Bridging the Gap (BTG) is a basic training class for aspiring or newer medical interpreters. ASL interpreters are welcome to take BTG, but the majority of BTG participants at LUNA are spoken language interpreters.
Early in the 40-hour class, BTG participants learn the Code of Ethics promoted by the International Medical Interpreters Association (IMIA) and the National Council on Interpreting in Health Care (NCIHC). In this Code of Ethics are seven common values: accuracy, advocacy, confidentiality, cultural competence, impartiality, professionalism, and respect.
For ASL interpreters, their guiding principles are strikingly similar. The National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf, Inc. (RID) have a Code of Professional Conduct that includes the guiding principles of: confidentiality, linguistic and professional competence, impartiality, professional growth and development, ethical business practices, and the rights of participants in interpreted situations to informed choice (NAD-RID Code of Professional Conduct).
At first glance, it may appear as if impartiality and advocacy are diametrically opposed. And it may pique one’s curiosity as to why “advocacy” doesn’t appear as one of NAD-RID’s guiding principles. But a more nuanced exploration reveals that impartiality and advocacy both have their place in medical interpreting and that a dynamic compromise known as Incremental Intervention allows interpreters to abide by both values in certain situations.
The very name of the class, Bridging the Gap, speaks to impartiality. In the United States, “the gap” typically refers to the linguistic and cultural barriers between healthcare professionals (HCP’s) and Deaf and non-English-speaking patients. “Bridging” refers to the bilingual medical interpreter who facilitates communication between two or more people who might otherwise not be able to communicate. And just as a real bridge connects two locations, a medical interpreter serves at least two people.
Some people may believe that a medical interpreter is on assignment on the patient’s behalf. They make this assumption because if it’s typically the patient who does not speak the lingua franca, then the interpreter must be present for the patient’s sake. While there is some logic to this line of thinking, ultimately, it’s not the best understanding. As soon as the medical interpreter takes “I’m here for the patient” as her point of departure, she is already (whether knowingly or unknowingly, intentionally or unintentionally) compromising impartiality. To abide by impartiality at a basic level, her point of departure must be “I’m here for both the healthcare professionals and the patient”.
The medical interpreter must also commit to being impartial throughout the interpreting assignment. She does not take sides. She does her best to suppress her biases for or against HCP’s and for or against the non-English-speaking and/or Deaf patient. In the privacy of her mind, the medical interpreter can hope for a collaborative and cheerful medical assignment, but even this very optimistic hope must not manifest itself in her work. It is not the medical interpreter’s role to play peacemaker, and if friction or hostility arise between the healthcare provider and patient, she is compelled by accuracy to maintain the curt and/or aggressive tone and word choice conveyed by each party. Even over and above sparing someone’s feelings, the medical interpreter’s prevailing commitment must be to facilitate accurate communication without any partial/biased interventions. As difficult as this may sometimes be, if the medical interpreter achieves this, she embodies accuracy and impartiality at an excellent level.
When considering advocacy as a value of medical interpreting, there appears to be a difference in codes of ethics between ASL and spoken language.
As of July 1, 2005, the National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf, Inc. (RID) adopted a Code of Professional Conduct that includes six guiding principles and seven tenets. The Code’s illustrative behaviors expound upon each of the seven tenets. There is no guiding principle of advocacy in the NAD-RID Code of Professional Conduct. Nowhere in the document will a reader find the words: “to advocate”, “an advocate” or “advocacy”. But there is significant development of “respect for consumers”, and one implicit element of “respect for consumers” is whether or not interpreters should advocate for consumers and if so, under which circumstances.
A look at the Code reveals:
- “The guiding principles in this document represent the concepts of confidentiality, linguistic and professional experience…and the rights of participants in interpreted situations to informed choice. The driving force behind the guiding principles is the notion that the interpreter will do no harm” (Registry 1).
- Tenet 4 – “Interpreters demonstrate respect for consumers” (Registry 2 & 4).
