Medical deontology and religious belief: between alliance and conflict.
Prof. Dr. Gonzalo Herranz, work of Biomedical Ethics, University of Navarra, Spain
lecture delivered at the Valencian Foundation of Advanced programs of study
Cycle on Ethics and Medicine
Valencia, 1987
II. Ethical standards regarding religious beliefs
III. What does respect for the patient's religious beliefs consist of?
IV. Deontology of disagreement
Medicine and Religion have maintained, since the beginning of human history, very close mutual relations. It does not seem risky to affirm that medical ethics was born, and to a large extent continues to live, as a result of the symbiosis of Religion and Medicine. This is as true for primitive medicine as it is for Western medicine, based on scientific knowledge . When Hippocrates emancipated Medicine from Religion and pointed out its destiny as a natural science, he sealed it at the same time and forever as an ethical activity, by means of an Oath taken before the gods of Olympus. He did so not simply in recognition of the divine present in nature, but also in response to the need to moderate the power of the physician and subject it to moral limits. For centuries, the Hippocratic Oath reminded the physician that his work was performed under the gaze of divinity.
Since then, with approaches and distances throughout history, the relationship between Religion and Medicine has been established at two different levels. One is an institutional and public level. The other is that of private relations.
In the former, alliances or confrontations between religious creeds and medicine as a professional corporation or with health policy are configured. Its history and present are rich in achievements, anecdotes and doctrine. For proof of this, a glance at the history sections of the Encyclopedia of Bioethics will suffice.1to Chapman's monograph2 or to the conference proceedings of the lecture on Health Policy, Ethics and Human Values convened in Athens by the committee of International Organizations of Medical Sciences (CIOMS)3. Hospitals founded for religious reasons, congregations dedicated to the service of the sick, confessionally inspired medical ethics and pastoral medicine are sufficient to evoke the fruitful alliance between medicine and religion that has existed for centuries.
The second level includes the private relationships that are inserted in the interpersonal level of the doctor-patient relationship. Here, what is specific is the meeting that takes place between two subjectivities: that of the doctor, who applies the scientific and ethical commitment of medicine in his own way staff and that of the patient, of whose personality religious beliefs form a more or less decisive part, his staff way of living his religion or of not living any religion at all. These are the relationships that I will analyze below, since I have been entrusted to deal with religious beliefs, with subjective religious assent, not with creeds, that is, with objective dogmatic contents.
II. Ethical standards regarding religious beliefs
In the Codes of Medical Ethics currently in force in the Western world, one of the fundamental duties of physicians is to respect the religious or philosophical convictions of their patients.
First of all, let us consider the ethical documents of the World Medical association .4. The Declaration of Geneva, the founding document of contemporary medical ethics, set the precedent that would be imitated by all subsequent ethical texts. It establishes this duty in a negative form, requiring the physician to promise not to allow considerations of religion, nationality, race, party politics or social class to come between his duty and his patient. Practically the same precept appears in one of the Rules for Times of Armed Conflict: "In emergency situations, the physician should always render care with skill and impartiality and without discrimination based on sex, race, nationality, religion, political opinions or any other similar criteria". Among the rights of the sick in the Lisbon Declaration is the right to "receive or refuse spiritual and moral attendance , including financial aid from a minister of their own religion".
The Code of Medical Ethics5 of the Spanish Collegiate Medical Organization establishes that "the physician must care with the same conscience and application for all his patients, regardless of their religion, race, nationality, political ideas, social condition and feelings that inspire him" (Art. 8) and imposes on the physician the obligation to respect "always the religious, philosophical and political convictions of the patient or his relatives" (Art. 24).
Also the Standards of Ethics6 of the high school Official high school of Physicians of Barcelona, strongly express the obligation to respect the religious convictions of patients in their Rules 4 and 9, when they prohibit that religious motivations may interfere in the quality of patient care and impose the obligation to "respect the religious, moral, ideological and political convictions of their patients and, taking into account the great staff influence that (the physician) may exercise, they must prevent their own convictions from conditioning the freedom of the latter".
Among the standards in force in the European Community, The European Principles of Medical Ethics7recently approved by the International lecture of Medical Orders, firmly impose respect for the patient's religious beliefs and personal convictions. They do so by prohibiting both discrimination between patients on religious grounds (Art. 1: "The vocation of the physician is to defend the physical and mental health of man and to alleviate his suffering with respect for the life and dignity of the human person, without discrimination as to age, race, religion, nationality, social status and political ideology, or any other reason, in time of peace as in time of war"), and intrusion into their privacy (Art. 3º: "In the exercise of his profession, the physician may not impose his own personal, philosophical, moral or political opinions on the patient" and Art. 5º: "...The physician may not impose his own personal, philosophical, moral or political opinions on the patient".The physician may not substitute his own concept of the patient's quality of life for his own").
There is no need to prolong this sample: medical ethics, in its recent versions as well as in the classical ones, imposes the duty to respect the patient's beliefs, either in a negative form (do not discriminate, do not interfere, do not substitute) or in a positive form (respect, honor). I believe that the latter, as with all positive precepts, is richer in content. It is therefore worth examining it more closely.
III. What does respect for the patient's religious beliefs consist of?
The whole of contemporary medical ethics is steeped in the notion of respect.8. It is with the Declaration of Geneva that respect bursts into medical ethics as an inspiring element of the physician's conduct. In today's secularized world, it becomes the secular and universally acceptable substitute for the command to love one's neighbor, which constituted the core of morality in the Judeo-Christian tradition.
The notion of respect includes, as a first element, the conventional rules of civility. These are like cultural crystallizations of a capital element of human coexistence: the notion that not only the powerful, but also the weak are very important. But respect goes far beyond the contents of politeness and good Education. As can be seen from the context of the deontological precepts, respect is the centerpiece, the nervous system, of the ethical organism. Obviously, moral life depends, in its abundance and quality, on the capacity to grasp moral values. And it is precisely respect that sharpens our sensitivity to perceive them. Moreover, the capacity to evaluate the elements of a moral problem, to order them according to their relevance and to conclude a correct ethical judgment is not only a matter of knowledge and intellectual habit for ethical reasoning: it depends to a great extent on how deeply rooted respect is in us. The disposition to follow the demands of our conscience also depends on respect: it makes it possible that the response to the ethical values enclosed in things and, above all, in man, can take the form of intelligent and lordly subordination, not fearful or servile.
This very brief characterization of respect opens the way for us to consider how the respectful physician manifests himself before the religious beliefs of the patients at all moments of the doctor-patient relationship. Analogously to what Siegler has done in another respect9we can distinguish three phases in the doctor-patient relationship: a first moment of perception and knowledge, followed by another of assessment and negotiation, and finally leading to the final phase of decision and action.
The physician sensitive to human values detects in the course of the anamnesis many data about the personality of his patient. Among them, there is no shortage of those that make it possible to discover his attitudes about the causes and the human significance of the disease, including his religious beliefs.10. Sometimes, the patient declares them openly; other times, he makes them known indirectly, through expressions and gestures. The physician, as the first expression of respect, must be attentive to this language, verbal or not, since the patient uses it to transmit a decisive message: the patient may show us, among other things, that he/she demands that his/her religious beliefs be taken into account, or simply that he/she consents to them being known, or that he/she is indifferent to them or, finally, that he/she forbids any intrusion into his/her privacy.
In turn, the physician can manifest himself in different ways. First of all, there is the attitude of respectful abstention, that of ignoring so as not to invade privacy. This respectful silence is a deontological duty. Thus, for example, our Code of Deontology5 imposes it in Art. 19 when it states that "in any medical act, the physician must ensure that the patient's right to privacy is scrupulously respected". This duty includes both the protection of modesty and the obligation to refrain from revealing the patient's biographical privacy beyond what is strictly necessary to obtain a correct medical history. Undoubtedly, a large issue of medical interviews concern only the epidermis of the patient's personality and do not require any incursion into deeper layers of the patient's being.
But, on many other occasions, respect obliges the physician to inquire, since only by knowing the patient's beliefs can he/she respect them. This duty has always been part of the good medical art, but perhaps in recent times it has become much more relevant. This is due to factors such as the firm establishment of patient autonomy as a relevant element of the doctor/sick person relationship, to the different interpretation of what has come to be called quality of life, and also to the broadening of social tolerance towards a number of lifestyles or cultural manifestations. Many things that were once considered taboo, socially repressed and jealously concealed, have become matters that are openly discussed and for which respect is openly demanded.
These circumstances are profoundly changing the shape of the physician/patient relationship. The Ethics guide of the American College of Physicians, for example, describes the new status as follows: "In fact, the traditional relationship can vary in many ways.... Physicians and patients often come from different cultures and differ in their concepts and ideas about the nature of the problem and what they wish to achieve. Patient care and the satisfaction of both parties are best served if the physician and patient do not refuse to talk openly about their concerns and expectations."11.
There can be no doubt that this more open attitude is a human enrichment of the medical internship . If the disease, because it is chronic, serious or incapacitating, has a profound effect on the patient's way of life, the physician then needs to intervene in deeper layers of the patient's personality. He must mobilize his patient's energies to make him bear the pain and the handicap or to keep hope alive during the hard days of an aggressive or uncertain treatment. To do this, the physician needs, first of all and as a manifestation of both expertise and respect, to know his patient's spiritual resources, among which his religious beliefs play a dominant role.
The physician does not need to be an expert in comparative religions, nor in medical folklore. But, in order to respect his patients, he cannot ignore the dominant cultural and religious factors in hisenvironment12,13. It is obvious that situations can vary very widely. There are physicians who practice in environments with very homogeneous religious demographics, while others practice in environments where adherents of many faiths and sects coexist with humanists of all persuasions. In any case, the respectful physician will not negligently neglect his obligation to know something about the customs and beliefs of the people who come to him, as this is part of his clinical skill .
Until recently, it was not easy to find information specifically directed to the healthcare world about the medical implications of religious beliefs. We now have, in addition to the well-documented articles in the Encyclopedia of Bioethics1a simple but highly informative book on the subject by the British nurse A.C.M. Sampson, with a significant degree scroll : "The Neglected Ethic. Religious and Cultural Factors in the Care of Patients".14.
Once the physician is aware of the patient's beliefs, the way is open for negotiation. This is a phase of growing importance, since it is here that the physician can gain the patient's trust. The high frequency of patient disobedience is due to shortcomings in this decisive phase of the doctor-patient meeting .15.
Fortunately, in the vast majority of cases, there is no conflict between the diagnostic and therapeutic measures proposed by the physician and the patient's convictions, nor between the patient's expectations and the services offered by the physician. There is, so to speak, a spontaneous coincidence of objectives that leads to cooperation without conflict.
I have indicated before, and I have done so deliberately, that the road to negotiation is a wide one. By this I mean that the physician should be inclined to compromise on everything that is not essential for the correct management of the clinical status . Despite the increasing publication of technical guidelines for the diagnosis and treatment of diseases (WHO guidelines, conclusions of consensus conferences), which are endowed with a certain binding character because of the great authority attached to them, it is ultimately up to the individual physician to decide how to proceed with each individual patient. The physician still enjoys, today as in the past, a wide discretion of judgment, in which there is room for a generous tolerance of certain behaviors called for by the religious or philosophical convictions of his patients. To this purpose the Ethics guide of the American College of Physicians points out: "Because the way patients are cared for is constantly changing, any clinical status is by its very nature tentative and provisional, and requires continuous negotiation and modification if the physician/patient relationship is to be successful".11.
The object of negotiation is not only interference from religious beliefs, but also from superstitions or non-scientific systems of healing. It is worth considering for a moment the edifying patience that the aforementioned Ethics guide recommends to the physician when faced with patients seeking remedy in marginal medicines. "The expressed desires of some patients for care outside of orthodox medicine create a conflict for the physician between his commitment to provide the best possible medical service and the patient's right to choose the care he wants and from whom he wants. Such a desire requires mature reflection on the part of the physician. Before giving any committee, the physician should determine the reason for this desire to change: dissatisfaction with the treatment or simple advertising appeal of the non-scientific treatment. Next, the physician should make sure that the patient has understood, in the spirit of informed consent, the nature, treatment and prospects of his or her disease. Physician and patient can then realistically and dispassionately discuss what the patient can expect from each of the two modes of treatment."
I have perhaps gone on too long in this quotation. Although it refers to the conflicts that arise due to the marginal Medicines, it seems to me, however, that it sample in an exemplary way the components of the negotiation.
Thus, doctor and patient must establish a deontologically correct negotiation in the face of any divergence of criteria. The physician must enlighten the patient, without arrogance and with clarity, on the medical aspects of the status of the patient.16. The physician's contribution to the ethical requirements of informed consent consists of providing medical information and respecting freedom. The physician's loyalty to his patient obliges him not to omit from his information any information morally significant for the patient. The patient must bring to the negotiation, in addition to his freedom, a thoughtful and considered consideration of what the physician makes known to him.
To give a topical example: Should the moral dictates contained in the Instruction on Respect for Nascent Human Life and the Dignity of Procreation be made known to Catholic spouses undergoing an assisted human reproduction program?
After the negotiation phase, it is time for decisions. It is obvious that most clinical situations either take place in an area of neutrality with respect to religious beliefs, or these represent a very important financial aid in the execution of this moment of the doctor/sick person relationship.17. The scope for cooperative alliance is very broad. Religious faith can help to accept treatment as another manifestation of Providence and to internship it as part of the moral obligation to care for the life one has received on loan from God. Religious faith plays in the behavior of many believers the role of a powerful auxiliary to medical treatment, particularly when it involves pain, permanent disability or very demanding or austere living habits.
But in addition to these more frequent types (neutrality, adaptation, alliance) of reaction to medical decisions, religious beliefs can give rise to situations of conflict or incompatibility, of deontological B
Its phenomenology is well known. The field of human reproduction is an area of conflict. Abortifacient contraception, abortion in any of its indications, assisted reproductive techniques pose situations, for patients and physicians, fraught with enormous tension. The increasingly less violent problems arising from the refusal of Jehovah's Witnesses to receive blood or plasma transfusions and the jurisprudence that has developed for the protection of minors and incapable persons in emergency situations are well known. No one is unaware of the risks that too literal an application of certain fasting rituals can bring to the administration of oral medications. The refusal of some to receive biological products derived from proscribed animals has prevented the administration of insulin or the implantation of heart valves of porcine origin in some patients. Precepts protecting women's modesty in some sects prevent physical examinations by male doctors or doctors who do not belong to the sect, which sometimes leads to dramatic situations in immigrant groups without their own doctors. On other occasions, the hospital becomes a hostile place for the internship religious duties, preventing the observance of certain rites of ordinary life, the fulfillment of traditions or ceremonies. The impossibility or inability to maintain the internship of religion can create dramatic conflicts, some of which have ended in patient suicide. This sample how some patients are unable to overcome the aggravation, sometimes unconscious, that the physician may inflict on their values: the feeling of guilt or of having been irreparably desecrated becomes unbearable and suicide seems the only way out of such a status.
Fortunately, there is more sensitivity to these problems among physicians today, but not much is done yet to respect the beliefs of certain religious groups and to meet their reasonable demands. The attitude of non-interference prevails in internship over the willingness to facilitate. And although in this area the nurses' performance is perhaps more important than that of the doctors, the latter should not be closed to yielding in what is reasonable. A few years ago, the Prince of Wales, in his capacity as President of the British Medical Association, indicated to the association, as one of the objectives for the period of his presidency, the improvement of medical care for certain immigrant communities, in order to avoid the serious disadvantages resulting from disregard for the cultural and religious peculiarities of these minorities.18.
IV. Deontology of disagreement
It happens, however, that no matter how much the physician's ability to understand and meet the demands of his patients is enhanced, sometimes a dead-end status is reached, in which agreement is impossible.
There are religious groups and sects that include among their practices impositions that are repugnant to reason. There are degraded, counter-rational cults, with demands that go beyond what, in the opinion of prudent and tolerant men, can be granted to the autonomy of individuals. Often, adherence to such practices, because of their differentiating character vis-à-vis the rest of society, acquires in the eyes of believers a decisive, non-negotiable value, which fanaticizes them: and deprives them of the ability to change their convictions through free discussion.
When the patient's demands conflict with what is civilly tolerable or lack a minimum of rational coherence, there is an incompatibility between the patient's autonomy and that of the physician, and a status of rupture is reached. This should always take the form of what I like to call educated dissent. It is not in keeping with an ethic of respect for the physician or the patient to add insult to disagreement. Addressing the status of incompatibility between the views of physician and patient regarding unorthodox medicines, the Ethics guide of the American College of Physicians aptly describes the moral mood of polite dissent: "The physician should not abandon the patient if the patient chooses to try unorthodox treatment. He or she should accept such a decision with patience and compassion, but may not participate in such a subject treatment. The physician is also a moral agent. He cannot be required to violate his own conscience. He cannot agree to do whatever the patient desires, particularly when it goes against the physician's moral convictions."11.
The physician's refusal will sometimes be based on a scientific objection: what the patient is requesting is not compatible with the state of the art in medicine at the time. At other times, it will be the result of a conscientious objection. In one case or another, it is more in keeping with the ethics of respect to give a reasoned explanation before dismissing the patient, which should include an invitation to return if he changes his mind.
A wider diffusion of human relationships based on respect and the growing sensitivity of physicians and patients to ethical issues will bring about a rehabilitation of the physician as the arbiter of clinical decisions. The only valid response, in my view, to the abuses, potential and actual, of patient autonomism and physician paternalism, is the well-formed and respectful conscience of the physician. Thomasma19 has proposed a new model, that of the physician's conscience, which recasts in a timely synthesis the most authentic and positive elements of the two antithetical models of the doctor-patient relationship, including a healthy respect for moral ambiguity, tolerance for whatever religious beliefs demand and whatever is compatible with human rationality.
But I insist, there is a limit to tolerance. When falsified, inauthentic religiosity becomes an aggressor of respect for life and the most fundamental values of man, when it means harm to others, then the level of tolerance is exceeded and belief becomes fanaticism. When access to life-saving treatment is denied to someone deprived of autonomy, such as, for example, the oft-mentioned cases of the prohibition of blood transfusion to minors by Jehovah's Witnesses.20 or the application of ordinary and life-saving treatments which the followers of Christian Science declare incompatible with healing by prayer alone2121 then resource to judicial intervention is justified in order to avoid the perpetration of an irreversible injustice.
If the physician's conscience is to play the role of arbiter without running the risk of becoming a new form of paternalism, the physician must stubbornly refine his sense of what is right, implicit in the Hippocratic tradition of respect for others.22 and to realize that his arbitral role implies a predisposition to consider and reconsider one's own position23. In-depth reflection on the major principles of medical ethics (the fundamental duty to respect the life and integrity of the staff his patient, the scientific nature of medicine, the conviction that the interests of society or science can never prevail over the interests of the individual) is the only way to harmonize their apparent contradictions.
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2. Chapman CB. Physicians, Law and Ethics. New York: New York University Press, 1984.
3. Council for International Organizations of Medical Sciences. Health Policy, Ethics and Human Values. An International Dialogue Z Bankowski and J H Bryant, eds. CIOMS: Geneva, 1985.
4. The World Medical Association. Handbook of Declarations. WMA: s.l., 1985.
5. General committee of the Medical Associations of Spain. Código de Deontología médica. Madrid: O.M.C. of Spain, 1979.
6. high school Official high school of Doctors of Barcelona. Deontology Standards. Barcelona: high school Oficial de Médicos, 1979.
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20. Holder A. Medical Malpractice Law. John Wiley and Sons: New York, 1975.
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22. Kopelman L. Justice and the hippocratic tradition of acting for the good of the sick. In: Ethics and Critical Care Medicine. J C Moskop and L Kopelman, eds. D Reidel: Dordrecht, 1985.
23. Beauchamp TL, Chidress JF. Principles of Biomedical Ethics, 2nd ed. Oxford University Press: New York, 1983.