AMA Journal of Ethics, February 2021 109
AMA Journal of Ethics®
February 2021, Volume 23, Number 2: E109-116
CASE AND COMMENTARY: PEER-REVIEWED ARTICLE
How Should Clinicians Respond to Language Barriers That Exacerbate Health Inequity?
Jason Espinoza, MD and Sabrina Derrington, MD, MA, HEC-C
Abstract
Patients and families with limited English proficiency (LEP) face barriers
to health care service access, experience lower quality care, and suffer
worse health outcomes. LEP is an independent driver of health
disparities and exacerbates other social determinants of health.
Disparities due to language are particularly unjust because LEP is
morally irrelevant and a source of unfair, unnecessary disadvantage.
Clinicians and health care organizations have duties to intervene, which
this article describes.
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Case
Dr J is a second-year emergency department (ED) resident physician who, during an
unusually busy shift, sees MM, a 13-year-old girl, accompanied by her father; this is their
third visit to the ED this week. MM, rubbing her belly, appears somewhat uncomfortable
but in no apparent distress. After 15 minutes of fumbling with an interpreter via phone,
Dr J realizes that MM and her father speak a language or dialect not available via the
interpreter phone service. The 3 navigate a broken English dialogue that seems to
reveal that, for 5 days, MM has had decreased appetite and abdominal pain, which was
most severe yesterday and since then has improved. Dr J’s physical examination of MM
reveals mild, diffuse, nonspecific abdominal tenderness that seems most consistent
with acute gastroenteritis. Dr J leaves MM’s room and confers with Dr C about a
treatment plan. Dr J returns to MM, suggesting she take acetaminophen for pain, and
arranges for MM’s discharge from the ED before moving on to another patient.
Two days later, MM returns to the ED with an abdominal abscess from a ruptured
appendix, in septic shock, and requiring urgent surgical intervention. Dr J wonders what
she might have done differently.journalofethics.org110
Commentary
MM’s story is one example of the many ways in which 25 million patients in this country
with limited English proficiency (LEP) experience inequitable health care, 1 sometimes
with devastating outcomes. LEP makes it more difficult for patients to navigate an
English-dominant health care system. In one study, Hispanics with LEP reported worse
access to care and health care status and received fewer preventive services than
English-speaking Hispanics. 2 Professional medical interpretation is effective in
improving care for patients with LEP, 3 but it is not always provided, despite its proven
efficacy and inclusion in professional guidelines and federal and state regulations. 2,3,4
This article examines barriers to interpreter availability and utilization, reviews the health
impact of language barriers, and describes ethical obligations for clinicians, institutions,
and health care systems related to improving care for patients and families with LEP, as
well as possible policy implications.
Health Disparities for Patients With LEP
Use of professional medical interpreters is associated with decreased health disparities
for patients with LEP, improved patient comprehension, fewer medical errors, and
greater patient and clinician satisfaction compared to use of ad hoc interpreters, such
as family members or bilingual staff. 3 Federal and state regulations require health care
organizations to provide trained interpreters for patients with LEP,4,5,6 but inadequate
interpreter staffing, functional limitations of video or telephone conferencing, and
interpretative inaccuracy cause persistent barriers to communication. 7,8,9,10 As in MM’s
case, a professional interpreter might not be available for less common languages,
dangerously limiting communication. Even when interpreters are available, some
clinicians choose not to use them11,12 or fail to use them effectively; one recent study
showed that only 23% of trainees received instruction on working with interpreters. 10
When communication barriers persist, patients with LEP are less satisfied with clinical
encounters, 7 have decreased comprehension of medication instructions, 7,9 and are less
comfortable with postdischarge care regimens.9,10,13 Poor communication also affects
clinicians’ understanding of patients’ complaints,7,13,14 which complicates diagnoses and
interventions, prompts inadequate or excessive testing, 7 and, when compared to
English-proficient patients, results in differences in length of stay 15,16 and increased
morbidity and mortality. 4,17,18
Although LEP is an independent determinant of health outcomes among adults and
children, it can overlap with other disadvantageous social determinants of health,
exacerbating disparities in health care access and health outcomes. Children of parents
with LEP are more likely to be uninsured, lack a medical home and specialty referrals,
and experience serious errors compared to children of parents who are English
proficient. 17 These disparities are further exacerbated in racial and ethnic minority
children18 and in children with special needs. 19
Linguistic Inequity
Health disparities related to LEP are profoundly unjust because LEP is morally irrelevant.
Language skills have no bearing on one’s personhood, value, or rights. Clinicians and
organizations have ethical and legal obligations to care for patients regardless of
language proficiency, ethnicity, or country of origin. Additionally, LEP is an unchosen
disadvantage. Immigrants to the United States are increasingly learning English, 20 but
individuals’ ability to do so varies, is complicated by numerous other factors, 21 and has
nothing to do with their need for or desert of health services. Justice requires thatAMA Journal of Ethics, February 2021 111
patients with LEP be able to access and receive the same quality of care as English-
proficient patients.
