|Excerpt, "Culture, Healing, and Professional Obligations,"
found in Cases in Bioethics, 3rd edition, by Bette-Jane Crigger
Dr. Leigh mused silently over a cup of coffee after a busy day at the
Oakside Community Clinic. "So how far am I supposed to go with cultural
sensitivity, anyway?" she asked herself. This question arose from
the lingering doubt she felt about how she had responded earlier that
day to a patient's mother, Ms. Ying Saeto.
Ms. Saeto had brought her youngest child, Marie, into the clinic for her
four-month immunizations. Marie is a lively, healthy baby who is growing
normally, in the 65th percentile for her age. Dr. Leigh usually enjoys
Ms. Saeto's visits and has learned much about the lu Mien culture of Ms.
Saeto's native Laos from their conversations. Ms. Saeto's excellent English
and her willingness to share information about Mien cultural heritage
have allowed Dr. Leigh to understand better the many Mien living in the
vicinity who use the clinic for (at least some of) their health care needs.
Ms. Saeto was born in Laos, but at the end of the Vietnam War she fled
with her family and neighbors and was finally resettled in the U.S. with
her grandparents when she was fourteen. Her first year in America was
hard for Ms. Saeto. When she became more comfortable with her new environment,
she went through what she now calls a "rebellious stage." She
refused to speak Mien except with her grandparents, who never learned
English. A part-time job provided money and independence, enabling her
to feel less like an outcast in school. But Ms. Saeto did not have many
years in this new life as an American high school student. She became
pregnant before graduating and she left school. The father of her baby
drifted away, leaving her without support except for her grandparents
and the lu Mien community. She was welcomed home.
Ms. Saeto has since married a Mien man. They live with her mother and
their three babies and her first child. She says, "Now I am a Mien
woman." She finds great value in the sense of belonging. She is proud
of her growing knowledge of Mien traditions and believes and eagerly informs
Dr. Leigh about Mien spirits, ceremonies, and cures during her visits
to the clinic.
Today Ms. Saeto had not hesitated to explain the meaning of the burns
on her baby's stomach. "Burns?!" Dr. Leigh asked incredulously
as she looked at the five red and blistered quarter-inch round markings
on the child's abdomen. Ms. Saeto explained that she had used a traditional
Mien cure for pain because she suspected that Marie had a case of "Gusia
mun toe." This is a rare fold illness among Mien babies characterized
by restlessness, unremitting crying, agitation, constipation, and loss
of appetite. A particular characteristic of the syndrome is that a baby
will keep "throwing her head back" when held.
The cure she used involved burning a "string" of the inner pulp
found in a special reed. The pulp is dipped lightly in pork fat and then
lit. The flame is then passed quickly over the skin above the pain site,
raising a blister that pops-"like popcorn," she said-indicating
that the illness is not related to spiritual causes. If no blisters arise,
then it is possible that a shaman will be needed to conduct a spirit ritual
for a cure.
Depending on the severity of illness, 3,5,7, or even 11 burns might be
made. Before the flame is extinguished it is used to burn a spot on a
wall of the room (or a block of wood) systematically, transferring the
pain. "The wall doesn't feel, so let the wall suffer instead of this
person," the person performing the cure says. "Wall, let the
pain go on in you forever, let the pain off this person." The burns
are then covered with Tiger Balm, a mentholated cream.
Ms. Saeto explained that the original pain will usually subside within
a half-hour and any pain from the burning will be gone within the hour.
In her experience infection is rare, and the burns heal in a week or so.
Sometimes scars remain afterward, but these are not thought to be disfiguring;
they are simply recognized as the result of this treatment.
Ms. Saeto explained that this method of cure was dangerous for children.
Dr. Leigh readily concurred, but soon discovered that their ideas about
the dangerousness of burning children did not match at all. Ms. Saeto
explained that this cure must be done by someone skilled in burning, like
her mother-in-law, because if a burn is placed too near to the line between
the baby's mouth and her bellybutton, the baby could become mute or even
retarded. In Marie's case the cure had been successful, according to Ms.
Saeto. The child had stopped crying immediately, calmed down, and regained
her appetite uneventfully. Upon examination, Dr. Leigh found no reason
to suspect otherwise.
