If you are reading this, I suspect you are a human (our household felines, though brilliant in their own way, adamantly reject the value of literacy). You are classified homo sapiens sapiens in scientific nomenclature. Sapiens, indicating intelligence in Latin, repeats to emphasize our firm belief that we are doubly the smartest creatures on earth and to distinguish our subspecies from homo sapiens neanderthalensis and our other supposedly less intelligent cousins now gone extinct. You and I resemble each other genetically to a remarkable degree: whatever your gender, skin color, blood type, or preference for Star Trek or Star Wars franchises, we are virtually identical in those spiraled strands of chemical instructions. We are also identical in our opening and closing chapters, however brief, all first gestating in a womb and all eventually ceasing our rhythms of breath and heartbeat somehow. Knowing the inevitability of that cessation point motivated the writing of this book, because despite attempted escape into social media, high art, or sports fandom, that final moment will visit us all, whomever we are and from wherever we are. Precisely because it is such a perennial theme, our understanding of mortality warrants regular updates if we are to understand our common fate (Havik et al., Reference Havik, Mapril and Saraiva2018, p. xiii).

This book is about intercultural understanding, written in a time of wars and rumors of war, pandemics exacerbated by politics, civilian gun fatalities, and other recent additions to the many ways humans die. It’s intended primarily to address extreme situations of critical and terminal illness. Death joins us together in biological inevitability, because all humans die, but, as we shall see, this can be a time when cultures clash. Amidst our similarities, beyond genetics and mortality, we all eat, drink, need shelter, and poop, and we tend to crave company of some sort. That’s where the similarities end. We depart commonality via the practicalities of where, how, and why we live and die; the differences increase if we consider our beliefs and thoughts, especially surrounding death (e.g. Selin & Rakoff, Reference Selin, Rakoff, Selin and Rakoff2019). The details depend on when, where, and with whom you grew up: matters of culture. Those factors will shape all of the mind-boggling differences in human existence, as a culmination of generations who created and passed along their behaviors, beliefs, and technologies to us here and now. We have forgotten our commonalities, too often falling into conflict with our forgotten cousins who now embrace other ways of thinking and behaving.

The book provides some tools to understand how culture shapes us and why people of other cultures might think differently from us. The goal is to explain why cultural differences cause issues in healthcare and to give voice to cultures sometimes marginalized in standard healthcare practice. Humans naturally communicate best within their cultures, for reasons to be discussed, and the tendency to favor our own ingroups sometimes causes us to treat people unlike ourselves less favorably, a politically sensitive statement that will be documented later. Healthcare provision happens inequitably almost everywhere. Resources flow to wealthier individuals, groups, and regions who get better treatment. Dominant groups get better education and jobs. Unfortunately, cultural differences and misunderstandings can be particularly detrimental in situations of critical and end-of-life care because these are situations where people are less adaptable and their resources are tapped out. Intercultural understanding can help alleviate these issues.

In March 2021, as I first pondered how to present these concepts, a scandal arose around a podcast made for and distributed by the Journal of the American Medical Association, JAMA (Crist & Kalter, Reference Crist and Kalter2021). Ed Livingston, MD, flatly dismissed the existence of racism in medicine, despite extensive evidence of differential provision of care for and professional achievement of non-Europeans. Boucher and Johnson (Reference Boucher and Johnson2021) provide just one example of contradictory evidence, highlighting the disparity in hospice utilization between WhitesFootnote ¹ (53 percent), contrasted with Blacks (40 percent) and Hispanics (43 percent). More disturbing are disparities in treatment, with non-White patients receiving fewer visits from physicians and poorer-quality care (Rhodes et al., Reference Rhodes, Teno and Conner2007, Reference Rhodes, Xuan and Halm2012; Teno et al., Reference Teno, Plotzke, Christian and Gozalo2016). Disparity in care transcends social and economic status; tennis star Serena Williams, internationally beloved, nearly died after giving birth in 2017 (Lockhart, Reference Lockhart2018). African American women die at nearly three times the rate of White women after childbirth, with many of the deaths determined to have been preventable. In North Carolina, ethnic minorities and those diagnosed with intellectual disabilities and/or autism spectrum disorders are less likely to receive treatment and Medicaid Exemption support, reducing their access to care (Franklin et al., Reference Franklin, Bush, Jones, Davis, French, Howard, Greiner and Maslow2022; Ming et al., Reference Ming, Jones, White, Pritchard, Hammill, Bush, Jackson and Raman2022). Some care providers are reluctant to take on disabled patients at all (Iezzoni et al., Reference Iezzoni, McKee, Meade, Morris and Pendo2022), another area of discrimination.

