One of the greatest challenges facing nurses and other allied health care professionals working in multicultural societies is caring effectively, appropriately and ethically for people from diverse cultural and language backgrounds. One reason why caring for people from diverse cultural backgrounds is challenging is that professional caregivers do not always know, understand or share the same cultural meanings and moral values held by those for whom they care. This lack of knowledge and understanding of the different cultural life-ways of different people can make it very difficult for professional caregivers to provide care that is culturally appropriate, meaningful, therapeutically effective and ethically just. This difficulty is compounded if professional caregivers also do not have appropriate knowledge and understanding of the complex relationship that exists between culture, health and healing (therapeutic) behaviours. A lack of knowledge and understanding about these things can result not only in disagreements between professional caregivers, and between professional caregivers and patients and families, but also in wrong judgments being made and ‘wrong care’, or what Kanitsaki calls ‘toxic service’ being provided (Kanitsaki 2003, 2000). This, in turn, can result in the undesirable moral consequences of patients’ safety and quality care, wellbeing and even their lives being placed in jeopardy, as examples to be given in this and the following chapters will show (see also Divi et al 2007; Johnstone & Kanitsaki 2006b, 2007a, 2007b; Smedley et al 2003).

In order to respond effectively to the challenges posed by caring for people from diverse cultural and language backgrounds, it is vital that nurses and allied health care professionals understand the nature of culture and its relationship to ethics. What particularly needs to be understood is that culture exists logically prior to ethics, not the other way around as has been classically contended in moral philosophy. In other words, ethics and the various systems of ethics that exist are every bit the products of the cultures and the times from which they have emerged and which have shaped, developed, refined and sustained them. In short, ethics and its derivatives have been, and continue to be, ‘culturally constructed’ (Cortese 1990: 1). That is, they are human inventions and not, as some have asserted, naturally occurring material facts that are interwoven into the fabric of the observable world (McNaughton 1988; Brink 1989; Dancy 1993).

Leininger (1990b), a noted American leader in transcultural nursing, has made the important claim that ‘culture has been the critical and conspicuously missing dimension in the study and practice of ethical and moral [sic] dimensions of human care’ (p 49). She has also criticised nurse ethicists for their failure to recognise the important and significant role that culture plays in guiding moral judgments and behaviour in human care contexts; and she contends further that some nurse ethicists have even ‘deliberately avoided’ the concept of culture altogether, preferring instead to assume the universality of the ethical principles, codes and standards of human conduct that have become so prevalent in mainstream nursing ethics discourse (p 51). Leininger concludes that, if nurses are to provide appropriate ethical care to individuals, families and groups of different cultural backgrounds, they must have knowledge of and the ability to uphold sensitively and in an informed way the culturally based moral values and beliefs of the people for whom they care (p 52). On this point, she states (pp 52–3):

Without this knowledge base, Leininger contends, it is not possible for nurses to make the ‘right’ decisions or to provide the ‘right’ (ethical) human care when planning and implementing nursing care (Leininger 1990b: 64).

Questions remain, however: What is culture? and, further: What is culture’s relationship to and role in ethics generally, and nursing ethics in particular? It is to briefly answering these questions that this discussion now turns.

Culture is an extremely complex concept, and one that has over time been defined, interpreted and analysed from a variety of disciplinary perspectives (see, for example, Beals 1979; Bullivant 1984, 1981; Fieldhouse 1986; Helman 1990; Kluckhohn 1962; Leininger 1991a; Mead 1955; Midgley 1991a; Sorokin 1957; Spindler 1974; Williams 1989; Wuthnow et al 1984). Not surprisingly, this has seen the emergence of a number of rival theories and viewpoints on what culture is, and on what its relationship to and role in human affairs is or should be (Kanitsaki 1992: 5). Even anthropologists do not agree about how culture should be defined, interpreted and analysed. Nevertheless, there is some agreement among scholars that culture is a human invention and one which is critical for human survival and the development of human potential.

What then is culture? As already stated, culture has been defined, interpreted and analysed in a variety of ways. Cohen, for example, argues that (1968: 1):

Bullivant argues along similar lines, adding to the description of culture that it is something which (1981: 19):

A more accessible description of culture, however, and one which is very helpful to this discussion, comes from an Australian nursing scholar and former Professor of Transcultural Nursing, Olga Kanitsaki, AM (Member in the Order of Australia). Kanitsaki describes culture as follows (1994: 95):

Kanitsaki further explains that (2002: 22):

Unfortunately, it is beyond the scope of this text to discuss the concept of culture at the level and depth it warrants, and its consideration must be left for another time. Nevertheless, there is room to emphasise the point that, regardless of the competing theories on what culture is, it is clear that it plays a fundamental and critical role in mediating people’s values, beliefs, perceptions and knowledge about the world within which they live, that it influences people’s behaviour and generally gives logic and meaning to a whole way of life in that world, and that it ultimately provides the ‘blueprint’ for their (human) survival in that world (Kanitsaki 2000). It is also clear that culture’s relationship to and role in ethics (including its relationship to the theoretical underpinnings and practical application of ethics) cannot be plausibly denied. One does not have to be a distinguished cultural anthropologist to recognise and accept the critical link between culture and people’s moral values, beliefs, perceptions and knowledge of what constitutes morally right and wrong conduct. As Mary Midgley points out (1991a: 72), the ‘communication explosion’ has meant, among other things, that:

Similarly, nearly all of us know that there are in the world many people whose moral values and beliefs are radically different from our own (Midgley 1991a: 72). And we also know that in any one society there is likely to be a diversity of valid moral viewpoints and approaches (moral pluralism), and that this has created the possibility for, and the actuality of, irreconcilable moral disagreements, examples of which are given throughout this text (Elliott 1992: 32). Questions arising here include: What, if any, is the best way to respond to moral pluralism? and, more specifically: How should nurses respond to the challenge of what can be appropriately referred to as cross-cultural ethics? It is to briefly answering these questions that this discussion now turns.

