Cross-Cultural Service and Medical Ethics: Illich and Fadiman

Illich's Critique of American Volunteerism

According to Ivan Illich (1968), hypocrisy is perhaps an instinctive trait shared by the majority of Americans. They are mentally prepared to accept that the motives potentially legitimizing the 1963 international volunteer action are not applicable when it comes to performing the very same act five years later. "Mission vacations" involving the poor people of Mexico were the trend among wealthy American students during the first half of the decade. Emotional concern for the newly discovered poverty beyond the nation's southern border, combined with utter thoughtlessness toward the far more severe conditions of the domestic poor, warranted this apparent benevolence. Intellectual understanding of the challenges linked to successful volunteer action failed to dampen the enthusiasm of the self-styled volunteers, papal volunteers, and Peace Corps members (Illich, 1968).

Illich (1968) believed the presence of institutions such as the Conference on Inter-American Student Projects was an insult to the Mexican nation. He claimed to feel revolted by the whole affair and believed that the volunteers' actions and their good intentions were unrelated. To him, the theological idea of good intentions helps no one. Indeed, according to the Irish proverb, good intentions mark the road to hell — a sentiment that captures this theological understanding well. However, Illich did state that he had profound faith in American volunteers' goodwill (Illich, 1968).

This goodwill, though, may be explained through a deep want of innate cultural sensitivity. By their very nature, Americans cannot help eventually becoming salesmen for a bourgeois American lifestyle, as they know no other way of life. Such a movement could not have emerged without a relevant cultural "mood" in America — one supporting the notion that a true American must share the blessings of the Almighty with underprivileged peoples. The notion that all Americans have something to give, and are always obligated to give it, explains the decision of students of that period to spend months in Mexican villages and aid local farmers in developing their communities (Illich, 1968).

American Idealism as Cultural Export

After weapons and money, American idealists are the third greatest export of North America. They can be found in every arena: teaching, voluntary work, missionary work, economic development, community organization, and vacationing altruism. Ideally, their role may be defined as service. In practice, they often either alleviate the destruction caused by weapons and money or attract third-world societies toward the advantages of a world of accomplishment and prosperity. At this point, Illich (1968) argued that it would be far better to emphasize to Americans that their lifestyle is simply not sufficiently alive or transferable to share with all.

America can only sustain its global influence, in Illich's (1968) view, if it persuades the rest of the world that it represents a kind of "Heaven on Earth." Its survival is contingent on universal acknowledgment by the world's "free" peoples that its bourgeois society has achieved its goals. The American way of life, for Illich, had grown into a religion that all must adopt or risk destruction by weapons such as napalm or the sword. America had been striving worldwide to protect and develop minorities who consume what is affordable to the American majority. This was the stated aim of the Latin America–United States Alliance for Progress (AFP). However, this partnership increasingly required protection by weapons to allow the minority capable of "making it" to safeguard their accomplishments and acquisitions (Illich, 1968).

The Alliance for Progress and Its Consequences

The AFP achieved considerable success within Latin America in terms of increasing the share of individuals who became more affluent — that is, the small share of bourgeois elites — while simultaneously creating ideal conditions for military dictatorship. Initially, such dictators served plantation owners; over time, they came to defend the new industrial complexes. Illich (1968) asserts that American students in Mexico ultimately helped the underdogs accept their destiny rather than challenge it. Their sole accomplishment in rural Mexico was the creation of chaos and, at most, convincing Mexican women to marry self-made, affluent young men who disregarded tradition. The worst outcome of community development efforts, he argues, would be generating enough disruption to spark actual violence by the end of the volunteer vacation — after which students could rush home to exchange jokes about Mexicans (Illich, 1968).

Finally, Illich (1968) advises students to stay home, actively participate in elections, understand what they are doing and why, develop communication skills, and come to terms with failure. He argues it is extremely unfair for linguistically ignorant Americans to impose themselves on rural Mexicans when they are entirely unaware of what locals think of them or what effect they are actually having. It is also highly detrimental, he believes, for individuals to define what they want to do in terms such as "good," "help," or "sacrifice" without genuine self-reflection (Illich, 1968).

Approaches to Cross-Cultural Service

The majority of the difficulties experienced by Lia Lee and her family can be attributed to their inability to adhere to physician-established therapeutic plans. In particular, their difficulty maintaining the strict medication schedule necessary for managing her repeated seizures led to severe medical complications that endangered Lia's life. To ensure compliance with her treatment plan, authorities decided to relocate Lia from her home and parental care into foster care. Seizure management in Lia's case was associated with innumerable challenges — including the need to administer several medications according to a rigid schedule and repeated modifications to her regimen for optimal symptom control. Such a complex medication plan proved especially difficult for Lia's non-English-speaking parents, who had no understanding of contemporary Western medicine. Furthermore, the absence of professional translation services meant that facility workers and home healthcare providers had few alternatives for helping her parents understand complicated instructions (Fadiman, 2012).

Different cultures perceive reality differently. It is therefore vital that healthcare practitioners recognize how these differing worldviews affect their understanding of clinical situations and patient care. Medical realities are constituted on a cultural basis, and the grounds for many healthcare-related decisions — such as when and where to seek medical assistance, how long to seek it, and how to assess success — emerge from outside the biomedical culture. As Kleinman argues, all clinical encounters are "transactions between explanatory models," typically entailing serious inconsistencies in cognitive understanding as well as in therapeutic values, aims, and expectations. Rather than issuing instructions and expecting patients to conform, practitioners need to understand patients' own explanations of their illnesses and negotiate therapeutic plans that incorporate patient perspectives (Fadiman, 2012).

Cultural clashes arise partly from the assumption within biomedical culture that biological matters are of greater clinical importance — more real, more interesting, and more fundamental — than sociocultural or psychological concerns. The primary object of interest is the disorder rather than the illness experience, and its main aim is to cure rather than to heal. This perspective prioritizes a technical problem-solving approach over psychosocial management and is comparatively unconcerned with questions of "meaning." Patients are effectively viewed as machines. Reorienting clinical strategy to incorporate psychosocial elements — which typically contribute more to patients' own understanding of wellbeing and illness — may render biomedical solutions more effective. Strategies that fail to account for patient perspectives on their condition risk producing non-compliance, suboptimal care, and dissatisfaction (Brinkmann, 2018).

Conclusion

Working with individuals from different cultural backgrounds can prove highly rewarding for healthcare providers. Fadiman explains how the Hmong community's culture deepened her personal insights into family, empathy, and assistance. Such valuable perspectives may be missed entirely if clinical emphasis falls solely on the delivery of biomedical solutions. Contemporary medicine provides tangible resolutions to illness and, according to Kleinman, can address "both disease and illness." Practitioners' efforts to provide such solutions to a culturally diverse patient population will succeed more reliably if they learn to accept others' views and cultivate the skills necessary for incorporating those views into everyday clinical decision-making. Their personal lives, too, will be enriched by remaining open to perspectives that differ from their own (Brinkmann, 2018).

References

Brinkmann, J. T. (2018, May). The spirit catches you: Cultural collisions and cooperation in medical encounters. Retrieved March 1, 2019, from

Fadiman, A. (2012). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. Macmillan.

Illich, I. (1968, April). To hell with good intentions. In Conference on Inter-American Student Projects. Cuernavaca, Mexico. Retrieved from http://www.swaraj.org/illich_hell.html

Laws, T., & Chilton, J. A. (2012). Ethics, cultural competence, and the changing face of America. Pastoral Psychology, 62(2), 175–188.