You wouldn’t have noticed, but there may have been someone else in the consultation room when you last saw your doctor. If this someone else was a medical student or a nurse you would be asked to give consent for their presence. However, in this case, it’s unlikely your permission was sought. What’s more unnerving is this someone else was whispering advice to the doctor during your consultation, influencing your diagnosis and treatment. Who was this? God, of course. After all, he is everywhere, didn’t you know?
Supernatural belief is likely part of the human instinct (Shermer, 2011), and an integral part of our cultural and intellectual history. It encompasses our first attempts at meteorology, agriculture, moral philosophy, geology, legal philosophy, and cosmology. In attempting to deal with the most important questions in life, it’s not surprising religion has offered answers related to healthcare also.
To be clear, this is not necessarily a discussion as to whether doctors should be religious, or whether irreligious doctors are better than religious doctors. It’s a discussion about a factor that influences medical decision-making, and to increase awareness of this fact. Are these decisions necessarily going to be wrong as a result? No. But it matters that we are honest about what is contributing to the formulation of diagnoses and treatment plans. By analogy, we know empirically that pharmaceutical marketing to doctors influences their decision-making (Grande et al, 2009; Spielmans & Parry, 2010; Stamatakis et al, 2013). Note that this does not translate to an assertion that every doctor exposed to pharmaceutical marketing will be influenced; nor does it necessarily follow that there is nothing beneficial to be gained from pharmaceutical marketing (lectures delivered by doctors that are sponsored by drug companies usually cover a broader area of interest than just a particular drug). Nor does it mean that if a choice of prescription is coerced by that marketing that it will be an inherently bad choice. What it does mean, however, is that some decisions are being made for reasons that are not otherwise validated or endorsed. This is important.
Religion specifically touches the most contentious topics in medicine. Most notably, abortion, contraception, assisted conception, mental health, and end of life issues are awash with religious coercion. If there were such an influence other than religion that dictated medical practise to such a degree, addressing it would be a priority in medical schools, hospitals, and the wider society. Yet, because it is religion, open and honest discourse appears strident and insensitive, so it has been almost completely avoided.
In recent decades, the medical profession, to its credit, has increasingly become aware and sensitive to the fact that patients are unique. Rather than bare diagnoses, patients’ medical conditions are coloured by their particular culture, relationships, financial status, education, values and religion. A number of patient-centred approaches to treatment have been established because we have recognised that these variables impact significantly on patients’ experiences and decisions. What hasn’t been done so well, however, is extending these humanising streaks to the doctors who treat them. Rather, doctors have been propped up as medical Turing Machines; algorithmic robots who take in a certain amount of information, combine it with their evidence-based training, and compute the most ideal response. Clearly, this is mistaken; in many ways doctors are as diverse as the population they treat.
The impact of religious belief on people’s values is hard to overemphasise. When one’s concept of the universe involves an all-powerful creator who harbours an interest in individual human lives, and an accompanying text that possesses answers to the deepest and most profound questions in existence, it tends to influence one’s life. To deny this is to say that one’s view of the universe does not impact one’s view of the universe. When a doctor steps into ethically murky waters, they will obviously draw on their world-view and resulting values for guidance. If a doctor is religious, much of this guidance will be dictated by their religion.
The first fact to point out is that, according to a study from the U.S. by Curlin et.al (2007), the religiosity of doctors meets or exceeds that of the general population. 88% reported religious affiliation, edging out the general population by one percent. 46% of physicians attended religious services twice a month or more often, compared with 40% of the general population. 76% believed in a god, compared with 83%. 56% identified as very or moderately religious, compared with 62% of general population. This may be surprising, as it does not correlate with the much higher prevalence of atheism and agnosticism in the wider scientific community, with only 33% of scientists who are members of the American Association for the Advancement of Science believing in a god (Pew Research Center for the People & the Press, 2009). Religious and scientific philosophies are in stark contrast when propped up beside each other and, as Australian comedian Tim Minchin once said, “Science adjusts its views based on what’s observed. Faith is the denial of observation so that belief can be preserved.” Furthermore, higher levels of income and more education have been found to correlate with lower levels of religiosity. One possibility for this discrepancy may be found in the nature of medicine. Typically, doctors learn facts about the human body (anatomy and physiology), how to identify when things go wrong (pathology), and how to treat them (pharmacology, surgery). Medicine is taught in a prescriptive manner. There is not so much focus on investigating and discovering novel aspects of the human body and disease, and few careers involve significant research. Arguably, religious doctrine is also taught in a more prescriptive way, and therefore conducive to the conventional way of thinking in medicine.
