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2.4.1 Treatment and Respect for Difference: Aboriginal Health

Anne Townsend, PhD, and Susan Cox, PhD

Updated December 11, 2013

Educational Objectives

  1. To respect individual characteristics of patients while still recognising, historical, social and cultural characteristics when supporting autonomy in the decision-making process.
  2. To be sensitive to the priorities of individuals in consultations when following a model of shared decision-making in consultations.


Mrs. Morgan, a 62-year-old widow with four adult children, is a member of the Swxexmx (People of the Creeks) branch of the Interior Salish peoples of BC. She has been a patient of Dr. Butterfield, a family physician in Merritt, BC, for four years. Mrs. Morgan sees Dr. Butterfield regularly about her rheumatoid arthritis (RA) and experiences severe and unpredictable symptoms. Mrs. Morgan’s condition was diagnosed six years ago by her Vancouver-based rheumatologist, whom she sees intermittently. Her functional ability is poor due to painful ankles and hips. She finds it particularly difficult to walk.

Because of her debilitating RA, Mrs. Morgan lives with her eldest daughter; she has told Dr. Butterfield privately that she prefers her daughter to come to consultations and be involved in treatment decisions. Mrs. Morgan is quiet during consultations and seems reluctant to offer opinions. Dr. Butterfield recognises this reluctance to take part in discussions may be due to cultural characteristic of Aboriginal peoples.

After trying a series of prescription medicines, the rheumatologist has prescribed Mrs. Morgan leflunomide (a disease-modifying anti-rheumatic drug) and celecoxib (an NSAID) which she has been taking for three months Mrs Morgan has been told that this combination of medicines will need close monitoring and regular blood tests. She tells Dr. Butterfield that her medicines are not touching her symptoms. Her daughter adds that her mother is tired and wary of trying out new combinations of medicines and particularly reluctant to have regular blood tests. Her rheumatologist has recommended hip replacement surgery, but Mrs Morgan is anxious about going ahead with this. Mrs. Morgan’s daughter is unhappy with the limited options that her mother is offered and the regular blood tests. She asks Dr Butterfield if there are any other medicines or treatments available. She does not want her mother to have surgery, and asks if physiotherapy and diet would offer relief. Mrs. Morgan does not express her own views and instead leaves the discussion to her daughter and Dr Butterfield.


  1. Given the circumstances, how could Mrs. Morgan’s treatment plan be effectively discussed?
  2. How might Dr. Butterfield facilitate the decision-making process?

Case Continuation

During the consultation, Dr. Butterfield notices that Mrs. Morgan’s daughter, who is also her patient, is moving awkwardly.  The physician suggests a brief examination and blood test, including testing for rheumatoid factor and antibodies for cyclic-citrullinated peptide (CCP). She explains that the anti-CCP test can search for an antibody that is often found in people who have or may soon develop RA. She describes the benefits of early diagnosis of RA and emphasizes that treatment could potentially prevent a devastating loss of joint flexibility. She adds that this is particularly relevant in her case, as members of Aboriginal groups may be more susceptible to RA.

Mrs. Morgan’s daughter interrupts and says that she feels that Dr. Butterfield’s words imply weakness and vulnerability, suggesting that her people are somehow flawed. She describes the experiences of the Nuu-chah-nulth people on Vancouver Island. This population has a high incidence of diagnosed arthritis. The group has been the subject of extensive genetic research. In 1985, 833 blood samples were taken from volunteers who had given their written consent for the samples to be screened for arthritis biomarkers. However, the blood samples were stored and, without the knowledge of the donors, subsequently used in genetic anthropology studies that identified the Nuu-chah-nulth as a distinct indigenous population dating back nearly 70,000 years. This had potential implications for the Nuu-chah-nulth’s cultural heritage. Because of this, the taking of blood for testing can be a sensitive issue for Aboriginal peoples.

Despite prior agreement that Mrs Morgan could be present when her daughter’s health is discussed in consultations, Mrs. Morgan's daughter complains to Dr. Butterfield that she has discussed the blood test in the presence of her mother. She asks for a private consultation.


  1. Based on previous agreements and practice, is Mrs. Morgan's daughter right to complain about Dr. Butterfield's discussion of her potential health status in the presence of her mother
  2. Considering both cultural and personal history, what are the implications of the blood test for Mrs. Morgan�s daughter and for Mrs. Morgan?


Q1. Given the circumstances, how could Mrs. Morgan�s treatment plan be effectively discussed?

In general terms, the patient�physician�s fiduciary relationship involves an understanding that the physician must promote the patient�s legitimate medical interests, and the patient trusts the physician to do so. Mrs. Morgan has the right to be fully informed about drug treatments that are available through provincial drug plans and to discuss a full range of treatments. From an ethical perspective, the moral requirement of autonomy means the physician needs to offer appropriate information about drugs and surgery in a meaningful way. The associated risks and benefits should be presented in a form that fosters understanding and facilitates an informed and supported decision. For example, in order to respect cultural difference in the consultation, the discussion may involve silences, less practitioner talk and more listening, and joint decision-making with family members.

Because the interaction needs to be meaningful to the patient and should maximize health benefits and minimize confusion, anxiety and bewilderment, the practitioner should not be presumptive about the extent, nature, detail, form and timeliness of information he/she offers. Information sharing is a process of ongoing negotiation between patient and physician. This extends beyond a straightforward one-off statement from the patient about declining or accepting to be �fully informed.� To presume that a patient shares the practitioner�s perception of information sharing demonstrates a lack of respect for the patient as an individual in a social, cultural and historical setting.

