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Should doctors come clean? Religion makes a difference to end-of-life decisions

In a paper released today in the Journal of Medical Ethics, a large survey of UK doctors found that doctors’ religion influenced their views and practice of end-of-life care. Why does this matter? A number of headlines highlighted that atheist or agnostic doctors were more likely to report having participated in “ethically contentious end-of life actions”: ie taking part in terminal sedation or in actions that they expected or partly intended would hasten the patient’s death. But other headlines emphasised the obvious flip-side: doctors who identified themselves as ‘very religious’ or ‘extremely religious’ were about 35% less likely than non-religious doctors to report having taken this sort of step.

To put this in context it is worth noting that the majority of British doctors do not have strong religious or non-religious views. In the survey, two thirds described themselves as neither religious nor non-religious or as holding mildly religious/non-religious views.

Our own religious sentiment, and position on euthanasia and end-of-life decisions will influence which group of doctors we are more likely to worry about. But there is some reason why we might worry more about the tendency of religious doctors to take such actions less. In the UK, and in many countries it is legal, and supported by professional guidelines to provide deep sedation to dying patients who cannot be kept comfortable any other way, or to take steps that are highly likely to hasten a patient’s death, for example by withdrawing burdensome treatments or by giving morphine. Some patients will want such steps to be taken, others may choose not to. However, on the face of it, it appears likely that religious doctors are less likely to be involved in certain elements of end-of-life care even if patients request it, or would have wanted it (if they were competent). The most troubling finding in the survey was that 1/3 of highly religious doctors reported not having discussed with their (conscious and competent) patients decisions that they had expected or intended to hasten death. 90% of non-religious doctors indicated that they had discussed with their patients these same steps.

Medicine is not a value-free exercise. It involves intervention in some of the most important and contentious elements of life. It is hardly surprising to find that doctors bring their own values to decisions, and are influenced by their own religious (or non-religious) views.

However, doctors should be aware of the way in which their values influence their practice, and the way in which those values may differ from those of their patients. Doctors don’t usually talk about their own personal lives with their patients. They are actively discouraged from discussing their religious views. But perhaps that should change. Should both believing and non-believing doctors advertise their views in a form of open disclosure with patients? One reason not to go down this route is that there are a range of perspectives within religions, and a range of strengths of religious belief. Knowing your doctor’s religion or lack thereof may not help a patient know what their view is on end-of-life issues, or how this will influence their own care. But it may sometimes be necessary. As a minimum, any doctor who is unable to accede to a patient’s or surrogate’s request should explain themselves, including the potential influence of their personal philosophy and be prepared to refer to patient to someone who shares the patient's own world-view.

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11 Comment on this post

  1. I suppose it should be noted that in addition to our own convictions dictating which segment of the doctor population we ought to be concerned about, they also influence, I would wager, which kind of doctor we go to. My bet is that if you were to compare the religious sentiments of doctors and their patients, a significant correlation would likely be found. If that is the case, then coming clean would achieve little, if anything at all.

    This, of course, does not help with those situations where doctor and patient are at theological and ideological odds. But I find that this conflict is already covered by the current tenets of medical ethics. It is the duty of the physician to discuss all medically viable alternatives of treatment, including no treatment, and their consequences. If it could be shown that a physician has failed to give a good presentation of alternatives during consultation, then he is quite clearly in breach of his ethical obligations to the patient. The physician should not be compelled to act against his conscience, but providing information or referring patients to competent sources of information about alternatives is nevertheless his duty.

    To my mind, the study has only scratched the surface and it is too early to call for mandatory disclosures of personal beliefs, or indeed anything less drastic than that. There is after all a recognized right to privacy and freedom of thought and we would not want to be too rash in acting so as to undermine these in an unjustified way. We have a picture of what is the case, but we do not yet know why it is so and it is reasons that must guide our actions here. The crucial question now is: Why?

