Common ethical terms defined

The question, ‘What is the role of the interpreter?’ is often used to begin discussions on the expected behaviours of interpreters. In response, practitioners, researchers, and educators typically respond with behavioural ideals conveyed through the use of metaphor. They might say: ‘Think of an interpreter as a bridge, a co-participant, or an advocate.'’ Conversations in healthcare interpreting have also relied on the use of metaphors (Davidson 2000; Hsieh 2008).

NCIHC Code of Ethics

IMIA Code of Ethics

]AMI Code of Ethics

Confidentiality

Recognises the importance of keeping information confidential except when doing so will result in harm to patients or others.

Recognises the importance of keeping information confidential except in the specific instances of self-harm or abuse.

No unique healthcare ethical content.

Accuracy

Specific concern for the medical interview and the importance of all data being faithfully conveyed due to clinical consequences.

Includes the subtopic of ensuring informed consent. Interpreters are encouraged to work in concert with the informed consent process.

No unique healthcare ethical content.

Advocacy

All healthcare workers including interpreters are expected to work in ways that avoid harm and advance the patients' welfare.

Identified as a derivative of beneficence. Interpreters may need to raise patients' awareness to laws that prohibit discrimination.

Professional Medical

Interpreters respect the dignity and rights of all people to live a healthy cultural life and to respect patients' independence in pursuing it.

In past publications, my co-author and I have critiqued the use of rhetorical devices such as ‘role’ and ‘metaphor’ as a means of discussing ethics; these terms and constructs fall under the category of descriptive ethics and therefore, differ from how other professionals engage in discussions of normative ethical behaviour (Dean and Pollard 2018). As such, the question about the role of the interpreter as it is related to ethics is more accurately conveyed through the construct of responsibility. In other words, to make the question normative is to instead ask, ‘What is the interpreter responsible for?’ The construct of responsibility is more readily recognised as a normative ethical term (Dean and Pollard 2011). We have further argued that answers to questions of responsibility should be reframed through a catalogue of values and not through a series of metaphors (Dean and Pollard 2018: 57 60). Regarding healthcare interpreting, the question should instead be framed as, ‘What are the responsibilities of the healthcare interpreter?’

This shift from the use of metaphors to the use of values is necessary when interpreters engage with other professionals. The latter, e.g. doctors, lawyers, teachers, social workers, to name a few, are taught to evaluate ethical actions through a normative lens and would likely be confused by some of the terms the interpreting field uses to talk about the interpreting role. The use of metaphors leads interpreters to think of themselves like something else (a conduit, a participant, an advocate). It is more effective to assume the responsibility of a particular set of values, as is typical for service-based professions such as doctors and nurses (Dean and Pollard 2018).

Normative ethics are those values, rules, or principles used to evaluate the ethics of a decision. The term descriptive ethics is used in the ethics field to describe actions without any type of evaluative element. The statement, the interpreter did not interpret the conversation she could hear about another patient is stated in a descriptive manner. It is also descriptive to say that the interpreter in this case was behaving like a filter, a gatekeeper, or a judge. However, to be normative and to have an element of evaluation within the realm of healthcare, the behaviour should be linked to a value in healthcare. Therefore, the action could also be stated as, the interpreter respected the privacy of another patient when she chose not to interpret overheard conversations. Respecting patient privacy is an established healthcare norm. As such, this type of statement would be more recognisable to healthcare professionals.

In professional ethics, the term normative should not be confused with the term prescriptive. Prescriptive is often used in a negative way to describe pre-determined actions or a type of behavioural rigidity. While it is true that normative ethics can be prescriptive, normative ethics can also allow for behavioural flexibility - a flexibility within the parameters set by a catalogue of normative material like values and principles.

