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Abstract

Aboriginal ethics and ways of gaining knowledge differ from those of contemporary health care in being narrative and relational. Decisions are not made through the application of rules or laws but evolve in dialogue from the stories told by everyone involved in the situation. In this conversation, all stories from everyone are heard. Decisions are often reached consensually through everyone sharing their stories until a ﬁnal narrative emerges that guides further behavior as compared to democratic approaches in which the majority wins or hierarchical approaches (the judge decides). Contemporary health-care ethics are rule based, guided by principles that are interpreted by experts in law, medicine, and ethics. Aboriginal people ﬁnd this process oppressive and dismissive of their culture. Previous research is summarized that describes the difﬁculties that aboriginal people have with contemporary health care and what they feel is lacking. They emphasized the importance of values being congruent among providers and recipients of services. They thought that the collectivism found in communities would work against individualist models of health care. They believed minority voices should be heard and, especially in communities in which the minority is the majority, and that these voices should be the primary organizers of service delivery. They believed that having an awareness of the effects of everyday racism is critical to the development of culturally appropriate health services. They believed that the ideal model for health-care service delivery is humanist, value driven, community oriented, and spiritual. It incorporates local culture, knowledge, and practice as it is reﬂected in the community today. Data is also presented about what traditional elders believe health-care workers coming into aboriginal communities should know.

Introduction

An aboriginal context invites one to situate oneself as to origins in every sense of the word. This material originates in a person who came from a long line of Cherokee people who escaped Andrew Jackson’s Trail of Tears, the forced march of our people to Oklahoma in 1836. His ancestors hid in the Appalachian Mountains of Kentucky and slowly assimilated with the White culture, primarily Scottish, also called hillbillies – the people famous for blue grass, ﬁddle playing, and sometimes moonshine. His father’s people were the result of the fur trade – a combination of French Canadian and Oglala Lakota from the Wounded Knee area of South Dakota. He grew up within his maternal grandmother’s Christianity, which later he discovered to be so far from conventional as to be Cherokee in disguise. For most of his generation, fathers were absent or dead as was his.

In keeping with an aboriginal style of presentation, he will relate an example of a story about being multicultural in the modern age and about one of the elders who helped him struggle with these concepts.

When the narrator entered the tipi, Old Ben was in the midst of a story. Old Ben was surviving into the twenty-ﬁrst century in the patchwork way common to many contemporary shamans. On the weekends he led ceremony. During the week he worked as a printer. Like many modern-day Native Americans, Ben’s life context was even more complex – he was a Navajo-Lakota mix living in Hawaii. He had come to Hawaii years before with the military, had started school while serving at Hickam Air Force Base, and had stayed.

Like a true resident of the Rainbow State of Hawaii, Ben borrowed freely from all cultures at will, changing the names to ﬁt his audience. His consciousness treated stories in the way that viruses treat DNA. As he heard and recalled stories, he substituted, deleted, and recombined various parts of the stories until something brand new resulted, never before seen or heard. Ben was telling a story about an ancient one who gave up his voice so that his family might never go hungry. This man was a great healer and storyteller but was perpetually poor. A spirit offered him a trade – his voice and his ability to heal for prosperity. “The healer’s wife was overjoyed,” Ben was saying. “Finally she would always have meat on their table and the things in life, which she felt she had deserved for all those many years that she had lived with the healer. A deer brought itself to their lodge and lay down for their food. The choicest roots began to grow behind their lodge. Barren bushes grew berries.

“Things were worse for the healer than he could have ever imagined,” Ben continued. “He had not realized how many little things in life that we do are healing. He could not make the softest touch for these are often more healing than the grandest ceremony. He could not reassure or comfort his wife and children. In fact, there was little he could do, for most of what we do in life is healing to someone or something. Unfortunately, his wife soon grew tired of prosperity, for what is wealth without love? What is prosperity without comfort or joy? What is the satisfaction of hunger and thirst without gentle companionship? Soon the healer and his family were more despairing than they had ever been.

“This is sort of a variant of ‘the grass is always greener,’” Ben said. “The man was now helpless for he had lost the capacity to heal himself and that is what makes us human. His wife vowed to help him but what could she do? She resolved to take him to all the best healers even in distant lands, to whatever it took to make thing right again.”

