Michelangelo’s Pietà, detail
It’s not often that patients near the end of life, or their relatives, invoke ‘God’s will’, but it does happen. When it does, the atheist doctor has a challenge. They ‘know’ that God does not exist, but must use words and arrive at decisions that take the patient’s religious convictions into account. This is not so hard, at the superficial level. They will ensure that the patient is offered spiritual support; they will tailor care to the patient’s goals and preferences; but they will never accept that their course is being observed or manipulated by a higher being. Perhaps it doesn’t really matter – as long as the right decisions are made, the difference in belief remains irrelevant.
When faced with a seriously ill patient (or more commonly their relatives) with an overtly religious perspective, I am respectful, but deflect the conversation to medical practicalities. This personal observation is borne out by previous studies. An analysis of 249 goals-of-care conversations, between 651 ‘surrogate decision makers’ and 441 health care professionals found that religion was brought up in only 40 cases (16.1%), despite 77.6% of the discussants saying that religion was a prominent consideration (Ernecoff et al, 2015). In only 8 of those conversations, ‘did health care professionals attempt to further understand surrogates’ beliefs, for example, by asking questions about the patient’s religion.’ A good proportion of doctors ‘redirected the conversation to medical considerations’.
The infrequency with which religion enters the room is surprising, given that religion serves as a great support in times of pain, distress or fear. Perhaps, confronted by the technical complexity of modern healthcare, and in environments that are not conducive to opening up their deepest, oldest beliefs, religion is left where is spends most of its time, within the private sphere.
However, faith definitely does influence decision-making. The Ethicatt study showed that ‘religiosity’ correlates with a tendency to request more medical interventions, and for longer (Bülow et al, 2012). Commenting on North American population, Maisha Robinson (2016) describes how religious ‘African Americans are more likely than Caucasians to choose life-sustaining treatment at the end of life—even if the burden of treatment outweighs the potential, limited benefits.’ It is necessary then, to have some knowledge of religious background even if it is not revealed during initial discussions. Palliative care teams are very good at actively seeking this information; those working in other specialties may be less proactive.
If an atheist doctor concludes that continued active treatment is no longer appropriate, how does she challenge a family’s preference without being seen to criticise their spiritual beliefs? This is very dicey ground, and one that most doctors choose to step away from. If the relatives’ opinion is based on their knowledge and greater understanding of the patient, who is the doctor to question the spiritual foundation on which that preference is based? Of course, she does not that. Instead, she restricts herself to medical matters. She ‘redirects’, as in the Ernecoff paper. In the Ethicatt study ‘eighty percent of respondents stated that they would try to convince a patient against treatment if they thought that treatment was futile’. It is common then, to challenge preferences that would prolong life without bringing benefit, even when those preferences are based in a heightened concern for life’s sanctity.
What are the words? If a relative says something along the lines of ‘we should let God decide,’ the doctor might explain that ‘we have been trying for three weeks, and the only reason your mother is alive is because of the life support machines. If there was going to be an improvement, we would have seen it by now.’ This avoids direct reference to God, but could be paraphrased as, ‘it is technology, not God, that has sustained your mother these last few weeks, and it is clear that no higher power has intervened to reverse the underlying disease.’ To say this would be offensive and unkind, but for the atheist who is reviewing a medical complex scenario from a causative perspective, no other conclusion can be drawn.
As doctors with our own views and beliefs (on non-beliefs), we are not trained to engage on theological or spiritual issues. Coincidentally, an example of faith sensitive therapy for depression is being widely reported in the media today – whereby a form of CBT called behavioural activation is linked to Islamic belief systems. Therapists involved in this service must be comfortable with faith based conversations – whether they need to believe or not is a more intricate question. Obversely, health care professionals have been disciplined for offering to pray for patients. How faith intertwines with health, fear (of dying), hope and nature’s sometimes cruel caprice is too subtle an analysis for us to undertake. It’s not revolutionary, but the message I take away is that doctors without faith must remain respectful, while adhering to what they feel, or know, is in the patient’s best interests while they lie in this visible, tangible realm.
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