(075) Transcultural Psychiatry in Medical Ethics: A Case of Assessing Decision Making Capacity (DMC) Within the Lens of an East African Refugee

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Background: Cultural competence is a practical, concrete demonstration of the ethical principles for respect ‎for persons, beneficence, nonmaleficience, and justice. While the principles of medicine are universal, they should be ‎applied in a cultural relativistic manner when appropriate. We present the complex case of an Eritrean refugee in ‎highlighting cultural relativism in assessing for DMC.‎

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Case Presentation: KW is 29 yo refugee from Eritrea with a history of HIV from sexual assault who presented ‎to ED after police found her wandering and emaciated after recent divorce from husband who took their son with him. ‎While in the ED, the patient ate minimally and refused medical treatment. She maintained she was still married and did ‎not need any medications. She was ultimately admitted for failure to thrive with noted BMI of 15.79 and CD4 count 190 ‎with viral load 1.1 million (copies/ml). At that time, she was deemed legally incompetent. Psychiatry was consulted for ‎involuntary ECT given continued poor oral. She had two sessions of ECT with questionable improvement before ethics, ‎legal guardian, and the psychiatry team met to discuss her language and cultural barriers. ECT was discontinued given ‎concern for re-traumatization, and she was eventually discharged.‎

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Discussion: In Ethiopian culture, divorce is a last resort as marriage is considered sacred. Patriarchal traditions ‎usually involve male elders formalizing a separation(1). This conventionalism could potentially explain the patient's ‎‎"delusion" of still being married. Further, the stigma surrounding HIV in Ethiopia may have contributed to the ‎continued denial of her diagnosis and refusal of treatment(2).‎

Although HIV cachexia contributed to her malnutrition, her lack of concern over her eating can also be culturally ‎considered. Eating disorders from an Ethiopian lens were previously described as an "eating arrest" in times of crises, ‎which was expressed through lack of ability to eat(3). The patient's restrictive eating may have been culturally ‎normative in the context of her acute stressors. ‎

With improving nutrition, she exhibited the capacity to refuse further ECT. She was soon discharged given continued ‎admission would have prevented psychotherapeutic intervention from those who shared her language and culture, as ‎noted by Lambo in creating his Aro Village System in Nigeria(4).‎

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Conclusion: This case highlights a situation in which Western medical/psychiatric evaluations and treatments ‎were applied to a patient whose cultural conceptualization of her physical and emotional health were vastly different. ‎It is crucial for clinicians to be able to understand the sociocultural contexts in assessing DMC.‎

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References: ‎
‎1. Bogale A and Ejigu G. "Marriage, Divorce, and Family Relations in Ethiopia." Journal of Divorce & Remarriage. vol. 49, ‎‎2008.‎
‎2. Chekole YA and Tarekegn D. "HIV-Related Perceived Stigma and Associated Factors Among Patients with HIV", Dilla, ‎Ethiopia: A Cross-Sectional Study." Annals of medicine and surgery 71. 2021: 102921–102921. ‎
‎3. Shem-Tov RG, Zubery E, Hecht NL et al. Israel Journal of Psychiatry; Jerusalem Vol. 55, Iss. 2. 2018: 22-31,66. ‎
‎4. Heaton MM. The politics and practice of Thomas Adeoye Lambo: towards a post-colonial history of transcultural ‎psychiatry. History of Psychiatry. 2018;29(3):315-330.‎