Assimilation and being "Differently ethical"

Fadiman reminds us of the different value systems that other groups can have in the chapter “Why did they pick Merced?”, where she discusses ways in which Hmong ethical codes contradict general American ethical codes. She give many examples to illustrate the differences, especially of the group ethic that the Hmongs value—for example, it is considered far more honorable to be loyal to one’s friends and family than to tell the truth to authorities; it is much better to live near family than to accept high paying jobs that would take one too far away. “Does money mean more or does family mean more?” is the question asked by one Hmong father mentioned in the book; the answer would be unequivocal for any Hmong.

There are also other ethical/values conflicts that exist besides the medical conflict that is the main subject of the book. What about the Hmong tradition of marrying young and having lots of children, perhaps more than can be comfortably (according to our notions of comfort) supported? I see this as conflicting with the traditional American plan of marrying after earning an education (preferably after getting a college diploma) and having a limited number of children that can be well supported through their own college educations. The chapter “Life or Soul” also briefly notes the conflict between traditional Hmong gender roles (the husband being the main contact with the social worker Francesca Farr, even though it is the wife’s health in question) and our own perceptions of a woman’s rights (in this case, the female should have been allowed to take control of her own health).

We talk about assimilation in terms of language and accepting American food, medicine, and pop culture, but asking the Hmongs to tell the truth to authorities they distrust, to use contraceptives, or to let wives make decisions about their health without having to get their husband’s approval is also a form of cultural assimilation. Is it appropriate for another group to intervene and “correct” these injustices or problems that we perceive in another culture? The answer of our ethical code would be “yes”—and the answer of the Hmong would probably be “leave us alone.” This attempted imposition of foreign value systems on the Hmong in other countries besides the U.S. has resulted in the multiple migrations of the Hmong; it has also played a role in numerous conflicts around the globe.

I think that a general “do no harm” policy works—don’t interfere with a practice unless someone gets physically or emotionally hurt by the tradition in question. But as the definitions of “harmful” or “beneficial” can be subjective, there is probably a need for other approaches as well. Also, I’m not sure whether outsiders should interfere in another culture’s practices, even if they perceive it as their duty to intervene. Perhaps it is a better route to raise awareness and let cultural insiders effect the changes themselves? Or are there certain traditions that call for “emergency intervention” by outside observers?

The Eight Questions to a New Idealism

In class on Wednesday, we spent a good part of the class debating Neil Ernst’s decision to file a claim to Child Protection Services on Lia Lee from The Spirit Catches You and You Fall Down. Chapter 17 sheds some light on the whole debate as Anne Fadiman pursues the cause behind Lia’s ultimate seizure attack that affects her brain permanently. Fadiman discovers that it was, in fact, Western medicine that pseudomonas aeruginosa bacillus to take over in her blood. She does bring up the point that Lia would probably not have survived past infancy if she had been in Laos but poses the important question of “which had hurt her family more” (260).
What is interesting when Fadiman presents this information to Lia’s doctors at Merced, she says that Neil focused “not on his relationship with the Lees but on his choice of medication” (257) while another doctor Dan Murphy “was less interested in the Depakene than in the interpreters” (259). This is interesting to note what is most important to each of them. Dr. Ernst does mention the cultural barrier and how he tried the best that he could and had to give up some of his control. Dr. Murphy then goes on to talk about the demise of his idealism. This idealism is something that I believe many pre-med students and even many doctors possess in the US. It’s easy to believe in the Hippocratic oath and use this as the end-all, be-all and make all decisions accordingly. What needs to be brought into account is that the US is fortunately a melting pot of a nation and each culture, whether you like it or not, is going to be bringing different practices and beliefs with them that may contradict Western medicine. Dr. Ersnt and all of Lia’s other doctors had to learn the hard way and we can discuss until we are blue in the fact, but the real question is what can we do?
Luckily, Fadiman ends the chapter with a suggestion for solution. She brings up Arthur Kleinman’s “explanatory model” which sheds light on a patient’s history, opinions and medical problems. Would this have saved Lia Lee’s life if her doctors had used it from the beginning, who knows. But it does help show doctors that there is a level of understanding that should be taken into account for every patient, and this is a kind of idealism for the future that should be invested in.

International Language of Medicine

During class, we discussed that many of the barriers between the Western doctors and Eastern culture in The Spirit Catches You and You Fall Down can easily be broken with translators and cultural negotiators. However, I have to wonder how much translators can help when discussing medicine. For example, "[the Hmong] don't have a word for pancreas. They don't have an idea for pancreas." With a problem like this, how can even a translator communicate information about the pancreas? The translator, of course, can just point and ask if the Hmong patient is feeling pain in the area, but can a doctor not do the same, even without the translator (in other words, practice veterinary medicine)?

