CULTURAL COMPETENCE IN ETHICAL

DECISION MAKING
GROUP 3
Bao, Hanna C.
Candillada, Leira Mae G.
Castillo, Anna Abigail R.
Dagatan, Hazel Mae T.
Dalman, Grace M.

CONTRASTING OF SOCIAL CONSTRUCTIONS OF MORALITY

The evolution of nursing as a profession has been intimately linked with society’s moral
philosophy, because the work of caring for and treating the sick and comforting the suffering, are
themselves morally worthy work. – (Jameton, 1984)

Social Construction of Morality

Moral Philosophy
- Consist of beliefs and assumptions about what is right and wrong.
The basis of ethics that prescribes the proper action to take in given situation.

Ethics
- Translates the moral philosophies into action.

The ANA and CNA code of ethics are sets of principles or standards guiding
professional nursing practice.
Morals and philosophic beliefs are constituted within the social, historical, and
cultural experiences of a society. These beliefs evolve as normative patterns or sets of
assumptions and beliefs that serve as an implicit framework to guide the actions and
thoughts of group members. These normative patterns or sets of assumptions and beliefs
may or may not be shared by persons outside the cultural group.

Ex. Chinese and Western culture

Western Moral Philosophic Theories

- Articulated by philosophers such as Voltaire, Diderot, and Condorcet, a new awareness
swept the Western world during the Enlightenment of the 17th and 18th centuries. These
new ideas or assumptions postulated that the human mind is "intendedly rational and
 scientific, that the dictates of reason are equally binding for all regardless of time, place,
culture, race, personal desire or individual endowment, and that in reason can be found a
universally applicable standard for judging validity and truth" (Lovejoy, 1974)

Naturalism vs Rationalism
- Two philosophic theories of ethics, naturalism and rationalism stemmed from the era of
enlightenment.

 Naturalism - Holds that all people have similar psychological tendencies and capacities.
Divergence in moral codes is attributed to differences in social conditions such as poverty
or lack of education. Once social conditions are ameliorated, it is presumed that uniform
morality can be achieved.

 Rationalism - Emphasizes the existence of universal moral truths independent of human

nature, known through reason and not by feeling or sensing (Raphael, 1994).

Teleological theories of ethics

- Derived from naturalism and grounded in the belief that an action is judged by its
consequence or outcome Consequential theories, such us Utilitarianism are teleological in
perspective Proponents of utilitarianism such as Jeremy Bentham and John Stuart Mill
argued that no action should be judged by itself but rather by its usefulness or end results
(Quinn & Smith, 1987)

 Utilitarianism - believes in the idea of the “greatest good for the greatest number”.
 Consequentialism - believes in the idea that the utility or consequence of an action is the
only relevant consideration in judging behaviors.

Deontological theories of ethics

- Are based on the rationalist view that the rightness or wrongness of an act depends on the
nature of an act itself rather than on its consequence. According to Immanuel Kant,
“humans are rational beings, are subject to universal rules, which have no exceptions and
which are discovered by reasoning”.

 Categorical imperative - states that every human being has a moral obligation to act in
such a way that his or her actions could become a moral law for everyone (Paton, 1961).

Based on the deontological theory of ethics, a professional code of ethics serves as a guide to
actions by members of the nursing profession (Burkhardt & Nathaniel, 1998).

Ex. Patient’s confidentiality…

ETHICAL PRINCIPLES
- Are basic moral truths that are taken for granted and guide deliberations and actions. So,
each of these principles has ethical principles that is an application of both deontological
and teleological theories of ethics.

Deontological
- Is a duty based, w/in duty or obligation of a nurse to do the right thing to do goodness to
the patient.

Teleological
- Is an approach to look for outcome or the end of the result. When the outcome is good
then it is good.