  2. Dimitri,

    it is possible that the religious views of doctors and those of patients would correlate. But there is no good reason for thinking that this is likely in a country like the UK unless you are in the majority. In the UK, and in most other countries doctors do not advertise their religious affiliation openly, and indeed they may seek to conceal it, as an element of their private life. Patients often have little or no choice about the doctor who provides their care – especially for acute hospital care, or specialised medical care, where most of these decisions are made.
    In an important study of more than 1000 doctors in the US published in 2007 (1), 17% objected to terminal sedation, 52% objected to abortion after failed contraception, 42% objected to prescription of birth control to a teenager without parental consent. When these same doctors were asked about dealing with conscientious objections in practice only 2/3 thought that doctors were obliged to explain their reasons for objecting to a requested procedure or treatment. 8% of the American doctors did not think that the doctor was obliged to present all possible options to the patient (6% were undecided), and 19% did not think that the doctor was obliged to refer the patient to another provider (11% were undecided). The authors of that article noted that potentially more than 40 million Americans may be cared for by doctors who do not believe that they are obligated to tell their patients about options that they do not personally approve of.
    The UK survey doesn’t provide this sort of detail, and the attitudes of UK doctors may be significantly different from their counterparts in the US. (36% of the US doctors classed themselves as ‘highly religious’, compared to 13% of UK doctors).
    Doctors, of course, have a right to privacy and to their own religious or non-religious belief. But, in a public health system they also have an obligation to offer or at least explain about and refer for treatments that they may not personally endorse. The difficulty for a patient is in knowing whether their doctors religion is (not necessarily deliberately) influencing the treatment options that they are providing. If patients ask, doctors should tell. If doctors say no to a treatment, they should explain why. If a doctor is unable, for reason of conscience, to discuss certain legal and socially acceptable treatment options with patients they should find an area of medicine that does not conflict with their conscience.

    1. Curlin FA,et al Religion, conscience, and controversial clinical practices. N Engl J Med 2007;356:593–600.

  3. It strikes me that when a person takes up the role of caretaker, serving persons who have no idea of what that caretaker does but depend on the caretaker’s advice, the caretaker is ethically compelled to provide some notice of those ares of that specialty where the caretaker will not go. This notice could indicate that the caretaker will not inform the patent/client of alternatives of which the caretaker does not approve (specifying those alternatives). Anyone who objects to such notice should become something less dangerous. There is no right to engage in such a caretaking activity.

    Regulation won’t compel the physician or lawyer or psychologist or pharmacist, etc. to do what is ethically right. That is where the law of negligence comes in.

  4. @Dominic:
    I’d start by noting that doctors have the same obligations under both the public and the private health care systems. It is among the distinctive features of the medical profession that they don’t (or at least ought not) sway with the wishes of the paymaster. Health is health, whether or not you’re paid by a HMO or NHS.
    That aside, the US study is definitely troubling. Although it is the minority of doctors that give reason for concern in how they care for their patients, its still a sizable minority, especially considering the number of doctors and patients in the US.

    At least as far as I read the study results, however, the problem seems primarily in education. Physicians are ignorant of their obligations, which, to be honest, does not surprise me. Ethics education has a lot of catching up to do in medical schools. It would hard to extrapolate the true beliefs, so to speak, of the relevant subpopulations of physicians in the study. Did they check “Not obligated to refer to another doctor” because they truly believe that they ought not do so, ie it is immoral, or were they ignorant of the extent of their obligations, ie they could come to understand that they ought to refer given the opportunity.
    Unfortunately, surveys are notoriously ineffective at getting at these kinds of truths. Hopefully, further research may develop a more accurate picture.

  5. “I’d start by noting that doctors have the same obligations under both the public and the private health care systems. It is among the distinctive features of the medical profession that they don’t (or at least ought not) sway with the wishes of the paymaster. Health is health, whether or not you’re paid by a HMO or NHS.”

