At its best, the patient-physician relationship is not simply a contract, but a covenant. Unlike a contract, the focus of a covenant is not on rigid duties and obligations, but on what the two parties can achieve together to optimize the patient's health. The physician's responsibility is to respond with commitment, empathy, and creativity, especially when the patient's health is at risk, as in the case of the 18-year-old female African patient.
In Covenant, Community, and the Common Good, Eric Mount builds on a Jewish philosophical tradition to describe the way a covenant relationship can accommodate the "vulnerable other."1 Like the groups that Mount discusses, the stranger, the fatherless, the poor, and the widow, this woman is vulnerable in that she may face considerable harm if left to confront her situation alone. Because this patient's experience of the world is so different from that of the physician, he or she may misperceive the patient's beliefs and attitudes. Due to this "otherness," her world is "accessible only to the extent that genuine dialogue occurs."
The difference between the cultures of the physician and the patient is a specific type of "otherness" that poses a considerable threat to communication. Many argue that applying Western concepts of feminism, sexuality, and human rights ignores the cultural values of the societies that participate in female genital mutilation (FGM). For example, Sudanese women may view infibulation as an "assertive, highly meaningful act that emphasizes female fertility by de-emphasizing female sexuality."2 However, it would be a mistake to assume that this patient supports the practice of FGM. There are wide variation in the beliefs of African women about this practice, and this patient's time in the United States may have further altered her perspective.
The physician must engage in a dialogue with the patient to discover her perceptions of FGM within her own community. I will consider 2 opposing responses to the question "What are your own beliefs about female circumcision?" to illustrate issues that may arise.
Response 1: I don't want to have the surgery! Please help me get out of this situation! This is a call to action to the physician, who could respond by referring her to African groups that work to replace or eliminate FGM. One project in Kenya offers a "noncutting ritual event" as a replacement for coming of age ceremonies involving FGM. If similar programs exist in the patient's home country, they might be a viable option. Referral to such a group could provide the patient with support and may allow her to avoid infibulation altogether. This simple step would empower the patient and help her to reclaim her autonomy. However, the patient might reply that she will nonetheless be obligated to undergo FGM to avoid ostracism and to be eligible for marriage. If she experiences this obligation as a form of coercion, the physician could help the patient to explore options such as political asylum.3
Response 2: Female circumcision is a tradition of my people, and I will not stray from it. In this case, the physician must realize that beliefs or values considered irrational in one culture may be rational in another, and remember that patients have the right to make informed decisions about their health. Regardless of his or her personal views, the physician needs to provide impartial information about different types of FGM procedures and the risks associated with them. The physician must also consider the legal, professional, and personal consequences of performing FGM. Physicians performing this procedure in the United States might face prosecution, since FGM is considered to be a form of assault under federal and state laws.4,5
Simply refusing to perform FGM would do nothing to resolve the patient's dilemma. The special covenant relationship requires that the physician offer alternatives to the patient. For instance, the physician could help the patient investigate the availability of trained health professions who are willing to perform FGM under sterile conditions in her home country. Mandara6 discusses the results of interviews with 250 Nigerian physicians, 20% of whom supported the medicalization of FGM, suggesting that this patient may find a similar alternative once she returns home.
A dialogue between the patient and physician is the foundation of providing a satisfactory response to the patient's status as the vulnerable other. What begins as an ethical quandary can then serve to provide empowerment to the patient. In the end, the vulnerable other is made less vulnerable, and opportunity is found in her otherness.
Brothers K. Covenant and the Vulnerable Other. JAMA. 2002;288(9):1133. doi:10.1001/jama.288.9.1133-JMS0904-4-1