Cross-Cultural Misunderstanding, the Patient-Physician Relationship, & the Role of the Christian Physician (Ch. 18-19)

In these final two chapters, Fadiman identifies cross-cultural miscommunication as the primary cause of Lia’s life being cut short.  Septic shock and noncompliant parents were a part of the problem, but the core issue was misunderstanding.  The final chapter also gives an account of the txiv neeb ceremony Lia’s family has a shaman perform.  During the ritual, the shaman chants and goes into a trance that allows his spirit to leave his body, and travel the spirit world to negotiate with the other spirits to return Lia’s lost soul.

In my first blog post, I discussed Fadiman’s vantage point as an “involved-but-objective” third party observer.  Fadiman believed this vantage point was the ideal perspective to examine the situation from.  By the novel’s end, however, Fadiman has shifted from describing the story in third person to first person, indicating how she now considers herself to be a direct part of the story.  Perspective plays an important role in this story, and is definitely influential in one’s perception of who (or what) is at fault for Lia ending up brain dead.

Lia’s doctors persisted in regarding Hmong beliefs as ignorant and superstitious while holding Western medicine as an infallible, objective set of practices that had managed to transcend culture.  Her doctors certainly cared for Lia and genuinely wanted her to get well, but all their efforts stemmed from their training in Western medicine and Western medical culture.  If healthy communication had existed between the Lees and Lia’s physicians from the beginning, Lia’s story would have likely ended differently. 

In an interview she gave in 2003, Fadiman explains her own take on what Lia’s doctors should have done differently.  She says, “The most important lesson is the necessity of seeing a case from the patient’s point of view.  Even if the doctor’s knowledge exceeds the patient’s by an incalculably huge factor, that knowledge will do little good if the patient does not trust the doctor or it the doctor does not understand the patient.  The best remedy for both those problems is for the doctor to look at things from the patient’s perspective (which may be culturally influenced).” (from an interview with Kathy Lammert, published 15 Sep 2003 by the Epilepsy Therapy Project-- http://www.epilepsy.com/articles/ar_1063680870)

Physicians need training in cultural sensitivity in order to understand the patient’s perspective (as is the standard in most medical schools nowadays), but it is also important to recognize the overarching presupposition that cultural misunderstanding can operate under; namely that Western medicine is infallible and without its own set of biases.  This was the case for the Lees and Lia’s physicians.  Cross-cultural miscommunication was the core problem, but it reflected the larger, overarching notion inherent in Western medicine that it does not possess its own set of biases or practice a set of rituals it believes will lead to a desired result.  Medicine is a science, but it is not an exact science.  It involves a lot of guesswork.  It is also limited. It cannot predict and cure all pathologies with complete accuracy.  It can tell us that Lia’s epileptic seizures were caused by her neurons misfiring, but it cannot yet tell us why this misfiring happens in the first place.  Hmong medicine sought to explain why the misfiring occurred, attributing the etiology to the spirit leaving her body. 

Science also sets much store by empirical evidence and observable, testable phenomena, but cannot apply this model to the unobservable, spiritual realm.  In valuing empirical evidence, it devalues other kinds of evidence, which in some sense, is a kind of bias.  Science is a way of knowing, but is not the ultimate way of knowing.  Western medicine is surrounded by its own culture, meaning that it cannot be purely objective.  If Lia’s physicians had been able to recognize Western medicine as a culture, and had known how to look beyond their own cultural tendencies, they may have been able to incorporate Hmong culture into Lia’s care.  Doing so could have had completely changed her life.  I say this not to condemn Lia’s physicians, because they did everything they knew how to do, and acted out of genuine compassion for her suffering. 

To respect the Hmong aversion to drawing blood, perhaps Lia’s physicians could have limited their use of blood tests, opting for other methods to gather information about Lia’s condition.  Interpreters could have also been used more frequently and throughout the story to overcome the language barrier.  Overall, the aim would be to meaningfully incorporate the patient’s cultural practices into their care.

