BRIDGE OR BARRIER?

1
BRIDGE OR BARRIER?

• ethical issues in the work of the cultural
  liaison 
• Miriam Shlesinger
• www.a2hc.org
• shlesm_at_mail.biu.ac.il

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Perceptions

• So these patients are totally dependent on
  you, Mrs. Das said.
• She spoke slowly, as if she were thinking
  aloud. In a way, more dependent on you than on
  the doctor.
• How do you mean? How could it be?
• gtgtgt

3
Perceptions

• Well, for example, you could tell the doctor
  that the pain felt like a burning, not straw. The
  patient would never know what you had told the
  doctor, and the doctor wouldnt know that you had
  told the wrong thing. Its a big responsibility.
• Mr. Kapasi had never thought of his job in such
  complimentary terms. To him it was a thankless
  occupation. He found nothing noble in
  interpreting peoples maladies, assiduously
  translating the symptoms
• Jhumpa Lahiri. Interpreter of Maladies

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The elusiveness of the role

• "He shall remember the limits of his particular
  function and not go beyond his responsibility
• Sign Language Interpreters'
• Code of Ethics (1965)

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The elusiveness of the role

• The interpreter might start by rendering the
  conversation between a provider and a patient
  faithfully, in the role of a message converter.
  Then she stumbles on a problem resulting from
  cultural differences and switches to the role of
  culture clarifier. Later she returns to the role
  of message converter. But then, the provider
  makes a discriminatory remark and the interpreter
  becomes a patient advocate.

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The elusiveness of the role

• Megasher one who bridges is used solely in
  relation to immigrants from Ethiopia. The culture
  gap between Israeli culture and theirs is seen as
  particularly pronounced.
• Meturgeman interpreter is used for
  immigrants from all other countries.

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Subtleties of cultural distance

• Cultural distances are different, I later learn
  in a sociology class, but I know it already. I
  learn restraint from Penny, who looks offended
  when I shake her by the arm in excitement, as if
  my gesture had been on of aggression instead of
  friendliness.
• Eva Hoffman, Lost in Translation

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Subtleties of cultural distance

• American co-chair to Israeli participants Well,
  thank you very much for your input. Im sure
  youd all like to go out now and take advantage
  of the Beer Sheva sun while we carry on with our
  meeting. (nobody leaves)
• Israeli co-chair spells it out The rest of the
  meeting is closed to you and youll have to
  leave. Thank you very much.

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The inherent conflict

• How does one reconcile the idealized construct
  of neutrality, unobtrusiveness, invisibility etc.
  with the reality of mediating between two
  cultures?

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The inherent conflict

• The emphasis on the use of the first person
  stems from the ideology of the interpreter as a
  translation machine
• (cf. Freuds blank screen)
• Bot (2005)

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The inherent conflict

• Strict adherence to a dry, formal, passive and
  detached interpreting style, though it might be
  in line with an idealised notion of professional
  conduct, is not always the best way to serve
  ones clients, especially when their intention is
  to engage in a friendly and co-operative
  dialogue. (Merlini Favaron 2006)

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The inherent conflict

• The notion of neutrality is a troubling ethic
  for community interpreters. Freire sees
  neutrality as siding with the oppressors. I
  believe it is fundamentally wrong for the
  interpreter to be engaged without regard for
  the communicative goals of the participants.
  This is very different ethically from taking
  sides.
• Ben Carlin (on Diversity list)

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The inherent conflict

• An interpreter has every right to set aside
  neutrality when that is clearly (in his/her
  conscience and professional experience) the right
  thing to do. Thats called advocacy and its a
  matter of the interpreter clearly identifying
  his/her role at the given point of time.
• Marjory Bancroft (on diversity list)

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Finding a voice

• The voice that interpreters, as third
  participants in the interaction, choose to adopt
  lies between the voice of medicine and the voice
  of the lifeworld. it is clear that
  strengthening the voice of the lifeworld promotes
  both humaneness and effectiveness of care
• Merlini, R. R. Favaron. 2007. (cf. E. G.
  Mishler 1984)

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Finding a voice

• The interpreters felt they were unable to
  influence the physicians discourse. They and the
  physicians all felt that much more weight was
  being given to the institutional discourse
  (biomedicine) than to that of the parents.
• Education, pediatrics and culture (Leanza
  2003)

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Finding a voice

• Patient I cant decide if I should have
  amniocentesis.
• Doctor I cant decide for you.
• Patient goes home confused. Her lack of
  self-advocacy skills is problematic.
• Interpreter I know I mustnt initiate
  information-seeking or information-giving, but I
  would have liked to. This is all wrong.
• Elaine Hsieh. 2006. Conflicts in how
  interpreters manage their roles in
  provider-patient interactions. Social Science
  Medicine 62. 721 730.

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• Emphasis must be placed on the interdependence
  of all individuals in the triadic interaction,
  not just the interpreter.
• Elaine Hsieh. 2006. Conflicts in how
  interpreters manage their roles in
  provider-patient interactions. Social Science
  Medicine 62. 721 730.

