International Ethics

Submitted by Kristine Kingsley, PhD, and Arshia Ahmed, MD

Treating a patient with a level of sensitivity to cross cultural, intra-ethnic and individual issues may impede or alternatively enhance treatment objectives in rehabilitation. Providing culturally competent assessment and intervention can promote rapport, improve engagement and optimize rehabilitation outcome. Additionally, creating positive, pleasant experiences for a patient can help increase future utilization of healthcare services, an area of special importance for individuals coming from predominantly underserved areas or demographics. The following vignettes can illustrate the importance of considering alternative explanations for a patient’s behavior and applying correct attributions to his/her response to intervention.

Pablo⃰  is a 68-year old Southern European, successful sales manager, who had planned to live it up during his retirement years. A highly outgoing man, he was well known as a generous spender who maintained cordial relationships with his two ex-wives and girlfriends. His plans became short lived when his noncompliance with diabetes forced a below the knee amputation.

In physical therapy, he was viewed often as labile, overly flirtatious with female staff, and not being consistently cooperative with the treatment. His responses to therapists’ urgings were experienced as off-putting, and soon enough therapists were recommending discharge from program. Upon further discussion, a recommendation was made for the patient to be referred to psychology.

Initially reluctant, Pablo was able to form a positive therapeutic alliance with the therapist, and quickly came to verbalize his fears “of falling”, of being trapped at home, of never resuming an active social life, as being sexually undesirable, and helpless. It became clear, that the amputation had highlighted the man’s existential anguish and awareness of his own mortality. It is when fear was acknowledged and validated as appropriate, that it began to lose its paralyzing impact. As Pablo felt more “understood”, he was able to exert more control and became less “demonstrative” with his affective responses.

A second example illustrates the ethical dilemma rehabilitation teams often face when working with adults who have sustained an acquired brain injury, and their families. Although not always readily acknowledged, the majority of American providers possess an individualistic world view in comparison with that of other cultures. That view often “taints” conceptualization of treatment, emphasizing individual rights, over a systemic approach. Finding a way to bridge this gap in the processes and goal(s) of rehabilitation is important to enhance treatment objectives. Below we have depicted an example of the complexity of brain injury within the cultural context introduced by consumers (clients, families) and health care providers.

Myrna is a 28 year old first generation immigrant female of Asian descent; six months ago, she sustained a traumatic brain injury, with significant physical, cognitive and affective sequelae. In treatment, she is significantly limited by anxiety and unrealistic goals.

Multiple providers report that in treatment, she has been unable to discuss plans or goals that do not include the patient returning to 100% of “how she was before.” She is reluctant to engage in home exercise programs, because she does not view them as leading to a “cure”. She rejects compensatory strategies in cognitive rehabilitation because she perceives them as a “crutch”.

The case is further complicated by family dynamics. Myrna’s parents are often viewed by the rehabilitation team as overprotective; mother in particular, is seen as limiting her daughter’s opportunities to try certain daily activities and strides in becoming more independent. Furthermore Myrna and her mother, often appear to have difficulty controlling their anger when they feel that their needs are unmet, and frequently “clash” over Myrna’s interests and attitude toward providers. Both have adamantly deferred psychology.

In many cultures, greater importance is placed on the family unit rather than the individual. Despite being encouraged to allow the patient to attempt to carry out tasks independently, there can be a strong cultural tendency for family members to tend to the patient at every instance where struggling may be detected. In this instance, once the rehabilitation team was able to acknowledge the differences, avoid biases, and refrain from applying any “pathological” labels, the family was able to begin verbalizing feelings of fear, vulnerability, worry, “shame” and stigma over perpetual dependency.

For health care providers it is equally important not to overly categorize individuals according to age, race, ethnicity, social class, urban vs. rural; the diversity encountered in rehabilitation settings may extend to include a plethora of subcultures as well as individual differences. Nevertheless, there are certain themes that are essential in developing skills in providers and as well as culturally competent interventions for individuals with diverse backgrounds.