What Fadiman aims to show her reader (and what I have come to understand from reading this book) is this: Western medicine may strive for objectivity, but is still beset with its own set of biases and rituals.  It may seem strange to think illness is caused by a spirit getting scared and leaving a person’s body, but to someone not immersed in Western medical culture, it would also seem strange that physicians extract bodily fluids to examine and run tests on them (i.e. blood tests), then fail to glean any answers from the fluid extraction.  To think that Western medicine is not a culture or that it has managed to transcend cultural subjectivity or bias is a fallacy.  Western medicine certainly has its own paradigms and brand of evidence (i.e. empirical evidence) it holds in higher regard than other kinds of evidence, and as such, has its own degree of fallibility.  Perhaps the failure of Western medicine in Lia’s case was to assume its own infallibility, or to not recognize it had the capability of being fallible. 

Western medicine values objectivity, experimentation, predictability, and sterility.  We place much more confidence in pharmaceuticals than “herbal remedies”.  We believe a product of Western medicine, produced using sterile methods in a factory somewhere, will always cure our ailments more effectively than a simply herb that grows in our backyard ever could.  Yet recent research debunks this cultural claim.  Bitter melon, a fruit indigenous to Asia and Africa, has been shown to decrease cell growth in breast cancer.  Turmeric, a spice commonly used in Indian cooking, has shown promise in the prevention and staving off of cancer cell growth.  Western medicine has given us chemotherapy to treat cancer once patients have it, but has yet to produce something to preemptively treat cancer.  Perhaps that in itself is a reason to value complementary alternative medicine along with Western medicine.

Just as Western medicine found Hmong practices strange and ignorant, it also (to some degree) regards Christian practices in much the same way.  Physicians who see their patient’s culture or religion as something to work past, as opposed to something to work with, denigrate what the patient values as centrally important to them, and by extension, denigrate the patient themselves.   

The lingering question I have after having finished this book (and this class) is this: How do Christians hold onto and practice their beliefs while respecting others’ beliefs?  In other words, how can we be in the world but not of it?  Furthermore, how do Christian physicians treat patients in a culture that believes it has transcended culture?  How do they apply the Christian narrative to patient treatment and practice medicine without compromising their values, all while respecting and honoring their patients’ culture and/or spirituality?

Christianity is supposed to be counter-cultural, so it is difficult to live the Christian life, particularly in the world of medicine.  Physicians routinely interact with patients of differing faith backgrounds and are trained in Western medical culture, which values certainty and that which can be observed and tested.  The task for Christian physicians, then, is to hold onto their beliefs with certainty and humility.  They can aim to treat patients as beings created by God in his image and likeness.  They can identify patients in their social, cultural, and spiritual contexts while acknowledging that these are all aspects of their whole personhood.  To relate to people in such a way honors their humanity, which is ultimately our call as Christians.  We are called, after all, to “love the Lord your God with all your heart, with all your soul, with all your mind, and with all your strength” and to “love your neighbor as yourself.  There is no other commandment greater than these.” (Mark 12: 30-31)

Spirituality in Healthcare (Ch. 16-17)

In these chapters, Fadiman discusses how the Hmong are a large portion of the Merced city population, yet are not a visible force in the city’s day-to-day life.  This highlights their insularity and strong ties to their own community.  Although Lia’s condition has stabilized since her big seizure earlier in the story, it becomes apparent that she has sustained serious permanent brain damage.  Nao Kao, Lia’s father, continues to practice Hmong medicine as he has in the past, and sees those he cares for return to health.  He sees a direct contrast between this and Lia’s experiences with American medicine, which did not immediately help Lia return to health. 

One of the core reasons for the clash between the Lee family and Lia’s American physicians is that the two sides differed in their purpose.  The central aim of American medicine is different from the central aim of Hmong medicine.  American medicine seeks to prolong life, while Hmong medicine seeks spiritual welfare.  Had Lia’s family never left Laos, Lia would likely have died in infancy from one of her epileptic seizures.  Her family’s move to the States prolonged her life, but Fadiman questions if this prolongation was ultimately for the best.  Western medicine prolonged her life (compromising it in some instances), yet it was the source of much suffering and hurt for the Lee family. 

We may think it is strange for the Hmong to attribute all illness to spiritual causes, yet the Hmong think it strange that American medicine does not seem to concern itself at all with the spiritual.  An American physician would never inquire about a patient’s “spiritual” health.  I would find it pretty strange if my doctor asked me about the state of my soul, yet for the Hmong, that would be the central question.  The Spirit (much like the Christian conception of the soul) is transcendent, and exists beyond the physical body.  It affect the body’s physical health in life, and lives on after the body’s earthly life has ended.  I can certainly understand the Hmong emphasis on spirituality in medical practice.  The soul, thought to belong to God, takes precedence over the physical body, but we do not consider it in Western medicine.  

