Abstract
Among the situations, in health and social care practices, that can be experienced as morally challenging are those ascribed to culture. The pandemic presented many examples of cultural ascriptions regarding the adoption of protective measures of infection prevention and also convictions towards vaccination of certain populations or groups. The argument of culture bears the promise to simplify or make manageable or workable what seems otherwise complex and unworkable. Culture can offer a “distress code” 1 for dealing with ethical complexity in clinical practice. Also, the code of Ethics for Nurses – both in its penultimate and the most recent version – states that “… nursing care is respectful of and unrestricted by considerations of age, colour, culture, ethnicity, disability or illness, gender, sexual orientation, nationality, politics, language, race, religious or spiritual beliefs, legal, economic, or social status.” 2
When the notion of culture is brought into play in the context of ethical issues, a dose of genuine skepticism is called for. This is because culture is seldom advocated to explore or to describe difference but rather to explain difference, to give ready-made reasons for behavior that seems to be “deviating” from received or customary patterns of behavior, that is, from what people normally want. Using culture to explain ethical differences can have far-reaching consequences when it comes to clinical decisions, simply because no other explanations are asked for. But the main task of the practice of ethics is to open the field to explore and negotiate alternative explanations which may not be as different as initially assumed.
One recurrent example in clinical practice are families wanting “everything” done for their beloved ones even when death appears to be imminent. In discussing with the families, what was perceived as an issue of culture that raised questions of overtreatment showed itself repeatedly to be a question of trust in the healthcare team and the family’s fear that the patient could be “abandoned”. According to the bioethicist George Khushf, 3 prima facie cultural issues between patients, families and the healthcare team should be considered as ethical issues expressed in culture terms. As an attitude, they require the basic assumption that people normally have reasons that explain their behavior and – as a ground rule – we do not know the whole story or have not sufficiently explored the values that could explain the behavior we observe.
Strangers at the bedside was the powerful metaphor coined by medical sociologist David Rothman in 1992. 4 The traditional ensemble standing around the bedridden patient, traditionally composed of characters like the doctor or the nurse, was enlarged by new characters like the healthcare chaplain and the clinical ethicist, but also the lawyer, the administrator, and the economist. Especially in the fields of palliative care, a new “company” of former strangers has now become narrow friends that gathered around the patient. This interprofessional team stood for a comprehensive culture with a set of axioms that claimed the naturalness of dying, the relevance of allowing death, avoiding futile treatment, and effectively controlling of symptoms of an incurable disease. We have strong reasons for appreciating this holistic approach. It has transformed many aspects of clinical practice when it comes to approaching death and dying. But at the same time, we must be aware that also this is an expression of culture and that not every patient and family might “fit” into the different roles that the culture of palliative care assigns them. Basically because we often do not know the whole story or have not sufficiently explored the values that could explain the behavior.
In resuming the complex relationship between ethics, culture and values, we can say that the practice of health care ethics comprises a threefold task: The first task is to bring these values to the fore and, especially to avoid a conspiracy of friends at the bedside who “apparently know” what is good for the patient, be she living or dying. The second task is to resist the temptation to use “culture” not as a context, but as a pretext for “managing differences” and silencing claims that may be legitimate (such as feeling safe and trusting professionals) 1 and, more simply, to ask for reasons. The third task is to listen to peoples' stories – maybe not from the perspective of an acquainted friend, who apparently understands what worries people – but rather from the perspective of a detached, but deeply sympathetic stranger, who is curious and who listens to the context in which values are expressed, who fosters understanding and facilitates negotiation.
