1. Autonomy? Structural Violence? Or a Right to Health Care
ANTH 3301
Health, Healing & Ethics
Carolyn Smith-Morris

2. Structural Violence

3. Leading Causes of Death: American Indians and Alaska Natives
Cause of Death
1980 Rank
2002 Rank
2002
All Persons Rank
Disease of heart 1
Malignant neoplasms 3 2
Unintentional injuries 5
Diabetes mellitus 8 4 6
Cerebrovascular diseases
Chronic liver disease and cirrhosis
>10
Chronic lower respiratory diseases 7
Suicide 10
Influenza and pneumonia 9
Homicide

4. Contrasting Ethical Systems
Biomedicine
Biomedical/Western assumptions
The Four Principles Approach (Beauchamp and Childress 2001, 5th edition)
Native Ethics/Priorities
Communalism (isolating
individuals is unethical)
Holism (reductionism is unethical)
Communalism (isolating individuals is unethical)
Holism (relegating culture to secondary importance is unethical)

5. Biomedical Ethics Four Principles Approach
Western/Industrialized cultural assumptions:
Autonomy
The target of care is the patient alone, reification of the individual
Beneficence
Non-Maleficence
Limited responsibilities of the provider
Justice
(Beauchamp and Childress 2001, 5th edition)
Limited responsibilities of institutions
Poorly suited to multi-cultural settings
(Marshall 2004; Sargent and Smith-Morris 2006)
Yes, there is damage to both individuals and communities if you disseminate models that are culturally incompatible; imperialistic.
Yes, there is variation in acculturation (desire for treatment/desire for healing), but this is decided differently within the boundaries of sovereign nations.

6. Native Ethics/Priorities
Greater importance of collectivism (esp. for reservation-based care)
Values that encompass genealogy and historical links
Relationships and sharing between individuals, families, and communities
Cooperation and coexistence with environments and sources of food
The recognition that some tribal knowledge is not accessible to all.
Tassell et al. “Principles of Indigenous Ethics and Psychological Interventions”

7. Native Ethics/Priorities
Lower disease/illness distinction
The cultural/symbolic relevance of:
Substance abuse
Incarceration
Peer groups
Age Mates/Generational Embeddedness
Historical trauma

8. “The Changing Ethics of Research in Indian Country”
Human Organization Vol.66, No.3, 2007
“A People in Peril: Pimas on the front lines of an epidemic”
The question of moving in to communities with EBM we decide is appropriate, but without proper local vetting.
NIH was kicked out; there ARE costs to disseminating culturally inappropriate treatment modalities!!!
Communities are becoming more self-determined; and for those that are not, an ethical obligation exists to allow them greater self-determination (if not facilitate it)
“Diabetes ravaging tribe despite decades of study”

9. Moral Hazards To get involved vs. extracting experience/data
To bring resources vs. personal/professional supplies
To return something to the community vs. sharing one’s knowledge
Outsourcing clinical trials where ethical restrictions are less
Post-research obligation (residual obligation) to those who volunteered
Engagement based on human dignity (all humans are equal) vs. engagement based on resources (some lives deserve less intervention)

10. Cross-cultural strategies: (an expansion from Kleinman’s 8 questions)
Social capital and social networks
Clinical modalities that incorporate the patient’s context
Decentralized models for care and treatment
Collaboration, not just involvement in care
Sustainability and co-learning in dissemination