While physicians must respect patient autonomy, they have a professional commitment to provide medical intervention when possible. Thus, a commentary piece published in the AMA Journal of Ethics suggested that physicians consult with chaplains and foster transparent communication with all parties so that patients may receive care in a way that respects their beliefs.

The ethical case study specifically addressed the case of “Mr L,” a patient indicated for a cholecystectomy, who declined the recommended post-procedure pain medication because of his belief that “God [wanted him] to be in pain.”  Dr J, the surgeon, met with the chaplain on call, Mr K, and the two concluded that it would be unethical to not provide pain medication, particularly given that such a decision could introduce complications. Mr K then met privately with the patient, who asserted that due to his past alcohol abuse “he [didn’t] deserve the pain meds.”

In navigating this case, the authors of the commentary first addressed the purpose of medicine, reframing healthcare as not simply a commitment to patient health but to patient spirituality and beliefs as well. When considered traditionally as a means of alleviating patient suffering, the authors argued, medicine must accommodate a patient’s “theological understanding of suffering.” Therefore, alternative approaches to medicine are appropriate when they do not contradict the physician’s “commitment to…[patient] health.”

In the case of Mr L, the authors suggested that Dr J listen carefully to the patient and fully explain her reasoning for recommending pain medication. Such an exchange would build trust and may allow for both parties to arrive more smoothly at a decision. The authors emphasized that engaging the patient in a debate is not dismissive of patient beliefs and in fact validates the “seriousness…[patients ascribe] to them.” If refusing a specific treatment could jeopardize patient recovery, however, the authors suggested that physicians override patient requests.

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The commentary authors also identified hospital chaplains as an important source of wisdom for physicians in addressing treatment refusal. Chaplains can be essential in titrating discussion to the patient’s specific beliefs system. Although chaplains should not meet with patients intending to “bring about a predetermined outcome,” they can attend to patient concerns about treatment and provide helpful information on medical care.

The authors also suggested involving the patient’s community — including friends, family, and members of their faith — to discuss the spiritual aspects of treatment refusal. Although involving the community may complicate matters, it may allow the patient to discuss their concerns more thoroughly than they would with a hospital chaplain.

Ultimately, the authors concluded that treatment refusal based on spiritual reasons is a highly personal decision that must be respected. Physicians must draw from their professional knowledge, but also from the wisdom of chaplains and the patient’s community, in addressing these ethical challenges.

Reference

Frush BW, Eberly JB Jr, Curlin FA. What should physicians and chaplains do when a patient believes god wants him to suffer? AMA J Ethics. 2018;20(7):E613-E620.