Yet a patient’s spirituality routinely plays into their return to health.  It is widely documented that patients who feel at peace before a surgery suffer fewer complications in surgery, fewer post-operative complications, and experience shorter recovery periods.  Medicine cannot not quantify this trend or predict the length of the recovery period, because it belongs to an intangible realm that medicine, with its empirical evidence and predictive power, cannot exert control over.  Patient experience is influenced by an individual’s values and spirituality, all of which belong to the intangible realm outside the direct reach of medicine.

Ethical considerations for Christian physicians, then, center on how to incorporate Christian spirituality into healthcare while respecting the patient’s own spirituality or value system.  Christian physicians have their ethics shaped by the Christian narrative, so their ethical system will undoubtedly be a part of their medical practice.  The question becomes: how can a Christian physician practice medicine in a way that honors his or her own spirituality while also respecting their patient’s spirituality, regardless of whether they are Christian?

Alas, that’s a question for next time.

Autonomy/"Rights" and Morality, continued (Ch. 13-15)

In this section, Lia is again admitted to the hospital with a high fever.  Despite her doctors’ efforts, nothing seems to help.  Lia’s parents take her home, opting instead for traditional Hmong rituals and herbs.  In their minds, since Western medicine has failed to produce immediate results, they ought to fall back on what they believe to be true- Hmong rituals.  Fadiman also discusses why the Hmong hold so strongly to their traditions and language.  The Hmong people have no country to call their own or geographical boundaries to define their homeland, so their language and traditions are paramount   To adopt another culture or language would mean a loss of identity.  Indeed, the Hmong came to American not out of choice, but out of desperation due to political turmoil.  The conditions under which they left their homeland further their steadfast commitment to their culture and language.  Despite Lia’s continued health problems, Fadiman notes that Foua and Nao Kao never see Lia as a burden.  Hmong parents rarely set their newborn children down, as Hmong culture values children very highly, and regards their care with the utmost respect. 

I’ve been thinking further about last week’s discussion of autonomy and morality.  Autonomy is an inadequate criterion for evaluating issues of morality because it accords with the ethics of autonomy, but not with morality as a whole.  Using autonomy as a moral criterion is insufficient because it fails to account for why people decide or should decide to stay alive.  If use autonomy as the highest moral criterion with respect to the issue of physician-assisted suicide, one would argue that once a person no longer desires to live, he/she has no reason to live.  Autonomy prevails, and a person’s choice to end his or her life to some degree categorizes that choice as moral.  If we uphold autonomy as the highest good in moral evaluation, we can categorize any choice that a person freely comes to as moral.  This is a pretty general statement, but I’m thinking about this in terms of patient autonomy now.  If a patient decides he or she wants to die, and the patient meets the criteria for socially acceptable physician-assisted suicide (such as having a terminal disease, being in pain, or being elderly), American medical culture tends to categorize this as moral.  However, it fails to address the possibility that life may be worth living out of obligation to the conditions under which it was granted: as a gift. 

Autonomy also fails to take into consideration that we live not only for ourselves, but also for each other, as our lives can find purpose in serving others.  I don’t say this to suggest that elderly patients on their deathbed should stay alive out of a sense of obligations to serve others.  I mean this to say that elderly patients on their deathbed can value their lives and themselves not only when they are productive members of society, but even when they are not.  Their lives are to be valued not only because of what they can do, but because they were created in the image and likeness of God.  They (and the rest of us) can recognize that their value lies not in what society deems it to be, but in Christ, or at least in something far more eternal than the world’s standards.  As a future physician, I can similarly value them simply because they were divinely created, and if they are Christian, respect them as fellow members of the Body of Christ.

The point of this whole spiel on autonomy in general and patient autonomy is not to denigrate patient autonomy.  Autonomy is how American medical culture respects a patient’s humanity and all the rights they are entitled to that stem from their humanity.  I’m suggesting that we look further, and recognize that autonomy is a means to an end, but not the end itself.  To regard people in this way, I think, respects their personhood in a much richer and fuller way than to simply respect their autonomy or utility.

