Interfaith physician panel: UCSD School of Medicine, May 5, 2016
I was invited by the Medical Student Maimonides Society to participate in an interfaith physician panel to discuss various questions where a physician's faith might affect his/her medical practice. I was invited as a Jewish physician to be on the panel with a Christian public health physician, a Jewish critical care doctor (I specialized in laboratory medicine) a Muslim oncologist, and a Sikh psychiatrist. Because there was already a Jew represented on the panel, and because at least 20% of our current Medical Students profess no religion, I suggested that we should also invite a Secular Humanist/skeptical rationalist to participate. When asked if I could suggest who this should be, I finally suggested myself. (You might recall that Dick Cheney did this when George Bush asked him to recommend a running mate in the 2000 Presidential campaign.) I believe that I am quite knowledgeable of and often guided by the Jewish approach to medical ethics, but I also have a strong Humanist philosophy. In our very multiethnic society, I think it is quite valuable, actually necessary, to explore ethical systems that are not dependent on one's particular view of God. A good physician needs to be aware of the wide variety of life philosophies in all the patients he/she will be asked to serve.
The students suggested ten possible topics for discussion. I made some notes about how I might reply. We did not get to all the topics, but they are all worthy of comment. What I think the students noticed was that all the physicians on the panel basically took the same approach to these questions regardless of the faith system in which they were raised. The ethics of medical practice: cure when you can; comfort always, were expressed by all of us. We also were unified in wanting to give patients as much autonomy as possible over their health care decisions. The ten questions and my notes on what I consider the Humanist approach follow.
1. Could you give an example of a time when you were really conscious of how your faith intersects with your medical practice.?
In a case where a blood drawer got an accidental needle stick from a comatose patient who had many symptoms suggesting HIV infection and AIDS, I authorized doing a test for HIV on the patient's blood even though he could not consent and it violated the law at that time. The issue for the blood drawer was that she had been started on HAART medication and we needed to know if she should be kept on it. There are serious potential side effects. The blood drawer was in her twenties; the patient was on his death bed. I opted to act in the best interest of the younger health care giver.
In a case brought before the Medical Ethics Committee, of which I was a member, a patient who was an IV drug abuser had infected his aortic valve. It lost function and had to be replaced. He was given a new valve. After intensive counseling, he nonetheless returned to his IV drug abuse and infected his new prosthetic valve. He was given a second replacement. Both of these surgeries are very expensive in both time and hardware. After this second procedure the surgeons brought his case to the Ethics Committee. They did not want to give him a third valve if he should return to IV drug abuse and re-infect his replacement valve. The committee agreed with the surgeons that the patient should be informed that he would receive no further surgeries and that he had to take responsibility for his own health. I strongly agreed with this principle. Patients must take responsibility for actions that affect their health. And--we must help them do that.
2. Does practicing your faith help or hinder you when trying to empathize with or treat your patients?
My guiding principle as a humanist and rational skeptic is to consider how to advance the health and welfare of my patients without regard to any particular religious pronouncements. Nor do I reject an idea because its origin was religious. I try to evaluate the quality and appropriateness of ideas without worrying about which religion might or might not agree with them. This can, of course, lead to disagreement. Sam Harris, prominent humanist/atheist author says that his definition of good is that which advances human welfare. By extension, since we are all passengers on, and stewards of, spaceship Earth, human welfare should be considered in the context of the health of the entire planet. This philosophy helps me be a better physician both for individual patients and in matters of public health. I don't consider it "faith." As a specific example, I support California's recent legislation denying the right of parents to "personal exemption" for vaccination of their children as a prerequisite for admission to public schools. "Anti-vaxers" are simply wrong as a matter of medical science. Back in about 400 BCE, Hippocrates counseled that patients should have as much autonomy as possible but they should not be allowed to harm themselves. Today's physicians do know a lot more about health than most of the public. They should use that knowledge for the benefit of their patients and steer them away from harmful beliefs.
3. Do you have advice in general for maintaining your faith as you move through your medical career?
My advice regarding "maintaining your faith" as you move through your medical career would be to critically examine your faith. Ancient texts do not contain all the wisdom of mankind. We need to adopt new values as our technological capacities increase. Ancient gods did not anticipate such technologies as in vitro fertilization and embryo selection for implantation in their pronouncements. Such a technique can eliminate a genetic disease from a family in one generation. Nor were ancient gods crystal clear about how the principles they did give us should be applied to new technologies that they did not address. Times change and data-driven, rational skepticism, always guided by a need for compassion, is a good way to approach these changing times.
4. How does your faith impact your view or practice of end of life care?
With regard to end of life care in either a hospice or a critical care unit: We physicians are all aware of the concept of futility. When we cannot cure, we still can, and must, comfort. Keeping someone "not dead" on machines when there is no hope of resolution and cure of their disease is futile, a waste of resources, and does the patient no good. All the physicians on the panel also pointed out that bringing a patient's faith into the discussion of their health care should be done considerably before the discussion is only about end of life issues. Patients and families need to understand what medical science can and cannot do and need time to digest the information.
5. Is there anything in the practice of medicine today that you find counter to your faith, i.e. distribution of health care, abortion rules, physician-assisted suicide, etc.?