Aboriginal Ethics

Ethics are predicated on values, many of which are assumed and rarely discussed. Aboriginal cultures communicate these values through stories as Old Ben did in the story above. This is why cultures have difﬁculty consuming the services of other cultures. Aboriginal people in North America do not relate well to the health-care services provided by the dominant majority. The unsatisfactory experience of aboriginal people with contemporary medical care is inﬂuenced by the sanctioned ideas and social norms of the dominant culture. In North America, the health-care model of the dominant culture relies upon mainstream sanctioned ideas and social norms and rarely considers indigenous ideas or values. The opinions and desires of indigenous people are not often considered when planning health services and implementing their delivery. Medical services are provided on an individualist model, while most First Nations are more collectivist. Health services may create as many problems as they solve due to labeling, assimilationist strategies, and perceived racism.

Dominant culture models stress caring for one dimension (the physical body) while aboriginal views include a more global, balanced worldview, often exempliﬁed by the medicine wheel (MehlMadrona 2003) (see four core chapters on the directions). A non-aboriginal approach to service delivery may actually contribute to “psychic colonization and existential frustration” (MehlMadrona 2003) since one must reject one’s own tendencies in favor of the structures provided by the dominant culture (Butson 1993). Current health services may be viewed as supporting an ethics of individualism and materialism, which undermines aboriginal values. This is largely because cultural and spiritual needs are as important as physical needs within aboriginal perspectives.

The more knowledge that providers have of their own culture and of their clients’ cultures, the more valuable is their service delivery, since they are aware of cultural differences and can honor values (Butson 1993; Trimble et al. 1996). They can better understand the people being served and take more account of the variety of aboriginal cultures found on this continent (there are over 500 identiﬁable tribal groups in North America). Bicultural people can provide an important link to mainstream culture, but “bicultural personhood is hard to come by” (Peavy 1995). When it is attained, it can provide an important bridge between integration and differentiation. Biculturalism can increase accountability, which is necessary to offset power differentials among groups. Most ethical systems emphasize the need for leveling power imbalances.

A series of 100 focus group meetings over 3 years was held with aboriginal people around the province of Saskatchewan, Canada. The size of the groups ranged from three people to 19. The focus of the groups was to discuss the relationship of aboriginal people with conventional healthcare delivery systems. A total of 851 people participated in these discussion groups. In each group, notes were made of people’s comments about how health care is delivered, the values implicit in health care, practical considerations, role models, spirituality, nonspeciﬁc aspects of providing care, uniquely indigenous tools, and how to heal colonization (Mehl-Madrona 2012).

Participants noted a difference in values between health-care services and aboriginal cultures. Aboriginal cultures tend to value family and community over individuals. They perceived contemporary medicine as focusing almost exclusively on biology and genetics of individuals. Their concepts of privacy were quite different from those of Euro-American culture. Family was more important than privacy for aboriginal people.

Aboriginal people recognized that dominant culture models implicitly separate subject and object, knower and knowledge, less common among aboriginal philosophies, which are more participatory and cognizant of ideas of interconnectedness and embeddedness. Aboriginal elders would never agree that illness is entirely biological. Within aboriginal knowledge systems, knowledge arises within a knower, not separated by a rationally measurable distance. Knowledge does not exist outside of a subject. Aboriginal people therefore tend to feel “objectiﬁed” when viewed within the gaze provided by current biomedical models.

Participants noted that a preferred model was a more balanced holistic model, delivered by

competent aboriginal providers, that is both ﬂexible to value differences and responsive to the local social environment. Providers must show respect for the land, the people, and, above all, the elders (Darou 2000).

Values

Although values differ from culture to culture, participants emphasized the importance of values being congruent among providers and recipients of services. Value differentials can cause considerable difﬁculty for people from any culture. Efﬁcacy may be greater, when physicians come from the same value system as their patients compared to differing value systems.

Participants agreed (Trimble et al. 1996) that “Indian clients undoubtedly will express values that are inconsistent with, if not disparate from, those of a non-Indian.” Values they ascribed to aboriginal clients included cooperativeness, concreteness, noninterference, respect for elders, organization by space instead of time, collectivity versus individualism, social astuteness, stoicism in face of hardship, and self-control.

