ISSN: 1579-9794

Hikma 21 (2) (2022), 257 - 286

Finding ethics in and out of deontological codes: ethical

dilemmas faced by healthcare interpreting student interns

En busca de la ética dentro y fuera de los códigos

deontológicos: dilemas éticos a los que se enfrentan

estudiantes en prácticas de interpretación sanitaria

CRISTINA ÁLVARO ARANDA

cristina.alvaroa@uah.es

University of Alcalá, FITISPos-UAH Research Group

Fecha de recepción: 09/03/2022

Fecha de aceptación: 24/10/2022

Abstract: Establishing a code of ethics is a requirement an occupation must

meet to become a full-fledged profession. In healthcare interpreting, several

professional associations have published their own codes. Students are

introduced to these codes in the classroom, but when they access the

profession they often face ethical dilemmas that may overlap with their

professional obligations. This paper explores a series of ethical dilemmas

faced by students that first encounter the workplace as part of an internship

programme. Drawing on participant observation and post-encounter

interviews, we identify ethical dilemmas, describe the interns’ behaviour, and

illustrate the rationale behind their choices. This allows us to isolate factors

that hinder participants from strict adherence to codes of ethics (i.e., the

theory-practice gap, contextual restrictions, and human emotion). In light of

results obtained, we encourage trainers and interpreters to develop critical

ethical thinking in different healthcare scenarios to facilitate assessing the

consequences of (not) following a code of ethics.

Keywords: Healthcare interpreting, Ethical dilemmas, Code of ethics, Student

interns, Training

Resumen: Establecer un código deontológico es un requisito que toda

ocupación debe cumplir para convertirse en una profesión plenamente

desarrollada. En el ámbito de la interpretación sanitaria, varias asociaciones

profesionales han publicado sus propios códigos. Los estudiantes se

familiarizan con estos documentos en el aula, pero al acceder al mercado

laboral con frecuencia encuentran dilemas éticos que pueden solaparse con

sus obligaciones profesionales. Este artículo explora una serie de dilemas

éticos a los que se enfrentan estudiantes que entran en contacto por

primera vez con la actividad profesional como parte de un programa de

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prácticas universitarias. A través de observación participante y entrevistas

posteriores a los encuentros, se identifican diferentes dilemas éticos, se

describe el comportamiento de los estudiantes en prácticas y se ilustran las

razones en las que basan sus decisiones. Este proceso permite delinear los

factores que impiden que los participantes se atengan estrictamente a los

códigos deontológicos (es decir, la desconexión teórico-práctica, las

restricciones contextuales y las emociones humanas). En vista de nuestros

resultados, se aboga por que profesores e intérpretes promuevan un

pensamiento ético crítico en diferentes escenarios sanitarios para así

facilitar evaluar las consecuencias de (no) seguir un código ético.

Palabras clave: Interpretación sanitaria, Dilemas éticos, Código

deontológico, Estudiantes en prácticas, Formación

NTRODUCTION

Social changes often entail the emergence of unattended needs and

empty spaces that must be occupied by new professional roles. This is the

case of healthcare interpreting, which arose to facilitate communication

between patients and healthcare providers in our ever-increasing

multilingual and multicultural societies. Despite its indubitable impact on an

individual’s well-being, healthcare interpreting is still an

underprofessionalised activity. There is no official agreement on the

healthcare interpreters’ role and professional tasks. In addition to this,

healthcare interpreters face precarious employment situations where

remuneration is low. Although some countries have taken appropriate steps

towards professionalisation with an increase in their training options (Valero

Garcés & Lázaro Gutiérrez, 2016; Álvaro Aranda & Lázaro Gutiérrez, 2021),

to this date healthcare interpreting still does not require a higher education

degree to enter the profession and there is no validation of credentials for

practice universally accepted (Angelelli, 2019). Consequently, ad hoc

interpreting practices continue to be the most recurrent and family members,

partners or friends often join the patients in medical consultations (Twilt et

al., 2020). Healthcare interpreting is yet to hold professional jurisdiction—

that is, to claim a monopoly of practice—by presenting itself to society as the

most appropriate solution to a «professional problem» (Abbott, 2014).

These signs are frequently mentioned as indicators of

underprofessionalisation in the sociology of the professions, a discipline

seeking to study professions as a special category of occupations (Reis

Monteiro, 2015) to become a fully-fledged profession, an occupation must

meet a specific set of criteria covering formal, legal, jurisdictional,

institutional, organisational, educational, economic, and ethical factors.

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Traditionally, the professionalisation process entails establishing a

professional association, as well as designing a code of ethics (Wilensky,

1964). These codes intend to regulate professional behaviour (Volti, 2008)

and guide decision-making in a way that matches the responsibilities of its

practitioners (Ortega Sánchez, 2010). Enforcing a code of ethics serves to

exert internal control and earn public trust (Tseng, 1992 in Mikkelson, 1996),

as ethical principles allow professionals to show the way they do things

(Garber, 2008). In a clear attempt to boost the professional status of

healthcare interpreting, several codes of ethics have been published by

professional associations, such as the California Healthcare Interpreting

Association (CHIA), the International Medical Interpreting Association (IMIA)

or the National Council on Interpreting in Health Care (NCIHC).

Healthcare interpreting students are introduced to these codes during

their education. However, when they leave the classroom and enter the

profession, they often face difficult situations where abiding by a code of

ethics inevitably entails facing ethical dilemmas that may overlap with their

professional tasks (Lázaro Gutiérrez, 2009; Pena Díaz, 2018). An ethical

dilemma involves cases in which the moral precepts or other mandatory

ethical obligations enter in conflict, thus making any possible solution to the

dilemma morally intolerable (Ruiz Cano et al., 2015). In public service and,

by extension healthcare interpreting, dilemmas may be caused by a myriad

of reasons, including conflicts of interest; sensitive, personal, or cross-

cultural issues and conflicting expectations from participants (Hale, 2007).

How do trainee interpreters conduct themselves in these contexts regarding

their code of ethics? Do they find codes a useful guide or, rather, a limiting

tool? What are the potential consequences of breaching the interpreters’

code(s) of ethics?

This paper sets out to explore a series of real healthcare-interpreted

scenarios presenting ethical dilemmas to five healthcare interpreting

students interns entering the practice for the first time as part of an

internship programme. Sections 1 and 2 present some basic theoretical

concepts related to ethics, deontology, and their application to the

healthcare interpreting (education) field. Subsequently, Section 3 describes

the methodological approach, nature of data and study participants; to later

on present six ethical dilemmas and three factors affecting decision-making

in Sections 4 and 5. Finally, Section 6 offers some reflections in the light of

our results.

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1. ETHICS, PROFESSIONAL ETHICS AND DEONTOLOGY: DEFINING AN ETHICAL

DILEMMA

Ethics is defined as a series of moral values or principles seeking to

distinguish between good or bad and establish moral duties and obligations

(Crommelin & Pline, 2007). Depending on the defining criteria, ethics can be

classified into several categories. Thus, personal ethics is defined as the

ethical system an individual chooses as a moral guide in life (Jacorzynski,

2009), whereas professional ethics reflects on what members of a

professional group do (or should do) to be ethical in the course of their

professional activity, regardless of whether this is captured or not in a code

(Hortal Alonso, 2002). On the other hand, deontology addresses ethical

contents from a normative, descriptive, and even prescriptive viewpoint

(García Fernández, 2007). It encompasses the set of norms, rules,

principles, and attitudes that regulate a profession (Vázquez Esquivel,

2011), which are reflected in a code and approved by a professional

association (Hortal Alonso, 2002). The intersection of these factors is a

common source of tension for practitioners, especially when professional

ethics contradict the individual’s ethical framework or, alternatively, there is a

lack of clarity on professional norms and values. Thus, ethical dilemmas

emerge when individuals must inevitably make a decision among different

course of actions to choose from and, regardless of their choice, there exists

a violation or compromise of one or more ethical principles (Team ARSu,

2020).