- Illustrative Behavior 4.4 – “[Interpreters] Facilitate communication access and equality, and support the full interaction and independence of consumers” (Registry 4).
One interpretation of “the right of participants in interpreted situations to informed choice” is that an ASL interpreter would never advocate on the Deaf person’s behalf without first requesting the Deaf person’s permission. To advocate without permission violates both the Deaf consumer’s independence and “rights…to informed choice.” The Deaf person may perceive the interpreter’s intrusive advocacy as an oppressive act, and in that sense, the interpreter is doing harm, which the next clause on Page 1 explicitly discourages.
From Illustrative Behavior 4.4, the clause that reads “[Interpreters]…support the full interaction and independence of consumers” further strengthens the preference that Deaf individuals advocate for themselves.
Having an interpreter or another hearing person advocate on behalf of a Deaf person is a hot topic commonly discussed in some Deaf and ASL interpreter circles. The NAD-RID council responsible for drafting the Code of Professional Conduct found an appropriately articulate and agreeable way to impart general guidance on the debate on advocacy without ever going into the weeds, without ever dropping any of the “A” words.
Whatever the reason for the omission of advocacy in NAD-RID’s Code of Professional Conduct, the point stands that between ASL and spoken language ethical codes, there is a difference in regard to advocacy. Spoken language openly identifies advocacy as a value, and NAD-RID has chosen not to do so. ASL interpreters and Deaf individuals may cringe at the thought of advocacy being among IMIA and NCIHC’s seven core values, but is the difference in approach to and understanding of advocacy between ASL and spoken language as big as it initially appears? No.
Incremental intervention as the compromise between impartiality and advocacy
Though advocacy is not explicitly identified as a guiding principle in the NAD-RID Code of Professional Conduct, Incremental Intervention (as described below) is a valuable consideration for both ASL and spoken language interpreters in the medical field. Incremental Intervention might wash away or at least temper the qualms felt by ASL interpreters and Deaf individuals when they see IMIA and NCIHC openly promote advocacy as a core value of medical interpreting.
[Disclaimer – “medical interpreting” is underlined to stress that Incremental Intervention is an approach that applies to medical interpreting. Incremental Intervention is not appropriate in other settings such as business and court interpreting. Read what follows with an exclusive focus on the medical field. Also of note is that whereas the IMIA and NCIHC Code of Ethics only apply to medical interpreting, the NAD-RID Code of Professional Conduct was purposefully designed to apply to interpreting for the Deaf in all sectors of society (i.e. healthcare, law, education, etc…). Evidence of the universal design of the NAD-RID Code is found in the following clause. “This Code of Professional Conduct is sufficient to encompass interpreter roles and responsibilities in every type of situation (e.g., educational, legal, medical). A separate code for each area of interpreting is neither necessary nor advisable” (Registry 1).]
It’s been said that the best interpreter is almost invisible, that the HCP’s and patient would ideally forget that the interpreter is present and instead focus on the matter at hand. In other words, the interpreter is nimble in her skills and un-intrusive in facilitating communication, using interventions sparingly and only when necessary.
Incremental Intervention is an approach for attaining this ideal and for allowing impartiality and advocacy to operate in dynamic tandem and coexist peacefully. Under Incremental Intervention, the medical interpreter has four roles. The roles are listed in order of 1-4. #1 is the most commonly used role. And #4 is the role that is the last resort, the option that is to be used sparingly.
- Conduit – In the conduit role, the medical interpreter is interpreting meaning-for-meaning and makes no interventions for differences in register and culture possibly present between the HCP’s and patient. The interpreter should strive to spend the bulk of her time in the conduit role, and when she ventures into Roles 2, 3, and 4, she should return to the conduit role as quickly as possible. She returns to the conduit role because she is striving to be as un-intrusive as possible while facilitating effective communication.