Participants thought that providers should stay open to differing values, be able to recognize value conﬂicts, and be able to help clients negotiate value conﬂicts. They noted that the inﬂuence of elders is common to most aboriginal groups and overrides all other considerations. Participants mentioned the importance of the seven guiding principles of elders listed by Benton-Banai, which included love, respect, wisdom, bravery, honesty, humility, and truth (Benton-Banai 1988). In agreement with Darou, they proposed that service delivery for aboriginal people should be based upon these principles (Darou 2000). Translation of these principles into practice was seen as problematic because aboriginal values of service and commitment to relationships and community go against the grain of individualistic, dominant cultural values upon which so many services are organized, especially in the USA, where health care is for proﬁt.

Practical Considerations

Participants noted that clients do not have the luxury of choosing their own health-care provider in many remote and rural communities. They thought that the collectivism found in communities would work against individualist models of health care. For example, diabetics often eat poorly because they will not suffer the loss of contact that would come from cooking differently for themselves than for the rest of the family. Contact over meals is important in aboriginal communities, and eating different foods from everyone else would be insulting. Similarly, culture has evolved so that nontraditional foods are now seen as traditional – bannock, fry bread, and other European-derived grains. People may be eating nontraditional foods that worsen diabetes and other illnesses in the name of being traditional.

Participants said that people might not have the luxury to engage the individualistic health-care model since they are already struggling to meet the day-to-day survival needs of their family group. Discussions led to participants concluding that health-care providers are often confused by what they perceive as resistance and noncompliance on the part of patients, who in the providers’ minds should be taking better care of themselves. Providers do not realize how busy and engaged their patient actually is in taking care of the family and how offered treatments may not have cultural or family support. Caring for oneself is usually at the bottom of an aboriginal person’s priorities. Caring for children and elders comes ﬁrst. This is often not understood by providers from other cultures. Health-care decisions are made by families and especially by the elders in those families, which providers also do not recognize. Excluding elders from medical appointments (by ignoring them, making them feel unwelcome, or not scheduling during times when the elders can come) causes treatment to be rejected.

Participants stated that health-care providers should be aware that personal and even spiritual development may be prerequisites to successfully addressing a physical illness – a reality that lies completely outside the contemporary biomedical model, true since described by Hallowell in 1955 (Hallowell 1955).

Participants noted that aboriginal patients could potentially perceive all non-aboriginals as racist and interfering proven otherwise. Healthcare providers coming into a community with patronizing attitudes or missionary zeal tend to undermine their perceived empathy, trustworthiness, and respect for the patient.

Role Models

Participants noted the asymmetrical power relationships between groups and within groups. From this viewpoint, culture is constructed as the more powerful and the less powerful segments of society contend for positions of power and privilege between themselves. Health care will never satisfy all subgroups, but minority voices should be heard, especially in communities in which the minority is the majority. These voices should be the primary organizers of service delivery. A sense of community may emerge from recognition of diversity and celebration of multiple voices so that we can feel comfortable speaking without fear of reprisal or oppression.

Learning styles also differ between Euro American and North American aboriginal cultures. Euro-American parents seem to reward their children for successive approximations of desired behavior (shaping); aboriginal parents appear to teach their children primarily through modeling (Brant 1990). The learner observes the teacher multiple times. When the teacher considers the learner ready, the opportunity to practice the skill is made available. For example, a friend, Donnie, could clearly lead a yuwipi ceremony, having assisted so many times. Yet, his teacher has not yet said he is ready, so he waits patiently for that permission. He has, of course, done all the required preparation to become a leader, but he must wait until he is told that it is his time to lead. This would not be common practice in Euro-American culture. When he does lead, his ﬁrst attempt will be almost perfect. Such modeling also serves to increase attachment to elders and to promote group cohesiveness and continuity. Biomedical health care is based more upon shaping behavior than upon modeling behavior. In fact, physicians’ own health promotion behavior may be abysmally poor. Elders request the youth to “do as I do.” Biomedicine emphasizes, “do what I say, not what I do.”

Participants universally endorsed spirituality as an important component of all services received by aboriginal people in agreement with Peavy (1995). One of Peavy’s informants said, “We have a special relationship with the land, with ancestors, with our community and with nature. To achieve harmony is sometimes more important than anything else” (p. 3). Participants were strongly in agreement with this concept.

