The interpretation mistake

The incident

The narrator tells us:

“I was in my first internship as part of my education as a Healthcare Assistant. I was doing my internship in Rigshospitalet (the largest and most important state hospital in Denmark, located in the City of Copenhagen, our rem.). As an intern, I followed my supervisor constantly. She had worked in the healthcare system for many years, originally being educated in the former healthcare educational system.

One day, we entered a hospital room, where an Arabic girl around 14 years was lying in her bed. The girl was terminally ill, suffering from a brain disease. She was, in fact, death marked and tended to have cardiac arrest as part of her disease. Until now, she received CPR in case of cardiac arrest. The whole situation made me kind of scared.

Her parents, an Arabic family with Lebanese background, were in the room together with a hospital doctor – apparently a senior doctor. Apart from the family and the doctor, a female Arabic speaking interpreter was present, due to the formal rules, when patients and relatives have a foreign background and are not totally familiar with the Danish language.

The doctor explained to the parents in Danish that in case of further cardiac arrest, the hospital would not provide CPR, because of the daughter´s terminal situation. The doctor didn’t directly mention euthanasia, but in practice this was actually the message and decision.

The interpreter passed this serious message to the parents in Arabic. But in fact, the interpreter gave the opposite message, as if the doctor would carry on the CPR. This was obvious to me, since I´m speaking Arabic myself.

The father actually spoke and understood Danish to the extent that he seemed to grasp the real message from the doctor. But I felt quite convinced in the situation that the mother would leave the room and the meeting with the clear conviction and belief that the hospital would continue CPR in case of cardiac arrest.

Due to my own Arabic and Muslim background I was quite dismayed, while I was pretty sure that the mother would never accept the doctor´s decision of cancelling the CPR in case of further cardiac arrest.

Therefore, I asked the mother, if she really understood the message from the doctor. When she confirmed, I had to suggest that she should really ask for another meeting with the doctor and also ask for another interpreter, thus to be sure that the new interpreter would master both Danish and Arabic 100 pct.

My hope was that I could help the mother in this indirect way to perceive the situation and the message correctly. I witnessed this serious misunderstanding and a mistreatment of an Arabic family, which may cause severe consequences from a Muslim-cultural perspective. I just couldn’t stand by to see this happen without any reactions.

I also approached the doctor, who was moving on. I told him that due to my linguistic background I realised that the mother was not properly informed about this serious matter. But the doctor shrugged and said that an interpreter had been summoned and present according to the rules – and thus, everything was accomplished in a proper manner. He would do nothing more about it.

I also informed my supervisor, and her answer was that the doctor was in charge, and I could do nothing about it. She pointed out that as an intern in the bottom of the hospital hierarchy, I actually would not be allowed to reprove a senior doctor in this manner.

So, I was shocked and shaken both from ethnic, cultural, religious and professional reasons…”

1. Identities of the actors in the situation

The narrator is a 24 year old Danish male healthcare student in the Danish healthcare education called Healthcare Assistant, an education of 3 years. At the time for the recording, the narrator is on his third year. Migrant parents, his mother originally came from Lebanon and his father originally from Iraq. The narrator speaks Arabic fluently, too. The narrator and his family have a Muslim-cultural background. However, in this incident he was also affected from professional motives and from a healthcare perspective. He has strong professional aspirations and has chosen his healthcare profession based on his interest in human relations.

The narrator is generally engaged in issues of equality, antidiscrimination and diversity etc. Apart from his healthcare education, he is also educated as a so called Young Agent/Counsellor in the City of Copenhagen, a corps of young people advocating for antidiscrimination in the vocational training system.

Thus, the narrator is used to reflect on and react to situations where he feels that justice or human decency is not fulfilled.

The situation involves a number of actors apart from the narrator, all being present in the hospital room:

An Arabic, Lebanese family – husband, wife – with a terminally ill daughter in hospital. The husband and wife are supposed to be in their thirties, the daughter is 14 at the time.

A male Danish hospital doctor.

A female professional interpreter translating from Danish to Arabic and vice versa.

A female healthcare assistant, being the training supervisor of the narrator in the hospital. Worked 38 years in the Danish healthcare system.

We don’t know whether the family and the hospital doctor already were acquainted, as many different doctors may be involved in the treatment of the individual patient and the relatives.  Likewise, the family wouldn’t know the healthcare assistant, the interpreter and the narrator. However, the professionals may know each other from the general professional work in the ward.

