A Cross-Cultural Dialogue on Health Care Ethics

Part IV, Conclusion

Part IV, Conclusion Joan Anderson and Patricia Rodney Listening to diverse voices At the outset of Part IV, it was claimed that health policy must aim for public participation that is sufficiently diverse to represent a wide range of meanings. It was further claimed that achieving this would require critical self-reflection on the part of those who develop and implement health policy. Chapter 13 by Blue, Keyserlingk, Rodney, and Starzomski underscored the importance of both claims in a North American context. Wolf (1994) warns that the professional-patient relationships most likely to flourish in our current North American era of cost containment will be those in which patients: [are] of a cultural background similar to the [professionals'], are not engaged in activities disapproved by the dominant culture and law, ... are not from population groups historically subject to bias within and outside the health care system, and ... have financial resources and a sense of options in their lives. (32) In other words, at least risk are those who come from a culture that is 257 258 A Cross-Cultural Dialogue on Health Care Ethics congruent with the culture of the professionals who practise within the dominant biomedical paradigm. If public participation in health policy development and implementation is to make a difference here, we will need to become more critically self-reflective about what we mean by participation. The concept of participation has become a key word in North American discourse on health, health care, and health research. Not only are we told that people should participate in decision making about their health and health care, but the notion of "consumer" participation extends to involving lay people in defining research problems in their community and in taking an active role in carrying out research projects. The pervasive ideology in some areas of research (such as health promotion research) is that people should have a say in what is researched, how it is researched, and how research findings are disseminated and used. This process, it is claimed, is in and of itself "empowering". While we do not disagree with the intent of such participation, we feel that the ideology in which the intent is embedded obscures a number of issues. First, as was indicated in chapter 13, fundamental social inequitiesoperate to exclude people from this participatory process. While participation is presented in ways that give the impression that the underclass in particular will now have a voice, in reality this is not the case. For instance, Anderson's research over the years has shown that a number of factors (particularly the contingencies of everyday life) operate in the lives of racialized women that exclude their voices from the discourse on health that takes place among middle class academicians and health care providers (Anderson 1996; Anderson et al. 1991; Anderson et al. 1997). Even if such women had the time or the inclination to participate in the discourse on health, the language of health professionals and the culture in which they operate exclude those who do not have access to the forms of thought and ways of speaking of the privileged. It is not just lack of English language skills that exclude people; even those who speak English might find no common ground of understanding with middle class health professionals and academics. But there is a further point that needs to be recognized. Women, such as those who speak in Anderson's research, are active agents who have their own notions about health and the health practices that they wish to use in their families. They may look to the professional sector for illness care and the notion of participation may have little meaning to them. Health may be viewed as encompassing domains of spiritual well-being, domains that might be best managed in the family through holistic healing practices that are far removed from Western "health care/illness care" systems. Such alternate views of health were certainly portrayed by Hui and Tangkanasingh in PartIV, Conclusion 259 chapter 14 and by the authors in Part III. Participating in programs to promote health that deal with health in a mechanistic way (e.g. diet and exercise) may be of little interest to those who conceptualize health as encompassing a more holistic perspective on life. The issue then is that the very notion of participation as conceptualized within our current North American discourse is constructed from within a eurocentric cultural perspective of...