Medicine and religion have been closely intertwined since the beginning of recorded history, with treatments offered by healers within the framework of their spiritual tradition. Although this remains true in some cultures, Western medicine has moved away from this model. Doctors tend to the body and clergy to the spirit. Doctors prescribe pills and perform procedures, while chaplains offer prayers and perform rituals. But can these roles really be so neatly packaged? No, according to a growing number of physicians and ethicists,1-4 who suggest that religion and prayer do not necessarily fall outside the bailiwick of modern-day Western medicine—or at least that the issue is complex and nuanced. To shed light on some of the complexities in the potential role of physicians in the religious lives of patients, MPR interviewed two physicians with expertise in the interface of religion and medicine. Benjamin Frush MD, a resident in internal medicine-pediatrics at Vanderbilt University Medical Center in Nashville, Tennessee, argues in favor of a role that physicians can play in integrating religion into their clinical practice. Rob Poole MB, FRCPsych, Professor of Social Psychiatry, Bangor University, Wales, contends that physicians should never incorporate a religious element into clinical practice. Religion Plays an Important Role in the Physician-Patient Relationship Dr Frush What is your own religious background and orientation? I am a Christian and my faith as a Christian is central to who I am and integral to my role as a physician. When I started medical school, it informed how I entered practice. Between my third and fourth year of medical school, I was a fellow at the Theology, Medicine, and Culture fellowship at Duke Divinity School, receiving my Masters in Christian Studies, and thought deeply about the intersection of faith, philosophy and medicine and how they transform and inform my interactions with patients and coworkers. Given your Christian orientation, what is your approach to patients with either no religious beliefs or beliefs that differ from yours? My orientation toward patients who hold religious, social, or moral beliefs with which I would disagree as a Christian is no different from my orientation toward patients of similar beliefs to my own. This comes not only from my medical ethic but also because the Gospel tells me to love and attend to that patient, particularly in his or her moment of sickness and vulnerability. My role as a clinician interfacing with someone vulnerable is to provide care and compassion, independent of what they believe. That is actually how Jesus Christ lived. How would you react if a patient asked you to do something that directly contradicts your own religious beliefs? I think that there are no absolutes in these types of situations and that they must be decided on a case-by-case basis. But the overriding principle is the health of the patient and respect for who the patient is. It is not my role to pass judgment on the patient's requests and my spiritual/religious reasoning is inextricably bound up in my clinical reasoning. I'd like to use as an example case that my colleagues and I wrote about,5 in which a patient refused postoperative pain medication because he believed that God wanted him to suffer because he had “done wrong” and deserved to be in pain.5 This is certainly not my religious viewpoint, but it was that of the patient. After consultation with colleagues, it was decided that if the patient had refused anesthesia during surgery, it would be so detrimental to his health that the request could not be granted. If, however, the patient's experience of severe pain would not in and of itself be damaging, I would have to respect his choice. Situations such as abortion or end-of-life care often raise difficult questions for clinicians whose religious beliefs might go counter to those of the patient. The overriding factor in these instances, however, should still be the physician's commitment to the health of the patient and not necessarily the unqualified protection of the physician's religious beliefs. Physician objections to controversial practices need not be religious in nature and frequently there are more robust arguments from abstention from such practices that do not exclusively invoke religion. Do you think that physicians should pray with their patients? I absolutely think that it is appropriate, under certain circumstances, for physicians to pray with patients. It requires a good deal of thought and attention to the patient's needs and religious/spiritual orientation, and it takes a lot of time to be able to assess what would suit the patient best in that moment. One challenge is lack of time to actually sit with patients and discern what is best for them; being short on time is a problem in all areas of healthcare. I think that it should usually be up to the patient to initiate the request for prayer. This is one area in which, since there is a power differential, physicians can overstep their bounds and make patients uncomfortable. Physicians don't want to interject their own beliefs into the picture. But if a patient initiates a request, I will always pray with them, whatever their religion. There are rare instances in which it's okay for a physician to initiate the offer to pray together, but one has to know the patient very well so that the offer won't backfire or appear coercive. Of all the patients I have encountered in training so far, I have offered to pray with only one patient and his family. I had gotten to know them well, they had been through some hard times, and I felt that the suggestion would be received well, which it was. If a patient wants to pray and the physician doesn't want to join, it is okay to say, “I will be here with you when you pray.” But I don't think physicians should go beyond their comfort zone. If they are uncomfortable even being in the presence of prayer, I would suggest calling the chaplain. Do you have any additional thoughts to share? The idea that we can cleanly separate religion and medicine, as pertains to both doctors and patients, is artificial because religion is not only a characteristic but for many people, it is a foundational orientation to the world. The physician's sacred obligation to alleviate suffering and foster the patient's health is paramount. The real question isn't whether religion has a place in medicine, but how it can be integrated into the clinical setting in a way that honors physicians as well as their patients, allowing for good care and avoiding pitfalls, coercion, and harm. Religion Has No Place in the Physician-Patient Relationship Dr Poole What is your own religious background and orientation? I was brought up as an atheist and I remain an atheist to this day. My siblings and I were brought up to believe that the most important thing was to be upstanding, but that did not entail being religious or accepting that type of authority. Part of me does not like framing myself as an atheist, insofar as I do not want to be defined by what I do or don't believe, but that is my perspective on religion. On the other hand, I think that people's religious beliefs are an integral part of who they are, so one could say that my lack of religious faith and attachment to rationality are an overriding principle that informs what I do, together with my feelings about social justice. You can't completely eliminate that or deny it, based on the part of you that is a clinician. But what you can do is try to stop it from having an adverse effect on patients or treating them differently. Given your orientation as an atheist, what is your approach to the religious beliefs of your patients? I believe that people of whatever religious/spiritual orientation should be respectful and tolerant of each other, but tolerance involves recognizing that, as a physician, your beliefs and belief systems have impact in complex ways, especially when you're in a position of power, as physicians are with their patients. I also think that, while the person's religious beliefs and observances must be respected and acknowledged, there is no role that religion should play in the physician-patient relationship. What do you think of shared prayer? I am opposed to it. I am here as a physician. There are several reasons for this. One is that I am neither trained, nor do I feel it's my role, to engage with a patient's religious life. Obviously, as a psychiatrist, I may explore aspects of patients' religious activity with them, but that is different from joining with them in those activities. Shared prayer can also open up a discussion with the patient about what the physician's religious beliefs are. Sometimes patients ask me about my religious beliefs or social or political perspectives. There is a school of thought in British medicine, especially British psychiatry that says if patients ask you about your personal beliefs you should always decline to answer and explore instead why the question is important to them. Although I agree that such an exploration is appropriate, declining to give a straight answer is discourteous. Additionally, some patients might want to be treated only by a person of their faith. Where I practice, there is a large Roman Catholic population and many feel unable to open up to a psychiatrist who is not Roman Catholic. But even if you are of the same faith community as the patient, this doesn't mean that you feel the same way about issues of doctrine or other approaches to religion. Beyond that simple piece of information, a discussion of the physician's faith is inappropriate in the clinical setting and is a boundary violation. Moreover, if there is a negative clinical outcome, such as unsuccessful surgery, patients – especially if they are seriously depressed – may conclude that their prayer hasn't been answered and the clinician, by virtue of having joined them in prayer, is implicated in that failure. That said, if a distressed patient wants the physician to pray with him or her, the physician should at least be aware that they are getting uncomfortably close to a boundary and it is a “slippery slope” to actually cross the boundary. Boundaries are not always absolutely unmovable, but if a clinician is going to breach or approach breaching them, they have to be able to justify crossing or coming close to the line. This is why I set a firm boundary of no prayer and no religious activity. In a rare circumstance in which a patient broaches the subject, I need to be prepared to justify the decision. One scenario for a clinician whose patient requests joint prayer is to agree to be present silently while the patient prays. Another is to suggest that a chaplain be involved instead. How would you react if a patient's religious beliefs dictated actions you felt were detrimental to him or her? Decisions about whether a patient is impaired by illness – especially mental illness – or whether the person is acting from an authentic religious belief are difficult to approach, with very little straightforward solution. It helps to discuss these matters with colleagues or supervisors. One memorable incident stands out. A young woman decided to live as a homeless person, saying that God wanted her to live a humble lifestyle without money or shelter. The homeless people brought her to us because they thought she was too vulnerable to be out on the street. We found no evidence of mental illness, although I thought it was strange and felt that it was unlikely that this was merely a religious matter. I asked a colleague with an evangelical Baptist background to assess her and he felt this was spiritual crisis, not a mental illness, so we kept an eye on her while living on the street. A few days later she became psychotic and we had to admit her to the hospital. My colleague wasn't necessarily wrong because it can be very difficult to distinguish between authentic religious belief and mental illness. The principle is that you have to take people as you find them and they may make unwise decisions based on religious faith. Under most circumstances, those decisions should still be respected, irrespective of our personal beliefs. References 1. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality: results from a multicenter patient survey. J Gen Intern Med. 2003;18:38-43. 2. Balboni MJ, Babar A, Dillinger J, et al. "It depends": viewpoints of patients, physicians, and nurses on patient practitioner prayer in the setting of advanced cancer. J Pain Symptom Manage. 2011;41:836-847. 3. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent). 2001;14(4):352-357. 4. Zaidi D. Influences of religion and spirituality in medicine. AMA J Ethics. 2018;20(7)E607-674. 5. Frush BW, Eberly JB Jr, Curlin FA. What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer? AMA J Ethics. 2018;20(7):E613-620. Source