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Gatekeeping

• The issue is not whether distress is universal
  or whether the experiences are real. It is more
  about how they are expressed and categorized and
  whether one explanatory model, associated with
  one cultural tradition, should have primacy.
• Hear our voices trauma, birthing and mental
  health among Cambodian women

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Subtleties of cultural context

• the context of the act, not only the act
  itself, defines child abuse in a culturally
  appropriate fashion. Each cultural group has its
  definition of good parenting and of acceptable
  child-rearing practices.
• Do we call it female circumcision or genital
  mutilation? Korbin 1977, cited in Soo See 2001

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Subtleties of cultural context

• The Chinese women in labor are so stoic. They
  never scream. Even at the last minute, it will be
  a grunt. You have to be more careful with them
  monitor them more closely. (nurse-participant 8)
• Communicating with culturally and linguistically
  diverse patients in the acute care setting
  nurses' experiences, Australia, 2003

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Gatekeeping

• Interpreters make crucial decisions about the
  selection of information to communicate, the
  terminology and the simplification of
  information. The modification of the providers
  message and of the patients answers has
  ramifications for ethical practices such as
  informed consent or advance planning regarding
  medical interventions.
• (Marshall et al. 1998 212)

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Adapting to the discourse conventions

• When the doctor said death I would avoid using
  the word. I would use letting go, sleeping, stop
  eating rice instead.
• (Interpreter cited in Wasongarz et al. 1995 13)

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Adapting to the discourse conventions

• Physician And if he doesnt make it, well know
  that weve done everything we can for him.
• Interpreter (into Hebrew) And if he doesnt make
  it, God forbid, well know that weve done
  everything we can for him.

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Gatekeeping

• They sometimes knew important details from other
  contacts with the client and/or family. They were
  unsure how to proceed. They described playing an
  educative role with the psychotherapist regarding
  issues of language, culture, refugee community
  politics, history and structure.
• Becker, Risé and Robin Bowles. 2001.
  Interpreters' experience of working in a triadic
  psychotherapy relationship with survivors of
  torture and trauma.

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Interpreter co-opted by client

• This doctor has stupid questions
• I told you not to tell the doctor
• Interpreters are described being co-opted by
  clients as an accomplice against the
  professional.
• Becker, Risé and Robin Bowles. 2001.
  Interpreters' experience of working in a triadic
  psychotherapy relationship with survivors of
  torture and trauma.

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Interpreter co-opted by the provider

• The patients, Jehovahs Witnesses, say theyre
  not allowed to have a blood transfusion.
• Doctor When the time comes, we are going to do
  it anyway. But you tell them thats okay.
• Interpreters are described being co-opted by
  professionals as an accomplice against the
  client.

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18 Amharic-speaking nurses studying healthcare
interpreting describe ethical dilemmas they have
confronted
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Ethical dilemmas

• Predicament The patient was rambling, not
  adhering to conventional western discourse
  patterns (question gt to-the-point answer)
• Dilemma Shall I explain about the patient to the
  physician?

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Ethical dilemmas

• Predicament I made a mistake conveying a phrase
  that the patient used. I cannot tell whether it
  is going to affect the diagnosis.
• Dilemma Do I draw attention to the mistake,
  thereby interrupting the flow of the dialogue,
  which has been going smoothly.

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Ethical dilemmas

• Predicament The patient has told me something
  that may be relevant, but has asked me not to
  tell the physician.
• Dilemma Shall I risk losing the patients trust
  or shall I risk not disclosing the information?

31
Ethical dilemmas

• Predicament The patient makes various derogatory
  remarks about the physician, and clearly does not
  trust him.
• Dilemma Shall I let the doctor in on what the
  patient is saying?

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Ethical dilemmas

• Predicament I understand the word in the source
  language, but do not know how to say it in the
  target language.
• Dilemma shall I ask for time off to check the
  term, or shall I make do with a more general term
  or paraphrase (e.g. instead of edema say an
  accumulation of fluids)

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Ethical dilemmas

• Predicament The patient has paused, just to
  breathe, but the physician assumes that it is
  now his own turn to speak, and interrupts the
  patient.
• Dilemma Do I assume the role of traffic cop
  and signal the physician to let the patient
  complete his sentence?

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Ethical dilemmas

• Predicament The physician has been speaking for
  a very long time, and I am not going to remember
  some parts of what he said.
• Dilemma Do I indicate this to the physician and
  ask him to stop or do I risk forgetting some
  points, rather than interrupt?

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Summing up theme 1

• The primary parties are dependent on the
  interpreters involvement in the interaction to
  be able to contribute in their own right to a
  communicative atmosphere.
• (Wadensjö 1998)

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Summing up theme 2

• It needs to be established during the education
  of interpreters that grey goes with the
  territory. Being able to act competently
  within the grey zone is an integral part of their
  professionalism.
• Tate Turner 2002