Religious belief and surrogate medical decision making

Journal of Clinical Ethics

Volumn 20, Issue 2, 2009, Pages 192-200

  Eskew, Stewart ^a   Meyers, Christopher ^b  

^a UNIVERSITY OF WISCONSIN MADISON   (United States)

^b CALIFORNIA STATE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANALGESIC AGENT;

ADULT; AGED; ARTICLE; BLOOD TRANSFUSION; CASE REPORT; CEREBRAL PALSY; CLERGY; CULTURAL ANTHROPOLOGY; DECISION MAKING; EMPATHY; ETHICS; FAMILY; FEMALE; HUMAN; INFORMED CONSENT; JEHOVAH'S WITNESS; MENTAL CAPACITY; METHODOLOGY; OVARY TUMOR; PAIN; PARENTAL CONSENT; PATIENT CARE; PROBLEM SOLVING; PSYCHOLOGICAL ASPECT; RELIGION; STANDARD; TERMINAL CARE; THINKING; TREATMENT REFUSAL; UNITED STATES; UROLITHIASIS;

ADULT; AGED; ANALGESICS; BLOOD TRANSFUSION; CEREBRAL PALSY; CLERGY; CULTURAL DIVERSITY; DECISION MAKING; EMPATHY; FAMILY; FEMALE; HUMANS; JEHOVAH'S WITNESSES; JUDGMENT; MENTAL COMPETENCY; OVARIAN NEOPLASMS; PAIN; PARENTAL CONSENT; PATIENT CARE TEAM; PROBLEM SOLVING; RELIGION; RELIGION AND MEDICINE; TERMINAL CARE; THINKING; THIRD-PARTY CONSENT; TREATMENT REFUSAL; UNITED STATES; URINARY CALCULI;

EID: 67650724115     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (36)