2. Context of the situation

The incident takes place in a hospital room, where a terminally ill Arabic girl is lying in her bed. The girl is suffering from a brain disease, and she and her parents are going to consult one of the hospital doctors about her situation and the prospects of her treatment.

3. Emotional reaction

The narrator was shocked and also surprised that such a situation and fatal misunderstanding could take place in a professional context. He also had a sense of being personally responsible and committed to respond to the serious mistakes he witnessed. As a kind of ethical truth witness he had to react.

The narrator reacted emotionally from more than one perspective:  Having both  Arabic and Muslim origins, he was upset about the lack of consideration to the family´s religious-cultural values. He was, in fact, reflecting – and transferring – his own values and the lack of respect towards other religious-cultural values in the situation.

Furthermore, his personal values and sense of responsibility was exceeded when he witnessed how the mother did not receive proper information or opportunity to react on what was effectively a final death sentence for her daughter.  Thus, the narrator decided to act without taking into account the organisational-/hierarchical order and decision-processes in the hospital system. He also felt that due to his own background and linguistic skills he discovered a serious mistake which neither the doctor nor the supervisor would ever be able to discover.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock

In the eyes of the narrator, the antagonists in the incidents would represent the following positions, giving cause to the narrator´s reactions: 

The intersection between religious, ethical and professional norms and values 

The father’s behaviour gave rise to both ethical/religious and professional scruples for the narrator, thus crossing norms and values on both a private and professional domain. The father was aware – even without the interpretation – that the doctor decided to stop the CPR treatment. Thus, the father probably also realised in the situation that his wife was misinformed about the medical decision. Maybe the father kept silent in order to protect his wife from the shock and the certainty that the hospital was going to stop the treatment, thus, in fact, providing euthanasia. Although euthanasia is an illegal action in Islam, the father may have wished for his incurable daughter to finally find peace from her suffering.

From the narrator´s private perspective, this was a breach of fundamental religious norms and values.

Furthermore, from a professional perspective, the father’s complicity on the false interpretation interpretational gave rise to professional scruples as wells. For the narrator, it is a very strong professional and ethical value that complicity and witnessing lead to disclosure, transparency, and openness, not tacit acceptance. Even though the father did not play a professional role in the incident, his silence and concealment would represent a professional dilemma for the narrator, who would be fully aware of the religious consequences for the whole family.

The intersection between hierarchical structures, intercultural competence and professional approach to all patients whatever their background 

The doctor gave rise to both professional and ethnic-cultural scruples, thus using his high position in the medical hierarchy to show professional, intercultural and compassionate indifference to a minority and Muslim family’s needs and requirements in a very difficult situation.  On both a professional, intercultural and human level, the doctor neglected to check whether the parents really received and understood the seriousness and consequences of his medical message. Here lied on the formal fact that an interpreter correctly was present. But he didn´t take further notice of the professional quality and correctness of the interpretation.

When the narrator informs him that the interpretation has gone wrong, he passes it off and answers that an interpretation was conducted, and he can do nothing more about the case.

One may raise the question whether he really meets and fulfills the medical code of conduct and the ethical standards and values in situation – or if his reaction could be described as unaccountability and responsibility failure. His professional culture commands him to respect certain ethical and procedural rules – like rules of using interpretation – but in practice he appears unprofessional by not ensuring that everyone present – especially all Muslim family members – really do understand the situation and decisions. Thus, he enforces a traditional hierarchic position. He refers in a very firm way to his overall and superior authority as the one who can decide on the daughter’s life and death, literally spoken in the situation.

The supervisor – ranking much lower in the medical system – apparently reacts in full accordance with the hierarchical rules.

The intersection between professional service and personal cultural acceptance

The interpreter gave rise to professional scruples, but maybe also rises to a well-known feeling of ethnic-cultural second-rate position and subservience in a system where white middleclass men – male doctors – generally are positioned at the top of the ranking. The interpreter is female, and she is Arabic, presumably also Muslim. As a professional she should check thoroughly whether she herself really understood and communicated the correct message in a situation of such serious consequences for the family involved. It cannot be ruled out that she, like the father, tried to protect the family – especially the mother – against the real message. She would probably know about the ban on euthanasia. However, she may have trouble to ask and thereby revealing signs of professional uncertainty in a situation, characterised by strong hierarchical rules and positions. If so, her fear to ask may even be reinforced by her gender and ethnicity.