Despite being different concepts, professional ethics and deontology

are used synonymously very often (Vives i Gracia, 2013). This explains to a

large extent why, although not identical, deontological codes, codes of

ethics, codes of conduct, standards of practice and professional standards

are used in healthcare interpreting interchangeably (Baixauli-Olmos, 2014).

For the aims of this paper, we will not delve further into conceptual or

semantic nuances and, to avoid ambiguity, the terms deontological code and

code of ethics will be used interchangeably to describe a set of moral

precepts or norms followed by a collective of professionals to ensure an

honest practice and an honourable conduct among its members (Vidal

Casero, 2003).

2. C

ODES OF ETHICS IN (HEALTHCARE) INTERPRETING

As indicated earlier in the paper, a code of ethics allows a profession

to ensure quality and accountability to the communities it serves (Yuen,

2003). Tenets of ethical behaviour found in codes of ethics are typically laid

out in the form of norms binding to all members of a profession (Kalina

2015), obliging them to adhere to a common set of rules (Moratto & Li,

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2022). They require adopting shared, well-considered professional values

(Baixauli-Olmos, 2017), which in turn offer practitioners a space to protect

themselves in their everyday practice when confronted with ethical dilemmas

(Pena Díaz, 2018). Nevertheless, codes of ethics for translators and

interpreters tend to be advisory, educational, rather than regulatory, and only

apply to those who join the professional associations that create them

(Drugan, 2017). The underprofessionalisation of healthcare interpreting

further exacerbates this problem, as interpreters are not obliged to join a

professional association and, as such, practising interpreters may not even

be familiar with deontological codes (Phelan et al., 2019).

In any case, deontological codes usually cover a series of elements,

including a description of the profession, professional duties, organisational

control, practitioner’s rights or prohibitions and some basic principles (Muñoz

Boda, 2018). In the field of healthcare interpreting, associations often

coincide in four basic principles. More precisely, healthcare interpreters must

respect participants’ privacy and avoid disclosing information to third parties

(confidentiality) and remain impartial along their work (impartiality).

Interpreters must not add, omit, or alter information (accuracy/fidelity) and

must be ready to declare potential conflicts of interest and withdraw from

assignments which surpass their skills (professionalism/professional

integrity). These tenets can be presented in isolation (e.g., IMIA, 2006) or

alongside protocols (e.g., CHIA, 2002) or even good practice guidelines

(e.g., NIHSSIS, 2004).

Codes acknowledge situations in which ethical principles should be

overlooked. To illustrate this, healthcare interpreters may ignore

confidentiality if there is evidence suggesting child abuse or suicidal

tendencies. Nevertheless, exceptions to the rules are presented in a

general, rather unspecific way, leaving interpreters in a difficult position

regarding how and when to ignore an ethical principle in the multiple

scenarios they face in practice (Raga Gimeno, 2014). Consequently, and

although ethical notions may seem undisputable at first glance, they offer an

unsatisfying guide for interpreters facing ethical dilemmas in conflict-ridden

events (Martín Ruano, 2017a).

There exist remarkable gaps between ethical codes and the realities

found by healthcare interpreters. As such, these documents are not exempt

from criticism. Ethical norms seem to perpetuate the conception of

interpreters as invisible linguistic conduits (Cox, 2015), which has been

severely criticised in the literature, inasmuch as they need to expand this

basic default role to explain cultural differences (Rosembaum et al., 2020),

explore ambiguous answers (Baraldi & Gavioli, 2018) or detail institutional

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procedures (Álvaro Aranda, 2020). This suggests that traditional ethical

codes might be only valid on paper (Pöllabauer, 2004). To support this idea,

research proves that interpreters working in different fields often have

trouble following ethical principles, with a special emphasis on the tenet of

impartiality (Cedillo Corrochano & Valero Garcés, 2014). Furthermore,

abiding by ethical rules may be unethical if, for example, unequal access to

power comes to light (Clifford, 2004). Regarding healthcare interpreting,

Angelelli (2008) severely criticises prescriptivism in codes of ethics and

states that ethical principles should be empirically tested and grounded to

address the complexity interpreters face.

This complexity becomes more relevant when focusing on the

peculiarities of the field. Healthcare interpreters interact with patients that

often find themselves in situations of vulnerability, which in itself is prone to

raise ethical issues due to a potential emotional response in interpreters. In

addition, interpreters work with other professionals (i.e., doctors, nurses, and

administrative staff) that ascribe to their own set of ethical norms. Employing

institutions may also impose rules contradicting the interpreters’ professional

values as defined by associations (Baixauli-Olmos, 2014). This makes

developing a (nearly) universal code of ethics very difficult (Rudvin, 2007),

especially considering that, however comprehensive, no code can predict

every situation that may arise in practice. For this reason, practitioners will

face events where elements present in codes of ethics will enter in conflict

or, alternatively, be overlooked (Drugan & Megone, 2011). Having said this,

some codes devote a section to put forward decision-making steps for

interpreters facing an ethical dilemma, but they seem to be rather subjective

(see, for example, CHIA 2002). This implies that in professional practice

some decisions are left to the interpreter’s «common sense» (Pena Díaz,

2018). Given the complexity of ethics in interpreting, it is thus not surprising

that it has emerged as a prolific area of research frequently addressed in

interpreters’ training programmes (Moratto & Li, 2022).

Attention has been brought to the desirability of training in ethics for

translation and interpreting students. Creeze & Asano (2016) reinforce that

familiarising students with ethical dilemmas should be one of the topics to be

addressed in education. However, this is not an easy task. Much of the

criticism surrounding teaching ethics focuses on the fact that university-level

trainers have long instructed students to follow ethical codes

unquestioningly, instead of encouraging them to reflect on the potential

consequences of their behaviour (Baker & Maier, 2011). As Dean & Pollard

(2011) indicate, the interpreting profession has generally adopted a

deontological ethical framework (i.e., strict adherence to pre-ordained rules),

in detriment of a teleological approach (i.e., reflection on the potential

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outcomes of one’s actions). Ethical rules are thus often presented as a

single, rigid set of norms that, as the Ten Commandments, seem to be

carved in stone (Brander de la Iglesia, 2017).

In light of this, more recent calls demand widening the emphasis

placed on teaching students to fulfil norms and, instead, encourage trainers

to foster their critical abilities (Martín Ruano, 2017b). Looking for good or

bad, right and wrong is not enough to address the complexity inherent to

ethics, since students need to learn to identify ethical issues and reflect

about how the latter shape their actions, to ultimately choose an action

translating into an effective response in a particular situation (Drugan &

Megone, 2011). Such a process resonates with the notion of professional

judgement, which allows interpreters to assess whether they should apply

their code in a specific situation, make a stand to enforce it or disregard it for

a higher good (Hale, 2007). In this sense, Ozolins (2014) states the highest

ethical priority for a healthcare interpreter is duty of care to patients. This

aligns with the principles of beneficence and non-maleficence governing the

ethical behaviour of healthcare personnel.

