Essentials for Medical Practice in an Ethically and

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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

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Ghost Stories
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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.
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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.
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Take Away Point

• The stories used to give meaning to a persons
  life are the stories used to give meaning to a
  persons health.

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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. 200583802.
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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.
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Health another description

• A term describing a human beings functional
  integration of their corporeal, psychofactual,
  and spiritual properties.

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Human B/b-eing
Corporeality
Spiritual Illumination
Psychofacticity
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Objective

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

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Take Away Point

• The stories used to give meaning to a persons
  life are the stories used to give meaning to a
  persons health.

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A decision-making matrix

Clinical Integrity
Beneficence
Autonomy
Justice/ Nonmaleficence
Dr. John Tuohey, Pandemic Planning.
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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.
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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.
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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
Scribners Sons, 1922) v. 6, p. 56
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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.
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Soranus

• Lays down a complex and perhaps efficient method
  of inducing abortion

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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.
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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.

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American Medical Association in 1847

• Domination of the Roman Catholic expression of
  Christian ethics is seen even as the ethics
  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.
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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
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Metamorphosis in Epistemology

• Judeo-Christian Hippocratic ethic dominant
  seventeen centuries
• Modernitys 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

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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

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Common Thread in Differences

• Objective moral norm
• Subjective moral norm

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Objective Moral Norm

• Emphasis on a universal imperative that demands
  action based upon some trusted source of authority

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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 physicians aid in suicide violates
  moral norm

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Subjective Moral Norm

• Emphasis on an individual preference that directs
  action based upon a personal construction of
  reality

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Subjective Moral Norm

• The human being is only comprised of the
  primordial material it evolved from
• Lifes 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.
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Overview
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Relevance in Context

• Conflicts of moral imposition
• Conflicts in professional integrity
• Conflicts of potential discrimination

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ACOG Ethics Opinion

• Imposition of Morality
• Effect on Patient Health
• Scientific Integrity
• Potential Discrimination

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Response to ACOGs Ethic

• a message of ideological intolerance and
  religious discrimination
• (CMDA Stevens et al)

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Celestial Fire of Conscience

• Religious issue
• Ethical integrity issue
• Collective professional issue

NEJM 35224 Jn 16, 2005 pp. 2471-73
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NW Spiritual Milieu
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Some Slices of Plurality
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Plurality Within Catholicism
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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 20002001, Perspectives on
Sexual and Reproductive Health, 2002,
34(5)226235.
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Plurality within Buddhism
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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
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Protestant Plurality

• 43 Abortion Protestant
• 13 Born Again/Evangelical

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Plurality within Non Religious
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Non religious Plurality

• Atheist and Agnostic Pro-Life League
• Council for Secular Humanism
• Pro-Life Alliance of Gays and Lesbians

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Plurality within Other
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Other Plurality

• Non-mainstream spirituality
• Northwest Tibetan Cultural Association
• WICCA
• New Age
• Vedanta Society

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Take Away Point

• Pluralism of opinions within religious
  communities necessitates clarifying patients
  understanding if patient raises spirituality as
  important

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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.
200429123 2881
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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. 200251 249-254.
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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
1491693-1700.
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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
1491693-1700.
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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.
511- 16, 1997
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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 20003129-37.
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What to Avoid

• Prescribing belief
• Forcing a history
• Coercing belief
• Arguing spirituality

Butler, et al Is prayer good for you health?
www.heritage.org
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"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
  patients spirituality and treatment?

Corporeality
Spiritual Illumination
Psychofacticity
Pausanias (10.24.1)