Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters9 min read

March 22, 2017

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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22 Comments on "Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters9 min read"

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The author makes some valid points as well as some gross assumptions. I would have preferred a well rounded and thoughtful discussion considering the appropriate use of VRI and the benefits and limitations to both VRI and onsite interpreting. When you refuse to consider both sides of an issue and are so extremely biased in your arguments you actually weaken your position.

I’m a CODA and find it hard to believe how one sided this article is, considering the vast benefits my parents receive by having VRI available to them. One set of parents live in a rural area, hours away from a town with certified interpreters, and in an emergency situation would have had to wait an agonizingly long amount of time for a skilled interpreter to show up. That is not equality! And even then there is no guarantee that this certified interpreter would be well-versed or skilled in a medical setting. We all know our Code of Professional Conduct… Read more »
Great article Shelly! I too have opted to not work for a well-known VRI company who provides medical interpreting services, for the reasons you mentioned. I was almost replaced by the robot interpreter…. I showed up at an appointment not too long ago and the receptionist said ‘Ohh! We don’t need your services today or any longer. We have the robot interpreter now’. The robot intetpreter? ‘Yes! (excitedly). On the computer, it’s a robot that interprets’. Do you mean an interpreter through the VRI? ‘No, it’s an actual robot who signs.’ I’ll go ahead and stay for the appointment since… Read more »
Shelly, I don’t think your article was one sided and I appreciate what you wrote. I am not going to jump all over you…sometimes it is not easy to step out on a limb and write what you are thinking. I am a medical interpreter, I have 4 national certifications and have been doing this for 18 years. I have witnessed and felt many of the things you talked about in your article. As a local interpreter, I do know those who would say yes, even if they didn’t understand and I have the opportunity to ask that the information… Read more »
Just few points, because I feel as though we should be hearing more from the actual Deaf community …more so than from interpreters about this issue. My main concern is to remind everyone of the fact that it is NOT leveling the playing field when a Deaf patient has to wait for hours for a certified interpreter to show up in an emergency situation, or for days before a certified interpreter is available. VRI, especially one who specializes in medical interpreting, is an excellent option to prevent this. Not in every case, but at least until an onsite can arrive.… Read more »
Maureen Moose
Thank you for this timely discussion. As a freelance interpreter in a rural area this is an issue that I see the Deaf community struggling with on a daily basis. We have hospitals in the area who take the patient’s preferences into consideration and others whose policy is “We only offer VRI.” Your statement that it is the most vulnerable patients who are unable to advocate for themselves that are the most disadvantaged by the “VRI only” policy is spot on. This is a discussion that we need to be having with both the Deaf and medical communities. I’ll be… Read more »
Suzanne Terrio
The passion of this article ,and the thoughtful responses, reflect the interpreters’ experiences in their respective geographic areas. Fortunately, the hospital systems in my metroplex have the hearing and deaf clients come to the conclusion when, and under which circumstances, VRI, VRS, in person Deaf Interpreters, and in person Hearing Interpreters are or are not effective. If VRI is attempted , it is usually well before I arrive, during the intake phase, or to ascertain the information that a specific type of live interpreter is being requested. If I am told that VRI was used prior to my appearance, once… Read more »

Amen! Perfectly summarized…thank you.

Suzanne Terrio

It may be presumptuous of me to have the opinion that I do not envision an interpreter, like the author of this article, to be robotic in any format. She would use her years of on-site interpreting, cultural mediation, linguistic skill set, and “professional empathy” to be candid with her hearing and deaf consumers, letting them know what she is able to do, or not to do, under the VRI, VRS, or on-site situation. I am honored to have colleagues like many of the serious interpreters who express themselves through articles and replies on Street Leverage.

I was very disappointed to read another article that presents VRI in a totally negative light. I believe this article gives a partial picture of the VRI experience . This really isn’t an article with strong evidence , its reads more like an editorial comment . I would not prefer that a VRI interpreter continue in a distressing news encounter with poor technology. Did I accept an assignment knowing that’s going to happen? This problem really stems from a lack of communication and understanding within the community and society at large. My other bone of contention is that this article… Read more »
I think part of the reason community interpreters have acquired such a negative view of VRI stems from the fact that we’re called in for ‘clean up work’ regularly. So we only see the total train wrecks. For consumers that VRI works perfectly for, we often never hear about it, except perhaps from nurses with stories of, “with our last deaf patient we used the machine and there was absolutely no problem. I don’t understand what is different about this D/deaf patient.” Personally I’ve been doing community work for 5 years now, and VRS for 2 years, and I’ve got… Read more »

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