H A S T I N G S C E N T E R R E P O R T 31March-April 2001

The public hospital where I work never seems tohave enough. It never seems to have enough doc-tors, nurses, technicians, interpreters, and janitors.

It never seems to have enough clinic hours, follow-up vis-its, and social services. Of all these shortages I want tofocus on one in particular: the shortage of interpreters forpatients who don’t speak English. I want to consider, in aphilosophical way, how the hospital should address thisproblem. But first I need to say more about the problem.

Many of the people who use this hospital and its clin-ics are working class immigrants. This is not a new devel-opment. The hospital has a long tradition of serving im-migrants, and it has a mission to serve people without re-gard to their ability to pay. What has changed at the hos-pital is the countries that immigrants come from and thelanguages they speak. Two generations ago, German, Yid-dish, Polish, and Italian were common at the hospital.Today, Spanish, Cantonese, Mandarin, and Bengali aremuch more common.

What has also changed is the number of languages spo-ken. During an eight-week period, the emergency depart-ment saw immigrant patients who spoke over thirty-fivelanguages.1 I suppose that more languages are spoken atthe United Nations, but at the UN people can reliably as-sume that someone they want to converse with will have aworking knowledge of English or French, and they cancall on an extensive staff of interpreters. At the hospital,

that’s not the case. More than one-third of the immigrantshave a poor command of English, and the hospital doesn’thave enough interpreters.

So how do patients and staff deal with this problem?Some staff members are bilingual. They themselves are im-migrants or are children of immigrants. Other staff mem-bers have learned to function in a second language, usual-ly Spanish, and keep a bilingual dictionary close at hand.The hospital has hired some interpreters and trained a fewvolunteers to act as interpreters. And, finally, some pa-tients show up with a family member—a spouse, child, orcousin—who knows enough English to help with themedical encounter.

Although the patients and staff muddle through eachday, and the hospital never quite turns into a tower ofBabel, problems do arise. Here are three examples:

� AA DDeepprreesssseedd PPaattiieenntt.. Mrs. Chen was waiting to beseen in the primary care clinic. She was sitting quietlywith her daughter, who looked to be about ten years old.It was almost six o’clock when Dr. Marsh called Mrs.Chen’s name and introduced himself. Mrs. Chen didn’tspeak a word of English, but her daughter was fluent.Although Dr. Marsh didn’t like to use family members asinterpreters, he didn’t know what else to do. The Can-tonese speaking receptionist had gone home at five, andso had the hospital interpreters. He didn’t want to sendthe patient away, so he began the interview through thedaughter. He asked a few open-ended questions andtook in the responses, all with the help of his ten-year-old interpreter. As the story unfolded, Dr. Marsh real-

When a doctor sees a patient, answers to a few questions can be crucial. So what to do when no

one at the hospital speaks the patient’s language? Doctors can often devise creative, makeshift ways of

communicating with their patients, but the problem calls ultimately for a creative organizational response.

Babel, Justice, and Democracy:Reflections on a Shortage of Interpreters at a Public Hospital

b y J A M E S D W Y E R

James Dwyer, “Babel, Justice, and Democracy: Reflections on a Shortage ofInterpreters at a Public Hospital,” Hastings Center Report 31, no. 2 (2001):31-36.

March-April 200132 H A S T I N G S C E N T E R R E P O R T

ized that Mrs. Chen was seriouslydepressed. He wanted to ask somepointed questions to assess the riskof suicide, but he felt bad aboutposing these questions through thedaughter.2

� TThhee YYeellllooww PPaaggeess.. The patientspoke Cambodian, two words ofEnglish, and one of French. Hekept coughing and pointing at hischest. The attending physician wasworried about tuberculosis. Theanswers to a few questions wouldhelp to clarify the matter, but noneof the staff spoke Cambodian. Theattending physician took the wholematter in stride. He asked the resi-dent to get him the yellow pages.The resident looked puzzled, butdid as he was asked. When the res-

ident came back with the phonebook, the attending physicianflipped it open to restaurants,found a Cambodian restaurant,called the number, and explainedthe problem. He then posed aquestion to someone at the restau-rant, and handed the phone to thepatient. The patient spoke Cambo-dian into the phone and thenhanded it back to the physician.That’s how the interview tookplace.

