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Although there is consensus regarding importance of cultural competency in healthcare delivery (Hoge et al., 2014), our ethical framework is distinctly western. Beauchamp and Childress’ Principlism theory (2019), which forms the basis for this focuses on four concepts- respect for autonomy, beneficence, nonmaleficence and justice- all having cross-cultural relevance. However, the way in which individuals from different cultures interpret these concepts may vary considerably, having downstream effects on informed consent.
In an article marking the fortieth anniversary of their theory, Tom Beauchamp and James Childress argue against an early criticism: that the framework ‘enshrines’ the principle of autonomy as its dominant moral principle reflecting an American bias towards individualism (Beauchamp & Childress, 2019). While this writer agrees that Principlism is, indeed, well balanced, Beauchamp and Childress’ description of moral norms clearly have roots in Platonism and the Abrahamic religious tradition.
Man is considered to have unique moral status among animals, as evidenced by his messianic religious roles. The four ‘cardinal’ Platonic virtues- wisdom, courage, moderation, and justice (Stanford, 2017)- suggest intellectual ability that is uniquely human, giving man the means for autonomous, morally informed decision making.
In contrast, Confucianism, which continues to undergird many eastern cultures, focuses on the ‘harmonious society,’ in which the embeddedness of persons in families and their communities take precedence over individualism (Tsai, 2001). The Confucian concept of wu-lun (five basic human relationships) suggests a ‘horizontal’ element to human decision making: that a person’s choices do not occur in a vacuum, and as a result, should reflect an altruistic responsibility towards family and the greater community (Tsai, 2003).
It is easy to imagine how these different perceptions regarding autonomy might impact the informed consent process. Legally and ethically, physicians are required to obtain written informed consent from patients deemed competent (Beauchamp & Childress, 2019). This might make a patient raised in the Confucian tradition uncomfortable, since such decisions should reflect the will of the family as opposed to the individual (Tsai, 2003).
In this situation, is the patient best served by the physician’s insistence in obtaining informed consent from that individual, or by accepting the individual’s autonomous decision to have the head of household act as the surrogate and sign the consent form?
Given justifiable concerns many physicians harbor regarding the potential for litigation, this is a difficult situation. But it is one which we as behavioral health providers should consider and discuss with our care teams. Healthcare is a global endeavor, and our ethical perspectives must evolve to reflect that reality.
Beauchamp, T. & Childress, J. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press. http://www.oup.com/us/he
Beauchamp, T. & Childress, J. (2019). Principles of Biomedical Ethics: marking its fortieth anniversary. The American Journal of Bioethics, 19(11), 9-12. https://doi.org/10.1080/15265161.2019.1665402
Hoge, M., Morris, J., Laraia, M., Pomerantz, A. & Farley, T. (2014). Core competencies for integrated behavioral health and primary care. SAMHSA-HRSA Center for Integrated Health Solutions. http://www.integration.samhsa.gov
Stanford (2017). Plato’s ethics: an overview. Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/entries/plato-ethics/
Tsai, D. (2001). How should doctors approach patients? A Confucian reflection on personhood. Journal of Medical Ethics, 27, 44-50. http://www.jmedethics.com
Tsai, D. (2003). The bioethical principles and Confucius’ moral philosophy. Journal of Medical Ethics, 31, 159-163. http://www.jmedethics.com
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