Volume 79, Number 3 The lournal of Clinical Ethics 223

Using Family Members asInterpreters in the Clinical Setting

Anita Ho

In recent years, in tesponse to gtowing immi-grant populations and thei¡ frequently inferiorcare experience in the United States, maly haveargued that more resources should be devoted tohiring professional interpreters to help improveaccessibility arrd quality ofcare.l Most proponentsof such services have argued agoinsú using familymembers as interpreters.'z This article challengesthis common rejection of family intetpreters as asuitable metlod to deliver information to limited-English-proficient (LEP) patients. Even thoughfamily interpreters may not have the same levelofhealth literacy as professional interpreters, theymay be able to facilitate understanding and in-formed decisions by serving as patients' culturalbrokers and advocates. in considering the natureof patienthood, particularly within the context offoreign culture and pnfamiliar ethos, this articleargues that famiìy iniolvement is often importantto a patient's identity and can facilitate informedand autonomous decision making. While it isimportânt to make professional interpreting avail-able in cases when patients prefer or need suchservices, consideration of patients' cultural safety

Anita Ho, PhD, is an Assistant Professor in the PhilosophyDepârtment at the Un¡versity of British Columb¡a inVancouver,Brit¡sh Columbia, and ¡s an Ethicist at Prov¡dence Health Care,anitah@interchange.ubc.ca.@2008 by The Joumal ol Cl¡n¡calElhics All rights reserved.

and larger decision-making contexts can help toexplain why it may sometimes be more appropri-ate to lespect a patient's wÍsh to use family mem-bers to serve as intetpreters than to impose pro-fessional services.3

ARGUMENTS FOR PROVIDINGPROFESSIONAL INTERPRXTING SERVICES

According to the U.S. Bureau of Census, ap-proximately 45 million ¡esidents speak a languageother than English at home, with 19 million withLEP.a The healùcare situation of LEP patients iiunfavorable compared to their English-speakingcounterpâ-rts.s Many LEP patients who face com-munication barriers with their healthcare provid-e¡s often defer needed medicaÌ ca¡e, have a higherrisk of missing follow-up appointments or lãav-ing the hospital against medical advice, have moretrouble accessing or negotiating the system, ot areless likely to have a regular healthcare provider.o

Language barriers also pose difficulties to ob-taining valid consent.t In recent decades, autono-my has been considered a capstone value in West-e¡n bioethics.6 The doctrine of informed consent,for exanple, demands that physicians providepatients relevant information regarding their con-ditions and medical options, so tìat patients candeliberate and decide according to thei¡ overallpriorities and interests. When clinicians aad pa-

Fall 2oo8The lournal of Clinical Ethics224

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tients soeal< different languages, professionals may

ttã"" ¿ìffi""f tv providing relevant' understand-

"bt", "rrd meaningful infirmation necessary for

intorme¿ decisionls and eliciting treatment pref-

erences from their patients afterward Without

direct and effective communication, healthcare

providers may also sûuggle to establish the nec-

åsrary e-putúy and rapport to reassure' motiva[e'

o. toppo.i their patients.n LEP patients. who are

alreaåv vulnerable because of their health status

u.rd asiociuted fears may be further disadvaltaged

if thev cannot voice concetns or negotiate their

prioriiies and care expectations with medical pro-

fessionals.As some have argued, healthca¡e is morally

soecial because it can help sustain/restore nor-

rial functioning and reduce suffering ro Commit-

ment to equal opportunity and respect for auton-

o*y t"quí." thát-patientJ' healthcare access and

decision-making pro"".."t are not compromise.d

bv morallv a¡bitiatv factors such as linguisticbáckerounã. ProfessìonaI interpreters, who have

profiiient knowledge and skills in the Patient's'primary language ai well as mastery of medical

iur-ittätogyl cãn promote health literacy and

triage co.ñm"nlcatìon gaps between patients and

clinìcians, and. thus hetp to fulfiil the society's

moral obligation to provide equal access to essen-

tial healthcare services. Since many interpretels

also have cultural understanding of the patient's

background, they can help interpret not only sPo-

ken iords, but also attitudes, expressions' expec-

tations, and emotional reactions'l1 Some have ar-

eued that when intelpreters operate as collabora-

iors and allies with clinicians, they can serve as

cultural informants and teach clinicians about the

Datients' world. In addition, they can facilitate

ässessment ofpailents and promote effective plan-

ning and delivery of heaÌthcare setvices'lz-Whil. th.te are important ethical reasons to

ensure adequate health literacy of LEP patients'

many who a¡e concerned about eqrral access. to

orralitv ca¡e do not stop at arguing for improvingi"""rt to professional interpreters' They often