� AAbboouutt 6600 PPeerrcceenntt EEffffeeccttiivvee.. Dr.Gold says that she is better atphysics and philosophy than at for-eign languages. Although she haslearned a lot of Spanish by study-ing on her own, she estimates thatwhen she does an interview inSpanish she is functioning at 60percent effectiveness. Every time apatient comes in who speaks onlySpanish, she wonders whether todo the interview herself or to call

for an interpreter. It often takesmore than a hour for an interpreterto arrive, at a clinic where a patientis scheduled every twenty minutes.In each case, Dr. Gold must decidewhether to call for an interpreter,make the patient wait, and intro-duce more chaos into an alreadychaotic schedule; or to muddlethrough at 60 percent effective-ness, get a little more practice atSpanish, and hope she doesn’t misssomething crucial.

As part of my work at the hospital,I discussed these cases with medicalstudents and hospital staff. The stu-dents, staff, and I tried to addressboth the particular ethical problemsthat the clinicians face and the gener-al ethical problem that the hospital

faces. I like to think that philosopherslike me can help people to addressproblems like these. But I’m not surethat’s true. All my life I wanted to behelpful and philosophical, an engagedcitizen and a real philosopher at thesame time, but this twofold aim hasproved more difficult than I everimagined.

Part of the difficulty is finding themost appropriate perspectives, dis-courses, and categories for the prob-lem at hand. To be helpful, the per-spectives, discourses, and categoriesmust be useful and accessible to thepeople engaged in the actual situa-tion. But philosophical perspectives,discourses, and categories tend to berather abstract, reflective, and critical.Given my desire to be both helpfuland philosophical, I came to view theshortage of interpreters as a kind oftest case, and the rest of this essay isboth a discussion of the ethical prob-lems and a reflection on the role ofpractical philosophy.

Clinical Ethics

To begin, I want to say somethingabout the ethical issues that the

clinicians face. The first case is themost dramatic and the most typical ofthe traditional conflicts in medicalethics. To grasp the full meaning ofthe conflict it presents, we need a feel-ing for the situation of the mother.She is a working class immigrant try-ing to get medical care in a strangeland where she doesn’t know the lan-guage. She is dependent on herdaughter to help her navigate a sink-ing ship in a strange ocean.

We also need a feeling for the situ-ation of the daughter. Children of im-migrants are often deeply attached totheir parents but also somewhat em-barrassed by them. Although thesechildren often have to interpret fortheir parents and grandparents, rarelydo they have to interpret while doc-tors ask: “Have you ever thought ofharming yourself?” We need to try toimagine what this experience wouldbe like for this ten-year-old girl, whatit would be like to learn that yourmother is thinking of killing herself.

A sensitive understanding helps usto grasp the particular problem. Thisproblem arises because Dr. Marsh isconcerned to help the patient, avoidharm to the daughter, get accurate in-formation, protect confidentiality,and proceed in an efficient way. Theseare important and legitimate con-cerns, but in the present case theycome into conflict. Dr. Marsh made ajudgment about the balance of theseconcerns when he began the inter-view, but now that he realizes that thepatient is depressed, he needs to re-consider what he is doing.

Although some philosophers liketo formulate conflicts as air-tightdilemmas so that people must chooseone side, I think that much of the realwork in moral life involves attendingproperly to the various concerns,finding satisfactory ways to reconcilethose concerns, and developing re-sponsive institutional structures. Animportant part of the work is to find away that responds to the concerns but

We all found it frustrating to discuss problems in

clinical ethics that could be avoided altogether with a

bit more money, effort, planning, and organization.

March-April 2001 H A S T I N G S C E N T E R R E P O R T 33

avoids the conflict. No one I dis-cussed the case with felt good aboutsending Mrs. Chen home without as-sessing the risk of suicide, and no onefelt good about conducting the rest ofthe interview through her daughter.Everyone looked for some way out.

