Western bioethics on the Navajo reservation. Benefit or harm?

OBJECTIVE To understand the Navajo perspective regarding the discussion of negative information and to consider the limitations of dominant Western bioethical perspectives. DESIGN Focused ethnography. SETTING Navajo Indian reservation in northeast Arizona. PARTICIPANTS Thirty-four Navajo informants, including patients, biomedical health care providers, and traditional healers. RESULTS Informants explained that patients and providers should think and speak in a positive way and avoid thinking or speaking in a negative way; 86% of those questioned considered advance care planning a dangerous violation of traditional Navajo values. These findings are consistent with hózhó, the most important concept in traditional Navajo culture, which combines the concepts of beauty, goodness, order, harmony, and everything that is positive or ideal. CONCLUSIONS Discussing negative information conflicts with the Navajo concept hózhó and was viewed as potentially harmful by these Navajo informants. Policies complying with the Patient Self-determination Act, which are intended to expose all hospitalized Navajo patients to advance care planning, are ethically troublesome and warrant reevaluation.