    I’m not sure I completely agree with this. I certainly think it makes sense to consider doctors as having obligations, but can there not be different doctors operating in difference social contexts and thus having different obligations? Why should the “wishes of the paymaster” not be a relevant consideration in this context?

  6. Peter,

    I am not disputing that different contexts generate different obligations on the doctor. However, I would contend that a doctor as such has a core set of obligations that are independent of the context of practice. To make a rough sketch: doctors have an obligation to promote and protect the health of their patients. The only influence that the context of practice can, indeed ought, to have on this obligation is in decisions regarding the best practical means to this end. Thus, “the wishes of the paymasters” ought only to count in so far as they influence the means by which health is promoted and protected, not whether it is or is not to be promoted or protected at all.

    I would note here that the concern for health on the part of the doctor ends at physical and psychological health, and doctors are not in the business of looking out for spiritual wellbeing. There is a separate profession, as old as medicine itself, that has been established and granted dominion over the health of the soul. The exclusive domain of medicine is the body, the spirit is left to the patient and his faith leaders, such as they are.

    To go a little further, if some physicians, pharmacists, etc. have these conscientious objections and faith-grounded resistances to certain areas of medicine, on which they purposefully act, they should not be allowed to practice on the public dime. To make a reaching statement, public funds supporting the practice of GPs like the ones of interest from the above study could reasonably be seen as translated into state sponsorship of a particular religious view or views. Overt as it is, I do not see a way of escaping the implication that some kind of favoritism, unintentional though it may be, that is the consequence. If we are committed to the neutrality of liberalism, then this certainly seems inconsistent.

  7. A number of comments Dmitri.

    1. I agree that all doctors have a core obligation to promote and protect the health of their patients. Where there is some reason why they do not wish to make use of all (practically) possible means to achieve that end, this needs to be overt and understood by the patients concerned. In some cases there may be a justification for preventing such doctors from practising at all, especially where the taxpayer is paying. But I think this is more a political question than a question of fundamental ethics. What about countries where a majority of the population is religious?

    2. When I see “this needs to be overt”, I mean the doctor’s unwillingness to perform specific treatments. His/her reasons for withholding such treatments, religious or otherwise, are, to my mind, his or her business and not that of the patient or the public.

    3. I question the distinction between “psychological health” and “spiritual wellbeing”. How do you these concepts as separate? If by “spiritual wellbeing” you mean something like “wellbeing as judged against irrational criteria of a religious or superstitious nature”, then you are ignoring a whole body of thought that seeks to bring words like “spiritual” into a more rational, evidence-based domain. The main difference between “psychological” and “spiritual” is that one is Greek and the other is Latin. Oh, and “spiritual” has a different connotation in the public mind, certainly more linked with religion and “faith” (see my next comment), but also tends to been seen by many as less, not more, esoteric and has more emotional resonance. If we disdain such words then we miss an important opportunity to improve the future of humanity (which I suppose is what we’re trying to do here, right?).

    4. Without “faith” it is impossible to live. Equally well, it is possible to doubt everything, even one’s own existence. (Wittgenstein’s critique of Descartes seems to me convincing in this respect.) The question is what to believe, in the sense of basing our actions on certain assumptions (such as “if I don’t eat I’ll get hungry”). What criteria do we use to make such choices? Evidence certainly, but should there be something else? In my opinion there should. In fact, the core question I ask myself in relation to my beliefs is, “Does this belief help me?”. To the extent that I am interested in the truth (and therefore the evidential basis) for my beliefs, it is because on the whole I believe that true beliefs are more helpful than false ones. (And I find that belief helpful.)

  8. Peter,
    Thank you for the comments. Here are a few responses in kind, as it were.
    The distinction between spiritual and psychological that I have in mind is not quite you mentioned. Simply put psychological health is the health of the patients mind and psyche and spiritual health is the health of the patients soul, if we grant such a thing, couched in, roughly, adherence to religious laws and the balance of good acts over sins; taking the Christian world view, your soul is “healthy” if you’re going to Heaven when you die.

    As such I would have no qualms with spiritual health being interpreted in rational and naturalistic terms: as the emergent phenomenon of the combination of physical and mental health. However that is not the notion that guides those with deep (and even moderate) religious convictions where spiritual health is couched, abstractly speaking, as being in a positive relationship with the supernatural force of the universe, most commonly God. My claim is that any and all such supernatural considerations with regard to health are beyond the reach of medicine and ought not be the concern of physicians.

    To be sure, though, this may at first appear as a minor point of contention in the larger argument. It seems to apply to those doctors who refuse to perform some procedure on grounds that it will in some way taint the souls of their patients. In general, the concern is far more selfish in that doctors do not want themselves to be implicated in what they consider to be acts against God.

    The line is blurred, however, when the refusal to perform transgresses into a refusal to inform or refer. Here the best interpretation seems to me to be one of refusal as a means of preserving God’s will and “saving” others from committing a sinful act in the eyes of the refusing doctor. Here it is the spiritual wellbeing of others that is a concern and it is a concern that doctors ought not have. Which brings me to the remark I made earlier, if a doctor worries so about the wellbeing of my soul, his in the wrong profession.

  9. Many thanks Dmitri. One practical problem I have with this position is that it would exclude great many doctors: probably a disproportionate number in the sense that I would guess (I don’t have any stats on this) that religion is relatively over-represented among doctors (compared with the general population in Western countries) because it provides an important motivation for entering the caring professions.

    A related point is that you seem to be implying that professionals (in this case doctors) should not have concerns that go beyond the reach of their profession. As a general rule this would clearly be absurd. A more plausible position would be that the rule should apply in cases where these extra-professional concerns create a conflict of interest, but then we should presumably treat this issue in the same way that we would treat any other conflict-of-interest issue (to the extent that we have consistent rules on this).

    To summarise, I would modify your last sentence in the following way: if a doctor worries about the wellbeing of my soul and this influences the way the treatment he offers or recommends, then I at least have a right to know about it. Otherwise, we should judge our doctors on the basis of how they perform their role, not on the basis of their extra-professional concerns, no matter how silly/irrational we judge them to be.

  10. This is an interesting discussion.

    Regarding the remit of the physican, there is an interestinare interesting questions of philosophical/theological anthropology to address. I do not think that the stereotypical ‘religious’ doctor would think in terms of a set of dogmatic propositions to which he is committed, associate them with fears of the religious destiny of the soul, and then circumscribe the range of options he is willing to transact with the patient. He is more likely to be influenced by the ‘wisdom traditions’ associated with his religion and the theological anthropology it implies. Thus, if he is committed to the ‘Abrahamic’ view that human beings are not mere aggregates of discrete body and soul, but integrated totalities of body, mind and spirit, then a relatively uninterrupted movement from concerns about the patient’s physicality, to concerns about the patient’s psychological and spiritual health is wholly intelligible. It is a deeply contestable view that medicine should be exclusively concerned with the patient’s physical and psychological health, based as it usually is on a reductionally physicalist or stringently dualist anthropology. The former tends to be associated with view of medicine as technical prosecution of a war against disease; the latter tends to be associated with the the kind of voluntarism that abstracts the patient andtransmutes him into an essentially “choosing” being.

  11. Peter,

    I suppose my position must be made more clear. It is not that I deny doctors concerns beyond those of their profession. That view would indeed be absurd. However, there should not a confusion between the concerns of a doctor as doctor and concern of a doctor as good Christian, for example. I see a definite problem when the later supersedes the former and that was what I had in mind in my prior post. A doctor, in his capacity as doctor (ie at the time of practice), is doctor first, Christian second. This may not be a shared view but it is the right one for my money, particularly when being a good Christian (I’m really not trying to be picky, just sticking to the example) results exercising effective restrictions on the options and opportunities of others, such as refusal to refer to a willing doctor.

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