Cultural Sensitivity and Ethical Considerations

Abstract

Global surgery is a burgeoning area of global health. Surgeons can engage in one–or many–of the facets of global healthcare delivery: clinical care, capacity building, education, research, etc. Working in an increasingly global community, surgeons must be aware of the richness of cultural diversity at home and around the world such that they can provide culturally sensitive care. This chapter focuses on the most common way in which surgeons engage in global surgery: surgical short-term experiences in global health (STEGHs). Surgical STEGHs pose an intricate set of ethical dilemmas. As team leaders, surgeons must understand the community they intend to serve on these trips. Further, they should confirm that everyone who joins them is prepared to deliver care in a culturally sensitive and competent manner. Finally, surgeons must consider potential ethical dilemmas that may arise before, during, and after surgical STEGHs and have strategies to navigate them.

Global surgery is a burgeoning area of global health. Surgeons can engage in one–or many–of the facets of global healthcare delivery: clinical care, capacity building, education, research, etc. As surgeons from countries around the world travel to remote locations, they and their surgical teams encounter cultures different from their own, which adds a layer of complexity to providing surgical services, creating surgical infrastructure, sharing knowledge, and conducting research. Additionally, surgeons will discover ethical dilemmas in every aspect of global surgery. A complete discussion of all the ethical considerations of global surgery could fill at least one textbook. This chapter focuses on the most common way in which surgeons engage in global surgery: surgical short-term experiences in global health (STEGHs).

Surgical STEGHs pose many challenges to surgeons, their surgical team, local partners, and the patients to be treated. As team leaders, surgeons must understand the community they intend to serve on these trips. Further, they should confirm that everyone that joins them is prepared to deliver care in a culturally sensitive and competent manner. Finally, surgeons must consider potential ethical dilemmas that may arise before, during and after surgical STEGHs and have strategies to solve them.

Defining Culture

Culture may be defined as the way of life—customs, ideas, and social behavior—of a particular population, that is perpetuated and preserved over time. Arising out of both internal (e.g., ethnicity, language) and external (e.g., geography, climate) factors, cultures that are very distinct from one another have developed as a result of temporal and physical isolation. Nevertheless, it is in human nature to explore, and each population has had its wayfarers. Returning travelers have enriched their local cultures, while those who migrate permanently have diversified their adopted homes.

With technological advancements, exposure to other cultures has become commonplace through travel, media, and education. Even as physical travel was restricted by the COVID-19 pandemic, cross-cultural engagement continued within the virtual world. We now have the concept of global citizenry, in which we no longer just view ourselves and our roles within our own local context but also how we relate to and impact the world.

Global surgery, a movement which aims to provide equitable access to surgery across international healthcare systems, could be seen as an expansion of the global citizenry concept. Altruistic in intent, implementation is complicated by the need to navigate differences in culture, which can manifest in the surgeon–patient relationship, between the surgical team and the local healthcare providers, and within the surgical team itself.

Cultural Diversity

Cultural diversity is the existence of a variety of groups within a society. ¹ These groups may differ with regard to ethnicity, language, gender, age, religious and political beliefs, and sexual orientation. Within the workplace, the presence of different professional categories may be viewed as also contributing to cultural diversity.

As mentioned before, ease of travel and migration has led to increasingly diverse populations, but this does not always translate to work environments. In many parts of the world, surgery is still a male-dominated profession, with limited ethnic diversity. Lack of diversity in surgical career pathways affects cultural competence, leadership, and equity in the workplace. In contrast, increasing cultural diversity has been shown to increase opportunities, solutions, innovations, staff retention and productivity, as well as improve patient outcomes. ²

Cultural Sensitivity

Cultural sensitivity is the ability to recognize, understand, and react appropriately to beliefs, values, norms, and behaviors of persons who belong to a cultural or ethnic group that differs substantially from one's own, without assigning a particular value (positive or negative) to those differences. ¹ This may be challenging when interactions between the healthcare team and the patient are between dominant and secondary cultures in a society.

