How do racial and religious differences create hidden challenges in the doctor-patient relationship? April Thant Aung explores this question by analysing the play ‘Good People’ (2007) by the Singaporean playwright Haresh Sharma.
Medical establishments are typically perceived as clinical sites for scientific operations. Yet, this reductive view disregards the wide range of cross-cultural encounters that take place every day in the clinic, especially in societies with increasingly diverse populations, such as Singapore, the United States and the United Kingdom. This is because it fails to recognise the unique socio-cultural contexts that frame each patient’s illness experience (Ye 2018; Thomas 2017; Burns et al. 2021).
In this article, I use Haresh Sharma’s Good People (2007) as a case study. Inspecting this play closely, I hope to reveal how Sharma presents a clinical space that is overlaid with a web of complex and overlapping socio-cultural forces. Hopefully, this will invite readers to reflect on the thought-provoking questions that Sharma raises about the impact of racial and religious differences on the doctor-patient relationship.
Racial and religious dynamics in Singapore
The racial dynamics in Singapore are particularly complex. Singaporeans are stratified into racial groups according to the Chinese-Malay-Indian-Others (CMIO) model. Among them, the Chinese ethnic group constitutes the majority of the population, followed by the Malay and Indian ethnic groups. The country is also religiously diverse. A large proportion of the population have one of the following religious affiliations: Buddhism, Christianity, Islam, Hinduism, and Taoism. As for the remainder, they are either without any religious beliefs or practice other unspecified religions.
Cross-cultural encounters in Good People
Haresh Sharma’s play Good People (2007) explicitly explores contemporary issues specific to multi-ethnic, multi-religious Singapore. The play begins with the arrival of Radha Krishnan, an Indian Hindu patient with terminal cancer, at Saint Theresa Hospice of Eternal Hope. Initially, she has a cordial relationship with both her Catholic Filipino doctor, Miguel de Alencar, who is also the director of the hospice, and her Malay Muslim nurse, Noorhayati Yusof (addressed as Yati in the 2007 performance at The Necessary Stage Black Box). However, the relationships between the three characters break down over the course of the play due to a series of conflicts brought about by racial, religious and cultural differences.
One of the triggers for this relationship breakdown is Radha’s decline of receiving chemotherapy. She declines chemotherapy because she believes her cancer-related pain is karmic. That is to say, she believes that suffering will absolve her of her sins and enable liberation from the cycle of death and rebirth in accordance with her Hindu faith. In contrast, medical practitioners, such as Miguel, typically view pain as a biomedical issue. In the play, however, medical concerns are overshadowed by the racial and religious differences between Radha and Miguel and the strain these differences put on their relationship.
The differences are brought to the fore through Radha’s insistence on using marijuana as her pain relief: as her pain becomes unbearable, the agony wears down her initial determination to endure the pain as a way of atoning for her karma. While Radha is aware that marijuana is an illegal substance in Singapore, she is frustrated by the ineffective pharmacological interventions, including morphine. Her continued demand for marijuana, in turn, exasperates Miguel who perceives her as a recalcitrant patient. Initially medical disputes quickly spiral into heated arguments about cultural and religious differences, because Miguel is unable to set aside his strong Catholic belief to empathise with his patient.
Clinical empathy and cultural humility
The tensions between Miguel and Radha escalate because he fails to realise that the situation demands a certain “cultural humility” on his part. Cultural humility is a term coined by Melanie Tervalon and Jann Murray-Garcia in 1998. “Cultural competence” broadly encompasses having an awareness and understanding of patients’ cultural background and the ability to respond to their cultural needs in order to deliver effective care. In contrast, cultural humility is a more rigorous concept. According to Tervalon and Murray-Garcia, it “incorporates a lifelong commitment to self-evaluation and self-critique, to redress the power imbalances in the patient-physician dynamic, and to develop mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations” (Tervalon and Murray-Garcia 1998, 117). The authors argue that the notion of the doctor as the expert must be “relinquished” in order to give precedence and importance to the patient’s narrative and perspectives (121).
Miguel’s attempts to engage with Radha sorely lack a desire to gain an informed knowledge of her cultural beliefs and values. Radha refers to the cultural practice of the use of cannabis by Hindu Gods as “[her] cultural right to consume this ancient herb” and “[her] divine right to continue this tradition of the Gods” (00:58:10) to justify her access to marijuana. Furthermore, Miguel repudiates her beliefs outright as “pagan” and “myths” (00:56:52). Cultural humility is a constructive force that would allow Miguel to distinguish opportunities to build rapport with his patient by exploring her cultural and spiritual beliefs by being attentive to her narrative, instead of being quick to rebut, to be able to probe beyond his superficial knowledge of the patient’s belief system.