It is not the purpose of this text to advance a substantive theory of cross-cultural ethics or cultural relativism, or to provide an in-depth study of the ethical concepts, theories and practices of different cultural groups. Such a task is beyond our present scope, and requires much more space than it is possible to provide here. (See, meanwhile, Cortese 1990; Coward & Ratanakul 1999; Elliott 1992; Fry & Johnstone 2008; Leininger 1990b; Macklin 1998; Marshall 1992; Midgley 1991a; Singer 1991.) Nevertheless, it is important to have some understanding of the nature and implications of cross-cultural ethics (a form of ethical pluralism), and of how nurses might respond better to the challenges it poses.

One crucial point requiring understanding is that, while all societies have some sort of moral system for guiding and evaluating the conduct of their members, the moral constructs of one culture (e.g. North American or English culture) cannot always be applied appropriately or reliably to another culture — at least not without some modification (Silberbauer 1991: 15). Further, language usage alone, and the difficulties encountered in reaching accurate culturally thick (rich) translations of accepted moral terms and concepts, may even make meaningful moral discourse across cultures impossible (Stout 1988). These points have, however, been largely overlooked by mainstream (Anglo-American) moral philosophers, who have tended to support an imperialist model of morality — that is, that their way of moral knowing and thinking is not only superior but ‘right’, and is thus something to be applied (read imposed) universally on to others whose moral systems they have judged to be inferior — even ‘savage’ (Midgley 1991a: 78).

This is an inadequate and fraudulent approach to moral thinking and conduct, however, and one which should be questioned. Nevertheless, this does not mean that mainstream Anglo-American moral philosophy itself should be abandoned. To the contrary — its rich traditions offer us important insights into our own culture-specific moral values and beliefs about how to be moral beings. We must, however, pay much greater attention to the influences of the primary organising principle of morality, namely, culture. We also need to recognise that, while it is true that all cultures have some ‘priority rules’, or principles for arbitrating between conflicting obligations and duties, just what these rules and principles are, how they are defined and interpreted, when they will be applied, and who ultimately applies them (and to what end) will, contrary to an imperialist model of ethics, vary across — and even within — different cultures (Midgley 1991b: 11; see also Tai & Lin 2001). In short, morality will be expressed differently cross-culturally and intra-culturally.

An interesting example of the different ways in which morality can be expressed cross-culturally or even intra-culturally can be found in the case of small-scale and large-scale societies. In small-scale or traditional societies, for example, morality tends to be viewed as a process — as a means to an end — and is expressed through the quality of relationships (characterised by upholding values such as friendship, loyalty to kin, empathy, altruism, familial trust, and so on), rather than a deontological adherence to abstract principles. Silberbauer explains (1991: 27):

This view is in sharp contrast to that upheld by large-scale (non-traditional or industrialised) societies, in which relationships are less proximate, less intense and less significant, both at the individual and the societal level. Here morality is viewed as an end in itself rather than as a means to an end, and is expressed by adherence to rules (viz adjudicating the conduct between strangers) rather than by and in the quality of relationships per se. On this point, Silberbauer explains (1991: 27):

To illustrate the different ways in which small-scale and large-scale societies might each express their different moralities, Silberbauer (1991) uses the simple example of the relationship between a bus conductor and a passenger. He suggests that, in large-scale societies, where relationships tend to be ‘single-purpose and impersonal’, the relationship between a bus conductor and a passenger would be of limited importance, and would probably manifest itself quite differently than it would in a small-scale society, where relationships were more proximate, multi-purpose and personal. He points out (p 14):

A more relevant example here can be found in the comparison of nurses working in large city-based university teaching hospitals with those who work in small, close-knit rural ‘outback’ country communities. It has been my experience that nurses working in the small rural or remote (‘outback’) country communities (where ‘everyone is known to everyone’) are far more vulnerable to putting local community members ‘off-side’ by offending an individual member of that community than are nurses working in the large city-based university teaching hospitals. In this instance, we could speculate that nurses working in small country-based community nursing care settings might put more weight on preserving the quality of relationships in that community than on upholding abstract moral principles. Conversely, nurses working in the large and impersonal communities may put greater emphasis on upholding abstract principles of conduct than on preserving the quality of relationships with ‘strangers’ whom they are unlikely to encounter more than once during their working lives.

Bear in mind, however, that this is only an example, being used here to help clarify Silberbauer’s point. In reality it is likely that nurses express morality both as a process (as a means to an end) and as an end in itself. Whether this is so, and the extent to which it is so (that is, where the balance lies), may depend ultimately on the nature of the context they are in — whether it is characterised by personal or impersonal relationships. When it is considered that it is not contradictory to view the maintenance of quality relationships as an important moral end in itself (not just a means to an end), there is room to suggest that the distinction Silberbauer makes may, in the final analysis, be overstated.

Despite this observation, Silberbauer is correct to point out that abstract moral principles do not always have currency in some cultural or social groups, and that, even if there do exist some commonly accepted standards of moral conduct, we cannot assume that these standards will be expressed or applied uniformly across, or even within, different cultural groups. A good example of this can be found in the wide and popular acceptance of the moral principles of autonomy, non-maleficence, beneficence and justice, which are considered in Chapter 3. These principles are referred to and used widely in mainstream bioethics discourse (see in particular Beauchamp & Childress 2001), and are viewed popularly as ‘self-standing conceptual systems by which we can impose some sort of order upon ethical problems’ (Elliott 1992: 29). But, as Elliott correctly points out, what proponents of this view tend to overlook is that in reality, ethics does not stand apart. It is one thread in the fabric of a society, and it is intertwined with others. Ethical concepts are tied to a society’s customs, manners, traditions, institutions — all of the concepts that structure and inform the ways in which a member of that society deals with the world (Elliott 1992: 29). He goes on to warn that, if people forget this inextricable link between ethics and culture (p 29):

A poignant example of the inaccuracy and fraud of viewing moral principles as self-standing conceptual systems rather than as ethical concepts tied to a particular tradition (culture) can be seen in the way in which the principle of autonomy tends to be interpreted and applied in professional health care contexts. As stated in Chapter 3, the concept of autonomy refers to an individual’s independent and self-contained ability to decide. As a principle, autonomy prescribes that an individual’s rational preferences ought to be respected even if we do not agree with them — and even if others consider them foolish — provided they do not interfere with or harm prejudicially the significant moral interests of others.