In order to attend to the treatment needs of the individual patient it is important to take guidance from the patient, thereby fostering appropriate and beneficial information-sharing in a timely and meaningful way.

Q2. How might Dr. Butterfield facilitate the decision-making process?

Treatment decisions based on detailed medical knowledge and a respectful patient�physician, trust-based relationship meet the moral requirement of a more individualistic definition of autonomy in patient care. From this perspective, the views of Mrs. Morgan�s daughter could be largely discounted as complicating any decision made. In Aboriginal culture, however, autonomy is likely to be rooted in the family and community, and the decision-making process may be shared and take some time. If Mrs. Morgan seems undecided and bewildered, a higher level of physician guidance during the consultation may not be the most beneficial approach, but may convey a lack of cultural sensitivity and harm the patient�physician relationship.

One approach might be to delay any treatment decision and bring the consultation to a close, with the shared understanding that Mrs. Morgan and her daughter will arrange a meeting or �sharing circle� with other family and community members. After an agreed period of time, Mrs. Morgan and her daughter would return to Dr. Butterfield to discuss treatment options.

Overall, regarding Mrs. Morgan�s consultation, her own passive behaviour and her daughter�s active participation, Dr. Butterfield should be sensitive to cultural differences, but not assume that these are the sole reason for particular types of communication. Rather, she should attempt to gain an understanding of the complex interplay between cultural, personal and other potential factors that may influence the patient�practitioner interaction. The physician should also confirm with Mrs. Morgan, in private, whether she remains happy for her daughter to be an active participant in the decision-making process.

Q3. Based on previous agreements and practice, is Mrs. Morgan�s daughter right to complain about Dr. Butterfield�s discussion of her potential health status in the presence of her mother?

With reference to the daughter�s request for privacy in the consultation, it is important to be aware of, but not assume, the role of cultural difference, and thereby subsume the individual into notions about the collective. Mrs. Morgan�s daughter needs to be treated with respect as an individual who is a member of an aboriginal group, and therefore her needs should be discussed on an individual basis. Although there was prior agreement and experiences of shared consultations, relating to both mother and daughter�s health and treatment, ongoing clarification of the situation is required. In this instance, there has been a clear violation of patient privacy. It is important to confirm that previous arrangements remain valid. This is relevant to all cases. Where agreement has been reached about confidentiality, the validity of the agreement must be checked regularly and not assumed.

Q4. Considering both cultural and personal history, what are the implications of the blood test for Mrs. Morgan�s daughter and for Mrs. Morgan?

Although the proposed blood test is for an individual, it is also potentially knowledge gained about a community and so has possible implications for both the mother and daughter as community members. Any discussion needs to be sensitive to Aboriginal perspectives of the individual versus the community in the context of historical colonialism and the current social situation. Bearing in mind the moral requirements of autonomy and respect for the individual and the community in a broader context, the physician should avoid constructing Aboriginals as a group susceptible to disease (an association with weakness and connotations of ”bad blood”). Rather, discussions should take place against the backdrop of wellness and resilience. The taking of blood in the context of RA and group vulnerability has a particular place in Aboriginal cultures. The physician should be aware of a range of ways of conceptualizing a blood test in order that a frank discussion of the past can inform the patient–physician discussion during the decision-making process.

Overall, to fulfil the moral requirement of respect for autonomy, discussions of treatments and procedures need to be framed in a culturally sensitive way, building on the trust relationship from both a fiduciary and ethical position. It is a moral requirement to protect patients from harm and to attempt to alleviate suffering as much as possible at the time of the consultation and in the future. With careful consideration of the complexities involved, shared decision making can underpin the consultation; in this way, all knowledge shared must be given equal respect. Listening to the individual experiences of the patient and exhibiting cultural sensitivity are important parts of treating the patient with respect, and offering therapeutic advantage.

Checklist of points/questions which have been addressed in completing this module

  1. How does Mrs. Morgan’s culture affect communication and decision-making?
  2. What factors are important to consider beyond a person’s culture?
  3. How do your own beliefs, culture, values, and previous experiences as a clinician affect the care options you discuss with your patients?
  4. How does the style in which you communicate affect your approach to decisionmaking?
  5. What assumptions do you tend to make when approaching decisionmaking with patients and families?
  6. How have your previous experiences treating someone from a different cultural background � e.g. an indigenous background � affected how you approach communicating and decision-making around treatment issues with Mrs. Morgan?
  7. What are your beliefs regarding family centered care vs. patient centered?
  8. How do these beliefs impact on the care you provide?
  9. What are your views on traditional therapies?
  10. How would you approach decision-making with Mrs. Morgan and her daughter?1


  1. Questions drawing on Ian Anderson�s continuing education program:

References and Further Reading

  • Browne AJ. Clinical encounters between nurses and First Nations women in a Western Canadian hospital. Social Science and Medicine 2007; 64: 2165�76.
  • Ellerby JH, McKenzie J, McKay S, Gari�py GJ, Kaufert JM. Bioethics for clinicians: 18. Aboriginal cultures. Canadian Medical Association Journal 2000; 163: 845�50.
  • Government of Canada. Aboriginal Canada Portal:
  • Kelly L, Brown JB. Listening to Native patients: Changes in physicians� understanding and behaviour. Canadian Family Physician 2000; 48: 1645�52.
  • Marinker M, Shaw J. Not to be taken as directed. British Medical Journal 2003; 326: 348�9.
  • Notkins AL. New predictors of disease. Scientific American 2007; 296: 72�9.
  • Panel on Research Ethics: Research Involving First Nations, Inuit, Metis (FNIM)
  • Schmidt CW. Indi-gene-ous conflict. Environmental Health Perspectives 2001; 109: A216�9.