argue ogoiìrsf allowing family mernbers to inter-

pret.Four arguments are common' First' some

worry that rising family interPreters-is clinicallyunsa-fe and may harm patients, since family mem-

bàr. ."" generally un-familia¡ with the medical

context and vocabulary. Despite their good inten-

tions, family interpreters may misinterpret key

concepts, distort ol omit messages about impor-

tant sj'mptoms and instructions, neglect questiols

t"g.täitt-g d.ng "llergies

or medical history, or in-

teivene iln thJassessment or tleatment process 13

As one study cautions, errors made by ad hoc ín-

terpreters ".L -ot" likely to have potential clini

"uli"o.r"qt"n""s than those made by hospitaì in-

teroreters,lo perhaps partly because of these afore-

mentioned errors' Reliance on untrained interpret-

ers, including family members, may therefore lenrì

a false sensJof security that accurate communi-

cation is actually taking place.'5 This is particu-

Iarly concerningin situations when family mem-

berã appear to be biased or emotionally compro-

mised due to high levels of stress. Unlike "neu-

tral" professional interpleters' who are pr€sÙm-

ablv äbiective and uninvolved intermediariestrained io systematically present clinical informa-

tion, family members often bring with them thei¡

own attituáes, judgments, feelings, and/or distress

that may negatively affeci their interpretation and

"o--rrïi"u1io.t with the clinician and the pa-

tient.16 This potential harm is not only a liabilityconcern, butàko an important ethical worry, since

ineffective care that may result from poor inter-pretation may deny LEP patients' equal opportu-

nitv to access essential servíces.Second, the suboptimal quality of family in-

terpreting also raises autonomy concerns' Respect

for patielits' autonomy is generally considered the

caostone value in Western bioethics, and the main

iuätification for requiring clinicians to obtain in-

îormed consent for treatments . When family mem-

bers are unable and/or unwilling to correctþ in-temret relevant information, patients' understa¡d-

inis of their situations, and tltrs their ability to

de'Íiberate according to their priorities or provide

informed consent, may be compromised People

ftom some cultures and/or religious backgrounds

consider it a taboo to discuss death and cancer

directly, and it is not uncommon for family inter-

oreters'to refuse to directly interpret ce¡tain words

to avoid these difficult subjects. However, despite

thei¡ sood intentions, these paternalistic actions

mav v"iolate patients' rights to be ínformed of their

sitriations and to make deliberative decisions ac-

cording to their own vaÌues. Worse yet, in situa-

tions lihere the families may exhibit oppressive

Volume 19, Number 3 The lournal of Clinical Ethics 225

cha¡acteristics or appear to be neglecting patients'preferences to get full information, suspicions mayarise regarding the families' motives in shieldingpatients from certain medical. information.

Third, the use of family interpreters rnay raiseconfidentiality and privacy concerns.'7I¡ the U.S.,for example, professional interpreters are trainedand obligated to abide by various ethical codesestablished by the National Council on Interpret-ing in Health Care (NCIHC) and the InternationalMedical Interpreter Association, including confi-dentiality, impartialit¡ respect, and profession-alism. Family interpreters, on the other hand, aregeneraÌly unfamiliar with these ethical require-ments. Some medicaì information may be sensi-tive or have significant implications, particularlysurrounding mental health, sexual health, geneticissues, and end-oflife care. Family interpreterswho have no professional training in such ethicalissues may not know how to interpret and deliversuch information in sensitive ways. Moreover, pa-tients may not want their family members to hearthe news before they themselves have had achance to digest the information or consider va¡i-ous implications. They may want to retain con-t¡ol and determine if, when, and/or how theywould like to inform their families of the situa-tion. Some conditions are stigmatizéd in certaincuÌtures, and direct disclosure to family interpret-ers during c_onsultation may subject patients toemba¡rassment and emotional devastation.

This last point brings out the fou¡th concernregarding relying on family interpreters. Familiesin certain cultuÌes have clearly defined st¡ucturesand hierarchies, such that involving intimates tointerpret may alter the power dynamics a¡rd cre-ate discomfort for all those involved.ls Depend-ing on the family structure, cultural background,and specific health conditiohs, some LEP patientsmay feel uneasy to have their intimates, particu-Iarly their children, to learn of their vulnerablesituations, since that may disturb the establishedhierarchy within the family. At the same time,family involvement in clinical interpreting mayalso put additional burden on intimates who areaìready stressed out by the patient's condition.This is especially concerning in cases when thediagnoses are unexpected and/or grim, since itmay be difficult for some family members to hearand tra¡slate about a loved one's c¡itical illness

and prognosis, and then assume their usual. rolewithin the family.le Given that many family inter-preters are also caregivers, who may have addi-tional familial and professional responsibilíties,imposition of such emotionally exhausting taskscan further compromise their wel.l-being.'zo Profes-sional interpreters, who are usually impartialstrangers to the family and the patient, cân re-lieve aII parties of such additional stress and maythus be a better resource fo¡ interpreting medicalinformation.

