Culturally Competent Ethical Decision Making - Essay Example

? Culturally Competent Ethical Decision Making of Teacher Culturally Competent Ethical Decision Making Step Description of the issue The case of Maya, who was a patient under my care in the psychiatric ward in Southern Health, was a case which presented before me the greatest culturally defined ethical dilemma I ever experienced in my profession so far. Maya was a 28 year old Asian woman married to a White American and she had an 8-year old son in that marriage. She was admitted to the hospital after she started showing symptoms of extreme depression and anxiety. All this had started after she came to know that she was into her second pregnancy but she could not proceed with that pregnancy because of a tumor that the two-month old fetus had developed, which called in for an abortion. Her husband, Thomas was banking professional who was going through a period of serious financial crisis owing to the economic recession and resulting salary cuts. I came to know from Maya, her husband and his sister that she dearly wanted the baby to be born. As I could involve her into an intimate personal conversation, she told me that her parents were eagerly awaiting the birth of her second child as there was a belief in her family that the second child of every girl in the family would be a girl child and she would be the cause of prosperity for the family (because their community had a matrilineal family system). In Maya’s current pregnancy also, the medical tests had showed that she was carrying a girl child. The family legend was that if you do not let the second child to be born, the whole family would be cursed. Her gynecologist had advised that if she wanted, she could retain her pregnancy but the child would live only for a very short period of time and that too in misery. This was a situation that Thomas wanted to avoid at any cost and hence he was trying to convince her to undergo an abortion. And he also did not have any faith in her family legend. But Maya was not totally uninfluenced by the family traditions and her father adamantly believed in that. And Maya and her parents were against abortion in their beliefs. Thomas had called her parents in Sri Lanka over phone to tell them that she needed to terminate the pregnancy but after that her father had refused to attend her or her husband’s calls. He had also wrote her a letter telling that destroying the child would bring in a curse on the family and will affect even the generations to come. He also wrote that she should keep her trust and leave the rest to God. After listening to Maya and all who were concerned (including Thomas, his sister Emma, Maya’s friend Lisa and Maya’s mother over phone), I was faced with an ethical dilemma- whether to support Maya in her decision or to try to convince her to undergo an abortion. I had heard that tumors in children have a better chance of getting cured than in adults but I had no scientific data available on that. So I started collecting data from books, scientific publications and authentic websites. The conclusion that I arrived at was that many tumors in children have a chance of getting cured and also I came to know that “over half of the children diagnosed with brain tumors will live more than five years” (Rosenbaum, Dolinger and Rosenbaum, 2008, p.549). But still there can be no blanket assurance that the child would survive. But the more important aspect of the problem before me was that Maya and her family belonged to a culture rooted in religiosity and family bonding, while her husband and his family hailed from the Western culture, which is less religious and more individualistic (White, 2005, p.206-207). Hence the ethical dilemma before me was a product of the interaction between two different cultures and hence it demanded certain amount of cultural competence from me as a nursing practitioner. Andrews and Boyle (2008) have drawn attention to this aspect by observing that “[e]quity, fairness, and meaningfulness in caring are fully realized by cultural competent practitioners, organizations and communities” (p. 421). In Maya’ case, there is a difference in perception of the problem between her and her husband basically. I needed to be sensitive to her emotions and beliefs and all the same I also needed to take into consideration what her husband had to say as the wife and the husband had equal moral rights and responsibilities regarding their child. It was evident that her husband loved her and he loved the unborn child as well to such extent that he did not want to let it live a miserable and short life full of pain and then die. All the same, Maya loved her child in a different way that she did not want to destroy it and then she was also considering the child as extra precious because of her religious beliefs. Added with this situation, were the beliefs of her parents who considered the child as their life line, their family’s only hope for future. Both Maya and her parents were believers of destiny. I could notice that Maya was throwing in emotional tantrums very frequently and she had started viewing her husband with some amount of hostility. As I wanted to have some additional information, I had talked to Maya’s friend, Lisa and she told me that Maya’s family bonding with her parents was very strong. She also informed me that Maya had even postponed her marriage with Thomas for almost one year just because her father initially had a dislike for him. But I also weighed inside my mind the fact that despite the religiosity inside her family, Maya had chosen to marry somebody outside her religious beliefs and also went ahead with that. But in the given scenario, what was at risk was not only the life or misery of a child but also the relationship between the husband and the wife, familial relationships and also the psychological well being of my patient. Basically this was Maya’s dilemma but in the process of my professional engagement with her, it was becoming my dilemma as well. And it was also becoming her husband’s dilemma as well. He was trying to rationalize with her and all the same he was also trying to find out a possibility, where he could concede to his wife’s wish. And this was turning out to be an issue in which familial bonding, marital relationship, responsibilities of parenting, pro-life arguments, and cultural beliefs were at play. But as a nursing practitioner, I could not ignore any of these aspects and I needed to tackle this multicultural issue with an ethical decision. The culturally competent ethical decision making tool that I used in this case was the model evolved by Kenyon (1999; as cited in Cormier, Nurius and Osborne, 2008, p.42). As I have discussed above, the first step of this model was to describe the issue, which included the below given components: Who is involved? What is their involvement? How are they related? Whose dilemma is it? What is involved? What is at risk? What are the relevant situational features? What type of issue is it? (as cited in Cormier, Nurius and Osborne, 2008, p.42). Once I described this ethical issue in detail, I achieved clarity of understanding regarding the issue and thus I could move ahead towards the next step of the process. Step-2- Considering ethical guidelines The second step in this ethical decision making process was to consider all ethical guidelines available (as cited in Cormier, Nurius and Osborne, 2008, p.42). This included the following: Consider all available ethical guidelines and legal standards. Identify my own personal values relevant to the issue. Identify societal and community values relevant to the issue. Identify relevant professional standards. Identify relevant laws and regulations. Apply these guidelines (as cited in Cormier, Nurius and Osborne, 2008, p.42). Following these procedures of ethical decision making, I made a study of all available ethical guidelines and legal standards. On theoretical level, I could see that what is ethically right or wrong is decided using different and sometimes mutually contradictory paradigms. For example, there is the American Nurses Association Code of Ethics that has assimilated the values and beliefs of a mainstream Western society, there is the “ethic of care” as is summarized from psychological and feminist theories, which is again based on “empathy, compassion, and relationships that promote trust, growth and well being,” there is the “deontological theory of ethics” which has fixed reason “as the basis for morality”, and also there is the “utilitarian” theory of morality which looks at the end results alone (Andrews and Boyle, 2008, p.409. paras.3-5). And I could understand that a “common source of moral conflict stems from contrasting views of a person between Western and non-Western cultures” as is the case of Maya (Andrews and Boyle, 2008p.411). And when viewed from the angle of religion, I could see that matters on earth can be left to the decision of God within its ethical framework and this was exactly the attitude of Maya’ parents (Andrews and Boyle, 2008, p.411). The legal framework of the country states that “women have a right to abortion before fetal viability, but allows states to restrict abortion access so long as these restrictions do not impose an "undue burden" on women seeking abortions” (National Abortion Federation, 2010). As Maya’s pregnancy has not yet reached a stage of “fetal viability”, an abortion in her case will be perfectly legal (National Abortion Federation, 2010). But all the same, in the US, the pro-life movement is very strong and the issue of abortion is an ongoing hot debate ((National Abortion Federation, 2010). Hence there are community and societal values that are at play in the case of Maya. And the community to which she belongs to is pro-life in a spiritual sense which can have deeper consequences on the decision making process. When my own personal vaues relevant to the issue were examined, I could see that I was closer to the stand of Thomas in my beliefs and attitudes but I was also culturally sensitive towards the beliefs of Maya. And as far as my organization, Southern Health’s policies were concerned, the community is recognized as a major component of health care and hence I needed to conform my ethical decision making to those policies (Southern Health, 2011). Also my organization has a declared commitment that says, “we celebrate our multicultural community as the source of both our consumers and our staff. Consultation with our consumers, carers and the community plays a significant role in the improvement of our health service” (Southern Health, 2011). Step-3- Examine the conflicts In order to apply these guidelines and standards in the specific case of Maya, I examined the existing and possible conflicts that arise in this case. I could see that the very relationship between Maya and Thomas was under threat and also the familial bonding between the individuals and families. Also a decision in favor of abortion was to leave a serious psychological blow in the mind of Maya. But inside my mind, I strongly believed that the unborn baby needed to be saved from all the misery it would go through if born. This was my internal conflict. Externally I faced the conflict between two cultures, Thomas’s Western one and Maya’s non-Western culture. I went on examining the conflicts by listing all the “external” and “internal” ones and then went on exploring whether I could “minimize any of these conflicts” (as cited in Cormier, Nurius and Osborne, 2008, p.42). The only way I could minimize the internal and external conflict was by accepting Maya’s position and to keep my scientific and spiritual faith in medical science and God respectively. Step-4- Resolve the conflict By supporting Maya’s position, I could get closer to create an atmosphere where she could improve psychologically. Along with this, I further studied relevant literature and collected scientific data to convince Thomas about the curability of the disease of the unborn baby. I also consulted seniors, my colleagues and my supervisors to verify whether my decision to support Maya was ethically right. I organized a review meeting for Maya’s case inside the organization involving experts and they also supported this decision. I also arranged a counselor’s assistance for Thomas so that he is not forced into a decision that was painful for him. Step-5- Generate Action alternatives The next step in this model was to evaluate the alternative actions possible and in this case, the only alternative was to convince Maya to undergo an abortion. But as is discussed above, I could see that such a decision would be culturally insensitive and also in violation of the codes of ethics and principles. Step-6- Examine and evaluate the action alternatives In order to examine and evaluate the action alternatives, I examined the “client’s and all other participants’ preferences based on understanding of their values and ethical beliefs” (as cited in Cormier, Nurius and Osborne, 2008, p.42). Then I had to eliminate the alternative that was discussed above as it was against the values and beliefs of the client and also a majority of other participants (as cited in Cormier, Nurius and Osborne, 2008, p.42). Also as the nursing ethics demands that the practitioner respect the autonomy of the patient, I had to give more weight age to her decisions and wishes (Butts and Rich, 2005, p.12). Step-7- Select and evaluate the preferred action I decided to take the increased possibility of curability of tumor in children as a valid ground to convince Thomas that Maya could give birth to this child. All the same, I tried to reason with Maya that she should pay more attention to the material aspects of the life of her child and not merely to the spiritual aspects emerging from the family legend and so on. I felt that on evaluation, this option was the best to keep the marital and familial bonding intact and also it would keep open a possibility that the child could get cured or get a prolonged and pain-free life. And this was an option that would impart a profound spiritual strength to the client and the participants. Step-8- Plan the action I planned the further course of action according to the above discussed conclusions and developed a step by step action plan. First, I tried to emotionally settle down Maya by telling her that her concerns will not be overlooked. Then I went on to help Thomas also settle down emotionally by getting him the help of an expert counselor. It was decided that Maya and Thomas would have a series of sessions between themselves so that neither feel regret on the decisions being taken. With proper and safe medication, Maya’s anxiety was brought under control. Step-9- Evaluate the outcome As the next step in the ethical decision making model that I was using, I evaluated the outcome. I could see that Thomas was slowly accepting the possibility of having the second child and caring for her. Maya was also visibly relieved and at peace with Thomas and her family. The emotional support that she got from her community and her family was amazing and the couple also got a couple of visitors from pro-life movement who gave them courage and encouragement. Step-10- Examine the implications In this last leg of ethical decision making, I closely examined the implications of the decision being made. One major implication was the possibility that the child would be born but not cured of the tumor and suffering a miserable death. But it was evident that it would be getting maximum care from its parents and both the families. Now the child was being looked at as a symbol of hope by both families. Both the families were also considering all available options of treatment, once the child would be born. The faith that they showed seemed to be contagious even for me who had always thought of myself as a totally rational being. And some expert oncologists whom they consulted also expressed hope in the curability of the disease. Personally I felt that whatever the religious beliefs that Maya and her parents held, there was no questioning the depth of their faith and I myself felt respect for that. The whole process of making a culturally sensitive ethical decision in Maya’s case was a great learning experience for me. I realized that there could be cultural values that would be above all scientific reasoning but still holding great sway over the well being of the people. I felt that in my future ethical decision making exercises, the case of Maya could be a turning point and a mile stone. References Andrews, M. A., & Boyle, J. S. (2008). Transcultural concepts in nursing care (5 ed.). Philadelphia: Wolters Kluwer Health / Lippincot Williams and Wilkins. Butts, J.B. and Rich, K. (2005) Nursing ethics: across the curriculum and into practice, Burlington, MA: Jones & Bartlett Learning. Cormier, S., Nurius, P. and Osborne, C.J. (2008) Interviewing and change strategies for helpers: Fundamental skills and cognitive-behavioral interventions, New Delhi: Cengage Learning. Kenyon, P. (1999) What would you do?: An ethical case workbook for human service professionals, New Delhi: Brooks/Cole Publishing. National Abortion Federation (2010) History of abortion, NAF, Viewed 07 October 2011, Retrieved from http://www.prochoice.org/about_abortion/history_abortion.html Rosenbaum, E. Dolinger, M. and Rosenbaum, A. (2008) Everyone’s guide to cancer therapy: How cancer is diagnosed, managed and treated day, New Jersey: Andrews McMeel Publishing. Southern Health (2011) Southern Health, Viewed 30 August 2011, Retrieved from www.southernhealth.org.au White, S. (2005) Foundations of nursing, Connecticut: Cengage. Read More