In the classroom, ethical dilemmas can be approached by means of

several tools. For example, students of the MA in Intercultural

Communication, Interpreting and Translation in Public Services (University

of Alcalá, Madrid, Spain) take part in roleplays and subsequent discussions

illustrating ethical dilemmas and assessing different solutions. Similar

approaches are described in other Spanish educational centres, which may

include discussion activities based on videos (Aguirre Fernández Bravo,

2019) and sometimes involve healthcare professionals in designing and

representing roleplays (Sanz Moreno, 2017). Despite its usefulness, these

are simulated encounters and trainers are advised to develop opportunities

for students to observe professional interpreters’ authentic performances,

thus introducing a higher degree of authenticity (Kaczmarek, 2012). Other

proposals take shape in the form of theoretical workshops, such as La ética

de la interpretación y autocuidado para los intérpretes (2020), in which

ethical dilemmas are approached together with self-care.

3. M

ETHODS, DATASET AND PARTICIPANTS

We aim to examine how five interpreting postgraduate students conduct

themselves in relation to codes of ethics in language-discordant events during

their internships at a public hospital located in Madrid (Spain) that is home to

an onsite team of healthcare interpreters. The name of the institution will not

be specified due to confidentiality issues. Following our goal, we identified

ethical dilemmas registered by participant observation in a dataset drawing

upon healthcare interpreted events and post-encounter interviews (Álvaro

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Aranda, 2020). For the purposes of this research, six ethical dilemmas were

examined using an exploratory case study approach, which allowed us to

analyse data with no hypothetical formulations or constraints (Streb, 2010).

Our analysis is thus preliminary and framed within conversational analysis

(Lazaraton, 2003).

Permission was obtained to conduct research twice a week for five

months in 2017 after signing a confidentiality form and presenting the study

to individuals in positions of authority at the institution. When fieldwork

began, participants were informed about the aims of the research and were

given a guarantee that confidentiality and privacy would be respected. In

addition, participants granted oral consent in every session before data

collection, which was adequately registered, sometimes making use of

interpreters to overcome linguistic barriers. They were also reminded that

they could withdraw consent at any time. It should be noted that obtaining

written consent was discarded due to time restrictions before medical visits

and the patients’ low level of (health) literacy, or inability to write or read.

Due to the sensitive nature of the setting, healthcare visits could not be

video, or audio recorded, which made it impossible to transcribe

conversations fully. However, manually written fieldnotes, which were taken

in situ during participant observation in the field, allowed the author to

In any case, participant observation allowed us to isolate ethical

dilemmas. Following Team ARSu (2020), selection criteria for ethical

dilemmas included (i) situations compromising at least one ethical principle

as laid out by most existing codes (confidentiality, impartiality,

accuracy/fidelity, professionalism/professional integrity), (ii) which required

interpreters to make a decision among different courses of action available.

In a subsequent step, we described the participants’ behaviour as observed

in the workplace and delved into the rationale behind their choices by means

of post-encounter interviews, which were manually written or first recorded

and then transcribed. Interviews did not follow a script, as they included

questions based on what was observed in each case, which allowed

participants to be introspective about their behaviour in practice (Amos

Hatch, 2002). This process illustrated factors preventing healthcare

interpreters of the sample from strict adherence to ethical codes.

Five healthcare interpreting students enrolled in the study (Table 1).

To protect their privacy, each of them has been assigned a general code

(e.g., Interpreter 1). Regarding their background at undergraduate level, all

interpreters had pursued a four-year degree in either Modern Languages,

Translation, Interpreting or Cultural Studies. These programmes provide

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students with a solid understanding of a minimum of two languages and

introduce them to the cultural systems of the people who speak those

languages. Concerning their postgraduate background, participants were all

enrolled in the MA in Intercultural Communication, Public Services and

Translation of the University of Alcalá, Spain (MA CITISP). As part of this

programme, students completed a module focusing on healthcare

interpreting and translation, in which they became familiar with ethical codes

both theoretically and through practical exercises. The latter involve

roleplays that include ethical dilemmas and emotional impact, and also test

professional role boundaries, as well as subsequent discussions about these

topics (Álvaro Aranda et al., 2021).

In addition, students must follow an internship programme to

successfully complete the MA’s. More precisely, participants developed an

unpaid internship programme at the hospital in which data was collected.

They attended the institution for approximately a month, five days a week,

five hours a day. Following the internship offer, their tasks included

facilitating communication between allophone patients and providers in

healthcare events, which covered medical consultations, test delivered by

nurses, delivery of samples, accompanying patients, assisting them with

administrative procedures or interpreting in healthcare education workshops.

This allowed them to interact with administrative staff, doctors, nurses,

orderlies, x-ray technicians, patients, relatives, or companions.

During these interactions, several ethical dilemmas were found. To

guide decision-making at the workplace, students were expected to rely on

the theoretical notions acquired during their training and the ethical

principles imposed by the interpreters’ organisation at the hospital, which

Participant

code

Gender Age Nationality

Mother

tongue

Working

languages

Undergraduate

background

Postgraduate

background

Interpreter

Female 23 Spanish Spanish French-Spanish

Modern

languages

MA CITISP

Interpreter

Female 22 Spanish Spanish French-Spanish

Translation and

interpreting

MA CITISP

Interpreter

Female 23 Spanish Spanish French-Spanish

Modern

languages and

translation

MA CITISP

Interpreter

Male 22 Spanish Spanish French-Spanish

Modern

languages and

translation

MA CITISP

Interpreter

Female 23 Moroccan Arabic Arabic-Spanish

Semitic and

Islamic studies

MA CITISP

Table 1: Profile of participants

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placed special emphasis on confidentiality, impartiality, accuracy and

refraining from taking personal advantage of any information obtained during

their work. Additionally, in this hospital in particular interpreters are

considered part of the assistance team and must abide by the ethical code

of healthcare providers, which underlines the principles of non-maleficence

and beneficence (Álvaro Aranda & Lázaro Gutiérrez, 2022).

4. A

NALYSIS

Healthcare interpreters are typically presented to ethical codes

during their training, but they are often confronted with ethical dilemmas in

the course of their work that may jeopardise strict adherence to ethical

principles. This section aims to gain a better understanding of the ethical

issues faced by five student interns and their behaviour regarding codes of

ethics when they first encounter the workplace. Drawing on our dataset, we

conducted an inductive search to identify ethical dilemmas as described in

Team ARSu (2020). Six pertinent scenarios (i.e., situations in which at least

one ethical dilemma occurred) were selected for analysis based on their

illustrative potential and suitability for our purposes (Table 2).

Title

Ethical principle(s) at risk

Scenario 1

Don’t tell him anything

Accuracy/Fidelity

Impartiality

Scenario 2

If you want to let him know

Accuracy/Fidelity

Beneficence

Scenario 3

Take this, hold here, give me that

Professional integrity

Scenario 4

I could fill that gap

Professional integrity

Scenario 5

If you don’t want me to say

something, shut your mouth

Accuracy/Fidelity

Scenario 6

That’s not the patient’s fault

Accuracy/Fidelity

Impartiality

Table 2: Description of scenarios involving ethical dilemmas

To present each scenario, a description of the context, participants

and ethical dilemma(s) is first provided. Subsequently, we examine the

interpreter’s behaviour and decision-making process, to conclude with an

assessment of the situation. For reasons of clarity, all excerpts are shown in

their original language and accompanied by a translation into English made

by the author. Parentheses present actions, such as leaving a consultation

room or shrugging unknowingly.

