Ethics and The Treaty of Waitangi
The provisions of the Treaty require that the Crown and its agents respect the principles of the Treaty. These principles, as enunciated by the Royal Commission on Social Policy, are partnership, protection and participation. The Treaty has been promoted as a suitable framework within which to consider social and economic development, which includes health. The difficulty for many lies in the translation of these principles into something concrete or tangible. What might these principles mean in relation to health?
Partnership refers to an ongoing relationship between the Crown, its agencies and Iwi. It means that Māori need to share in decision making about the nature of their health services, with this leading to increased Māori control over their own health.
Protection creates an obligation for the Crown to actively protect Māori and their interests. In health, this is about health promotion and preventive strategies, and it implies the State will seek out opportunities to enhance Māori health.
Participation is about equality of opportunity and outcomes, and emphasises positive Māori involvement in health care services at all levels.
True acceptance of diversity and the concept of New Zealand as one nation made up of many peoples are about awareness of, respect for, and the valuing of other cultures. There is a common misconception that culture is primarily about visible aspects such as clothing, customs, singing and dancing, language and physical appearance - the tangible or conspicuous aspects of culture. Much of culture (it has been estimated about 90%) is invisible or beyond conscious awareness. The invisible part of culture includes non-verbal communication, family life, social network, beliefs and world view, and concepts of health and illness. The translation of the Treaty principles into meaningful reality for Māori cannot be done without an understanding of the effects of culture on both the provider of health services and the recipient.
A more accurate definition of culture is that it is a system of shared understandings. In the provision of health services consideration must always be given to one of the most significant aspects of culture - communication, both verbal and non-verbal. At the point of interaction between healthcare professional and patient what steps will be taken to minimise the possibility of talking past persons from another culture? This may require the services of an interpreter, but more often, it will require the healthcare professional to have some understanding of the culture of the patient, and some skill in the use of reflective listening. Checking with the prospective participants that what they heard and understood is what the speaker intended prevents misunderstandings. If reflective listening skills are used, the incidence of missed communication in a bicultural situation is greatly reduced.
The principles of bioethics give integrity to our interactions as human beings these include respect for autonomy (respecting the dignity and independence of the individual), beneficence (doing good), non-maleficence (not doing harm) and equity (fairness). These principles are derived from the human nature we all share, and as such they are cross-cultural in their essence. The principles of the Treaty are also cross-cultural, because they too arise from the social aspect of our human nature. There is a harmony between both sets of principles which reflects their common origin in human nature. However the Treaty principles remind us that in the application of ethical principles we must always be aware of the filter of culture. Together these two sets of principles provide a substantial framework in which to plan, develop and evaluate culturally appropriate health services for Māori.
Sharron Cole is a Researcher for The Nathaniel Centre