The idea for this book arose in a discussion with a psychologist friend who survived cancer and, at the time, directed mental health services for the oncology units of a large hospital system. Despite best intentions, cultural differences frequently generate challenges in oncology and hospice care, as well as in other sectors of healthcare and life. Much of what and how health professionals are taught to think during training may include underlying cultural biases, and some of our practices will unintentionally violate the norms and beliefs of those we must help. Is it inappropriate to mention certain body parts (see Figure I.1)? Can a woman be touched, even on the wrist to take a pulse, by a male not of her family? Who can make a decision about treatment, the person or the family patriarch? Is that service dog a friendly delight to the children’s cancer ward or an unclean beast that defiles those it touches? How can we know what is helpful or offensive? Beyond cultural variation, individuals within cultures vary as well, making a comprehensive template or how-to guide impossible (e.g. Koenig, Reference Koenig2011). While there is no way to understand all the cultures one might encounter in healthcare or any other setting, we can develop sensitivity and honor the uniqueness of cultures while interacting with the specific ones we do encounter. This book provides some clues to dimensions of cultural variation that might help you navigate this complex terrain with slightly greater sensitivity.

Figure I.1 “Miracle of Nature” (Piraro, Reference Piraro2015), used by permission of the artist.

How This Book Works

Cultural issues form a growing problem in healthcare, driving a growing need for intercultural competence training, particularly in end-of-life and critical care when the stakes and pressures are highest (e.g. Semlali et al., Reference Semlali, Tamches, Singy and Weber2020). This book should enhance intercultural competence and provide insights to help medical and mental health practitioners in cross-cultural encounters, whatever their specialty, and for families and friends navigating the passage of loved ones. The task is daunting because we are not neurologically wired to see beyond our own cultural origins, something I have experienced by living in multicultural contexts and while teaching cultural psychology. These pages are designed to help you understand factors underlying cultural difference and how these differences shape ways people behave and the choices they make. You will encounter cultural processes you have almost certainly experienced, some as you learned your own culture in childhood, along with unfamiliar experiences or ideas you may encounter interacting with people from other cultures. Hopefully, you will gain more understanding of why the differences exist because familiarity statistically breeds understanding, not contempt. We will explore your assumptions and implicit biases by considering cultural dynamics and processes, then exploring some cultural beliefs and experiences in the domains of health and mortality.

I have struggled with inclusivity in this book as I do in my cultural classes. There are far too many cultures to include them all, but the point of the book is to provide tools for understanding. I selected examples and quotes I felt best illustrated useful and necessary concepts. The same limitation applies to sources and research; in pulling together research on healthcare and mortality from psychology, medicine, anthropology, sociology, social work, and so on, an overwhelming array of materials become relevant. I’ve winnowed several thousand sources accessed down to around 400 that seemed most relevant to the specific topic of intercultural understanding in healthcare. I wish there was more to ease your mind when dealing with death, but one book cannot cover everything to discuss around death; perhaps there is a sequel to follow.

We begin by discussing concepts and theories describing culture and cultural variation, providing insights into why people think and behave in particular ways. We will examine cultural processes common across cultures, such as interactions with family and friends, but those common contexts of interaction may function unexpectedly in cultures other than your own, demonstrating human diversity. We then turn to intercultural interactions because those often disturb our cultural safe-zones, and insight into differences in behavioral norms may be important to your professional work or personal life. The next modules provide an overview of how culture shapes our views of health, healing, and well-being.  Then, we turn to cultural perspectives on the great finality of death itself and how culture shapes our experiences and choices approaching the end. The finale looks at the arrangements and adjustments around and after death, hopefully bestowing a bit of solace while discussing the supports our cultures provide as we and our loved ones depart the world.