1. Autonomy - the right/freedom to decide (the patient has the right to refuse despite the
explanation of the nurse) Example: surgery, or any procedure. Patient Self Determination Act of
1991- is a legal protection of a person’s autonomy or self-determination in these situations
through advance directives.
2. Beneficence - Is obligation to do good or for the goodness and welfare of the clients.
3. Nonmaleficence - Is obligation to prevent harm or the duty not to harm/cause harm
maybe physical, financial or social)
4. Justice - relates to the fair, equitable, and appropriate treatment or use of resources in
light of what a person needs, weighed against the needs of others.
5. Fidelity - faithfulness/loyalty to clients.
6. Veracity - the act of truthfulness.

Individualism As the Context for Ethical Decisions in Western Society

The philosophic traditions of universalism and rationalism have shaped the western
concept of the person as the focus of moral reasoning. In contrast, to the western value of
individualism, members of the Xhosa tribe in South Africa emphasize collective decisions about
individual member’s care. Elders in the tribe make major decisions about the distribution of
human and material resources to provide care for their members.

ETHICS AND CULTURAL DIVERSITY

- Richard Shweder (1997) has argued that not all human behaviors can be classified as
simply rational or irrational culture. According to shweder is primarily is constructed by
groups of people.
Jehovah's Witnesses
- Disregard the identically based treatment of blood transfusion as a life saving measure
and violate the logic of biomedical reasoning.

Western
- Emphasis on self-determination, many societies value collective harmony and
relationships of individuals with one another.

Orthodox Jewish
- Beliefs uphold the sanctity of life. Euthanasia may not acceptable

In some groups, religions and spiritual dimensions highly influence behaviors

such ethno religious groups as devout Muslims, Hindus and Jews religion is embedded in
everyday life In contrast to the autonomy paradigm, the social framework paradigm plays
a greater role in other countries as well as in many cultural group in the United States and
Canada Patient autonomy is a lower priority than beneficence; Nonmaleficence, and
distributive justice among Blacks, Chinese, Koreans and Mexicans Communitarian group
such as Koreans and Chinese use a family-centered bread approach.

Community Based Theory of Ethics

- Emphasizes communal values, the common good, and social goals based on the members
shared assumptions and beliefs about morality that is rooted in a common sense and
tradition

Cultural Conflict in Ethical Decision-Making

- This section presents selected case studies in health care and nursing relevant to cultural
diversity.

Compliance With Professionally Prescribed Regimen

A Hmong Family
- Fediman’s (1997) story about a Hmong Family’s experience with healthcare in Merced,
California, portrays two contrasting explanatory models for illness (Epileptic Seizures)

Truth Telling About Diagnosis and Prognosis: The Pakistani Culture

Veracity and fidelity are ethical principles guiding the interactions of practitioners with
patients and families. These principles are supportive of individual autonomy and are assumed to
benefit and minimize harm to the patient, who needs truthful information to make a sound
decision. Moazam (2000), a physician who practiced and was trained in the United States,
accepted a position at a medical university in Pakistan.

Moazam (2000) noted the following:

 When illness struck a family member, it was the family and the doctor rather than the
patient who took center stage.
 Family members generally avoided disclosing terminal illness to patients, believed to
prevent further burden on the patient and allow the patient to die in peace.
 Family- centered decision-making worked with the active, directive role assumed by the
physician, emphasizing the principles of beneficence and nonmaleficence rather than
patient autonomy.

Studies done, according to Holland, Geary, Marchum, & Tross, 1987 in;

Africa Shows that fewer than 40% of oncologists avoid using the word
"cancer" or "terminal" when talking to patients. Valle (2001) also
Hungary notes that among communitarian groups such as Mexicans, Chinese,
and Koreans, patient autonomy and truth telling are secondary to
Japan beneficence and nonmaleficence in ethical decisions.

Portugal

Italy

Spain

Pakistani medical decision-making

- Deeply rooted in the moral philosophy shared by many Eastern cultures that recognize
the religious obligation of the family and the physician to the patient

Muslim Religion
- Defines the role of the individual, the family, and the physician in life transitions such as
illness and death. The physician is viewed as a trusted family member and an instrument
of God, who is part of the extended family.

