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.