Often the deontological or rule-based approach to decisions is perceived of as the prescriptive brand of normative ethics. Teleological or goal-based decisions, while still normative, allow for behavioural flexibility. A deontological approach is characterised by its list of rules whereas a teleological approach is characterised by a list of values. Unlike rules which guide the practitioner to a right and wrong choice, values identify multiple effective and ethical choices (Dean and Pollard 2005: 270). In professional ethics, the consequences of a practitioner’s decisions are assessed in terms of which professional values are prioritised by the decision or whether they are prioritised at all. For example, imagine the decision that needs to be made by mental healthcare providers when they are faced with a patient who has suicidal thoughts and intentions but who makes assurances about their safety and asks to be discharged to go home. That provider is facing the choice between two valid but conflicting principles. The first is to maintain the safety of the patient and the other is to respect the individual’s autonomy (free from controlling and constraining behaviours). The provider has to uphold one value while forfeiting the other. These are the very same teleological decisions that healthcare interpreters must make about their own practice (Dean and Pollard 2018).

Normative ethics establishes the shoulds - how a person should act in a given situation. Whether that should is best conveyed through rules (deontology) or values (teleology) is determined by many factors. Ethical codes of service professions (such as those professionals who work in healthcare) almost exclusively come to be articulated through values. However, the ethical codes found in community interpreting have traditionally been articulated through rules (Cokely 2000; Dean and Pollard 2011). Many have found rules unhelpful because, like other service professionals, community interpreters encounter highly nuanced contexts. Instead of a list of dos and don’ts, interpreters should instead be taught to apply values to each situation referred to in the ethics field as specified principlism5 (Beauchamp and Childress 2012: 17-24; Dean and Pollard 2011: 157-158). It has yet to be determined or at least stated in overt terms which values interpreters should be responsible for. There are however, established theories that offer possible guidance in how these values might be determined.

Vermeer’s (1989/2000) Skopos theory guides the practitioner towards considering the aims, goals, and objectives of the client and/or the expectations of the target audience. In healthcare interpreting, the audience or the clients are providers and patients. The aims and goals of a healthcare provider, and arguably those individuals seeking their services, are governed by the values inherent in biomedical ethics. While biomedical ethics can be traced back to the ancient times of Hippocrates, it was still in its nascent stages throughout most of the 20th century (Raupich and Vollman 2011).

The Principles of Biomedical Ethics by Thomas Beauchamp and James Childress (2012/1985), now in its 7th edition, is credited with creating a systematic and standardised analysis of healthcare principles. Beauchamp and Childress (2012) derived the four core principles of biomedical ethics from a series of universal moral ideals (e.g. nurture the young and dependent). While it was originally written in regard to biomedical ethics, others have proposed that these principles undergird all service-based professions (Dean and Pollard 2018: 59; Jonsen 1995:248). The four core principles are: respect for autonomy, non-maleficence, beneficence, and justice, and are defined as follows.

Respect for autonomy: Most know the term autonomy to mean allowing individuals to make decisions for themselves - to have the freedom to direct their own destiny by the choices they make. However, in healthcare this principle is operationalised by two types of obligation: positive obligation and negative obligation. In this case, the terms positive and negative refer to the presence of something (positive) or the absence of something (negative). These terms are used the same way in medicine (e.g. a positive test result means the presence of something, such as cancerous cells). Therefore, respecting someone’s autonomy in a negative obligation manner would be to, for example, allow an individual to make decisions for themselves (i.e. self-determinacy) in the absence of controlling or constraining behaviours (Beauchamp and Childress 2012: 107).

Non-maleficence and beneficence: While these two principles share commonalities and are often identified and discussed in tandem (as in NCIHC 2004: 8), they are not ethically the same. Non-maleficence dictates that practitioners should not inflict harm, where harm is defined as, ‘the thwarting, defeating, or setting back of some party’s interest’ (Beauchamp and Childress 2012: 153). It is the value first articulated by Hippocrates in his ‘First, do no harm’. Beneficence carries a greater ethical obligation than non-maleficence. Beneficence is not just avoiding the direct act of inflicting harm, but protecting and removing other potential harms (as cited in Dean 2015: 55-56). It is also characterised by those actions which contribute to the welfare of another (Beauchamp and Childress 2012: 202).

