““Essentials for Medical Practice in an Essentials for Medical Practice in an Ethically and Spiritually Pluralistic Ethically and Spiritually Pluralistic

Environment”Environment”

Jerome R. Wernow Ph.D., R.Ph.Jerome R. Wernow Ph.D., R.Ph.

NW Center for BioethicsNW Center for Bioethics

www.ncbioethics.orgwww.ncbioethics.org

Ghost StoriesGhost Stories

Mythos Mythos and and LogosLogos

Mythos Mythos describes “worldly things by describes “worldly things by tracing them to exceptional, tracing them to exceptional, sometimes sacred events, that sometimes sacred events, that caused the world to be as it is now.” caused the world to be as it is now.”

Logos Logos “a kind of logical analysis that “a kind of logical analysis that places things in the context of reason places things in the context of reason and explains them with the pure and explains them with the pure force of thought.”force of thought.”

Palmer, Donald: Looking at Philosophy: The Unbearable Heaviness of Philosophy Made Lighter. (Mountain View, CA: Mayfield Publishing) second edition, 1994, p. 2.

Mythos Mythos and and LogosLogos

““There are other accounts, however, There are other accounts, however, accounts that suggest that Western accounts that suggest that Western

Logos-Logos-philosophy and science is just our philosophy and science is just our version of version of mythosmythos.” .”

Palmer, Donald: Looking at Philosophy: The Unbearable Heaviness of Philosophy Made Lighter. (Mountain View, CA: Mayfield Publishing) second edition, 1994, p. 2.

Take Away PointTake Away Point

The stories used to give meaning The stories used to give meaning to a person’s life are the stories to a person’s life are the stories

used to give meaning to a used to give meaning to a person’s ‘health.’person’s ‘health.’

Pluralism in Notions of HealthPluralism in Notions of Health

Numerous of definitions of ‘health’Numerous of definitions of ‘health’Different concepts of health in non-Different concepts of health in non-

religious contexts i.e. WHO definitionreligious contexts i.e. WHO definitionDivine views of health persists to this Divine views of health persists to this

era era

Üstün & Jakob: Bulletin of the World Health Organization. 2005;83:802.

Pluralism Amidst ChristiansPluralism Amidst Christians

Biopsychosocial integrity that Biopsychosocial integrity that permits life to be lived faithfully in permits life to be lived faithfully in communitycommunity

A state of physical well-beingA state of physical well-beingA holistic consideration of being in A holistic consideration of being in

relationship to God and His relationship to God and His sovereignty sovereignty Lammers, Stephen and Verhey, Allen: On Moral Medicine: Theological Perspectives in Medical Ethics. (Grand Rapids, MI: Eerdmans, Publishing, 2nd edition 1998) pp. 241-266.

Health – another descriptionHealth – another description

““A term describing a human A term describing a human being’s functional integration of being’s functional integration of

their corporeal, psychofactual, and their corporeal, psychofactual, and spiritual properties.”spiritual properties.”

Human B/b-eingHuman B/b-eing

Corporeality

Spiritual Illumination

Psychofacticity

ObjectiveObjective

Recognize significant conflict Recognize significant conflict potentialspotentials

Understand foundations beneath Understand foundations beneath conflictsconflicts

Avert conflict or avoid escalationAvert conflict or avoid escalationMinimize conflict consequencesMinimize conflict consequences

Take Away PointTake Away Point

The stories used to give meaning The stories used to give meaning to a person’s life are the stories to a person’s life are the stories

used to give meaning to a used to give meaning to a person’s ‘health.’person’s ‘health.’

A decision-making matrix

Clinical Integrity Beneficence

Autonomy Justice/Nonmaleficence

Dr. John Tuohey, “Pandemic Planning.”

Metamorphosis of Medical Metamorphosis of Medical EthicsEthics

The Quiescent The Quiescent Period-the Period-the Hippocratic ethicHippocratic ethic

The Period of The Period of PrinciplismPrinciplism

The Period of Anti-The Period of Anti-principlismprinciplism

Period of CrisisPeriod of Crisis

Edmund D. Pellegrino: “The Metamorphosis of Medical Ethics,” The Journal of the American Medical Association. v. 269/9 (March 3, 1993) pp. 1158-1162.

Part of Hippocratic Oath Part of Hippocratic Oath

““I will not give to a woman a I will not give to a woman a pessary to produce abortion.” pessary to produce abortion.”

Hippocrates: Hippocratic Writings, in The Great Books of the Western World Series, chief editor Robert Maynard Hutchins, trans. by Francis Adams (Chicago: Encyclopedia Britannica, 1952) volume 10, p. xiii.

