Contributors.

Among the greatest challenges to improving health is determining how cultural diversity should influence healthcare practices and organizations, public health measures, biomedical research, and community partnering. Important but seldom addressed are challenges for bioethicists.

Empirical evidence demonstrates that minority and marginalized populations receive less and lower quality healthcare than more advantaged groups. Ethical analyses of these disparities explain their injustice. That disparities exist and constitute a moral wrong are uncontroversial views. Less clear are the exact causes of healthcare disparities.Thanks go to several reviewers who read and commented on earlier drafts, including John Stone, John Arras, Jay Baruch, Terry Rosell, and an anonymous CQ reviewer.

Taking seriously the value of cultural competence in healthcare requires at least three general commitments. First, it involves accepting the view that patients' health beliefs and behaviors are influenced to a significant degree by their own social and cultural practices. Second, it requires careful attention to how health professionals typically respond to patients' different social and cultural standards at various levels of the healthcare delivery system. And third, it calls for developing interventions that are sensitive to these first two issues to assure the delivery of quality healthcare for culturally diverse patients. This much is plain, insofar as we are talking about the broadest of commitments necessary to support the value of cultural competence in healthcare. But what other, more specific commitments are implied in accepting the value of cultural competence?I thank the guest editors of this issue, John R. Stone and Erika Blacksher, for their helpful suggestions on an earlier draft of this paper.

The shared values, beliefs, and behaviors by which people interpret life events are what we call culture. More than medical science, culture determines how people react to illness and death. Science may determine which drug or surgery best treats the disease, but culture often determines how the health professional best treats a patient with the disease. Culture influences when the patient believes he is ill, which treatments he accepts, and which results he prefers. Because culture surely affects illness outcomes, health professionals must not ignore it.This project received financial support from the Mexican American Medical Treatment Effectiveness Research Center and the Aging Research and Education Center at The University of Texas Health Science Center and from the Ecumenical Center for Religion and Health, San Antonio. Presented in an earlier version at the Seventh Annual David C. Thomasma, Ph.D., Memorial International Bioethics Retreat, Medical Faculty, University of Padova, and Fundazione Lanza, Padova, Italy, 26 June 2004; presented at the Second International Conference on Clinical Ethics Consultation, Basel, Switzerland, 19 March 2005; and accepted for presentation at the national meeting of the Society of General Internal Medicine, New Orleans, Louisiana, 13 May 2005. Erika Blacksher, John Stone, Susan Bagby, and David J. Doukas thoughtfully critiqued earlier drafts of this article. Andrew K. Diehl and Helen P. Hazuda critiqued a research abstract of the material. I thank all these people for their many helpful suggestions.

Hideo Kimura, a 46-year-old Japanese male patient in a Boston hospital, needs to undergo surgery to remove part of his lower intestine but resists signing the consent form and has little understanding of English. Discussing this with an interpreter, Hideo is puzzled, because he has already authorized his wife Sachiko to decide on his behalf. The interpreter points out to him that he has a right, a moral right, to give his informed consent to the surgery and that Hideo is quite competent to decide for himself. Nonetheless, Hideo cannot grasp the meanings of “informed consent” and “moral right.” Hideo agrees to sign the consent form only after he is told that this is official hospital policy.My thanks for insightful comments and critique by reviewers.

In the United States, healthcare providers, institutions, and society have failed to ensure the conditions necessary for racial and ethnic minority communities to be in good health. Many scholars and federal government officials consider racial and ethnic disparities in health to be an injustice and have called for national attention and strategies to eliminate them. Several of these strategies, including cultural competency, focus on addressing deficiencies within the health care system. Cultural competency is the ability of a healthcare provider to function effectively in the context of cultural differences with the clients they serve. Increasing cultural competency among healthcare providers has been shown to improve the quality of healthcare received by racial and ethnic minorities, which contributes to reducing health disparities. Achieving equity in the quality of healthcare received is a necessary strategy, but is insufficient for eliminating disparities in the health status of racial and ethnic minority populations. A growing body of literature reveals that health disparities are determined, not only by inequities in health care, but by social factors. The implication is that strategies that focus solely on healthcare perpetuate the misconception that health status is determined by access to or quality of healthcare. To eliminate racial and ethnic disparities in health status, the fundamental conditions for good health, which include but are not limited to healthcare equity, must be acknowledged and ensured for all people.Special thanks to the editors of this issue, John R. Stone and Erika A. Blacksher, as well Eugenia Eng, Shelley Golden, and Mondi Mason, for their helpful comments.