WHY FAMILY INTERPRETERS CAN BEPREFERABLE IN SOME CONTEXTS

The¡e are strong ethical a¡:.d clinical reasonsto suppoú the provision ofprofessional interpret-ers and for clinicians to ensure that LEP patientshave equal access to quality care and a right toinformed consent. Howeve¡ it is unclea¡ that thefour common arguments presented justifu a blan-ket rejection of family interpreting, Depending onthe intimates' familiarity with the patient's con-dition and their overall dynamic, iheir involve-rnent does not necessarily violate LEP patients'rights and well-being. Since familial reÌationshipsare often integral in preserving LEP patients'iden-tity and promoting their agency in the clinical set-ting, family interpreters may sometimes even bepreferable to professional interpreters who are un-familiar with the patient's background and cul-ture.

First, while it is important to ensure tìat pa-tients' clinical safety is not compromised becauseof language barriers, it is unclear that the use offamíly interpreters wouìd ¡ecessori,ly block pati-ents' understanding, lead to suboptimal care, orharm patients' clinical interests. Professionals a¡egenerally suspicious of the ability of family mem-bers in conveying essential information to LEPpatients, but it seems that such judgment shouldbe made on a case-by-case basis, since familymembers may have varying abilities to interpretfor their loved ones. In fact, even the aforemen-tioned study that reports potential clinical conse-quences of errors made by ad ?roc interpreters re-ports tlat tlere is no statÍstically significant dif-/erence between hospital and od ioc interpretersin the frequency of errors; it appears instead thatuntrained interpreters, such as family members,

make far fewer fluency errors (that is, use ofin-

"omect -o.d, o. one ihat does not exist in that

i.rrerr"g") than trained interpreters'21 Another

stuãv r-eports that, even though physicians are

often corrce.ned about using family interpreters'

most LEP patients are satisfred with and find com-

fort in thË assistance of such intimates'22 Before

assuming an inability to interpre-t, cìiniciansshould talk with the potential family interpreter

to find out how familiar she or he is with the pa-

tient's medical history and current condition' his

à. he. o-n comfort level with medical terminol-

ogy, potential concerns about interpreting, and so

oi. S""h conversations can give clinicians a

plimose into the potential interpreter's grasp of

Ëlinital uocabulary, relationship with the patient'

and willingness to promote the patient's under-

standing.Furiher empiricaì studies would help explore

the reason for s-uch discrepancy in data, how fam-

il.v members come to accrue knowledge of medi-

cåì terminology, and the correlation between pa-

tients' satisfaãiion in family interpreters and the

Iatters' interpreting skills. One possible explana-

tion for divergent-obse¡vations is that critics offamily interprãting have not considered whether,

or how, intimates can compensate for their lack

of formal. training in various ways. Many studies

that looked at od hoc interpreters did not distin-puish between familv members and other un-

ilained interpreters' FãmiIy members who are fa-

miliar with a patient's medical, personal, and care

history often have a larger medicalized vocabu-

lary than clinicians realize,'3 since many family

*"-*b"ts may have accomPanied the patient to

medical appointments, discussed wíth healthcare

professionåls regarding their loved one's condi-

iions, searched for information ftom other sources,

and/o¡ cared for the patient at home a¡d in the

hosnital.^Euen in cases when a family interpreter may

Iack extensive knowledge in medical terminology'

she or he may still be able to explain complex

issues to the pãtient in meaningful terms withoutusing medical iargon' For example, in explaining

the natural course of advanced leukemia to a pa-

tient, a family member may make reference to the

patient's priãr experiencà, or the situations-ofätler relaiirres or aìquaintances who had similarconditions to convey the message. While the fam-

ilv interDreter mav not k¡ow or use specific medi-

"ál t"r-'r. d"p"ttding on the patient's medical his-

torv and othlr pe¡sonal experience' such anec-

doial explanations may suffice in faciiitating thepatient's^ understanding. In some cases, personal'

ized explanation may be even more effective in

"orrlr"yíng -u"ttingful information than direct in-

terpreiatión of complex and unfamiliar clinicalterms. As some have pointed out, despite the

promise of informed consent, even native-speak-

ing patients often do not retain or understand a

toiot ttte information presented to them'2a There

a¡e thus reasons to challenge the assumption that

the cunent practice ofproviding "objective" clini-cal data is iecessariþthe most effective method

to promote undelstanding, and that the use of al-

ternative methods to plesent the information willnecessarilv compromise patient comprehension'

