When Religion and Medicine Clash: How Caregivers Might Respond

By Dennis J. Doherty, PhD, JD
Dr. Doherty is associate professor of Christian Ethics in the
Department of Theology at Marquette University in Milwaukee,
Wisconsin.  

In a Chicago hospital in December of 1993 an expectant mother was
advised by her doctors that her baby should be delivered
prematurely by C-section because it was being starved of oxygen
and would suffer damage.  The woman refused because she and her
husband believed that God would take care of the baby.  The
hospital sought a court order which was ultimately denied; the
mother's right to religious freedom and privacy prevailed. She
was not only free to believe that God would provide but also
legally entitled to act on that belief.  As things turned out,
happily, the baby was born on schedule and apparently in good
health.

More commonly, an impasse or dilemma between religion and
medicine is apt to occur when one's life is ebbing away, not when
it is just beginning.  That is, the usual scenario is that of a
person--usually an adult--who is dying and for whom continued
aggressive treatment would, in the best medical judgment be
futile.  But the same can be true of an infant whose condition is
incompatible with life but the parental religious conviction is
that everything possible should be done and God will take care of
the rest.

The purpose of this article is to consider the relationship
between religion and medicine from the standpoint of ethics and
to suggest how physicians and other health care providers might
respond when the faith-based preference of an autonomous patient
(or the patient's surrogate) clashes with the medically indicated
treatment modality.  The legal standpoint is important, to be
sure, and the legal dimensions of an issue must be considered in
ethical analyses.  But law is not ethics; folk wisdom knows that
"just because something is legal doesn't mean it's right."  Of
course, it doesn't mean it's wrong, either; rather it's arguable. 
Perhaps in health care matters especially, no one really wants to
get the courts involved.

What interests us here are those situations in which patient and
practitioner really need to understand each other's vantage
point--or, said popularly, where the other is coming from.  In a
nutshell, the patient knows that the doctor certainly intends
what is best but the patient does not believe that "the doctor
knows best" in this instance.  Only God does.  The doctor can
clearly spell out what the symptoms mean, what test results show,
and what medicine indicates by way of treatment--and the patient
understands this.

                                The Problem

Part of the problem is that patients cannot be as clear in
explaining why they believe that God has a different idea. 
Indeed, no explanation is necessary or even possible for
otherwise, if it could be explained, belief or faith would not be
necessary.  In other words, we do not have faith regarding that
which we can prove to be true.  For example, people may believe
in the existence of UFO's on the word of someone who claims to
have seen one or even to have been abducted in one.  But when one
has first-hand knowledge of something, it is no longer a matter
of belief (even though, popularly but inaccurately, it is said
that "seeing is believing" or the sight of something that one has
been skeptical about now has made a "believer" of him.)  We
believe in that which we cannot see or otherwise perceive through
the senses. The believer knows in his heart that God exists; he
may adduce reasons to prove this existence but the God that can
be reasoned t (Aristotle's "Prime Mover," for example) is not
necessarily the God in whom one believes personally.  This God is
taken on faith.  And, for the believer, the one who has faith,
this suffices.

Another part of the problem is that medical personnel can be
overly sensitive to religion which is seen to be so private and
to be usually the domain of the chaplain or pastoral counselor. 
How can doctors and others get a handle on understanding the
outlook of a devout believer?

                         Background Considerations

Enter theology!  Literally, the word means the "study of God" (or
"God Talk") which does not tell us a whole lot.  Theology is a
study of religion, a critical study of what religion teaches
about God.  Theology is a reasoned inquiry into the nature of
religion -- its origin, history, sources of information (such as
scriptures or sacred writings, oral traditions), rituals,
disciplinary practices and always, contemporary relevance.  It is
accurate to say that whereas religion indoctrinates, theology
evaluates.  Religion and theology are interrelated but are not
the same.  Religion implies a recognition of a transcendent being
or beings;  theology asks questions and articulates theories
(belief systems) about that.

A patient may or may not profess adherence to an organized
religion.  Not that it matters in our context.  What does matter
is that the patient genuinely believes that God's ways are not
always our ways and, hence, the doctor should attempt to
appreciate this.  In general, however, in or outside of organized
religion, it should be helpful for medical professionals to know
-- and I speak now as both a professional theologian and former
pastoral minister -- what is usually behind a religious
conviction regarding medical treatment.  Because of that deeply
held conviction a patient is either insisting on treatment that
the doctors regard as futile or is refusing treatment that the
doctors think is beneficial.

Just as religion and theology are interrelated, so too,
historically, are religion and medicine; both with the same human
mysteries -- birth, suffering, dying and death.  A history of one
reflects the other.  Hippocrates, the Father of Medicine, was
himself religiously oriented;  he wrote: "Before the gods, the
physicians bow since they have not superabundance of power in
their art." 1  Nonetheless, he was the first to separate medicine
from philosophy and the role of the physician from the role of
the priest.2  That said, once religion is introduced into the
discussion of this patient's care it becomes part of the whole
conversation and can be asked about.  Insightful physicians
should be able to identify (and, often enough, can identify with) 
the underlying reasons for the patient's conviction and be able
to respond accordingly or in a way that must not be perceived as
argumentative.  (Arguing about religion rarely makes converts.)
Principal among those behind-the-scenes reasons are consolation,
guilt and hope.

