Moral mediation in interpreted health care consultations

Highlights

• Moral identity is difficult for patients to convey in interpreted consultations.

• Interpreters often intervene to try to shape patients' moral reputations.

• Interpreters sometimes fail to translate morally-relevant material.

• This may contribute to dissatisfaction with diabetes care for non-English speakers.

Abstract

This paper reports on the moral work done in routine diabetes review consultations in primary care with nurses. Consultations with fluent English speakers are compared with consultations where an interpreter was present, largely involving patients of Bangladeshi origin. The study setting was Tower Hamlets in London, where type 2 diabetes is particularly common. Existing research has shown some dissatisfaction with diabetes care amongst Bangladeshi patients, and studies of care providers in other locations suggest that they at times experience the care of this group as particularly challenging. Through analysis of video-recorded consultations recorded in 2010–2011 we shed light on possible reasons for these difficulties. The 12 non-English speakers often experienced difficulties in raising issues that concerned them, particularly if their interpreter did not translate their utterance because it was deemed to be unrelated to diabetes. These difficulties were not shared by the 24 fluent English speakers, who also found it easier to convey a positive moral reputation and to excuse behaviour that deviated from recommended self-management practices. Interpreters at times also acted as moral mediators. For example, where a participant in the consultation made statements that appeared to convey a negative moral judgement of an other participant, these would often go untranslated. Probably, neither health care providers nor patients are fully aware of the nature of their communication difficulties. Given this, interpreters possess considerable power to influence matters. Understanding the moral work of consultations is important in explaining the findings of other studies showing difficulties in the provision of diabetes care to people with limited English language skills.

Introduction

Moral work is ubiquitous in health care consultations (Heritage & Lindström, 1998). Typically, patients feel obliged to demonstrate that their decision to visit a care provider is justified, since an unjustified visit fails to provide legitimate entry into the sick role, whereby the temporary deviance that would otherwise be imputed to the patient is forgiven or sanctioned (Parsons, 1951). Thus medical encounters often begin with an inquiry about the reason for the visit followed by a variety of responses by the patient in ‘accounting for the visit’ (Heritage & Robinson, 2006, p.48) and subsequent phases of consultations also demonstrate justificatory practices (Heath, 1992, Peräkylä, 1998). These interchanges are subtle and require participants to deploy considerable linguistic skills.

What happens to moral work, though, when participants do not share a common language? Some evidence suggests that where the patient lacks fluency in the language of the care provider it is harder for these patients to communicate about matters that are not strictly clinical and to influence how the care provider perceives them as a patient (Moss & Roberts, 2005). In particular, such patients have been found to convey their ‘moral self’ in different and less ‘orderly’ ways than fluent patients (Roberts, Sarangi, & Moss, 2004). The analysis reported here goes a step further, to examine the moral work done in consultations where the patient's language skills are such that an interpreter is used. We focus on routine review consultations for patients with diabetes carried out by nurses in primary care, but our findings have general relevance for understanding the mediation of moral elements of interpreted consultations.