4.1. Scenario 1: Don’t tell him anything

Interpreter 1 must accompany a Sub-Saharan 15-year-old male

patient to get a blood test. Blood holds great symbolism in Sub-Saharan

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African cultures, as it embodies life and strength (Navaza et al., 2012), and

fear of needles, mistrust of hospitals and concerns of discrimination are

important barriers (Klinkenberg et al., 2019). In fact, false myths regarding

blood reutilization and distrust of Spanish doctors were commonly observed

in our dataset. The patient displays clear signs of fear: he has teary eyes

and speaks with a trembling voice. Before arriving to the box, the patient

reinforces his refusal to get his blood drawn and starts to turn around, which

requires an intercultural mediation from the interpreter. He asks how many

blood collection tubes are required and expresses his fear and discomfort.

The patient agrees to the test only when the interpreter reassures him that

blood tests are common procedures used to diagnose illnesses and

disorders in healthcare centres. Eventually, they enter the box and meet the

nurse.

Excerpt 1

1. Interpreter 1: Hola, soy la intérprete de francés. [Hello, I’m the French interpreter]

2. Nurse: ¿De qué idioma? ¿Francés? [Which language? French?]

3. Interpreter 1: Sí. [Yes]

4. Nurse: Salut, attends un moment. Dile que se descubra. [Hello, wait a second. Tell him

to uncover (his arm)]

(The patient sighs)

5. Interpreter 1: Si tu as peur, ne regarde pas comment elle prélève le sang. [If you’re

scared, don’t look how she draws blood]

6. Nurse: Le han pedido algo más y no sé si es para el mismo test. Un momento. [They

asked for something else and I don‘t know if it’s for the same test. Wait a moment]

(The nurse leaves)

7. Interpreter 1: Elle revient tout de suite. Elle est sympa, elle parle Français. [She’ll be

back shortly. She’s nice, she speaks French]

(The nurse comes back)

8. Nurse: ¿De dónde viene? Vous venez d’où? [Where’s he from? Where’re you from?]

9. Patient: Côte d’Ivoire. [Ivory Coast]

10. Nurse: J’aime Africa. Je connais Mali, Sénégal… J’aime voyager. Africa est mon pays

favori. [I like Africa. I know Mali, Senegal… I love travelling. Africa’s my favourite country]

11. Interpreter 1: Está un poco nervioso por los análisis. [He’s a bit nervous because of

the tests]

(The nurse touches the patient’s arm)

12. Nurse: No duele, tranquilo. [It doesn’t hurt, don’t worry]

13. Interpreter 1: Ça ne fait pas mal, t’inquiète pas. Quiere saber cuántos tubos. [It doesn’t

hurt, don’t worry. He wants to know how many tubes]

14. Nurse: Solo tres, bueno, cuatro. [Just three, well, four]

15. Interpreter 1: Elle va retirer quatre tubes. [She’s gonna take four tubes]

(The patient sighs in relief)

16. Nurse: No tiene las venas muy bien, pero no le digas nada. [He doesn’t have very

good veins, but don’t tell him anything]

(The interpreter remains silent. The nurse struggles and moves the needle. The patient

winces in pain)

17. Nurse: Dile que la vena no va bien y que hay que buscar otra buena. [Tell him this

vein isn’t okay and we need to find a good one]

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18. Interpreter: La veine n’est pas bien and il faut en trouver une autre qui soit bonne. Ça

m’arrive tout le temps. [The vein isn’t okay and it’s necessary to find another good one.

That happens to me all the time].

This excerpt is a typical example of an ethical dilemma. In this case, the

interpreter surpasses her prescribed role as a linguistic conduit in different

ways, which reflects patient advocacy and intercultural mediation to facilitate

the job of the nurse and increase the patient’s comfort level. This helps

understand the special situation of healthcare interpreters in Spain, as they

are expected to perform interpretation and mediation tasks, which leads some

authors to label these professionals as MILICs or «Mediadores

Interlingüísticos e Interculturales» [Interlinguistic and Intercultural Mediators]

(Grupo CRIT, 2014). More precisely, the interpreter advises the patient not to

look if he is scared (turn 5) and ventures information that has not been

articulated in the presence of the nurse but is, however, elicited from previous

dyadic interaction with the patient (turns 11 and 13).

Acting paternalistically, the interpreter gives the nurse an opportunity to

address the patient’s fears in turn 12 (i.e., «It doesn’t hurt, don’t worry»). Later

on in the interaction, the nurse confides in the interpreter and comments on

the patient’s veins. She openly requests not to render the message (turn 16).

The interpreter remains silent, overlooking the principle of fidelity. As the nurse

is struggling to draw blood and the patient is displaying facial expressions of

pain, the interpreter disregards the principle of accuracy in turn 18, when she

shares personal experience (i.e., «That happens to me all the time»). When

asked about this situation in a post-encounter interview, the interpreter justifies

herself:

Post-encounter interview 1

1. Researcher: ¿Por qué no le has contado lo que ha dicho la enfermera sobre sus

venas? [Why didn’t you tell him (the patient) what the nurse said about his veins?]

2. Interpreter 1: El código ético es una cosa y está bien, pero en algunos casos... la

decisión es tuya. No le he dicho nada porque estaba ya muy nervioso. [The code of ethics

is one thing and it’s okay, but in some cases… the decision is yours. I didn’t tell him

anything because he was already very nervous].

This interview sheds insight on the interpreter’s decision-making

process in scenario 1. She mentions the code of ethics and accepts its

general validity, at least in theory. Nevertheless, she prioritises assessing the

peculiarities of each situation encountered in professional praxis before

deciding. In this case, she overlooks the ethical code and sacrifices its

principles for the «higher good» governing the interaction: ensuring that the

patient remains calm so the nurse can take his blood successfully. This can be

considered as an example of collaborative work with the healthcare provider,

since the interpreter eradicates barriers that can jeopardise the nurse’s work

(see Álvaro Aranda et al., 2021).

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4.2. Scenario 2: If you want to let him know

As stated earlier in the paper, participants of the sample sometimes

accompany patients to hand in urine and stool samples. In scenario 2,

Interpreter 3 accompanies a Cameroonian 19-year-old patient to deliver his

samples to detect parasites in his gastrointestinal tract. Detection of stool

parasites usually relies on at least three independently collected stool

samples. However, the patient only hands in two containers.

Excerpt 2

1. Laboratory assistant: Tiene que traer tres botes, no dos. [He needs to bring three

containers, not two].

2. Interpreter 3: Tu dois apporter trois échantillons, pas deux. [You need to bring three

samples, not two].

3. Patient: Voilà ce qu'ils m'ont donné. [That’s what they gave me].

4. Interpreter 3: Esto es lo que me han dado. [That’s what I was given].

(The laboratory assistant sighs).

5. Laboratory assistant: Le cogeremos solo los dos. Este viene abierto y, si es así,

puede que se pierda la muestra. Si se lo quieres decir… [We’ll take just these two. This

one’s open and, if that’s the case, the sample might go to waste. If you want to let him

know…].

(The interpreter remains silent for approximately thirty seconds).

6. Interpreter 3: Asegúrate de cerrar bien los botes. [Make sure to close the containers

properly].

(The patient nods once, but he is looking elsewhere).

7. Laboratory assistant: Veo que le importa poco. [I see that he doesn’t really care].

(The interpreter looks away and stays silent).

