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Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters

Shelly Hansen explores the ethical implications of VRI in medical settings, especially the impacts of dropped connections during sensitive consultations and loss of consumer choice regarding live, on-site sign language interpretation.

Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters

It’s all the rage. Those smooth little carts with satisfying clicks and keys. Sweet control, right here at my fingertips for your eyes. No more waiting for a live interpreter to arrive. No more scheduling…it is on demand 24/7/365. No more incorporating another breathing human being into the interaction; we’ve gone high-tech and modern, happy to share our space with a “machine interpreter”, the term used locally by health care provider staff for Video Remote Interpreting/VRI. The medical facility loves this kind of sterile control.

[View post in ASL]

The patient, on the other hand, may have a mixed response to the cyber–signer. Like cafeteria food and military MRE’s, this is a one-size-fits-all solution. If a person has vision issues, is not a strong signer and/or struggles with the style, speed or information from the “machine interpreter”, if they are dizzy, lying down awkwardly, giving birth, going into a radiology department, are from a foreign country and need a specialized sign language, are elderly and prefer a familiar interpreter, are an active child with attention issues or a CODA utilizing the interpreter, would benefit from techniques used by CDIs such as physical movement, drawings or references to visual aids in the immediate environment (including the current meds list on the computer charting screen), or struggle with paperwork and literacy challenges, they are out of luck. Not only are these individuals out of luck, they now need to self-advocate against a large medical institution or physician who has already invested in a “solution” to this communication barrier, and who feels that due diligence has been satisfied.

Communication in Context

When I step back and consider these experiences as a whole, the impact of VRI appears to be greatest on vulnerable adults. We can all find ourselves vulnerable at times, and some individuals may consistently interact as vulnerable adults. I have noticed that communication is most effective in the context of relationship when interpreting for these encounters. The negotiated meaning within a tangible human relationship provides a context for effective communication that mitigates barriers for vulnerable adults and provides a level of comfort needed to genuinely engage with others. While it may seem an overstatement, trust in the interpreter allows for depth of conversation that is not possible for some clients via technology which has an “outside, looking-glass” quality. I consistently hear feedback about “not remembering what they said”, “not understanding but agreeing anyway” and being told there “weren’t any live interpreters available” when those facilities aren’t calling live interpreters any longer as a standard procedure.

“Do No Harm”

RID Certified sign language interpreters historically have been vigilant to “do no harm”, maintaining high professional standards of ethical conduct, creating ethical codes of conduct, establishing ethical review boards and making every effort to provide quality service to the Deaf, Hard of Hearing, DeafBlind, Late-Deafened, and Hearing communities as allies and professionals. This commitment to the profession has enabled increased access to places of public accommodation throughout society and is a source of quiet pride and job satisfaction for many sign language interpreters who are committed to increased equality, autonomy, and self-actualization.

As a freelance community sign language interpreter, I have seen a dramatic shift in medical interpreting assignments from live interpreting to VRI supported interactions. As I sit on the cyber-fence, wanting to continue the work I love and provide services to people who need, want, and are requesting live interpreters, I am faced with an ethical dilemma. Do I participate in a flawed and “do some harm” medical VRI system because my livelihood is being affected by marketplace shifts?

Sample Scenario of a Botched VRI Appointment

A patient goes to a medical appointment in a facility to discuss the results from a recent scan with a specialist. The office uses a VRI system. The patient is optimistic about VRI, despite prior frustrations with freezing screens and dropped connections resulting in re-scheduled appointments with a local, familiar, RID certified “live” sign language interpreter. The doctor begins to review the results of the scan along with the possible issues that may be causing symptoms of concern. The “worst case scenario” is discussed and then the VRI starts to cut out, freezing. The tech issues cannot be resolved, again. The doctor, exasperated says, “This is not a service, it’s a DIS-service.” The appointment is abruptly curtailed and a follow-up appointment is scheduled for next week with an onsite, “live” interpreter.

Shelly Hansen

When the appointment begins the following week, the “live” interpreter is unaware of the previous snafu. The doctor begins again to explain the medical condition, and informs the patient that s/he does NOT have the fatal condition. The patient breaks down. For an entire week, the last message about the fatal flaw and partially explained scan image had left the person believing that they had the dreaded malformation and the condition was terminal. The visible relief on the face of the patient is combined with frustration and anger. Both the patient and doctor commit to no further VRI appointments, expressing relief to have an in-person sign language interpreter on site. They agree that using VRI just isn’t worth the frustration, miscommunication and emotional duress.

