2.4.1 Treatment and Respect for Difference: Aboriginal Health
Anne Townsend, PhD, and Susan Cox, PhD
Updated December 11, 2013
- To respect individual characteristics of patients while still recognising, historical, social and cultural characteristics when supporting autonomy in the decision-making process.
- 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.
- Given the circumstances, how could Mrs. Morgan’s treatment plan be effectively discussed?
- How might Dr. Butterfield facilitate the decision-making process?
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.
- 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
- Considering both cultural and personal history, what are the implications of the blood test for Mrs. Morgan�s daughter and for Mrs. Morgan?
Checklist of points/questions which have been addressed in completing this module
- How does Mrs. Morgan’s culture affect communication and decision-making?
- What factors are important to consider beyond a person’s culture?
- How do your own beliefs, culture, values, and previous experiences as a clinician affect the care options you discuss with your patients?
- How does the style in which you communicate affect your approach to decisionmaking?
- What assumptions do you tend to make when approaching decisionmaking with patients and families?
- 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?
- What are your beliefs regarding family centered care vs. patient centered?
- How do these beliefs impact on the care you provide?
- What are your views on traditional therapies?
- How would you approach decision-making with Mrs. Morgan and her daughter?1
- Questions drawing on Ian Anderson�s continuing education program: http://www.cme.utoronto.ca/endoflife/Modules.htm
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: www.Aboriginalcanada.gc.ca.
- 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) http://www.ethics.gc.ca/eng/policy-politique/interpretations/research-recherche/
- Schmidt CW. Indi-gene-ous conflict. Environmental Health Perspectives 2001; 109: A216�9.