Running head: MAJOR THINK PIECE: MEDICAL ETHICS
Major Think Piece: Medical Ethics
University of New Hampshire
NURS 500.01 Intro to Professional Nursing
MAJOR THINK PIECE: MEDICAL ETHICS
Abstract
The novel The Spirit Catches You and You Fall Down, written by Anna Fadiman, is a
story about the dissonance between the Hmong’s spiritual and cultural beliefs against the
Americans’ scientific and medicinal ways. This true story occurs when a refugee family from
Laos moves to California and their second youngest and favored daughter, Lia Lee, is diagnosed
with severe epilepsy (quag dab peg). The family faces a clash that is defined by the cultural
barriers that those in the medical field certainly come across. This novel is undeniably eyeopening and an utterly engaging read that impacts the way others will approach cultural
situations going forward. Learning about the life of Lia Lee, it raised the question of how cultural
barriers are defined and treated in the medical field and thus how ethical implications get in the
way when two different worlds collide. In this particular instance, Lia’s doctors and Lia’s
families had different views and morals; is there a right side to choose? The ultimate ethical issue
thus becomes if health care workers should adjust their own morals to their patients cultural
beliefs even if it means supporting actions that they don’t medically agree with or if the patient
and family is better off abiding by a physician’s orders even if it goes against their culture. There
may be no right answers to these questions but it is worth further exploring for the sake of
cultural significances that are sometimes undermined.
Keywords: epilepsy, quag dab peg, cultural barriers, Hmong, ethics, morals, undermined
MAJOR THINK PIECE: MEDICAL ETHICS
The only thing the Lee family ever wanted was a fulfilled and healthy life according to
their ways. Although being refugees from Laos, the family maintained strong ties to their roots
and traditions. It wasn’t until their daughter, Lia, was diagnosed with epilepsy that they began to
reconsider their valued cultural practices. Epilepsy in the Hmong culture is known as Qaug dab
peg; it is believed to be an honorable condition in which one is chosen to be the host of a healing
spirit that allows them to communicate with a spirit realm. Whereas, in the United States it is
seen as a neurological illness that needs to be managed. This differing view was the sole reason
of the majority of misunderstanding when it came to Lia’s treatment. If the health care workers
taking care of Lia had known that the reason her family wasn’t treating her according to her
physicians orders was because they thought Lia was entering a spiritual realm and being given a
gift to heal others than they would have realized that it, in fact, was not due to her parent’s
neglect. On the contrary, they thought they were protecting her. This particular misunderstanding
at one point caused Lia to be taken away by Child Protective Services, even though her family
showed her an infinite amount of love. From Lia’s parents parents point of view they were taking
care of her as best as they could and preparing natural, medicinal recipes passed down from their
ancestors; thus turning away from the physicians treatment plans. In fact, “For them the crisis
was the treatment, not the epilepsy” (Fadiman, 1998, Page 53). Therefore, Lia’s parents had a
mixture attitude of concern and pride for Lia’s seizures. The prideful attitude was indicative of
Lia’s parents not wanting to administer medicine that would perhaps heal her seizures because of
the high regards the condition had in their culture, but the doctors did not know or realize this.
From the health care workers point of view, they knew (medically speaking) what would help
Lia and it was frustrating for them to not see Lia get the medical attention that she needed. It is
difficult to come to a definite answer on which path was best for Lia. I think that the hardest part
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about seeing both sides clashing is never getting Lia’s opinion. Others were always making
decisions for her, whether it be her family or physicians. Not once in the story are we ever able
to discover how it was that Lia truly felt or how she desired to be treated. Therefore, there is no
clear way of determining how or if Lia would want to prolong her life and then how she would
prefer to go about doing it.
Lia’s parents and her doctors both wanted was best for Lia, but the lack of understanding
between them is ultimately what led to her downfall. The doctors rarely took the time to get to
know the Lee’s background and what their spirituality meant to them. As Nao Kao said, “The
doctors can fix some sickness that involve the body and blood, but for us Hmong, some people
get sick because of their soul, so they need spiritual things” (Fadiman, 1998, Page 100). The Lee
family had high standards for upholding traditions and customs in their family and they had a
hard time letting go of that to comply with Western medicine. Hmongs have many customs that
contradict the American mainstream and medical field. For example, their traditional beliefs
don’t allow anyone to go through an invasive surgery for fear of their soul escaping. The Lee
family was constantly being torn between their cultural roots and the unfamiliar world of
medicine. Yet, neither side tried very hard to understand one another. It was only after Lia’s
parents regained her custody that they gave in to the medicinal ways because it was the only way
for them to not lose her again; this portrays how perhaps the only reason Lia’s parents agreed to
give her medicinal drugs was out of the fear of losing her again. That reasoning, in no way,
reflects a therapeutic relationship between the Lee family and physicians. Yet, in the perspective
of the providers, they only wanted to fix Lia in the only way they knew how. Although the area
of this hospital in California had a strong Hmong dominance, the health care workers still had
little experience and understanding of the Hmong culture. There would, most of the time, be a
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translator between both parties but that kind of communication wasn’t effective enough. For the
Lee family, “The language barrier was the most obvious problem, but not the most important.
