Touching the Other’s Suffering: Cross-Cultural Challenges in Palliative Treatment Along Geopolitical Crossroads

Abstract

The authors describe the cross-cultural considerations in caring for a Palestinian breast cancer patient by an Israeli heath care team. The processes that facilitated a metamorphosis from possible hostility to receptiveness based on historical cultural conflicts were rooted in professionalism, patient-centered care, and cross-cultural sensitivity, woven into the patient’s own health beliefs and affinity to traditional Islamic medicine.

In Israel, because of the bitter conflict between two sets of people living in close proximity, the encounter between Jewish professional staff and Palestinian patients may be colored by feelings of distrust. We here report the case of a Palestinian woman with advanced breast cancer who explained to her Jewish physician that her sisters had been killed by an Israeli soldier. Through the course of her treatment, she grew to put aside feelings of enmity and formed close bonds with the medical team, even as her illness progressed. This dying patient’s grace and generosity toward individuals she might have held suspect inspired awe in the staff caring for her. She taught us to put our own petty concerns aside and led all of us to a renewed sense of commitment to our role as healers. The story may serve to remind all heath care professionals that when we reach out to those suffering from illness in a spirit of deep respect and caring, we have the capacity to heal wounds with deeper roots even than bodily illness.

Salma, a 37-year-old single woman living with her parents in an Arab town in northern Israel, was admitted to the Clalit Health Services oncology service for neoadjuvant chemotherapy for left breast carcinoma. One year later, tumor progression was diagnosed and weekly paclitaxel was initiated. Following eight paclitaxel cycles, Salma’s nurse-oncologist referred her for a complementary and traditional medicine (CTM) consultation provided by an integrative physician (IP) trained in CTM and supportive care. The IP consultation is oriented toward patients receiving chemotherapy and/or palliative care, with the aim of improving quality of life and addressing specific concerns such as anxiety, fatigue, painful neuropathy, nausea, diarrhea, and, in Salma’s case, a “sense of heat” all over her body. Salma arrived for consultation with the IP dressed in a traditional Muslim garment, escorted by her sister. Upon inquiry, Salma reported having used Islamic herbs traditionally used to treat cancer, having sought advice for food that could “strengthen” her, and undergoing cupping and bloodletting by a traditional Arab practitioner. She expressed deep religious faith concerning her illness: “I am not miserable as a result of my cancer. God loves me.”

When discussing her care team, Salma learned that the IP was acquainted with her family physician, a relation of hers. This came as a surprise to Salma and transformed the atmosphere in the room. She was amazed that the IP had visited her physician/relative at his home to express condolences following a family loss. A metaphorical door had opened, as Salma seemed to perceive the Jewish IP’s visit to a grieving Arab physician’s home in an Arab town to be a unique and unexpected human gesture. Salma subsequently disclosed her loss of two sisters, who “were murdered a few years ago in a terror attack executed in my town by a Jewish soldier.”

Salma left the initial meeting with a treatment plan aimed at improving her fatigue, emotional distress, depression, nausea, diarrhea, and neuropathy. The plan was presented to Salma’s oncologist, family physician, nurse, and social worker, all of whom supported it and helped her comply with it. Her plan included herbs, such as wheatgrass juice and black cumin (Nigella sativa), which is regarded in the Quran as the black seed that “can heal every disease, except death” [1] and is used in traditional Islamic medicine; participation in cuisine workshops; and weekly acupuncture, acupressure, and tuina (massage therapy). In time, Salma started wearing less-formal traditional dresses, and felt comfortable enlisting her Islamic faith during the treatment sessions: following each acupuncture needle insertion, she blessed the healing action of the needle, praising the Lord (Bismillah al rahman al Rahim, meaning “In the name of God, most Gracious, most Compassionate”). Salma came to trust her CTM providers with her care, saying, “I did not think there were people like you.” Upon conclusion of her manual treatment, Salma dedicated a blessing to nurse Bella’s hands. Patient-centered care and compassion were intertwined at times with a sense of redemption and forgiveness.

As the CTM treatments progressed, Salma reported gradual improvement in fatigue, mood, nausea, appetite, and tingling sensations, and in the concluding assessment questionnaire she wrote, “The treatment provided by the integrative nurse significantly helps me. It gives me ‘fuel.’ I return home as new, going around with no nausea and diarrhea.” Improvement in quality of life became evident while evaluating her condition following the 19th paclitaxel cycle, 11 weeks after the initial IP consultation.

