The Need for Clinical Compromise A Challenge for Bioethics

Respecting cultural difference may offer a profound challenge to healthcare practitioners' most fundamental values. In perhaps the best "text" explaining the cultural dynamics underlying the treatment of a critically ill patient, Anne Fadiman, in The Sprit Catches You and You Fall Down (1997), offers a detailed account of how the physicians caring for a young Hmong child with life-threatening, difficult-to-control epilepsy ultimately fail her because of their desire to offer her "state-of-the-art" care identical to that offered to any of their other patients. Through her detailed ethnographic account, Fadiman reveals how in this case the physician's quest for the "perfect" treatment was the proverbial "enemy of the good." The parents of the child, Lia Lee, were refugees from the American war in Southeast Asia, illiterate in their own language, with ideas about the cause of epilepsy and its appropriate treatment that were completely at odds with the views of the Western healthcare team. They were not, however, the only participants in the exchange shaped by cultural background and context. Fadiman's work documents the culture of biomedicine, explaining with great clarity how the physician's uncompromising dedication to perfection kept them from negotiating a treatment regimen acceptable to all.

Often in cross-cultural settings it is imperative to learn to compromise one's own clinical goals in order to meet the patient "halfway." Fadiman's book recounts the profound miscommunication between the pediatricians and family physicians involved in Lia's care, the Lee family, and the broader Hmong community. When her parents are unable to carry out a complex regimen of anti-epilepsy drugs, the child is turned over to the state's child protective services agency, provoking a profound and deepening spiral of tragedies. In the end, the physicians wish they had compromised their goals and prescribed a more simple medication schedule. Ironically, the parents' observation that the medicines were making Lia sick proved true in that one of the antiepileptic drugs contributed to an episode of profound sepsis that resulted in Lia's persistent vegetative state. A number of American medical schools assign this book as a required text in cultural sensitivity training. Its brilliance lies in revealing both sides of a complex equation: a Hmong enclave transported to semi-rural California and a group of elite, Western-trained physicians and healthcare practitioners caught up in a drama they cannot understand, not because the Lee family's cultural practices are so esoteric but because they fail to recognize how their own cultural assumptions and deeply held values limit their ability to help the ill child.

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