                                The Consult

Consolation

To the believer,life is a mystery.  It is something God-given,
not the result of a random throw of the cosmic molecular dice,
and no one has a right to "play God."  The usual context of this
sentiment is that no one has a right to take another's life and,
hence, the omission of medical treatment is tantamount to that. 
In this view, aggressive treatment should always be provided.  If
God wants the patient to live, the patient will live.  What
humans consider futile is hardly persuasive to an omniscient
Creator.  If the patient dies, then that is what God wills.  This
is enormously consolative: whether one lives or dies is in the
hands of God.  When illness strikes, God has a plan.  When
someone dies unexpectedly or is killed tragically, God has some
purpose for this.  This outlook cushions grief for the survivors
and enables a patient to "go gentle into that good night" since
death for one who believes in a hereafter (or reincarnation) is a
moment of transition.

of course, no one knows what this "divine plan" or "purpose" is -
- nor can it be known; it is something of faith.  Whether futile
treatment is insisted on, or helpful treatment refused, whatever
ultimately happens is acceptable since a provident of God is in
charge.  Because such attitudes make the unendurable somehow
endurable, they are undoubtedly most consoling.  They are also
more than a little troubling, both theologically and medically.

Response

War is a terrible thing.  When biology declares war, the forces
of nature will eventually win.  Death is inevitable.  When the
medical view is that treatment is futile, the believer's
understanding of God's will can be diplomatically discussed.  If
all indications are that God is calling someone form this life
(i.e., the patient is dying), the caregiver can urge that the
patient should receive comfort care and be left in the hands of
the "Divine Physician" for the Creator, while not bound by the
laws of created nature, appears content to let them play out
naturally.

Fire burns.  God expects people to be careful around it and
parents, even believers, will not let their children play with
matches; parents do not believe that God will keep children from
being burned.  Nor should anyone expect God to reverse the dying
process.  Planes crash because of mechanical failures.  Someone
may believe that whatever happens is God's will, but it is not
likely that even the most devout believer, knowing that a plane
was grounded for repairs, would want to board it thinking that
God would provide.  If the defect can't be remedied, if all
attempts would be futile, then it is best to make other plans. 
Faith in God for a safe flight in such circumstances would be
misplaced; any believer would realize this.

A man is charged in a paternity action.  After much soul-
searching he insists that "God has assured me that I am not the
father."  But the judge, herself sincerely religious and
respectful of the respondent's religious sincerity, looks at the
physical evidence and concludes that he is.

Believers have no problem with the obviousness of the above
examples which may even seem inane.  When it is a question of
medical treatment, however, there may be a blind spot impervious
even to the light of reason.  It is not that these examples or
comparisons will resolve the problem, but they may well give the
patient pause.  Analogies always limp but can be used to show the
soundness of clinical judgments in the face of contrary religious
fervor.  If the person does not belong to an organized religion,
it may be helpful to consult with a spokesperson (minister,
pastor, elder) who is "believed" to have a clearer grasp of what
God wills in the circumstances.

Similarly, if treatment is indicated but is being refused, the
competent person can indeed refuse and ordinarily this poses no
problem.  If, however, the person is not competent and someone
else is deciding on no treatment by reason of a personal
religious conviction, what has to be considered is that the
surrogate may now be playing God for someone else.  Gentle
communication to that effect in these circumstances can be
conducive to a reconsideration by the surrogate.

Guilt

Feelings of guilt are not necessarily, or even primarily,
something religious.  But guilt can have a religious overtone and
a patient may feel (although usually it is the patient's family)
that unless every treatment modality available is used, God will
somehow be displeased.  For others, nothing should be done in
order that God's plan might be realized.  A great part of the
anguish expressed by patients or their surrogates is the burden
of guilt they experience in deciding to terminate or not even
begin treatment.  In that regard, they feel or fear that the
person's death will be on their conscience.  This seems to be
true in a special way for parents whose decision, if followed,
will result in the death of their child.  And, as everyone can
appreciate, the resulting guilt, coupled with the attendant
grief, is an extraordinary burden for anyone to bear.  This is
perhaps clear from the sigh of relief that people breathe, the
"thank-God-it's-over" feeling, when the situation is very grim
and nature intervenes and the patient dies naturally, therby
relieving others of the onus of making a decision that will
hasten someone's death.  In the instance of deciding on no
treatment, they simply feel that medical intervention is a
hindrance to what God really wants and is, therefore, contrary to
God's will.

