Cultural Humility and Bioethics

Diverse Intersections

Written by John R. Stone, MD, PhD

Cultural humility is widely influencing healthcare delivery, biomedical research, and public health. Bioethical issues cut all through cultural humility in concept and application, which is why cultural humility is examined at length in Creighton University’s Bioethics master’s program. In the following article, John R. Stone, MD, PhD, Professor within Creighton’s Department of Interdisciplinary Studies and School of Medicine, aims to raise your awareness of cultural humility, explore its origins, discuss how it can be applied in research and public health, and what it means for bioethics and students in our health care ethics program.

Melanie Tervalon and Jann Murray-Garcia, two Oakland, California physicians, wrote their seminal paper in 1998: “Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education.” The authors argued convincingly that: 

1. Healthcare providers (here physicians) should develop diverse patients’ culturally appropriate care through lifelong learning. Professionals’ humble awareness of their incomplete and/or incorrect cultural understandings should guide and motivate such efforts. (Cultural scope today would include race/ethnicity; LGBTQ orientation; national origin; and community historical trauma, oppression, or discrimination.)
2. Culturally humble healthcare professionals actively work to understand and correct their own stereotypes, prejudices, and discriminatory actions that perpetuate healthcare inequities. 
3. Cultural humility includes a moral duty to address power imbalances and advocate for social justice regarding health-related inequities pertaining to culture. Such duty encompasses not only individual healthcare, but also institutional structures and public policy.  (Readers can access instructive video discussions that Tervalon and Murray-Garcia and commentators provide. See example links below.)

Since 1998, Tervalon and Murray-Garcia’s essay has fortunately influenced how research and public health interventions are done and should be done. No surprise. Take biomedical research of a common condition like diabetes mellitus. What and how (practically, equitably) to investigate and intervene significantly depends on the cultural population, typically a specific community. 

Such research is exponentially employing what’s most commonly called community-based participatory research (CBPR). CBPR’s general idea is equitable and collaborative partnership of community and investigators. The partners must determine what equitable or just collaboration would mean, including guiding ethical and practical/operational principles. Key ethical features include mutual respect and empowerment, trustworthiness, fair decision procedures, and much more. 

What would “true” collaborative and equitable partnership mean with a specific community? What provisional ethical and corresponding operational principles should partners adopt? What model(s) of equitable deliberation should guide the collaboration? How should partners address their varied cultural perspectives? How should partners consider historical mistreatment and corresponding distrust? How should participants ensure equitable power arrangements?

Bioethical analyses can help answer these questions. Graduates in healthcare ethics can provide provisional frameworks of principles and values for partners’ deliberation. And by incorporating cultural humility, such bioethical input promotes respect for participants’ knowledge and perspectives. Also, cultural humility mitigates against exerting expertise that exerts “power over” some partners. 

As part of Creighton’s Master of Bioethics program, students review the following articles by Baldwin et al. (2009), Israel et al. (1998), and Wallwork (2008), among others in MHE 602, Research Ethics. They write a paper analyzing ethical frameworks for community-based research. 
 

John R. Stone, MD, PhD

Professor, Department of Interdisciplinary Studies
Department of Medicine, School of Medicine

Video
Melanie Tervalon & Jann Murray-Garcia on Cultural Humility:

1.     Cultural Humility: People, Principles and Practices - Part 1 of 4
2.     See all parts of Cultural Humility: People, Principles and Practices

Articles

1. Baldwin, J. A., Johnson, J. L., & Benally, C. C. (2009). Building partnerships between indigenous communities and universities: Lessons learned in HIV/AIDS and substance abuse prevention research. American Journal of Public Health, 99(S1), S77-S82.
2. Israel, B. A., Schulz, A. J., Parker, E. A., & Becker, A. B. (1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health, 19, 173-202.
3. Mikesell, L., Bromley. E, & Khodyakov, D. (2013). Ethical community-engaged research: A literature review. American Journal of Public Health, 103(12), e7-e14.
4. Stone, J.R. (2016). Racism and bioethics: Experiences & reflections. American Journal of Bioethics, 16(4), 13-15.
5. Tervalon, M., & J. Murray-Garcia. (1998) Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117–25. 
6. Wallwork, E. (2008). Ethical analysis of research partnerships with communities. Kennedy Institute of Ethics Journal, 18(1), 57-85.