In this interaction, a patient’s ethnic background and limited English proficiency obstructed her care. Instead of taking steps to facilitate communication, the physician continued only with his established treatment plan and methods, failing to appreciate the value of the patient’s contribution to or understanding of her care. This contributed to the physician failing to treat the patient fairly and a poor outcome.
Failure to diagnose an impending myocardial infarction
Four Basic Principles of Medical Ethics5
- Beneficence — acting for the patient’s good
- Nonmaleficence — doing no harm
- Autonomy — recognizing the patient’s values and choices
- Justice — treating patients fairly
A 66-year-old female patient with a past history of diabetes mellitus, hypertension, and vascular disease presented to an internist complaining of a cough and wheezing. The patient had immigrated to the United States from Ecuador several years earlier, and she spoke mainly Spanish. She lived with her son, who had been in the U.S. longer, spoke English fairly well, and worked as a computer technician. The son had sometimes come to medical visits with the patient in the past, but he did not come to this visit. The internist diagnosed sinusitis and attempted to convey to the patient, without using an interpreter, that she should take acetaminophen, rest, and drink fluids.
This physician had a very strong and often-expressed view that people who come to the U.S. should learn to speak English. His grandparents had emigrated from Italy, and the physician liked to point them out as an example of people who had quickly adopted the language of their new country and successfully assimilated to American culture. He had repeatedly said he did not agree with spending his practice’s money on interpreters. If patients wanted interpreters, they could hire their own or use family members, this internist believed. He had expressed this view to the patient and her son at some past visits.
A week after this visit, the patient was significantly worse, and her son took her to the emergency department of the local hospital. Her examination in the emergency department revealed bilateral wheezing. A chest x-ray showed left lower lobe consolidation. Labs taken in the emergency department included elevated blood glucose, slightly elevated white blood cell count and abnormal CPK and troponin levels. The patient was admitted to a general medical floor with a diagnosis of pneumonia, and a nephrology consult was ordered. The patient’s internist was her attending physician. He did not use a language interpreter while she was in the hospital. For the first two days of the hospitalization, the patient’s status seemed to be improving: her respiratory symptoms and kidney function were better. However, the patient then developed shortness of breath and nausea. The internist ordered furosemide and an antiemetic. Repeat labs still showed an elevated CPK level.
The next day the patient had continuing nausea and shortness of breath, and her internist ordered a 100% NRB (non-rebreather) mask and intravenous theophylline. The patient developed respiratory and metabolic acidosis. That evening, at about 11 p.m., the patient had a cardiac arrest. She was resuscitated but remained minimally responsive in the intensive care unit (where she was transferred). Her son withdrew medical care two days later. The patient’s son subsequently brought a lawsuit against the internist alleging failure to monitor cardiac status and failure to diagnose and treat an impending myocardial infarction, which led to the patient’s death. The son testified in deposition that his mother’s care was further compromised by the internist’s lower level of vigilance toward the care of a Latina patient. The son’s deposition testimony included his recollection of the physician’s statements that immigrants should learn English and that patients in his practice were responsible for getting their own interpreters. The son said that is why he usually came with his mother to her appointments, although his work schedule sometimes prevented him from accompanying her. He also said that he had at several times talked to his mother about changing doctors, but the internist’s office location was convenient for her, and she was generally reluctant to alter any arrangement that she had become familiar with in the U.S.
Expert reviewers criticized the internist for not admitting the patient to a critical care floor, not ordering a heart monitor, not following up on the elevated CPK level, and for delaying in treating the patient’s worsening respiratory and metabolic symptoms. They also faulted the physician for not having used language interpretation services to better communicate with the patient in his office and at the hospital. The experts believed the physician did not meet the standard of care and that his failure to act on the elevated CPK level caused harm to the patient; therefore, the case was settled.