It is crucial to note that the tenets of self-evaluation and self-critique in cultural humility are tethered to the specific aim of redressing power imbalances in the doctor-patient relationship. The tenets are explicitly linked to power hierarchy because of the vulnerable position that patients are placed within a medical setting. The power imbalance between the patient and the doctor is accentuated through the actors’ bodies during the verbal dispute.
Radha is seated on a bench in her ward pyjamas while Miguel stands a few feet away. When he firmly tells Radha to “think about what [she] has done”, he points his index finger at her and jabs it at her emphatically, as if he is reprimanding a child. The juxtaposition of the character of the doctor in a confrontational and domineering position next to the frail-looking character of the patient is a stark reminder of the vulnerabilities that patients are exposed to. Patients are vulnerable, because they depend on the medical and healthcare professionals who possess the expertise, knowledge and authority for their treatment and care. Without disregarding the challenges that the professionals face in caring for various types of patients, Miguel’s intransigent disposition nonetheless underscores the necessity of cultural humility for him to recognise that his clinical judgments are modulated by his beliefs. Miguel repeatedly diminishes the legitimacy and sacred quality of Radha’s beliefs from his position of power and authority. These acts are especially detrimental to the patient in the context of end-of-life care where belief systems are pivotal to making sense of her illness.
Miguel’s exercise of cultural humility could take place through the inclusion of allied health workers in the hospice or a multidisciplinary approach to patient care. At the end of Radha’s rumination about her cancer as a karmic disease, Miguel simply defers the dialogue to a religious leader. He may be hesitant to engage with Radha’s religious beliefs due to his lack of prior knowledge of Hinduism. However, deferring the dialogue to a religious leader is not the solution as he simply hands over the issue to another person instead of working together with the patient to address it. One of the ways to navigate this complex and delicate scenario is to include the religious leader in his conversations with Radha. This three-way dialogue creates an open and supportive atmosphere where the patient has the space to express her beliefs and be understood and the doctor is no longer the reigning authority but a participant of the conversation learning about his patient’s beliefs.
Conclusion
Illness does not exist in a cultural vacuum and is not a purely biomedical matter. The illness experience is mediated and shaped through the different embedded cultural practices of ethnic groups. Diverse stories of sickness expose us to various cultural myths, attitudes and assumptions that form the basis for the way patients deal with their illness and navigate through the illness experience. Good People demonstrates that cultural humility is an indispensable skillset that needs to be consciously exercised to manoeuvre the racial and religious differences that permeate all clinical spaces and develop a good doctor-patient relationship. Cultural humility is paramount in this age of diversity, and end-of-life care where technical competency alone is no longer sufficient as religious and spiritual beliefs come to the fore in patients’ illness journey. A non-paternalistic approach and multidisciplinary team that exercises cultural humility are necessary to administer holistic care for patients rather than strategies of avoidance.
About the author
April Thant Aung is a PhD Candidate at the Medical Humanities Research Cluster, Department of English at Nanyang Technological University, Singapore. Her research interests are in the intersection of medicine, theatre, literature and medical education. She has published in the Journal of Medical Humanities. Her book chapter “HIV/AIDS on stage in Singapore: Mass media and stigmatising discourses” was recently published in The Routledge Companion to Performance and Medicine (2024).
Acknowledgement
An earlier version of this article appeared as part of: “Theatre as a Site of Resistance in Haresh Sharma’s Good People: Questioning Authorities and Contesting Truths in the Clinic” in the Journal of Medical Humanities.
References
Burns, Rachel, Claire X. Zhang, Parth Patel, Ida Eley, Ines Campos-Matos and Robert W. Aldridge. 2021. “Migration Health Research in the United Kingdom: A Scoping Review.” Journal of Migration and Health 4: 1–10. https://doi.org/10.1016/j.jmh.2021.100061.
Sharma, Haresh. 2007. Good People. Directed by Alvin Tan, The Necessary Stage, Black
Thomas, Mary B. 2017. “Cultural Competency Is Essential in an Increasingly Diverse Society.” Hospital Case Management 25 (4): 45–60.
Tervalon, Melanie, and Jann Murray-Garcia. 1998. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” Journal of Health Care for the Poor and Underserved 9 (2): 117-125.
Washington, Karla T., George Demiris, Patrick White, Holly C. Mathis, John E. Forsythe, and Debra Parker Oliver. 2021. “A Goal-Directed Model of Collaborative Decision Making in Hospice and Palliative Care.” Journal of Palliative Care 37 (2): 120–124. Available online at https://doi.org/10.1177/08258597211049138.
Ye, Junjia. 2018. “Differential Inclusion through Social Assistance: Migration, Precarity, and Diversity in Singapore.” In Relational Poverty Politics: Forms, Struggles, and Possibilities, edited by Victoria Lawson and Sarah Elwood, 43–60. Athens: University of Georgia Press. Available online at https://www.jstor.org/stable/j.ctt1vhtrdj?turn_away=true.
