Transcript “Essentials for Medical Practice in an Ethically and Spiritually

“Essentials for Medical Practice in an Ethically
and Spiritually Pluralistic Environment”
Jerome R. Wernow Ph.D., R.Ph.
NW Center for Bioethics
www.ncbioethics.org
Ghost Stories
Mythos and Logos

Mythos describes “worldly things by
tracing them to exceptional, sometimes
sacred events, that caused the world to be
as it is now.”
 Logos “a kind of logical analysis that
places things in the context of reason and
explains them with the pure 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 and Logos
“There are other accounts, however, accounts
that suggest that Western Logos-philosophy
and science is just our version of mythos.”
Palmer, Donald: Looking at Philosophy: The Unbearable Heaviness of
Philosophy Made Lighter. (Mountain View, CA: Mayfield Publishing) second
edition, 1994, p. 2.
Take Away Point
The stories used to give meaning to a
person’s life are the stories used to
give meaning to a person’s ‘health.’
Pluralism in Notions of Health
Numerous of definitions of ‘health’
 Different concepts of health in nonreligious contexts i.e. WHO definition
 Divine views of health persists to this era

Üstün & Jakob: Bulletin of the World Health Organization. 2005;83:802.
Pluralism Amidst Christians
Biopsychosocial integrity that permits life
to be lived faithfully in community
 A state of physical well-being
 A holistic consideration of being in
relationship to God and His 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 description
“A term describing a human being’s
functional integration of their
corporeal, psychofactual, and spiritual
properties.”
Human B/b-eing
Corporeality
Spiritual Illumination
Psychofacticity
Objective
Recognize significant conflict potentials
 Understand foundations beneath conflicts
 Avert conflict or avoid escalation
 Minimize conflict consequences

Take Away Point
The stories used to give meaning to a
person’s life are the stories used to
give meaning to a person’s ‘health.’
A decision-making matrix
Clinical Integrity
Beneficence
Autonomy
Justice/
Nonmaleficence
Dr. John Tuohey, “Pandemic Planning.”
Metamorphosis of Medical Ethics
The Quiescent Periodthe Hippocratic ethic
 The Period of
Principlism
 The Period of Antiprinciplism
 Period 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
“I will not give to a woman a 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 Aristotle
“proper disposal in secret of the sort born
defective” as a social common good
 “merely of animal species and part of the
mother until it falls as fruit from the 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
“No physician should give or even show an
abortifacient to a pregnant woman.”
 “drugs being like divine hands and 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.
Soranus
Lays down a complex and perhaps
efficient method of inducing
abortion
Claudius Galenus
practitioners opted out of abortion due to
conscience
 based upon the principle of beneficence sourced
in the Hippocratic Code
 founded on a worldview of some superior being
that ordered nature
 “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
“The woman who purposely destroys her unborn child is
guilty of murder…. The punishment, however, of these
women should not be for life, but for the term of ten
years.”
American Medical Association in
1847
“Domination of the Roman Catholic
expression of Christian ethics is seen even as
the ethic’s content became part 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 Worldview
‘enlightenment philosophy and rationality leavened the
bread of moral philosophy in the medical schools,
studies in humanist psychology began to be
substituted for Christian ethics’
op cit : Chester R. Burns, “American Ethics: Some Historical Roots”
Metamorphosis in Epistemology





Judeo-Christian Hippocratic ethic dominant
seventeen centuries
Modernity’s early epistemological drift embraced
mutual influence of Christian theology and
scientific belief
John Locke introduced split empirical knowledge
from that of the world of faith
Drift became a torrent from atheists David Hume
to Richard Dawkins to Samuel Harris
Evolutionary materialism became dominant
explaining what exists through empirical
observation of the material world
Metamorphosis in Ethics
The new ‘mythos’ not only determined what we
know, but fixed limits on human behavior and
promulgated rights based upon the mores of
those in power.
 The gods and their stories of mythos in war and
conquest were replaced by the logos, that is,
philosophies of a commerce-based society. The
“gods are dead, and the whirlwind rules”
Aristophanes/The Clouds

Common Thread in Differences
Objective moral norm
 Subjective moral norm

Objective Moral Norm
Emphasis on a universal
imperative that demands action
based upon some trusted source
of authority
Objective Moral Norm
Biblical belief that the human being is
created in the image of God
 Sacred human value inheres all human
beings due to resident Divine image
 Moral norm of medical practice preserves,
protects, and promotes human person
 Requests for physician’s aid in suicide
violates moral norm

Subjective Moral Norm
Emphasis on an individual
preference that directs action
based upon a personal
construction of reality
Subjective Moral Norm
The human being is only comprised of the
primordial material it evolved from
 Life’s value is personally determined by
“pleasurable states of consciousness”
 The irretrievable loss of pleasure permits
physician assisted suicide to be a proper
medical practice