The philosophy of the humanist objects to an inequitable distribution of medical care resources. Many (not all) humanists think that medical care should be considered a right of all the citizens in the society. They often favor a single payer system funded by income taxes as we see in the Nordic countries. This results in a longer average lifespan for its citizens and lower rates of neonatal mortality. It also costs about 2/3rds as much as we spend in the USA, as measured by medical expense to GDP ratios. Humanists almost all favor a woman's right to control her own reproductive life, including abortion, when she does not wish to be pregnant. Embryos and fetuses are not considered to have a "right to life." Humanists generally favor a patient's right to decide with their families and physician when their lives should end. Holland does this. Oregon does this. Nobody is killed against their will. The concept of "Death Panels" is right wing hysteria, totally lacking a basis in fact.
6. How do you handle a situation where your faith prohibits you from performing a certain procedure? Would you be comfortable referring the patient to a different physician?
In the cases of abortion, contraception, and physician-assisted-suicide, the humanist position is generally not categorically against any of these. In the case of contraception, humanists enthusiastically support it, taking the position that the life of women is immeasurably improved by the ability to control reproduction. In a broader response to this question, many humanists expand their answer to include the idea that the Earth is already overburdened with people, especially in "Third World Countries" and having too many children just insures an endless cycle of starvation, disease, under-education and under-employment, perpetuating poverty. As more and more women become educated, they have fewer children. That women do this everywhere should tell us something. Having ten children is incompatible with having a career outside the home and fulfilling a woman's other talents.
7. Has your faith changed, weakened, or strengthened during your time as a physician? What events triggered the changes?
My philosophy as a humanist has been strengthened by becoming a physician. In general I have become ever more knowledgeable about the human condition and grown in confidence that my approach to problems with the values of a humanist is appropriate and in the best interests of my patients and of health care in general for humankind. I would say that becoming a physician was instrumental in my "conversion" to humanism.
8. Have you ever felt that a patient has discriminated against you because of your faith?
This issue has never come up. Most patients do not know what my life philosophy is nor have any tried to find out. Instead, it was my job to find out what they believed and how I could work within that framework to get the best health outcome for them.
9. What is your approach to taking a spiritual history of your patients? Do you ever integrate prayer into your care if a patient expresses that they would appreciate it? Is this respected in the medical community?
I have never taken a spiritual history but I have discussed a patient's faith and the faith of the family when serving on the VA Medical Ethics Committee. We were largely concerned with end of life decisions and with resolving conflicts between family members, some of whom understood and some of whom did not understand that further attempts at curative therapy were futile. I have been present when the hospital chaplain prayed with a family in such situations. I regard prayer as a tool to center one's psyche in a difficult situation. Some patients seem to benefit from prayer although there is no statistically significant evidence that prayer has any medically curative effect.
Here is a personal anecdote. In December, 2015, my wife and I were in New York City to visit our son, Daniel, his wife, Becky, and our grandkids, Noah and Talia. We also saw several Broadway shows as we do every December. One evening, while in a restaurant, I experienced sudden, excruciating abdominal pain and asked Danny to call 911. I was taken to NYU Medical center were a diagnosis of small bowel obstruction was made and I underwent curative, laparoscopic surgery by Dr. Paresh Shah. He found an adhesion that was cutting off blood supply and lysed it. My bowel pinked up; recovered peristalsis, and none of it died and had to be resected. I was cured by prompt diagnosis and expert treatment. I woke up in the recovery room where I spent almost 24 hours because the hospital was so full that no rooms were available upstairs. During this day and because NYU has a heavily Jewish patient population, there were seemingly dozens of Rabbis visiting all the other patients in the recovery room. The melodies and words of prayers for healing continually floated through the air. It made me feel better. And, when I finally got upstairs, Mitch Greenspan, who was married to my daughter-in-law's sister Caryn, came to visit me. Caryn had xeroxed Jacob's blessing for me in Hebrew (The Lord bless you and keep you...) Their two kids had each drawn me a get-well card. When Carol came to visit, she told me that a retired, Catholic priest that she met over breakfast at our hotel also said he would pray for me. All of this demonstration of caring lifted my spirits and, I am sure, contributed to my uneventful recovery. When I got back to the hotel after three days, my grandkids had also made cards for me. Good wishes, whether in the form of prayer, cards, or visits do help patients heal.
10. Do you have an example of how integration of faith into your practice has or has not benefitted your patients?
Since my philosophy as a humanist requires that I be both objective and compassionate at all times with all patients and their families, I have never wavered from this. Different religions and philosophies are all part of being human and may be thought of as just different ways of looking at life. As a physician, truly caring for your patient as an individual and as a fellow human being is what is most important. I hope that all my patients have benefitted from this set of humanistic principles.
Humanists get good ideas from all periods of history and all philosophies. I shall close with two examples.
Rabbi Hillel (a famous rabbi who lived one generation before Jesus) was approached by his students with the following question: "Rabbi can you tell us the whole law while standing on one foot?" This means, can you very briefly summarize what is most important in all of the 613 commandments in the Torah? Rabbi Hillel replied, "What is hateful to you, do not do to any man. That is the whole law. All the rest is commentary. Now go study." You will recognize the Golden Rule. What is usually left out is the admonition, "Now go study." Even with strong guiding principles, it takes a lot of time and study to learn how to apply these principles to daily life--and medicine.
And: If you argue with someone about any subject, including religion or the existence of God, and win that argument, you have accomplished exactly that. You have convinced one person of one thing. If, on the other hand, you spend the time and effort to understand the other person's point of view, then you will have gained understanding of thousands of others' point of view. Which of these results do you think is more valuable?