If the “live” sign language interpreter left the room at the moment of diagnosis, s/he could lose her/his certification for ethical malpractice. The patient could file an ethical complaint with RID stating that the interpreter violated NAD-RID Code of Professional Conduct tenets 6.2 and 6.4 (see below).

Unintended Consequences

In my area, an older gentleman took his own life after receiving a terminal diagnosis. His family found him alone in the backyard. To my knowledge, this was not an interpreted interaction. However, it is possible that someone could react with serious consequences to a misunderstood partial-diagnosis. A scenario like this happened January 2017 at the Limerick Hospital in Ireland. A man received a terminal cancer diagnosis and took his own life in the hospital chapel.

Codes of Professional Conduct

Let’s look at some pertinent codes of conduct for medical sign language interpreters.

IMIA (International Medical Interpreters Association)

“Responsibility Toward Ensuring Adequate Working Conditions” The interpreter shall strive to ensure effective and productive communication in any professional situation and make every effort to have working conditions in place that will allow him or her to provide quality interpretation services.

“Right to equal treatment” Patients have a right to receive treatment in a language they understand; these rights are governed by federal anti-discrimination laws and the ADA.

“Informed consent” Patients should be aware of treatment options and consent to treatment only after understanding these options. Communicating information accurately is essential to informed consent.

“Beneficence” The health and wellbeing of patients is a core value in all health care professions, as well as in medical interpreting.

The NAD/RID Code of Professional Conduct

4.0 Respect for Consumers

4.1 Consider consumer requests or needs regarding language preferences, and render the message accordingly (interpreted or transliterated).

4.4 Facilitate communication access and equality, and support the full interaction and independence of consumers.

6.0 Business Practices

6.2 Honor professional commitments and terminate assignments only when fair and justifiable grounds exist.

6.4 Inform appropriate parties in a timely manner when delayed or unable to fulfill assignments.

6.5 Reserve the option to decline or discontinue assignments if working conditions are not safe, healthy or conducive to interpreting.

Similarly, the National Code of Ethics for Interpreters in Health Care includes “beneficence” and “do no harm,” along with “fidelity”:

“The essence of the interpreter role is encapsulated in the value of fidelity. The American Heritage Dictionary of the English Language describes fidelity as involving the unfailing fulfillment of one’s duties and obligations and the keeping of one’s word or vows.”

More Questions than Answers

How can a career medical interpreter agree to work as a VRI medical interpreter with the knowledge that predictable and unresolved VRI technical issues, including consistently disrupted and poor quality connections and communications, are occurring throughout the healthcare system and political practice issues in which “one size fits all” approaches that dictate language use without options for live on-site sign language interpreters are creating barriers for consumers that violate medical and RID certified interpreter ethical standards? Does the interpreter ignore these issues and shift that duty to the health care system and VRI employer, and ignore the systemic impact of complicit participation in a flawed approach to health care interpreting?

At the moment, I am working triage. Those failed VRI encounters, re-scheduled appointments, miscommunicated partial diagnoses are creating a clean-up tier of work for live interpreters. I’m holding out for “live” interpreting, despite the economic uncertainty of increased VRI use and the lower hourly wages those positions offer. Do I want to be part of the machine interpreter phenomenon? How can I ethically participate in quality healthcare interpretation in 2017 and beyond?

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Questions to Consider:

  1. What protections are in place for consumers of medical VRI? Are there rating or feedback mechanisms available to track customer and provider satisfaction post-appointment?
  2. What alternatives are available or recourse do consumers have in the event a VRI appointment fails and are there systems in place to allow patients to pre-select live or VRI preferences especially for sensitive or technical appointments?
  3. What duty does an RID certified interpreter have in medical VRI settings and is that duty usurped by VRI companies and medical facilities choosing to eliminate live on-site interpreting in favor of machine interpreting?


The National Council On Interpreting In Health Care, and Working Papers Series. A NATIONAL CODE OF ETHICS FOR INTERPRETERS IN HEALTH CARE (July 2004.): 8. Web. 21 Mar. 2017.

Registry of Interpreters for the Deaf, Inc. “NAD_RID Code of Professional Conduct.pdf.” N.p., 2005. Web. 21 Mar. 2017.

“International Medical Interpreters Association Code of Ethics.” IMIA – International Medical Interpreters Association. International Medical Interpreters Association, n.d. Web. 21 Mar. 2017.

Collins, Pamela. “Bringing Scheduling Into View: A Look at the Business of Sign Language Interpreting.” Street Leverage. N.p., 17 Aug. 2016. Web. 21 Mar. 2017.