Plato and AristotlePlato and Aristotle

““proper disposal in secret of the sort born proper disposal in secret of the sort born defective” as a social common gooddefective” as a social common good

““merely of animal species and part of the merely of animal species and part of the mother until it falls as fruit from the mother until it falls as fruit from the tree;” tree;”

Plato: The Republic in The Loeb Classical Library, trans. Paul Shorey (Cambridge, Mass: Harvard University Press, 1932) bk. v, ix, c, p. 463.

A. E. Crawley, “Foeticide,” Encyclopaedia of Religion and Ethics, eds. James Hastings, John A. Selbie, and Louis H. Gray (New York: Charles Scribner’s Sons, 1922) v. 6, p. 56

Scribonius Largus Scribonius Largus

““No physician should give or even No physician should give or even show an abortifacient to a pregnant show an abortifacient to a pregnant woman.” woman.”

““drugs being like divine hands and drugs being like divine hands and their effects like divine intervention” their effects like divine intervention”

E.D. Pellegrino and Alice A. Pellegrino: “Humanism and Ethics in Roman Medicine: Translation and Commentary of a Text of Scribonius Largus,” in Literature and Medicine: Literature and Bioethics 7 (1988) p. 35 , 25.

SoranusSoranus

Lays down a complex and Lays down a complex and perhaps efficient method of perhaps efficient method of

inducing abortioninducing abortion

Claudius Galenus Claudius Galenus

practitioners opted out of abortion due to practitioners opted out of abortion due to conscience conscience

based upon the principle of beneficence based upon the principle of beneficence sourced in the Hippocratic Code sourced in the Hippocratic Code

founded on a worldview of some superior founded on a worldview of some superior being that ordered nature being that ordered nature

““the goodness and ingenuity of the creator.” the goodness and ingenuity of the creator.”

Claudius Galenus, Galen on the Therapeutic Method: Books and I and II. trans. R.J. Hankinson (Oxford: Clarendon Press, 1991) p. xxiii.

Basil of Cappadocia Basil of Cappadocia

““The woman who purposely destroys her unborn The woman who purposely destroys her unborn child is guilty of murder…. The punishment, child is guilty of murder…. The punishment,

however, of these women should not be for life, however, of these women should not be for life, but for the term of ten years.” but for the term of ten years.”

American Medical Association American Medical Association in 1847in 1847

““Domination of the Roman Catholic Domination of the Roman Catholic expression of Christian ethics is seen expression of Christian ethics is seen

even as the ethic’s content became part even as the ethic’s content became part of the code of ethics.” of the code of ethics.”

Chester R. Burns, “American Ethics: Some Historical Roots” in Philosophical Medical Ethics: Its Nature and Significance, eds., S.F. Spicker and H.T. Englehardt Jr. (Dordrecht-Holland: Reidel Publishing Company, 1997) pp 21-26.

Metamorphosis in WorldviewMetamorphosis in Worldview

‘‘enlightenment philosophy and rationality enlightenment philosophy and rationality leavened the bread of moral philosophy in the leavened the bread of moral philosophy in the

medical schools, studies in humanist psychology medical schools, studies in humanist psychology began to be substituted for Christian ethics’ began to be substituted for Christian ethics’

op cit : Chester R. Burns, “American Ethics: Some Historical Roots”

Metamorphosis in Metamorphosis in EpistemologyEpistemology

Judeo-Christian Hippocratic ethic dominant Judeo-Christian Hippocratic ethic dominant seventeen centuries seventeen centuries

Modernity’s early epistemological drift Modernity’s early epistemological drift embraced mutual influence of Christian embraced mutual influence of Christian theology and scientific belief theology and scientific belief

John Locke introduced split empirical John Locke introduced split empirical knowledge from that of the world of faith knowledge from that of the world of faith

Drift became a torrent from atheists David Drift became a torrent from atheists David Hume to Richard Dawkins to Samuel HarrisHume to Richard Dawkins to Samuel Harris

Evolutionary materialism became Evolutionary materialism became dominant explaining what exists through dominant explaining what exists through empirical observation of the material worldempirical observation of the material world

Metamorphosis in Ethics Metamorphosis in Ethics

The new ‘The new ‘mythosmythos’ not only determined ’ not only determined what we know, but fixed limits on human what we know, but fixed limits on human behavior and promulgated rights based behavior and promulgated rights based upon the mores of those in power. upon the mores of those in power.

