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Case example
Dr. Jordan is a neonatologist providing intensive care for Baby Sanjay, a 2-week-old premature infant with a large unilateral cerebral hemorrhagic infarct (a blood clot in the brain causing bleeding and tissue damage). Because his lungs are not fully developed, Baby Sanjay is currently dependent on a mechanical ventilator to support his breathing. Dr. Jordan believes that Baby Sanjay has a fairly good chance of survival (60–70 percent) with continuing intensive care. It is very probable, however, that he will be both physically and mentally disabled. At this early stage of Baby Sanjay’s development, the degree of his eventual disability is still highly uncertain. It could be mild to profound, and there is a small chance he would survive without disability. Dr. Jordan has provided intensive care for hundreds of infants with medical conditions like Baby Sanjay, and he is committed to preserving the lives and promoting the health and well-being of his patients.
Baby Sanjay’s parents are citizens of India; his father is working temporarily in the USA, but they plan to return to India shortly. They visit their son frequently and are very concerned about his serious medical problems. After hearing that, if he survives, Baby Sanjay will probably be mentally and physically disabled, the parents have asked Dr. Jordan to discontinue ventilator support and allow the baby to die. They explain that in their home city in India, disabled people face severe discrimination; little education, rehabilitation, or health care is available to them. Therefore, they prefer to allow Baby Sanjay to die rather than to live what they believe will be a life of profound suffering and indignity.
To evaluate the parents’ request, Dr. Jordan consults several of his colleagues who received their medical training in India. They corroborate the parents’ claim that mentally disabled persons, and their families, suffer great discrimination and receive little support in India. How should Dr. Jordan respond to the parents’ request?1
The ubiquity of cultural diversity
Until the twentieth century, most of the world’s people lived and died within their own community, region, or nation and had little contact with foreigners or “strangers.” Developments in travel, technology, communication, politics, and economics since that time have transformed this situation in all but the world’s poorest and remotest regions. Increasing global study and work opportunities, and responses to the plight of political and economic refugees, have made the United States, Canada, and western European nations distinctly multicultural societies. In addition to the many immigrants with multiple national, racial, and ethnic origins living in North America and Europe, “native” North Americans and Europeans commonly identify themselves as members of several subcultures, based on shared religious belief (e.g. orthodox Judaism), region (e.g. “Southern culture”), age (e.g. youth culture), gender (e.g. feminist culture), sexual orientation (e.g. gay culture), and even professional affiliation (e.g. biomedical culture). Identification with one or more cultural groups and participation in cultural practices are central to the personal identity and self-concept of most people. I will use the term ‘culture’ in this chapter in a broad sense to refer to the complex and changing set of relationships, practices, beliefs, and values generated and widely shared within a national, racial, religious, or other social group.2
When everyone in a homogeneous community has the same cultural beliefs, values, and practices, they are very likely to agree about how to work together to achieve their common goals. Because people of different cultures and subcultures often do not share important beliefs, values, and practices, they are likely to disagree about what goals to pursue or how to pursue them. And, because decisions about health care are among the most important choices most people confront, cultural disagreements about health care are common occurrences in contemporary multicultural societies. Some of these disagreements have persisted for decades. One prominent example of a longstanding disagreement is the reluctance of health care professionals to comply with the parental refusal of blood transfusions for their minor children by members of the Jehovah’s Witness religious community.3 Another widely discussed example involves a cultural practice of modification of the female genitalia known as “female circumcision.” In the 1990s, US physicians reported requests from recent African immigrants for this procedure. In response, the AMA and other health care organizations argued that the practice is more accurately described as “female genital mutilation” and that it should not be offered or condoned, but some have questioned this conclusion.4 How, then, should health care professionals and patients address these culture-based disagreements? This chapter will examine several moral responses to cultural diversity in health care.
Moral responses to cultural diversity
When culture-based disagreements arise in health care, as in other settings, several different moral responses are possible. I proceed now to a description and evaluation of three common responses, which I will call “moral imperialism,” “moral relativism,” and “moral negotiation.”
Moral imperialism
Proponents of the position I will call “moral imperialism” typically identify strongly with the moral convictions of their own cultural tradition. They may, for example, make the following assertion: “My culture’s moral beliefs are true and must therefore be respected; other cultural beliefs (insofar as they disagree with mine) are false and may be disregarded.”
An obvious advantage of this position is its ability to simplify moral decision-making for its adherents, since it enables them to rely entirely on their own beliefs and to discount the beliefs of those who have different views. If, moreover, one can provide compelling reasons for one’s moral beliefs, then everyone ought to accept and respect them.
The challenge for moral imperialists, however, is to provide reasons or arguments powerful enough to compel the agreement of others. Mere assertion of the truth of one’s beliefs is obviously not enough to convince others, nor is simple appeal to intuition or to one’s own personal experience. The historical record certainly suggests that no one national culture has a monopoly on moral truth, but rather that all are susceptible to immoral practices, including slavery, persecution, genocide, and unjust aggression. Similar charges can be brought against racial, religious, and other cultural groups. Without compelling arguments for his or her own position, the moral imperialist’s out-of-hand rejection of another culture’s moral claims seems disrespectful, even dehumanizing to members of the “foreign” culture.
Moral relativism
The general response to cultural disagreements that I will call “moral relativism” stands in stark contrast to moral imperialism. Rather than asserting the truth of one set of cultural beliefs, the moral relativist questions the ability to make any cross-cultural moral claims. The moral relativist may thus state this position as follows: “There is no legitimate way to evaluate or criticize the moral beliefs of another culture. Each culture’s moral beliefs are valid for that culture.”
Moral relativists obviously show substantial respect for and deference toward the moral beliefs of persons of different cultures. Moral relativists may be inspired by recognition of the great diversity of beliefs and practices across different cultural groups, but it is important to note that this position goes beyond the empirical evidence for wide cultural diversity to make the claim that different cultural beliefs and practices cannot be evaluated outside of their own cultural context. It thus resists the imperialistic or ethnocentric tendency to assume that one’s own beliefs are correct and to impose those beliefs on “primitive” or “inferior” cultures.
Acceptance of moral relativism rules out any criticism of the beliefs of another culture. At least some cross-cultural moral judgments, however, appear to be both meaningful and legitimate – there is, for example, strong consensus in support of judgments like “slavery is wrong” and “human sacrifice is wrong.” Despite their differences, people of different cultures also have significant beliefs and values in common; they can appeal to these shared values and beliefs to reach agreement on moral questions and to cooperate on common projects. The relativistic position may thus underestimate our ability to make and defend cross-cultural moral judgments.
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