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Sign Language Interpreting: The Benefits of Think Aloud Protocols

Marty Taylor presented Sign Language Interpreting: The Benefits of Think Aloud Protocols at StreetLeverage – Live 2016 | Fremont. Her presentation discusses how focusing on process can result in more effective and nuanced interpretations.

You can find the PPT deck for her presentation here.

[Note from StreetLeverage: What follows is an English translation of Marty’s StreetLeverage – Live 2016 presentation. We would encourage each of you to watch the video and access Marty’s original presentation directly.]

If you enjoy this presentation and accompanying article, consider going to StreetLeverage – Live 2017.

Sign Language Interpreting: The Benefits of Think Aloud Protocols

My topic today is “Sign Language Interpreting: The Benefits of Think Aloud Protocols.” Think Aloud Protocols, abbreviated as T.A.P., refer to the process of talking about thinking. This is a commonly researched topic for discovering how people think and identifying qualitative and quantitative data. Think Aloud Protocols (T.A.P.) have been studied regularly since the 1960s with increasing frequency. We need to apply the data from this research to sign language interpreting and to our work as practitioners. In addition to applying the research, we can also apply T.A.P. directly to our work. That is what I’d like to talk about with you today.

Think Aloud Protocols as a System

First, let’s talk about protocols. When we talk about protocols, we are looking at a system – something that can be replicated and shared with other sign language interpreters. They represent ways we can discuss and debate our thought processes. The establishment and use of a system allow us to take our interpreting work to a more advanced level.

Usually, when we talk about Think Aloud Protocols (T.A.P.), we are talking about a simultaneous process. While a person is performing their work – regardless of the type of task – they talk about or sign about their work. As sign language interpreters, it would be impossible to talk about what we are doing while simultaneously interpreting. There is no way to do that. If a person is translating from a written text, it would be possible to talk about the translation process. So there is also what is called, “Think After Protocol” which is much like “Think Aloud Protocols.” They are similar processes.  For “Think After Protocols,” an interpreter would perform the work and once they had completed the task, they could look back on their work through self-analysis, asking, “What did I do? What could I do next time? How can I apply this learning to the future?”

It is important to have a system rather than a random method of looking at our work. Instead of having endless approaches, T.A.P. focus on specific ways to examine our thinking, the meanings behind those thinking processes, and the reasons for making each decision. These protocols help us to gather information about the whole process. This is what we are looking for in the T.A.P. experience.

Thinking about Thinking

We often hear the terms “cognitive thinking process” and “metacognition” which is thinking about thinking. So, thinking about thinking. We can do that. What we are doing with T.A.P. is taking our thinking and talking about it. Sharing information, learning, and teaching other people about our process.

Each individual has their particular way of thinking. There is no “right” or “wrong” answer in this case. There is simply process. Some people process information in a structured, methodical way. My thinking process is not like that. My thoughts typically meander from point to point. I will eventually get to the main topic, but my thoughts usually take a circuitous route. As a nonlinear thinker, I’m fascinated by a linear thinker’s process. How do they accomplish such structured thinking? It’s almost like meditation. And again, everyone is different. We all think differently. While I may be thinking about children, babies, interpreting, life and world travel, you all may be thinking about StreetLeverage – Live, about interpreting, about going to work tomorrow. You may be thinking, “I hope the presenters today are interesting or I’m out of here!” Today, you have to think about which workshops you will attend in the afternoon. Hopefully, you are clear that the four speakers will present their longer workshops twice in the afternoon. The workshops are an hour and a half each and we present them twice. This means you can select two presenters and attend their workshops – mine and one other. So, you may be thinking that one workshop isn’t interesting to you, but you know you can select two of the others.  Unfortunately, you can’t attend them all.

The point is that we each think differently. This is an important thing. The diversity of thinking benefits us. I can learn how you think, what you think about, how you feel, how you express yourself, the topics you discuss.  For example, a person might talk about animals or their love of photography, or their interest in baseball. You may know that I live in Canada and that I am a proud Canadian.

The Venditte Rule

A rule means that a new situation has emerged and thought is given to examine, discuss, and decide how to proceed in this new situation. In baseball –  Do you like sports? Some of you may be thinking, “I am so not going to that workshop this afternoon if Marty Taylor is going to talk about sports!”  That’s perfectly all right.  Back to the “Venditte Rule.” As you may know, some batters are more proficient batting left or right. That’s a fairly common occurrence. A pitcher who can pitch proficiently with either arm is not common at all.