At first glance, this articulation of the concept and principle of autonomy appears unproblematic. And it is probably true that most nurses familiarising themselves with the moral nature and application of the principle of autonomy value the ‘right’ to make their own self-determining choices, and would probably feel a strong sense of outrage if their considered wishes were overridden arbitrarily by another. They may also share a strong conviction that patients should always be informed about their diagnoses, and about the details of their proposed treatment and care, and that it would be a gross violation of patients’ rights not to accept or facilitate patients’ self-determining choices regarding their own care and treatment options. In most cases, this position would probably be a demonstrably justifiable one to take. It would, however, be a grave mistake to accept the concept and principle of autonomy (as articulated above) as holding universally; that is, without exception. Consider the following.

Earlier in this book, it was pointed out that definitions of ethical terms and concepts can be ‘ethically loaded’, and hence can themselves be an important influence on how a moral debate or analysis might be conducted and what the outcomes of a given debate or analysis might be. This is true even (or perhaps especially) in the case of moral principles — the moral principle of autonomy being a case in point. It will be noted, for example, that even the definition of the concept and principle of autonomy reflects the dominant cultural values of the highly individualised large-scale Western Anglo-American culture from which it has arisen (Blackhall et al 1995; Tai & Lin 2001; Hanssen 2004; Kuczewski 1996; Marshall 1992; Neves 2004). Of particular importance to this discussion are the following terms individuals, independent, self-contained. Here the ethical loading clearly rests on respecting individualism, independence and isolation (insulation) from one’s social ‘connectedness’. (As a point of interest, in contemporary Italian culture the notion autonomy [ autonomia] is often used synonymously for isolation [ isolamento] [Surbone 1992: 1662].) For people who hold these values, this ethical loading is not a major problem. But for people who do not hold or share these values — who may, for instance, subscribe to the values of collectiveness, interdependence, and social connectedness (context) — it is open to serious question whether the concept and principle of autonomy as popularly defined and applied in mainstream bioethics discourse could, or indeed should, be given any currency in mediating the relationships, and the responsibilities within those relationships, of people who do not subscribe to the values embraced by autonomy as described.

To illustrate the kinds of moral problems that can arise as a result of applying the principle of autonomy in an abstract, universal and context-independent way rather than in a substantive, context-dependent, culture-specific way, consider the case of Mr G (taken from Johnstone & Kanitsaki 1991). Mr G, an elderly Greek man who spoke no English, was admitted to hospital for investigations, and was later diagnosed as having cancer of the lung. Mr G had a number of other health problems, including a mildly debilitating hemiplegia — although he could move about with assistance. Before his admission into hospital, Mr G was totally dependent on and cared for by his family.

When radiological and laboratory tests confirmed the provisional medical diagnosis of a malignant lung tumour, Mr G’s physician arranged for an interpreter to come to the ward and through him informed Mr G directly that he had cancer of the lung. In this instance, it was the physician’s personal policy to be candid with his patients, and inform them according to what he judged to be ‘their right to know and be informed’, as prescribed by the moral principle of autonomy. Unfortunately, in this case, although well intended, the physician’s approach was culturally inappropriate, and had the undesirable moral consequence of causing the patient and his family otherwise avoidable suffering (Johnstone & Kanitsaki 1991).

A mainstream ethical analysis of the physician’s actions in this case would probably support the view that informing the patient of his cancer diagnosis was a ‘morally right’ thing to do. And, interestingly, when I present this case to students (nursing and medical students alike), most contend that the physician’s actions were not only morally correct but praiseworthy, given the reluctance by some doctors to be candid with their patients about diagnostic, care and treatment matters of this nature.

From a cultural perspective, however, the physician’s actions can be shown to be not only mistaken but morally harmful, for reasons that will now be explained. In this case it would have been more culturally appropriate and morally beneficial had the physician communicated the cancer diagnosis to the patient’s family rather than to the patient himself (see also Kanitsaki 2000, 1994, 1993). This is because, as Johnstone and Kanitsaki point out (1991: 280), during a health crisis, patients like Mr G who are of a traditional (rural, small-scale societal) cultural background, tend to prefer:

By not recognising the protective authority of Mr G’s family to decide ‘ if, when, how and by whom the diagnoses should be disclosed to Mr G’, the physician inadvertently ‘pointed the bone’ at his patient and thereby undermined rather than promoted Mr G’s autonomy. The reasons for this are complicated, but important. Kanitsaki (1989a) explains that for many rurally based Greeks who emigrated to Australia during the 1950s and 1960s the very word ‘cancer’ carries a whole range of negative connotations and thus is something never to be mentioned, since to do so would be to risk stimulating the nocebo phenomenon. The nocebo phenomenon (from the Latin noceo, ‘I hurt’, and the Greek nosis, ‘disease’) is defined by Helman (1990: 257) as ‘the negative effect on health of beliefs and expectations — and therefore the exact reverse of the “placebo” phenomenon’ (see also Dossey 1982, 1991; Chopra 1989; Moyers 1993). Kanitsaki (1989a: 46) explains that during the 1950s and 1960s, rural Greece had virtually no hospitals, and that if people required treatment for serious illness they would have to travel great distances to the nearest cities. She goes on to point out that, because of this, as well as because of a scepticism about scientific medicine’s ability to treat diseases effectively, people from rural areas would seek hospital treatment only as a last resort. As Kanitsaki explains (p 47):

As a result of this reluctance — and, indeed, inability — to access scientific medical services, many people suffering from cancer-related illness did not receive the optimal treatment available, and as a result frequently died painful and agonising deaths (Kanitsaki 1989a). And it is the memories of these kinds of cancer-related deaths that many rural Greek immigrants have brought with them to Australia and which persist to this day (see Irwin 2007). Kanitsaki explains (personal communication) that many Greek immigrants of this background simply do not have any experiential knowledge of, or even a conception of, the kind of treatment and care that is currently available in Australia; thus, even mentioning the word ‘cancer’ is sufficient to trigger in ill persons an overwhelming sense of hopelessness which ultimately finds its expression in their losing their will to live. Under these circumstances, to tell such patients, ‘You’ve got cancer’ — no matter how benevolent the intention in doing so — would probably be sufficient to trigger the nocebo phenomenon, resulting ultimately in the ill person’s premature death (Kanitsaki, personal communication).

