Ethics in Tension: The Christian Physician Sharing His Faith
by Drs. Elizabeth K. Hensley and Samuel D. Hensley
Today's Christian Doctor - Spring 2010
The role of spirituality is being increasingly recognized as important and clinically significant in health outcomes.* For well over a decade, articles have been appearing in the medical literature supporting the integration of spiritual care as a routine part of the medical encounter. Many medical schools now teach courses on spirituality. JCAHO requires the spiritual assessment of patients in many of the clinical settings that they accredit, such as hospitals, long-term care facilities, and behavioral health facilities.
While the acknowledgment of the importance of the spiritual dimension of patient care is encouraging, it does raise questions regarding ethical issues for physicians. In a pluralistic society it is not surprising that there are differing opinions about the role of the physician in addressing patient spirituality.
As Christian physicians, we may feel conflicted and unclear about our roles and responsibilities. We may sense an ethical tension between our identity as a Christ follower, compelled by the gospel and our physician identity, bound by societal and professional expectations. We do not view our patients through the lens of scientific reductionism. Rather we see them as unique and complex beings with spiritual, emotional, moral, and physical needs throughout life.
Acknowledgment of this is not isolated to Christian belief. Many in the medical profession representing diverse religious and philosophical positions are embracing the concept of holistic patient care. Much of this stems from the recognition that illness brings suffering into the lives of our patients, and this suffering is not limited to the physical body. Any physical compromise can impact the patient and their family in innumerable ways, causing a fracturing of everything that has brought meaning and purpose to their lives. Not surprisingly, studies have shown that a large percentage of patients feel their physicians should acknowledge and inquire about their religious beliefs. Typically only a very small percentage of patients find this sort of inquiry problematic.
Many physicians are legitimately concerned about how to ethically proceed with the integration of spiritual care into their clinical practices or even how to respond to patient requests for spiritual help.
As Christians we view our relationship with our patients as covenantal, always seeking their good in all aspects of their lives.* In years past, most physician-patient relationships were based more in the ideals of covenants and oaths. The fiduciary nature of the relationship required the physician to always act in the best interest of the patient. The nature of the relationship was generally one of mutual trust, respect, and responsibility. This naturally allowed for more spontaneous dialogue regarding spiritual matters. Many changes in both the culture and in medicine have occurred over the last several decades that have altered the nature of this relationship. Many feel that some physicians acted in a paternalistic manner making decisions independent of their patients, thus contributing to the erosion of this trust relationship. There has also been an increasing emphasis on patient autonomy and self-determination in medical decision making. Lastly, through the increasing emphasis on quantifiable performance, disease management protocols, and practice guidelines the medical encounter has been significantly impacted, approaching the factory or business model in severe instances.
This is not to say that each of these changes has not been supported by valid concerns or observations and are not without merit. Indeed, it is prudent for us to consider the benefits these changes have provided that enable us to offer better and more ethical care to our patients. As Christians we affirm the dignity of all human beings and respect their rights to make independent and well-informed decisions. It would be abhorrent to use coercion or ignore our patients’ core beliefs and desires. We also believe that we should be excellent in our work for the glory of God and the good of our patients. We embrace advances in medicine that enhance our ability to offer quality care to our patients. Perhaps as Christians where we differ is in the realization that we are by nature in relationship with our Lord and with our fellow man. We are “our brother’s keeper” and therefore we approach all these issues through a unique paradigm. Our practices, like our lives, cannot be compartmentalized, but are integrated into the new life that we live in Christ. Likewise, our earnest desire and hope is that our patients live and flourish in every aspect of their lives through the restoration and hope offered in the gospel.
In the CMDA ethics position statement on sharing faith in our practice it is stated, “our faith should be implicit in our actions.”* We must remember that first and foremost our patients come to us for good, quality medical care. In CMDA’s “Saline Solution,” William Peel reminds us that it is not merely competence but character, integrity, and compassion that make us agents of positive spiritual influence. We would be very ineffective ministers of the gospel if there were incongruence between our words and our actions. We know that we do not convert anyone. The Holy Spirit is the power at work in revealing the light of the gospel.* For this reason, we acknowledge the role of prayer, faith in God’s sovereignty, and the discernment provided by the Holy Spirit to know when and how it is appropriate to share our faith. Our goal is always to express the love of God to our patients and to serve them, knowing that God is always at work. We should never see our patients as our personal salvation projects. Patients are very discerning and may feel a lack of real compassion and respect from the physician who appears to be merely proselytizing.
How well we all know that we are given both the privilege and responsibility of walking with our patients through many difficult and perplexing situations. It is in times like these that patients will often open up to us with regards to spiritual issues. When our patients indicate a desire for spiritual help or for prayer, we should accept the opportunity to offer what they need.* It is also in these times that we may feel prompted to share with our patients our own faith. This should always be done with permission from the patient, recognizing their vulnerability, especially in those from other cultures or in those with diminished decision-making capacity.*
We should be open, authentic, and thoughtful while being attentive to the stories and messages our patients are providing. We should be careful that we respond to patient’s beliefs, questions, and struggles in ways that are not condescending or judgmental. We are all comfortable (or should be) in applying these ethical guidelines with patients when dealing with other intimate issues such as sexuality or lifestyle choices. It is very reasonable to assume that equally ethical dialogue can take place in spiritual matters.
For many physicians, the increasing emphasis on attending to patients’ spiritual needs has made it easier to initiate these conversations with patients long before critical situations arise. There are many resources now available to help physicians take a spiritual history on their patients and incorporate it into the medical record. Once again, this should always be done with the patient’s permission and in a non-threatening or intrusive way. Many physicians will not be comfortable using a prepared form or methodology to gain insight into the spiritual lives of their patients. Each physician, acknowledging their unique equipping, can find ways to incorporate ethical, caring communication with their patients with regards to their spiritual well-being. Many find that this can be a natural component of the social history. Others may find they can develop their own style of caring inquiry that will seem more natural and authentic both to them and their patients.
We remember one highly regarded orthopedic surgeon who was known to be a man of deep faith and few words. His common verbal entry into the hearts of his patients was simply to ask them, “How is your world?“
It is not unusual for people of faith to choose to openly display their beliefs through the office environment. Many do this using artwork, attire, literature, videos, or a variety of other means. Although there are a few who have commented negatively on this sort of display, most feel that if this is done in a sensitive, tasteful, and respectful manner it is entirely appropriate. It also has the added benefit of making patients aware upfront of their physician’s faith perspective. Generally, clinics and medical ministries that are directly linked to their faith alliances are free to speak and minister openly according to their religious profession.
We are certainly entering a new era in medicine as we deal with the issues of right of conscience. Some physicians may find that their particular work environments have policies that prohibit the sharing of their faith. Physicians that are applying thoughtful and ethical means to caring for their patients’ spiritual needs are acting within their rights to freedom of speech and religion.*
In the classic sense the concept of tolerance implies that there are differences to be tolerated. Respectful, noncoercive, and informed dialogue regarding spiritual matters communicates a true concern for the dignity and wholeness of all of our patients. It demonstrates what true tolerance can be in a free society.
It is important that each physician remember they do not solely bear the burden for their patients’ spiritual health. To feel that way would be to put us in the place of God — a job that none of us is qualified for. We are given the unique privilege of entering into a sacred part of our patients’ lives through each medical encounter. It is of necessity that we remain humble and truly grateful to be a part of their journey. We must realize our limitations and remember that we are a part of a greater body. The physician should know the spiritual resources of the community and of the local chaplain services where he practices. Often difficult theological questions arise that are beyond the expertise of the physician. In those instances, patients are often better helped by others who are excellently prepared to handle difficult issues. It also should be an encouragement to us to continually deepen our understanding of spiritual issues and to grow in the wisdom and knowledge of such things. We should work to develop ways to articulate our faith through an ethic of love and caring. Let us always remember that the apostle Peter said that, “We should always be prepared to give a reason for the hope that is within us.“
Notes from the CMDA Ethics Statement: Sharing Faith in Practice
“The Saline Solution” - A CMDA resource, provides enhanced understanding of the issues presented in this article. It is a very helpful tool for any physician wishing to learn more about sharing Christ in their practice and we would highly recommend it.
Walt Larimore, MD, writes a helpful article addressing many of the issues in The American Family Physician, “Providing Basic Spiritual Care for Patients: Should It Be the Exclusive Domain of Pastoral Professionals?” See: http://www.aafp.org/afp/2001/0101/p36.html
Al Weir, MD, provides beneficial and compassionate ideas on the integration of faith and medicine in his article in The Community Oncologist, “Where faith and medicine meet.” See: http://www.communityoncology.net/journal/articles/0306372.pdf
Farr A. Curlin, MD, Daniel E. Hall, MD, MDiv, Journal of General Internal Medicine (2005: 20): 370-374. “Strangers or Friends? A Proposal for a New Spirituality-In-Medicine Ethic.” This is an extremely insightful article proposing that physicians can “engage patients regarding religious concerns guided by an ethic of moral friendship that seeks the patient’s good through wisdom, candor, and respect.” Highly recommended for the physician seeking to understand where some of the dissenting arguments have been raised. They briefly discuss, as have other authors, that “moral neutrality is not possible.” We agree and feel that refusal to be authentic and open with patients regarding spiritual matters can convey a “moral and ethical message” that can be antithetical to the goals of patient care and to both our personal and professional ethics. The professional boundaries that many commentators would set are both artificial and disingenuous. Spiritual and religious preferences inform most decisions patients are faced with and the thoughtful physician should be able to discern and communicate ethically and sensitively with his patients as needed.
ABOUT THE AUTHORS
Samuel Hensley, MD, serves as Bioethics Consultant to Mississippi Baptist Medical Center. He is on the Board of Directors of Matthew 25:40 Ministries, an outreach to the elderly in Chicago. He is also a member of the Executive Committee of the local campus-based chapter of CMDA and has served on the CMDA National Ethics Commission. Dr. Hensley received his MD from West Virginia University in 1979, completed a Residency in Anatomic and Clinical Pathology in 1983 at Wilford Hall in San Antonio, and a Fellowship in Neuropathology at the Armed Forces Institute of Pathology in 1985. He received a Master’s Degree in Christian Thought and Ethics from Trinity Evangelical Divinity School, where he now serves as a Fellow with the Center for Bioethics and Human Dignity in Deerfield, IL.
Elizabeth Hensley, MD, received her medical degree from The University of Mississippi. Her work experience has included private clinical practice in pediatrics, public health, and corporate administrative work. She has served on the CMDA National Ethics Committee and works on the local level teaching and mentoring students in the CMDA chapter in Jackson, MS. She is also a Fellow with the Center for Bioethics and Human Dignity in Deerfield, IL. Along with her husband, Sam, she has taught and coordinated an elective course in bioethics for senior medical students at the University of Mississippi Medical Center.