Seconã, the possibility that family members

can facilitate understanding in nontraditionalwavs can also address a corlcern about patients'

autonomy. Recall that critics are worried that bi-

ased and emotionally involved famiìy members

mav undulv edit information regarding grim news

a¡d thus ,r¡dermine patients' autonomy. However,

echoing Kaufert and Putsch,'s I question.the un-

criticaiassumption that neutrality is possible and

always necessary to promote patients' autonomy'

Whiie many differentiate between "obiective"professionais and "biased" family members, it isimoortant to note that clinicians of equivalentcoåpetence often have different instincts about

how-much information to disclose to their pa-

tients, which available clinical options shouklbeoffe¡ed, and how such information shouldbe com-

municated. Depending on the clinicians' lespec-

tive backgrounds, personalities, clinical experi-

ence, and communication styÌes, there can be sig-

nificant va¡iations even among professionals interms of how and what to disclose - there canbe

manv "versions" of the t¡uth. Depending on the

patiËnt's situation, presenting an edited ve¡sion

àf the overall situation to avoid a difficult subiect

does not necessaríly confound the patient's un-

derstanding or violate his or he¡ autonomy, aslong

as the communication cha¡nel is open and thepatient is given meaningful opportunities to seek

hjrther infórmation and/or cla¡ifi cation.'z6 Depend-

ing on the patient's medical history, cunent con-

dilion, and family communication style, some'

Volume 79, Number 3 The Journal of Clinical Ethics 227

times a patient may recognize what is happeningto him or her by observing how the family inter-preter communicates certain information, even ifspecific words (for example, "death") are neveruttered.

We need to take the conce¡n of medical pater-naì.ism seriously, which might allow profession-aLs who have little knowledge of a patient's de-sires and backgrounds to withhold informationfor the patient's own good. Many clinicians arestrangers to their LEP patients, and are unlikelyto know for certain what may constitute a pati-ent's best overall interest and preferences.2t How-ever, intimates are often in a different situation

- many are familiar with the patient's goals andvalues, and how she or he processes medical andother important information. In some situations,family members may have even rnore knowledgeregarding a patient's medical history than the clinician, since the patient may not have sought priorclinical help for the current condition, or themedical chart may not contain previous informa-tion ftom the patient's home country. For example,the spouse ofa patient probably knows a lot abouttlre patient's medical histor¡ prior medical pro-cedures, impact of such interventions, and so on.Such information carr help the family member indelivering information to the patient in an under-sta¡dable and relevant way.

'While empirical studies are needed to con-firm this hypothesis, it is possible that some fam-ily interpreters who omit information at the timeof consultation will continue to provide clarifica-tion and further information fo¡ the patients whenthey return home. Incidentally, many patients in-dicate that the ability to help after the consulta-tion is important to them.z8 While most studiesfocus on the information exchange at the consul-tation, it is important to note that this setting maynot show the whole picture. For example, somefamily interpreters are also caretakers, who mayconsider it unnecessary to give the patient all themedication information right at the clinic or hos-pital, especially if they will receive printed in-structions. Since some caregivers/interpreters willbe helping the patient with medication and otherforms of care, it may not be of utmost importanceto give the patient all tle specific ard detailedinfo¡mation at the facility. The family interpretermay want to expÌain omitted information in pri-

vate (for example, after the clinicia¡r has Ieft theroom) or once the patient has returned to a morefamiliar and comfortable setting, that is, his orher home.

Third, the fact that many family members typi-callyhave intimate knowledge of and involvementin LEP patients' medical and personal back-grounds also helps to address critics' worry ofconfidentiality. While many argue against usingfamily members as interpreters on grounds ofpro-tecting patients' privacy and confidentiality, sucharguments only require physicians to clearly ex-plain the sensitivity of information and confiden-tiality implications, either through printed mate-rials in the patient's first language, or by provid-ing patients ready access to professional interpret-ers. Even though the requirement of confidential-ity prohibits professionals ftom divulging infor-mation to othe¡s without the patient's consent, itdoes not preclude LEP patients îrorr' voluntarilygiving their family members access to their medi-caÌ information. Some LEP patients who havestrong bonds wÍth their intimates may considerthe family their advocates or decision-makingunit, and may consider privacy and confidential-ity familial rather than individualist concepts, thatis, tlrey may be open with their family membe¡sregarding their situation but not with others out-side of the family, including an interpreter. Shar-ing our most private information with our inti-mates and alÌowing them to take care of us can bepart of what it means to be loved or to be part ofthe family." In fact, some patients with stigma-tizing conditions may particularly wârrt to keepinformation within the family, especially if thecuLtural community in the new country is rela-tively small and the interpreter is also a memberof the same community. These family membersmay also be the patient's caÌegiver or hold powerof attorney, or have interpreted for the patient inother settings that involve personal information,such as fi¡ancial matters. The confidentiality con-sideration should, therefore, be evaluated in ref-erence to the patient's familial context a¡d ove¡-all decision-making pattem.

