From Paternalistic to Patronizing: How Cultural Competence Can Be Ethically Problematic

Abstract

Cultural competence literature and training aim to equip healthcare workers to better understand patients of different cultures and value systems, in an effort to ensure effective and equitable healthcare services for diverse patient populations. However, without nuanced awareness and contextual knowledge, the values embedded within cultural competence practice may cripple rather than empower the very people they mean to respect. A narrow cultural view can lessen cultural understanding rather than grow it. In its first part, this paper argues that a hasty, unrestrained, and uneducated willingness to accept something as a cultural good, despite being well intentioned, can still cause significant harms-particularly when based on false, misinformed, and stereotypical conceptions-including the minimization of issues, the reinforcement of stereotypes, and the impediment of cultural change. The second part of this paper examines medical autonomy within the context of Saudi Arabian women. It pushes back on the common perception that Saudi women, by virtue of culture and religion, view dependency on and deference to male relatives as a cultural good. Through a historical examination and a presentation of the current women's movement in Saudi Arabia, it is argued that the continued assumption that personal agency is a value external to Saudi women is false, misguided, and ethically problematic. Lastly, this paper considers some approaches to help providers navigate the narrow grounds between paternalism and patronization when caring for patients.

A qualitative study of cancer care professionals’ experiences of working with migrant patients from diverse cultural backgrounds

“…They commonly focus on the individual patient as different rather than difference as emerging from interactions with others (be it other cultural backgrounds, or systems imbued with specific values). Whether focused on comprehension of advice,16 adherence to treatment17 or barriers to communication,18 the emphasis has been placed on the individual and in some respects potential individual deficits that need accommodating 19. Such models of cultural competence have been criticised for addressing culture-in-isolation; focusing on perceived cultural traits; ignoring diversity within ‘culture’; engendering stereotype slippage and erasure of patient individuality; and ignoring the nexus of patient identity and the structural causes of health inequality 19–21.…”

“…Whether focused on comprehension of advice,16 adherence to treatment17 or barriers to communication,18 the emphasis has been placed on the individual and in some respects potential individual deficits that need accommodating 19. Such models of cultural competence have been criticised for addressing culture-in-isolation; focusing on perceived cultural traits; ignoring diversity within ‘culture’; engendering stereotype slippage and erasure of patient individuality; and ignoring the nexus of patient identity and the structural causes of health inequality 19–21. Yet little is known about how healthcare professionals’ experience this evolving sphere of intercultural care—and the everyday dilemmas in achieving culturally competent care—a gap in knowledge that we begin to address in this study.…”

Communication patterns in the doctor–patient relationship: evaluating determinants associated with low paternalism in Mexico

“…However, there are extreme precedents that suggest that the value of life and primary survival nullify the value of truth [46], but this clearly does not constitute a generality in medical practice and is a function of other ethical values. However, in an environment of conservative conscience, with deeply rooted cultural values, paternalism is accentuated, whereas the possibility of autonomy and empowerment of patients [47] is not a consideration. In the psychiatry field, paternalism emphasizes that staff members must ensure the patient's best interest in daily care and treatment, but that decisions are to be taken by the professionals only [48,49].…”

Communication patterns in the doctor–patient relationship: evaluating determinants associated with low paternalism in Mexico.

“…While there are extreme precedents that suggest that the value of life and survival nulli es the value of truth [3], this clearly is not a general principle in medical practice. In an conservative environment with deeply rooted cultural values, paternalism is accentuated, and the possibilities of autonomy and patient empowerment [62] are not considerations. Despite the discomfort and uncertainty that communicating a diagnosis or a poor prognosis can evoke, physicians should have to tell the truth.…”