Marty Taylor

The “Venditte Rule” requires the pitcher to declare to the batter which hand he will use before each pitch. Every time. This allows the batter to decide whether to bat left- or right-handed. Clearly, you can see my prowess on the baseball field by my stance here on the stage. That is the “Venditte Rule.”  The pitcher can change their approach every pitch and the batter can switch batting sides, as well. This illustrates a different way of thinking. So, Canada has one baseball team for the entire country as compared to the numerous teams in the United States. We also have an ambidextrous pitcher who is equally proficient pitching with either arm, striking players out with regularity. As an aside, in baseball, a strike is represented by a K. Two strikes is KK and three strikes is represented as KKK. This is just an FYI for everyone. This is the truth. They don’t use XXX for strikes in baseball. Just sharing my T.A.P. knowledge with you. I’m keeping you all informed and now you know about baseball’s special rule.

Focus on the Process

There have been numerous people who have researched Think Aloud Protocols (T.A.P.) related to a variety of topics. In our field of interpreting and translating, for both spoken language and signed language interpreting, there is some research available.  Not a lot, but there is some. For example, Debbie Russell, Betsy Winston, and Jemina Napier have all done some research. I’ve borrowed from their work, as well as research from other disciplines, whether it be research on children, mathematics, geography, technology, computers, etc.  In the vast body of research these disciplines represent, a common theme emerged, indicating that the most experienced, the leaders and top practitioners in these disciplines, all model and focus on process. They focus on the process of doing the work at least 75% of the time. The remaining 25% of the time is focused on product. It is interesting to note that we typically think about the product – the thing we produce, the things we can see, the result of our work. So, for our purposes, T.A.P. encourages us to focus on process.

Looking Deeper

It seems that research in the field of interpreting and translating, whether spoken or signed languages are involved, has come to similar conclusions cited above. If a sign language interpreter is able to utilize more advanced thinking skills or thinks more deeply, their interpretation is going to be more successful. That’s pretty obvious. So, when I say “deeper”, you might be wondering what I mean. I’ll give you a few examples.

  1. When a sign language interpreter considers the speaker’s intent, they are able to focus on the deeper meanings within the message. If they consider the speaker’s purpose, they will ultimately produce a more effective interpretation.
  2. Consider audience/participant needs. We have to look at the makeup of the audience – who is present? Are they Deaf or hearing? Is the audience comprised of U.S. residents or are there some Canadians in the audience? Today, we at least have one Canadian present, maybe more. I don’t know – I haven’t seen anyone yet. So, considering audience make-up is important.
  3. Finally, the interpreting process has to be considered.

If we can incorporate these three considerations in our process – speaker’s intent, audience needs and preferences, and the interpreting process itself, we typically see a more advanced, more successful work product. By including these three aspects, we are able to demonstrate our experience and our level of proficiency as compared to novice or less experienced interpreters.

Knowledge Lean vs. Knowledge Rich Skills

If we look at “knowledge lean skills” versus “knowledge rich skills”, we can see that “knowledge lean skills” represent more simple meanings. For example, an interpreter who is focused on vocabulary, grammar, sentence structure/syntax, will provide a more limited, superficial interpretation. This is focusing on product. This knowledge lean view may also include some language “challenges” that the interpreter must work through and resolve.

In contrast, “Knowledge Rich Skills” focus on process, deeper meaning, and context. We consider all the participants involved, the purpose of the communication. We also look at the interpreter’s purpose – why are they there? Are they doing a good job? All these things are part of the process. Again, if we are looking at process 75% of the time, we are good to go. I’m sure you are all spending 75% of your time looking at process. I’m sure you are all doing just fine.

“Knowledge Rich Skills” also examines social interactions. Most commonly, we see Deaf individuals in isolation. If we think about a Deaf child who is mainstreamed – they are usually isolated. Where is that social interaction for them? Where do they get social exposure to develop relationships? If we look at situations involving Deaf adults, even if the purpose of a meeting is informational, there is still a social component to it. It is so important to consider those deeper meanings and pieces of information in order to use these “knowledge rich” skills.

Interpreters are more sensitive and aware of social cues. In recognizing the emotional tenor of participants, sign language interpreters can incorporate that information in their process, not just staying on the more surface-level product.

Think Process

Regardless of our status as introverts or extroverts, our goal is to think about the system, the process of interpreting. In this afternoon’s workshops, I will expand on T.A.P. in more detail. For now, consider this:  Think Aloud Protocols can benefit our interpreting practice. Think hard. Think wisely. Think process.

Hand waves to you all!

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