Decision-Making Across Cultures.

This chapter surveys the range of different orientations toward decision-making, common clinical scenarios, and considerations to bear in mind when caring for culturally diverse patients at the end of life. While this chapter draws on the cultural competency literature, its primary goal is to articulate an approach to end-of-life care that is rooted in cultural humility and structural competency. Medical providers, as representatives of the social institution of medicine, have their own cultural values that often come into conflict with patients' cultural values, especially when patients and providers have different unspoken visions of the "good death," or when patients wish to receive interventions that their providers deem futile. In the final section of the chapter, we seek to move away from this confrontational paradigm by analyzing two case studies of decision-making across cultures in order to empower providers to engage in value-based shared decision-making and thereby achieve goal-concordant care.

Black Lives in a Pandemic: Implications of Systemic Injustice for End-of-Life Care.

In recent months, Covid-19 has devastated African American communities across the nation, and a Minneapolis police officer murdered George Floyd. The agents of death may be novel, but the phenomena of long-standing epidemics of premature black death and of police violence are not. This essay argues that racial health and health care disparities, rooted as they are in systemic injustice, ought to carry far more weight in clinical ethics than they generally do. In particular, this essay examines palliative and end-of-life care for African Americans, highlighting the ways in which American medicine, like American society, has breached trust. In the experience of many African American patients struggling against terminal illness, health care providers have denied them a say in their own medical decision-making. In the midst of the Covid-19 pandemic, African Americans have once again been denied a say with regard to the rationing of scarce medical resources such as ventilators, in that dominant and ostensibly race-neutral algorithms sacrifice black lives. Is there such thing as a "good" or "dignified" death when African Americans are dying not merely of Covid-19 but of structural racism?

Earning Patient Trust: More Than a Question of Signaling.

Laura Specker Sullivan's article "Trust, Risk, and Race in American Medicine" is a philosophically grounded and highly practical call for medical professionals to take on the task of comprehending the sources of patients' mistrust. This is not only a clinical competence but also a moral obligation, in particular, when mistrust is warranted-as with African American patients who rely on medical institutions that have breached and continue to breach the trust of their communities. While Specker Sullivan focuses on how clinicians can signal comprehension once it has already been attained, I wish to step back and examine the nature of the efforts to gain knowledge. The effort to comprehend requires, at a minimum, the following actions: educating oneself about medical racism, examining one's implicit biases, and engaging, with empathic curiosity, with the patient or family members in the clinical encounter at hand.