The gods and their stories of The gods and their stories of mythos mythos in in war and conquest were replaced by the war and conquest were replaced by the logoslogos, that is, philosophies of a commerce-, that is, philosophies of a commerce-based society. The “gods are dead, and based society. The “gods are dead, and the whirlwind rules” Aristophanes/the whirlwind rules” Aristophanes/The The CloudsClouds

Common Thread in Common Thread in DifferencesDifferences

Objective moral normObjective moral normSubjective moral normSubjective moral norm

Objective Moral NormObjective Moral Norm

Emphasis on a universal Emphasis on a universal imperative that demands imperative that demands action based upon some action based upon some

trusted source of authoritytrusted source of authority

Objective Moral NormObjective Moral Norm

Biblical belief that the human being is Biblical belief that the human being is created in the image of Godcreated in the image of God

Sacred human value inheres all human Sacred human value inheres all human beings due to resident Divine imagebeings due to resident Divine image

Moral norm of medical practice Moral norm of medical practice preserves, protects, and promotes preserves, protects, and promotes human personhuman person

Requests for physician’s aid in suicide Requests for physician’s aid in suicide violates moral normviolates moral norm

Subjective Moral NormSubjective Moral Norm

Emphasis on an individual Emphasis on an individual preference that directs action preference that directs action

based upon a personal based upon a personal construction of reality construction of reality

Subjective Moral NormSubjective Moral Norm

The human being is only comprised The human being is only comprised of the primordial material it evolved of the primordial material it evolved from from

Life’s value is personally determined Life’s value is personally determined by “pleasurable states of by “pleasurable states of consciousness”consciousness”

The irretrievable loss of pleasure The irretrievable loss of pleasure permits physician assisted suicide to permits physician assisted suicide to be a proper medical practice be a proper medical practice Kuhse, Helga. The Sanctity of Life Doctrine in Medicine: A Critique. (Oxford: Clarendon Press, 1987) p. 217.

OverviewOverview

Health Care Provider

Patient

State

Institution

Relevance in ContextRelevance in Context

Conflicts of moral impositionConflicts of moral impositionConflicts in professional integrityConflicts in professional integrityConflicts of potential discriminationConflicts of potential discrimination

ACOG Ethics OpinionACOG Ethics Opinion

Imposition of Imposition of MoralityMorality

Effect on Patient Effect on Patient HealthHealth

Scientific IntegrityScientific Integrity Potential Potential

DiscriminationDiscrimination

Response to ACOG’s EthicResponse to ACOG’s Ethic

“a message of ideological intolerance and religious

discrimination” (CMDA Stevens et al)

““Celestial Fire of Conscience”Celestial Fire of Conscience”

Religious issueReligious issue Ethical integrity Ethical integrity

issueissue Collective Collective

professional issueprofessional issueNEJM 352:24 Jn 16, 2005 pp. 2471-73

NW Spiritual MilieuNW Spiritual Milieu

Cat

holic

No

relig

ion

Bud

dhis

t

Chr

istia

n

Jeho

vah'

sW

itnes

ses

Ref

used

S1

0

5

10

15

20

25

Oregon - Kosmin, Mayer & Keysar (2001-12-19). American Identification Survey, 2001

Series1

Series2

Some Slices of PluralitySome Slices of Plurality

Oregon 2001

Catholic

No religion

Christian

Baptist

Mormon/LDS

Buddhist

Refused

Other

Plurality Within CatholicismPlurality Within Catholicism

Oregon 2001

Catholic

No religion

Christian

Baptist

Mormon/LDS

Buddhist

Refused

Other

Catholic PluralityCatholic Plurality

27 percent abortions in 200127 percent abortions in 2001Catholics for ChoiceCatholics for ChoiceAmerican Life LeagueAmerican Life League

Jones RK, Darroch JE and Henshaw SK, Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001, Perspectives on Sexual and Reproductive Health, 2002, 34(5):226–235.

Plurality within BuddhismPlurality within Buddhism

Oregon 2001

Catholic

No religion

Christian

Baptist

Mormon/LDS

Buddhist

Refused

Other

Buddhist PluralityBuddhist Plurality

““One stance is that human life begins at One stance is that human life begins at conception and therefore abortion at any conception and therefore abortion at any

stage in the pregnancy is wrong - full stage in the pregnancy is wrong - full stop. Another stance might be that the stop. Another stance might be that the

offence is worse the more developed the offence is worse the more developed the fetus or embryo. Yet another might be fetus or embryo. Yet another might be that the seriousness of the offence can that the seriousness of the offence can

only be determined by taking into account only be determined by taking into account the full circumstances surrounding the the full circumstances surrounding the

abortion.” abortion.” http://buddhism.about.com/cs/ethics/a/Abortion.htm

Protestant PluralityProtestant Plurality

43% Abortion Protestant43% Abortion Protestant13% Born Again/Evangelical13% Born Again/Evangelical