The way to avoid this disastrous situation is for the patient to be spared the information likely to stimulate the nocebo phenomenon, and for the patient’s family to be respected as having the surrogate authority to decide — in the moral interests of and for the wellbeing of their sick loved one — whether, when, where, how and by whom information about the diagnosis of a serious illness and poor prognosis will be given (Kanitsaki, personal communication). A major moral motivation for this, Kanitsaki explains (personal communication), is to avoid undermining the sick person’s hope (about getting better and being able to go on living a meaningful life), and thereby to maximise the person’s ability to continue making important life-interested choices; that is, to maximise the person’s autonomy. In sum, maintaining hope is the linchpin to promoting autonomy. This is because, without hope there is simply nothing left to choose for (Kanitsaki, personal communication). Interestingly, research has shown that, even in contemporary Greek society, truth telling about a diagnosis of serious life-threatening illness (especially cancer-related illnesses) is still viewed by many Greeks (urban as well as rural) as being harmful and hence ‘undesirable’, on the grounds that it could undermine hope and the will to live (Georgaki et al 2002; Mystakidou et al 1996; Dalla-Vorgia et al 1992).

It should be noted that this moral world view is not held exclusively by Greeks of rural or traditional cultural backgrounds. People of other traditional cultural backgrounds and cultural contexts (e.g. European, Pakistani, Japanese) also believe that in some circumstances patients should not be told that they have a serious life-threatening illness, and that to do so would be harmful (see, for example, Tai & Lin 2001; Grassi et al 2000; Irwin 2007; Jafarey & Farooqui 2005; Karim 2002; Kwak & Haley 2005; Lee & Wu 2002; Macklin 1998; Pellegrino 1992; Surbone 1992). The following anecdote shows this. The case concerns an elderly non-English-speaking Italian man who, like Mr G, had emigrated to Australia in the 1950s. He was admitted to hospital for tests which later confirmed a cancer diagnosis. Although the man’s family explicitly requested that their father not be given any information about the test results if they were positive, an interpreter was called in their absence and the man was told of his cancer diagnosis and poor prognosis. This information caused the man to become extremely distressed and, as his son commented later, ‘The life just went out of his eyes and we knew he would die very soon.’ The son, who was Australian-born and a qualified pharmacist, decided in consultation with the rest of his family to remedy the situation. This he did by contacting Italian–Australian friends who worked as doctors at the hospital where his father was a patient and arranging for all his father’s tests to be repeated. His friends agreed to explain to his father that the tests needed to be repeated because ‘there had been a terrible mistake’ and that ‘his earlier test results had got mixed up with someone else’s’. They later returned to tell the man that his tests showed he in fact did not have cancer. The son explained that his father was told he still needed medical treatment, but that he would ‘be all right’. Ultimately, the family took their father home and cared for him. He continued to live well beyond the time limit suggested by his poor prognosis and, in fact, was still alive at the time the anecdote was being shared — 18 months after being told that he would not live very long. The son attributed this to the fact that they were able to convince their father all was not hopeless, which in turn had the effect of restoring his will to live. In short, the son’s actions reversed his father’s sense of hopelessness, and thus promoted rather than undermined his father’s autonomy.

Interestingly, when I have shared this anecdote with students, many are appalled at the blatant deception that was employed in this case. Others, however, notably those whose parents are from rural Greece or Italy, have expressed enormous relief at the insights this and other cases like it have given them. One postgraduate nursing student, for example, commented (personal communication):

The comments of this student are included here because, among other things, they demonstrate the very practical help that adopting a cross-cultural view of ethics can offer; of particular note, they help to support the view that, by tying ethical views to the cultural traditions that inform them, we will be in a much better position to embrace morality as an experience rather than as an abstraction (Marshall 1992: 53–7). And that by embracing morality as an experience rather than an abstraction we can avoid falling prey to the unhelpful, idle fantasies of moral fiction which, as Elliott (1992: 2) suggests, are suited more to the purposes of intellectual convenience than to resolving genuine practical difficulties in the concrete circumstances of life. The student’s comments and, indeed, the anecdotes themselves also show, to borrow from Cortese (1990: 157) that ‘relationships … are the essence of life and morality’, and that to view morality simply as conceptions of abstract reified rational principles is ‘to remove us from the real world in which we live, and separate us from real people whom we love’ (Cortese 1990: 157). The lesson to be learned here is that, unless we embrace morality as an experience rather than as an abstraction, what we will end up with is only a concept of morality and not morality itself. And, borrowing again from Cortese (p 158), unless we have a ‘deep sense of relationship, we may have a conceptualisation of the highest level of justice, but we will not be moral’. The point being that without relationships, justice — morality — ‘contains no system of checks and balances. It becomes primarily an end in itself without regard to the purpose of morality’ (p 158).

Although only the principle of autonomy has been considered here, the other principles considered in Chapter 3 (non-maleficence, beneficence and justice) could all be examined along similar lines. We could, for example, ask in regard to each of these principles: From whose perspective are these principles to be meaningfully and appropriately defined, interpreted, analysed and applied? In the case of non-maleficence, for instance, meaningful questions can be asked about what constitutes a ‘harm’ in a given culturally constructed clinical context? By whose standards and cultural perspectives is the notion of harm to be measured and evaluated? Likewise for the principles of beneficence and justice.

Where then does this leave the role of moral principles and culturally different moral viewpoints and approaches in our nursing ethics discourse? In answering this question, it might be useful at this point to consider the nature and implications of diversity or pluralism in moral values and moral world views.

The world in which we now live is characteristically multicultural in its nature and outlook. According to the United Nations Development Programme (UNDP), more than 5000 different ethnic groups live in just 200 countries in the world today. The UNDP estimates that in ‘two out of every three countries there is at least one substantial ethnic or religious minority group, representing 10 percent of the population or more’ (Fukuda-Parr 2004: 2).