The novel reaches out to a greater problem in the medical field: the language of medicine. As I recall watching Indian television shows at home, I am always fascinated by the sudden language changes involved when a hospital comes into play. Anytime a patient communicates with a doctor or nurse, the medical professional always responds in English. As I would watch, I would wonder if the producers of the show had considered the idea that much of the audience cannot understand English, and therefore, is watching the show. I asked my mom (who is a doctor) about this language change and why it occurs, and she explained to me that medicine is an English language. I think about this all the time now, and although I can't find a definite answer that English is the official language of medicine, I have found support for this argument. In an issue of the Journal of the American Medical Association dated 2000, an article appears that was published a full 100 years before, in 1900, in a special section. In the article, the author states,
English is coming more and more to the front. The recognition by Germany that it is the coming international tongue is an important step, in which, however, it has been anticipated in some degree by one or two Hollandish societies that have for some time printed their transactions in English. . . . It is the present language of the future and there is no reason why it should not be the international language of medicine and science wherever and whenever such a language is required.

This article from over 100 years ago states that English should be the "international language of medicine." This is a great idea...universalizing the language of medicine. Doing so will only make communication in the medical community much more seamless. However, what happens when we encounter someone like the Hmongs? What do we do when a basic anatomical part, the pancreas, is nameless in another culture or language? Is there any solution? Is universalizing the medical language actually a good thing? Only time can answer some of these questions, but I'm afraid that time will give us the answers we don't want. I don't think translators are going to be enough to communicate medicine to people who don't speak or understand English. There are always going to be words (even outside of medicine) that can't translate between languages. Will this be a problem?


http://jama.ama-assn.org/cgi/content/full/284/23/2977

A Lack of Villains

The first time I read this book, the guide I was reading cited a quote by German philosopher Christian Friedrich Hebbel: “Genuine tragedies in the world are not conflicts between right and wrong. They are conflicts between two rights.” I definitely believe The Spirit Catches You and You Fall Down is a story of two "rights," which makes it ever frustrating when tragedy befalls Lia Lee and in turn her numerous caregivers. Growing up in the Western tradition, I initially identified with the doctors involved in Lia's case. As Fadiman states, most family practice physicians, who are paid the lowest on average, choose their specialty for "altruistic reasons." (63) While the numerous articles that we've discussed in this class clearly show the falsely elevated status that medical professionals tend to have, I can understand why it would "rankle" to work thirty-three hour shifts a day and not be liked by your patients or even thanked. Fadiman allows the reader to become frustrated along with Neil Ernst and Peggy Philp as they try to control Lia's epilepsy despite not being able to control what happens when she is out of the hospital.

Contrarily, I also sympathize with Foua and Nao Kao. They basically came to this country against their will and therefore with no desire to assimilate into American culture. Their spiritual and cultural beliefs are the only constant in their lives full of pain, destruction, and death. Nevertheless, their ultimate inability to express themselves in America leads to complete disregard for their wishes about their daughter's care. Additionally, most of the health care professionals they meet show no desire to learn about Foua and Nao Kao's preferred treatment of quag dab peg. With such a lack of support, Foua's resignation is not surprising: "I am very stupid...too many sad things have happened to me and my brain is not good anymore." (103)

Although I remember from my first reading that Fadiman later suggests methods of preventing such a tragedy from ever reoccurring, I am unsure if such a serious cultural divide could have ever been completely resolved. My best guess at a solution (besides more interpreters) is an idea we discussed in class: making little concessions, like hospitals allowing placentas to be taken home rather than incinerated, to build trust and minimize antagonism between cultures. Over time, small acknowledgments of other cultures may make the bigger treatments, like major surgery or medication requirements, easier to accept.

Autonomy and Beneficence

What is wrong with having different standards of care to accommodate all the different cultural backgrounds of potential patients? When Dr. Fife used that approach (p. 77), other doctors obviously did not respect him for it. But patients preferred him, and a good relationship between a patient and his or her physician is critical when it comes to compliance. Why stick to methods that patients do not understand, support, or believe in? Is that really what is best for people? Being forced into doing what is considered best for them, because that is the only option? It is their body. So why is respecting the patient's wishes above all else considered a "lower" standard of care? The "higher" and "lower" distinction gives the impression that other methods of treatment are lesser than Western medicine. And even if you, as a doctor, strongly believe that Western medicine is the end all be all, your patient might believe in something else entirely that is just as important to him or her. The suggestions from the conference on interacting with Hmong patients that we looked over in class yesterday was one example of an attempt at bridging that gap. Maybe they wouldn't work verbatim in practice, but any effort made by a doctor to better comprehend where a patient is coming from can't hurt. If it's good enough for McDreamy...

On p. 80, Fadiman mentions "the principle of autonomy" and "the principle of beneficence". I looked up those terms because I am absolutely torn about bioethical principles these days, and now I'm even more confused about where I stand. Despite the fact that I keep leaning heavily toward autonomy, the truth is that there simply isn't always time to gain an understanding of a patient's wishes. And since many Hmong patients only seek medical attention when it is an emergency, the principle of beneficence is especially relevant.