Here is a list of suggestions thatpeople made, along with a few com-ments from the discussion:

� Page a medical student whospeaks Cantonese. (“There’s proba-bly a student running errands inthe hospital who speaks Can-tonese.”)

� Page any hospital employee whospeaks Cantonese. (“Why isn’t thisinformation on the computer, in akind of language bank?”)

�Find a bilingual patient in one ofthe waiting areas. (“Patients spenda lot of time waiting, and anotherpatient would be better than thedaughter.”)

� Call one of the hospital inter-preters at home. (“Wouldn’t wepage a doctor at home if we need-ed her?”)

� Call the International BuddhistProgress Society. (“Buddhists prac-tice compassion, and there is atemple right in the city.”)

� Call the AT&T interpretationservice. (“If the clinic doesn’t havean account, charge the call to yourown credit card.”)

� Ask the patient if she will agreeto be hospitalized for an importantevaluation. (“But what will she dowith her daughter, and what if shehas other children at home?”)

I do not want to contend that this listis exhaustive. Indeed, I hope thatother people can come up with othersuggestions. Nor do I want to con-tend that all the suggestions are equal-ly good. Part of the work of the dis-cussion was to evaluate the relativemerits of the various suggestions.

Some suggestions seemed better thanothers, and some seemed much betterthan making the daughter interpretthe rest of the interview.

In the process of discussing theproblematic cases, a real educationtook place. The students, staff, and Iall became more aware of the need toget accurate information, protectagainst harm, maintain confidentiali-ty, act efficiently, consider family life,and attend to the situation of immi-grants. When we discussed a case in agroup, the group was often able tocome up with more alternatives thana single person could. And when thediscussion went well, we were able toevaluate the relative merits of the al-ternatives. The better alternatives en-tered into people’s stock of ideas—thehospital’s human and social capital—to be called on when needed.

Although the discussions provededucational, they also proved frustrat-ing. We all found it frustrating to dis-cuss problems in clinical ethics thatcould be avoided altogether with a bitmore money, effort, planning, and or-ganization. We all wanted to shift thediscussion from clinical ethics to or-ganizational ethics. So we did.

Organizational Ethics

Some people began to discuss orga-nizational ethics in a way that

would have bypassed most of the eth-ical problems. They claimed that pa-tients who are not proficient in Eng-lish have a right to an interpreter. Icautioned against this approach. I ar-gued that simple claims about rightstend to ignore difficult ethical prob-lems about assigning responsibilities,setting priorities, allocating resources,and resolving conflicts between differ-ent rights. Claims about rights tend,unwittingly, to imply that all theseethical problems can be replaced byadministrative problems about moni-toring and enforcing rights. But ethi-cal life is not so simple.

I wanted to pause to discuss theforces behind global migration, themeaning of national borders, the ef-fects of political responses, the mis-

sion of the public hospital, and the al-location of resources at the hospital.But these matters were seen as too ab-stract, too distant from the problemat hand. Perhaps they were, at least atthe time. Because the shortage of in-terpreters was so immediate, people(including me) were quick to makesuggestions and propose solutions.Here is a list of suggestions that peo-ple made:

�Hire more interpreters, and placesome of them on call.

�Hire more bilingual staff. In em-ployment decisions, consider com-petence in a second language as arelevant skill.

�Contract with a telephone inter-pretation service like AT&T. Makesure everyone knows how to accessthe service, and that the equip-ment complements the service(speaker phones compromise con-fidentiality, and single phones haveto be handed back and forth).

� Encourage staff members tolearn a second language. Offer freeclasses, and give people time off toattend the classes.

� Start and maintain a languagebank on the computer. List all stu-dents and staff who speak a secondlanguage. List where they workand how to contact them.

� Recruit and train more volun-teers. Establish relationships withassociations from the different lan-guage communities.

� Encourage premedical studentsto learn a second language. Com-petence in a second language couldbecome a de facto requirement formedical school, just as volunteerservice and research have becomede facto requirements.