Healing Colonization

Participants’ discussions paralleled Fanon’s (1967) description, as the colonized person begins to master the language and ways of being of the colonizer; in the world of the colonizers, the colonized person imagines herself becoming more free. As she masters the language and culture of the colonizer, the colonized person hopes to be seen as more human by the colonizer. At the same time, the colonized person becomes more alienated from her own people. Du Bois (1903/1989) described this phenomenon as a double consciousness in which the colonized begins to judge her own behavior, actions, looks, and relationships by the standards of the colonizers. Fanon wrote that colonized people judge relationships and themselves by a third force consisting of European norms and values. In this way, the norms of the colonizer are in the middle of their lives and relationships. This can be seen prominently in Canada through the effects of the residential school experience on sexuality, ambition, self-esteem, and life goals.

Participants agreed with Akinyela (2002) that having an awareness of the effects of everyday racism is critical to the development of a culturally appropriate health services. It can be tiring for aboriginal people to continually face and deal with racist assumptions, actions, structures, and practices. For example, at a recent reception following a lecture, a well-meaning cardiologist asked, “What do you think of the employers’ claims that you cannot employ First Nations people because every other Friday when they get paid, they disappear for a week.” Wearily an associate responded, “That hasn’t been true for generations. Our young people are responsible workers.”

The Ideal Model

Participants mentioned that the ideal model for health-care service delivery is humanist, value driven, community oriented, and spiritual. It incorporates local culture, knowledge, and practice as it is reﬂected in the community today. The approach is consistent with the four dimensions of the medicine wheel and with Roger’s three conditions, particularly respect (Rogers 1957). It takes a service orientation toward the larger community and considers issues of community cohesion. It takes into account social causes of medical problems, especially economic disparities.

Participants noted that the emphasis on story as a key metaphor informs indigenous approaches. The telling of stories is a very signiﬁcant part of aboriginal culture. Perhaps most relevant is the recognition of the complementary roles played by the storyteller and the audience. Akinyela (2002) writes about African culture and storytelling, noting that the story is only complete when there is both a teller and a witness to the story. In fact, he says, “it is this call and response interaction between the storyteller and the witnesses that actually makes the story and gives it meaning. The story is created through the process of the call and response. The meaning of the story is created in the dialectic or relationship of call and response, of storyteller and witness. In the USA, if you attend any charismatic black church, you are likely to see this process in action. Those leading the ceremony are consistently joined by the witnesses who sing, call out, and respond in a variety of ways to cocreate the rhythm and the meaning of the stories that are being told.” Story emerges as a more powerful metaphor for health education and instruction than the conventional didactic instructions given in contemporary medicine.

In aboriginal traditions, ethical decisions and the construction of meaning occur through dialogue, through conversation, and through the telling of stories and acknowledging that every story carries multiple meanings. Akinyela (2002) describes a similar process for African cultures. Participants noted that health-care provider and recipient are engaged in a joint process of divining meaning and creating alternative meanings in relation to the events and stories of people’s lives. In this way, the question of meaning is vitally important. This is what contemporary medicine misses – this need to pursue meaning as part of health. The educational theorist Paulo Freire noted that an experience of oppression is one in which the meaning, interpretation, or cure is imposed upon people who come for assistance.

An especially helpful chart prepared by the Swinomish Tribal Mental Health Project describes aboriginal values of family orientation, spirituality, respect for elders, and putting the community before the individual.

Traditional elders consistently point to community as the basis for ethics. They believe that indigenous people are embedded in families. Ethical decisions should be made through dialogue arising from relationships and not from abstract principles as is promoted in mainstream North America. When relationships are disturbed, the potential for ethical decision-making is compromised. Local knowledge is crucial for making correct decisions for that place at that time and those people. Ethics cannot be codiﬁed or turned into abstract principles. Ethics are always for the purpose of securing or improving the life situation of everyone affected in the locale where they are affected.

Difﬁculties arise when dominant culture practitioners impose their ethics and values upon aboriginal people. In every era, those from the dominant culture were completely convinced of the correctness of their ethics; yet the practices of the past resulted in conquest, widespread genocide, abrogation of treaties, the reservation experience, and the ﬁnal insult of residential schools’ experience cannot be ignored (Colmant et al. 2004; Duran and Duran 1995; Lux 2004). Contemporary aboriginal people are justiﬁably skeptical of the ethics of mainstream America. In the residential school experience, children were removed from their homes at ages 5, 6, and 7; placed in overcrowded “schools,” mostly operated by the Anglican or Catholic churches; forced to work to maintain the school; disallowed contact with their families and cultures including punishment for speaking their language; and often suffered physical, sexual, and emotional abuse.