More Information About Medical Ethics and Physician-Patient Encounters
- Closed Claim Case Study: Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians
- Closed Claim Case Study: When Patients Refuse Treatment: Medical Ethics Issues for Physicians
- Closed Claim Case Study: Personal Relationship With a Patient Leads to Below Standard Care
- Closed Claim Case Study: Patient Confidentiality: Understanding the Medical Ethics Issues
- Closed Claim Case Study: Medical Ethics Issues with Shared Decision-Making in Patient Encounters
- Closed Claim Case Study: Improper Informed Consent Leads to Allegation of Negligent Supervision
- Closed Claim Case Study: Ethical Dilemmas with Disclosing Medical Errors
The main medical ethics principle that fits this case is justice. The patient’s ethnic background was a barrier to her receiving proper care when it should not have been. An important tenet in medical ethics is that “the sick should be cared for regardless of race, religion, gender or nationality.”1 In this case, poor care was exacerbated by communication problems as well as by ethnic bias and lack of cultural sensitivity in health care delivery on the part of the physician. Jonsen and colleagues point out that today, biases against various ethnic groups “may be less explicit but still present.” They write that “many studies reveal that racial and cultural minorities receive lower quality of care.”1 As these authors exhort, “It is ethically important that these biases be identified and eliminated from clinical decisions.”1
Medical Liability Risk Management Recommendations
Interactions with Patients of Diverse Ethnic Backgrounds and Those who Speak Languages Other than English
- Be sensitive and alert to cultural differences between you and your patients.
- Consider that you and a patient may have different beliefs about life, death, time, eye contact, personal space, relationships, who should consent to medical treatment, etc.
- Honestly assess your feelings about those with cultural beliefs different from yours, and work vigorously to address biased attitudes that may interfere with objective patient interactions.
- Study other cultures, especially those for which you have a significant patient population base.
- Learning the basics about these cultures can help you have general ideas about what communication or treatment issues may arise.
- Online resources include:
- The University of Washington Medical Center’s “Culture Clues” tip sheets for clinicians.
- Management Sciences for Health (accessed 7/5/2017)
- The U.S. HHS Office of Minority Health Minority Population Profiles (accessed 7/5/2017)
- Avoid stereotyping by remembering that each patient is an individual who will likely differ in some ways from the norms of the cultural group to which he or she belongs.
- Think about how you and your practice could offer more language services. Recognize that you must take meaningful steps to provide reasonable access to healthcare treatment for all patients. Federal law forbids discrimination based on race, color or national origin in programs that receive assistance or reimbursement from the government.2 Courts have interpreted “national origin” to include language, and “thus recipients of federal funds cannot discriminate against those who do not speak English.”3 Guidance from the U.S. Department of Health and Human Services helps define language assistance that should be made available to limited English proficiency (LEP) patients. The guidance calls for physicians to work to close language gaps and address cultural concerns.4
- Consider using interpreters if access is possible. Use a live interpreter who comes to the office, a bilingual staff member who is competent to translate medical terminology or an interpreter on a language telephone line (offered by long distance carriers or at Language Line Solutions).
- It is best not to plan for or rely on LEP patients’ family members or friends to translate for them. Having a family member interpret may inhibit the patient, or a family member may be reluctant to translate some information because of modesty or embarrassment. Family members may also be ill-equipped to translate medical terminology.
- The Office of Minority Health of the U.S. Department of Health and Human Services has online resources that provide information about language access services.
- Document objectively in patient records about language and cultural issues, including use of an interpreter, name of the interpreter or telephone service used, language spoken, your evaluation of the patient’s understanding of his or her disease and recommended treatment, and whether or not the patient had questions. Keep documentation clear, straightforward and free from any disapproving or ambivalent tone about communication frustrations or costs of language services.
1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:118.
2. 45 C.F.R. 80.3 et seq.
3. Youdelman M. Can the care be high quality if the communication is not? Virtual Mentor. 2007;9(8):559-565. (accessed 7/5/2017)
4. U.S. Department of Health and Human Services. Think Cultural Health: Advancing Health Equity at Every Point of Contact. (accessed 7/5/2017)
5. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press;2012:99-288.