The multiculturalism of the world has brought with it a diversity or pluralism of moral values and beliefs. Some fear that this diversity or pluralism of values may be ‘the barrier to agreement’ (Elliott 1992: 32), and, hence, the catalyst to producing a world hopelessly divided by radical and destructive moral disagreement. Others reject moral pluralism outright on the grounds that, in their view, it is ‘just another name for confusion’ (Stout 1988: 1). Moral diversity need not lead to destructive disagreement, however, nor to blinding confusion. Indeed, as is well recognised within the discipline of moral philosophy, moral disagreement has historically been the beginning and has seen the development of moral thinking, not its end or disintegration (see also Stout 1988; Benhabib & Dallmayr 1990). Further, as Mary Midgley correctly points out, ‘nobody is infallible; and for that reason many different points of view are needed’ (Midgley 1991a: 83).

What must also be recognised and understood here is that, just as diversity is the key to survival in other areas (e.g. market diversity, agricultural diversity, artistic diversity etc (Lakoff et al 2006), a diversity of values and beliefs is the key to morality’s survival; it prompts critical reflection, rather than uncritical acceptance, and in so doing invites constant revision and creative refinement. Moral diversity also helps to ensure that no one moral point of view dominates; in short, it helps to prevent what might otherwise be termed ‘moral fascism’. Meanwhile, its emphasis on understanding difference rather than striving for uniformity will help to ensure that the moral systems we end up embracing will be of a nature that is truly responsive to the lived realities and experiences of all human beings, not merely those of a select few whose positions of power have enabled them to manipulate morality into a tool for repressing unwanted truths and legitimating further the authority of moral imperialists who would impose their values on others as a means of maintaining rather than challenging their cultural hegemony.

Adopting a cross-cultural approach to ethics can be beneficial in a range of ways. Among other things, at a global level, it can enable cross-cultural interactions that ‘build bridges of understanding between persons and cultures that make cooperation possible and conquest unnecessary’ (Fasching 1993: 6). It can also help to avoid the perils of ‘moral suprematism’ such as those which have been amply exemplified during wartime (see, e.g. Fasching 1993). For instance, during the second world war, the world bore witness to Nazis believing in ‘their own moral superiority (supported by ultimate justification)’ and the consequential rendering as mute ‘all opposing views’ (Gergen 1994: 113). As Gergen points out in relation to this historical period (p 113):

We thus stand warned that what is sometimes presented as the ‘superior morality’ might well prove to be little more than ‘the morality of the superior’ (meaning the extremely powerful and the dominant), with little to recommend itself to ‘the other’, rendered by it (the ‘superior morality’) as having only inferior moral status, or worse, as having no moral status at all (as indeed happened in the case of Nazi characterisations of the Jews) (Bauman 1993: 228).

At a more local level, a cross-cultural approach to ethics can enrich greatly our moral view of the world and the various relationships (including nurse–patient relationships) we experience within it. In the case of the nurse–patient relationship, however, a cross-cultural approach to ethics may not only enhance the moral quality but also the therapeutic effectiveness of that relationship (most notably through avoiding the harmful consequences of the nocebo phenomena [Kanitsaki 1994]), and hence the moral ends of nursing itself (referred to in the previous chapter).

An important lesson for nurses here is, I believe, that moral diversity is not something to be feared, but something to be embraced as a means of challenging our complacent thinking about the moral world we live in, and of improving our understanding of and ability to experience both ourselves and others as moral beings who have a mutual interest in living a worthwhile and meaningful life. Further, whether we wish to admit it or not, as Elliott points out (1992: 35):

Elliott goes on to make the additional point that (p 35):

Before concluding this discussion, it is important to acknowledge that upholding a cross-cultural view of ethics can sometimes be extremely difficult, and may give rise to serious ethical dilemmas for health care professionals — nurses included. For instance, it is not uncommon for nurses to encounter a situation in which a patient requests one thing and his or her family requests another. A typical scenario is as follows.

A patient from a traditional cultural background (e.g. Greek, Italian or Chinese) discloses to an attending nurse: ‘If my test results come back positive and I have cancer, I want to be told. I know my family has told you not to tell me, but I must ask you not to take notice of them. I want to know. And that is the end of the matter.’ The family, meanwhile, may request: ‘If our father’s test results come back positive and he has cancer, under no circumstances is he to be told. We know him. Such news will kill him. You must give us the information and we will deal with it. This is family business and that is the end of the matter.’ Usually, the attendant nurses in these kinds of situations are desperate to do what is best for all concerned, but are troubled about how to decide what, in fact, is best for all concerned. Typically, the questions they ask include: ‘Who do I listen to — the patient, or the family? How best can I serve the patient’s interests given that the family just might be right — that is, the information might “kill him”? What should I do?’ Just what attending nurses ought to do, all things considered, might not be as problematic as at first it appears to be. Consider the following.

In responding to the kind of scenario just outlined, it is vitally important that nurses do not stereotype people of different cultural backgrounds and assume that ‘all immigrants’ ipso facto practise traditional life-ways, or that ‘all immigrants’ ipso facto practise a family-centred (versus an individualistic) model of informed decision-making in health care contexts. Many immigrants to a host country assimilate to the mainstream culture of their new country, and have internalised very effectively the core cultural values of the (new) mainstream culture. Immigrants to Australia are no exception in this regard. Thus, when a ‘new Australian’ (as immigrants to Australia have been known in the past) makes an explicit request to the effect ‘If my test results come back positive and I have cancer, I want to be told’, it is highly probable that not only does he or she mean it, but will also be able to deal with it in a culturally adapted way. In such instances, there is no question that the nurse’s primary responsibility is to initiate steps to ensure that the patient’s request for information is honoured. Where then does this leave the family’s request?

Giving primacy to the patient’s request for information does not mean that the family’s request has no bearing on the matter or should be ignored altogether (see, for example, Kuczewski 1996). To the contrary. The family’s request is just as deserving of consideration as is the patient’s — not least because they too are experiencing the health crisis of their loved one. What differs, however, is the way in which nursing and medical staff might respond to a family’s requests. Kanitsaki, for example, advises (personal communication) that after securing consent from the patient, the following actions might alleviate the situation considerably:

In most instances, a ‘commonsense’ approach to managing individuals and families experiencing grief crises will result in satisfactory outcomes and a ‘therapeutic partnership’ between lay and professional (nursing) carers.