This last point helps to address critics' for:¡thconcern, that is, how involvement of family in-terpreters may affect the family's dynamic andintimates' well-being. Certainly, prior to the con-sultation, it would be helpfuI for a professional

FalI 2oog228 The lournal of Clinical Ethics

interpreter to explain the process to ensu¡e that ciinicai safetv and ability to understand presented

äiïil;;à r"-irv ,,,",''tå, ¡iï"J""iã"ã'-l- materials máy partly depend on whether the pa-

ãil;ffi;;;ä;å'"rrìì"iivi",pir"",ì""',-*a,t'"t tient feels cuitiratly safe. while professional in-

all parties voluntarily "oor".t

ìo"titìl*;;Ñt;8 terpreters can help promote health literacy by

ârransement. But it is important not to pit pati- using mutually inteliigible terminoìogy and vo-

i"ä:?äii'if"i; r.-,liär'J".*e ili; ìi;"-"iìii cubuÏurv to decipher óomplex clinical data, the

ness and stress. lt is worth noting that many pati- locus on providing "objective".clinicaì data does

ents are not only concerned aùãut ttr"ir "iitricat not capt.re other fundamental and systemic is-

well-being; they "." "tro

*o.riä äùÀ"i rr"* ,rr"ir sues tliat continue to affect LEP patients' ability

ffiil;ilt i*pact their families..o whiÌe it is to comprehend and cope with their situation.

important to consider 'ro* ""i"ãìäe "l¡.;"*-

Culìural safety is not just about individual

preting duties may affect intimãies'ïe''-being, intera_ctions - it ii about the envitonment or the

resoect for autonornoo, "g"r,"f "ìrãr.qrri."r thãt overall f¡amework in which patients receive ca¡e'

ï:""Ti,j#;ää;;J,h;T;ã;til;; i;å;ì;;;i"" A cutturaltv safe environment. is one that fac¡i-

an acceptable level of involvement by themselves' tates and engages in respectful practices as well

based on their own ".r.rr-"niã?',tiiiñiltty ;ã as delivers sãfe-services' as defined by those who

boundaries. Many LEp putien; ftom thesó cul- receive the care.33 lt acknowledges and respects

tures rely on family -"-u"r.1o-u" their main that patients come from diverse backgrounds with

;;;;* ;"t*";k uia "ariråir,-pãrticularly

in vary-inq needs and cultural references. Patients in

times of illness ard crises. F;il;ìii;-;ft;";*- a cuttu".ally safe environment feel empowered to

braces a rich anay or "*"rr*gll,'"rd these inti- voice their concerns without havinS to wo''y that

äää -åv "Jiiti"t or -rr"t"t1täv-u"" aoi"! tot their concerns or experience will be marginaliz-

one another as giving rr"rp ".

låãiiii"i"g.;íh"y_ ed or dismissed as irrelevant, strange, or back-

-"u "o"tia"t tËeir cäe for each other as part of *"t9-'

iïr"ir"";ìi""u;;;;rp""rì¡rrr,väããiå"Ñít-¿"¡- . Various structural and institutional consider-

nition.32 Allowing adutt pati;nts;d'their con- ations can shed light on LEP patients' lack of cul-

senting family members t" áãiìt"t"t" *Jtn "".tt tural safety. Despite promises of patient-centered

other to determine the appropriate level of in- care and respect for autonomy"p.ower structìÙes

volvement provid", "' "tt "tlä'f*iiu. trrãoppo"- continue to ãominate relationships between cli-

tunity to decide how they can p'romote eucË àth- nicians and patients 3a LEP patients in the clini-

àr.;ãä*"v -¿ "otorro-y. So*åp"ti*ts and their cal setting no1 only enter.a different linguistic ter-

intimates may prefer to rr*" i"-ify members ritory; thãy also fàce a IIiEhJy controlled and bu-

;;ih;ah"" piofìssionaÌs interpret bËcause they reaucratic culture that likely is in stark contrast

il;ì th"iìËi" fu-ily *"-báÅ "r"

ir, " rpe"i"i with. their prior care experiglce, While Western

p"riìi"" i"frap -"t" ¿""irio"r tfr"t will prämote medicine offers promising clinical results' it some-

all parties' overall intetests times alienates patients by inadvertently teatin8them as collectións of symptoms or diseasedbody

' cuIjTURAL SAFETY parts rather ttran as whole persons with rich per-

AS KEY To uNDEiðrÑoruc io#:;:,1*:;'.:tH::t T:åïï r".ît"ïii:îLt

patients, trust and reliance on their family ca.rried out in sterile settings, where patients are

members in the ctinicat setting bring out one lm- studied, tested, a¡d proddedby unfamiliar instru-