As noted by the laboratory assistant, the patient fails to bring the

minimum number of samples required for an intestinal parasite’s examination.

She points out that the patient has only brought two samples (turn 1) and the

interpreter conveys this observation (turn 2). The patient simply justifies

himself by shifting the responsibility to the doctors that requested the samples

(turn 3). In turn 5, the laboratory assistant warns the interpreter that one of the

samples might be contaminated, and leaves rendering this message to the

patient to the interpreter’s best judgement. After a brief silence, she instructs

the patient to make sure the sample containers are appropriately sealed in the

future, but betrays the ethical tenet of accuracy when she overlooks informing

him about the potential contamination of one of the samples (turn 6). The

patient, however, does not seem interested, as he just nods and avoids eye-

contact. The nurse criticises his attitude in turn 7, which is not interpreted to

the patient. This violates the tenet of accuracy. Later on, the interpreter

reflects on her decision:

Post-encounter interview 2

1. Researcher: ¿No sabías si contárselo o no? [You didn’t know whether to tell him (the

patient) or not?]

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2. Interpreter 3. Es una de esas situaciones en las que no sabes si transmitir información

por la situación que pueda generarse luego. Imagínate que el paciente se enfada o algo

así. ¿Qué se gana? [That’s one of those situations in which you don’t know whether to

transmit information (or not) because of what could happen after. Imagine that the patient

gets angry or something like that. What do we achieve?].

Interpreter 3 balances the consequences of different courses of action

available in the situation at hand. She considers the benefits and shortcomings

of rendering (or omitting) the message and, eventually, she chooses the latter,

even if it means sacrificing the tenet of fidelity. To some extent, she is also

violating the principle of beneficence, as one of the patient’s samples may be

contaminated, in which case he will need to come back to the hospital and

have the test repeated. However, in this case the interpreter is guided by

conflict prevention and avoidance. She deems it important to maintain a

distended atmosphere among participants, a decision largely influenced by the

patient’s unconcerned attitude and the subsequent laboratory assistant’s

criticism in turn 7. Nonetheless, it is worth mentioning that the patient’s

reaction might have been different had the interpreter informed him about the

potential loss of the sample. In any case, ethical reasoning and decision-

making happens in interaction and is heavily dependent on contextual

features, such as the other participants’ reactions and attitudes.

4.3. Scenario 3: Take this, hold here, give me that

Interpreters of this study break down communication barriers in

consultations with providers of different areas of specialty, such as tropical

medicine, traumatology, or gynaecology. Encounters sometimes cover more

than medical interviews and complementary tests are additionally performed.

In scenario 3, a twenty-seven-year-old Congolese woman attends a sexual

health consultation with her daughter, who is two and a half years old. The

doctor must elicit the patient’s health history and take some samples for

analysis. Unfortunately, the female nursing assistant that usually helps the

doctor is absent and there is just one male staff available for several,

simultaneous consultations. This leads the provider to ask for the interpreter’s

help to perform a vaginal swab, which she accepts. The interpreter also allows

the toddler to sit on her lap and draws with her in a piece of paper whilst the

patient is getting changed.

Post-encounter interview 3

1. Interpreter 1: El hombre no estaba y he tenido que hacer de auxiliar. He sujetado los

tubos de las muestras, me he puesto unos guantes. «Saca esto, sujeta aquí, dame

aquello...» Y la mujer mientras en la camilla con las piernas separadas (...) Después,

mientras se cambiaba la mujer, he cuidado a la niña y la he estado entreteniendo [The

man wasn’t available so I had to be the (nursing) assistant. I’ve held the sample tubes,

I’ve put some gloves on. «Take this, hold here, give me that…» And, in the meantime,

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the woman was in the examination table with her legs spread. I’ve taken care of the little

girl and I’ve entertained her whilst the woman was getting changed].

This scenario presents a challenging ethical dilemma. Following the

tenet of professional integrity, interpreters must withdraw from situations that

imply surpassing their duties as communicators. As there is no alternative

option available to perform the vaginal swab at that time, the interpreter flouts

her code of ethics. She handles specialised medical materials and plays with

the patient’s daughter. While standard training advocates for interpreters to

«stick to interpreting», contextually bound factors and institutional constraints

force the interpreter to adapt herself to the situation and expand her role. More

precisely, she acts as a nursing assistant and babysitter, which reinforces the

idea of healthcare interpreting as a situated practice where the connection

between setting, expectations and actual performances come to the fore

(Angelelli, 2019). This might be common to all healthcare occupations, as staff

may need to go beyond their clinical role to ensure the health of their patients

(e.g., counsel or help them overcome administrative procedures).

4.4. Scenario 4: I could fill that gap

As shown in Table 1, most participants of the sample have French and

Spanish as their working languages. Scenario 4 presents an exception.

Interpreter 3 must accompany an English-speaking Tanzanian forty-one-year-

old female patient to a sexual health consultation, get a blood test and collect

a urine collection container. No English<>Spanish interpreter is available to

facilitate communication at the time of the appointment and, thus, Interpreter 3

is asked to provide her services. As reported by the interpreter, several

providers participate in the interaction.

Post-encounter interview 4

1. Interpreter 3: La médico hablaba muy bien lo que es el inglés, pero la

enfermera no. Entonces, bueno, la enfermera me llamó para que yo acompañara a la

paciente a hacerse unos análisis de sangre muy, muy, muy urgentes. Y, bueno, yo

estaba allí, e intentaba interpretar. Y una cosa muy, muy curiosa que te iba a contar es

que la médico hablaba en inglés con ella, pero cuando la médico hablaba con la

enfermera, entre ellas, no le contaba lo que le había dicho, entonces la paciente miraba

raro. Entonces yo en inglés, aunque bueno, lo tengo un poco oxidado, pero lo intenté,

intenté explicarle lo que pasaba, ¿sabes? Como la médico ya hablaba inglés pues yo

tampoco podía meterme mucho, y ya eran términos muy técnicos que no conocía. Lo

único que… para lo que me sirvió esa intervención es para… digamos, corregir ese

agujero de… Bueno, qué están contando. Que fue lo que yo hice, la única intervención

que yo hice. Luego ya cuando la tuve que acompañar a sacarse sangre, ahí sí que tuve

que estar 100 % porque… Casi ninguna enfermera hablaba bien inglés. Entonces, lo

que tuve que hacer fue… explicarle… tuve que explicar en qué consistían los análisis

de sangre, explicarle que tenía que mear en un bote, tres botes, la noche anterior, la

orina del día anterior y todo eso, y que el lunes tenía que venir porque no podían hacer

unos análisis y tal, y que no estaba bien. Entonces tuve que explicar toda la situación

yo en inglés, ¿sabes? Oxidado, ya, eh… porque hace ya un año y medio que no

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practico, o más, entonces, bueno. Pero bueno me salió bien y me entendió, ¿sabes?

Vamos, que tampoco fue… Yo además las palabras me iban viniendo, pero sí que tuve

que intervenir bastante y lo que hice fue importante porque tuve que explicarle pruebas

y las pruebas si no las hace bien a lo mejor la hemos fastidiado.

[The doctor spoke English really well, but the nurse didn’t. So, well, the nurse

asked me to accompany the patient to get some really, really, really urgent blood tests.