Another kind of problem that is not uncommon in nursing care domains involves extended-family members visiting in contravention of hospital visiting rules; for example, visiting outside of a hospital’s regulated visiting hours and/or in numbers in excess of a two-visitors-per-patient visiting rule. In regard to the latter, this is seen as problematic by nurses since it sometimes compromises the privacy and other entitlements of other patients — especially when the presence of a large number of extended-family members creates undue conversational ‘noise’. It is also seen as problematic by nurses since it is not uncommon, over the duration of their visit and/or the patient’s hospital stay, for different family members to ask the same nurse the same question about the health condition of their loved one. Nurses not infrequently cite being frustrated at repeatedly being asked the same question by different family members as, among other things, this is commonly seen by nurses to stretch even further their already strained ‘time resources’ to attend other patients. All things considered, however, this problem is not as problematic as at first it might appear to be.

First, research is increasingly showing that, rather than being a ‘problem’, the presence and participation of family members in a patient’s care can be very protective. Because of a family’s (and friends’) prime position as informants of the patient’s condition and personal circumstances, constant bedside vigilance, capacity to mediate important information between the patient and health care team, capacity to help modulate a patient’s illness/injury experience and support the patient’s decision-making (including, where necessary, act as a surrogate decision-maker), families can contribute substantially to achieving positive health and patient safety outcomes in their loved ones (Åstedt-Kurki et al 2001; Berwick & Kotagal 2004; Carr & Clarke 1997; Carr & Fogarty 1999; Chang 2001; Dudley & Carr 2004; Jubb & Shanley 2002; Koutantji et al 2005; Levine & Zuckerman 2000; Meyers et al 2004; Weingart et al 2005).

Second, and related to the above, it is important for nurses to understand that ‘presencing’ by extended-family members is a crucial component of the lay–therapeutic relationship (Kanitsaki 2000, 1994). By being ‘present’, family members believe they are contributing to the healing process by ‘giving strength’ to their loved one. Significantly, it is not uncommon, especially in the case of seriously ill patients, to see family members strategically placed around the bed of a sick person, for example, with one family member touching the head, another the left hand, another the right hand, another the left foot, and another the right foot of the ill person. This ‘touching’ (often manifest as massage of a given part of the body or the sprinkling of healing waters over the part) is an important component of the process of giving ‘healing energy’ to the ill person and to assist them to ‘get well’. The loved one, meanwhile, generally regards the presence of his or her family members as an indication of their ‘caring’. To ask family members to leave under these circumstances thus stands as a major violation of the lay–therapeutic relationship, and it is understandable that extended-family members might react ‘badly’ to a nurse’s directives to ‘be considerate’ of other patients and to observe a ‘two-visitors-per-patient’ rule. The question to arise here is: How can nurses best manage the situation?

Key to the effective management of extended-family visiting is for nurses themselves to understand the lay–therapeutic (healing) nature of this visiting, as well as the crucial role it also plays as a ‘quality assurance’ check of the care a loved one might be receiving. For instance, the repeated questioning of nursing staff by family members is an attempt to secure as much information as possible about the care of their loved one, which can subsequently be interrogated by family members for its consistency, accuracy and hence reliability (Kanitsaki 2000, 1994). Obviously, if six family members ask the same nurse the same question, yet receive six different answers, they would have grounds to be suspicious about whether their loved one was, in fact, receiving optimal care. Similarly, if their repeated requests for information are met with annoyance or hostility by nurses, this could be construed as meaning that the nurses ‘do not care’ and, again, that their loved one is not receiving optimal care. This, in turn, could result in the family removing the loved one from a given location of care and taking them elsewhere for care — even overseas (Kanitsaki 2000, 1994).

There are a number of strategies which nurses might use to help remedy a situation such as this. These include:

Feedback from nurses over the years has indicated that the implementation of these and related kinds of strategies have been very effective in maximising the quality of care experienced by patients (and their chosen carers) of culturally diverse backgrounds, and improving nurses’ job satisfaction when involved in the care of such patients.

The third and final kind of problem to be considered here, and which nurses not infrequently have to deal with, concerns the codified demand on nurses to respect certain religious and traditional practices of patients. The nature of the problem is as follows.

The International Council of Nurses (2006) Code for Nurses prescribes that ‘in providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’. The Code of Ethics for Nurses in Australia (2008b) similarly prescribes that when caring for people from diverse cultural and language backgrounds, nurses have a responsibility to ensure that the care they provide is ‘just, compassionate, culturally competent, culturally safe and culturally responsive’ to the human rights and health needs of the populations they are serving (Value Statement 2). The nursing ethics codes of other countries carry similar provisions. The problem for nurses, however, is that some religious and traditional practices either pose a threat or are actually harmful to patients — the case of female genital mutilation (called ‘traditional cutting’ by its proponents) being an instructive example here. In such instances, nurses are troubled by what appears to be two conflicting demands: on the one hand, to respect the patient’s cultural values and beliefs; and yet, on the other hand, to protect the patient from harm. This dilemma is compounded by postmodernist requirements to explain: ‘harm’ by whose standards? ‘harm’ by whose world view?, and to demonstrate that the apparent moral dilemma at issue is not merely a creation of ‘moral ethnocentrism’ or ‘cultural (moral) imperialism’ (James 1994).

This kind of problem is enormously complex, and requires a much deeper examination than is possible here. Further, addressing this kind of problem requires a deep understanding of the cultural complexities and dynamics informing the practices at issue. Nevertheless, at the risk of oversimplifying the issue, I offer the following comments.