Not only are doctors a particularly religious subsection of society, their respective religions really do influence their decisions. Furthermore, this influence increases as various aspects of religiosity increases, such as reported “intrinsic religiosity”, frequency of church attendance, and whether or not one looks to god as a way to cope (Curlin et al, 2007). In this same study, in response to a hypothetical question of a patient with depressed mood, those doctors who were more religious were less likely to refer the patient to a psychiatrist or psychologist. Religious doctors were also more likely to describe moral objections to certain procedures, less likely to believe they were obligated to disclose all possible treatment options, and less likely to believe they were obligated to refer a patient to another doctor who will offer such treatment. Shockingly, the doctors who conducted the study simply concluded that “patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.”
Another similar study found that non-religious doctors were much more likely to give continuous deep sedation until death, make decisions they expected or partly intended to end life, and discuss these decisions with patients judged to have the capacity to participate in discussions (Curlin et al, 2007). Whilst we are on the topic of so-called “controversial clinical practices”, I am immediately reminded of the 2012 case of 31-year-old Indian dentist Savita Halappanavar, who died in a hospital in Galway, Ireland, after not being offered an abortion when medically indicated because, as the hospital’s staff were quoted as saying, “Ireland is a Catholic country”. (The Guardian, 2012)
On a more personal note, every week I meet with other psychiatrists, psychologists and occupational therapists to discuss the ongoing management of our psychiatric patients in the community. One case involved a patient suffering from schizophrenia who experienced the very common symptom of auditory hallucinations (hearing voices). The patient believed this voice was god’s, who would commonly instruct her to eat sugary foods and not clean her house (perhaps many of us know this ‘god’). The psychologist summarised the case along the lines of “This patient suffers from a psychotic illness in which she hears the word of god, has a personal relationship with him, who tells her what to do.” I responded, tongue-in-cheek, that it sounded a lot like the biblical Noah (although I could have chosen any of the past famous Christians who have heard ‘the word of god’). To my surprise the comment was met by a glaring silence, until a psychiatrist in the room finally responded “But Noah was proven to be right”. This would have been funny, had he not been steadfastly serious. He went on to advise that the patient should be told that god speaks to us all in many more ways, such as scripture and ‘signs’ in our day-to-day lives. Needless to say, it is frightening when someone with a psychotic illness, who is responding to non-existent stimuli, is told to seek more sentient and personal significance in their surroundings. Indeed, this is a major component of the illness that is schizophrenia, with sufferers commonly interpreting messages and commands from televisions, radios and traffic signs.
Judeo-christian religion does not have a great track record when it comes to handling psychiatric illness. Traditionally, mental health has been thought to be achieved by accepting god, and having a meaningful, loving relationship with ‘Him’. When someone was psychologically suffering, god had loosened his grip and allowed demons or the devil to wreak havoc. Exorcisms provided the cure, by tortuous practices that could involve tying up the suffering individual whilst a priest yelled at them with a cross in hand. This is not an ancient act mind you – exorcisms occur to this day. It seems every few months news surfaces of yet another child who has been needlessly maimed, neglected or killed through attempted exorcisms by the deluded. Sadly, Pope Francis recently officially recognised the International Association of Exorcists, a group of over two hundred priests spread across thirty countries who supposedly cast out demons (Independent, 2014). The head of the association, Rev Francesco Bamonte, announced this was a cause for joy, because, “Exorcism is a form of charity that benefits those who suffer.”
