A Cross-Cultural Dialogue on Health Care Ethics

11. Comparing the Participation of Native North American and Euro-North American Patients in Health Care Decisions

Chapter 11 Comparing the Participation of Native North American and Euro-North American Patients in Health Care Decisions Edward Keyserlingk This chapter compares the relevance of the notions of autonomy, informed consent, and personal choice in the attitudes and expectations of contemporary Euro-North American patients and Native North American patients. The comparison intended is one between the two patient groups, not between two medical "systems" as such, modern biomedicine and traditional healing.1 The specific question addressed is whether Euro-North American patients differ markedly in their views and expectations about individual autonomy, informed consent, and desired participation in health care decisions. The conclusion will be that the gap between the two patient groups in respect to these notions and expectations maybe a narrow one. This is not a claim that the specific terms "informed consent" and "autonomy" are used by both patient groups or that when they are they have identical meanings. David Schneider's observation about some other words 176 Native and Euro-North American Patient Participation 777 is equally applicable to these terms which, like other notions of human agency reflecting conceptions of self and social relationships, are culturally constructed and cannot be used without qualification across cultures as if they are neutral, objective units of analysis (Schneider 1968). Terms such as "informed consent", "autonomy", and "individualism" are clearly indigenous to a Western, and more specifically Euro-North American, context. Nevertheless, in Native North American cultures there exists considerable respect for individual persons and choice. While that may be in part a result of contact with the dominant culture and modern biomedicine, these attitudes are also present in the much earlier sources of those cultures. The conventional view -focused on idealized systems, not contemporary patients One of the origins for a view that there is a wide gap between the expectations of the two patient groups may be the tendency in ethnographic and other studies to compare aspects of medical systems, rather than the attitudes of those availing themselves of the systems. There is no denying that significant differences exist between modern biomedicine and Native North American healing regarding, for instance, curative powers, rituals, and medicines, as well as concepts and sources of health, disease, and illness. Nevertheless, the nature of the relationship both patient groups seek with their healers and the degree of participation they want in decision making is arguably similar. Access to patient attitudes and expectations, particularly those of Native North Americans, is obviously more difficult than is access to information about the medical systems as such. But to the extent that they are available the attitudes are arguably contextually richer and provide more reliable indicators of the distinctiveness of a culture. In this regard Marcus and Fischer (1986, 45) note that contemporary anthropologists are beginning to depend less on "their traditional media, such as public rituals, codified belief systems, and sanctioned familial or communal structures", and are resorting more to "cultural accounts of less superficial systems of meaning". The advantages of shifting from observations about systems to the attitudes, emotions, social relationships, and expectations of people apply equally to analyses about how Euro-North American patients appear to relate to modern biomedicine. Surveys and interviews of Euro-Canadian patients regarding their attitudes and expectations about autonomy, informed consent, and choice suggest that the familiar goal of modern biomedicine as catering to fully autonomous, self-reliant, and biomedically informed patients may be unrepresentative of the actual priorities of real patients. There is a second factor which may contribute to the conclusion that there 178 A Cross-Cultural Dialogue on Health Care Ethics exists a wide gulf between the views of these two patient groups. It is the fact that the two clusters of culture in question, Euro-North American and Native North American, tend to be examined in isolation one from another. Doing so is understandable since the laudable goal is to identify the distinctive features of each group of cultures and medical systems. The result, however, is less attention to the similarities and a degree of romantization of the cultures and medical systems. In reality neither culture group and neither system is static or unaffected by the other. Clearly traditional healing has been more influenced by modern biomedicine than the other way around, and it is the system most under threat. At the same time, however, modern biomedicine is also evolving. It is, for example, less resistant to holistic and...