Patients with LEP experience both distributive injustice—poor health outcomes as a
result of decreased access to care—and relational injustice, which involves devaluation
of identities. Patients who do not speak English might be seen by some as outsiders or
as “other,” which makes it dangerously easy to devalue and depersonalize them and to
make damaging assumptions about unrelated attributes such as their intelligence,
religion, culture, or attitudes towards health and illness. “Othering” may be encouraged
by the frustrating challenges of accommodating language differences, such as the
additional time required to use a professional interpreter. 14,22 Correcting distributive
injustice requires ameliorating resource maldistribution, but correcting relational
injustice requires changing the structure and character of interpersonal relationships,
which in turn requires changes to social and institutional norms and practices. 23,24
Linguistic Redress
Although data show the importance of medical interpreters’ roles in care quality, positive
health outcomes, and cost savings, 3,25 many organizations still don’t provide adequate
interpreter services; only 13% of hospitals are compliant with all 4 National Standards
for Culturally and Linguistically Appropriate Services (CLAS) in health care. 26 Costs of
interpreter services tend to be inflated and their cost effectiveness
underappreciated, 4,7,27 which might lead payers to limit reimbursement and
organizations to limit services. Inconsistent, inadequate reimbursement remains a major
systems-level barrier to meeting CLAS standards. 4 Telephone and video interpreter
services offer a more affordable alternative28 but might not be adequate for all
languages and dialects, as in MM’s case. Additional limitations to remote interpreter
services include reliance on stable internet connectivity and an impersonal quality that
can hamper clear communication of complex health information, especially during
emotionally distressing encounters. A qualitative study found that clinicians’ choice of
whether to use professional interpreting services depends on time constraints,
subjective preferences, and therapeutic objectives. 12 Even when professional
interpreting is utilized appropriately for informed consent discussions, care conferences,
and daily updates, patients and families with LEP still receive a fraction of the
communication that English-speaking families receive from their health care team,27,29
which affects the therapeutic relationship between health care team members and the
patient and family, complicating shared decision making. 22,29,30
If distributive injustice can be redressed by increasing access to professional
interpreting services, correcting relational injustice requires restructuring health care
systems to develop bilingual competence and to recruit and hire more bilingual
clinicians. Patient-physician non-English language concordance has been shown to
improve a range of patient outcomes, including glycemic control, pain management, and
cancer screening adherence.1 Few studies compare use of trained interpreters with use
of language-concordant clinicians, but those that do indicate that language concordance
promotes question asking and patient empowerment and is generally preferred by
patients with LEP. 31,32 Fostering systemic changes in the health care workforce is a long-
term strategy with many peripheral benefits that could ultimately prove more
economically favorable than focusing on technology solutions.journalofethics.org112
Intersectionality
Patients with LEP often have other disadvantages, including limited financial resources,
and their communication difficulties may be compounded by lack of formal education,
vulnerability due to insecure immigration status, and mental health issues, such as
anxiety and stress. 14,18,33 Language barriers make it even more difficult for patients in
English-dominant environments to advocate for themselves, ask questions, and
navigate the nuances of health care systems that lead to better care. 34 Individual
clinicians should be attuned to these overlapping vulnerabilities and can make a
difference by listening to and advocating for patients. 35 However, meeting the complex
needs of patients and families with LEP is a shared responsibility across medical teams
and organizations. 36
Efforts to address health inequities related to language barriers should be situated in
and integrated with comprehensive efforts to improve health equity. 37 As one example,
researchers demonstrated that Latinx children in their hospital’s pediatric intensive care
unit (PICU) had a 3.7-fold higher risk of mortality than White and African-American
children after controlling for covariates, including illness severity, age, sex, insurance
status, and diagnosis. 38 In response, the hospital implemented a multilevel intervention,
including cultural sensitivity training for clinicians, hiring additional bilingual staff,
expanding the availability of trained interpreters in its emergency department and PICU,
making consent forms and educational materials available in multiple languages, and
expanding outreach to Latinx communities. 38 In the 3-year postintervention period, PICU
mortality for Latinx children dropped to a level comparable to the levels of White and
African-American children. 38 The striking improvement in outcomes achieved by this
multilevel system-wide intervention suggests a moral imperative for health care
organizations: first, to assess outcomes data by race, ethnicity, and language, and then
to act to address those disparities.
Why are these types of assessments and interventions not more widely employed?
Collection of data on race, ethnicity, and primary language is inconsistent and error
prone, and perhaps this is why organizations infrequently analyze their outcomes by
sociodemographic factors.39 Organizational leaders may doubt the existence of racial,
ethnic, or LEP inequity in their organizations, just as individual clinicians may deny the
roles of implicit racial, ethnic, or LEP biases in their practices, but health care inequities
and implicit bias are widespread. 40,41 System-wide change will likely require legislation
that creates financial incentives and that implements accountability for outcomes for
patients with LEP.
What’s Your Language Behind the Veil?
John Rawls, best known for his foundational work in justice theory, suggested that a just
society could best be designed behind a “veil of ignorance,” such that no stakeholders
would know what place in that society they might have. 42 Rawls’ thought experiment
reminds us that the circumstances in which we are born have nothing to do with our
worth or whether we deserve to flourish. So, with a veil of ignorance in mind, imagine
what it would be like to need health care for yourself or your spouse, child, or parent in a
country where you didn’t speak the language and where few health care clinicians spoke
yours. Imagine how vulnerable you would feel, struggling to navigate the untranslated
signage and unintelligible forms. Imagine having to wait for interpreting services to
connect via video or phone—or, if you’re lucky, in person—every time you wanted to
communicate concerns or ask questions.
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