Koreans and Chinese

- Tend to accept the physician's decision rather than assume an assertive role in decision-
making (Valle, 2001).
Moazam (2000), a physician who practiced and was trained in the United States, accepted a
position at a medical university in Pakistan. Moazam noted the following: cont…

● Decisions regarding full disclosure about an illness or prognosis need to take into account
the religious and moral contexts of people's lives.
● Accommodating their system of meanings can prevent divisions within a family unit.

Advance Directives: The Filipino Family

The Filipino Family Health care practitioners are mandated to provide patients with
information about advance directives. Asking a Filipino patient if he or she has a living will is
likely to produce a negative answer. Planning for one's illness or death-events considered beyond
one's control is viewed as tempting fate and will likely bring the potential event into reality.

Among traditional Filipinos, a sense of fatalism that is deeply rooted in their religious
and supernatural beliefs conditions an individual to attribute either positive or negative events to
God's will.

Filipino and Chinese nurses’ express discomfort in discussing advance directives with
hospitalized patients because they see their role as caregivers to patients. As with many Filipinos,
the patient's welfare is entrusted to family members, who will act according to his or her best
interests. Many Blacks equate advance the directives as legitimizing abandonment by
practitioners. Interest is taken for granted as the inherent responsibility of the Cohesiveness and
mutuality among members removes the necessity for an individual to worry about his or her
future, because the individual's goals and aspirations are deeply embedded in the group.

Informed Consent: The Mexican Family

The Western presumption that a competent adult can be relied on to make decisions is not
universal. Cultures emphasizing collective solidarity have an established social structure that
governs the actions of members based on their positions within the hierarchy. The act of
obtaining an informed consent needed to accommodate family hierarchy, and family
involvement.

Concepts Of the Human Body: The Muslim Patient

Members of some Muslim groups are reluctant to submit to autopsies or organ donations
for fear of offending their religious beliefs, according to a study by the Islamic Society of North
America (ISNA) published in the British Journal of Anatomy and Biomarkers (BAS). Devout
Muslims prefer to bury the body whole so the individual can meet his or her creator with
integrity. Muslim scholars have deduced from the Qur'anic text that it may be possible for the
deceased to feel pain. The Western concept of dualism reduces the human body into distinct
parts with separate body and soul.

Quality Versus Sanctity of Life: The Orthodox Jewish Family

American and Canadian medicine is thought to be leaning toward a utilitarian practice
model in which patients are deemed as discardable when quality of life is not possible. This
concept is congruent with the ethos of self-determination, but incompatible with the values and
beliefs of many cultures. An 80-year-old Orthodox Jewish woman was admitted to the hospital
with an earlier diagnosis of breast cancer. Throughout her hospitalization, groups of visitors from
her community took turns visiting and praying at her bedside. In Judaism, death is seen as a
natural ending of the cycle of life. When death is imminent, the person is faced with anxiety-not
about dying but about how he or she will be judged after death. One's life is measured by one's
deeds and by whether one has lived up to his or her potential, so the dying patient spends most of
the remaining time in reviewing his/her life (Levine, 1997; Ponet, 1996). In Jewish tradition,
because life is God given, human beings cannot take it away. Judaic tenet of life created by and
in the image of God emphasizes sanctity of life. Decisions that are deemed beneficial and
meaningful are made within a multifaceted framework of religion and community.

The Meaning of Life in The Context of Hinduism

In the Western worldview, death connotes finality, and only the legacy of the deceased
lives on. In contrast, death is viewed by Hindus and Buddhists as a step to another life.
Buddhism's pervasive belief in impermanence underlies the concept of cease less transmutation
of all existing forces. The Hindu belief in reincarnation or transmigration of life is rooted in the
cosmological concept of samsara. A dying Hindu may refuse nourishment and pain medication
to prepare for a "good death". Family members remain at the bedside and pray or sing
devotional songs to help the dying fix their mind on the Divine.