Most nurses would agree, I believe, that they have at least a prima-facie obligation to respect the cultural practices of their patients. More specifically, they would probably accept that:

This does not mean, however, that nurses are obliged — either on the basis of the above view or of the nursing profession’s formally adopted code of ethics — to tolerate, without reflective judgment, all religious and cultural practices of their patients. There are a number of reasons for this. First, to borrow from Macklin (1998: 17), we can ‘be respectful of cultural difference and at the same time acknowledge that there are limits’ [emphasis added]. Second, the ‘limits’ to our obligation of respect can be discerned by a critical examination of: (1) the internal cultural justifications and considerations raised in support of a given ‘harmful’ religious or traditional practice; and (2) external viewpoints (that is, from other cultural groups) about the ‘harmfulness’ of the practice (recognising here that culture is not static and can change in positive ways when exposed to relevant influences). Third, we are not obliged to be respectful of practices which, when examined comparatively from an intra-cultural and cross-cultural perspective, are themselves disrespectful and oppressive of persons (see also the United Nations Development Programme (UNDP), Human development report 2004: Cultural liberty in today’s diverse world (Fukuda-Parr 2004)).

The question remains, however, of how these considerations might apply to the case of requests being imposed on nurses to assist with medical procedures that are culturally prescribed, but nevertheless judged by nurses to be ‘harmful’ to persons? Let us consider a possible answer to this question in relation to the practice of female genital mutilation, taken here as referring to a traditional procedure (as opposed to a medically therapeutic procedure, say for cancer) that may involve ‘only’ a clitoridectomy, or may include (as well as the removal of the clitoris) the excision of parts of the labia minora or the removal of virtually all of the external female genitalia (James 1994: 6–7).

The World Health Organization (WHO) estimates that between 100 and 140 million girls and women have been subjected to ‘traditional cutting’ of their genitals in more than 45 countries, and an additional two million girls are at risk annually (Affara 2000, 2002; Reyners 2004; WHO 2000). Of those who have undergone traditional cutting or female genital mutilation (FGM), or who are at risk of this traditional procedure, most live in 28 African countries; others live in Asia and the Middle East and are also being increasingly found in the immigrant and refugee populations of Europe, Australia, Canada, New Zealand and the United States (US) (WHO 2000; Reyners 2004). According to UNICEF (2007), cutting is traditionally done by ‘traditional birth attendants’ (e.g. mothers, grandmothers and family friends) or midwives. The tools used are often crude and unclean, and the procedure itself is often done without anaesthetic. Because of the harm that it can cause, FGM is regarded by some groups (e.g. Amnesty International) as ‘a human rights issue of huge and compelling proportions’ (see also Affara 2000, 2002; Baron & Denmark 2006; Hopkins 1999).

There are a number of internal cultural justifications offered for the brutal practice of FGM; these include ‘appeals to custom, religion, family honour, cleanliness, aesthetics, initiation, assurance of virginity, promotion of social and political cohesion, enhancement of fertility, improvement in male sexual pleasure, and prevention of female promiscuity’ (Sherwin 1992: 62; see also Affara 2002; Baron & Denmark 2006; Morris 2006; Reyners 2004). Significantly, most of these justifications do not stand up when considered from an internal cultural perspective.

First, although practised by Muslims, Christians, Jews and animists alike, FGM as such is not supported by any formal doctrine of religion (Braddy & Files 2007). Rather, its support ‘can be attributed, at least partly, to the manipulations of knowledgeable, male religious elites’ who continue to this day to perpetuate ‘false understandings among their followers’ that the procedure is a religious requirement rather than an inherited custom (James 1994: 10). Perhaps an important lesson for nurses here is to ascertain whether a given questionable ‘cultural’ practice does in fact have the legitimacy being claimed.

Second, there is ample evidence to show that the practice of FGM fails to achieve a large number of the outcomes for which it is thought to be internally justified, namely: the promotion of family honour, cleanliness, aesthetics, assurance of virginity, promotion of social and political cohesion, enhancement of fertility, and the prevention of female promiscuity. Research has shown that the negative health effects of the procedure far outweigh the supposed benefits (Baron & Denmark 2006; Braddy & Files 2007; Morison et al 2001; Morris 2006; Reyners 2004). As James explains (1994: 8–9):

It is also known that the procedure does not ‘assure virginity’ or prevent ‘female promiscuity’.

Third, it is wrong to assume that FGM is unanimously supported in the countries and cultures where it is practised. For instance, many internal sub-cultural groups of the cultures believed to support FGM are actively working for the eradication of the practice (James 1994; Morris 2006; Walker & Parmar 1993). The workings of these internal sub-cultural groups have included the development of local community health education programs, the production of film documentaries, and political lobbying (James 1994; Walker & Parmar 1993). There is also an increasing religious tolerance in some countries for supporting an international human rights approach to help eradicate the practice. James (1994: 24) writes, for example, that there is some suggestion ‘Islam would be favourable to international human rights protection based on the equality of women and the moral wrongness of discrimination on the basis of sex’ since in Islam, ‘piety alone was to be the final test of a person’s worth — woman or man’. An important example of this can be found in Egypt where, despite the procedure being banned in 1997, doctors were nonetheless permitted to operate in ‘exceptional circumstances’ (Aiba 2007: 20). A government survey in 2000 found that around 97% of the country’s women (both Muslim and Christian) aged between 15 and 45 years had undergone the procedure — many in underground clinics after the ban was imposed. However, in June 2007, the government announced its intention to officially ban the procedure via legislation after a 12-year-old girl died following ‘female circumcision’ (Aiba 2007). Powerful religious leaders are also reported to support the government’s stance and to be starting to speak out against the practice. The chief Mufti, Ali Gomaa, for instance, is reported to have declared ‘female circumcision forbidden under Islam’ (Aiba 2007: 20).

Another important consideration is that many cultural groups and countries condemn the practice of FGM (and the cultures that support it) on grounds of human rights violations; in some instances, countries have even outlawed the practice (e.g. the United Kingdon) (James 1994; Robson 1994). In Australia, girls facing ‘female circumcision’ have been regarded as ‘at risk’ by child protection agencies and placed under supervised care (see, e.g. the 1994 case of an 18-month supervision order granted by a Victorian court for the protection of two children aged 21 months and 3 years [Saunders 1994: 2]). Amnesty International, among other organisations, has also been at the forefront of campaigning against FGM, and the contravention of children’s rights and the rights of women ‘to equality, integrity and health’ that the procedure constitutes. In 1994, the Australian Medical Association called on the federal government to outlaw FGM in Australia (Robson 1994). These and other groups have presented substantive evidence supporting the harmful nature of the practice and the need for its eradication.

