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PALLIATIV CARE IN GENERAL PRACTICE

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					    CROSS CULTURAL MEDICAL ETHICS


                          Manfred Maier




Kranjska Gora, Slovenia                    Dept. of General Practice,
2004                                      Medical University of Vienna
                               OVERVIEW

       •   key terminology
       •   recent data
       •   patient autonomy
       •   epidemiology of disease




Kranjska Gora, Slovenia 2004               Dept. of General Practice,
                                          Medical University of Vienna
                               OBJECTIVES


 participants should be able to

 • recall key aspects of medical ethics
 • deduce the influence of cultural context on the
   autonomy of the patient
 • to estimate the consequences of the cultural
   background for the prevalence of illness /
   disease

Kranjska Gora, Slovenia 2004                 Dept. of General Practice,
                                            Medical University of Vienna
                               MEDICAL ETHICS



      • access
      • beneficience - non maleficience
      • equality – justice/disparity (resource
        allocation )
      • autonomy – informed consent
      • truthfulness (interpreter)


Kranjska Gora, Slovenia 2004                     Dept. of General Practice,
                                                Medical University of Vienna
       Fragment of the Hippocratic Oath on Papyrus from the Third Century.
                     Courtesy of Wellcome Library, London.



Kranjska Gora, Slovenia 2004                                 Dept. of General Practice,
                                                            Medical University of Vienna
                                    EQUALITY
Characteristics of Primary Care Physicians According to Visits by White and Black Medicare
Beneficiaries
Characteristic of Physicians              Visits by White      Visits by Black         P Value
                                          Patients             Patients
Race - % (no. of pairs)
    White                                 85.3 (35,824)        59.7 (1947)             <0.001
    Black                                  0.7 (370)           22.4 (650)
    Asian                                 11.2 (3939)          15.7 (483)
    Other                                  2.7 (1067)           2.3 (98)
Location of practice - % (no. of pairs)
    Urban                                 73.0 (34,256)        72.9 (2744)               0.99
    Rural                                 27.0 (7289)          27.1 (467)
Provide some charity care each mo - %
(no. of pairs)
      Yes                                 78.8 (31,317)        83.4 (2452)               0.06
      No                                  21.2 (10,228)        16.6 (759)
Board certification - % (no. of pairs)
    Board certified                       86.1 (36,570)        77.4 (2644)               0.02
    Not board certified                   13.9 (4822) )        22.6 (559)
                                                     Source: N ENGL J MED 2004;351(6): 575
  Kranjska Gora, Slovenia 2004                                        Dept. of General Practice,
                                                                     Medical University of Vienna
                         JUSTICE - EQUALITY

   The principle of justice requires that all people
                 be treated equally.




Kranjska Gora, Slovenia 2004                Dept. of General Practice,
                                           Medical University of Vienna
                                           ACCESS
Primary Care Physicians’ Perceptions of the Quality of Care Provided in Relation to the Race
of Patient
Index of Quality of Care                         Visits by White   Visits by Black       P Value
                                                 Patients          Patients
Access to high-quality specialists - % (no. of
pairs)
     Always                                      82.1 (33,271)     76.0 (2437)            0.04
     Not always                                  17.9 (8189)       24.0 (774)
Access to high-quality diagnostic imaging -
% (no. of pairs)
    Always                                       83.4 (34,443)     75.6 (2449)            0.003
    Not always                                   16.6 (7082)       24.4 (762)
Access to nonemergency hospital
admission - % (no. of pairs)
    Always                                       63.0 (23,414)     51.5 (1613)           <0.001
    Not always                                   37.0 (13,946)     48.5 (1261)
Able to deliver high-quality care to all
patients - % (no. of pairs)
     Agree                                       80.7 (32,588)     72.2 (2398)            0.02
     Disagree                                    19.3 (7960)       27.8 (688)
                                                         Source: N ENGL J MED 2004;351(6): 575
   Kranjska Gora, Slovenia 2004                                         Dept. of General Practice,
                                                                       Medical University of Vienna
                               ACCESS




Kranjska Gora, Slovenia 2004             Dept. of General Practice,
                                        Medical University of Vienna
                               AUTONOMY



       Autonomy of the patient means respect for
             his/her self – determination.