Dr. Leigh had gone ahead with Marie's immunizations, noting to herself
that the procedure considerably disturbed the baby's contentment, and
wondering-not for the first time-about the pain she routinely inflicted
upon children in the course of her practice. She had not mentioned her
misgivings about Ms. Saeto's practice of burning her baby. But now, at
the end of the day, Dr. Leigh wondered if she should have said something.
After all, didn't she think it was cruel to burn babies? Didn't she know
it was dangerous, and not for the reasons that Ms. Saeto had stated?
When reviewing this case study within the context of the ethical theories,
a person has to determine how to approach this situation with Ms. Saeto's
ethical stance in mind. A reader can clearly understand from this passage
that Ms. Saeto prioritizes her child's best interest, and that her motivation
is purely that of a concerned mother. She believes that her actions, burning
the child multiple times in order to treat the baby's illness, were ethically
correct. Dr. Leigh who is also concerned with her patient's well being
does not seem sure that Ms. Saeto's actions were ethically correct. The
doctor recognizes the fact that the lu Mien and Western cultures differ.
However, she also understands that both cultures inflict pain upon a patient
in order to improve the patient's health. She questions where the boundary
of acceptable pain inflicted upon a patient is, especially in the case
of a child.
In the following paragraphs, we will approach this case study with various
ethical theories in mind. We will determine the important factors that
Dr. Leigh must consider if she is a deontologist, act or rule utilitarian,
casuist, rights theorist or a virtue theorist. After taking the important
factors into consideration for each type of theory, we will guide Dr.
Leigh to the most ethically correct decision.
If Dr. Leigh is a deontologist, her initial task would be to decide what
her duties and obligations are to her patient and to society.
The relationship between Dr. Leigh and her patient is one that is considered
to have special obligations. Dr. Leigh is obligated to care for her patient
since she has the medical training and is given authority to do so by
Ms. Saeto. She has the duty to make sure that the burns heal and that
the child's health is maintained. This set of special obligations requires
that Dr. Leigh do her very best to treat the child and to discuss the
cultural differences respectfully with Ms. Saeto in order to establish
a trustful and open relationship between them so that the child's health
can be maintained at a high standard.
Dr. Leigh has a duty to society to uphold the law and to practice medicine
according to professional standards. These professional standards include
practicing sound medicine, being a patient advocate and keeping an updated,
confidential medical record for each patient. According to the story,
Dr. Leigh is upholding all of her duties to the medical profession. She
should be able to use her medical training and experience to decide whether
Ms. Saeto has committed child abuse. If Dr. Leigh believes that Ms. Saeto
has committed child abuse, then she must decide whether or not it is ethically
correct for her to release the child's confidential medical records to
the authorities. In this particular circumstance, Dr. Leigh should report
the case and release the medical records to the authorities because child
abuse is considered special case in which it is acceptable for the physician
to disregard confidentiality in order to protect the patient.
It may be best for Dr. Leigh to discuss her concerns with Ms. Saeto first
so that any discrepancies can hopefully be resolved with the child's best
interests in mind. If Dr. Leigh determines in future examinations that
the child's health is being threatened by Ms. Saeto's continuation of
harmful non-Western medical practices then it may be time for Dr. Leigh
to break her duty of confidentiality and report Ms. Saeto to the authorities
in order to protect her patient.
In act utilitarianism, the choice that yields the most benefit for the
most people is considered the ethically correct choice. Dr. Leigh would
have to decide which decision is best for the most people regardless of
the law and justice.
It appears that the choice that keeps Dr. Leigh as a practicing physician
and the Saeto family together will be the most beneficial because Dr.
Leigh will be able to continue to practice medicine, and the Saeto family
can maintain its normal lifestyle. Since Dr. Leigh is a good physician
who follows the professional standards, then she will discuss her concerns
with Ms. Saeto regarding the nonwestern medical practices. If Ms. Saeto
and Dr. Leigh maintain an open relationship then they could culturally
educate each other and relay the information to their respective communities.
Although the child may be burned or hurt in future instances, the Saeto
family as well as Dr. Leigh will continue to benefit, thereby sacrificing
the child's good for the good of the majority.