And well, I was there, and I tried to interpret. And something very, very interesting that I

was going to tell you is that the doctor spoke in English with the patient, but when she

spoke with the nurse, between them, she didn’t tell the patient what she’d said, and

then the patient had a puzzled look. So, I, in English, even though, well, I’m a bit rusty,

but I tried, I tried to explain to her what was going on, you know? As the doctor already

spoke English, I couldn’t get involved a lot, and there were many technical terms that I

didn’t know. The only thing that… My participation was useful… Was to… Let’s say, I

could fill that gap of… Well, what they’re saying. That's what I did, the only thing I did.

After I had to accompany her to take the blood test and I had to do my best there

because… Hardly any nurses spoke English well. So, what I had to do was…

Explaining… I had to explain it to her what the blood tests were about, explain it to her

that she needed to pee in a container, three containers, the night before (…) So I had to

explain the entire situation to her in English, you know? Rusty, uh… Because I haven’t

practiced in a year and a half, maybe more, so, well. But that went well, and she

understood me, you know? (…) What I did was important because I had to explain the

tests to her and if she doesn’t do the tests properly maybe we’ve messed it up].

Interpreter 3 reveals that she is familiar with her professional limitations,

as she comments repeatedly that her command of English is rather limited,

which she defines as «rusty». Additionally, she points out that she struggles

with specialised terms. Following the ethical norm of professional integrity in a

general sense, she should have declined the assignment, especially

considering that she is a student intern. In the reality of the workplace,

however, she faces a situation with no alternative solution, as there is no other

source of interpreting available at the time of the appointment. This is

contemplated as an exception to the principle of professionalism in IMIA

(2008). Thus, the interpreter seeks «the lesser of two evils». She is aware that

her limited level of English will not guarantee an immaculate interpretation, but

also acknowledges that the patient is not kept in the loop when the providers

interact with each other. This is particularly evident when the patient has a

puzzled look, and she tries to rectify the situation by filling the gap. In so doing,

she ensures the patient is still part of the interaction and aware of future steps

to monitor her health condition. Furthermore, the nurses’ poor command of

English in a subsequent communicative event prevents the patient from

understanding how to perform the urine collection test, and this triggers the

interpreter’s involvement again.

4.5. Scenario 5: If you don’t want me to say something, shut your mouth

Participants sometimes enable communication in healthcare promotion

workshops. In scenario 5, an interpreter not included in the current sample of

participants interprets for a group of French-speaking, Sub-Saharan patients,

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while Interpreter 5 does whispered interpreting (chuchotage) into Arabic for

another patient. In the course of this activity, she encounters and ethical

dilemma that she addresses as follows:

Post-encounter interview 5

1. Interpreter 5: Los pacientes africanos han hecho muchas preguntas sobre la

sangre. Estaban muy preocupados por si se vendía. Y el chico para el que he interpretado

me ha preguntado: «¿Pero por qué preguntan eso? ¿Son subnormales o qué?» Al

principio lo he ignorado y he hecho como que no lo oía. He seguido interpretando, pero

como no paraba, [nombre de la persona que imparte el taller] ha parado el taller porque

parecía que estábamos teniendo una conversación paralela muy larga y le he dicho: «Me

pregunta que por qué hablan tanto de la sangre». No he dicho lo de «subnormal». Como

el chico no entiende nada, cree que he dicho lo de subnormales y me dice: «Joé, ya no te

digo nada» y yo le he dicho: «Eso es lo que tienes que hacer. Si no quieres que diga

nada, te callas la boca». [The African patients were asking many questions about blood.

They were very worried about their blood being sold. The guy I was interpreting for was

asking me: «Why’re they asking that? Are they retarded or something?» I ignored it at first

and pretended I hadn’t heard him. I carried on interpreting, but he wouldn’t stop and [name

of staff delivering the workshop] interrupted the talk because it seemed like we were

having a very long side conversation and I told him: «He’s asking why they’re talking about

the blood so much.» As the guy doesn’t understand anything, he believes that I’ve said the

thing about «retarded» and he says to me: «Damn, I’m not going to tell you anything

anymore» and I said: «That’s what you have to do, if you don’t want me to say something,

shut your mouth].

The interpreter is confronted with a patient attempting to engage in a

side conversation with her. To prevent conflict, she acts as if she did not hear

anything, but the patient does not desist. Consequently, the person delivering

the workshop interrupts the activity to inquire about the situation, which

translates into an additional ethical dilemma. Rendering the patient’s comment

entails transferring the ethical dilemma both to the provider and

French<>Spanish interpreter. Additionally, there is a risk that the other

patients understand some of the words, which further complicates the

interaction. Thus, the interpreter decides to provide a general explanation, in

which she purposefully chooses to omit the insulting remark. However, the

Arabic-speaking patient does not understand Spanish, and he believes the

interpreter has informed everyone and reproaches her. When confronted, the

interpreter does not explain what has truly happened, but reinforces her code

of ethics and sets a precedent for future occasions. Thus, she deploys a

flexible approach to her ethical code. The interpreter assesses when strict

adherence damages the situation potentially, when to «bend» ethical

principles and when to impose them.

4.6. Scenario 6: That’s not the patient’s fault

Interpreters of the study often assist foreign patients with administrative

procedures of the hospital. These are important steps to access the

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healthcare system and receive medical assistance. For instance, patients’

hand in referral slips and identification stickers to book medical appointments.

In scenario 6, Interpreter 3 encounters an ethical dilemma when

accompanying a patient to book his next hospital’s visit:

Post-encounter interview 6

1. Interpreter 3: Y luego, bueno, le tuve que acompañar porque tuvo un problema

en Admisión porque no tenía papeleta, una papeleta, y el médico había escrito mal los

números, pero igualmente los números se veían, de su historia. Tuve que acompañarlo y

la señora, una señora que no había visto nunca, ahí en Admisión, me dijo… es que claro,

vienen aquí y vienen sin papeles y sin nada y claro, yo es que si no tengo la pegatina, no

puedo… No sé qué. Y digo, bueno, ya, pero es que eso no es culpa del paciente. Y me

dice, ¿qué me estás queriendo decir? Dice… the thing is that here... Y digo nada,

simplemente es eso, que no es culpa suya. Y que el comentario de… es que viene sin

papeles. Yo es que ese comentario no me ha gustado. [And then, well, I had to

accompany him because he had a problem in the Admission’s office because he didn’t

have a document, a document, and the doctor had wrongly written down the numbers, but

the numbers could be seen anyway, of his history. I had to accompany him, and a woman,

a woman I’d never seen before, there in the Admission’s office, she told me… They come

here, they come without any papers, without anything, and without the sticker I can’t…

Whatever. And I said, yeah, well, but that isn’t the patient’s fault. (…) And she said…

What’re you trying to say? And she said… But here. And I said «Nothing, it’s only that, it’s

not his fault (…)» That comment about… He comes here without papers. I didn’t like that

comment].

2. Researcher: ¿Lo tradujiste? [Did you translate that to the patient?].

3. Interpreter 3: Se lo expliqué luego [I explained it to him later]..

4. Researcher: ¿Y cómo se lo tomó? [And how did he take it?]

5. Interpreter 3: [Nombre paciente] es que es muy… muy tranquilo. Le he dicho

mira, ha pasado esto. He estado hablando con ella porque como ha dicho que tú no

tenías, bueno lo de los papeles no se lo dije, pero se lo dije de otra forma. Se lo dije como

tú no tenías la pegatina y muchas veces dice que venís [los pacientes], en general, sin

pegatina y yo le he dicho que no, que no es culpa tuya. [(Name of patient) he’s very…

Very calm. I told him look, this happened. I was talking to her because she said you didn’t

have, well, I didn’t tell him that thing about the papers. But I told him in a different way. I

told him like… As you didn’t have the sticker and many times you [the patients] come, in

general, without a sticker and I told her that it’s not your fault].

