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The American Journal of Bioethics

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Religious Delusions and the Limits of Spirituality in Decision-Making

First Published on: 01 July 2007 To cite this Article: Cochrane, Thomas I. (2007) 'Religious Delusions and the Limits of Spirituality in Decision-Making', The American Journal of Bioethics, 7:7, 14 - 15 To link to this article: DOI: 10.1080/15265160701399560 URL: http://dx.doi.org/10.1080/15265160701399560

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The American Journal of Bioethics

Religious Delusions and the Limits of Spirituality in Decision-Making

Thomas I. Cochrane, Harvard University
There is much to like about Kuczewskis (2007) framing of spirituality and religion as a foreign language that requires translation. Religiously-framed assertions are common in healthcare, and translation of such assertions requires patience and concerted effort. Kuczewskis example of a patient contemplating do-not-resuscitate orders who says that Death [is a] matter of when God calls is a nice illustration: it is meaningless as a response to the question of whether cardiopulmonary resuscitation (CPR) should be performed. God could call either with or without CPRso should we perform it or not? It requires a longer discussion to determine whether CPR makes sense. This discussion is what Kuczewski suggests, and he provides some valuable guidance regarding how to arrive at a common understanding with patients. However, for the practitioner who does not harbor a belief in supernatural entities such as souls, spirits, or God, Kuczewskis (2007) advice regarding transparency and sharing of spiritual views, if taken too far, might be counterproductive. For such a clinician being too transparent, too early, could irreparably harm the patientclinician relationship. Recognizing two aspects of spirituality may help rationalist clinicians cope with the claims of patients who have a supernatural worldview. First, even the most self-identied religious or spiritual persons ethical and moral beliefs do not in fact originate from scripture or religious teachings, and in theory can always be translated into nonreligious ethical and moral terms. Second, beliefs that directly contradict obvious facts are delusions, whether the beliefs are religious in nature or not. Patience and sensitivity is required to help people overcome religiously-framed delusions while remaining respectful of their religious and spiritual beliefs, but transparency on the part of the clinician can be dangerous. SPIRITUAL AND RELIGIOUS MORAL CLAIMS ARE NEITHER SPIRITUAL NOR RELIGIOUS No one, not even a self-identied religionist, derives ethical or moral beliefs from the teachings of God, scripture or other supernatural instruction. Rather, the religionists moral beliefs are selected from scripture or religious instruction, on the basis of nonreligiousalthough often unconscious and unexaminedcriteria. Consider the Bible. Not even a biblical literalist can accept every biblical teaching as moral instruction. It is impossible because all religious texts contain some vague and contradictory instructions. One must therefore interpret vague passages and choose among contradictory instructions on some basis. The manner of interpretation, or the criteria used to choose, whether conscious or not, are the real moral codenot the instructions themselves. For example, how does one reconcile the following contradictory instructions, both found in Exodus: Thou Shalt Not Kill, and [put your neighbor to death for working] on the Sabbath? (Exodus 31:1415 in Holy Bible, New King James Version [1985]). One could seek guidance elsewhere in scripture, but then one must choose to follow that guidance and reject one of the two original alternatives. Or, one could decide that only these passages are meant as instruction, whereas those are allegorical. A choice has to be made at some point, and the individual must ultimately provide the rationale for the choice. The rationale might be: its not right to kill people except in defense of self or others, or people who violate (particular) religious instructions deserve to die and I am obligated to enact their death. Or choose the action that my priest tells me is right. Whichever it is, it is not God doing the choosing, and in choosing which religious instructions to follow, one reveals ones actual moral beliefs. And since these moral beliefs are ultimately chosen on a nonreligious basis, in theory they can always be translated into secular terms. Regarding the patient contemplating do-not-resuscitate orders who claims death is a matter of when God calls, the rst question is whether this patients as-yet-unarticulated moral code requires that every possible intervention to prolong life, even for a brief period, must be performed in all circumstances. Usually, this is not what patients mean. If not, then the patient either: 1) has not decided whether CPR is reasonable, or 2) already has criteria in mind for deciding whether CPR is reasonable. In the former case, the work ahead consists of helping the patient with the psychological difculty of contemplating his or her own death or with understanding the facts relevant to the decision. In the latter case, the job is to discover what are the unspoken criteria for reasonableness of CPR and whether they apply in the circumstances. Let me be clear: I do not insist that patients must express their decision in nonreligious terms or that they must not

Address correspondence to Thomas I. Cochrane, Department of Neurology, Brigham and Womens Hospital, 75 Francis Street, Tower 5D EMG, Boston, MA 02115. E-mail: tcochrane@partners.org

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Talking about Spirituality in the Clinical Setting

consult scripture or religious authorities for guidance. I do not necessarily tell patients that I am trying to translate their religious language into secular language. I do frequently ask for help from hospital chaplains or patients spiritual leaders. Patients need to feel that I am not judging their religious beliefs and need to feel free to express their thoughts in whatever language feels most comfortable. The point, however, is that one need not be satised with an assertion such as God will decide when its time simply because its framed religiously. And even when patients give frustrating religious non-answers, one can be condent that there are secular principles underlying their religious assertions, even if these principles are not always easy to uncover. WHEN A DELUSION IS EXPRESSED AS A RELIGIOUS CLAIM Kuczewski writes of the pregnant HIV-positive woman who believed that she had been healed by faith, and claims that she clearly possess[ed] decision-making capacity. This is a strange assertion, if one of the prerequisites for decisionmaking capacity is the ability to understand the basic facts relevant to the decision. This patients claim that she is HIVnegative is factually wrong, and if she fails to appreciate this most fundamental fact regarding treatment, one cannot properly conclude that she possesses decision-making capacity for this decision. I would be willing to accept a claim that she possessed decision-making capacity for every decision except ones that required an understanding of her HIV status. But as the vignette is written, one must either make a religious exception to the denition of capacitysuch that one retains capacity if ones failure to understand the facts is religiously basedor conclude that she did not possess capacity for this decision. In fact, this patient was suffering a delusion, and the fact that her belief was religiously based does not make it less of a delusion. The fourth edition of the Diagnostic and Statistical Manual denes delusion as a false belief based on incorrect inference about external reality that is rmly sustained despite what constitutes incontrovertible and obvious proof or evidence to the contrary (First 1997, 830). But the fact that she currently lacks decision-making capacity due to delusional thinking does not mean that she is incapable of overcoming the delusion and then obtaining capacity. This is why one would not treat her as if she had a psychiatric illness, perhaps overriding her decision and compelling her to take the antiretroviral zidovudine. But how can she obtain decision-making capacity? This is where I can return to agreeing in part with Kuczewski

(2007). One way might be to help her see that her religious community does not share in her delusion, by asking for help from that community. One should also try to help her overcome the psychological difculty in giving up the delusion. And if clinicians share some spiritual beliefs with the patient, then I see nothing wrong with being open about those beliefs, since this might be helpful. But it would not be helpful for a nonreligious clinician to claim the belief that God works through medicine, because such a falsehood, if detected by the patient, would result in a loss, rather than a gain, of trust. IMPLICATIONS FOR THE RATIONALIST CLINICIAN Why do I insist on translating religiously framed assertions? First, because I would like it to be clear that it is almost always possible to do so and that it is rare to be completely stymied by religiously-framed assertions. Patience, listening skills, and a willingness to interpret patients assertions in a charitable (but secular) light will usually overcome even the most intractable language barriers. Secondly, translation results in greater clarity for both the patient and the clinician. By uncovering and examining the patients true underlying nonreligious values, patients and clinicians can better understand the choices with which they are faced. And if I do not advocate overriding patients authority when they lack decision-making capacity because of false but religious beliefs, why do I insist on using the word delusion? First, this term allows clinicians to avoid the conversational strain of speaking as if it is possible that deluded persons are correct in their false beliefs. Second, recognizing false beliefs as delusions allows one to look for and overcome the real cause of the delusions (e.g., the psychological mechanism of denial.) Finally, it is important to note that one need not share (or pretend to share) religious or spiritual beliefs to successfully and sensitively care for patients facing hardship and difcult decisions.

REFERENCES
First, M., ed. 1997. Diagnostic and statistical manual text revision, 4th ed. Washington, DC: American Psychiatric Association. Holy Bible, New King James Version. [1985]. New York, NY: Thomas Nelson Publishers. Kuczewski, M. G. 2007. Talking about spirituality in the clinical setting: Can being professional require being personal? American Journal of Bioethics 7(7): 411.

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