristotle claimed that slavery was natural and necessary in Greek society. But I think hardly anyone today would argue that slavery is ethical. Most people today would believe that, even though it was culturally accepted, it was still wrong. If we were asked a hypothetical question about modern-day slavery in another culture in an MMI would we be expected to concede to that accepted cultural view? Or do we lay down our ethical framework, and make an ethical decision about what's right and what's wrong, and then express an understanding for the sensitivity of the issue given that it is/was an accepted cultural practice?

     I know that slavery is an extreme example compared to circumcision, but I am just trying to make the point that just because it is culturally accepted does not necessarily mean that it is right. If someone could make the argument that circumcision in new borns is wrong because it doesn't respect the autonomy or values of the child (in much the same way slavery is wrong because it represents a lack of respect for persons), then aren't they free to express this during the MMI? If I was a physician and I was against circumcising babies, I think that I would refuse to participate in the circumcision of new borns. I agree that I would have no place to tell the parents of the child that their cultural views are wrong, and I would help the parents in finding another physician who was willing to perform circumcision, but I also don't think that it is fair to say that it is not okay to express my views. I might even state my opinions and discuss my concerns with the parents, and allow them to make an informed decision with considerations of safety, autonomy, and culture in mind. If they still decide to follow the cultural practice of circumcision, then that have every right to do so. I would not interfere, but I would also not set my views aside and perform the circumcision just because they said so.

Yeah, sure....I meant in the situation they described but if you want to extrapolate it to slavery than that's an entirely different topic and I'm not saying they should support slavery by any means...

[EM4me]

Yeah, sure....I meant in the situation they described but if you want to extrapolate it to slavery than that's an entirely different topic and I'm not saying they should support slavery by any means...

 

 

     I wasn't insinuating that you support slavery or that you were suggesting that OP should support slavery, I was just arguing the point you made about cultural practices trumping ethics in all cases: "I'm guessing you would never tell someone their cultural views were wrong in real life, so just treat this the same way." All I was saying is that sometimes it is right to question someone's cultural views, because cultural views are not always ethical. You're speaking in absolutes when you say they would "never" tell someone their cultural views are wrong in real life. In an ethically-charged scenario, use of absolutes will get you into trouble. There's usually an exception to every rule. I used the extreme example of slavery (which I acknowledged was extreme in my previous post) to try and drive that point home. i.e. Slavery is an example of a time when it was appropriate to tell people that their cultural views were unjust and wrong.

     Basically, I disagree with your point about leaving your views out of it, and about never telling someone that their cultural views are wrong in real life. Sometimes standing up against injustice means speaking out against cultural practices (like slavery, as an extreme example). In my opinion, circumcision of young males is not a huge injustice, so I wouldn't personally object to it as a cultural practice, but I'm sure there are some doctors who would object on ethical grounds. And I think that they have every right to object, as long as they can refer their patient to a doctor to provide the procedure. If doctors weren't able to reason through problems to determine what is right and what is wrong, they might as well be replaced by pill-dispensing robots. That's what I was trying to get at... maybe my slavery example detracted from my main point.

[SunAndMoon]

     I wasn't insinuating that you support slavery or that you were suggesting that OP should support slavery, I was just arguing the point you made about cultural practices trumping ethics in all cases: "I'm guessing you would never tell someone their cultural views were wrong in real life, so just treat this the same way." All I was saying is that sometimes it is right to question someone's cultural views, because cultural views are not always ethical. You're speaking in absolutes when you say they would "never" tell someone their cultural views are wrong in real life. In an ethically-charged scenario, use of absolutes will get you into trouble. There's usually an exception to every rule. I used the extreme example of slavery (which I acknowledged was extreme in my previous post) to try and drive that point home. i.e. Slavery is an example of a time when it was appropriate to tell people that their cultural views were unjust and wrong.

     Basically, I disagree with your point about leaving your views out of it, and about never telling someone that their cultural views are wrong in real life. Sometimes standing up against injustice means speaking out against cultural practices (like slavery, as an extreme example). In my opinion, circumcision of young males is not a huge injustice, so I wouldn't personally object to it as a cultural practice, but I'm sure there are some doctors who would object on ethical grounds. And I think that they have every right to object, as long as they can refer their patient to a doctor to provide the procedure. If doctors weren't able to reason through problems to determine what is right and what is wrong, they might as well be replaced by pill-dispensing robots. That's what I was trying to get at... maybe my slavery example detracted from my main point.

I agree on everything you have said except I would reformulate the end: "If doctors were't able to reason through problems to determine what is right and what is wrong to them, they might as well be replaced by pill-dispensing robots". 

 

IMO, physicians should hold themselves to high ethical standards but are not to put themselves at a moral high ground. Objecting to different cultural practices on moral or ethical grounds should only be translated in practice as a refusal to be directly involved in many cases, such as male circumcision or PAS for instance. 

 

If little harm is done by executing a certain practice, and if that practice is important to the people involved (Jews and Muslims), then we should have no right in labeling it as reprehensible or in trying to suppress it.