These suggestions are quite diverse.They embody different views aboutthe availability of resources, the locusof responsibility, and the urgency of

March-April 200134 H A S T I N G S C E N T E R R E P O R T

the problem. Some suggestions wouldrequire substantial and ongoing fund-ing, whereas others would requireonly a modest grant to pay for start-up costs and administration. Somesuggestions focus on society’s or thestaff ’s responsibility, others look tothe community or the immigrantsthemselves. Some suggestions aim atan immediate solution, other focus onthe long term. Some suggestionsmight work well for common lan-guages but prove impractical for rarelanguages. Of course, these sugges-tions are not mutually exclusive, andthe list is not exhaustive. Administra-tors may find good ways of combin-ing suggestions or good ideas that arenot on the list at all. Part of the workof administrators is to formulate andevaluate alternative modes of organi-zation that respond to the problem.

But how—in what categories andfrom what perspectives—should ad-ministrators think about the varioussuggestions? Some useful categoriesemerged in the discussion of clinicalethics. Administrators need to consid-er cost-effective ways to help the staffget accurate information, respect con-fidentiality, attend to families, care forimmigrants, and so on. But are therebroader categories that might guideadministrators in their work? I thinkit would be helpful to focus attentionon three ethical ideals: the good, thejust, and participatory democracy.

The Good and the Just

It is unrealistic and simpleminded toevaluate organizational suggestions

without taking into account the costof those suggestions. After all, theproblem arises because the hospitalhas limited resources. Every adminis-trator would like to have more re-sources—more money, people, andequipment. More would often be bet-

ter, at least for the hospital, if not forsociety as a whole. But given the hos-pital’s limited resources, administra-tors should try to increase the gooddone with those resources. This mayseem like an obvious idea, but I don’tthink people attend to it carefullyenough. People don’t usually thinkand respond in terms of increasing thegood. Let me try to illustrate thispoint.

Physicians often tell me, and teachtheir students, that 90 percent of theinformation needed to make a diag-nosis comes from the patient inter-view. Yet language barriers are block-ing the flow of information. In Dr.Gold’s case, for example, she estimatesthat she is only 60 percent effectivewhen conducting an interview inSpanish. If physicians had to order adiagnostic test that was only 60 per-

cent as effective as another test on themarket, they would demand that thehospital get the more effective test.Likewise, if they had to prescribe adrug that was only 60 percent as ef-fective as another drug, they wouldseek immediate changes.

When better outcomes can beachieved with tests, medication, orequipment, people are concerned andtake action. Clinicians voice theirconcerns, and administrators work toincrease resources or to reallocate thegiven resources so as to achieve betteroutcomes. But when the limitationsare a matter of language, time, or or-ganization, people tend to acceptthese limitations as a fact of life. Thereis no good reason to adopt this doublestandard.

Maybe hiring another interpreterwould do more good than hiring an-other lab technician. Maybe adding atelephone interpretation servicewould do more good than adding an-other MRI scanner. I don’t know, ofcourse, but neither do most adminis-

trators and clinicians. They should tryto find out. They should considerhow to allocate the financial andhuman resources in ways that increasethe good. After all, part of the art andscience of management is to do betterwith the same resources, and “better”is the comparative of “good.” It mightbe possible to get better outcomes, todo more good, if the given resourceswere allocated in a way that addressedthe language problem.

In addition to trying to increasethe good, administrators and clini-cians need to attend to how the goodis distributed. Justice may not be ade-quately expressed simply by maximiz-ing the good. In discussing questionsof social justice with the staff, I start-ed to articulate some philosophicalcritiques of the way power, wealth,opportunity, and health care are dis-tributed in American society. Theproblem I encountered was not thatpeople disputed the critiques. For themost part, they agreed that there issomething cruelly unjust about ahealth care system that fails to providebasic care for so many poor and work-ing-class patients. And they foundthat philosophical critiques based onsocial justice were useful in making acase that public hospitals are under-funded in comparison to the rest ofthe health care system.

The problem, rather, was thatmost philosophical views of social jus-tice seemed to them too distant andabstract to provide much guidanceabout the distribution of goods at anunderfunded hospital where the pa-tients come from the most disadvan-taged classes in the larger society.What the staff wanted was more guid-ance about distributing goods amongtheir patient population. About thisproblem I had much less to say.

