Ethical Issues in the Psychiatric Treatment of the Religious 'Fundamentalist' Patient

Ronald W. Pies, MD; Cynthia Geppert, MD, PhD, MPH, MSBE


March 19, 2013

In This Article

Differences in Values: Secular vs Sacred

Like most of US medicine, the ethics of contemporary psychiatry rest on 4 fundamental ethical principles, derived from the Hippocratic spiritual tradition and given its secular formulation in the work of Beauchamp and Childress.[8] These principles are usually expressed by the terms autonomy, benevolence (or beneficence), nonmalfeasance (or nonmaleficence),and justice. These are fairly broad and malleable concepts that have affinities with general moral values in most of the world's great religious traditions. However, the sources of these values differ radically with respect to psychiatry and the major religious faiths.

In Western medicine, psychiatric values are derived largely from the liberal-democratic tradition, borne of the 18th century European Enlightenment. This tradition emphasizes reason, freedom, natural law, individual happiness, and an approach to healthcare decisions based on the value of their consequences ("consequentialism"). Secular medical ethics in Western countries typically emphasize instrumental or pragmatic, rather than absolute, values and individualized, patient-centered solutions to ethical problems rather than solutions based on "categorical" (Kantian) principles of right and wrong.

Of perhaps the most importance, secular medical ethics in the postmodern era increasingly view the physician/patient relationship as fundamentally a contract of mutual rights and responsibilities in which "informed consent" is the legal and ethical foundation of treatment decisions. This contrasts with the Judeo-Christian perspective (Table), in which the patient trusts his health and life to the physician as the agent of God's healing power, and as one who has a sacred duty to place the good of the patient above all other interests. The autonomy of both physician and patient is thus circumscribed under the divine will.[9]

Table. Salient Differences Between Psychiatric and Fundamentalist Ethics and Orientation

Secular Psychiatric Ethics Fundamentalist Medical Ethics
Based on ideas of the European Enlightenment (reason, freedom, natural law, individual happiness). Based on scripture, tradition, religious law, religious authorities, statements or confessions of faith, rabbinical teachings, etc.
Relative, consequentialist values (eg, susceptible to modification on the basis of circumstances, and achieving patient-centered goals). Absolute or categorical values (eg, the Kantian principle that certain acts are always and absolutely wrong).
The patient/physician relationship is contractual, with the patient's informed consent and autonomy as cornerstones. Patient and physician are engaged in a relationship of trust and faithfulness in which the autonomy of both is limited and subordinated in obedience to God.
Cognitive style tends toward "gray" responses to complicated dilemmas and tolerance of ambiguity in life choices. Cognitive style tends toward "black and white" answers to complex questions and intolerance of uncertainty in making life choices.
Goal of medical ethics is respect for patient preferences and wishes in the process of shared decision-making geared toward actualizing patient happiness and health in this world. Goal of medical ethics is to preserve the sanctity of human life and health so that individuals may fulfill God's plan for the salvation of humankind.

Indeed, the concept of "autonomy" may best exemplify the differences between the secular values of medicine and the sacred values of Judeo-Christian fundamentalism. In Orthodox Judaism, for example, the patient's "autonomous choice" plays a fairly limited role. The Orthodox rabbinical tradition explicitly rejects the notion that "what the patient says, goes" in any straightforward sense. This is owing to the noncontractual nature of the physician/patient bond in rabbinical Judaism. Thus, Avraham Steinberg, MD,[10] argues that:

The physician-patient relationship in Judaism is not a voluntary-contractual arrangement but a Divine commandment and obligation. The patient is commanded to seek healing from the physician and to prevent illness if possible. The physician is obligated to heal and is considered to be the messenger of God in the care of patients. The patient is not free to decide autonomously to refuse treatment which might be beneficial or save his life.

Although theologically very different from Orthodox Judaism, evangelical Christianity also takes a negative view of many principles that are taken for granted by secular psychotherapists, including the notion of personal "actualization" and the desirability of "self-esteem." In Psychology and the Evangelical Church,[11] minister TA McMahon writes:

The basic theories of psychological counseling are contradictory to what the Bible teaches about the nature of man and God's solution for his mental, emotional, and behavioral problems. Psychotherapeutic concepts regard humanity as intrinsically good. The Bible says that other than Jesus Christ, man is not good but was born with a sinful nature...Psychotherapy attempts to improve the self through concepts such as self-love, self-esteem, self-worth, self-image, self-actualization, etc. The Bible teaches that self is humanity's main problem, not the solution to the ills that plague mankind. And it prophetically identifies the chief solution of psychological counseling, self-love, as the catalyst to a life of depravity...The Bible teaches that reconciliation to God through Jesus Christ is the only way for man to truly remedy his sin-related mental, emotional, and behavioral troubles.


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