Salma developed new challenges 1 month after the second IP assessment, including difficulty in eating and weakness of her right leg. MRI imaging revealed brain and meningeal metastatic spread. CTM treatments were discontinued for 7 weeks while she underwent brain irradiation at another facility. During the Muslim “Feast of the Sacrifice” (Eid al-Adha), Salma returned to the clinic in a wheelchair, reporting that since the last CTM session, she had become extremely fatigued, depressed, and nearly unable to walk. Her sister asked to be taught acupressure and gentle massage aimed at relieving Salma’s pain at home. Salma attended three more weekly sessions and received daily gentle manual treatment provided by her sisters. She reported better pain control and state of mind and attended what turned out to be the last session, prior to subsequent deterioration and hospitalization.

Five days following the last meeting with Salma, the IP attended an oncology conference in Rome, at a time of hostilities in the Gaza Strip. With Salma’s consent and blessing, the IP presented her treatment program, which had lasted 5 months, thereby acknowledging that supportive care in cancer is an alternative language to hostility [2].

Health Care Providers on the Cross-Cultural Abyss Versus Bridge-Building

The unconditional commitment of physicians and health care practitioners to the patient’s wellbeing is inscribed in the Hippocratic Oath: “Whatever houses I may visit, I will come for the benefit of the sick” [3]. The Oath of Maimonides, attributed to the 12^th-century Jewish scholar and physician, likewise advocates profound empathy toward patients: “May I never see in the patient anything but a fellow creature in pain” [4]. Following World War II, the Geneva Declaration adopted by the World Medical Association in 1948 stated, “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient” [5].

In regions of conflict across the globe, physicians may find themselves faced with ethical dilemmas that can sometimes endanger their lives [6]. In multiethnic societies such as Israel, with its Jewish-Arab mosaic of ethnic and religious subpopulations, cross-cultural encounters are daily events in hospitals and in the community at large. Despite these circumstances, medical professionals provide unbiased, respectful care to patients and collaborate with colleagues regardless of ethnicity [7, 8].

In our story, Salma and her medical care-giving team were aware of their difficulty in meeting “the other,” yet never doubted the sacred safeguarding of medical commitment and provision of the best supportive care possible. Medical neutrality, however, was merely the initial foundation in bridging the religious, social, and ethnic communication gap between the patient in our story, Salma, and her health care providers. Instead of perpetuating the difficulty, the triangular doctor-nurse-patient therapeutic relationship grew thanks to a simple, unsophisticated medical modality: skillful and compassionate body touch of the nurse, aimed at alleviating pain and fatigue, while, in return, Salma figuratively touched Bella’s heart:

• Salma: I can trust you and lean on you. I can feel myself being supported. Every treatment provides me with the oxygen to keep on going.

• Bella: Looking at and touching each other forged ​​a special bond between us. Emotion came through touch. Salma’s body asked for more, she was willing to touch me, she held my hands, blessing and kissing them.

In this atmosphere of mutual acceptance, openness, and curiosity toward the seemingly estranged “other,” we were witnessing integration. Metaphors and gestures formed a mosaic of therapies that included chemotherapy, herbs, and nutrition in accordance with traditional Arab medicine, touch, and acupuncture, supplemented with prayer and spirituality [9]. The processes that facilitated the metamorphosis from hostility to receptiveness were rooted in professionalism, patient-centered care, and cross-cultural sensitivity [10], woven into Salma’s own health beliefs and affinity to traditional Islamic medicine.

Although Salma is approaching the end of her journey, her spirit along the palliative course inspires us in our encounters with other patients and with the healer within each of us. In the high-risk environment of oncologists’ burnout and compassion fatigue [11], Salma’s journey creates an opportunity for the patient to serve as a mentor and guide for the caregiver’s growth in compassion and open-heartedness.

Acknowledgments

We thank Dr. Ana Rabkin and Marianne Steinmetz for editing the English manuscript.

Author Contributions

Conception/Design: Elad Schiff, Bella Shulman, Jamal Dagash, Eran Ben-Arye, Michael Silbermann

Provision of study material or patients: Eran Ben-Arye

Collection and/or assembly of data: Eran Ben-Arye

Data analysis and interpretation: Eran Ben-Arye

Manuscript writing: Elad Schiff, Bella Shulman, Jamal Dagash, Eran Ben-Arye, Michael Silbermann

Final approval of manuscript: Elad Schiff, Bella Shulman, Jamal Dagash, Eran Ben-Arye, Michael Silbermann

Disclosures

The authors indicated no financial relationships.