"One clear example exists in health care where the principle of beneficence is given priority over the principle of respect for patient autonomy. This example comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.
In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the physician's opinion is in the best interests of the patient, without consulting the patient, or by overriding the patient's wishes, it is considered to be "paternalistic." The most clear cut case of justified paternalism is seen in the treatment of suicidal patients who are a clear and present danger to themselves. Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment." (http://depts.washington.edu/bioethx/tools/prin3cs.html)

In the case of an attempted suicide, the discrepancy between autonomy and beneficence is at its most extreme. It is their body. But when a person does not respect their body and tries to destroy it, that is one situation when the doctor definitely does know better.

"A Perfect Vegetable"

Though I realize that Dr. Peggy Philp was speaking sarcastically when she likened Lia's post-brain damaged status to a "perfect" vegetable, this line still struck me as odd and discomforting. In looking at Lia Lee after her final grand mal seizure (the big one), Dr. Philp sees that the septic shock to her brain has ironically resolved her epilepsy (and her problem of obesity). In Dr. Philp's opinion, Lia "was the healthiest she had ever been." This idea of health seems ridiculously distorted as, at this point, Lia is severly brain damaged. It seems that here health is equated with the ease with which the doctors can work with the patient. The seizures made treatment physically difficult while the obesity made it hard to insert an IV, therefore these conditions were unhealthy.
Lia, in her vegetative state, represents the ideal patient, one that neither complains nor physically resists any treatment. This sarcastically spoken remark is echoed at the end of the book when Fadiman mentions that cadavers are nicknamed "ideal patients" because they cannot complain or sue (much less be killed).

Shifting to the Hmong perspective, specifically that of Nao Kao and Foua, on Lia's progressive states, there is overwhelming evidence that they would consider Lia to have been healthiest and more importantly happiest when she was living with epilepsy. The simple facts that epileptic seizures are viewed as transcendental visionary experiences in Hmong culture and that Nao Kao and Foua held firm to their belief that the medicine was the ultimate cause of Lia's severe condition, highlight the differences in perspective. Lia was initially their well-fed princess with great spiritual potential. Foua and Nao Kao sought western medicine only when her seizures were severe and she appeared to be in intense pain. And they soon linked anti-convulsion medicine to Lia's declining state by causation. In the end, Lia is physically and mentally debilitated and while her parents still love her more than anything, they have deep regrets and miss the Lia they had.

East vs West

The first few chapters of The Spirit Catches You and You Fall Down highlighted a situation that seems inevitable in a country as diverse as the United States. The tension between Lia's parents and her doctors are painfully evident, and a result of Lia's doctors, Neil and Peggy, were genuinely concerned with Lia's health and well-being. Fadiman writes that "unless Lia died, they could see themselves driving to the emergency room in the middle of the night until she was grown up and had graduated to the care of an internist." It is clear that they are dedicated to Lia and all their decisions most likely would be made with Lia's best interest in mind, at least from the doctors' perspective. Fadmin writes that it was "agonizing to watch Lia...[to] fail to receive the treatment [Neil and Peggy] believed might help her lead a normal life." First, it is interesting to note how the use of the word normal is brought up again in medicine. As seen in past readings, it is clear that in medicine there is a clear distinction between what is considered normal and abnormal. The majority of the practice seems to revolve around restoring an individual to normal function, both physically and socially. It seems doctors have taken on the role of fixing patients so that they fit within the confines of society just as much as they help continue life. This is evident in all the intersex unit that was covered in the course, which, like the desires of Neil and Peggy, was to allow their patients to lead a normal life. It is interesting to note that their desire to do so, at this point in the novel, was to fix Lia so she could have a normal life. It was not to save her life (yet). Of course, this becomes an issue later in the novel. But still, the initial motivating factor was to fix Lia so she could be normal, drawing parallels to past units.

It is clear though, that from the perspective of the doctors, they felt that the medication and the treatment they wanted Lia to take was Lia's best bet at dealing with the seizures. Of course, their viewpoint that their treatment was the best is grounded and supported by Western medicine. Certain aspects of Western medicine conflict with Hmong culture and methods, and from the viewpoint of the family and Hmong culture, the decisions of the doctors were not absolutely the best course of action for Lia. It places the doctors in such a difficult position because according to their standards, they know the best treatment for Lia. But, from the perspective of the parents, the doctors overlook things that the parents feel would help out Lia. In addition, they do not understand the principle behind the medication and there is confusion with the medication plan as well due to the language barrier.


The disparity between their cultures illustrates a situation that probably has occurred with individuals of other races and cultures. It creates quite a predicament for both the patient and the doctors. It is interesting to think about cultures other than the Hmong and their potential issues they may have had with medical care. Given the diversity within this country, it is expected that there was already a method in place to deal with situations like Lia's. It seems though, that in order to avoid the miscommunication between doctors and patients , every nuance of a culture must be understood, a difficult proposition for a diverse country with varying population distributions.