Plurality within Non ReligiousPlurality within Non Religious

Oregon 2001

Catholic

No religion

Christian

Baptist

Mormon/LDS

Buddhist

Refused

Other

Non religious PluralityNon religious Plurality

Atheist and Agnostic Pro-Life LeagueAtheist and Agnostic Pro-Life LeagueCouncil for Secular Humanism Council for Secular Humanism Pro-Life Alliance of Gays and Pro-Life Alliance of Gays and

Lesbians Lesbians

Plurality within ‘Other’Plurality within ‘Other’

Oregon 2001

Catholic

No religion

Christian

Baptist

Mormon/LDS

Buddhist

Refused

Other

Other PluralityOther Plurality

Non-mainstream spirituality Non-mainstream spirituality Northwest Tibetan Cultural Northwest Tibetan Cultural

AssociationAssociationWICCANew AgeVedanta Society

Take Away PointTake Away Point

Pluralism of opinions within Pluralism of opinions within religious communities religious communities

necessitates clarifying patient’s necessitates clarifying patient’s understanding if patient raises understanding if patient raises

spirituality as importantspirituality as important

Purpose for Spiritual HistoryPurpose for Spiritual History

Reveals belief impact on medical Reveals belief impact on medical decisionsdecisions

Reveals social support structuresReveals social support structuresPredictor in success for copingPredictor in success for copingPredictor in remission of depressionPredictor in remission of depressionPredictor of discharge mortality Predictor of discharge mortality

Koenig, HG: Taking a Spiritual History, JAMA. 2004:291;23 2881

Barriers to taking a Spiritual Barriers to taking a Spiritual HistoryHistory

Lack of timeLack of time Lack of trainingLack of training Expertise concernsExpertise concerns

Personal discomfortPersonal discomfort Sense of impositionSense of imposition Lack of interestLack of interest

Ellis, MR: “What do families think about spirituality in clinical practice,” J Family Pract. 2002;51: 249-254.

When to obtain a Spiritual When to obtain a Spiritual HistoryHistory

Part of new patient historyPart of new patient historyPart of a hospital admissionPart of a hospital admissionDuring a well-patient check-upDuring a well-patient check-up

Koenig, HG et al: “Religious coping and depression,” Am J Psychiatry. 1992; 149;1693-1700.

Patient Appropriate Spiritual Patient Appropriate Spiritual HistoriesHistories

Patients terminally illPatients terminally illPatients chronically illPatients chronically ill Inter-personal relationship Inter-personal relationship

paramountparamountKoenig, HG et al: “Religious coping and depression,” Am J Psychiatry. 1992; 149;1693-1700.

What to askWhat to ask

S - spiritual belief systemS - spiritual belief systemP - personal spiritualityP - personal spirituality I - integration with a spiritual I - integration with a spiritual

communitycommunityR - ritualized practices and R - ritualized practices and

restrictionsrestrictions I - implications for medical careI - implications for medical careT - terminal events planningT - terminal events planning

Maugans TA. The SPIRITual History. Arch Fam Med. 5:11- 16, 1997

What to askWhat to ask

F - Faith and Belief F - Faith and Belief "Do you consider "Do you consider yourself spiritual or religious?" yourself spiritual or religious?"

I - Importance I - Importance "What importance does "What importance does your faith or belief have in your life?” your faith or belief have in your life?”

C – Community C – Community "Are you part of a "Are you part of a spiritual or religious community?”spiritual or religious community?”

A - Address in Care A - Address in Care "How would you like "How would you like me, to address these issues in your me, to address these issues in your healthcare?"healthcare?"Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Pall Med 2000;3:129-37.

What to AvoidWhat to Avoid

Prescribing beliefPrescribing beliefForcing a historyForcing a historyCoercing beliefCoercing beliefArguing spiritualityArguing spirituality

Butler, et al: Is prayer good for you health? www.heritage.org

"Know yourself" "Know yourself"

What stories inform What stories inform your spirituality your spirituality and ethic?and ethic?

What stories inform What stories inform your understanding your understanding of health?of health?

What is your What is your position on the position on the place of the place of the patient’s spirituality patient’s spirituality and treatment?and treatment?

Pausanias (10.24.1)

Corporeality

Spiritual Illumination

Psychofacticity