Cross-Cultural Issues and Diverse Beliefs

Cross-cultural Issues and Diverse Belief

NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion.  Please check back soon for updates!


Douglas S. Diekema, MD, MPH, Professor, UW Dept. of Pediatrics, Adjunct Professor, UW Dept. of Bioethics & Humanities

Core Clerkships: Pediatrics I Rehabilitation Medicine

Related topics: Physician-Patient Relationship I Parental Decision Making I Termination of Life Sustaining Treatment 


Topics addressed:

  • Why is it important to respect what appear to me to be idiosyncratic beliefs?
  • What are some ways to discover well known sets of beliefs?
  • What is my responsibility when a patient endangers her health by refusing a treatment?
  • Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?
  • What kinds of treatment can parents choose not to provide to their children?
  • Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing?

Patients may bring cultural, religious and ideological beliefs with them as they enter into a relationship with the physician. Occasionally, these beliefs may challenge or conflict with what the physician believes to be good medical care. Understanding and respecting the beliefs of the patient represents an important part of establishing and maintaining a therapeutic relationship. While the principle of respect for autonomy requires that a physician respect the medical decisions of a competent adult patient, in cases of surrogate decision-making, the physician has an independent duty to guard the interests of the patient.

Why is it important to respect what appear to me to be idiosyncratic beliefs?

Respecting the beliefs and values of your patient is an important part of establishing an effective therapeutic relationship. Failure to take those beliefs seriously can undermine the patient's ability to trust you as her physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it.

What are some ways to discover well known sets of beliefs?

There are many groups that share common sets of beliefs. These belief systems may be based on shared religion, ethnicity, or ideology. Knowledge of these beliefs and the reasonable range of interpretation of doctrine can be very helpful in deciding if unusual beliefs should be respected. Good resources for guidance in this area include patients and family members themselves, staff members with personal knowledge or experience, hospital chaplains, social workers, and interpreters. Unusual beliefs that fall outside known belief systems should prompt more in-depth discussions to insure they are reasonable.

It is important to explore each individual's beliefs, as shared membership in a particular religious or cultural group does not necessarily entail identical belief systems.

What is my responsibility when a patient endangers her health by refusing a treatment?

Adults have a moral and legal right to make decisions about their own health care, including the right to refuse treatments that may be life-saving. The physician has a responsibility to make sure that the patient understands the possible and probable outcomes of refusing the proposed treatment. The physician should attempt to understand the basis for the patient's refusal and address those concerns and any misperceptions the patient may have. In some cases, enlisting the aid of a leader in the patient's cultural or religious community may be helpful.

Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?

Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a significant risk of serious harm to the child's health. Parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering. If necessary, the physician may need to pursue a court order or seek the involvement of child protective services in order to provide treatment against the wishes of the parents. Nevertheless, the physician must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family.

What kinds of treatment can parents choose not to provide to their children?

Parents have the right to refuse medical treatments when doing so does not place the child at significant risk of substantial harm or suffering. For example, parents have the right to refuse routine immunizations for their children on religious or cultural grounds.

Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing?

A physician is not morally obligated to provide treatment modalities that they do not believe offer a benefit to the patient or which may harm the patient. Physicians should also not offer treatments that they do not feel competent to provide or prescribe. However, it is important to take the patient's request seriously, consider accommodating requests that will not harm the patient or others, and attempt to formulate a plan that would be acceptable to both the physician and patient.

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Cross-cultural Issues and Diverse Beliefs

Case 1

A mother brings her 18-month-old daughter to your office for a routine physical examination. The child has had no immunizations. Her mother says that they believe that vaccines weaken the immune system and have heard that vaccination can cause autism.

What is your role in this situation? Can parents refuse to immunize their children?


Case Discussion

Cross-cultural Issues and Diverse Beliefs

Case 1 Discussion

The risk faced by unimmunized individuals is relatively low, and the mother's refusal to immunize does not pose a significant likelihood of serious harm to her child. The physician should be sure that the child's mother understands the risks of remaining unimmunized and attempt to correct any misconceptions about the degree of risk associated with getting immunized. If the mother persists in her request, the physician should respect her wishes.

A 23-year-old Navajo man has injured his leg after a fall. He presents to the emergency room of the reservation hospital where he is complaining of pain. His leg appears to be broken. The man requests that you call a medicine man before doing anything further.

Should you find a medicine man? Should you proceed with treatment?

Case Discussion

As a competent adult, this patient has the right to make decisions about his medical care. You must respect his wish not to be treated until he gives you permission to do so. Calling the local medicine man will show your respect for the patient and strengthen the patient's trust in you and your abilities.

A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, "We'd prefer to take him home and have our minister pray over him."

Can the parents refuse treatment in this case? How should you handle this?

Case Discussion

The physician has a duty to challenge the decision of parents when their refusal of treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his or her view with the family and seek to elicit their cooperation through respectful discussion. The physicians should be open to alternatives that satisfy the parents’ concerns and achieve the goal of keeping the child safe. Inviting the family’s religious leader to the hospital while also providing standard medical therapy may prove to be an acceptable compromise. Should these efforts not result in parental permission, the physician is justified in seeking legal authority (in the form of a court order of authorization from a state child protection agency) to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm.