Medical disclosure and refugees. Telling bad news to Ethiopian patients.

The strong value in American medical practice placed on the disclosure of terminal illness conflicts with the cultural beliefs of many recent refugees and immigrants to the United States, who often consider frank disclosure inappropriate and insensitive. What a terminally ill person wants to hear and how it is told are embedded in culture. For Ethiopians, "bad news" should be told to a family member or close friend of the patient who will divulge information to the patient at appropriate times and places and in a culturally approved and recognized manner. Being sensitive to patients'' worldviews may reduce the frustration and conflict experienced by both refugees and American physicians.     

'Hitting you over the head': oncologists' disclosure of prognosis to advanced cancer patients

The disclosure of prognosis to terminally ill patients has emerged as a recent concern given greater demands for patient involvement in medical decision-making in the United States. As part of the informed consent process, American physicians are legally and ethically obligated to provide information to such patients about the risks, benefits, and alternatives of all available treatment options including the use of experimental therapies. Although not legally required, the disclosure of a terminal prognosis is ethically justified because it upholds the principle of self-determination and enables patients to make treatment decisions consistent with their life goals. To understand oncologists' attitudes about disclosing prognostic information to cancer patients with advanced disease, we interviewed fourteen oncologists and conducted one focus group of medical fellows. Although oncologists reported to disclose prognosis in terms of cancer not being curable, they tend to avoid using percentages to convey prognosis. Oncologists' reported reluctance to disclosing prognosis was conveyed through the use of metaphors depicting the perceived violent impact of such information on patients. Oncologists' reluctance to disclose prognosis and preserve patient hope are held in check by their need to ensure that patients have 'realistic expectations' about therapy. We discuss these data in light of the cultural, ethical, and legal dimensions of prognosis disclosure, patient hope and the doctor–patient relationship, and recommend ways to enhance the communication process.     

Managing the unmanageable: elderly Russian Jewish émigrés and the biomedical culture of diabetes care

In this article, we examine the apparent resistance of elderly Russian Jewish émigrés to the dominant U.S. biomedical model of diabetes treatment. Cultural competence on the part of medical professionals who make assumptions about Russian culture tends to be based on particularly American values of self-control and individual agency. The American consumer model of health care incorporating risk, individual responsibility, autonomy, and choice, when applied to elderly Russian Jewish émigrés, results in a reading of different values and choices as failed self-management or noncompliance. This article argues for a more reflexive understanding of U.S. biomedical culture as a replacement for the current "sound bite" model of cultural diversity.     

The biology of cultural conflict

Although culture is usually thought of as the collection of knowledge and traditions that are transmitted outside of biology, evidence continues to accumulate showing how biology and culture are inseparably intertwined. Cultural conflict will occur only when the beliefs and traditions of one cultural group represent a challenge to individuals of another. Such a challenge will elicit brain processes involved in cognitive decision-making, emotional activation and physiological arousal associated with the outbreak, conduct and resolution of conflict. Key targets to understand bio-cultural differences include primitive drives-how the brain responds to likes and dislikes, how it discounts the future, and how this relates to reproductive behaviour-but also higher level functions, such as how the mind represents and values the surrounding physical and social environment. Future cultural wars, while they may bear familiar labels of religion and politics, will ultimately be fought over control of our biology and our environment.     

An economic theory of patient decision-making

Patient autonomy, as exercised in the informed consent process, is a central concern in bioethics. The typical bioethicist's analysis of autonomy centers on decisional capacity--finding the line between autonomy and its absence. This approach leaves unexplored the structure of reasoning behind patient treatment decisions. To counter that approach, we present a microeconomic theory of patient decision-making regarding the acceptable level of medical treatment from the patient's perspective. We show that a rational patient's desired treatment level typically departs from the level yielding an absence of symptoms, the level we call ideal. This microeconomic theory demonstrates why patients have good reason not to pursue treatment to the point of absence of physical symptoms. We defend our view against possible objections that it is unrealistic and that it fails to adequately consider harm a patient may suffer by curtailing treatment. Our analysis is fruitful in various ways. It shows why decisions often considered unreasonable might be fully reasonable. It offers a theoretical account of how physician misinformation may adversely affect a patient's decision. It shows how billing costs influence patient decision-making. It indicates that health care professionals' beliefs about the 'unreasonable' attitudes of patients might often be wrong. It provides a better understanding of patient rationality that should help to ensure fuller information as well as increased respect for patient decision-making.     

Attitudes among NHS doctors to requests for euthanasia.

OBJECTIVES--To explore NHS doctors'' attitudes to competent patients'' requests for euthanasia and to estimate the proportion of doctors who have taken active steps to hasten a patient''s death. DESIGN--Anonymous postal questionnaire, with no possibility of follow up. The survey was conducted from December 1992 to March 1993. SUBJECTS--All (221) general practitioners and 203 hospital consultants in one area of England. RESULTS--273 doctors responded to a question on whether a patient had ever asked them to hasten death. Of these, 163 had been asked to; 124 of these had been asked to take active steps to hasten death; 38 of 119 (32%) of these had complied with such a request (95% confidence interval 23% to 40%). This proportion represented 12% of all those who returned a completed questionnaire and 9% of all those who had been sent a questionnaire (95% confidence interval 6.3% to 11.7%). A larger proportion of the respondents (142/307 (46%)), however, would consider taking active steps to bring about the death of a patient if it was legal to do so. CONCLUSIONS--Many doctors face difficult decisions about euthanasia. For the benefit of both patients and doctors euthanasia should be discussed more openly.     

Managing the Unmanageable: Elderly Russian Jewish Émigrés and the Biomedical Culture of Diabetes Care

In this article, we examine the apparent resistance of elderly Russian Jewish émigrés to the dominant U.S. biomedical model of diabetes treatment. Cultural competence on the part of medical professionals who make assumptions about Russian culture tends to be based on particularly American values of self-control and individual agency. The American consumer model of health care incorporating risk, individual responsibility, autonomy, and choice, when applied to elderly Russian Jewish émigrés, results in a reading of different values and choices as failed self-management or noncompliance. This article argues for a more reflexive understanding of U.S. biomedical culture as a replacement for the current "sound bite" model of cultural diversity.     

Culture,dental professionals and oral health values in multicultural societies: measuring cultural factors in geriatric oral health research and education

Culture has significant impacts upon professional practice and patient health behaviours, especially in multicultural societies. This paper introduces the concept of culture and examines how it may be of importance to dental health professionals. Using the Dental Impact Profile and other dental social science measures, dental researchers and students can be engaged in studying cultural values and characteristics as a way of dealing with cultural differences.     

The practitioner,the patient and resistance to change: recent ideas on compliance.

Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients'' lives. This article focuses on how clinicians'' consulting methods can affect patients'' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients'' intrinsic motivation to make their own decisions. This approach also promotes clinicians'' acceptance of patients'' decisions, even if these decisions run counter to current medical wisdom.     

Ethnic intermarriage in Britain

Hebrewism, Globalized Israeliness and Mizrakhiut are examined as three major variants of Israeliness that struggle between them over dominance in the Israeli field of national culture. By discussing typical styles of literature and popular music associated with each variant, it is demonstrated how each is committed, albeit in a different way, to the belief in the idea of 'one nation - one culture', and to the construction of one, unique 'Israeli Culture'. Israel serves as a case to support a general argument about contemporary national cultures being a 'Bourdieusian' field in which invented tradition, global culture and sub-national / 'ethnic' culture are the major types of positions, struggling between them to define the dominant national cultural capital.     

Media and breastfeeding: Friend or foe?

This short essay examines infant formula marketing and information sources for their representation of "choice" in the infant feeding context, and finds that while providing information about breast and bottle feeding, infant formula manufacturers focus on mothers' feelings and intuition rather than knowledge in making decisions. In addition, the essay considers how "choice" operates in the history of reproductive rights, shifting the discourse from a rights-based set of arguments to one based on a consumerist mentality. Utilizing the work of historian Rickie Solinger and a 2007 paper for the National Bureau of Labor Statistics, I argue that the structure of market work, and not abstract maternal decision making, determine mothers' choices and practices concerning infant feeding. For true freedoms for mothers to be achieved, freedoms that would include greater social provisions for mothers, our culture will have to confront how structural constraints make breastfeeding difficult, as well as how the concept of choice divides mothers into those who make good choices and those who do not.     

Cultural Orientation and Its Associations with Alcohol Use by University Students in China

Cultural orientation is defined as an individual’s cultural preferences when encountering imported culture while still living in the native culture. Data was analyzed from 1305 Chinese university students attending universities in Beijing, Kunming, and Wuhan. Cultural orientation was assessed with the Chinese Cultural Orientation Questionnaire, which assesses both Western and Traditional Chinese cultural orientations. The analysis used hierarchical logistic regression with nondrinkers as the reference group and controlling for demographic factors (age, gender, and urban/rural background). Western cultural orientation was found to significantly increase the odds of recent drinking. The results indicated that higher Western cultural orientation was, after gender, the second most important factor associated with Chinese college student drinking frequency. Traditional Chinese cultural orientation was not associated with drinking frequency. This study highlights an unexpected outcome of globalization on students who have not left their home cultures.     

Charismatic Catholic Renewal in Bougainville: Revisiting the power of Marian devotion as a cultural and socio‐political force

This article explores the interplay between culture and Christianity by detailing the history, experience, and impact of the Charismatic Catholic Renewal in the Autonomous Region of Bougainville in Papua New Guinea (PNG). In 1985, the PNG Catholic Bishops' Conference approved the charismatic movement as one of the authentic movements for spiritual renewal of the Catholic Church in PNG. However, the conference stressed this renewal not to be made independent or outside of the Church. In this article I discuss how in Bougainville the Catholic Charismatic Renewal (CCR) has been predominantly operating ‘outside’ the institutional Catholic Church, drawing upon both Catholic and cultural logics to mobilise devotees across Bougainville towards renewal and political change. In particular, I will focus on various local Marian movements, elucidating the power and force of the CCR in contexts of Bougainville's civil war (1988–1998). In doing so, this paper will explore what Catholicism and CCR may contribute to discussions about the positioning of culture within Christianity, at the same time showing how charismatic Marian devotion invites reassessment of recent prevailing discussions on cultural ‘continuity’ versus ‘rupture’, as well as doctrinal boundaries held so dearly by the CCR and the Roman Catholic Church in general.     

Environmental Exchange Box

In this activity, teachers in one state create and share an “exchange box” of environmental and cultural items with students of another state. The Environmental Exchange Box activity enables teachers to improve students' skills in scientific inquiry and develop attitudes and values conducive to science learning such as wonder, curiosity, and respect for different social perceptions. Teachers will be able to work beyond the limits of the classroom and introduce outside resources to help increase students' global awareness and promote respect for the culture and environment of diverse populations. Specifically, this activity can help teachers fulfill national Teaching Standards B, D, and E.     

Attitudes and sterotypes of supporting fields towards the persons with disabilities

The aim of this research was to establish the attitudes, the views and reactions of the helping fields (which include social workers and medical nurses) and those who aren't the part of that cathegory, towards the mentally ill people. One hundred and twenty persons questioned have taken part in this research where in the group of supporting fields consisted of social workers and medical nurses (N = 40). The questionnaire was used in examining the attitudes of those questioned persons, the questionnaire that was used in Joki?-Begi?'s research (2005) and it turned out to be a really good one in defining the attitudes and stereotypes towards the mentally ill persons. The questionnaire consisted of several parts in which different things have been examined such as stereotypes, knowledge, attitudes, level of acceptance and social- demographic information. The research has shown the differences among the attitudes and the level of acceptance of the mentally ill as well as the level of knowledge which the examinees had. All the examinees that have been the part of this research mentioned "ill" as a dominant trait of the mentally disturbed person. Furthermore, the characteristics such as instability, insecurity, nervousness and inclination to suicide, indicate that all of these three groups of examinees have sterotypes about unstable emotional condition and state of mind of the sick. The examinees that don't belong to this group of supporting fields have enough knowledge neither about the emergence of the disease nor about its development and preventive measures. However, the social workers have a bit more negative attitude towards the mentally ill if compared to medical nurses which could be explained by insufficient working experience with the mentioned group of patients. It's important to say that all of the three groups of examinees don't have extremely negative attitudes towards the people with mental disorder. We shouldn't ignore the fact that these three groups have noticable social restraint towards the mentally ill and they cannot easily accept them in their own environment. Considering the fact there is a low number of researches that deal with this problem of labelling or in other words- stigmatization of the mentally ill, this research gives a great stimulus for writeup this very important problem area, especially if we take into consideration that the attitude of the community may help to bring about the feeling of marginalization and unacceptability with the mentally ill.     

Cultural Identity and Illness: Fulani Views

Cultural identity – who the Fulani think they are – informs thinking onillnesses they suffer. Conversely, illness, so very prevalent insub-Saharan Africa, provides Fulani with a constant reminder of theirdistinctive condition in Guinea. How they approach being ill also tellsFulani about themselves. The manner in which Fulani think they are sickexpresses their sense of difference from other ethnic groups. Schemas ofillness and of collective identity draw deeply from the same well andweb of thoughts. Three different approaches of schema theory are used totrace what ties illness to identity. These are 1) the schema asprototype; 2) a connectionist approach associates schemas for illnesswith other cultural schemas; and 3) a hierarchy of schemas. Thehierarchy includes master schemas for ethnic identity, schemas forillness generally and sub-schemas for separate ailments. Schemas orientand provide a framework for the practice of being Fulani – in the sensethat Bourdieu would describe practice as the application of practicalknowledge. Illnesses above the waist are said to be part of the Fulanicondition of belonging in arid climates while they need suffer thehumidity of Guinea. Illnesses below the waist are thought to arise whenone does not act like a Fulani, especially in matters of food and sex.As individuals disclose or conceal illness, as they discuss illness andthe problem of others they reflect standards of Fulani life – beingstrong of character not necessarily of body, being disciplined,rigorously Moslem, and leaders among lessors. To disregard standards orto suggest one does not care about such standards is shameful and placesone out of phase with others and with cultural norms. But to be in stepwith others and with cultural norms is to have pride in the self and thefoundations of Fulani life.     

Issues in Health Care of Middle Eastern Patients

Relationships between Middle Eastern patients and Western health care professionals are often troubled by mutual misunderstanding of culturally influenced values and communication styles. Although Middle Easterners vary ethnically, they do share a core of common values and behavior that include the importance of affiliation and family, time and space orientations, interactional style and attitudes toward health and illness. Problems in providing health care involve obtaining adequate information, “demanding behavior” by a patient''s family, conflicting beliefs about planning ahead and differing patterns of communicating grave diagnoses or “bad news.” There are guidelines that will provide an understanding of the cultural characteristics of Middle Easterners and, therefore, will improve rather than impede their health care. A personal approach and continuity of care by the same health care professional help to bridge the gap between Middle Eastern cultures and Western medical culture. In addition, periodic use of cultural interpreters helps ameliorate the intensity of some cultural issues.     

Braving Difficult Choices Alone: Children's and Adolescents' Medical Decision Making

Objective

What role should minors play in making medical decisions? The authors examined children''s and adolescents'' desire to be involved in serious medical decisions and the emotional consequences associated with them.

Methods

Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: (1) own informed choice; (2) informed parents'' choice to amputate; (3) informed parents'' choice to continue a treatment; and (4) uninformed parents'' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice.

Results

Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants'' responses.

Conclusions

Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel. The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process.