9 Curlin FA, et al. The association of physkians' religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the ...
Does religion affect medical students' attitudes tovvard ethical dilemmas? By Richard L. Elliott, MD., PhD, Morium Chowdhury, Laurie Wilson, Francis C Dane, PhD, and R. Stephen Williams, MD., MHSA
eligious faith and medicine have had an intimate relationship since antiquity. Physical and mental conditions were often attributed to demons or failures in faith, and shamans and other religious leaders were among the earliest healers. More recently, research has examined the effects of religious faith on medical outcomes, and clinical trials have been conducted to examine the effects of prayer as a clinical intervention.1· 4
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From an ethical perspective, religious faith also plays an important role in medical decision making. In Western medicine, autonomy in medical decision making is the paramount principle, i.e., competent patients have the right to determine what is to be done, and medical decisions are influenced by a number of personal and cultural factors - including religious faith.
Silvestri et al asked 100 patients with advanced lung cancer, their caregivers, and 257 oncologists to rank seven factors - cancer doctor's recommendation, faith in God, ability of treatment to cure disease, side effects, family doctor's recommendation, spouses recommendation, and childrens recommendation - as to their importance in making treatment decisions? Patients (and their caregivers) ranked faith in God second. The only factor patients and caregivers ranked as more important than faith when making treatment decisions was the physician's recommendation. Even though physicians as a group ranked faith last among factors to be considered when making a treatment decision, one-quarter of physicians ranked faith among the top three factors to be considered. Other studies found that 45 percent and 68 percent of phy icians agreed that religious/spiritual beliefs played a role in their medical practices, including affecting options offered to patients.6· 8 Thus a significant number of patients will be exposed to physicians who are influenced by faith in making recommendations. Since patients and physicians often have different faiths, there is a potential for conflict to anse m making, and accepting, treatment recommendations.
Table 1 Catholic priests - 2
Pentecostal pastor - 1
Presbyterian pastors - 2
Hindu priests - 4
Baptist preachers - 4
Imams (Muslims) - 2
Episcopalian priest - 1
Methodist pastors - 2
22 MAG Journal
Methods Based on extant literature, four situations were identified in which faith was expected to play a role in making a medical decision: use of invitro fertilization (IVF), abortion, termination oflife supports, and whether to communicate "bad news" about a terminal condition. Based on interviews with 18 religious leaders from nine different faiths or denominations (Table 1), we developed a multiple choice questionnaire involving four scenarios. We piloted the questionnaire on Mercer University School of Medicines (MUSM) class of 2012 medical students. The portion of the questionnaire that is relevant to the first scenario is shown in Table 2. Students were asked to provide information on their religious background and gender. Of the 60 students given the questionnaire, 40 responded. Data were analyzed with SPSS using Chi square and Mann Whitney U statistical tests. Results There were no statistical differences among religions or between genders with regard to responses to any of the scenarios. Overall, 85 percent of responders would offer IVF. In the case of abortion, 85 percent of responders would offer emergency contraception. Six weeks into pregnancy, 17 out of 40 (43 percent) would decline to abort the fetus - but they would refer the patient to a colleague who would be willing to perform the abortion. And seven out of 40 ( 18 percent) would abort the fetus them elves. Two out of 40 (five percent) would advise the patient that she continue with the pregnancy. And seven out of 40 ( 18 percent) would advise her to continue with the pregnancy and consider adoption. Discussion
Religious leaders interviewed
Russian Orthodox priest - 1
Several groups have studied the relationship between physicians' religious beliefs and clinical decision making.6·14 This brief report describes our attempt to develop an instrument for assessing the relationship between religious affiliation and attitudes about common ethical issues, and it presents the results from a survey of second-year medical students.
That religious affiliations had no effect on attitudes toward common ethical situations might seem surprising given that some faiths take opposing views on the situations that were presented, e.g., abortion is generally forbidden by the Catholic Church but permitted by Hindus, some Protestant denominations, and Islam when the mother's life is in danger.