These practices lasted from the 1880s well into the 1970s. Currently, lawsuits have resulted in claims being paid by the perpetrators and the government of Canada to First Nations people, but these monetary payments do little to change the long-term effects of residential schools. The USA has largely ignored claims related to residential schools.

In Canada, the Indian Act, enacted in the 1870s and continually revised and modiﬁed until the 1960s, denied indigenous people the opportunity to own land, run businesses, or to be educated (Lux 2004). It gave the Indian agent authority to control virtually every aspect of an indigenous person’s life, including marriage, sexuality, and religion. Traditional ceremonies were made illegal. Today, aboriginal people are the poorest in North America. Since real estate is a primary way wealth is deﬁned and distributed, the act of preventing a people from owning real estate while allowing Europeans to claim the land guaranteed a culture of despair.

Elders ethics study. LMM conducted a study of aboriginal elders that led to some understanding of aboriginal ethics (Mehl-Madrona and Kennedy 2009). He used a method of intuitive inquiry (Anderson 2008) to explore elders’ beliefs.

Ethics begins with listening. Primarily, elders believed that ethics begins with genuine listening. One elder said, “People tell you what needs to be done if you listen.” Ethics and ethical decision-making arises from dialogue, which means “talking in order to listen.” Within that listening, the elders spoke about capturing the stories that lead to ethical decision-making. All behavior is framed within stories. When we have everyone’s stories, we can understand what everyone is thinking and feeling, what the operative beliefs and desires are. Then we can negotiate so that everyone feels respected and heard. Elders spoke about suffering existing within the context of a story, for all we are is story. In explanation, they said that all that is left when we die are the stories told about us. They believed that the self that we believe we are is just the story we tell ourselves to make sense of all the stories that have been told about us. The story lives us as we live the story. They stressed that to understand a situation, it is necessary to contextualize it within all the stories that are being told. To make an ethical decision, we must hear as many stories that are being or have been told about the situation as is possible. We can never hear them all, but the more we hear, the more ethical we can be.

Several elders commented that most of the professionals they met were convinced of the superiority of their ethics compared to that of the elders. When they encountered these attitudes, the elders acted “stupid.” To them, ethical decision-making involved listening, which implied respect, and respect mattered.

Ethics is relational. None of the elders believed in abstract principles. They believed that good decisions arise through a process of relational, social interaction. They saw each person as contributing importantly to a ﬁnal decision. They saw ethical decisions arising through interaction of all shareholders in the outcome, through a process of dialogue, embedded in long-term relationships. The elders did not need books or case examples to arrive at their conclusions.

The elders believed that we construct a story about problematic situations based upon the results of our reﬂections, and then we perform that story in the world. They agreed that the performance of our story gives us corrective feedback from the others whom we encounter that can steer us in the right direction. They did not believe in a truly correct decision could occur without interacting with others to get feedback about the story we are constructing.

Ethics consists of helping people ﬁnd their own solutions rather than telling them what to do. The elders were consistent in their belief that imposing an answer on someone or a family or a community was decidedly unethical. People must ﬁnd their own answers. They must be empowered to receive their own divine guidance. They believed that the helper or elder was only present to facilitate the conversation. The elders’ perspective was consistent with the view that increasing emphasis on the individual in communities and increasing isolation of problems from group concern lead to social disruption and consequently prohibit the formation and utilization of the necessary social relationships for the development of local solutions.
Ethics requires selﬂess of intent. Time and again, the elders emphasized the power of intent and the need for selﬂess intent. For some, it took the form of never proﬁting. All insisted that it was necessary to hold the highest good of the person or people involved in the question in the highest light above all considerations of personal reward.
Ethics must be independent from politics. The elders were insistent that laws, politics, and the medical establishment could not inﬂuence making the right decision.
Empowerment is better than instruction. Empowerment leads to people making their voices heard, regardless of other considerations. When all voices are heard, then the right action can result from that dialogue.
Ethics exist within community. Community contains the wisdom, which the individual lacks. Collective minds offer more wisdom than individual minds. This is why, some elders said, ceremony is done with more than one person. Everyone’s prayers and intents matter.
Ethical decisions are ultimately spiritual decisions. The goal for all deliberations was to connect with the spiritual dimension and to receive guidance and direction. The spiritual dimension represents the “deepest” level from which guidance can be received. The spirit’s willingness to help was a necessary ingredient.