Autonomy and Morality (Ch. 10-12)

In these chapters, Fadiman explains the importance of the Hmong connection to the earth, particularly the mountains.  The Hmong in China and Laos are also nomadic, a theme reflected in Hmong music and artwork.  Fadiman also discusses the Hmong’s history in foreign relations, noting that the Hmong support countries they feel will safeguard their autonomy as a people.  The insular and nomadic nature of their culture, she explains, is at the root of the centrality of autonomy in their culture.  As we have seen in previous chapters, the Hmong are indeed a very independent people, and were oftentimes weary of American medical professionals, regarding their intervention with resentment and dismissal.  While the Hmong conception of autonomy looks different from the American conception of autonomy, it is an important concept in both cultures.    

It is obviously very important for physicians to respect their patient’s cultural/religious beliefs and their autonomy, but I don’t think autonomy is an adequate criterion for evaluating an issue’s morality. For the rest of this blog post, I won’t be discussing patient autonomy, but autonomy in a general sense, and how it is used in moral evaluation.

American culture (and Western culture in general) value autonomy very highly.  I would dare say it is the value we uphold as the highest good.  Autonomy certainly ought to be respected.  Laws centering on respect for human rights are the primary way we seek to ensure that a person’s well-being is not threatened.  From the context of the Christian narrative, however, autonomy operates separately and above the realm of rights.  Christians are called to love God, but are also mutually obligated to one another, making love, not autonomy, the highest good.  As members of the body of Christ, we have claims on each other’s lives.  Being in a community requires that we both lift each other up and hold one another accountable.  Members of a Christian community are called not only to respect each other’s autonomy, but to go beyond this and help one another walk the path that Christ has set for us.  Rights and autonomy, it seems, are only a part of the greater picture of morality as a whole.  I mean this to say that in deciding whether a decision is moral, we must take factors besides autonomy into consideration.  Do we respect one another’s rights simply because to infringe upon them would be an affront to others’ autonomy? Or do we respect the rights of others because these rights serve to respect their humanity and a greater, fuller sense of morality?  The point I’m trying to make here is that “rights” are in service of morality, not the other way around.  Rights are important, but do not equate to morality.  Autonomy and respect for “rights” are not the litmus test for morality from the Christian perspective, precisely because Christians are called to live not only for themselves, but also for each other. 

Chapters 8-9: State Protection of Minors, American Medical Culture, and Hmong Culture

In these chapters, we see Lia taken away from her parents because they repeatedly failed to administer her seizure medication properly.  Lia is placed in a foster home temporarily but is later allowed to return home.  Lia’s case is rare, as children are generally not taken away from loving, non-abusive, attentive parents.  Lia’s parents tried to administer her medication as directed, but failed to do so either due to miscommunication or misunderstanding.  A CPS caseworker, committed to bringing Lia home, is the one responsible for Lia being reunited with her family.  The caseworker works with Lia’s parents regularly to address their cultural concerns and explains the medication’s administration clearly to them. 

Spirituality in the context of illness is also explored in this section.  The Hmong do not distinguish between mental and physical illness, so their approach to all illnesses is spiritual.  For example, in examining the etiology of a particular sickness, the Hmong identify a dab (malevolent spirit) as the cause, and would seek to sacrifice a dog to cure the spiritual illness, which cure the physical sickness.  Though western medicine ath the time dismisses the mind-body connection (though this is increasingly not the case today), the Hmong, in contrast, see no distinction between the two.  The body’s illnesses are caused by the spiritual, so it does not enter the Hmong consciousness to try and heal a physical ailment while neglecting a person’s spirituality. 

Lia’s separation from her parents is the culmination of the clash between American medical culture and Hmong culture.  Lia’s physician, acting out of his training from his American medical training and a sense of ethical obligation, decides the last option left is to have the state take Lia away from her parents.  Lia’s parents are mistrustful of American medicine and physicians, and are unable to partake in animal sacrifices to heal her as they would if they still lived in Laos.  Bound by American laws, they must work through American medical channels. 