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The resolution to this apparent contradiction between religious doctrines and answers to our questionnaire is that, generally, members of a faith often do not agree with particular doctrinal positions. Thus, while the Catholic Church has taken a firm stance against abortion - even when the mothers life is at risk - most Catholics disagree with this position.15 These results are also consistent with those of Guiahi et aL, who found that medical students at a faith-based medical school, where training on family planning and abortion was limited, preferred greater exposure to these topics.16 Physicians and patients often have differing religious backgrounds and perspectives, and it is imperative for each physician to consider the influence that his or her faith might have on medical decision making. They should also consider how conflicts between these beliefs and the beliefs of patients might best be resolved. As medical students have often formed strong opinions on issues affected by religious faith, we would encourage medical schools to include discussion of religious faith and medical decision making at an early stage of training.17 This study has several important limitations. The sample size was small, and because of its historical Judea-Christian philosophical orientation, MUSM might attract students from less diverse backgrounds. In addition, the attitudes of students may change as they progress in their careers, and it is unclear exactly how the religious beliefs of physicians actually affect their recommendations and practices.
Please contact Dr. Elliott at e/Liott rt@mercf:l:edu for more information about the study and to obtain the full questionnaire. Editor's Note: Chowdhury and Wilson completed this study while they were medical students at the Mercer University School of Medicine. Dr. Dane is the director of Health Psychology at the Jefferson College ofHealth Sciences in Roanoke, Virginia. Dr. Elliott is the director ofMedical Ethics at the Mercer University School of Medicine. Dr. Williams is the director of Clinical Diagnostic and Skills Assessment Center at the Mercer University School ofMedicine.
References 1
Gillum RF, King DE, Obisesan TO, Koenig HG. Frequency of attendance at religious services and mortality in a US. national cohort.Ann Epidemiol. 2008 Feb;l8(2):124-9.
2
Jantos M, Kiat H. Prayer as medicine: how much have we learned? Med J Aust. 2007 May 21;186(10 Suppl):S51-3.
3
Coruh B,Ayele H, Pugh M, Mulligan T. Does religious activity improve health outcomes? A critical review of the recent literature. Explore (NY). 2005 May; I (3): 186-91.
' Hall DE, Meador KG, Koenig HG. Measuring religiousness in health research: review and critique. J Relig Health. 2008Jun;47(2):134-63. ' Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oneal. 2003 Apr I ;21(7):1379-82. 6
Ramondetta L, Brown A, Richardson G, Urbauer D, Thaker PH, Koenig HG, Gano JB, Sun C. Religious and spiritual beliefs of gynecologic oncologists may influence medical decision making. Int J Gynecol Cancer. 2011 Apr;21 (3):573-81.
" Ecklund EH, et al. The religious and spiritual beliefs and practices of academic pediatric oncologists in the United States.] Pediatr Hematol Oneal. 2007;29(11):736-42. 8
Cheever KH, et al. Surgeons and the spirit: a study on the relationship of religiosity to clinical practice. J Relig Health. 2005;44(1):67-80.
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pediatricians in the United States.Acad Med. 2008;83(12):1146-52. 12
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" Seal C. The role of doccors' religious faith and ethnicity in taking ethically controversial decisions during end-of-lire care. J Med Ethics. 2010; 36(11):677-82. 15
O'Brien, Jon; Morello, Sara (Spring 2008). "Catholics for Choice and Abortion: Pro-choice Catholicism IOI''. Perspectives: Catholic, Religious Coalition for Reproductive Choice.
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Guiahi M, Maguire K, Ripp ZT, Goodman RW, Kenton K. Perceptions of family planning and abortion education at a faith-based medical school. Contraception, 2011 Nov;84(5):520-4.
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Strickland SL. Conscientious objection in medical students: a questionnaire survey. JMed
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Table 2
Faith and medical decision making survey A 35-year-old soldier in the U.S. army is married to a 33-year-old woman. The couple has been happily married for 10 years and has been attempting to have children for the last five years. They approach you regarding the feasibility of in vitro fertilization. A medical evaluation confirms that IVF is appropriate. What would you recommend? A. In vitro fertilization with the couple's gametes B. Encourage further attempts to conceive naturally C. Encourage exploration of adoption
If medically appropriate, would you recommend the use of donor gametes? A.Yes
B.No
If medically appropriate, would you recommend the use of a surrogate? A. Yes
B.No
If the husband died in combat and had frozen sperm, would you recommend its use for IVF? A. Yes
8.No
D. Other (specify) _ _ _ _ _ _ _ __ __
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