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““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