Examine the basis of your ethical values

In an informal online poll in the May issue of Virtual Mentor, the ethics journal of the American Medical Association, 62% of the responding physicians agreed strongly or agreed somewhat that their medical ethics derived from their religious beliefs. Do you agree? If so, how do your beliefs influence the patient-physician relationship?

Reply:

Medical ethics is perceived by many as being secular. It may thus seem surprising even in a small sample that 65% of physicians support the statement "my medical ethics derives from my religious beliefs." Is this really so surprising?

Should I inform my patients if I, too, support this statement? Are personal belief and professional ethics in conflict?

Perhaps more surprising is the premise behind the inquiry--that medical ethics varies from one individual to another. I'm not sure this is true. Clearly individual beliefs could color or even determine an individual's application of the profession's ethics; however, there is more in common among medical professionals than there is separating them.

Admittedly, there is ongoing debate about the foundation for contemporary medical ethics. Some say it is based on virtue (Edmund Pellegrino and David Thomasma), others on prima facie principles (Tom Beauchamp and James Childress), still others on consequences or on narrative.

In The Virtues in Medical Practice, Pellegrino and Thomasma articulate eight virtues that are foundational to the individual practitioner: fidelity to trust, compassion, prognosis (practical wisdom), justice, fortitude, temperance, integrity and self-effacement. These foundational virtues are not particularly religious.

In a subsequent book, The Christian Virtues in Medical Practice, these authors add the three Christian virtues of faith, hope and charity and assert that these Christian virtues underlie Beauchamp and Childress' principles of respect for autonomy, beneficence and justice.

Albert Jonsen, a historian of medical ethics, attributes contemporary medical ethics to two ancient threads: competence, underscored by the Hippocratic tradition; and altruism, introduced by Christian teachings. These two threads became interwoven over the centuries to form the ethos of modern Western medicine. The religious foundation of medical ethics seems incontestable.

In the not-so-distant past, there was much consensus regarding the ethos of Western medicine. If we share this heritage, why do individual physicians hold divergent views on such issues as abortion, physician-assisted suicide, the use of feeding tubes, and embryonic stem cell research?

It is because advances in technology have raised some new questions and made the answers to some of the older questions more nebulous and because postmodern interpretation of the foundational virtues and principles has made their application more individualistic.

So to answer the main question posed here, suppose a patient is referred to a specialist who is a stranger to the patient. Can the patient make any assumptions about the physician's medical ethics based on the name on the door? Even if the name might be traditionally Roman Catholic, or Jewish, or Hindu, or Muslim, can one assume anything about the physician's medical ethics?

The pluralistic nature of North American culture makes any such assumptions subject to frequent error. But even so, foundational medical ethics (fidelity, compassion, prognosis, etc.) is likely to be the same for physicians from any religious/cultural background. Their personal application to the contentious issues of contemporary medical and societal ethics, however, remains unknown.

What can be known, however, is that each physician has a world view that influences his or her stance on the contentious issues. That view includes how the physician views the patient: Is the patient a unique individual created in the image of God, a very intelligent animal, or something between these extremes?

It includes a belief about when that patient's identity begins (fertilization, implantation, birth, three months after birth) and when it ends (last heart beat, total brain dysfunction, neocortical dysfunction, loss of ability to relate to others, fatal diagnosis, unbelievable suffering, when the patient chooses, etc.). And, not surprisingly, physicians' views are -- like our patients' views on these issues -- shaped by their personal world view, which in turn may or may not be influenced by their religious beliefs or heritage.

Whether the physicians who answered the survey were talking about the religious foundation of medical ethics, or whether they were referring to their personal beliefs about the contentious issues, their responses are quite consistent with North American values in general.

Everyone, physicians included, has a world view that influences how he or she assesses the difficult questions in medical and societal ethics today.

Robert D. Orr, MD, Clinical ethicist, Fletcher Allen Health Care and the University of Vermont College of Medicine, Burlington

Reply:

People raised in religious households often are told they must behave morally or else face dire consequences. Although the particular threats vary -- some religions threaten eternal damnation, others threaten expulsion, others invoke angry forebears -- the basic idea is that people ought to act correctly because their religions demand it of them.

So I'm not surprised to hear that, according to one recent online poll, 62% of physicians believe that their medical ethics derives from their religious beliefs. I'd wager, though, that most of these respondents haven't thought much beyond their own religious indoctrination or realized that, even though religion might have been their principal introduction to moral behavior, ethics -- and perhaps especially medical ethics -- does not stem from religion.

If medical ethics were derived from religion, we would quite likely have a number of different competing medical ethical principles. Moreover, we would have no way to account for an ethically upstanding physician who was also an atheist.

And what exactly would a religion-based medical ethics look like in practice? Would a physician who was an Orthodox Jew not treat a wounded Christian who stumbled into his emergency department? Would a devout Christian not treat Muslim or Jewish patients? Would a medical ethics based on religion be able to respect the otherness of those from different religions and treat them without prejudice?

And what about those from within one's own religious community who don't share the same level of religious belief? Would a fundamentalist conservative Christian physician refuse to treat a liberal Christian who, he felt, had forsaken Christianity? Would an Orthodox Jewish physician actually refuse to treat a Reform Jew who, in his mind, had turned away from true Judaism?

The reason these scenarios don't enter into our medical ethical discussions is that the ethical principles that guide most medical practice are not based in religion and have, in fact, been handed down to us from the Greek Hippocratic tradition.

Hippocrates was not a Jew. He was not a Christian. He was not a Buddhist. He did not follow Islam. The ethical principles he set forth are the basis for good medical ethical decision-making and action for any physician, regardless of any religious belief, because they are derived from principles of right and wrong that are broader and more encompassing than ideas put forward by any particular religion.

Along these lines, I'll wager that many of the values most physicians think are related to their own religion are actually shared across many religions: Provide the best treatment possible for one's patients. Serve the poor. Respect the dignity of one's patients. Don't abuse one's power. These values and others, although espoused within various religions, clearly transcend any single religion.

So if various religions essentially agree on these basic tenets, then de facto religion is mostly if not entirely irrelevant to ethically sound medical practice, even if religious indoctrination might be the place where most of us have our initial contact with ethics. Therefore, I do not believe that ethics is founded in religion or that without religion there could be no ethics.

I'll go even further and declare that it is actually a good thing that ethics is not derived from religion. I'd rather have people acting correctly because of the general sense of ethical duty rather than out of fear of retribution from God or religious authorities.

Religious organizations need to preserve themselves and maintain their membership numbers, if not increase them. Because of this basic need, religions can condemn bad behavior only to a certain degree, and they need to employ some fairly straightforward ways to forgive or otherwise allow their followers to atone for misdeeds. It might be through praying directly to God or confessing to a priest, or it might be fasting and reading scripture on special holy days at designated times during the year; but one way or another religions allow people to move on after unethical behavior.

By contrast, a guilty conscience -- much less an angry patient or a hospital disciplinary committee or a state licensing board -- often does not allow so easy a means of repenting and moving past an ethical lapse.

In the end, when it comes to guiding physicians toward ethically acceptable behavior, I'll take Athens over Mecca, Jerusalem or Rome.

J. Wesley Boyd, MD, PhD, Lecturer, Department of Psychiatry, Harvard Medical School, Boston; associate director, Physician Health Services, Massachusetts Medical Society