I did suggest that the hospitalneeds a process that is fair, reasonable,and transparent. I also suggested theneed to avoid invidious distinctions.Because the hospital was having diffi-culties meeting the basic needs of allthe patients, some staff suggested dis-tinctions based on the idea of desert.A few people suggested that immi-

The hospital must try to encourage and empower

people to meet together, deliberate about, and address

the problems of their public hospital.

March-April 2001 H A S T I N G S C E N T E R R E P O R T 35

grants who have been in the countryfor many years but have not learnedEnglish are less deserving than others.A few people thought that illegal im-migrants are less deserving that legalimmigrants. And a few people suggested that hearing-impaired patients who use sign lan-guage are more deserving of inter-preters than speakers of foreigntongues.

In one sense, there is no gettingaway from the idea of desert. After all,justice is giving people their due—what they deserve. But I am skepticalabout appealing to a narrow concep-tion of desert. First of all, in this con-text it is very difficult to determinewho is more deserving. It is easier tojudge who is more deserving of anaward in a piano competition thanwho is more deserving of an inter-preter at a public hospital. Further-more, a narrow conception of desertdoes not seem appropriate for dealingwith the problem of distributinghealth care across a diverse patientpopulation. A narrow conception ofdesert is most at home in allocatingparticular goods that go beyond basicneeds, in situations where the criteriaof effort and achievement are veryclear.

Participatory Democracy

Iexpect the hospital to increase thegood and attend to justice. But

that’s not all. I also expect the hospitalto foster democracy. To do that, thehospital must do more than providepatients with individual rights—likethose listed in a patient’s bill of rights.The hospital must try to encourageand empower people to meet togeth-er, deliberate about, and address theproblems of their public hospital. Itmust foster participatory democracy.Such a change is a very significant butnot unreasonable expansion of a hos-pital’s mission, and it generates somepractical suggestions.

A robust democracy requires morethan an occasional act of voting. It re-quires forms of life where people meet

frequently to deliberate about issuesand are empowered to address prob-lems. But this kind of civic life doesnot happen by itself, especially in ine-galitarian societies that encouragepeople to act as consumers andclients. Civic engagement has to befostered by social institutions. Ofcourse, one public hospital cannottransform the economic inequalitiesand civic withdrawal that characterizeAmerican democracy, but it can do itspart.

One practical suggestion is for thehospital to work with communitygroups to recruit and train volunteerswho can serve as interpreters. If sucha measure is to realize its full poten-tial, however, we need to considercarefully how and why the use of vol-unteers should be connected to theidea of participatory democracy. At itsworst, the use of volunteers may serveas a palliation for a lack of justice inthe larger society. It may just be an in-expensive and private way to dosomething that should be funded anddone in a public way. But at its best,the use of volunteers could increasepeople’s understanding, provide a ser-vice in a culturally sensitive way, en-courage further civic engagement,and develop habits of citizenship. Inshort, it could foster civil society andthe social ideal of democracy.

The shortage of interpreters is acommunity problem. Because it af-fects members of linguistic communi-ties and the hospital that serves them,it is an occasion for the hospital staffto work with these community mem-bers to address the problem. As a firststep, people need to come to a betterunderstanding of the problem. Forexample, community members needto understand that one of the currentpractices—the use of family membersas interpreters—does not insure ahigh standard of coverage, accuracy,and confidentiality. And staff mem-bers need to understand how to inter-pret terms in those languages that arequite distant from American English,and how to interpret elements inthose cultural beliefs that are quite

different from American medicine’sview of illness. Only when people un-derstand the scope and depth of theproblem can they helpfully discusswhat might and should be done. Re-cruiting and training volunteers fromcommunity groups can help.