The biggest problem was the cultural barrier” (Fadiman, 1998, page 69). The question remains
whether Lia’s condition may have been prevented or controlled had their not been a clash
between the two cultures.
A major ethical issue in instance was if health care workers should adjust their own
morals to their patients’ cultural beliefs even if it means supporting actions that they don’t
medically agree with or if the patient and family is better off abiding by a physician’s orders
even if it goes against their culture. There was certainly a tug-of-war for Lia’s life between her
parents and her doctors. The battle was between Western and Eastern medicine and how each
side viewed Lia in a different way. The Lees looked at the world as one that was not always in
their control, while Western medicine was fixed on attaining ways that would achieve that
control. Lia’s parents never felt understood by the health care workers nor did they understand
the logic behind their reasoning for procedures. Even when the physicians would explain
everything to them, the Lees had their own version of occurrences. They understood Lia’s
demise to be as, “They just took her to the hospital and they didn’t fix her. She got very sick and
I think it is because they gave her too much medicine” (Fadiman, 1998, Page 148). With this
kind of understanding, or lack thereof, on Lia’s parent’s behalf it is easier to see why they were
hesitant and then bitter about Western medicine; they related the medicine to Lia’s worsening
condition. On the other side of the situation, some of Lia’s providers showed immense cultural
dissonance when dealing with her illness and hospitalizations. One of Lia’s residents said, “I was
in no state to put up with any bullshit from a father, whether he was a caring, concerned father
who had customs that were different from mine or not. I really was not particularly feeling like
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having a discussion with him about cultural differences” (Fadiman, 1998, Page 179). The
reaction that this particular resident, Dave, had with his patient’s father is unfortunate and
unnecessary because although every human is allowed their faults, your role as a provider also
includes the patience to deal with every kind of case. The morals of this particular resident was
that his medical expertise and views were above any kind of patient cultural beliefs; he didn’t
even allow himself the opportunity to learn about his patients’ apparent spirituality. Thus
according to the ethical concern, it is evident that this provider was by no means going to adjust
his own medical morals in order to accommodate his patients’ cultural needs.
My position in regards to the ethical issues and cultural conflicts that the two sides faced
is that it always the health care workers responsibility to develop the tools and skills to reach
culturally competent care. These tools and skills should be developed with the intertwining of the
ethnic, cultural, and religious groups in our society. That being said I fully take the side of the
patient in this ethical dilemma and support their need for cultural advocacy. Although
interpreters are essential in the communication process, it doesn’t solve the issue of cultural
misunderstandings between a patient and his or her provider. Solving the communication
problems doesn’t address the religious, ethical, cultural, and health belief differences. To solve
the problem of cultural misunderstandings one would have to completely immerse themselves
into a culture, which is nearly impossible considering every different kind of culture and beliefs.
Therefore, a new approach of health care education is needed. The U.S Department of Health
and Human Services Office of Minority Health describes cultural competence as, “a set of
congruent behaviors, attitudes, and policies that come together in a system, agency, or among
professionals that enables effective work in cross-cultural situations.” This portrays how it is
essential to have the tools necessary to first achieve competence. I believe that patients have the
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right to understand their condition, accept their treatment, and receive support for their care. This
also means that health care workers should display an interest and concern from the patient’s
perspective. In fact, everyone in society should develop a healthy concern for learning about the
cultural differences we are surrounded by. No matter what race, ethnicity, or culture of a patient
everyone is different and has had unique experiences; it is important to understand and respect
those differences. It can be as simple as asking a patient what they believe in. This small gesture
can open many doors and develops a standard cultural sensitivity that affects the impact on the
care we provide. It could also make a vast difference if a standard approach to patient
interviewing is developed where patients can freely share their beliefs, views, and values.
Therefore, if Lia’s physicians had taken this route there would have been greater effective
communication and prevented trauma not only to the patient but also her family.
Overall the lessons learned from this tragic but true story is that one cannot make
assumptions about the beliefs of a patient. This novel effectively portrays the concept that there
is a cultural need in America caused by demographic changes; it represents the struggles and raw
truth of what a family endures when there are cultural barriers in a medical situation. As for Lia’s
demise, it is hard to point fingers at anybody in particular. In an ethical situation such as this, one
can empathize and reason to support with both sides. Although Lia’s parents could have kept Lia
on her prescribed drugs from the beginning, it wasn’t a part of their cultural beliefs so although it
led to her death I feel as if she died holding onto her roots as much as possible, which was most
important to the family. The ways that cultural dissonance can be prevented in the future is to
implement cultural trainings in educational levels of society, thus introducing and preparing for
unfamiliar concepts before facing it in real life. Overall, everyone going into the health field is
going to come across someone with different beliefs, morals, and cultures than their own. In
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conclusion, it is important to assess what the latter means to you as an individual and how you
would face an ethical decision such as the one Lia’s providers and family had to make.
MAJOR THINK PIECE: MEDICAL ETHICS
References
Fadiman, Anne. (1998) The spirit catches you and you fall down :a Hmong child, her American
doctors, and the collision of two cultures New York : Noonday Press
Office of Minority Health. US Department of Health and Human Services, (2013). What is
cultural competency?. Retrieved from website:
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11