Milton Bennett's Developmental Model of Intercultural Sensitivity is a framework that describes the orientation of those exposed to cultural differences. ³ An ethnocentric response involves the mechanisms of avoidance or denial, defense, and minimization, to preserve one's sense of identity. This often involves assigning negative values to the other culture. A more evolved response is ethnorelative, which is characterized by acceptance, adaptation, and integration of other cultures.

Cultural Competence

The ability to appropriately engage with people from cultures different to one's own is termed cultural competence, and requires awareness, attitude, knowledge, skills. Although such competencies are trainable, the challenge lies in measuring the outcomes of such training. Within the healthcare context, several tools for measuring cultural competence, such as Sheu and Lent's Multicultural Counseling Self-Efficacy Scale, have been developed to help identify areas for improvement, but need further validation. ⁴ It is salutary to note that the Accreditation Council for Graduate Medical Education (ACGME) recognizes cultural competence as an essential part of professionalism, and that several surgical residencies have incorporated teaching and learning, as well as assessments, on cultural competence in their curricula. ⁵

Cultural Humility

Cultural humility is the final step along the cultural sensitivity–competency–humility continuum. As defined by Tervalon and Murray-García, cultural humility “incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient–physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.” ⁶ In this way, this term acknowledges that culture is ever changing and evolving. While cultural humility should be the goal for surgeons and their teams when traveling to remote locations and working with local partners and treating patients, it may not be an achievable goal. Thus, we will focus on cultural sensitivity for the purposes of this chapter.

Cultural Sensitivity in Global Surgery

When patients and healthcare providers from different cultural backgrounds interact, it is important to ensure that care is not negatively impacted by these differences, i.e., culturally competent care should be provided. Nevertheless, it has been consistently shown that ethnic minority groups often receive poorer quality of care and inaccurate diagnoses. Research within the nursing profession suggests that healthcare providers' perception and delivery of culturally sensitive care is hindered by their own biases, resulting in “othering” or microracism. ⁷

However, the differential access to diagnostics, treatment, and involvement in studies is not entirely explained by microracism. For example, willingness amongst migrant populations to participate in medical research has been shown to be influenced by their age and educational level. Indirectly, language was also a barrier, as consent forms were only available in one language. ⁸

While work has been done to explore the impact of culture on patients' access to healthcare, another context that should be remembered is when trainees and trainers from different cultural backgrounds interact. The Expert Advisory Group prevalence survey commissioned by the Royal Australasian College of Surgeons in 2015 revealed that International Medical Graduates were the cohort of trainees who was most likely to experience discrimination in the workplace. ⁹

More recently, a survey of general surgical residents in ACGME-accredited programs revealed that lesbian, gay, bisexual, transgender, queer, questioning (LGBTQ + ) residents were more likely to experience oppressive behaviors in the workplace, consider leaving the program and express suicidal ideation. ¹⁰ In Asia, the limited literature with regard to surgical training suggests that female gender increases the risk for experiencing discrimination and sexual harassment, with attendant risks of depression, but both genders experience high levels of bullying. ^{11 12}

Cultural Sensitivity Training

Like the communities that surgeons serve locally, there are nuances to the way(s) in which underserved populations around the world interact with the medical community. Additionally, surgeons will find similar cultural diversity with the local healthcare teams. As leaders of their team, the surgeon is responsible for ensuring that they and their team are prepared to interact in a culturally sensitive manner, prior to leaving home. But what is important to know and how does one find this information?

Global surgery is under the umbrella of global health. Thus, the tenants of global health are important to understand. Concepts such as imperialism, ¹³ neo-colonialism, ^{14 15} the White Savior Industrial Complex, ^{16 17} and “good intentions” ^{18 19} are worthy of pre-trip journal club discussions. These concepts explore some of the ways in which our actions can unintentionally perpetuate disparities, discrimination, and power differentials. Of equal importance, is an understanding of the population(s) with which one will interact and treat. Yet, it can be challenging to find resources to learn about these nuances and community(ies). Additionally, sociopolitical factors add another layer of complexity to providing healthcare in a surgical STEGH.