To some, the activities of powerful Western lobby groups like medical associations or international human rights organisations might seem little more than ‘Western cultural imperialism’ or an instance of the ‘morality of the superior’ being imposed as the ‘superior morality’. There is room to suggest, however, that to characterise the moral activism of these and like groups as ‘moral ethnocentrism’ or ‘cultural (moral) imperialism’ is rather hollow. The millions of females who have suffered as a result of this practice might have quite a different view. And I wonder what the answer would be if these women were asked the question: ‘If there was another way — a way that would enable you to function fully as respected members of your society without the need to undergo “traditional cutting” — would you still submit to such a procedure?’ But then, for many women, this question would be redundant, since being traditionally cut was never a matter of ‘real’ choice for them. And currently, for two million girls annually, it still is not — notwithstanding the powerful enculturation process that occurs in young girls from the day they are born to accept the practice as ‘normal’ and to submit to it or else risk the shame, stigma and social ostracism that would inevitably follow should they refuse. As Boulware-Miller (1985: 167) explains:

The activism of a range of groups (not just one cultural group) aimed at eradicating FGM at the very least draws attention to the need to question and to call into question things as they are. It reminds us that while culture can provide a group with a ‘blueprint for life’, it can also be imprisoning, oppressive, cruel, and provide a ‘blueprint for death’. In such instances, ‘minding our own cultural business’ (viz ‘looking the other way’ and allowing mutilating traditions to arbitrarily supplant moral considerations of human wellbeing) can be just as ‘imperialistic’ (viz exercising supreme authority) as ‘making other people’s cultures our business’.

The activism of external cultural groups reminds us of both the possibility and the importance of making critical discretionary judgments about the kinds of religious and traditional practices which we, as health care professionals, ought and ought not to respect (see Fukuda-Parr 2004). This critical discretionary judgment may, however, rest less on questions of ‘tolerance’ (including the problematic questions of intolerance and over-tolerance), than on questions of culturally informed critical reflection grounded in the lived experiences of those who suffer demonstrably and intolerably on account of cultural practices that no longer serve the survival and prosperity interests of the group if, indeed, they ever did. By engaging in such critical reflection we should be able to discern the practices against which our conscientious objection, at least, is warranted if not our fully committed collective activism aimed at their eradication.

When discerning and focusing on ‘harmful’ traditional and religious practices, however, it is important that we do not become distracted from our original project of improving understanding and informed respect of cultural diversity, or the merits of a cross-cultural approach to ethics. Every culture has its ‘down side’ in regard to upholding questionable and possibly harmful traditional values, beliefs and practices. Furthermore, just because a certain behaviour is seen to be characteristic of a given culture, it does not follow that the behaviour in question is either accepted or regarded as being acceptable by all members of that culture. For instance, child abuse and domestic violence are characteristics of Australian society and culture. Aside from the perpetrators of such abuse and violence (religious elites among them), the Australian people would, I suggest, firmly reject any notion that such abuse and violence is culturally accepted and acceptable.

The above considerations are all important and need to be taken into account when ‘reading the cultural world’ and drawing upon it for cues to guide our moral values, beliefs and actions both as individuals and as professionals. But most important of all, they remind us of the need to remain committed to acquiring and maintaining a deep understanding of the cultural complexities and dynamics that inform the range of practices which people from different cultural groups may observe, and the potential for disagreement (both from within and outside of those cultural groups) about the moral acceptability of those practices.

Cross-cultural ethics, like feminist ethics, recognises the inherent difficulties associated with genuine moral problems in human life being ‘confronted as abstraction rather than experiential realities’ (Marshall 1992: 52), and affirms that, if moral abstractions are to count for anything, they must be brought ‘back to earth’ (Stout 1988: 8). It also recognises the inability of abstract and decontextualised moral thinking to provide concrete answers to complex questions concerning a range of human experiences. Key among these experiences are: human pain and suffering, intense and sometimes conflicting human emotions, ambivalent and ambiguous human relationships, and, not least, differing cultural world views about the value and meaning of life — all of which often (too often) have to be dealt with in the face of overwhelming uncertainty, the unpredictability of probable outcomes (positive and negative), fallible modes of communication, and the fallibilities of decision-makers (Elliott 1992; Marshall 1992; Cortese 1990; Stout 1988).

Unlike other moral critiques, however, cross-cultural ethics offers an optimistic outlook. Its suggestion that acceptance of — and achieving a harmony of — moral diversity offers the key to sustaining the existence and purpose of morality provides an important basis upon which we can all develop, not just our moral thinking and sensibilities, but our ability to actually be moral in a world characterised by diverse and competing valid world views. This is not merely compromise, as some might believe, or even tolerance — the blinded eye of an indiscriminate mind (see Midgley 1991a; Wolff et al 1969). Nor is it confusion. Rather, it is celebration. In particular, it is the celebration of the ‘other’ as different, but not inferior or fallacious or superstitious — as having something worthwhile to share, not as being something worthless to be marginalised, trivialised and ignored. If we accept this, we will all be in a much better position to judge what is really unethical as opposed to being merely disliked; what is truly wrong, as opposed to being merely unfamiliar and strange; and what is really confusion as opposed to simple misunderstanding of another’s moral language with which we are not familiar (Stout 1988). This insight is, among other things, what we stand to gain by embracing a diversity of moral values and beliefs as being the beginning of morality and not its end.

In conclusion, I should like to list a number of questions nurses ought to ask when making moral decisions about the nursing care of people from diverse cultural backgrounds. Borrowing from Kanitsaki (1989b: 70):

By asking these and similar questions, and by seeking the ‘right’ answers to them, nurses will demonstrate successfully that they are able to embrace morality as something more than a set of abstract self-standing principles. They will also demonstrate that, in the ultimate analysis, it is people and relationships that count — not a blind deference to rules, which, when stripped of their cultural content, context and hence meaning become little more than intellectual curiosities empowered by arbitrary will, incapable of responding to the lived realities and needs of human beings who have been born into circumstances which are very often beyond their control. Embracing this approach will also remind us that: