Issues can become contentious, however, if the physician’s reluctance to provide a requested treatment is based on moral rather than medical reasons. The paradigm here is a patient’s request for an abortion, a procedure formerly considered both immoral and illegal that is now deemed by our society to be legally permissible in some circumstances. The physician’s right of conscience has traditionally allowed him or her to decline participation. However, in recent years, this right of conscience has been challenged by those who claim that the physician is obligated to provide any treatment that is legally available or at least to refer the patient to someone who is willing to provide the service[xi],[xii].
Religious beliefs should inform our discussion of issues of public policy in health care, recognizing that it may not always be possible for people of faith to convince others in the public square if they do not share those beliefs. However, when we are confronting moral dilemmas at the bedside, dilemmas that involve individuals rather than public policy, we not only may, but we must recognize the importance of religious beliefs of the patient, family and healthcare professional. This articulation of and focus on matters of faith may open the door in our multi-faith culture, an opening that could transform our culture.
Four brief case vignettes illustrate dilemmas in clinical ethics stimulated by differing religious beliefs:
CASE 1 A previously healthy woman develops a condition that will inexorably lead to her death within a few days. Dialysis might postpone her death by a few hours or days, but she decides against it. Her devout nurse has been witnessing to her about salvation from eternal damnation. She insists that dialysis be used because she believes the patient is not prepared for eternity and is almost ready to make a decision to accept Jesus. Should dialysis be used in spite of the patient’s refusal?
CASE 2 A 4 month old infant is clearly dying from an uncorrectable birth anomaly, but his mother insists on continued life support. His nurses and physicians believe he is needlessly suffering from this treatment and urge her to consent to withdrawal of life support. She says she is waiting for God to miraculously intervene, and further that she believes God will not intervene if she does not demonstrate faith by continuing the treatment. Should life support be continued?
CASE 3 A 13 year old girl with severe anemia urgently needs surgery that will cause substantial blood loss. Her surgeon is unwilling to operate without first giving her blood transfusions. She has recently been accepted into her parents’ Jehovah’s Witness congregation. She and her parents decline blood products, even if that means she will die. Should a court order be sought to give blood?
CASE 4 A 63 year old previously healthy woman suffers a devastating stroke with a dismal prognosis for any significant recovery. She could live in a severely disabled condition if major interventions are continued. Two of her children are convinced she would not want to survive in this condition and would prefer to go to heaven. They ask that the treatment be stopped. However, a third daughter insists that it be continued because she believes human life is sacred. Should the treatment be continued?
 I have been unable to identify whether this was first said by Leon Kass or Eric Cassell.
 From the mission statement of Loma Linda University
 It is estimated that when an individual dies in a hospital setting, 70% of the time, the timing of death is a matter of choice.
 The societal mandate is different if the patient is a child and the decision to decline treatment is based on parental religious beliefs. In such a case, the physician is obligated to request judicial intervention to protect the child if refusal of treatment endangers the child’s life or is likely to lead to permanent disability.
 These cases are taken from Medical Ethics and the Faith Factor (Orr, 2009) where each is reported and analyzed in detail.
[i] Jonsen, Albert R. The New Medicine and the Old Ethics. Harvard University Press, 1992
[ii] Verhey, Allen and Lamers, Steven. Theological Voices in Medical Ethics, Wm. B. Eerdmans,1993:1-2
[iii] Orr, RD. Bioethics and the fundamentalist agenda (guest editorial). Ethics & Medicine Spring 2004;20(1):3-5
[iv] Puchalski CM. The role of spirituality in health care. Proceedings (Baylor University Medical Center) 2001;14(4):352-7
[v] Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed., Oxford University Press, 2008:99-280
[vi] Jouanna J. Hippocrates. The Johns Hopkins University Press, 1999
[vii] Orr RD. Medical Ethics and the Faith Factor: A Handbook for Clergy and Healthcare Professionals. Wm. B. Eerdmans Pub. Co., 2009
[viii] Orr RD. Pain management rather than assisted suicide: The ethical high ground. Pain Medicine 2001;2(2):131-7
[ix] Havel V. The Politics of Hope. New York: Vintage Books, 1991:180-1
[x] Micah 6:8 (Holy Bible, New International Version)
[xi] Orr RD. Medical ethics and the faith factor: The endangered right of conscience. Ethics & Medicine 2010;26(1):49-54; on-line In Pursuit of Truth (www.cslewis.org/journal) and at: findarticles.com/p/articles/mi_qa4004/is_201004/ai_n53077376/?tag=content;col1
[xii] Orr RD. The right to refuse to treat: Conscience clauses and the duty of medical professionals. Christian Bioethics (in press)