Spirituality, Religion and Ethics

Dr. Thomas R. McCormick

Dept. of Medical History & Ethics

U.W. School of Medicine

Ethical Decision Making

• Patient’s often rely upon their religious beliefs in making ethical decisions about their own care and the care of their loved ones.

• How might we respect religious and cultural values of the patient, while working for “beneficent” treatment?

Sometimes We Are Surprised When:

• The patient refuses to seek diagnosis and medical treatment for religious reasons;

• Or, the patient accepts the diagnosis, but will not accept the most efficacious care plan, for religious reasons;

• Or when the patient seeks to modify the care plan offered by the h/c professional, even at the risk to his health and possibly his life.

Ethical Problem Solving

• Modern health care gives rise to many value ladened issues for which medicine alone cannot provide an adequate answer.

• Patients may seek a solution – that maximizes possibilities for a good outcome– or, that fulfills their sense of duty to self-others– or, that follows a rule or principle such as “do unto

others...”(utility, duty, virtue, natural law)

– Rule or principle may stem from religious belief.

Moral Analysis Begins. . .

• When there is confusion about competing alternatives for action;

• When values of the health care team and the values of the family are in conflict about what is in the best interest of a patient;

• When a true dilemma emerges in which none of the alternatives are entirely satisfactory.

Consider these cases. . .

• Ask yourself, “what should be done”

• Ask yourself again, how do you justify your answer, over competing answers?

Traditional Navaho Patient

• Presents to the clinic with indigestion, abdominal and back pain, jaundice.

• Clinical exam and radiography suggest pancreatic cancer.

• Traditional Navaho’s do not want to hear of a fatal diagnosis, one must speak in a “positive” way.

• What ought we to do?

Eight year old girl at Children’s with acute lymphocytic leukemia

• Patient is from a J.W. family• Needs blood transfusions to prepare her

for life saving chemotherapy due to anemia

• With blood transfusions and chemotherapy she has a 95% chance of long term survival—w/o this, she will surely die.

• Parents refuse to give permission for blood. What ought to be done?

Jehovah’s Witness Patient Needs a Blood Transfusion

• A 30 y.o. male was injured in a logging accident on Whidbey Island.

• Examination in the ER discloses internal injuries and bleeding with significant loss of blood volume and pressure.

• This is a life threatening emergency.• Recommended care plan is immediate surgery to clamp

bleeders and hang blood to restore safe volemic and pressure levels.

• Family is in the room, claim he can’t have blood due to his religion, patient agrees.

• What should be done?

Two gay male partners in a commited relationship desire child

• Request egg donor;• Utilization of one

partner’s sperm to create embryos;

• Request surrogate gestational host who will be implanted with two embryos & carry pregnancy.

• At birth, the child will go home with partners.

• Is this a medical problem?

• Does a purely elective procedure entail a “duty” in the health care team?

• Should doctors provide “any service” requested?

• How do the values of the health care team enter into the equation?

25 y.o. female in premature labor

• Married woman, desired pregnancy, well educated, at 27 weeks gestation, in labor.

• Admitted for tocolytic therapy to stop labor.• Requests that “nothing be done” to resuscitate

or support if infant born prematurely due to risk of morbidity.

• Claims that her religious beliefs require her to act on behalf of a good “quality of life” for her premature infant—more important than survival.

• What should be done?

Christian Scientist Parents

• Seven year old boy is taken to Childrens by babysitter when he becomes very ill.

• Symptoms: high fever, stiff neck, head ache and emesis, suspected dx meningitis

• Spinal tap confirms bacterial meningitis• IV antibiotics are initiated in PICU• Parents arrive at the hospital requesting all tx

halt, claiming they want to take the child home and have a practitioner pray for him.

• What ought we to do?

The Case of Baby Roger

• Born at 24 weeks gestation;

• Needed ventilator support;

• Now at 32 weeks with “ventilator lungs,”

• Unable to maintain oxygen saturation;

• parents want everything done, are praying for a miracle.

Principles in Bioethics

• Respect for Autonomy

• Nonmaleficence

• Beneficence

• Justice

Four Box Method

• Medical Indications for Intervention

• Quality of Life

• Preferences of the Patient

• Contextual Issues

Medical Indications Patient Preferences

Quality of Life Considerations Contextual Features

Medical Indications Patient Preferences

Quality of Life Considerations Contextual Features

Discuss Discuss the case and its context; analyze how principles might guide us toward a

solution, note which values should take preference over others, do we know of precedent cases?

Make a recommendation what is your suggested care plan in the light of the above?

Respecting Diversity in Religion and Culture

• U.S.A. is the most religiously pluralistic country in the world.

• How do we respect the religion and culture of our patients and also adhere to the ethics of our professions and the laws of the land?

Please Discuss. . .

• The cases in tonight’s handouts are actual cases, many of them from Seattle.

• Please discuss them in small groups and see if you can come to a consensus about what ought to be done and why.

• Please offer reasons and justifications including values that substantiate your positions in these cases.

• After small groups we will discuss in plenary.

Discussion in Total Group

More Information. . .

First Amendment

• The first amendment recognizes that religious liberty is an inalienable right for all human beings.

• This includes the liberty to worship as one chooses, or to exercise the liberty not to worship or participate in religious exercises.

Washington State Law

• Calls for the protection of minor children in order that children not be subjected to “medical neglect.”

• Oliver Wendell Holmes, “Parents have a right to martyr themselves in following their religious beliefs, but they do not have the right to martyr their minor children.”

Duties of Health Care Professionals

• Health Care Professionals are at the bedside of the sick;

• HCP’s are advocates for the vulnerable;

• In a unique position to monitor if the “best interests” of patients are being carried out by those with decisional capacity or surrogacy rights.

UW Teaching HospitalsChildrens, UWMC, HMC Policy

• It is the policy of these hospitals to provide appropriate life saving procedures, including the administration of blood to minor children in emergency situations.

• The only exception to this policy would occur if the parents have immediately in hand a court order forbidding such treatment.

Refusal of Treatment: Adults

• Competent adult patients with current capacity for decision making, when fully informed of the intended treatment, (& alternative treatment modes) its purpose, risks, benefits and the risks inherent in treatment refusal such as disability and death, have the right to refuse.

Cases involving Conflict Require Good Communication Practices

• Maintain respect for the patient and the patient’s religious beliefs, even if you do not agree or think them irrational.

• Enter into conversation, listen to the patient, ask if there are any ways in which his/her beliefs may differ from others in their faith community, or culture.

• Discuss which values are most important to the patient under these circumstances