Unfortunately, there are no best practices regarding how surgical groups should prepare for STEGHs. A recently published literature review of the status of academic global surgery curricula concluded there are no universally established competencies for the fundamentals of academic global surgery and that most of the existing literature has been published by high-income countries (HICs) for HIC healthcare providers. ²⁰ Further, Sbaiti et al raise the question “Whose voices should shape global health education?,” which is a particularly relevant question given the dearth of available resources. ²¹

In the limited literature that exists, there are a broad range of options of preparation resources. On one end of the spectrum, surgical STEGH participants could enroll in a semester-long course such as the one that Duke University offers its medical students. ²² A course such as this offers the breadth and depth of material relevant to global surgery; however, it may not be a feasible time commitment for all STEGH participants. In contrast, there are some publicly available fact sheets and primers for just-in-time learning. ^{23 24 25} Additionally, there are some resources, such as The Equal Curriculum, which focus on other areas of healthcare disparity. ²⁶ The final chapter of that textbook describes topics in global LGBTQ+ health. Yet, there remain many gaps.

This offers surgeons and their team the opportunity to meaningfully contribute, in collaboration with their local partners, to developing resources for culturally sensitive care for the population(s) with which they will engage. One potential project could be hosting listening sessions with the local community to hear what they want surgical STEGH teams to know about the community and their needs. Based on these sessions, culturally competent healthcare fact sheets could be created to provide an overview of topics pertinent to the community.

Ethical Considerations

Delivering quality clinical care in a low-resource setting is challenging. Historically, most healthcare delivery models within global surgery were short-term, mission-based efforts, whereby a team from a high-resource setting visited a remote geographic location with limited resources. These efforts lasted from a few weeks to a few months and were not part of an overarching, continuous partnership. ²⁷ Surgical STEGHs create numerous ethical dilemmas, best described by Grant et al in their scoping review in 2020. The authors outline four domains of ethical dilemmas: 1) Clinical Care and Delivery; 2) Education, Exchange of Trainees, and Certification; 3) Research, Monitoring, and Evaluation; and 4) Engagement in collaboration and partnerships. In this chapter, we will focus on ethical issues encountered in the clinical care and delivery of healthcare in surgical STEGHs. The example cases below highlight ethical considerations related to the subsequent chapters in this issue. After each case, we provide questions for the reader to explore how they would resolve the dilemma. We will also suggest a few readings to guide your thought process. Our goal is to offer the reader a framework they can use to better contextualize the content in upcoming chapters, leading to a more robust understanding of the issues. While we cannot offer solutions to these dilemmas in the space allotted, we hope of offer an opportunity for the reader to think critically how they might solve them in the comfort of their own home before they must solve them in a foreign locale.

Benign Anorectal Disease

Case 1: A 39-year female patient presents to the anorectal clinic for painless rectal bleeding on the last day of your surgical STEGH. You diagnose an internal hemorrhoid and offer to perform a banding procedure in the clinic that same day. Everything goes well and she discharges home. Two days after you arrive back in your country, you receive an email from your local partner alerting you that the patient developed pelvic sepsis and is critically ill in the hospital. Your partner is worried that the patient will not survive and that the family will sue the clinic.

Questions to consider:

1. Who is responsible for a complication during a surgical STEGH from a medical–legal perspective? From a patient care perspective?

2. What recourse does the patient's family have?

3. What is an acceptable level of risk for patients to assume based on the level of care available when the HIC medical team leaves?

4. What role does licensing/credentialing play in surgical STEGHs?

These readings offer insight regarding the numerous medical–legal aspects to consider and include some country-specific examples. ^{28 29}

Rectovaginal Fistula

Case 2, Part A: You are called from the anorectal clinic because a pregnant woman needs an emergent cesarean section. Your local surgeon partner is not available, and you are asked to do the operation. You have not performed a cesarean section in 20 years.

Questions to consider:

1. Should you perform the surgery even though you are not credentialed to do this operation in your home country?

2. If you operated, could it be supported by it being “better than nothing?” Is that an acceptable standard for providing care in low- and middle-income countries (LMIC)?

3. Do surgeons have an obligation to prepare themselves for potential surgical emergencies that they may encounter when doing global work? If so, to what end?