1. C.F. Slieper, K. Wasson, and L.M. Ramondetta, "From Technician to Professional: Integrating Spirituality into Medical Practice," American Journal of Bioethics 7, no.7 (July 2007): 26.
2. Farr Curlin and Chad Roach point out, though, that physicians report no such discomfort, but instead are open and responsive to patients' religious beliefs ("By Intuitions Differently Formed: How Physicians Assess and Respond to Spiritual Issues in the Clinical Encounter," American Journal of Bioethics 7, no. 7, July 2007: 19-21). We suggest this discrepancy may reflect the common difference between research subjects' self-reporting and observation of practiced behavior.
3. The notable exception is in the case of a minor child. Because the courts have consistently determined, for example, that parents who are members of Jehovah's Witnesses may not refuse needed blood products for a young child, clinicians are much less reticent to seek judicial relief.
4. Such studies have produced mixed results, based in part on the difficulty of testing for prayer's impact, but some point to a clear beneficial effect.
5. See, for example, the series of articles in American Heart Journal (April 2002, April 2006, and in the same journal's on-line-only issues, September and October 2006).
6. See also, H.G. Koenig, The Healing Power of Faith: Science Explores Medicine's Last Great Frontier [New York: Simon and Shuster, 1999).
7. Experienced clinicians learn a multitude of ways to manipulate patients and family to agree to their preferred choices, the effect of which is, in fact, to pressure decision makers. Compare with J.M. Luce and D.B. White, "The pressure to Withhold or Withdraw Life-sustaining Therapy from Critically Ill Patients in the United States," American Journal of Respiratory Critical Care Medicine 175 (2007): 1104-1108
8. M.G. Kuczewski, "Talking about Spirituality in the Clinical Setting: Can Being Professional Require Being Personal?" American Journal of Bioethics 7, no.7 (July 2007): 5. Kuczewski's target article, with commentaries (some of which we reference above and below), is, to our knowledge, the first to explicitly address this issue within the bioethics literature.
9. We are grateful to Stephen Campagna-Pinto for informing us that the term "theological" now carries prejudicial connotations, being seen as exclusive to monotheistic belief systems. We nonetheless retain the terminology, mainly because it is embedded in Robert Audi's principles, upon which we heavily rely.
10. Putting religious motivations back on the table is also Kuczewski's, and the commentators', principal goal, with focus on what we call "communicative strategies," below. Kuczewski, see note 5 above.
11. Compare with N.F.S. Ferrè, Reason in Religion (London: Thomas Nelson, 1963), 16.
12. The two cases have been modified, in part to protect the privacy of those involved.
13. We explain the difference below.
14. T.I. Cochran, "Religious Delusions and the Limits of Spirituality in Decision-Making," American Journal of Bioethics 7, no.7 (July 2007): 14.
15. See W.V.O. Quine, "Two Dogmas of Empiricism," in Philosophy of Science: The Central Issues, ed. M. Curd and J.A. Cover (New York: W.W. Norton & Company, 1998);
16. W. Sellars, Empiricism and the Philosophy of Mind (Cambridge, Mass.: Harvard University Press, 1997);
17. and H. Putnam, "Why Reason Can't be Naturalized," in After Philosophy: End or Transformation, ed. K. Baynes, J. Bohman, and T. McCarthy (Cambridge, Mass.: MIT Press, 1987).
18. T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001), 398.
19. "All" is misleading, given that the most demanding version, wide reflective equilibrium, requires consistency among the totality of one's beliefs - religious, moral, metaphysical, scientific, social, and psychological. As explained below, we seek only religious and moral coherence. Farr Curlin et al. also suggest that equilibrium, "integration," can be found between best medical practices and spiritual beliefs.
20. F. Curlin et al., "When Patients Choose Faith Over Medicine: Physician Perspectives on Religiously Related Conflict in the Medical Encounter," Archives of Internal Medicine 165 (10 January 2005): 88-91.
21. Charles Culver and Bernard Gert make a similar move in Philosophy in Medicine (New York: Oxford University Press, 1982). Audi more thoroughly explains and defends his principles, hence our reliance on him.
22. R. Audi, Religious Commitment and Secular Reason (Cambridge, U.K.: Cambridge University Press, 2000), 86.
23. Ibid., 96.
24. Ibid., 130.
25. Surrogate decision making more clearly satisfies our "impact on others" criterion (below). Further, when patients are primary decision makers, respect for autonomy holds greater moral weight; we can imagine cases in which patients' direct choices would satisfy the impact criterion, but these will be rare enough, and made complex enough by autonomy, that we focus here on surrogate cases only.
26. These complexities call into question whether the son was a de jure surrogate, since he seemed to be acting out of his interests, rather than expressing his mother's will. No other family member, however, was willing to challenge his status and thus without a court order his de facto status became legally binding.
27. Respect for the patient's autonomy is also what distinguishes this case from those of minor children of parents who are Jehovah's Witnesses. In both cases the patient lacks decisional capacity, but the minor child never had the opportunity to choose a life plan. Assuming the parents' veracity on this point - and there was no reason to doubt it - this case was like any other involving respect for a nowincompetent patient's previous autonomous choice.
28. Medical staff were committed to providing pain management, but all agreed that achieving this would require both optimal compliance on the part of the family, and, eventually, enough medication to effectively sedate the patient.
29. As noted above, mis question makes up the bulk of Kuczewski's analysis and the commentators' replies. Our approach largely mirrors the dominant theme in all the essays: more conversation, a greater willingness to explicitly address the religious, is needed. Our only significant departure resides in our greater, if still quite reluctant, willingness to seek judicial relief.
30. Kuczewski, see note 5 above.
31. See also A.S. Brett and P. Jersild, " 'Inappropriate' Treatment Near the End of Life: Conflict Between Religious Convictions and Clinical Judgment," Archives of Internal Medicine 163, no.14 (28 July 2003): 1645-1649;
32. and B. Lo et. al., "Discussing Religious and Spiritual Issues at the End of Life: A Practical Guide for Physicians, Journal of the American Medical Association 287, no. 6 (13 February 2002): 749-754.
33. Kuczewski adds the more controversial recommendation that clinicians - especially physicians and ethicists - also consider discussing their own religious beliefs as a way of connecting with the patient or surrogate. Most of the commentators reject that option, citing the potential for abusive proselytizing. Our sense is that the commentators do not sufficiently appreciate Kuczewski's point, that such communication is not reducible to clear-cut rules, but instead emerges from discerning judgment, on a case-by-case basis. Such judgment by definition includes recognition of the power healthcare professionals typically wield over patients.
34. Kuczewski, see note 5 above.
35. Obtaining a court order involves not only the alienation and costs noted above, but also lengthy delays, made more problematic, in this case, by the patient's expected limited life expectancy. We nonetheless believe it warranted in this and similar cases.
36. We are grateful to Steven Gamboa and Stephen Campagna-Pinto (and to the anonymous journal reviewers) for their helpful suggestions to earlier drafts.