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POINT: Is It Ethically Appropriate for Physicians to Offer to Pray With Patients in the ICU? Yes

2022; Elsevier BV; Volume: 161; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2021.10.005

1931-3543

Benjamin W. Frush, Farr A. Curlin,

Religion, Spirituality, and Psychology

Despite ample evidence that religious beliefs and practices are important to many patients, particularly in the context of critical illness, the idea of physicians offering to pray with patients stirs controversy.1Balboni M.J. Balboni T.A. Hostility to Hospitality. Oxford University Press, New York2019Google Scholar,2Christensen A.R. Cook T.E. Arnold R.M. How should clinicians respond to requests from patients to participate in prayer?.AMA J Ethics. 2018; 20: E621-E629Crossref PubMed Scopus (8) Google Scholar Such controversy, we suggest, is a symptom of underlying disagreements about the nature of medicine and, therefore, what kind of relationship patients and physicians share. If medicine is best understood as an industry in which powerful experts provide technical services to vulnerable subjects with whom they have no relationship of trust, then offering to pray for patients seems contrary to professional boundaries and patient autonomy and largely beside the point. A more adequate understanding of medicine and the patient and physician's place in it, however, leads to a different conclusion: that offering to pray with patients is compatible with good medicine and can be a fitting response to the shared human predicament of being mortal and spiritual creatures. In what one might call the traditional view of medicine, medicine is a paradigmatic moral practice that aims at a particular human good, namely the patient's health.3Curlin F.A. Tollefsen C. The Way of Medicine: Ethics and the Healing Profession. IN: University of Notre Dame Press, Notre Dame2021Google Scholar "Health" here does not serve as a placeholder for whatever the patient believes is required for his well-being but rather is an objective human good: something that makes any person better off and something about which physicians might gain an authority of expertise through long study and experience. This shared understanding has been assumed by the Hippocratic movement, by Plato4PlatoThe Republic. CDC Reeve, translator..Book I. IN: Hackett Publishing Company Inc, Indianapolis2004: 346aGoogle Scholar and Aristotle,5AristotleNicomachean Ethics. David Ross, translator. Oxford University Press, New York2009: 1094a10Google Scholar and by Jews, Stoics, Christians, Muslims, and countless others practicing medicine over the centuries.6Eberly Jr., J.B. Frush B.W. Doing theology in medical decision-making.J Med Ethics. 2019; 45: 718-719Crossref PubMed Scopus (4) Google Scholar In this traditional view, the patient-physician relationship is characterized both by a shared purpose—healing for the patient—and by mutual vulnerability. The patient is overtly vulnerable by virtue of the illness and so depends on the physician's unconditional commitment to act in accordance with the patient's good. The physician shares the vulnerability of a fellow human being with finite abilities to heal and relieve suffering and with all of the moral and spiritual challenges that attend this task.7Tilburt J. Shared decision making after MacIntyre.J Med Philos. 2011; 36: 148-169Crossref PubMed Scopus (10) Google Scholar This shared vulnerability, together with the collective pursuit of the patient's health, makes possible a "moral friendship" between patient and physician.8Curlin F.A. Hall D.E. Strangers or friends? A proposal for a new spirituality-in-medicine ethic.J Gen Intern Med. 2005; 20: 370-374Crossref PubMed Scopus (44) Google Scholar This friendship requires and promotes a bidirectional trust between patient and physician and occurs between human beings in all of their particularity; it therefore respects but is not reducible to the roles they inhabit.9May W. The Physician's Covenant: Images of the Healer in Medical Ethics.First ed. Westminster Press, Louisville, KY1983Google Scholar This traditional view of medicine still accounts for much of what physicians do; however, over the past two generations a rival view has grown in influence. According to what one might call a "provider-of-services" view,3Curlin F.A. Tollefsen C. The Way of Medicine: Ethics and the Healing Profession. IN: University of Notre Dame Press, Notre Dame2021Google Scholar medicine is not a moral practice but instead the expert provision of "healthcare services."7Tilburt J. Shared decision making after MacIntyre.J Med Philos. 