For centuries, medicine approached relieving suffering as a component of attending to health. Physicians today, however, face a competing approach, which champions relief of suffering as an important goal. This can put physicians at odds with patients who refuse treatment based on the belief that God wants them to suffer.
Three physician experts suggest that to discern when to accommodate a patient’s refusal of treatment on religious grounds, doctors should embrace medicine’s traditional orientation toward preserving and restoring health.
The AMA Code of Medical Ethics provides additional guidance on end-of-life care, such as opinion 5.3, “Withholding or Withdrawing Life-Sustaining Treatment,” to help physicians understand when it is ethically appropriate to accommodate a patient’s, or a surrogate’s, request to decline an intervention.
- Benjamin W. Frush, MD, MA, a resident in internal medicine-pediatrics at Vanderbilt University Medical Center in Nashville.
- John Brewer Eberly, Jr., MD, MA, a research assistant at the University of North Carolina School of Medicine’s Maternal-Fetal Medicine Units Network in Chapel Hill.
- Farr A. Curlin, MD, a professor of medical humanities at Duke University School of Medicine in Durham, North Carolina.
Using a hypothetical case of a 47-year-old man with a history of alcohol abuse who declines pain medication following surgery because he believes God wants him to atone for his sins, the authors suggest six ways to move such difficult conversations forward.
Determine if the patient’s refusal compromises your commitment to his health. Concerns for the patient’s health circumscribe what is acceptable. If evidence suggests that withholding treatment would unduly threaten the patient's health, you should refuse to offer this course of action, regardless of the religious rationale for the request. Conversely, if foregoing the treatment would not unduly threaten the health of the patient, you may accommodate the request, even if you disagree with it.
Inquire about how the patient’s religious beliefs inform his decision-making. Ask the patient how he understands the decisions he is facing in light of his religious beliefs. “This approach conveys respect, builds trust and opens up the possibility of finding an accommodation that both patient and physician can pursue with integrity,” the authors wrote.
Respectfully challenge the patient’s beliefs and refusals of needed care. “Indeed, as part of their professional commitment to the patient’s health, physicians have some obligation to respectfully challenge patients’ refusals of medical care that the physician believes is needed,” the authors wrote, explaining that a sincere debate in no way denigrates the patient’s religious beliefs.
Consider encouraging the patient to invite members of his faith community into discussions. “It can be helpful to broaden the conversation beyond the confines of the hospital and the medical team,” the authors wrote, noting that many patients have more confidence in their own clergy than in hospital chaplains. Such an approach is not without risk, however, as the faith community could reinforce the patient’s resistance to treatment.
Give the chaplain freedom to do his work. While the chaplain should not work in service of a predetermined outcome, he is trained to help the patient consider whether there are alternative understandings of suffering within his religious tradition.
If you have to refuse, explain your reasoning. Whatever your decision, candidly explain your reasoning to the patient. Be clear that your rationale is based upon professional judgment, not disrespect for the patient’s religious ideas.
This AMA Journal of Ethics article is part of a themed issue on religion and spirituality in health care practice.