- Clarifier – As a clarifier, the medical interpreter adjusts for register. If the HCP is using highly technical language that the patient doesn’t understand, ideally the patient would self-advocate and say/sign in his or her respective language, “I’m sorry, doctor, I don’t understand. Could you use simpler language?” This self-advocacy would spare the interpreter from assuming the clarifier role and would put the responsibility of adjusting for register on the doctor.
However, should the patient not speak up and should the doctor remain unaware of the patient’s lack of understanding, the interpreter can and should intervene by adjusting the doctor’s high register speech to a lower register explanation that is more comprehensible to the patient.
If the disconnect in register is a prolonged occurrence and requires the medical interpreter to stay in the clarifier role, a more appropriate intervention would be for the medical interpreter to make things more explicit for the doctor – “Interpreter speaking: I’m sorry, doctor. I’m consistently having to adjust your technical explanations into simpler language so that the patient can understand. Would you mind using simpler language?” This request from the interpreter could rightly be understood as being bold and intrusive, but the interpreter is making this request so that she can be less intrusive throughout the rest of the interpreted session. And it that spirit, it is an un-intrusive act.
- Cultural broker – Cultural broker refers to the times the medical interpreter intervenes to explain the cultural differences between the HCP’s and patient. It’s not the medical interpreter’s role to be a cultural ambassador, but as a cultural broker, the medical interpreter should offer cultural intervention only when the need for it arises organically or when the HCP’s or patient initiate this type of intervention.
- Advocate – The more common barriers to effective communication between HCP’s and Deaf and non-English-speaking patients are the barriers of language, register and culture. But there is a fourth group of barriers that emerges in extenuating circumstances – systemic barriers. A systemic barrier could be that the patient lacks knowledge of his rights and access to care under the American healthcare system and is thus going underserved. A systemic barrier could be that an HCP (knowingly or unknowingly, intentionally or unintentionally) withholds knowledge or treatment to which the patient has a right. Another systemic barrier could be that of systemic racism in the American healthcare system and that the patient just so happens to belong to the minoritized or excluded demographic. These are sweeping descriptions of systemic barriers in the medical setting, but how is a medical interpreter to identify and react to a systemic barrier in a specific situation?
When a systemic barrier occurs, in luckier circumstances, the patient will be knowledgeable about his rights and will self-advocate in an assertive (but not passive or aggressive) way. The interpreter would thus be off the hook and could simply interpret in the conduit role.
However, should the patient prefer for the interpreter to advocate on his behalf or should the patient be incapable of self-advocacy for whatever reason (i.e. ignorance of his rights, lacking courage, cultural custom of being deferential toward authorities), then the medical interpreter starts to consider the advocate role. Chief among the interpreter’s considerations are:
- Should I intervene?
- How should I intervene?
Though each situation is unique and an interpreter should never relinquish her well-informed judgement, below are some NCIHC and IMIA guidelines for deciphering whether or not to advocate.
“The NCIHC Standards of Practice suggest that and interpreter may take on the role of the advocate if they must ‘speak out to protect an individual from harm’ or ‘to correct mistreatment or abuse’ ” (The Cross Cultural 183).
“The IMIA Standards of Practice suggest that the interpreter has a duty to ‘deal with discrimination’. These standards also suggest that an interpreter use effective strategies when ‘the interpreter feels strongly that either party’s behavior is affecting access to or quality of service, or compromising either party’s dignity’ ” (The Cross Cultural 183).
Just as NAD-RID may have some qualms, debate and division on advocacy, so too is this likely the case within NCIHC and IMIA. The spoken language community also has opposing viewpoints on the appropriateness of advocacy in medical interpreting.
“Some people believe that medical interpreters should not act as advocates at all. However, others feel that that are many reasons that advocacy should be a part of the medical interpreting process. As a result, there is debate about the role of advocacy in the health care setting” (The Cross Cultural 81).