In thinking about social problems,people often focus on what govern-ments or markets can do and neglectthe important role of civil society—all those associations that are neither commercial nor governmen-tal. Robert Fullinwider has describedsome of these associations and theireffects:

civil society extends from churchesto soccer leagues to reading circlesto social movements. It encom-passes highly organized nationalfederations as well as informalneighborhood crime watches; itincludes associations as large as theAARP and as small as the family.Its activities produce an amazingarray of goods—from communitysafety to companionship to med-ical care to spiritual guidance. Andin producing these goods, it gener-ates such valuable byproducts associal trust, political competence,and civic spirit.3

Thinkers from Alexis de Tocquevilleto Vaclav Havel and Robert Putnamhave also stressed how importantthese byproducts are to the realizationof a meaningful democracy.4

Democracy needs people who per-ceive social problems, discuss thecauses and remedies of these prob-lems, listen to other people in an at-tentive way, and deliberate aboutwhat should be done. Democracyneeds people who are concerned, en-gaged, and public-spirited. Peopletend to develop these habits and atti-tudes in associations that embody de-mocratic spirit. John Stuart Millrefers to such development as “the pe-culiar training of a citizen, the practi-cal part of the political education of afree people.”5 According to Mill, thiseducation involves taking people

out of the narrow circle of person-

Ihave been teaching health care ethics at St. John’s Uni-versity in Jamaica, New York, since 1984. Although Ihave researched and written a great deal in the field of

health care ethics, I had done no work in the area of trau-matic brain injury, nor do I remember ever attending aprofessional conference where that topic was examined. Ihad never thought about traumatic brain injury as a dis-tinct topic of medical ethics and certainly had not studiedthe topic in depth. All of that changed, however, as a re-

al and family selfishness and accus-toming them to the comprehen-sion of joint interests, the manage-ment of joint concerns—habituat-ing them to act from public orsemi-public motives and to guidetheir conduct by aims that uniteinstead of isolating them from oneanother. Without these habits andpowers, a free constitution can nei-ther be worked nor preserved, as isexemplified by the too-often tran-sitory nature of political freedomin countries where it does not restupon a sufficient basis of local lib-erties. (p. 108)

At the local level, the hospital has arole to play in democratic education.

Does an approach that depends oncivil society presuppose the existenceof robust democratic communities?Yes and no. It presupposes that thereare groups, associations, and organi-zations with members who are willingto help with the problem. But that

seems realistic. There are associationsof Latino medical students, Buddhisttemples with Chinese speaking mem-bers, Christian churches with Koreanspeaking members, organizations ofBengali business people, and so on.There is the potential to solve theproblem and to make society a littlemore democratic if we look for solu-tions that come from and contributeto more participatory forms ofdemocracy.

Does this approach shift a burdenonto the very groups that are alreadyburdened with involvement? Yes andno. It does, of course, depend on thecivic involvement of everyone who isable and willing to help. But we neednot think of civic involvement as anonerous and extra burden. We needto remind ourselves that civic involve-ment is not only a social duty, butalso an important mode of self-real-ization. And we need to remind our-selves that the most just and fortunate

societies are societies that develop de-mocratic forms of life where self-real-ization and civic involvement rein-force each other.

Acknowledgments

I want to thank Jean Maria Arrigo,William Ruddick, Lloyd Wasserman,and Elisabeth Wassmann for their help.I also want to thank all the students andstaff who participated in discussions ofthe ethical issues.

References

1. Unpublished study by Lewis Gold-frank and colleagues.

2. Christopher Taurani and Damara Gut-nick deserve credit for this case.

3. R. Fullinwider, “Civil Society and De-mocratic Citizenship,” Philosophy and PublicPolicy 18, no. 3 (1998), 1-2, at p. 2.

4. See A. de Tocqueville, Democracy inAmerica (New York: Doubleday & Compa-ny, 1969); V. Havel, Summer Meditations(New York: Knopf, 1992) and R. Putnam,Bowling Alone (New York: Simon & Schus-ter, 2000).

Family members are widely believed to be the best decisionmakers for those with brain injuries, but

the rehabilitation process does not in fact give them that authority.

Decisionmaking Issues in the Rehabilitation Process

b y M A R I L Y N M A R T O N E

Marilyn Martone, “Decisionmaking Issues in the Rehabilitation Process,”Hastings Center Report 31, no. 2 (2001): 36-41.

36 H A S T I N G S C E N T E R R E P O R T March-April 2001