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13 Communitarian values in medical decision-making: Native Americans
The Case
An anesthesiologist approaches the bedside of a young Native American woman to complete a pre-anesthetic evaluation. The woman is scheduled for a lumpectomy and appears anxious. The anesthesiologist introduces herself and begins asking questions. “How long have you had diabetes? Do you measure your blood sugar at home? Why does it say here that you haven’t eaten for 48 hours?” The patient does not look at the anesthesiologist nor does she immediately reply to the series of questions. She seems to be looking around the room for someone else. Three people approach the bedside. The patient looks directly at them and seems relieved, but still does not answer the anesthesiologist’s questions. The three visitors stand quietly. The anesthesiologist begins again: “Have you had any surgery before today?” She is frustrated, not knowing to whom to address her questions, or when to expect answers.
There are more than 500 “tribal entities” in the US, with over 200 in Alaska alone. There are thought to be about three million Native Americans and Native Canadians. No more than 30%–40% of these individuals live on reservations or associated land trust areas.
The Indian Health Service (IHS) is a US governmental agency charged with providing preventive, curative, and community healthcare for US Native American populations throughout the US. Many Native Americans will be cared for outside of Indian Health Service (IHS) hospitals, and therefore may need care from anesthesiologists not employed by the IHS. Although most states have less than 2% of their population identified as Native Americans, some states have significant Native American populations, such as Alaska 19.0%, Arizona 5.7%, Montana 7.4%, New Mexico 10.5%, Oklahoma 11.4%, and South Dakota 9%.1 Anesthesiologists who practice in one of these states would be well served to acquaint themselves with the customs and cultural understandings that nearby Native Americans share. The cultural effects of Native American beliefs in the medical workplace serve to illustrate problems common to the care of patients whose cultural beliefs are significantly different from that of the traditional “healthcare” culture with regard to autonomy, beneficence and informed consent.
Native Americans have populated the North American continent for at least 10 000–20 000 years – indeed, some archeologists believe it has been much longer. There is ample evidence that the tribal cultures of North America were from early times advanced in their languages, kinship systems, sacred histories, and sophisticated methods of living in sustainable ways on the land. Native Americans should not be confused with depictions of pre-historic “early man” found in many museum dioramas, which are intended to illustrate very early use of animal skins for clothing, early possible social structures, group hunting, survival behaviors, and early forms of tool-making. Confusing Native Americans with African and European evidence of early humans does a distinct disservice to Native Americans, whose history is much more recent and whose cultures are far more sophisticated than that of early man before the development of cultural identities.
Principles of respect for autonomy, respect for community, and the principle of beneficence
Communitarian values
Native American cultures are far more communitarian than mainstream American cultures. Communitarian cultures are based on the fundamental premise that the “community” is the most valued entity, with part of each individual’s worth being measured by the degree to which they are able to contribute to the community’s well-being. Individual members of a community have an obligation to put the community’s interests before their own personal interests. In such “utilitarian” value systems, the principle of “beneficence” may therefore be practiced less in the context of individual beneficence, than in one of beneficence to the community.
Competitive white American culture often assigns social status to individuals based on their accumulation of money and possessions. Native Americans, instead, often value their ability to distribute what abundance they have to make sure that no one in their community is without necessary food, shelter, and means to care for their families. These fundamentally different value systems may lead people to make quite decisions with regard to their healthcare.
Native American views on illness
There are over 550 federally recognized Native American tribes in the US. Defining what constitutes a “tribe” would be academically difficult, but we know in general that the requirements for a distinct tribal community include: (1) having a common homeland; (2) speaking a common language; (3) having an agreed kinship system; and (4) sharing a sacred history. It would be impossible to describe the tribal customs or beliefs regarding illness and healing for each of the hundreds of federally recognized “tribal entities.” There are, however, common themes among many tribes that are useful for anesthesiologists to appreciate when caring for Native American patients. What follows is a description of some features of a belief system surrounding illness and healing of one of the largest tribes in the US – the Navaho, or Dine.
Southwestern pueblo cultures, particularly the Navaho, value being in correct relationship with others in the community, with the Great Mystery, with other living creatures, with even with the features of the homeland landscapes which are thought to be part of the birthright of the tribal community. When a Navaho person becomes ill, the root cause of the illness is thought to be the loss of a “correct” relationship. Relationships must be in balance to avoid or terminate illness. Each tribal member must strive to maintain a correct relationship to other tribal members, the right relationship with spiritual forces in other life forms, and maintain respect and gratitude to the homeland earth and climate. To restore health or “beautiful” living, the sick person may want to consult a tribal elder or a tribal member with medicinal powers. Western medical treatments may also be needed. Western medicine can be respectfully combined with tribal beliefs about restoring “right relationships” to achieve successful health outcomes for Native Americans.
Respect for the tribal homeland and designating landforms and its local flora and fauna features as sacred is part of the interrelatedness which native cultures value. The earth is often spoken of as a “mother” who nourishes and cares for the people. Traditional creation stories in many native tribes reveal that a spiritual being, the Great Mystery, preceded and then created mankind. The earth, the sun, the forces of weather, the cardinal directions, and the “brotherness” of other living creatures make everyday interactions “sacred” activities. Natives developed sustainable relationships with the flora and fauna of their homelands because they knew that the existence of their community depended on this.
The recent worldwide attention to “sustainable” living has renewed interest in the tribal ways of Native Americans. They recognized and valued sustainable living thousands of years before the emergence of the current interest in conservation of resources, preservation of species, and the development of renewable resources.
Navajo culture and informed consent
An important way in which the differences between Western and Native American values in healthcare ethics can be illustrated is through the process of informed consent. Western medical ethics place great value in “authentic” or autonomous choices of patients. In order for choices to be truly autonomous, this value system holds that a patient must be sufficiently informed and able to choose without coercion. Such information includes the nature of the treatment, risks, chances of success or failure, and alternatives to the recommended treatment.
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Conflicts of interest in research funding
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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