Kuhse, Helga. The Sanctity of Life Doctrine in Medicine: A Critique.
(Oxford: Clarendon Press, 1987) p. 217.
Overview
Health Care Provider
Institution
Patient
State
Relevance in Context
Conflicts of moral imposition
 Conflicts in professional integrity
 Conflicts of potential discrimination

ACOG Ethics Opinion
Imposition of Morality
 Effect on Patient
Health
 Scientific Integrity
 Potential
Discrimination

Response to ACOG’s Ethic
“a message of ideological intolerance
and religious discrimination”
(CMDA Stevens et al)
“Celestial Fire of Conscience”
Religious issue
 Ethical integrity issue
 Collective professional
issue

NEJM 352:24 Jn 16, 2005
pp. 2471-73
NW Spiritual Milieu
Oregon - Kosmin, Mayer & Keysar (2001-12-19).
American Identification Survey, 2001
25
20
15
10
5
Series1
Series2
S1
Refused
Jehovah's
Witnesses
Christian
Buddhist
No religion
Catholic
0
Some Slices of Plurality
Oregon 2001
Catholic
No religion
Christian
Baptist
Mormon/LDS
Buddhist
Refused
Other
Plurality Within Catholicism
Oregon 2001
Catholic
No religion
Christian
Baptist
Mormon/LDS
Buddhist
Refused
Other
Catholic Plurality
27 percent abortions in 2001
 Catholics for Choice
 American 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 Buddhism
Oregon 2001
Catholic
No religion
Christian
Baptist
Mormon/LDS
Buddhist
Refused
Other
Buddhist Plurality
“One stance is that human life begins at
conception and therefore abortion at any stage
in the pregnancy is wrong - full stop. Another
stance might be that the offence is worse the
more developed the fetus or embryo. Yet
another might be that the seriousness of the
offence can only be determined by taking into
account the full circumstances surrounding the
abortion.”
http://buddhism.about.com/cs/ethics/a/Abortion.htm
Protestant Plurality
43% Abortion Protestant
 13% Born Again/Evangelical

Plurality within Non Religious
Oregon 2001
Catholic
No religion
Christian
Baptist
Mormon/LDS
Buddhist
Refused
Other
Non religious Plurality
Atheist and Agnostic Pro-Life League
 Council for Secular Humanism
 Pro-Life Alliance of Gays and Lesbians

Plurality within ‘Other’
Oregon 2001
Catholic
No religion
Christian
Baptist
Mormon/LDS
Buddhist
Refused
Other
Other Plurality
Non-mainstream spirituality
 Northwest Tibetan Cultural Association
 WICCA
 New Age
 Vedanta Society

Take Away Point
Pluralism of opinions within religious
communities necessitates clarifying
patient’s understanding if patient raises
spirituality as important
Purpose for Spiritual History
Reveals belief impact on medical decisions
 Reveals social support structures
 Predictor in success for coping
 Predictor in remission of depression
 Predictor of discharge mortality

Koenig, HG: Taking a Spiritual History, JAMA. 2004:291;23 2881
Barriers to taking a Spiritual History
Lack of time
 Lack of training
 Expertise concerns

Personal discomfort
 Sense of imposition
 Lack 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 History
Part of new patient history
 Part of a hospital admission
 During a well-patient check-up

Koenig, HG et al: “Religious coping and depression,” Am J Psychiatry. 1992;
149;1693-1700.
Patient Appropriate Spiritual Histories
Patients terminally ill
 Patients chronically ill
 Inter-personal relationship paramount

Koenig, HG et al: “Religious coping and depression,” Am J Psychiatry.
1992; 149;1693-1700.
What to ask
S - spiritual belief system
 P - personal spirituality
 I - integration with a spiritual community
 R - ritualized practices and restrictions
 I - implications for medical care
 T - terminal events planning

Maugans TA. The SPIRITual History. Arch Fam Med. 5:11- 16, 1997
What to ask

F - Faith and Belief "Do you consider yourself
spiritual or religious?"

I - Importance "What importance does your
faith or belief have in your life?”

C – Community "Are you part of a spiritual or
religious community?”

A - Address in Care "How would you like me,
to address these issues in your 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 Avoid
Prescribing belief
 Forcing a history
 Coercing belief
 Arguing spirituality

Butler, et al: Is prayer good for you health? www.heritage.org
"Know yourself"
What stories inform
your spirituality and
ethic?
 What stories inform
your understanding of
health?
 What is your position
on the place of the
patient’s spirituality
and treatment?

Corporeality
Spiritual Illumination
Psychofacticity
Pausanias (10.24.1)