What's Right When "Their Way" Clashes with "Our Way?"
Created by Catherine Rainbow for an undergraduate course at Davidson College.
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 her decision.

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 rights.

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 medicine practices.

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

© Copyright 2002 Department of Biology, Davidson College, Davidson, NC 28035
Send comments, questions, and suggestions to: carainbow@davidson.edu
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