Kranjska Gora, Slovenia 2004               Dept. of General Practice,
                                          Medical University of Vienna
                               AUTONOMY

  the cultural background of a patient may
    influence

  • his/her way of living
  • his/her understanding of health / illness
  • his/her authority over his/her own life
    (informed consent)




Kranjska Gora, Slovenia 2004                     Dept. of General Practice,
                                                Medical University of Vienna
                          CULTURE AND DIET
 • classification of food / non food (frogs – cats – dogs)
 • sacred food – profane food (forbidden)
     – Hinduism (cows, animals)
     – Islam (pork/pig, fish with fins, ritually slaughtered-
       halal)
     – Judaism (pork/pig, fish with fins, kosher)
     – Sikhism (beef – pig, jhatka)
 • parallel food classifications
     – hot – cold (symbolic value)
     – medicines as food
 • social food (ritual aspects, social status, group identity)
 • infant feeding practices (breast feeding)

Kranjska Gora, Slovenia 2004                      Dept. of General Practice,
                                                 Medical University of Vienna
DIETARY CULTURE AND HEALTH / DISEASE


             •   malnutrition
             •   rickets
             •   anaemia (Asians)
             •   overnutrition
             •   cancer




Kranjska Gora, Slovenia 2004         Dept. of General Practice,
                                    Medical University of Vienna
                    CULTURE AND GENDER

    • components of gender (genetic, somatic,
      psychological, social)
    • gender cultures / sexual behavior
    • medicalization (stress, menstruation, old age)
    • health (male- female)
    • reproduction and birth culture
    • fertility / infertility


Kranjska Gora, Slovenia 2004              Dept. of General Practice,
                                         Medical University of Vienna
                          CULTURE AND PAIN


     • response to pain (private- public
       pain)
     • pain perception and pain tolerance
     • communication/presentation of pain
     • response to pain behavior




Kranjska Gora, Slovenia 2004                  Dept. of General Practice,
                                             Medical University of Vienna
                          CULTURE AND PAIN

• pain behavior
   – beliefs about meaning and significance
   – context in which it occurs
   – emotions associated with it

• social aspects
   – reaction to pain behavior
   – pain – “bad behavior” – guilt
   – attitudes shaped by society

Kranjska Gora, Slovenia 2004                  Dept. of General Practice,
                                             Medical University of Vienna
              CULTURE AND MEDICATION

response to medication may vary

• total drug effect (attributes, recipient, prescriber,
  setting)
• placebo effect (culture bound)
• abuse and dependence (alcohol, smoking,
  psychotropic drugs)
• sacramental drugs (rituals, social interactions)


Kranjska Gora, Slovenia 2004               Dept. of General Practice,
                                          Medical University of Vienna
                               RITUALS

• “aspects of prescribed and repetitive formal
  behavior, which have no direct technological
  consequence and which are symbolic”

• types of ritual
   – calendrical rituals
   – rituals of social transitions
   – rituals of misfortune


Kranjska Gora, Slovenia 2004              Dept. of General Practice,
                                         Medical University of Vienna
              CULTURE AND PSYCHIATRY

• normality – abnormality
• mental disorders (biological, social labeling or
  combined approach)
• somatization (vague, particular organ)
• culture bound psychological disorders (amok,
  hsieping, susto,..)
• family role in the cause and cure of mental disease
• prevalence in migrants


Kranjska Gora, Slovenia 2004              Dept. of General Practice,
                                         Medical University of Vienna
 PERCEPTIONS OF SOCIAL BEHAVIOR
                                       controlled

                                              symbolic inversions
                         „normality“          religious states
                                              culture – bound -syndromes


         normal                                               abnormal

                               „bad“                „mad“


                                       uncontrolled
Kranjska Gora, Slovenia 2004                                 Dept. of General Practice,
                                                            Medical University of Vienna
                    CULTURAL FACTORS IN
                       EPIDEMIOLOGY
• economic situation           • personal hygiene
• family structure             • housing arrangements
• gender role                  • sanitation arrangements
• marriage pattern             • occupation
• sexual behavior              • religion
• pregnancy/birth practices    • funerary customs
• child rearing practices      • culturogenic stress
• body image alterations       • leisure pursuits
• diet                         • domestic animals
• dress                        • self/lay treatment

Kranjska Gora, Slovenia 2004                  Dept. of General Practice,
                                             Medical University of Vienna
      STANDARDS FOR ACCREDITATION OF
       MEDICAL EDUCATION PROGRAMS
                               LCME, September 2003




ED-21. The faculty and students must demonstrate an
understanding of the manner in which people of diverse
cultures and belief systems perceive health and illness and
respond to various symptoms, diseases, and treatments.




Kranjska Gora, Slovenia 2004                           Dept. of General Practice,
                                                      Medical University of Vienna
      STANDARDS FOR ACCREDITATION OF
       MEDICAL EDUCATION PROGRAMS
                               LCME, September 2003




ED-22. Medical students must learn to recognize and
appropriately address gender and cultural biases in
themselves and others, and in the process of health care
delivery.




Kranjska Gora, Slovenia 2004                           Dept. of General Practice,
                                                      Medical University of Vienna
      STANDARDS FOR ACCREDITATION OF
       MEDICAL EDUCATION PROGRAMS
                               LCME, September 2003




ED-23. A medical school must teach medical ethics and
human values, and require its students to exhibit
scrupulous ethical principles in caring for patients, and in
relating to patients' families and to others involved in
patient care.




Kranjska Gora, Slovenia 2004                           Dept. of General Practice,
                                                      Medical University of Vienna
Kranjska Gora, Slovenia 2004    Dept. of General Practice,
                               Medical University of Vienna

				
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