Scenario 6 readily illustrates that interpreters may struggle to follow

their ethical codes in practice. In this case, it is unclear whether the

administrative worker is seeking the Interpreter’s 4 complicity or venting her

frustration, as identifications stickers are required to book a medical

appointment. In any case, Interpreter 3 clearly struggles to remain silent and,

rather, leaps to the patient’s defence. Emotions play a part in this decision, as

the interpreter states that she did not approve of the staff’s comment (turn 1),

which prompts her to engage in a side conversation that does not get fully

interpreted to the patient. Disregarding fidelity, and in an attempt to prevent

conflict, the interpreter gives the patient a general overview of the situation,

without going into specifics.

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5. FINDING ETHICS IN AND OUT OF CODES

Cases presented in the previous section illustrate ethical dilemmas

faced by novice healthcare interpreters. Participants deploy a flexible

approach to these challenging situations and choose what they believe to be

«the lesser of two evils», even if sometimes their decisions imply flouting their

codes of ethics for a «higher good» or «greater cause» seemingly governing

interactions. In this sense, ethical codes provide interpreters with general

principles serving as a point of departure for decision-making, but in

professional practice they acquire a broader sense that may lead them to

deviate from strict compliance. Based on the interpreters’ comments and

situations observed, decisions are heavily influenced by three factors: human

emotion, contextual restrictions, and the theory-practice gap.

5.1. Human emotion: Why not make people having a hard time smile?

As illustrated in scenario 6, healthcare interpreting is a professional

activity riddled with human emotion, which poses ethical dilemmas to

practitioners. Patients often find themselves in situations of vulnerability that

are further exacerbated by cultural and institutional differences, linguistic

barriers or low levels of literacy, and asymmetrical relationships with providers.

In such situations, interpreters need to balance strict adherence to ethical

codes and the emotional dimension inherent to their work. As stated by Dam

(2017, p. 230), «the scene is set for clashes between personal morality and

professional ethics». The following post-encounter interview illustrates how

interpreters struggle to follow ethical principles when emotions are present:

Post-encounter interview 7

1. Interpreter 3: Es imposible... no imposible, pero muy complicado siendo algo

humano ser totalmente neutra... No imparcial, imparcial sí que tienes que ser en todo

momento, pero no... No mostrar... No ayudar a esa persona si esa persona necesita en

ese momento, por ejemplo, yo qué sé, algo de comer y ves que esa persona de verdad lo

necesita y que... hombre, el código deontológico te dice que fuera... de puertas para fuera

se acabó. Pues, oye, pues... Eso no es así, no es real. Muchas veces... Y acompañarlos y

a lo mejor hablar con ellos... El código deontológico... Muchos profesores te dicen: «no, tú

cuando estés en el pasillo no hace falta que hables con él, te separas de él, tal, para no

crear un vínculo». Pero es que es muy complicado. Y yo me pregunto... ¿por qué? A ver,

no voy a crear un vínculo con el paciente porque... Pero... ¿por qué no hablar con él,

sacarle una sonrisa a esas personas que lo pasan mal? Y por lo menos sacarle una

sonrisa, que yo creo que es muy importante. O sea que con el código deontológico sí, se

aplica, quizá más dentro de la consulta que fuera, pero hay cosas que no... No puede ser

cien por cien. [It’s impossible… Well, not impossible, but very difficult as it’s something

human, to be completely neutral… Not impartial, yes, you need to be impartial at all times,

but not showing… Not showing… Not helping that person if that person needs it at that

moment, for example, I don’t know, something to eat and you see that that person really

needs it and that… Well, the deontological code tells you that… Outside the consultation

room it’s over. Well, listen, well… It’s not like that, it’s not real. Many times… And

accompanying them and maybe talk to them… The deontological code… Many lecturers

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tell you: «No, when you’re in the corridor you don’t need to talk to him, you move away

from him, so as not to create a bond.» But that’s really complicated. And I ask myself…

«Why?» Well, I’m not going to create a bond with the patient because… But… Why not

talk to him? Why not make people having a hard time smile? And at least make them

smile, I think that’s really important. So the deontological code yes, it’s applied, maybe

more in the consultations than outside, but there’re things that… That cannot be like that

100%].

Although neutrality and impartiality are concepts often used

interchangeably (Zimányi, 2009), Interpreter 3 distinguishes them. She

emphasises the need to be impartial (i.e., not favouring any of the parties

involved) throughout her work, but also refers to the impossibility to remain

neutral or, as she understands the concept, unaffected by the patient’s

emotional (i.e., distress) and physical (i.e., hunger) needs. Additionally, she

highlights that ethical codes are mainly applied in the course of medical

consultations but suggests that they may not offer an optimal solution in other

activities in which interpreters also take part, such as accompanying patients

or waiting with them in the corridor (see Álvaro Aranda, 2021, for the roles

enacted by interpreters in activities different to consultations). As also stated in

the post-encounter interview, the interpreter somewhat questions the advice

received in the classrooms during her studies, and this leads us to our next

point.

5.2. The theory-practice gap: It’s a different world

Interpreters participating in the study denounce a gap between what

they should do in theory, as seen in the classroom, and the reality they

encounter in the workplace. This resonates with the situation described by

Angelelli (2008), who considers that there exists no converging dialogue

between theory and practice but, rather, a parallel conversation. This is readily

illustrated in the following excerpt:

Post-encounter interview 8

1. Researcher: ¿Cuáles son los aspectos más positivos de esta experiencia?

[What’re the most positive aspects about this experience?]

2. Interpreter 4: El aspecto en sí más positivo de haber estado aquí ha sido la

experiencia que he adquirido y poner en práctica lo aprendido en el máster y la carrera, y

también ver que hay diferencias entre lo que te dicen en clase y luego la… vamos,

ponerlo en práctica, que… Que hay unas cuantas. [The most positive aspect about being

here was the experience I acquired and putting into practice what I learned in the Master’s

and my undergraduate degree, and also seeing that there’re differences between what

you are told in class and then, well, put it into practice. There’re several differences].

3. Researcher: ¿Has aplicado la formación recibida a esta experiencia profesional

o por algún motivo detectas una contradicción entre la realidad del centro y la teoría de

las aulas? [Did you apply your training to this professional experience, or do you see a

contradiction between the reality you found at the hospital and the theory taught in the

classroom for some reason?]

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4. Interpreter 4: En sí al principio intenté aplicar la formación recibida durante mis

años de estudios, y luego… Es que es eso, es que vi que hay… Es un mundo diferente,

así que al menos la formación recibida me ayudó para tener una base y ya… Luego es…

Como lo vaya desarrollando yo. [At the beginning I tried to apply the training I received

during my studies and then… Then yeah, I saw that there’s… It’s a different world, so the

training received at least helped me to have a base and then… Then it’s… How I develop

it.].

Interpreter 4 reflects on the dissimilarities between the knowledge

acquired by means of lectures, roleplays and class discussions and the

reality found during his internship, which he defines as a «different world»

(turn 4). However, it should be noted that he considers training as an

important foundation proving to be a useful tool to analyse situations and

resolve conflicts in professional practice. It could be considered that training

and education provide interpreters with basic theoretical skills related to

ethics, but decision-making in healthcare contexts is heavily influenced by a

constellation of factors external to interpreters. This is key to understand our

next section.