Given his own background, the narrator would be very much aware and sensitive to such unspoken feelings. As we know, he would also be very much in opposition to any kind of ethnic-cultural subservience, even if it takes place hidden in the situation.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

Anger, dismay and surprise when confronted with the lack of professional sense of responsibility of the doctor, the supervisor and also the professional interpreter.

Anger, when confronted with the lack of respect – and apparently also for some of the antagonists the lack of knowledge and interest – for Muslim-cultural values, not the least the disrespect especially towards the mother´s religious position.

Powerlessness towards the organisational culture and hierarchy that can cripple accountability among professionals in the healthcare system. Especially while the system is dealing with life and death.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator

The Danish hospital doctor:

Apparently, the doctor doesn’t really care, whether a family with a Muslim-cultural background and linguistic challenges properly understands the seriousness of the daughter´s situation and the consequences of the medical decision. His professional culture commands him to respect certain ethical and procedural rules – like rules of using interpretation. But in practice he appears unprofessional by not ensuring that everyone present – especially all Muslim family members – really do understand the situation and decisions. Thus, he enforces a traditional hierarchic position. He refers in a very firm way to his overall and superior authority as the one who can decide on the daughter’s life and death, literally spoken in the situation. 

The Arabic family and especially the father:

The Arabic family involved in the situation have a Muslim-cultural background.  This appears to play a significant role from their point of view, while euthanasia is banned in Islam. If you are incurably ill, you would have to choose yourself, whether you want to end treatment. But in fact, this is also difficult due to the suicide ban in Islam.

In this unhappy and difficult situation, the father seems to be positioned in a severe ethical dilemma: should he, according to his religion and faith, oppose the euthanasia, which the doctor is about to initiate? Be it regarded as an active or passive kind of euthanasia. Or should he follow his heart and be merciful by helping his terminally ill daughter to get peace from all her suffering? By choosing this, he would have to protect his wife from the truth.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

Ethical and professional dilemmas connected to euthanasia

Euthanasia from time to time appears in the Danish press and the media, especially in the wake of an actual case. Recently (long after this incident) an elderly man was convicted, because he stood up and declared that he had helped his terminally ill and tormented wife with a lethal dose of medicine.

Usually you will find a distinction between three different kinds of euthanasia in Denmark (and other countries):

  • Euthanasia
  • Assisted suicide
  • Passive euthanasia

Euthanasia would be cases where a doctor in accordance with the patient’s desire takes the patient’s life through medication. This is illegal according to the Danish Criminal Code.

Likewise, assisted suicide would be cases where the patient is taking her or his own life, but with a doctor’s transcript of deadly medicine. This is also illegal according to the Danish Criminal Code.

Passive euthanasia would be cases where a terminally ill patient has a right to refuse treatment that may only postpone death. A patient can receive appropriate pain killers, even if they accelerate the time of death. A doctor or other health professional may also fail to start or continue life-prolonging treatment to terminally ill patients who are no longer able to use their autonomy. This is not illegal according to Danish law.

However, in this incident, the narrator is aware of the special rules of euthanasia within Islam. Euthanasia is banned, and this ban will for some Muslims weigh heavier than the legal framework. In this particular case, we may face an example of passive euthanasia. But it would still be banned within Islam.

Thus, the question of euthanasia in this case actualises a dilemma between the general legal framework on the one hand – and Islamic laws on the other side.

Ethical and professional dilemmas connected to interpretation and communication.

The Danish healthcare system has for several years been operating with formal rules and procedures related to ethnic-cultural-religious differences among patients and relatives. The rule about interpretation is one of the basic regulations.

Furthermore, the system is increasingly geared to meet intercultural challenges and communicative requirements.

However, this incident witnesses that there is still a long way to go. Building intercultural competences into highly hierarchic professional structures and traditions doesn’t work over night, while such competences influence the professional hierarchy, the professional self-image, privileges and decision-making.

As long as the rules and procedures – for instance around interpretation – are only formally followed, we may see incidents where patients and relatives are not properly informed, thereby being deprived of their right to self-determination or participation in treatment plans etc.

Thus, we are facing a dilemma, where formal rules may be overruled by professional’s lack of responsibility as well as lack of recognition and empathy to patients and relatives.