Response

It is a truism to observe that one can be guilty of something and
yet not feel any guilt and, equally, one can feel pangs of
conscience without in fact being responsible for any wrongdoing. 
Psychologists know that unhealthy feelings of guilt can be
effectively, though usually not easily, overcome.  Someone whose
feelings of guilt are traceable to what would be for the
individual, a transgression of a religious conviction might well
think that healers of whatever professional station are simply
out to explain away a violation of what the Almighty intends. 
Such a confirmed believer may not be amenable to any type of
objective counseling and this can create an impasse that is
virtually impenetrable.

When doctors are told to do everything possible and leave the
rest up to God, lay persons usually have no clear idea of what
doing "everything possible" can entail.  They need to be informed
in living color.  And they need reassurance that the religiously
"safer" approach (continued aggressive treatment, or no treatment
as the case may be) is not always in their loved one's best
interest and, to the point, that God's will is not being
contravened.  A caregiver, just as a minister of religion, can
remind them that death is at once a natural part of life (which,
though true, is hardly consoling), indeed is the ultimate
mystery, and that no one, minister or doctor, can understand it.

What patients, family members and friends can find
understandable, however, is that continued treatment can itself
induce feelings of guilt by virtue of the daily reminder that the
patient is not getting better, that there is nothing dignified in
prolonging bodily existence, that the body embodies a person
whose dignity can be violated by the constant assault of
aggressive treatment, that limited resources that might be used
beneficially for others are being needlessly used and this is
surely displeasing to God, and so on.  Or, for one who  is
refusing treatment which could help, that cures which have been
discovered in nature have been put there by the beneficent Author
of nature, God, who intends that they be used.  Caregivers can
also explain, when treatment is being refused, that human beings
are instruments in the divine plan and medical personnel are
cooperating with God in preserving or enhancing the precious gift
of life -- when, that is, it can be both preserved and enhanced. 
This is, by and large, an affective approach admittedly, but it
is response that is appropriate to an emotionally laden
situation.  

Hope

When futile treatment is insisted on, religious faith, in a way
closely akin to that stage of dying which Kubler-Ross described
as bargaining,3 often means that if an individual directs that
everything possible be done, then God will spare the person. 
Family members may have personal or hearsay knowledge of
instances of persons who have been "miraculously" restored
(awakening from a coma, cancer remission) and these instances are
proof positive of the truth of the adage that "where there's
life, there's hope."  Unspoken is the belief that God may choose
to reward  that hope (faith) if only one believes strongly
enough.  Nonetheless, whatever happens is God's will.  And this
takes things back to the consolative aspect of belief.  There is
a certain symmetry here.  God will answer our prayers -- if not
in the way we would hope for, the in the way God deems best, and
no one need be troubled with fear-laden guilt for having offended
God.

Response

It is not always true, and usually is not true, that where there
is life there is hope.  Persons who are diagnosed as being
terminally ill usually do not outlive their caregiver;  they die. 
A persistent vegetative state persists.  When, extraordinarily,
this is not the case, the event makes headlines.  Doctors know
that a so-named "miracle" cure does not mean the same in medicine
as it does in religion.  In the former, such a cure is a
phenomenon which cannot be explained as yet.  (A wrong diagnosis
might also be the explanation.)  The usually religious
understanding  of a miracle cure implies divine intervention, a
suspension of the laws of physical nature.

A caregiver, or a religious official, can delicately hints that
it is presumption, not faith, to expect a suspension of these
laws -- as parents know who take matches for their children or as
a pilot knows who prays for a safe flight but packs a parachute
just in case.  Health care providers can recount both personal
and anecdotal instances of unexplainable cures (if, in fact, most
can be termed "cures") but medicine is not thereby inclined
always to use every weapon in its arsenal to fight off death or
to extend life.  This would be dehumanizing; it would be to 
deify life, something which a believer would object to.

Conclusion

To caregivers whose bent is agnostic or even atheistic this whole
approach must seem incomprehensible.  It is, in a way, even to
many caregivers who are professedly religious.  For believers who
follow the dictates of their heart, faith has its own reason; to
recall Pascal:  "we know truth no only by reason but also by the
heart... The heart has reasons which reason does not know>'4  But
there need be no opposition, much less antagonism, between faith
and reason, between religious views and medical judgments. 
Medical providers who may or may not believe in the providence of
God can suggest that God who, all believers acknowledge, works in
mysterious ways is now providing in a way that is consonant with
the usual order of things.  

Finally, all else failing, society's sanctuary of secular
religion -- with its robed high priest, other ministers of the
court, expert witnesses, and statutes and case law as its bible -
-may have to be recurred to at times if the impasse between
medicine and religion is otherwise insurmountable.                
   

          

 



1.  RH Major, A History of Medicine, Vol. I, Springfield, IL,
Charles C. Thomas Publisher, 1954, p. 123.

2.  Id., at 121

3.  E Kubler-Ross, On Death and Dying, New York,
Macmillan/Collier Books, 1969, pp. 82 - 84.

4.  B pascal, Pensees, New York: Washingtom Square Press, 1965,
Nn. 282, 287.
.