2011; 36: 148-169Crossref PubMed Scopus (10) Google Scholar Rather than aiming at an objective good (health), medicine aims at what the patient desires, so long as that is legal and technologically possible3Curlin F.A. Tollefsen C. The Way of Medicine: Ethics and the Healing Profession. IN: University of Notre Dame Press, Notre Dame2021Google Scholar; hence, the common moniker of physicians today as "providers." This provider-of-services view leads to a very different understanding of the patient-physician relationship. In it, the physician is a gatekeeper to and wielder of technologic interventions. Patients are viewed as consumers who dictate their wishes in accord with their self-perceived well-being. Neither can assume a shared purpose of their relationship. Rather than understanding one another as "moral friends," physicians and patients are reduced to their roles as providers and consumers and thus remain moral strangers.1Balboni M.J. Balboni T.A. Hostility to Hospitality. Oxford University Press, New York2019Google Scholar As moral strangers, they may regard each other with detachment and suspicion, rather than trust, compartmentalizing the "personal" away from their "professional" interactions. Because these two views of medicine result in contradictory accounts of the patient-physician relationship, they also give rise to contradictory postures toward physicians offering prayer in the context of this relationship. In the provider-of-services account, prayer is understood as a technical intervention. Thus, physicians should focus on what they have been trained technically to do, leaving to other trained experts, in this case chaplains, those interventions, including prayer, that are beyond their training and professional purview.10Bessinger D. Kuhne T. Medical spirituality: defining domains and boundaries.South Med J. 2002; 95: 1385-1388Crossref PubMed Scopus (17) Google Scholar Physicians overstep their professional boundaries when they offer prayer, threatening harm by their inexpert interventions. In contrast, on the traditional view of medicine, prayer is not a technical intervention but a religious practice. It is offered not for purposes of efficacy but as a response to the reality of shared vulnerability and dependence between patient and physician. It is not a clinical intervention but the moral gesture of a clinician who is aware of both her/his own and her/his patient's humanity who both stand, before God, as those who are not in full control, dependent on God knowing and caring for them in their vulnerability. Such prayer, so long as it does not hinder the physician's commitment to the patient's health, can be a form of genuine care, with the potential to deepen trust and fortify the moral friendship between physician and patient. Beyond the question of technical efficacy, in the provider-of-services view of medicine, prayer seems an obvious transgression of boundaries between personal and professional roles and domains. If physicians are technicians and patients are consumers, then their idiosyncratic personal and religious experiences are beside the point, out-of-bounds within the supposed morally and religiously neutral professionalized space of the hospital. In contrast again, the traditional view does not treat the personal as a threat to the professional, nor does it appeal to the illusion of a morally neutral public space.6Eberly Jr., J.B. Frush B.W. Doing theology in medical decision-making.J Med Ethics. 2019; 45: 718-719Crossref PubMed Scopus (4) Google Scholar There is no "view from nowhere" for patients or physicians.11Camosy C. No view from nowhere: the challenge of grounding dignity without theology.J Med Ethics. 2015; 41: 938-939Crossref PubMed Scopus (4) Google Scholar Both come to the encounter with sincere moral and religious commitments. As such, in this view, medicine does not ask physicians to pretend to set their personal commitments aside. Instead, it asks them to deepen their commitment personally to the patient's health. Generally speaking, offering to pray with patients is not problematic so long as the physician does so in a way that respects the patient and that does not hinder the physician's attention to the patient's health. Indeed, such prayer acknowledges that patients do not cease to be religious beings when they fall ill, nor do physicians when they offer care. Finally, given the presumption of suspicion between patient and physician operating as moral strangers in the provider-of-services model, the offering of prayer is deemed a clear infringement on patient autonomy.12Scheurich N. Reconsidering spirituality and medicine.Acad Med. 2003; 78: 356-360Crossref PubMed Scopus (45) Google Scholar There is little imagination that such prayer could prove anything other than coercive to sick and vulnerable patients. The traditional view, in contrast, presumes that the physician is committed to the patient's good and earnestly seeks that good, including when offering prayer, while respecting the patient's authority to decline anything the physician proposes.3Curlin F.A. Tollefsen C. The Way of Medicine: Ethics and the Healing Profession. IN: University of Notre Dame Press, Notre Dame2021Google Scholar In such instances, offering prayer can be a leveling practice insofar as the physician is not claiming power but acknowledging shared human dependence as a fellow person before God. Both the practice of medicine and the experience of severe illness invariably raise questions of meaning and purpose. Unlike the provider-of-services view, the traditional view of medicine gives space for physicians and patients to attend to these questions in a relationship of mutual trust. This space seems particularly important in the ICU, where technique often meets its limits, the vulnerability of both patient and physician is laid bare, and the prospect of attending to and experiencing suffering require resources that are not merely medical, but religious.