;ä;, ;;;.td"r"tio' trr"t is Ëften îeglected by ments in mechanical and invasive ways. Their

critics of famity irrterpret"rr, *ho ru"*"to "rrlr*ä diets, diagnostic or check-up schedules, access

tfrü "ir*""f ;'f"tv i. *"i"fv år

"""" rol"lyb"r"d to specialists, consultation time, and discharge

ä" ,""iù"g a*Jit"d cliniä"t data from neutral plans are determined mostþ by strangers, not out

o¡ofessionals. certainly, opporti.rities to review -of patients' autonomous choices but primarily

iå:"äi;rïi*r àf;;i"ìí"i;;ì*lort*t, r"t based on tab,ôed availability, cost-benefit consid-

ir." i-gir-ã""r"xt of information delirrery and erations, professionals'.convenience' insurance

pàitåif*p"ri""ce is also ,ig"ifi"""t. r ""g*

th"t coverage,ãnd so on.3s Given the increased provi-

Volume 19, Number 3 The Journal of Clinical Ethics 229

sion of ca¡e by healthcare teams and division oflabor, patients may have little contact with anyparticular provider, and they often experience nocontinuity of care. Specialized medicine causespatients to be attended by more clinicians tha¡rever before, and care has ironically become ín-creasingly impersonal and fragmented. Healthcareteam members, especially in intensive carer arestrangers at the bedside who usually only focuson their own specialized area. Even though manyprofessionals are well meaning, they are oftenoverworked and can only attend to patients in avery specific set of clinical circumstances. Con-temporary medicine has inadvertently reducedmany patients with full histories and relationalidentities to diseased body parts and medical jar-gon.

While it is important to note that such experi-ence is not unique to LEP patients, it may be par-ticularly disconcerting for those who are accus-tomed to holistic care methods. Many LEP paii-ents have minimal formal education and/or littleeconomic means, and may be unfamiliar withsymptom-focused Western medicine, the hierar-chical institutional medical system, complex pay-ment a¡d insurance schemes, ald hospital diets.36It is therefore not surprising that many immigrântpatients would first talk to their family and ftiendsor are cared for by their intimates at home beforeconsidering professional help.3'/ This may particu-larÌy be the case for immigrants who have lowincomes and inadequate health insurance.

Professional interpreters who are familiar witha patient's linguistic and cultural histories canexplain medical terms in culturally relevant waysand bridge communication gaps between clini-cians artd the patient. However, some LEP patientsmay have difficulty relating to interpreters whoa¡e of a different professional or socioeconomicbackground and with whom they have had mini-mal contact. Moreover, individual sensitivity andparticular attempts by professional interpretersmay still be inadequate in ensuring cultural safetyand changing the overall care environment. De-pending on the institutional culturaì dynamic anda patient's care history and experience in the hi-erarchical medical structure, even a welì-mean-ing professional interpreter may be perceived asyet another stranger or bureaucratic reptesenta-tive at the bedside. Most patients have had lim-

ited interaction with professional interpreters,some ofwhom only offer services over the phone.Aìso, since hospital or clinic-based intetpretersare primarily accountable to the institution thatemploys them, some LEP patients may mistak-enly perceive these professionals as the institu-tion's gatekeepers, rather than as their advocates.

Putting aside the issue of power and controÌor dominance in this triadic Iclinician-interpreter-patient) relationship,3s the process of working witltwo professionals (simuÌtaneously in an unfamil-iar setting during a time of vulnerability) can bephysically and emotionally exhausting. Since fam-ily involvernent has sometimes been integral topatients' recovery and continued well-being, arrdfamily members maybe able to continue to clarifyand provide information after a consultation, in-timates can serve as crucial cultura-l brokers andadvocates for patients. They are constants in aplethora of health professionals, and can providethe much-needed reminder that patients are notmerely collections of dysfunctional body parts orunfamiliar argot, but a¡e mo¡al agents who havefuII histories and important relationships. Sincemost professional interpreters do not usually havethe opportunity to inquire into a patient's personalbackground or values, some LEP patients may takecomfort in having medical information, particu-larly news that may have important implicationson tleir functioning, capabilities, and mortality,come from a trusted and loving family memberrather tha¡ a süanger.3e Some LEP patients mayhave already been marginalized as "the other" inclinical and larger societal settings, so they maybe more inclined to trust their family's judgmentand resist medical domination or doctors' claimof beneficence.ao In these cases, involvement oftheir i¡rtimates can be integral to maintain or re-store ihei¡ identity and cultural safety.