Amazingly, the Australian Government has committed $243.8 million over four years from 2014 to 2018 to assist approximately 2900 schools engage the services of a school chaplain (Project Agreement for the National School Chaplaincy Programme). Whilst not performing exorcisms, these chaplains are expected to assist psychologically distressed youths without adequate formal training. Although the National School Chaplaincy Program (NSCP) Project Agreement states chaplains are “not permitted to proselytise”, this doesn’t seem to be the case. Evonne Paddison, CEO of Access Ministries which receive $5 million per annum in Federal funding (The Big Smoke, 2014), has said, “Without Jesus, our students are lost…In Australia, we have a god-given open door to children and young people with the Gospel. Our federal and state governments allow us to take the Christian faith into our schools and share it. We need to go and make disciples. What really matters is seizing the god-given opportunity we have to reach kids in schools. We have the responsibility of fulfilling the great commission of making disciples. We need to see our scripture teachers, our chaplains especially, as facilitators. We need to be missional.” (The Age, 2011)
Should this attitude be surprising? Of course not. In the words of Ron Williams, the plaintiff in two High Court Challenges against school chaplaincy, “We may as well spend millions of dollars on a National School Clowns Program. Let’s put clowns into schools to make kids happy, and then make it clear in the guidelines that clowns are prohibited from being funny.” The question is, why are we paying money for these clowns when we have trained professionals, such as psychologists and social workers, who are specifically trained and better prepared to deal with the problems of young people? Whilst the Australian Psychological Society (news.com.au, 2011), Black Dog Institute (Canberra Times, 2014), Australian Education Union (Sydney Morning Herald, 2014), and the New South Wales Teachers Federation (Sydney Morning Herald, 2014) have all voiced opposition to the NSCP, unfortunately the Royal Australian and New Zealand College of Psychiatrists has yet to take a stance on the issue.
Another issue with religious influence in psychiatry is free will. Free will is a fundamental necessity of the major monotheisms, for without it, the capacity to choose god, choose good versus evil, and the pending judgement upon which these are scored, doesn’t make sense. For how could god create you, then send you to an eternity of hell-fire for how you behave during your life, without free will? As I addressed in my article Psychiatry versus ‘Real Medicine’, the illusion of free will is undoubtedly holding psychiatry back. For those psychiatrists who adopt it as true, the idea of free will acts like a smoky mist. It hangs between them and the patient, obscuring the doctor’s view of the true clinical picture. They feel that if only they could brush it aside for long enough to ascertain what part of someone’s behaviour is their free choice, they could finally get a clear picture of what the true illness that lies behind is accountable for. It contributes to the ongoing negative connotations attached to psychiatry. It contributes to the shame that patients feel about their mental illnesses.
On a different note, various forms of fasting are practised in religion, including Ramadan in Islam and Lent in Christianity. During my intern year, a more senior doctor described to me her experiences whilst fasting during Lent at work, at which time she only ate dinner each day. She was working in the challenging, fast-paced and physically demanding emergency department, with shifts lasting between ten and twelve hours. She described how she would read the Bible during her breaks, and felt a profound significance and attachment with any page she’d open to, and in general felt different. Her accounts sounded all too like hypoglycaemia. Hypoglycaemia inflicts many functional impairments that are found in those intoxicated by alcohol. Speed of reflexes, concentration, fatigue, inhibition, nervousness, tremor and problem-solving are all affected by both hypoglycaemia and alcohol intoxication (Mitchell, 1985; Ahmed, 2010). What if a doctor’s religious instruction involved drinking a sacred, symbolic alcoholic drink three times per day? This would obviously not be allowed, with the cited reasons being impairments to the doctor. However when the same impairments are afforded by not eating and being dehydrated due to religious instruction, we must accept this without question or concern. As soon as you acknowledge that being a doctor in an emergency department involves cognitive demands close to or in excess of driving a car, you acknowledge that this poses a serious issue.
In conclusion, what all of this shows is that there is a clear need for open and honest discussion about religion in medical schools, hospitals, and the wider medical community, without fear of being branded strident, insensitive or discriminatory. The medical profession prides itself on rational and evidence-based practice, but this is immediately undermined when iron-aged, outmoded ways of thinking and customs are stepping into play. We know religious beliefs affect doctors’ decisions and practises, so I argue that it simply follows that we should all acknowledge the marked relationship between doctors’ religious convictions and clinical decision-making. The good news is that there are some initial steps we can take to mitigate such influences. For instance, awareness is a key to reducing the influence of cognitive biases in decision making. By simply knowing that certain biases and influences exist, and adopting a collaborative approach where possible, one can help lessen their impact (Kahneman, 2011). I have singled out religion in particular in this article, but it is one of a raft of factors that can have an undue influence on the treatment of patients that we must strive to counter.
The Believing Brain, Shermer, 2011
Thinking Fast and Slow, Kahneman, 2011