Why Cultural Humility Requires Metaphysical Competency: The Duality of Clothing and Unclothing in the Hospital
Joseph Swindeman, Saint Louis University, Saint Louis, MO

Cultural competency has been a long-standing qualification of clinical ethicists for the American Society of Bioethics and Humanities (ASBH). Nevertheless, as cultural education programs were developed for clinicians, these programs were subject to significant criticisms from anthropologists and critical theorists. Shortly, by teaching cultural knowledge using stereotypes, competency programs have failed to respect the dynamic aspects of culture and undermined patient centered care. Furthermore, these critics have shown how cultural competency fails to address the way hospital culture sees itself as a non-cultured entity, yet is conditioned by western culture, and so comes into conflict with non-western cultures. The strength of this critique required ethicists to reconsider whether competency is a helpful concept for describing the skill set ethicists use when engaging their patient’s culture. The most prominent alternative to competency is a model of cultural humility, which seeks to recenter the focus of cultural engagement on the patient. In this new model, the culturally humble clinical ethics attends to particular patients by asking them questions about the meaning of their culture, instead of imposing learned stereotypes. This shift from cultural competency to humility should be a welcome step forward in the development of clinical ethics because cultural humility succeeds in reconnecting clinicians with their patients as unique persons. Nevertheless, my position is that cultural humility is not a sufficient model for clinical ethics because it fails to adequately address the dynamics introduced to the clinical encounter by the physician’s culture. To attend adequately to the patient-physician relationship, clinical ethicists need to attend to the particular enculturation of both the patient and the physician and recognize how their cultures are obscured by medical culture. Cultural competency has been a long-standing qualification of clinical ethicists for the American Society of Bioethics and Humanities (ASBH). In the face of significant criticism coming from anthropologists and critical theorists, cultural humility has been proposed as an alternative model. This paper will perform an immanent critique of cultural humility by demonstrating how its opposition to competency has introduced a dialectic between activity and passivity. But the juxtaposition between competent clinician, who actively imposes cultural stereotypes upon patients, and the humble clinician, who passively receives the particular enculturation of the patient, is far too. Indeed, this juxtaposition has obscured how the activity of becoming passive before the patient can harmfully deculture the clinician when cultural humility is one-sidedly focused on the patient. This deculturation is only a more subtle form of the current grammar of the hospital that requires all its participants (both patients and clinicians) to remove the marks of their culture and wear a uniform before entering the clinical space. In this paper, I will first argue that unless the clinical ethicist attends to both the culture of the patient and the clinician, they will inevitably obscure the cultural dynamics at work in mediation and potentially harm the clinician. Then, I will argue that, while we cannot abandon cultural humility, clinical ethicists must develop the metaphysical competency of discerning how cultural activity and passivity are at work in mediation to perform the task of ethics: discerning how particular agents can cooperatively seek their common good.