5.3. Contextual restrictions: you don’t always have the theory in mind

because the reality doesn’t allow you to

Healthcare interpreting is a situated practice (Angelelli, 2019) and it

needs to be understood together with the constraints associated to the setting

in which it occurs. Echoing this statement, interpreters of the sample indicate

that they are sometimes unable to follow the tenets presented in their ethical

code due to limitations imposed by their working environment, together with

expectations and petitions made by patients and other professionals with

whom they work and maintain hierarchical relationships.

Post-encounter interview 9

1. Interpreter 5: Muchas veces, no puedes, no… o sea, no puedes solo estar con

el… la teoría al 100 % delante de tus ojos. No siempre la teoría la tienes por delante

porque es que muchas veces en la realidad no te lo permite, entonces eso. Eh… Por

ejemplo el código deontológico y todo esto a veces no puedes aplicarlo al 100 % (...)

Cuando pasas por una experiencia como esta de interpretación en las prácticas con… en

un hospital o en cualquier otro servicio público ves que tienes que adaptar muchas cosas

de la teoría y de lo que has aprendido. Entonces eso es fundamental, porque si no, no

puedes avanzar, no puedes. Tienes que adaptarte. [Many times you can’t, no... I mean,

you can’t always be with... the theory before your eyes 100%. You don’t always have the

theory in mind because many times the reality doesn’t allow you to, so yes. Eh… For

example, the deontological code and all of that sometimes you can’t apply it 100% (…)

When you have an interpreting experience like this one in my internship at… a hospital or

any other public service you see that you need to adapt many theoretical things and that’s

what I learned. So that’s essential because otherwise you can’t move forward, you can’t.

You need to adapt].

278 Finding ethics in and out of deontological codes […]

Hikma 21 (2) (2022), 257 - 286

The interpreter states that the working environment and its demands

undoubtedly shape her behaviour in practice. To quote her, sometimes

interpreters need to «adapt theoretical things» learned in class «to move

forward.» This may imply that trainee interpreters are often presented with

complex and even contradictory messages, underlining once again the theory-

practice gap previously mentioned. In these circumstances, interns of the

sample learn to balance the theoretical knowledge acquired in the classrooms

with other important elements also affecting interactions, such as contextual or

even institutional restrictions.

6. F

INAL REMARKS

This paper examines ethical dilemmas faced by healthcare

interpreting trainees at a Spanish hospital located in Madrid. For the

purposes of our study, ethical dilemmas included situations in which at least

one ethical principle was compromised and required interpreters to decide

among different courses of action available (Team ARSu, 2020). To guide

their behaviour, trainees resorted to the theoretical notions received in their

training, as well as the ethical principles imposed by the internship institution

(i.e., confidentiality, impartiality, accuracy, refraining from taking personal

advantage from any information obtained in their work, beneficence and

nonmaleficence).

Throughout the fieldwork, participant observation and post-encounter

interviews revealed that interpreters of the sample deploy a flexible

approach to challenging situations and disregard ethical principles at times.

Participants choose what they believe to be «the lesser of two evils», even if

this implies flouting their codes of ethics for a «higher good» or «greater

cause» governing interactions. In this sense, codes of ethics provide interns

with guidelines serving as a point of departure for decision-making, but in

professional practice they may need to deviate from strict compliance. More

precisely, students perform tasks beyond interpreting that include handling

healthcare materials when there is no other option available (scenario 3). On

the other hand, they sacrifice the tenet of fidelity when it entails assuaging

the patient’s discomfort, facilitating the provider’s clinical work (scenario 1) or

avoiding conflicts (scenarios 2, 5 and 6).

Based on the previous observations, it can be stated that interpreters

seek effective responses to respect their paramount ethical priority—duty of

care to patients (Ozolins, 2014)—which aligns with the tenets of beneficence

and nonmaleficence common to other healthcare professions. As seen in

our dataset, trainees sometimes justify breaching the code of ethics to stand

for these principles. Nonetheless, their understanding of these tenets may

lead to challenging situations. This is illustrated in scenario 6, in which the

Cristina Álvaro Aranda 279

Hikma 21 (2) (2022), 257 - 286

trainee interpreter does not fully render the staff’s criticism and, instead, only

provides a general overview of the situation. In this case, she filters the

message to avoid a conflict, but sugar-coating nuances present in the source

message also involves concealing the administrative worker’s real attitude. In

turn, she removes the patient’s right to get angry or know what is truly

happening. This leaves the patient in a situation of inferiority and vulnerability

as opposed to Spanish-speaking patients, who would be informed and could

replicate, if they so wish.

On the other hand, preliminary findings indicate that interpreters are

influenced by the theory-practice gap, human emotion, and institutional

expectations or restrictions. Healthcare interpreting is a situated practice

(Angelelli, 2019) and, consequently, ethical dilemmas do not occur in

isolation from the participants’ attitudes or contextual limitations. Thus, there

appears to be a conflict between interpreters' standardised training regarding

professional ethics and institutional expectations (post-encounter interviews

1, 7, 8, 9), in line with previous criticism on teaching ethics (e.g., Baker &

Maier, 2011; Brander de la Iglesia, 2017; Dean & Pollard, 2011; Martín

Ruano, 2017b). Prescriptivism found in ethical codes thus leaves interpreters

in a difficult position when confronted with demanding situations. Interpreters

of the sample considered professional practice as «a different world» (post-

encounter interviews 7 and 8), in which abiding by ethical tenets blindly does

not always provide clear-cut solutions.

This disconnect between theory and practice does not necessarily

mean that ethical codes are not useful tools, but they are ignoring voices

from the workplace. Teaching ethics and deontology must not overlook the

experiences of practitioners to enrich and foster the link between education

and practice. Drawing on our data, interpreters are expected to perform

tasks exceeding interpretation in consultations, such as accompanying

patients and assisting them with administrative procedures. These tasks

bring the interpreters’ role close to that of intercultural mediators (Pokorn &

Mikolič Južnič, 2020), and this should be included in existing or future codes

of ethics, which usually advocate for interpreters as linguistic conduits. This

is particularly relevant in geographical contexts such as Spain, where

healthcare interpreters are expected to develop interpretation and mediation

tasks (Grupo CRIT, 2014).

Furthermore, interpreters should be encouraged to develop critical-

thinking skills in their training. They must be ready to assess the potential

consequences of their actions and balance the influence of institutional

constraints, interactional goals, and participants’ attitudes or needs, together

with their own. To facilitate reflection and knowledge-sharing, it could be

280 Finding ethics in and out of deontological codes […]

Hikma 21 (2) (2022), 257 - 286

interesting to develop a collaborative, open-access platform for practising

interpreters, trainees, academics, and healthcare providers to interact with

one another and discuss experiences regarding ethical dilemmas. These

experiences could be filtered and organised under different labels (e.g.,

patient’s requests, provider’s expectations, prejudices, cultural differences...)

that may offer extremely valuable information to revisit deontological codes

and education programmes. In this sense, a selection of events could be

discussed by an interdisciplinary panel involving the voices of medicine and

healthcare interpreting at different levels (i.e., practitioners, trainees, and

trainers) to agree on convenient ethical behaviour, and/or assess the

potential consequences of different courses of action, which could be further

tested in focus group discussions with migrant patients.

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