Saturday, July 11, 2009

Praying with and for patients

I recently attended an inspiring forum sponsored by Andover Bread Loaf, "a private, non-profit organization based at Phillips Academy in Andover that works with U.S. and international public and private school teachers and students to enhance the teaching and learning of writing and to help catalyze educational renewal in classrooms, schools, school systems, and communities."
Teachers from New Orleans described programs they are developing in an effort to rebuild education and community after the Katrina disaster. A young teacher ended her presentation by saying - "if you pray, please pray for my students."

Her request got me thinking about a patient of mine with chronic schizophrenia who I had seen intermittently for several years, a sweet man who - though quite impaired by his ailment - radiated honesty and integrity. He was going through a bad patch in which his baseline anxiety and paranoia were more severe. We reviewed stressors, coping mechanisms and medication. As he left the office he said "please remember me in your prayers." I immediately replied "I will."

I've thought a lot about my response. I don't do petitionary prayer and don't believe in a divine being who might listen and respond. But I felt that I was being truthful with my patient. I interpreted his request to mean something like "I want you to care deeply about my well being," and because I did, my reflexive response was to confirm that I would indeed remember him in my prayers. If he had said "when you go to bed tonight please go onto your knees and ask God to make me better" I would have said something like "doing that isn't my custom, but I hope you know that in my heart I wish for you to be well..."

The U.K is in the midst of a flap about the ethics of prayer in the context of clinical care. Earlier this year a nurse, Caroline Petrie, was temporarily suspended for asking a patient whether she would like to be prayed for. The incident was widely publicized. Comments were highly polarized, some attacking "absurd political correctness" and "discrimination against Christians" while others found "invoking a non-existent deity in the course of medical care is foolish at best and potentially offensive."

This month the following motion will be brought to the British Medical Association:
That this Meeting:

• (i) recognises that the NHS is committed to providing spiritual care for patients;
• (ii) notes the position on inappropriate discussion of faith matters in GMC Guidance on Personal Beliefs and Medical Practice;
• (iii) while welcoming the constructive and necessary advice in the document "Religion or belief", is concerned that some paragraphs suggest that any discussion of spiritual matters with patients or colleagues could lead to disciplinary action;
• (iv) believes that offering to pray for a patient should not be grounds for suspension;
• (v) calls on Health Departments to allow appropriate consensual discussion of spiritual matters within the NHS, when done with respect for the views and sensitivities of individuals.
My guess is that one of the paragraphs of concern to those who are bringing the motion to the BMA is the following:

Members of some religions, including Mormons, Jehovah’s Witnesses, evangelical Christians and Muslims, are expected to preach and to try to convert other people. In a workplace environment this can cause many problems, as non-religious people and those from other religions or beliefs could feel harassed and intimidated by this behaviour. This is especially the case when particular views on matters such as sexual orientation, gender and single parents are aired in a workplace environment, potentially causing great offence to other workers or indeed patients or visitors who are within hearing. To avoid misunderstandings and complaints on this issue, it should be made clear to everyone from the first day of training and/or employment, and regularly restated, that such behaviour, notwithstanding religious beliefs, could be construed as harassment under the disciplinary and grievance procedures. Where one or more people from the same religion are working in the same environment, an individual could be pressured to conform to certain religious practices, which is again a form of harassment. There may also be differences of opinion on conformity within groups, for example between orthodox and reformed branches of certain religions, which could cause tensions and make an individual feel under pressure because of his or her religious beliefs.
If Ms. Petrie was trying to convert her patient the suspension would have been warranted. If her patient had asked to be prayed for it would unquestionably have been reasonable to agree to do so.

But what about offering to pray, which is what Ms. Petrie did?

If I were in charge of policy for Ms. Petrie's district or for the NHS I would find it hard to make a rule about offering to pray for a patient. It's clear from multiple research studies that when patients feel that their clinician genuinely cares about them they do better. If Ms. Petrie had a gentle, unintimidating manner, knew that her patient liked to pray and said "I'm a person who likes to pray for those I care about...would you like me to include you in my prayers tonight?" I would find that acceptable. But if she asked in a strong way "would you like me to ask Jesus to touch you with his healing hand?" I would find the episode unacceptable.

It's not a matter of the clinician's freedom of speech or religion. The guiding principle is that we clinicians should shape what we bring into the care relationship based on a reasoned judgment of what's best for the individual patient. (A "reasoned judgment" can come rapidly, as for me with the patient I agreed to remember in my prayers.) It would be wrong to forbid responding to a request to be prayed for. And I would not want to legislate that no clinician should ever offer to pray for a patient, but I would want my colleagues to be capable of distinguishing between their own beliefs about what is best for others (for example, belief in Jesus, Buddha, Allah or in no god) and a thoughtful assessment of what is best for this particular patient.

That's what clinical responsibility entails. But if clinicians at a hospital or in a district were blurring the boundary between preaching and caring, a prohibition would be required.

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