Christian physicians in particular can likely understand the desire to respect a patient’s spirituality in treating them.  In this case, however, the patient’s parent’s spiritual beliefs fly in the face of conventional medical knowledge.  I don’t agree with Lia’s doctor’s decision to have her separated from her parents.  I did agree with the CPS caseworker’s insistent commitment to making her parents understand her medication and why it was so important to ensure that Lia took it properly.  Both the CPS caseworker and Lia’s physician believe they are advocates for Lia’s best interests: the caseworker to bring her back home to her family, and her physician for Lia’s proper medical care. 

The ethical question about the protection of minors takes a central role in this section.  Lia’s seizures are increasing in their frequency and severity, signs her physician believes are indicators of her eventual death.  Lia’s life hangs in the balance, yet the people who care about her cannot, despite their best efforts, seem to find a way to help her in the way that she needs.  Her parents do what they know how to do, sacrificing a cow in her honor and working with Lia’s physicians and caseworker.  However, it is simply not in their nature to fully trust western medicine.  They comply with the doctor’s orders primarily out of legal obligation, and instead place their faith in Hmong spirituality to heal Lia.  Lia’s physician tries to work with Hmong beliefs to get through to her parents and work alongside them to help Lia.  So far, though, the situation is not improving. 

It is frustrating and saddening to think that cultural and religious differences may be a causal factor in a child’s death.  Her medical condition is obviously the real cause, but the idea that her parents and her doctors are unable to come to a functional common ground to save her life is difficult to contend with.  I’ll be able to speak more on this topic as the story unfolds in the coming chapters.  For now, all I can say is that I see how incredibly important it is for physicians to understand their patient’s spirituality/culture, especially as it relates to their medical care.  In Lia’s case, as for many other patients, it could mean the difference between life and death.  Lia’s physicians are doing their best, but Lia needed more.  She needed the kind of physician who knows how to treat patients in a way that honors their bodies, their cultural backgrounds, their spirituality, and their humanity.

Cultural Barriers and Different Approaches to Wellness

Chapters 6-7 describe the linguistic and cultural barriers between the Hmong patients and their American doctors.  The older Hmong immigrants in Merced typically don’t speak English, and the translators have difficulty translating medical terms (that don’t exist int the Hmong language) for their patients.  The biggest barrier, however, is cultural.  Patient-physician relations are difficult because the Hmong don’t wish to disrespect their physicians by asking questions, so patients often leave the visit without any understanding of what their doctor said, what the recommended treatment was, or how to comply with it.  The Hmong have no concept of the different internal bodily organs (except for the heart), as they don’t practice autopsy.  Shaman training involves rituals to appease the spirits, not anatomy and physiology. 

The gap between patients and physicians Fadiman discusses in this section reminds me of my discussion last week of the medical profession’s approach to death.  Physicians, by nature of their profession, do their best to avoid death.  Some physicians see acquiescence to death as a sign of complete failure, and think about death in terms of which procedures they could have done to save their patient’s life.  Death is the enemy, in part because it reminds them of medicine’s limitations: they can fight death but ultimately cannot overcome it.  Christianity, in contrast, offers an alternative.  Through the cross, Christ overcame death forevermore.  Those who believe in His sacrifice are granted eternal life in Him.  From this perspective, death is not the enemy, but a part of life we accept when the time comes.  Earthly death does not have the same sting, because it has lost its finality in the face of eternal life.  Physicians coming from this perspective do their best to alleviate their patient’s suffering and encourage them to fight, but do not try to avoid death at all costs.

That being said, if one of my loved ones was suffering from an illness, the last thing I would want his/her physician to say is, “They may be suffering, but don’t worry- it’ll ultimately make them stronger.  Plus, they have eternal life, so their earthly death isn’t all that bad.”  I don’t mean to suggest that all suffering ought to be held as valuable, or that we ought to seek it out, but rather that when we are inevitably faced with it, we allow ourselves to feel the pain it brings.  Christianity also allows people to recognize that in our suffering also lies the possibility of growing in understanding and closeness to God; it can teach us about ourselves, our loved ones, life, or God Himself.  The question, then, is how to practically apply this idea.  How much suffering do we let it as a way of recognizing it as a natural part of life? Conversely, how much do we shut out so that we don’t end up wallowing in it? How do we allow it to be a source of instruction without wallowing in it or welcoming it in all circumstances in attempt to ascribe meaning to something that may simply be painful? Can all instances of suffering be used for instruction? Is it even entirely healthy to try to make it so?

This alternate approach to death reminds me Fadiman’s quotation of Dostoyevsky’s Prince Myshkin.  It points to an alternate way of looking at disease.  He asks, “What is a disease? What does it matter that it is an abnormal tension, if the result, if the moment of sensation, remembered and analyzed in a state of health, turns out to be harmony and beauty brought to their highest point of perfection, and gives a feeling, undivined and undreamt of till then, of completeness, proportion, reconciliation, and an ecstatic and prayerful fusion in the highest synthesis of life?” (29)  If we approached disease in this way, what implications would this have for medicine and the people it seeks to return to wellness?  

Chapters 3-5: Dealing with Suffering and Death

Chapters 3-5 opened with an event from Lia’s infancy.  When she was three months old, her sister slammed the front door of their home very loudly.  The Lee family believes (in accordance with Hmong tradition) that the loud sound of the slamming door startled Lia’s spirit so much that it left her body and became lost.  In Hmong, this is represented by the phrase “qaug dab peg”, which means “the spirit catches you and you fall down”.  For the Hmong, the “spirit” is a soul-stealing being whose displeasure one ought to avoid incurring.  Fadiman explains that children are regarded very highly by the Hmong, as they are the most treasured possession a person can have.  Fadiman also gives an account of Lia’s admission to a hospital in California.  Her physician, Dr. Dan Murphy, approaches her case rationally, as any physician immersed in American medical culture would.  He treats her, and prescribes drugs to cure her pneumonia and prevent further seizures. 

This section also marks the beginnings of the tension between Hmong culture and American medical culture.  Dr. Murphy later prescribes phenobarbital for Lia, but due to a misunderstanding, Lia does not receive the medication as instructed.  Lia’s nurse and doctor are frustrated by what they see as the parents’ unwillingness to comply with physician instructions, even when it involves their daughter’s health.

The Hmong’s valuation of children highlights how difficult it will be for Lia’s parents to make the decision they do concerning her medical care.  Lia’s epileptic condition, in fact, is considered to be a blessing.  The spirits chose to reside in her, indicating Lia has the capability to one day become a shaman.  Because of this, she is regarded much like a member of royalty. 

These chapters reminded me of ideas about suffering in Christianity.  Suffering, while it is painful, can be purposeful.  While we don’t seek it out, it can still be a source of instruction.  As Paul says, “Three times I begged the Lord about this, that it might leave me, but He said to me, ‘My grace is sufficient for you, for power is made perfect in weakness.’ I will rather boast most gladly of my weaknesses, in order that the power of Christ may dwell with me.  Therefore, I am content with weaknesses, insults, hardships, persecutions, and constraints, for the sake of Christ; for when I am weak, then I am strong.” -2 Cor. 12:8-10.  While it may seem contradictory, from this perspective, God uses our weakness to form our strength.  Moreover, weakness allows our strength to be elevated and “perfected”. 

As a future healthcare professional, I will certainly do everything in my power to ease my future patients’ suffering.  Whether a physician embraces suffering as painful and inevitable (but possibly valuable) or tries to avoid it at all costs can have huge implications for how he/she sees and treats patients.  We can examine this idea through the lens of attitudes toward death, particularly in the field of healthcare.  Like suffering, we can embrace or try to reject death. 

We read an essay by William Mays in my Bioethics class dealing with this topic.  Mays labels western society’s approach to death the “pornography of death”.  This refers to society’s two-fold approach to the subject of death: much like pornography, we simultaneously label it taboo and obsess over it.  It is a positive feedback loop.  Because it is taboo, we avoid it for the sake of “propriety”, yet we also obsess over it because we are never allowed to engage with it regularly in some way.  We end up engaging with death indirectly, as in the case of violent video games.  Thus, discussion of death is relegated to the realm of the morbid and morose.  As a result, we are not comfortable enough with death to see it as a sad but natural part of life, or see that it can be healthy to openly discuss it. 

For Lia’s family, suffering is not seen as a means of sanctification or instruction, but much like in Christianity, it is not something one tries to avoid at all costs.  Christianity and Hmong culture both see value in suffering, albeit for different reasons.  If we were to follow the Christian model of suffering and death, what implications would this have for interactions between patients and their physicians? I don’t know the details of the tragedy Fadiman alludes to on the book’s back cover, but I’m sure applying this model would have completely changed the tone of the clash between these two cultures.