Case Studies

Nancy was a 25-year-old pregnant woman who was quite psychotic. Sometimes she didn’t believe she was pregnant and other times she did. The GP and the social workers worried that she wouldn’t know when she went into labor and wondered if they should invoke guardianship on her and control her behavior during the last part of her pregnancy. A talking circle was held with an elder who wondered out loud if Nancy didn’t always go for medical care when she felt a pain. Her physicians agreed. A talking circle proceeded and everyone reached consensus that Nancy would go to the clinic when she had pain, whether or not she thought she was pregnant, and whether or not she thought she was in labor. Nancy’s family rallied around her, caring for her 24 h × 7 days per week. The family planned to absorb the baby until Nancy was able to care for it, and so no problems at all. The problems were all those perceived by ofﬁcials in the health-care service as quite severe, but the family wasn’t concerned at all. They had all met and discussed things and were quite prepared to take over managing Nancy’s life and baby until she recovered or as long as it took. The members of the health service staff were quite uncomfortable with this plan without legal orders, but the family (her parents, the baby’s father’s parents, the grandparents on all sides, brothers, sisters, aunts, uncles, cousins, etc.) could care less about the courts and the law; they simply planned to step in and do what was required for as long as was required. The gulf between ethics system was obvious in that the non-aboriginal people believed that rules and laws were required and the aboriginal people believed that families take care of their own and laws were superﬂuous. In the end, the health services people could not get orders in time and the family did what they said they would do, and in six months Nancy was no longer psychotic and was still surrounded by her family and was taking care of her baby.
Vanessa was in the throes of mild cognitive impairment, close to dementia, and wanted to give away all her money. Her social workers didn’t think this was a good idea because she would not have any money left to care for her in her later years. They wanted a guardianship for her to protect her money. The family’s solution was to get together everyone in the community and let their mother give away the money and have people in the community give it back. This seemed perfectly logical to everyone for it matched the “give-away” culture that was so familiar to everyone. In Vanessa’s culture, it was acceptable and desirable for people to periodically give away all their possessions to others knowing that others would do the same and that possessions would return. The sense of ownership was quite different. The government social workers were appalled at this solution, but the community was content. The social workers couldn’t believe that anyone would give the money back and the family couldn’t believe that anyone wouldn’t. Luckily for the family, the government legal system moves so slowly that their plan was working long before orders were written by a judge.
A conﬂict arose on the reservation in which a younger sister wanted to send her brother to residential treatment off the reservation. The social workers thought this was a good idea because her brother had inhaled too many solvents and had some brain damage and wandered around the reserve and didn’t care for his house very well and seemed somewhat aimless and possibly dangerous to himself. His other relatives called a community meeting and didn’t want the young man removed from the community. They thought he would be easy prey in the big city. They also questioned the motives of his sister for wanting his house. A circle was called for discussion and the consensus that was reached was that the young man was better off being maintained in the village on the reservation. His sister would just have to wait for another opportunity to have a house. Community members volunteered to help him. The owner of the one restaurant in the village offered to provide him food and the family agreed to maintain a bill with the owner so the young man could come and eat and not have to worry about whether or not he had any money. They negotiated that he could only eat mostly nutritious food. Other community members agreed to keep an eye on the young man and make sure he didn’t wander too far away into the bush. A resolution was reached that was satisfactory to everyone but the young woman who wanted a house. It was implemented more quickly than the social workers could protest and eventually even they realized the plan was working and was as good as one could get. Family members volunteered to help manage the repairs on the house and monitor its condition.

Conclusion

Ethics are different in aboriginal country because of community relationships, extended families, and different values. Aboriginal ethics work, and non-aboriginal service agencies could do well to realize this and to work with aboriginal stakeholders rather than to attempt to externally impose a rule-based ethics upon aboriginal people that is blind to relationships and community and how these factors change the ﬁeld of negotiation.