Dr. Leigh as a rule utilitarian will still take into account that an ethically
correct decision is the one that benefits the most people. However, as
a rule utilitarian she seeks to follow the law and include justice in
As a rule utilitarian, Dr. Leigh will first use her professional training
in order to determine whether or not Ms. Saeto has committed child abuse
by burning her child. In the case that Dr. Leigh classifies the burning
as child abuse, she will report Ms. Saeto to the authorities. However,
if Dr. Leigh determines that Ms. Saeto has not committed child abuse,
then she will probably discuss her concerns and interests of the nonwestern
medical practices in order to gain a better understanding of them. She
will also take the opportunity to educate Ms. Saeto about Western medicine
so that she has the ability to make informed decisions about her child's
health care. Dr. Leigh and Ms. Saeto could use their open dialogue about
medical practices to educate their respective communities about the various
benefits and dangers of available medical procedures.
In this situation, the most people will benefit if Dr. Leigh does not
classify the burning incident as child abuse. However, since she is a
rule utilitarian, her fist obligation is to uphold the law. If in a future
examination Dr. Leigh finds that the child has been abused, then Dr. Leigh
will have to report Ms. Saeto to the authorities for child abuse. Dr.
Leigh will make the ethically correct decision by following the law while
attempting to benefit the most people.
As a rights proponent Dr. Leigh will determine whether Ms. Saeto violated
her child's rights. She must review the law and determine whether Ms.
Saeto has infringed upon her child's rights. According to the story Ms.
Saeto is providing her child with the best life possible and is protecting
her child appropriately from disease. However, the laws of the United
States may show that Ms. Saeto abused her child, violating the baby's
In this case, Dr. Leigh should use the law as her guide. If under the
law the mother has abused the child, then Dr. Leigh will have to report
Ms. Saeto to the authorities. Intentionally burning a child is generally
accepted as being child abuse. Therefore Dr. Leigh will report Ms. Saeto
to the authorities. If perhaps burning one's child is acceptable under
the law due to a cultural context clause, then she is free to continue
her nonwestern medicine as long as the practices stay within the parameters
of all the laws.
A casuist compares a current ethical dilemma with paradigms that contain
similar situations. If Dr. Leigh is a casuist, then she will look at other
similar cases in which a Western medicine physician has had to face nonwestern
medicine practices that are controversial. Dr. Leigh would hope to find
extreme paradigms with conclusions that would help her to determine how
she should approach Ms. Saeto and her child.
For example, a nonwestern medical practice that includes cutting off a
child's hand when a wart grows on it would be considered an extreme case
of abuse in which the perpetrator would be reported for child abuse. Another
paradigm, the opposite of the extreme abuse case, would be that of a mother
who rubs a leaf that causes the appearance of a temporary rash upon her
child's chest in order to relieve a cough. In this case, the physician
would not report the mother for child abuse, but would probably try to
educate the mother about the rash and the toxic effect of the leaf upon
humans. If Dr. Leigh uses these two paradigms to determine her decision
in the case of Ms. Saeto, she would probably decide that Ms. Saeto nonwestern
medical practices are more similar to the rash paradigm than the severed
hand paradigm. Therefore, Dr. Leigh should not report the Ms. Saeto's
burning incident to the authorities, but should educate her in order to
prevent future situations like this.
One pitfall of the casuist approach to ethical decisions is that it assumes
that there are extreme paradigms for each real life situation. However,
this is not always the case. If Dr. Leigh has no paradigms available,
then she will have to use her best judgment or another ethical approach
to solve the Ms. Saeto situation. If Dr. Leigh only knows of paradigms
with unsuccessful resolutions, then Dr. Leigh will be forced to choose
the best of the unsuccessful resolutions.
A virtue theorist would approach this situation by first reflecting upon
Ms. Saeto's reputation and past behavior. According to the story, Dr.
Leigh has classified Ms. Saeto as a good mother who is very concerned
with her child's welfare. Ms. Saeto has put her child's interests first
by using what she believes to be ethically correct medicine. If Dr. Leigh
is a virtue theorist, it appears that since she has already judged Ms.
Saeto to be a good mother that Dr. Leigh would approve of the cultural
The subject of nonwestern healers in a Western nation is a delicate subject
that requires sensitivity. Fortunately in this situation, the physician
and the guardian both have the child's best interests in mind. Each of
the ethical theories listed above provides Dr. Leigh with guidance for
how to treat the controversial issue of cultural differences in medical
practices. In reality Dr. Leigh will probably use a combination of these
theories along with her own personal experiences in order to come to an
ethically correct decision