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:: By Laura Stuart

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Investigations ::

Belief in medicine

Labeling physician neutrality a “problematic” ideal, medical ethicist Farr Curlin studies how faith influences the way physicians do their jobs.

To Chicago internist and medical ethicist Farr Curlin, medicine is a “moral practice,” a vocation informed by each physician’s particular religious and spiritual beliefs. Since 2003—when he first surveyed clinicians’ religious characteristics and found that 76 percent reported a belief in God and 55 percent said their beliefs influenced their medical practice—he has examined a knotty question: how does religion affect physician care? And what does the answer mean for medicine?

Curlin’s survey results contradict the conventional “ideal,” he says, that demands physicians be “generic, interchangeable, objective, religiously neutral scientists who take it as a matter of professionalism to not let their personal values influence their professional practice.” More than a myth, neutrality, he argues, is the wrong goal. “Our religious traditions—and if we’re not religious, the secular analogs of those traditions—inform everything we do and, in fact, have to.” He suggests moving “toward an ethic of candor and respect, where we are more self-conscious, more candid about why we practice as we do.” Then physicians and patients can “respectfully negotiate how they are going to work together” to choose the best treatment.

Sometimes, Curlin concedes, negotiation may not be possible. A woman might seek an abortion from a physician who will not provide one. Patients would likely be better served by discussing potential areas of disagreement with their physicians in advance, he says, and physicians must be up-front about their objections. Ultimately, however, physicians must be allowed to decline giving treatment that contradicts their beliefs, Curlin argues. Asked about the hardship this can cause patients, he replies, “A condition of living in a peaceable plural culture is that we’re willing to live with inconveniences—sometimes grave inconveniences—imposed by the fact that a lot of people will not provide what we seek.” The alternative, he says, would force physicians unwilling to violate their consciences to leave the profession.

The data, he says, bear out his conclusions. In the February 8 New England Journal of Medicine, Curlin reported that 63 percent of surveyed physicians believe that when a patient requests a controversial medical procedure, such as terminal sedation, to which the physician morally or religiously objects, it is ethical to describe that objection to the patient. Eighty-six percent believe the physician is obligated to present the patient with all options, and 71 percent believe the physician is obligated to refer the patient to someone who does not object. More religious physicians tended to say that doctors should describe their objections and less frequently said that physicians must present all options or refer patients elsewhere.

In many cases, Curlin emphasizes, religion does not affect medical decisions. All emergency-room physicians treat broken legs and acute pneumonia using standard protocols. Religion comes into play at what he calls the “margins,” areas that until 50 or 60 years ago were not considered part of the medical profession: end-of-life issues, sexual and reproductive health, and mental health. As long as medicine continues to reach beyond broken bones and acute disease into “areas in which people disagree,” physicians will, he argues, make moral judgments. And those judgments will be colored by religious, spiritual, or secular beliefs.

Curlin conducted his initial survey, published in the July 2005 Journal of General Internal Medicine (see “Citations,” October/05), during a two-year stint at the U of C Hospitals as a Robert Wood Johnson clinical scholar. Before that he completed a 2001 internal-medicine residency at Chicago. Now a Pritzker assistant professor and associate faculty member at the MacLean Center for Clinical Medical Ethics, he calls himself a churchgoing Protestant, “a person of faith.”

Funded in part by the Greenwell Foundation (Curlin is a foundation faculty scholar in bioethics, receiving three years of research funds), his 12-page survey was the first to examine physicians’ religious and spiritual characteristics in depth. A sample of 2,000 practicing physicians randomly selected from the American Medical Association physician masterfile—1,144 responded—were asked to identify their religious affiliations. Protestants topped the list at 38.8 percent, followed in order by Catholics, Jews, the non-religious, Hindus, Muslims, Eastern Orthodox Christians, Mormons, Buddhists, and others. To measure “intrinsic religiosity,” which Curlin calls the “most coherent” gauge of how fully people “live” their religion, he asked physicians to agree or disagree with two statements: “I try hard to carry my religious beliefs over into all my other dealings in life” and “My whole approach to life is based on religion.” Saying yes to both statements qualifies one as “highly religious.” Other questions addressed physicians’ attitudes and behaviors in specific clinical encounters.

Curlin continues to analyze the survey data. In the May 2006 Medical Care, he reported that highly religious physicians’ approach to patient spirituality differs across the board from that of less religious physicians, even after adjusting for differences in religious affiliation. For instance, 76 percent of highly religious physicians ask about their patients’ beliefs, compared to 23 percent of the least religious, and 76 percent pray with their patients, compared to 30 percent.

Curlin is now surveying pediatricians to compare their willingness to give patients two new vaccines—one for rotavirus, a childhood diarrheal illness, and the other for the sexually transmitted human papilloma virus (HPV). He suspects the first won’t correspond to religiosity, but the HPV vaccine, best administered before a girl’s first sexual encounter, will find fewer prescribers among devout pediatricians. Curlin also plans to survey obstetrician/gynecologists and correlate religiosity with approaches to practices such as abortion and emergency contraception.

Envisioning an alternative to the “problematic” ideal of physician neutrality, Curlin proposes a medical system in which physicians practice in separate, clearly identifiable groups that work “in a certain cast of mind or tradition.” Divisions are “regrettable,” he says, “but it’s better than trying to force everyone to fit one standard. The reality is that we’re not going to agree.”