Biomedical health care was developed within a Eurocentric paradigm and perspective that has largely ignored these differences. For example, sole reliance on “evidence-based medicine” could be considered unethical by aboriginal people. The concept proposes that correct methods of treatment for any deﬁned group and illness exist without regard for context and cultural differences and that these are best determined by large, anonymous, randomized, controlled, clinical trials. The concept permits dominant culture physicians to believe that their way of delivering health care is the only way and all must adapt to them. The concept of “outcome-based medicine” would be more suited to negotiations with aboriginal people, in which we can combine traditional practices, cultural preferences , and outcome studies to result in approaches to health care that work optimally in aboriginal settings, regardless of whether or not we can explain why they work (e.g., as traditional cultural healing practices).

Blanchard, from his book, Ancient Ethics for a Modern World, summarizes the differences in ethical systems well:

Conventional ethics courses have taught me many rules, that if followed, would guard conﬁdentiality, establish healthy boundaries with patients, safely store patient ﬁles, alert me to the risks of pro bono care, and instruct me on how to properly transfer patients, among many other mandates. But only occasionally did the courses and guidelines invite me to think things through reverentially. I noted there was a legalistic quality to my earliest ethical instruction which served as an exoskeleton of support but didn’t instruct me on how to think about my thinking. It was timely ﬁrsthand exposure to indigenous people on several continents, however, that ultimately opened my eyes to ancient wisdom traditions that not only could help to prevent professional mistakes and professional impairment, but could improve the quality of my life….

This paragraph exposes some core differences in values, many of which are underappreciated by those from the dominant culture. Our current concepts of privacy are uniquely European derived, probably from living life in large urban environments. Privacy is a class concept, for the poor have little, while the wealthy can buy it. Collectivist cultures that diminish the importance of the individual also diminish the necessity of privacy, for keeping information secret undermines the common good. Privacy is, of course, a necessity of competitive capitalism in which we are competing to sell goods and services and do not want the other side to know how we have developed or constructed our product or what we actually do in our services, lest they duplicate us and undermine our market share. Collectivist societies in which the common good predominates have less need for the protections that preserve competitive capitalism. Mehl-Madrona (2003) wrote about his ﬁrst impulse, as an aboriginal physician, to bring everyone whom the proposed patient knew to the appointment to consider the problem. Rather than hide the problem in a private visit with one other person who is considered to “have” the problem, Mehl-Madrona proposed that healing resulted from everyone sharing the problem and relieving the “patient” of the burden of sole proprietorship. European versions of this idea are found in the family therapy literature, the practice of Open Dialogue that began in Northern Finland, and in the group therapy literature. Aboriginal people can go so far as to believe that the sick person is suffering on behalf of the entire group, taking the burden of harmony and imbalance into his or her own body, for the good of the community, and therefore, needs the ministering and care of the entire community to achieve the healing. Everyone in the community must look within to determine what he or she contributes to the person’s illness, regardless of whether he or she is sick. Privacy serves what a Lakota elder has called homo economicus, the species of human whose primary motivation is greed.

Aboriginal people have difﬁculty understanding conventional medicine and psychology’s prohibitions against giving free care. Elders frequently say that one should never charge for healing; no price could ever be set. The practice in many aboriginal communities is to make gifts (which can be monetary) to elders who help people reduce their suffering, but no menu of services or price lists exist. Conventional medicine considers this unethical, even as it prohibits acts of kindness toward those who suffer. Ethics courses teach that it is unethical to give someone with whom we are working a ride home if he or she has none. Likewise, it would be unethical for us to feed them a meal if they were hungry. All these practices undermine the hierarchical boundaries between professional and client. Aboriginal cultures are more tolerating of multiple roles that a healer might have with another community member – so-called dual relationships. The emphasis is on the correct performance of each role carried rather than the insistence on having only one role.

Further cross-cultural dialogue is needed to clarify these differences in view points, but the recognition of valid differences is a good beginning. These differences come to the fore when conventional Western health care encounters aboriginal people and their knowledge systems. Attempt should also be made to recognize and label acts of moral imperialism and ideological colonialism – what Megan Bang has called “cultural genocide.” Through dialogue people become aware of the differences in how various groups perceive the world and envision the right and the wrong way to do things.

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