Bioethics Forum Essay
Covid Doesn’t Justify Cutting Corners on Medical Interpretation
As it has done to so many other areas of medicine, Covid-19 has interfered with medical interpretation, the invaluable federally-mandated service of translating medical information for patients who are not fluent in English. Hospitals are required to provide medical interpreters free of charge to patients who don’t speak English, but with increased demand and reduced supply of interpreters during the pandemic, many hospitals have cut corners, providing incomplete or subpar professional medical interpretation to the patients who need it.
Covid-19 has disproportionately affected communities of color, including Latinx people, many of whom have limited English proficiency, driving up the need for interpreter services. At Massachusetts General Hospital in Boston, for example, the percentage of patients needing interpreter services increased from about 9% before the pandemic to between 29% and 35% in only a matter of months after the pandemic hit. This need has likely fluctuated along with Covid cases in different regions over the course of the pandemic, and is it probably increasing now in areas where Covid-19 cases are again rising.
Since the start of the pandemic interpreters have faced challenges in doing their jobs. Initially, medical interpreters (like other caregivers) often did not have proper personal protective equipment. But even when interpreters were able to be fully masked and gowned, they experienced difficulties hearing and translating accurately through PPE. And using a phone or an iPad to assist with interpretation increases the risk of contamination. To compound matters, we are aware of some caregivers, including residents, psychologists, and psychiatrists, who grew accustomed to working remotely at the height of the pandemic and have since refused to meet face to face with patients who test positive for Covid-19 despite being vaccinated themselves.
One common solution has been to provide interpreter services by phone. At Cambridge Health Alliance in Massachusetts, for example, approximately 99% of interpretation was done remotely after the start of the pandemic. However, interpretation by phone can worsen the quality of care because interpreters cannot incorporate information gained by observing body language or reading facial expressions. Although video interpreting alleviates some of these concerns, it raises others, such as potentially unreliable Internet connections.
Another limitation to telephone interpretation is that the wait for an interpreter can be longer than an hour. Given the potentially long wait time, some health care workers only call to obtain informed consent or to tell relatives that their family member has died. In some cases, physicians omit information that can be comforting to patients during difficult times, such as asking patients to think of happy memories directly prior to sedation and/or intubation. In other cases, efforts are made to try to communicate without professional interpreters, which can result in a misunderstanding of critically important information. In New York, a physician who spoke limited Spanish attempted to get through an encounter himself and decided to admit a patient because he thought she had had heart surgery three years earlier and was therefore at increased risk. As it turns out, the patient had had heart surgery when she was 3 years old and did not warrant hospitalization.
Are deviations from the standard of care for medical interpretation morally justifiable during the pandemic? We believe the answer is no. Cutting corners would pose additional harm to patients from communities that have been disproportionately harmed by Covid-19, given that many of these patients are not proficient in English. The rights of both patients and clinicians can suffer. Without accurate information, patients cannot exercise their right to autonomy and offer informed consent, and medical professionals cannot fulfill their professional duties and obligations.
The use of professional interpreters improves many aspects of clinical care, including comprehension, health care utilization, satisfaction, and outcomes. Furthermore, fewer medical errors occur when professional interpreters are used, compared with ad hoc interpreters—doctors or nurses who happen to speak a patient’s language. It is difficult to even consider the possibility of health care being equitable and just for patents with low English proficiency if professional interpreters are not involved in every clinical encounter when needed. The upshot is that failure to provide professional interpreters to patients who need them is a violation of fundamental ethical rights and principles.
Some might argue that the cost of providing interpretation services precludes the widespread use of professional interpreters in crisis situations. This utilitarian calculus has not been thoroughly examined because cost analyses are limited. A review article in 2020 cited a total of 11 studies, only two of which addressed inpatient care in the United States, and only one of these examined costs of in-person interpretation. This study found that only 1.5% of the cost of patient care for a hospital stay was attributable to interpreter services. Furthermore, the use of professional interpreters has been found to decrease the amount of unnecessary testing and imaging.
We acknowledge that there might be practical limitations that could preclude the use of in-person interpreters. For example, it may be impossible to find interpreters for patients who speak languages that are not frequently encountered. There also might be times when a patient’s clinical status is deteriorating so quickly that even an extra minute or two of trying to locate a professional interpreter might result in a catastrophic outcome. In these rare instances we would support using nonprofessional interpreters.
In conclusion, except in the most extreme of circumstances, during the Covid-19 pandemic, patients with low English proficiency, who are at higher than average risk due to the pandemic, ought not be placed in further jeopardy by being denied adequate, standard of care language interpretation.
Katherine Freedberg is a medical student at Tufts University. J. Wesley Boyd, MD, PhD (@JWesleyBoydMD), is a professor of medical ethics and psychiatry, Baylor College of Medicine.