TIIE CASES OF CONTROLLING ANDPROTECTIVE FAMILY INTERPRETERS

So far I have argued that family can be an im-portant part of patients' identity and a valuableresource for LEP patients in the interpreting pro-cess, However, there are situations in which apatient may prefer to have a professional inter-prete¿ but may appear to be pressured or inveigledinto abiding by family members' wishes to take

Fall 2oo8The Iournal of Clinical Ethic!230

over the process. LEP patients who come ftom

,o"i"ti".'tft"t focus on hierarchical status and

cooperative harmony may not velbalize their con-

cerris,nt particularly to strangers. In these cases'

fr"* titJ"f¿ cünicians resolve such potential fa-

milial conflict?While many professionals are well meanÍng'

thev onlv have iimited contact with their patients

^"ã "tt"'"a to them under a very specific set of

"lini"ul "it"n*ttances, and thus may be unfamil-

iar with a family's history and dynamics Cer-

iainlv, within thäir capacity, professionals need

to carefully evaluate whether patients understand

t¡"it.igftt to use a professionaì' interprete-r' and

wh"thei their exprJssed desire to use a family

interpreter in theìonsultation process try]V Jen-

,"r"rit, th"i, values. Attention to potential signs

ãinegl"ct and abuse' such as a family's explicit*a àäu-uttt t"f"sal to consider a patient's well-

beinq, o¡ repeated attempts to override a patient's

pr"f"i"t"" to involve a professionaì interpreter'

ã* n" ft"tpttt. Howevei, professionals need to

keep in mittd that a patient's change of mind upon

i"-ìly ittflr."tt"" mãy not be a reliable indicator

of abise or neglect' Given the realities of stress

and vuinerability, many patients may prioritize

familial ha¡mony orr"t h"ìiog a professional- in-

ter¡reter deliver ihe info¡mation, especially if they

n"åerallv trust their family interpreter's inteBrity

ãnd .Uitlty. Professionals who have Iittle knowl-

edee of a"patient's familial background should

nåi"raltv úust the patient's expressed wishes and

íehain from making premature assumptions that

an LEP patient whó ãccepts the family's wishes

to interyret over the patient's initial desires are

necessarily under undue pressule'Some general strategies can help to suppo+

patients' iitbrpreting pt"f"t"tt""t and deal withiotential conflicts. For example, through printed

ilraterials in the patient's language and/or a pr-o-

fessional interprãter, registration staff and/or cli-nicians can fuit explain to patients and families'preferably separateiy, their right to professional

interpretårs and the services these professio-nals

offer. Such initial cornmunication would aìIow

iEP oatients a chance to fust meetthe professional

interpreter, learn how she or he can help commu-

nicat-e essential information and relieve pressure

on the family, and discuss this with family mem-

bers to determine if they would iike to take ad-

vantage of such se¡vices. Patients who are con-

cerneä about family pressure and feel awkward

about verbaLizing súcL wonies can indicate their

nreferences usin-g a fo¡m (for example, check the

lnnrooriate box)' Such conversâtions and tools

"ài piouid" staff with an initial, albeit limited'

elimÞse of the family dynamic. lf a patient chooses

t"o use a family interpreter' the professional inter-

oreter can facilitate the process in a different way;

.h" or he can enhance family members' ability to

interpret by clarifying unfamiliar terms and in-

formation.In cases in which patients profess to want fam-

ilv members to interpret potentially because of

súb e familial pressure, clinicians can discuss

with patients.r.ìio,rt *"yt to support their. pref-

erenc^es without creating more familial animos-

ity, such as by having both professional and fam-

ilI interprete¡s available. Relationships between

f"'-ilu *"-b".t and patients a¡e often far more

compiicated than traditional dichotomous notions

of oipression and equality acknowledge Since

nrofãisionals a¡e usually unfamiliar with patients'

iamily dynamics, it is more important for profes-

siona'ls tô follow their patients' own assessments

and expressed wishes than to second-guess and

naternalisticallv "Èee" them from their families'a'

iltho,rett totné LEP patients do appreciate the

oooortrinitv to interact with professional interpret-

ãir'otft"t ti"" t¡eir family members, others who

have spent all thei¡ lives in an oppressive rela-

tionshþ and have not been able to break free of

such cåntroliing influence may have even less

courase or desire to do so when they are sur-

,ourrdäd by strâ¡gers and plagued with illness. or

iniudes. While the family may be -exerting

undue

pr"rrr.r" on a patient, it may still be the patient's'most important suPport system and part of his or

her identiry As some have argued, targets.of op-

pression rarely experience themselves solely as

ìrictims.o'Moréover, it seems reasonable to assume

that most families, including those that appear

controllins, are not malicious towa¡d tìeir mem-

bers or thã patienU they do not usualìy use the

clinical setting as the tool to exploit their mem-

blrs.on rhe faãily may be such an integral part of

the patient's identity that denial of the family's

. oppårtunities to intelpret rnay cause mo¡e dis-

Volume 19, Number 3 The lournal of Clinical Ethics 237

tress, further isolate the patient, and increase thepatient's powerlessness in an unfamiliar setting.Since some of these patients will return to theirfamily upon discharge, and interpreters usualÌydo not work with patients outside of the clinicalsetting, it may be counterproductive for well-meaning professionals to pit patients against theirfamilies.

