Posted on May 11, 2019 at 9:32 AM
The Trump administration’s new rule expanding religious conscience objection in health care puts the physician’s religious commitments back in the news. Because religious denominations historically sponsored most American hospitals, this is part of an old story.
I recall that 20 years ago, the late Cardinal John O’Connor, the archbishop of the New York archdiocese, in his annual address to the medical staff at St. Vincent’s Hospital, urged physicians to remind suffering patients that God loves them. His suggestion fell flat. Writing from the perspective of over 30 years of practice as a medical oncologist, I propose a different way to approach the conflict between secular and religious in health care.
The three case histories that follow may help illustrate the issues at stake. Since I am Jewish, I will reference Jewish texts, but could imagine others that would suit the purpose.
Patient 1, age 60, has had aggressive cancer surgery, many chemotherapy treatments, radiation, and several experimental treatments for breast cancer over the course of 20 years. The cancer has now worsened and spread to the brain. The patient, who is Catholic, remains active and is hoping that I will find another medication to treat the cancer.
Patient 2, age 70, has breast cancer that has spread to the liver, now worsening despite chemotherapy; she reports weakness, loss of appetite, and inability to function. The patient’s children are asking me how long the patient, Jewish, has to live.
Patient 3, age 65, has an intra-abdominal cancer diagnosed 10 years ago and has been in and out of remission. Despite aggressive treatment a CT scan shows progressive cancer. The patient, Catholic, is anxious and unable to sleep.
Should religion play a role in the care of these patients? Harvard psychology professor Steven Pinker has written, “the belief systems of all the worlds traditional religions and cultures . . . are factually mistaken . . . the worldview that guides the moral and spiritual values of an educated person today is the worldview given to us by science.” Pinker might argue that physicians ought practice “atheistically.”
I see my foremost task as meeting the physical needs of my patients—for pain medication, antibiotics, transfusion support, and any anticancer treatment that could be helpful. My second responsibility is more nebulous: to sustain patients’ hopes even as the outlook grows dire. Does this task have anything to do with God or religion?
I offer a middle ground between Pinker and the Cardinal. The scientific worldview is useful and powerful, but incomplete. Other worthy traditions speculate about the nature of things. Over the long haul, it is hard to sustain compassionate care for the sick absent connection to a community dedicated to love of humankind, which is what religious communities at their best are about.
A physician’s outlook may be shaped by religious standards without having to impose it on the patient. A physician can show love in conscientiousness and devotion, but ought always to encourage patients to express openly what they are thinking and feeling.
In the Jewish view, a famous rabbinic dictum from the 2nd Century offers guidance: “The world stands on three pillars: study, worship, and acts of loving-kindness.” In text study, one learns of God’s love, debates the causes of human suffering, and establishes love as a standard for medical care. While the God of the Hebrew Bible is sometimes caricatured as punitive, the Jewish tradition offers a range of views of who God is.
At first glance, Judaism suggests that suffering is punishment for wrongdoing, and so may deepen a patient’s despair. For instance, “From the tree of knowledge, good and evil, you shall not eat, for on the day you eat from it, you are doomed to die.” (Gen 2:17) Or from Leviticus, “But if you will not hearken to Me, and will not do all these commandments . . . I will do this to you: I will appoint terror over you, even consumption and fever, that shall make the eyes to fail and the soul to languish” (Leviticus 26: 14-16)
These texts are only one side of a timeless conversation within the religion. Patients may themselves feel punished and health care professionals may harbor critical sentiments. When health care professionals are unaware of their ungenerous attitudes toward the sick, they may reject their patients and unconsciously act with coldness.
That the sick actually seldom cause their own suffering is hardly is a new insight. The Psalms are all about that sense of worldly unfairness, about God turning His face from us. “O God, why do you stand at a distance? /Why do you hide in the seasons of distress? /The wicked man is very proud and persecutes the poor, and the poor man is trapped in his schemes.” (Psalm 10)
The ancient back and forth reflects how human beings have always responded to the trials of existence. Are we responsible for our sufferings or blameless? The book of Job asks whether there is a just and compassionate God or whether we are alone in a meaningless universe. Although it comes down on one side, just raising the question opens up the possibility of the other.
Is suffering redemptive? On the one hand, yes: the Talmud writes of the so-called “chastisements of love.” “Out of love and compassion, God cleanses people from their inadvertent sins by afflicting them in this world.”
But the Talmud then follows with the story of rabbis Hanina and Yohanan: “Rabbi Yohanan fell ill. Rabbi Hanina entered to visit him, and said to him: Is your suffering dear to you? Rabbi Yohanan replied to him, I welcome neither this suffering nor its reward.” That is, suffering is pointless.
The Jewish response to existential questions, then, is to honor the questions that serious illness raises. Job wants most to be seen and heard, to have his suffering acknowledged by God. This is a key lesson for physicians. Even when our bag of therapeutic tricks is close to empty, we can always listen to our patients, acknowledge what they are experiencing, hold to the essential goodness of existence, and do our utmost within the limits of ethical practice, to restore the patient to health.
I return to my three patients:
Patients one and two died at home surrounded by family. Patient three continues to fight the illness. I struggle to find ways to provide support and suggest helpful treatment. Religion may offer my patients and their families consolation, but for medical personnel, our role is to show, through awareness and commitment, rather than to tell.
Alan B. Astrow, M.D., is chief of hematology/medical oncology at New York-Presbyterian Brooklyn Methodist Hospital, a professor of clinical medicine at Weill Cornell Medical College, and an adjunct professor, teaching Jewish medical ethics, at the Jewish Theological Seminary.