Justice: The final core principle is justice which can be further defined by a particular justice theory. There are many theories of justice: distributive, libertarian, egalitarian, to name a few (Beauchamp and Childress 2012: 253-264). Not in every situation, but certainly in most professional service settings, the conceptualisation of justice is utilitarian in nature. Utilitarian is often described as the greatest good for the greatest number of people.

Seeking ethical guidance from established ethical norms in healthcare and working in accordance with these values is to firmly root healthcare interpreters in a time-honoured ethical foundation. The four core principles are not to supplant ethical norms established by either generalist or setting-specific ethical codes, as discussed above, but to enhance them. These four core principles and the values that grow out of them can be added to the values that healthcare interpreters are responsible for. That is, instead of asking, what is the role of the interpreter in healthcare settings, the normative question could be framed as, ‘What values established by the healthcare setting should similarly compel or contain the actions of the interpreter?’

The following illustration demonstrates how the values of the setting dictate patient, provider, and interpreter behaviour: in a psychiatric inpatient unit, the purpose is to keep patients and staff safe. Safety is the main purpose of the setting and this purpose dictates decisions at every level. It dictates the very decision about admitting (or not) suitable patients to the unit - only those who are an imminent harm to themselves or others are admitted (i.e. to keep them and others safe). The unit is almost always locked and patients are not permitted to leave without the supervision or the permission of the staff. Safety also drives the behaviours of individual clinicians. As an example, no jewellery or ties should be worn in the presence of patients who might seek to use them to cause harm. Clinicians are often discouraged from meeting with patients alone in the patient’s room and are instructed to never let the patient move between the clinician and the door. Therefore, in this shared values-based approach to interpreting ethics, the interpreter’s behaviours should reflect a similar concern for patient safety. That is, interpreters should work in collaboration with (or at least not against) the purpose and values of the setting (Dean and Pollard 2013: 56; Pym 2000: 182).

The challenge is that most interpreters are not taught what the setting-specific values are nor how to operationalise them (i.e. how these values might be reflected in their decisions). If an interpreter did not fully appreciate the value of patient safety in the example of a psychiatric unit, they could inadvertently make decisions that compromised patient safety. Not only should interpreters follow the safety lead of the service professionals in the setting (e.g. similar placement in a room with a patient), but should actively apply the safety value in interpreting-specific decisions. As an example, an interpreter may intentionally choose not to interpret something overheard by a patient in another room if they determine that it is likely to cause additional stress and therefore, instigate possible unsafe behaviour. In other words, the decisions that interpreters make in a given setting need to be evaluated based on the values of the setting and not only evidenced in interpreting (such as, accuracy, impartiality, etc.). If they were only evaluated based on the values included in a generalist code of interpreting, then the interpreter might be compelled by the value of fidelity or completeness (e.g. everything is interpreted) and therefore, interpret all material heard, regardless of concerns for safety. Just like the mental healthcare provider in the above example who had to choose between the value of safety and respect for autonomy of a suicidal patient, the interpreter in this example must choose between safety and fidelity.

The preambles to both the International Medical Interpreters Association (IM1A) and the American National Council on Interpreting in Health Care (NCIHC) do include a series of core values. Both the NCIHC (2004: 8-9) and the 1M1A (2010: 1-2) directly identify beneficence as one of its core values but not the other three (i.e. respect for autonomy, non-maleficence, and justice), at least not in those terms. Instead, they identify: fidelity, respect for the importance of culture and cultural differences (NCIHC 2004), transparency, right to equal treatment, confidentiality, and informed consent (IMIA 2010). The four principles put forward by Beauchamp and Childress are deemed core or foundational in healthcare because they are intended to generate other related ethical tenets. For example, right to equal treatment is arguably an outgrowth of justice and informed consent, or the intention that all patients understand and choose freely from available treatment options, is an outgrowth of respect for autonomy.

This contribution has thus far focused on ethical content material in biomedical ethics, generalist ethical codes in interpreting, and those ethical codes specific to healthcare interpreting. The next section returns to a review of available ethical content material for healthcare interpreters. This includes other ethical documents such as standards of practice and norms established by practice and discussions about practice.

 
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