Healthcare has always been a practice of meaning as well as a science. Beneath the diagnostic language, beneath the protocols and data, lies something quieter, older and harder to name: the human need for recognition, understanding and dignity. In cross-cultural contexts, this need becomes more complex because it reveals depth.

In an earlier article, I reclaim the sublime, not as an aesthetic pleasure, but as moral and emotional disorientation in the face of vastness, in this case, the vastness of culture. In healthcare, the sublime appears when healthcare professionals confront beliefs, logics or choices that exceed their frameworks, when they are pulled beyond the limits of what they can explain or control yet are still expected to act.

We have also explored the concept of liminality, the state of being between roles, systems or certainties. Patient, healthcare professionals and systems alike find themselves in liminal space when care unfolds across cultural divides, when diagnoses are not yet fixed, or when belief and medicine coexist without resolving.

The sublime, vast and overwhelming, often vertical in metaphor: the infinite, the terrifyingly beautiful. Liminality, suspended and ambiguous, often horizontal in metaphor: a crossing, a becoming. The sublime and the liminal, both involve disorientation and a certain amount of putting oneself back together again. The sublime destabilises by scale. The liminal destabilises by transition.

This article brings these threads together, through a revisitation of one of the most well-known images in cultural work: the iceberg.

The Iceberg of Culture

Culture is often described as an iceberg. Above the waterline are visible expressions: food, clothing, language and customs. These are what cultural competence training often focuses on. They are important, albeit cosmetic and incomplete.

What impacts more on health outcomes is underneath: the vast, submerged terrain:

·       Beliefs about time, family, suffering and fate.

·       Spiritual meanings of illness.

·       Concepts of personhood, autonomy, shame, stigma, healing, death

·       Histories of trauma, mistrust, displacement.

These unseen forces shape behaviour more than anything above the waterline. And yet most healthcare tools, be these COAs, checklists, translated leaflets, patient satisfaction scores, skim only the surface.

When the tools fail to make sense of a patient encounter, it is often because they were never designed to reach what lies beneath.

The Sublime is the feeling of depth

When a healthcare professional encounters something that resists translation, when a patient speaks through metaphor or refuses treatment due to ancestral logic, or silently endures what others would otherwise voice, that moment creates sublime dissonance. This is a feeling of:

·       Not fully grasping what we are confronted with.

·       Not being entirely sure what to do.

·       But knowing that it is something that we have to respond to.

This is what happens when we brush against the submerged part of the iceberg.

And just like with natural icebergs, ignoring what lies beneath is dangerous. Titanic healthcare or, indeed, social care moments happen when systems assume that the visible is all that matters.

Healthcare professionals as navigators

If the iceberg is the structure, then the healthcare professional is the navigator – not in control of the sea, not able to go to every depth, but attuned to the tides, aware of the undercurrents and wise enough not to mistake the surface for the whole.

The navigator, one who can feel dissonance without panic, sense depth without drowning, act without needing full comprehension. This is the ethical maturity of care.

From mastery to presence

Healthcare education still too often prioritises mastery: mastering symptoms, mastering cultures, mastering communication techniques. But when we deal with human suffering shaped by migration, memory, belief and pain, what is required is presence, rather than mastery.

Presence means:

·       Being honest about what you do not understand.

·       Being courageous enough to ask.

·       Being disciplined enough to listen without reducing.

·       Being strong enough to act when action is needed – even without full cultural fluency.

What this looks like in practice

A sublime-aware model of care could look at widening the frame beyond medical science:

·       When a patient refused a medically indicated procedure, the healthcare professional could ask ‘what it means’, in addition to ‘why’.

·       When a family speaks for a patient, the healthcare professional could explore whether that reflects coercion or cultural coherence.

·       When beliefs appear irrational, the healthcare professional could pause before correcting them. They may be deeply rational within another system.

Healthcare professionals must be trained not just in facts, but in threshold ethics: the capacity to act at the edge of certainty, with both humility and integrity.

To care for someone culturally different from you is not about accommodating to their customs, but to stand at the edge of their world, knowing you cannot cross it completely, but also knowing that you are called to meet them, with skill, truth and compassion.

This means to:

·       Hold space for what cannot be said in your language and maybe theirs.

·       Recognise the logic of a belief even if you do not and cannot share it.

·       Act decisively when harm must be prevented, without vilifying what you oppose.

·       Stay present when clarity does not arrive.

This could be a moral stance, not just for individual professionals, but for healthcare systems, research design, leadership and education.

Care at the threshold

For the healthcare professional to practice sublime-aware care is to walk toward the unknown with their eyes open. It is to act wisely in the face of what they do not know. It is to recognise that the unseen part of the patient is often the most important part.

This could be a new ethic of care. It is not one centred on politeness or performance, but a deep commitment to stand at the shoreline, attuned to the tides, ready to respond to whatever emerges from beneath.

What matters most is not always visible. It is always there, beneath the waterline, waiting to be heard.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025