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

1. “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

2. Ghost Stories

3. 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.

4. 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.

5. 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.’

6. Pluralism in Notions of Health • Numerous of definitions of ‘health’ • Different concepts of health in non-religious contexts i.e. WHO definition • Divine views of health persists to this era Üstün & Jakob: Bulletin of the World Health Organization. 2005;83:802.

7. 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.

8. Health – another description “A term describing a human being’s functional integration of their corporeal, psychofactual, and spiritual properties.”

9. Human B/b-eing Corporeality Spiritual Illumination Psychofacticity

10. Objective • Recognize significant conflict potentials • Understand foundations beneath conflicts • Avert conflict or avoid escalation • Minimize conflict consequences

11. 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.’

12. A decision-making matrix Clinical Integrity Beneficence Autonomy Justice/ Nonmaleficence Dr. John Tuohey, “Pandemic Planning.”

13. Metamorphosis of Medical Ethics • The Quiescent Period-the Hippocratic ethic • The Period of Principlism • The Period of Anti-principlism • 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.

14. 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.

15. 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 Republicin 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

16. 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.

17. Soranus Lays down a complex and perhaps efficient method of inducing abortion

18. 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.

19. 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.”

20. 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.

21. 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”

22. 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

23. 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

24. Common Thread in Differences • Objective moral norm • Subjective moral norm

25. Objective Moral Norm Emphasis on a universal imperative that demands action based upon some trusted source of authority

26. 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

27. Subjective Moral Norm Emphasis on an individual preference that directs action based upon a personal construction of reality

28. 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.

29. Overview

30. Relevance in Context • Conflicts of moral imposition • Conflicts in professional integrity • Conflicts of potential discrimination

31. ACOG Ethics Opinion • Imposition of Morality • Effect on Patient Health • Scientific Integrity • Potential Discrimination

32. Response to ACOG’s Ethic “a message of ideological intolerance and religious discrimination” (CMDA Stevens et al)

33. “Celestial Fire of Conscience” • Religious issue • Ethical integrity issue • Collective professional issue NEJM 352:24 Jn 16, 2005 pp. 2471-73

34. NW Spiritual Milieu

35. Some Slices of Plurality

36. Plurality Within Catholicism

37. 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.

38. Plurality within Buddhism

39. 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

40. Protestant Plurality • 43% Abortion Protestant • 13% Born Again/Evangelical

41. Plurality within Non Religious

42. Non religious Plurality • Atheist and Agnostic Pro-Life League • Council for Secular Humanism • Pro-Life Alliance of Gays and Lesbians

43. Plurality within ‘Other’

44. Other Plurality • Non-mainstream spirituality • Northwest Tibetan Cultural Association • WICCA • New Age • Vedanta Society

45. Take Away Point Pluralism of opinions within religious communities necessitates clarifying patient’s understanding if patient raises spirituality as important

46. 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

47. Lack of time Lack of training Expertise concerns Personal discomfort Sense of imposition Lack of interest Barriers to taking a Spiritual History Ellis, MR: “What do families think about spirituality in clinical practice,” J Family Pract. 2002;51: 249-254.

48. 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.

49. 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.

50. 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