Tuesday, August 7, 2018

The Moral Responsibilities of Pastors and Psychiatrists

A recent New York Times article reports accusations of "inappropriate" sexual behavior on the part of Reverend Bill Hybels. The article describes Hybels as a "superstar pastor" who initiated the megachurch era by founding the Willow Creek Community Church.

In 1985, feeling lost after her divorce, Pat Baranowski felt that God had spoken to her when Reverend Hybels reached out to her, drew her into the church, gave her a job, and ultimately invited her to live with him and his wife and children. She alleges that Reverend Hybels drew her into a relationship that included oral sex. She ultimately ended the relationship, but was plagued with guilt, shame and a feeling that God's servant had betrayed her.

Ms. Baranowski kept her story to herself until other women brought forward allegations of their own. Reverend Hybels vigorously denies all of the allegations, calling them a mix of "misinterpretations" and "outright lies." The church elders investigated the allegations against Reverend Hybels and concluded that they were not believable. But a day after the New York Times article, Reverend Hybels resigned from his leadership role in the church.

The Hybels/Baranowski story illustrates in dramatic fashion the tinder-box nature of pastoral and psychiatric relationships. A vulnerable person feels uniquely understood by a trusted caretaker who is invested with the charisma that comes from being seen as a pastor serving God or a physician serving the healing profession. The pastor or physician receives love, gratitude and idealization. Used skillfully and responsibly, this "transference" can promote healthy development. But as Ms. Baranowski and other members of the Willow Creek congregation allege, the relationship of trust can be exploited, with potentially devastating consequences for the congregant or patient.

As is so often the case, this is a "he said/she said" situation. Reverend Hybels presents himself as a victim, not an exploiter/sinner. There is a continuum of possibilities. At one extreme, he could be the victim of a combination of misunderstandings, fantasies, and malicious accusations. At the other he could be an exploiter who is fully aware of his duplicity and issues denials he knows to be false. In between is a range of misunderstandings and human frailties on the part of all parties to the relationships.

Pastors and psychiatrists have distinctive ethical obligations associated with their roles in society. These obligations go beyond ordinary morality. Whatever religion they follow, pastors present themselves as servants of gods, devoted to the salvation of their congregants. Psychiatrists and other physicians present themselves as servants of medicine, devoted to serving their patients' health and well-being. In return for these commitments, society grants pastors and physicians distinctive forms of respect and privilege.

Whatever the truth is about the Willow Creek Church situation, it's a tragedy. #metoo will see one more example of male exploitation. Some of the faithful Willow Creek congregants will see misunderstanding, maliciousness, or even the devil instigating false accusations. An anthropologist from Mars will not claim certainty about the truth of the situation, but will see it as an inevitable hazard created by our human needs, vulnerabilities and limitations.

(For posts that discuss the power of transference in the pastoral and psychiatric relationships, see here and here.)

Friday, August 3, 2018

The Enduring Wisdom of Franz Ingelfinger

On May 5, 1977, Dr. Franz Ingelfinger, editor of the New England Journal of Medicine, delivered the George W. Gay lecture on medical ethics at Harvard Medical School. I was in full time practice at the time and, alas, was not at the lecture.

Dr. Ingelfinger, one of the world's experts on esophageal cancer, had developed the disease he had taught so many others about. Here's what he tells us with regard to the difficult question of whether to undergo chemotherapy and radiation after surgery:

I received from physician friends throughout the country a barrage of well-intentioned but contradictory advice. As a result, not only I, but my wife, my son and daughter-in-law (both doctors), and other family members became increasingly confused and emotionally distraught. Finally...one wise physician friend said, "What you need is a doctor." He was telling me to forget the information I already had and the information I was receiving from many quarters, and to seek instead a person who would...tell me what to do, who would in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief."
Yesterday I spoke with a dear friend whose spouse is suffering from a profoundly serious medical condition that calls for complex clinical, psychosocial and financial decisions. My friend reported "if I had a dollar for every time I was asked - 'what should we do about XYZ' - there would be no financial problems to deal with!" My friend described feeling "you are the doctor - what do you think we should do?"

My friend was encountering a common medical ethics dilemma. We physicians are taught to provide "patient-centered" care, to "respect patient and family autonomy" and to avoid "paternalism." But as Dr. Ingelfinger described so poignantly, in the context of serious illness, patients and families also need support and guidance. Physicians need to develop communication skills that allow us to thread between respecting autonomy and providing structure and guidance.

There's no single right answer as to how to do this. I often found it helpful to (a) elicit the patient's goals and values, (b) give my view of what course of action these goals and values called for, but then (c) check on whether, from the patient's perspective, I'd gotten it right.

Over the years with medical students and residents I've often quoted Muhammad Ali's philosophy of boxing: "float like a butterfly/sting like a bee." Ali's eight-word formula conveys the need to embrace and integrate ostensibly incompatible components. Doing this takes experience. It also takes time.

I don't know if my friend's physicians felt rushed. My brilliant colleague Dr. Amy Ship recently wrote about how limited time constrains us in our efforts to be the best we can with patients and families. But whether or not time was a factor for my friend's physicians, Dr. Ingelfinger's guidance from his own experience as a patient holds true forty-one years after his lecture.

(Dr. Ingelfinger's lecture, published in 1980 after his death, is available here. "Physicians as counsellors," a previous post on a related topic, is here. )