Many cultural competency efforts in healthcare stress the importance of cultural diversity and difference. This emphasis is necessary and well justified. It has helped sensitize healthcare systems to the differences among people and their health-related attitudes, preferences, and behaviors. However, the emphasis on diversity and difference has, unfortunately, also detracted from serious consideration of the things that cultures have in common and the possibility that socioeconomic differences are today far more important than cultural ones in determining healthcare outcomes.We thank the Comprehensive Cancer Center at Case Western Reserve University and University Hospitals of Cleveland, Ohio, for supporting the research on which this paper is based. We are also grateful to the wonderful people of Masidaal, our project coordinator, Debbie van Stade, and our large team of research assistants for making the research possible.

The notion of “cultural competency” in healthcare has gained currency in recent years. Health professionals are expected to be sensitive to the cultural backgrounds and language of their patients. Courses on cultural competency are now routinely offered to physicians, nurses, and others working in health fields. Although the rhetoric of cultural competency has been applied to clinical contexts, little attention has been given to its applicability in health research generally or, more specifically, in international health research. In this paper, I briefly explore the relevance and limitations of cultural competency for informed consent to international health research, particularly in the context of low-resource settings.This paper is based upon material included in Ethical Issues in Research Design and Informed Consent to Biomedical and Social Research in Resource Poor Settings, a monograph by Patricia Marshall (2007) commissioned by the World Health Organization, Ethics, Trade, Human Rights, and Health Law, and Special Topics in Social, Economic, and Behavioral Research Series of Programme for Research and Training in Tropical Diseases. Work on this manuscript was supported by funding from the NIH/National Human Genome Research Institute (PI: Patricia Marshall, 2 R01 HG002207-04), the Center for Genetic Research Ethics and Law, Case Western Reserve University (PI: Eric Jeungst, NIH/National Human Genome Research Institute, P50-HG-03390), and the Case/UHC Center for AIDS Research (CFAR), (PI: Michael Lederman, NIH AI36219). I am grateful to John Stone and Erika Blacksher for their helpful remarks on an earlier version of this manuscript.

To promote so-called cultural competence in work of direct-care providers and other health professionals among diverse peoples, cross-cultural training (CCT) is now widely advised. However, in ethically assessing aims and content of CCT, and surrounding issues and concerns, what should guide us? And if we can elaborate satisfactory moral touchstones, what do they imply for healthcare professionals, overarching structures, and bioethicists? Building on prior work, this paper tries to help answer these questions.Work in this paper is indebted to discussions with Annette Dula, Insoo Hyun, Muhjah Shakir, Melanie Tervalon, and colleagues at Tuskegee University and the Tuskegee University National Center for Bioethics in Research and Healthcare. Erika Blacksher, Leonard Ortmann, and Madison Powers provided useful comments about earlier drafts. This work was supported by CDC Cooperative Agreement Number P76/CCP424229-2.

These CQ Sources were compiled by Bette Anton.

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated.

The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration.

All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.I would like to thank research seminar members at the Centre for Applied Philosophy and Public Ethics at the University of Melbourne, Australia, Armin Schmidt, Julie Lucas, and Tuija Takala for their helpful comments.

An evaluation of mental capacity is critical to a clinician's judgment about whether or not persons can make medical treatment decisions on their own behalf, and uncertainty about their ability to meaningfully participate in that process is one of the more common reasons an ethics consult is requested. The care of decisionally incapable patients—particularly those who lack advance care documents and no living relative who can speak for them—presents a quandary to healthcare personnel attempting to plan care in their best interest, especially when options are multiple but none are ideal. These situations can be further complicated if involving a patient with a dual diagnosis of mental retardation and mental illness living in a community group home.I acknowledge the support of Mark G. Kuczewski, Professor of Medical Ethics and Director of the Neiswanger Institute for Bioethics & Health Policy Stritch School of Medicine, Loyola University of Chicago, for his guidance and support in the preparation of this manuscript.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.