Ms. X, a G2P1 23-year-old pregnant Navajo woman, came with her mother to an Indian Health Service clinic on the Navajo reservation. Her complaint was a bloody discharge for 1 week, and Ms. X and her mother were very concerned. The patient had been receiving regular prenatal care but had missed her last appointment. There was a slight language barrier, as her primary language was Navajo. Ms. X grew up on the Navajo reservation, and like the rest of her family, she utilized Navajo traditional medicine. She participated in Navajo traditional ceremonies and consulted medicine men and women, but she also sought medical care from providers of Western medicine.
A fetal gestational age of 23 weeks had been determined from Ms. X's last menstrual period. An ultrasound was performed, which showed no fetal activity and no cardiac activity. Further examination of the fetus revealed a gestational age of 17 weeks, according to femur length. The patient and her mother were informed of the ultrasound results and told that the fetus should be removed. They immediately requested a second opinion.
The patient received a second opinion from a medicine woman, who told her, “The doctor is lying, and the baby is alive. The baby had a hard time breathing but is fine now.” The medicine woman told the patient to wait 2 days and then return to the hospital, at which time the doctors would realize they were wrong. The patient returned to the clinic and reported the second opinion to the doctor. The provider proceeded to explain the findings of the ultrasound. Ms X. and her mother informed the doctor that they were very traditional people and did not appreciate the provider delivering such a negative statement. Based on the consultation with their traditional healer, they believed the baby was very much alive and well.
The ethical question
How can the provider handle this case in a way that both respects the patient's beliefs and practices and responds in a medically appropriate way to the death of the fetus?
Discussion
Medical indications In this case, the medical indications are based on the ultrasound results, which show fetal demise. This occurs in approximately 15% to 20% of clinically verified pregnancies,1 and current medical treatment— removal of the fetus to avoid further complications, such as sepsis, disseminated intravascular coagulation, depression, potential loss or failure of reproductive organs, and maternal death—is highly successful, in most instances with no sequelae.1,2 If the patient decides against removal, sepsis could develop and her future fertility could be at risk. These potential outcomes were explained to the patient, and she understood the risks involved.
Patient preferences Ms. X's preference is to receive care from both Western medicine providers and traditional Indian medicine providers. As someone from a Native American cultural background, she has the right to practice her cultural beliefs and traditions; but at the same time, the provider is obligated to keep the patient's best interests in mind. The provider had trouble understanding the cultural practices and beliefs of the patient. As Jonsen and colleagues note, “persons from cultural traditions differing from the prevailing culture may view the medical practices of the prevailing culture as strange and even repugnant.”3 When patient and provider do not understand each other's cultural practices, miscommunication is sure to occur.
The provider also assumed that the patient wanted to have another child. The provider informed the patient of all the potential negative outcomes of not having the fetus removed. The information distressed the patient somewhat, and her mother even more, and as a result they were unwilling to hear the provider's recommendations. Many Navajo patients believe “discussion of negative information to be a dangerous violation of traditional Navajo values.”4 However, from the viewpoint of Western medicine, “explicit and direct discussion of negative information between health care providers and patients is the current standard of care.”5 Their differences in cultural beliefs and practices could potentially lead the provider to question the patient's mental capability. The patient's belief about her pregnancy was based largely on her visit to the traditional healer. She was told that her fetus was viable, which convinced her and her family to disregard the Western medicine provider's assessment.
Quality of life Ms. X should have a high quality of life with treatment, which would lower her chances of 
devastating outcomes significantly. She is a young woman, and she has years to think about having more children. Her decision not to seek medical treatment for her condition could be very detrimental. She could possibly become septic and eventually die. She may not be able to carry a child in the future. This could affect not only her own well-being, but also her relationship with her partner if her partner wanted to have another child.
On the other hand, appropriate treatment could still render her susceptible to a retained product, infection, and other complications. If she were to proceed with the recommended treatment, it might also negatively affect her traditional Indian medicine beliefs and practices in the future. She could begin to question her traditional practices and the healers and wonder why the medicine woman told her that her fetus was alive. This might adversely affect her relationships with other family members who also practice traditional medicine. Navajo families rely heavily on one another for moral support.
This experience could also have a significant impact on the provider's view of traditional Indian medicine and could affect how the provider treats other patients in the area who follow traditional practices. Any resulting bias would put a strain on the provider-patient relationship. The provider is fully aware of the medical complications that could affect the patient's future quality of life.
Contextual features Traditional beliefs and practices are very important in this case. The patient clearly has moral support, primarily from her family. It is common in the Navajo culture for a person's decisions to involve the input of various respected elders in that person's family.
The clinical indications for fetal demise have been met. Therefore, according to medical standards, the pregnancy has ended and the removal of the fetus is necessary. The situation becomes controversial when cultural beliefs play a significant role in the patient's decision. The traditional healer's assessment contradicted the Western provider's assessment, and Ms. X's cultural beliefs were a major factor in her rejection of the Western medical provider's advice.
Other factors that could have played a role in the patient's decision include language barriers and education level. The patient's first language was Navajo, and she had not completed high school. These factors limited communication and understanding between the provider and the patient. Finances were not a concern; the patient was a beneficiary of the Indian Health Service.
Case analysis This case is an example of how different groups of people view health, medical care, and treatment. When health care providers have educated themselves about local culture, practices, and beliefs, such cases can be approached more thoughtfully. When the positions of the Western medical provider and the traditional Indian medicine healer contradicted one another, the provider knew that she could not discount her patient's cultural beliefs and practices. In this case, differences in cultural practices between the patient and provider raised the issue of whether or not the fetus was viable. The provider used the appropriate tools and methods to determine fetal demise. The patient-provider relationship could be impacted severely if disrespect became an issue. It is vitally important for providers to attain an understanding of traditional cultural practices that their patients might follow.