In the uncertainty surrounding advocacy, one detail is very important. For those who maintain that advocacy has its rightful place in medical interpreting, advocacy is always understood as the last resort. “Last resort” is a bit of a cliché expression, but here it’s an apt descriptor. “Last” stresses that the medical interpreter only comes to advocacy once all other options are exhausted. “Resort” suggests that the medical interpreter is not coming to advocacy willingly; rather the difficult circumstances compel her to adopt a strategy (advocacy) that she would otherwise avoid. If the medical interpreter fully embodies this “last resort” mentality toward advocacy, her conscience can be at greater (but not full) ease on the rare occasions in which she reluctantly steps into the advocate role.
In regard to advocacy, the medical interpreter’s second question is “How should I intervene?” As just described, the medical interpreter should intervene reluctantly; her instinct should be not to intervene unless otherwise compelled. But once she chooses to advocate, she should commit to doing it well. How can the medical interpreter advocate effectively?
Aristotle taught of the Golden Mean, that the ideal moral behavior falls in the middle of two extremes. Setting up a spectrum of confrontation/advocacy styles might look like this:
Passiveness, Assertiveness, and Aggressiveness
Passiveness is the extreme to the far left. A passive person is idle; he lets people do things onto him without speaking up for his needs and desires. He may have a valid concern but doesn’t act upon it for some reason. Passiveness fails as an approach because needs go unmet and because no attempt has been made for positive confrontation.
To the far right is the other extreme of aggressiveness. An extreme, exaggerated characterization of aggressiveness is that a person employs whatever means to get what he wants without any concern for ethical conduct or others’ well-being. He is very active and even violent in pursuing his objective. Fortunately, not many people embody this exaggerated characterization of aggressiveness. Aggressiveness too is a less ideal approach because it sours relationships, creates victims, and compromises the aggressor’s professionalism/integrity.
Assertiveness is the golden mean. It’s the standard to which patients, HCP’s and, if necessary, medical interpreters should strive. Under assertiveness, the party with a concern does indeed act but does so in a firm and polite way that preserves the dignity of both parties and advances an agreeable solution to the concern. The one thing to keep in mind is that assertiveness is not a silver bullet. When the patient and/or interpreter uses assertiveness, it is not a guarantee that they will achieve their desired outcome. But assertiveness does stack the cards in favor of other favorable outcomes. If done well, assertiveness may yield: new understanding, self-empowerment, trust, concessions, and/or compromise. Similar to how a romantic couple may feel they’ve grown closer when reconciling after a fight, seeking solutions through assertiveness can strengthen relationships: patient-provider, patient-interpreter, and provider-interpreter.
The Dynamic Compromise
Impartiality and advocacy do indeed represent a dichotomy. But with refined consideration, they also represent a dynamic duo, a concessionary coexistence.
To advocate requires a medical interpreter to temporarily relinquish her impartiality. But she only arrives at advocacy reluctantly and after following the four levels of Incremental Intervention. In those hard times, she chooses to advocate because some shortcoming or violation is occurring, and if it goes unaddressed, the patient’s dignity and/or health could be severely compromised. She advocates as a last resort but does so effectively on the rare occasion when it’s necessary.
Outside of her interpreted assignments, the medical interpreter respects the wider debate on advocacy. She may not entirely share the viewpoint of NAD-RID or she may be ill-at-ease with IMIA and NCIHC’s open recognition of advocacy as a value. Yet she recognizes that professional discussion of advocacy is worthwhile. And in all her humility, she acknowledges that there is not “one correct solution” to the advocacy dilemma.
Wes Bremer is LUNA’s Training and Virtual Interpreting Coordinator. Wes has been with LUNA for over a year and continues to bring a great perspective on language access and training.
Registry of the Interpreters for the Deaf. NAD-RID Code of Professional Conduct. Online PDF. https://drive.google.com/file/d/0B-_HBAap35D1R1MwYk9hTUpuc3M/view. Accessed 25 Mar 2020.
The Cross Cultural Health Care Program. Bridging the Gap Medical Interpreter Training – A Textbook for Medical Interpreters. Cross Cultural Health Care Program, 2014.