There are other situations in which a patientclearly prefers using a family interpreter, but cli-nicians worry that the latter wilÌ intentionallyomit relevant information on protective grounds.For example, a family member may refuse to al-low a professional interpreter to be plesent dueto the worry that the professional interpreter mayuse certain words (for example, cancer) that canaffect the patient's psychological well-being or are

considered taboo in the patient's cultu¡e. The fam-ily interpreter may also try to persuade a clini-cian not to use certain language in a consultation.In tlese cases, it may be helpfuI for clinicia¡s tofi¡st use a professional interpreter to ask the pa-tient about past interpreting experience and thefamilial decision-making model, and talk to thepotential family interpreter to find out how she

or he might deliver the info¡mation. It is impor-tant to distinguish cases in which the patient'sfamily member simply does not want to use cer-tain words, Irom cases when the interPreter te-fuses to convey particular ideas. As we consid-ered earlier, fàmil.y interpreters can sometimes de-

liver a message and facilitate understaading with-out using certain terminology.

After listening to both the patient and the fam-ily, ctinicians can remind them of the benefits ofhaving professional interpreters present to clarify,and to offer multiple opportunities and methodsto disclose and interpret essential information.When professionals reframe the conflict as anopportunity to learn more about the patient's andthe family's concerns, they can acquire betterunderstanding of the patient's and family's pri-orities and negotiate a suitable approach to de-liver information.nu Such a.n approach may alsohelp a family to be more receptive to accessingother supporting resou¡ces that can enhance thepatient's care and also ease the family's burden.At the end of a consultation, clinicíans can ask,again through printed maie¡ials or a professional

interpreter, if patients aad family interpreterswould like any clarification. Clinicians can alsoprovide translated materials and contact phonenumbers in printed form in the patients' Ianguageto be given to patients upon discharge, and letthem know that the team welcomes further dis-cussion and clarification.

CONCLUSION

In closing, it is important to emphasize that Iam not arguing against the use of professionalinterpreters or the careful presentation of clinicaldata. Family interpreters aÌe not always available,and they should not replace other much-neededefforts to improve patients' cultural safety. Moreimportantly, their potential ability and willing-ness to se¡ve as the communìcation liaison shouldnot be used as an excuse to not make professionalinterpreting services and other resources avail-able. After all, there are likely different preferencesamong LEP patients and their family membersregarding interpreting methods. It is also impor-tant to find out whether a deshe on the pari ofpatients or family members to not utilize a pro-fessional interpreter is the result of a perceptionthat the offered professional services are inad-equate or inappropriate.

I also acknowledge that fufiher empirical evi-dence needs to confirm the ability of family mem-bers to enhance patients' understanding and tofacilitate informed and voluntary decision mak-ing. To fully respect patients' agency and to pro-mote their well-being, a case-by-case approach todete¡mine the suitability of family interpreting ismore helpful than a blanket policy prohibitingsuch communication methods. \,Vhile professionalinterpreters can be a valuable resource for LEPpatients who prefer"such services, sorne LEP pa-tients may be concerned not only about one par-ticul.a¡ consultation, but also the ca¡e situationafter the visit. Since most interpreters ale strang-ers who will not be able to assist in person afterthe consultation, family members who ca¡ offe¡continual language and ca¡e assistance may beparticularly valuable to LEP patients.a6 When pro-fessionals deny family involvement Ín tìe nameof protecting patients' safety, autonomy, and con-fidentiality, they may ironicaliy be exacerbating

232 The Iournal of Clinical Ethics FaIl 2oo8

tìei¡ lrrlnerability and perpetuating their margin-alized status.

ACKNOWLEDGMENTS

An earlier draft of this article was presented at

the Cente¡ for Bioethics at the University of Minne-sota in February 2007. I would like to thank the at-

tendees at that presentation for their questlons andcomments. I am particularly indebted to Carol Tauer,

PhD, for her suggestions.

NOTES

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C. Blake, "Ethical Considerations in Working withCulturally Diverse Populations: The Essential Roleof ProfessionaL lnterpreters," CPA Bulletin 35, no. 3

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nority Health, U.S. Department of Health a¡d So-

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