Part B: You return a year later and see the same woman in your pre-op clinic for evaluation of rectovaginal fistula, which is significantly affecting her livelihood. She has undergone multiple previous repairs that have failed. Based on your judgment, any subsequent repair would need to be paired with a diverting ostomy to improve the chance of the repair healing. She begs for you to do the repair without a diversion. She is only willing to consider a temporary ostomy if she can stay in the hospital until she is able to have her ostomy taken down due to the stigma associated with having an ostomy.

Questions to consider:

1. If you do the surgery, what is the opportunity cost to the local community for the patient to stay in the hospital for multiple weeks to months?

2. If you do not perform the surgery, what is the opportunity cost for this patient? Could she lose her job? Could she lose her social support system?

These readings offer information regarding the common surgical procedures performed in LMICs as well as the potential stigma that stomas can create. ^{30 31 32}

AIN/Anal Cancer Management

Case 3: A 34-year man who has sex with men (MSM) presents to the anorectal clinic to be evaluated for a perianal lump that is painful and occasionally bleeds when he defecates. He has had it for years but was afraid to seek care because he was worried that he might get sent to jail because sodomy is a crime. Recently, the lump seems to be getting bigger, malodorous, and the pain is now constant. He wants to know what you can do to make his pain go away. On physical exam, you see a firm, non-mobile, fungating mass protruding from the anus. You are concerned he has a locally advanced anal squamous cell cancer that might be invading the sphincter complex. When you discuss the case with your local partner, you are cut off. “We do not treat those people here. What they do is illegal.”

Questions to Consider:

1. What strategies could you employ to ensure the patient receives appropriate care and does not face legal repercussions

2. What can you do to ensure this patient has access to safe follow-up care?

3. What obligation do you have to explore how your local partners' views create healthcare disparities for patients?

4. What obligation do you have to adhere to local laws, even if you think they are unethical?

This reading explores the variety of healthcare disparities that members of LGBTQ+ community experience around the globe. ²⁶

Colorectal Cancer Management

Case 4: You arrive at the clinic on the first day of your surgical STEGH. You had arranged to see a few patients to evaluate them for surgery and finalize operative plans for later in the week. When you open the door, you see at least 50 patients in the room, all waiting to see you. As you begin to triage the patients, you find a few who would require longer operative times and many that would require shorter operative times.

Questions to consider:

1. Who should be prioritized when there is limited time? The patients that live the closest or that traveled the greatest distance? Those that have waited the longest? The ones who are the easiest to treat—“treat the most”; or the ones who will benefit the most?

2. How can you develop selection protocols with your local partners prior to traveling?

This reading provides one prioritization structure that could be used when selecting patients for surgery. ³³

Developing Colorectal Surgical Capacity

Case 5: A 56-year male patient presents to the emergency room with severe lower left-sided abdominal pain, fever, and diarrhea. He is tachycardic and peritonitic on examination. Abdominal XR demonstrates free air in the abdomen. There is no CT scanner available. The local surgeon whom you are working with states that he would not recommend operating because they do not have sufficient resources to care for the patient due to the elective surgeries that you have been performing on your mission trip. You are worried that without surgery, the patient will die but you are also concerned that if you demand that the patient gets an operation, you will irrevocably damage the relationship with the local surgeon.

Questions to consider:

1. How do you balance the health/safety of the patient in front of you (risking your relationship with your local partner) and the health/safety of the potential patients you will care for in the future (only possible if you do not push back against your local partner)?

2. If the resources needed to care for one patient means that 3, or 5, or 10 cannot get care - who do you prioritize?

3. Which standard of care dictates how patients should be treated (home country or local community)? Is this different if you are conducting research?

Summary

Global surgery is a growing area of clinical care. As more surgeons and their surgical teams engage in global work, care must be taken to avoid perpetuating past mistakes (e.g., colonialism, white savior industrial complex, good intentions). While there is no single “right” way to engage in global surgery, there are many “wrong” ways. It can be difficult to navigate this evolving field and its many facets. Yet, approaching global surgery with cultural humility and a willingness to consider many perspectives is a good place to start. Ask questions rather than asserting an outsider's solution. Finally, taking time to critically think about the potential ethical dilemmas that may arise will ensure that you are not only being a global surgeon, but also a global citizen.