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From its beginnings, bioethics has been a secular enterprise. Catholic scholars have long been involved in bioethics, but have been disenfranchised in debate or writing as incapable of rational discourse.
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Catholic bioethics has been marginalized in the university and in the public square because it is the heritage of five hundred years of serious cogitation by Catholic scholars. The growing societal schism between moral and epistemological doctrines of militant skepticism and a balanced view of the place of both reason and faith is at issue.
This dialogue is essential to humanity's common need to respond intelligently to the central question posed by the new biology: how are we to use our new powers for the betterment of human life without being overshadowed by our own ingenuity?
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The growth of secularism and the militant anti-religious spirit in academia has weakened religiously grounded bioethics and its influence in academia is deleterious to progress and societal good.
In the "post secular age," where secular and religious world views will live side by side, productive dialogue between opposing world views is essential. Catholic bioethics must be represented in the academic milieu.
I will begin by considering the fundamental schism between the rationalist and the religious world views, and conclude by outlining why Catholic bioethics must occupy an unavoidable place in the moral controversy and the university.
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The dialogue between secular bioethics and biology is essential if we are to find agreement on practical ethical guidelines.
The scientific method can teach us nothing else than how facts are related to each other. However, knowledge of what is does not open the door directly to what should be.
Einstein's distinction between physical and biological sciences is just as true for the biological sciences as it is for the physical sciences.
In a post-secular world, both secular and religious worldviews must interact with one another to ensure that biotechnology benefits all.
CATHOLIC BIOETHICS AS AN ACADEMIC DISCIPLINE
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Catholic bioethics is a branch of ethics that focuses on the use of biological knowledge in human affairs. It uses a variety of analytic methods, both philosophical and theological, to examine right and wrong, good and bad human conduct.
Catholic bioethics differs from secular ethical systems in important ways, but it is still a valid academic discipline. It is crucial for believers as well as non-believers.
Catholic bioethics argues its propositions from the point of view of reason, and its conclusions are open to reasoned objection. It does not offer scripture, tradition, church teaching or papal encyclicals as evidence against reasoned objections.
Catholic bioethics is a bipolar discipline, which engages the intellect through reason at one end and through faith at the other. Reason complements faith, while faith complements reason.
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SECULAR AND CATHOLIC BIOETHICS: THE WIDENING GAP
Catholic bioethics can engage in productive dialogue and dialectic with secular bioethics, but the gap has been made difficult in academic circles by narrowing the legitimacy of reason itself as a means of ascertaining truth.
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The limitation of reason to scientific reason has dealt a double blow to bioethics, which has further reduced moral truths to psychology, axiology, or evolutionary biology. The societal revolution of the mid-sixties of the last century atomized moral standards, making them matters of personal preference.
THE FRACTIOUSNESS OF CURRENT BIOETHICAL DISCOURSE
H.T. Engelhardt, Jr. viewed the state of ethical discourse in bioethics in 1997 with a mixture of satisfaction and foreboding. He argued that the project of discovering a shared normative consensus in general secular terms must always fail, and that the same failure is becoming evident between and within religion-inspired moral narratives.
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The current discord between "moral strangers" impedes discourse on topics of common concern, and has too often ended in socially ruinous eventualities. In democratic societies the tendency is often to think that legislative judicial fiat or a simple majority plebiscite will "settle" the issues.
De Tocqueville saw a conflict between equality and freedom when he advocated for the resolution of moral issues by legislation or the courts.
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The Catholic teaching on conscience and moral accountability is imperiled in the United States by pressures to equate legality with morality.
ONE MECHANISM FOR ACCORD: “CONSENT AND FORBEARANCE”
The consent and forbearance method is a process of decision-making in the absence of consensus on a moral narrative. Participants voluntarily set aside ideological, metaphysical, and theological differences to actualize particular undertakings.
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Agreements between nations and individuals representing a wide variety of cultures, legal philosophies, and religious beliefs have been reached despite their moral and cultural diversity and the complexity of the issues.
CONSENT AND FORBEARANCE: SOME PROBLEMS
Today, constructive collaboration among bioethicists is difficult because of the diversity of their moral viewpoints and their partisan political sympathies. Common consent and forbearance are thus harder to achieve.
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Bioethicists today come from a wide variety of disciplines in the humanities, social sciences, political science, the law, and medicine. They are often shaped in terms of "values" rather than moral principle or reasoning, and they want to be "comfortable" with their conclusions rather than being rationally convinced by them.
The current trajectory toward normative decay in bioethics is due to the failure of traditionalists, modernists, and postmodernists to engage the deeper issues. This is not a plea for nostalgia but recognition of a cultural heritage within the perennial philosophy.
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Catholic bioethics must engage in productive discourse with the rationalist world view. This can only be accomplished in an intellectually serious way if Catholic bioethics is a full partner in academia with the bioethics of Western rationalism and skepticism.
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Western philosophical reflection dates from classical times to the contemporary era. It can still enrich contemporary thought.
The modern rationalist and naturalist interpretations of scientific evidence are crucial to any creditable moral philosophy, but so are the ways in which these concepts have been interpreted by philosophers and theologians
over the ages in the classical and Catholic moral traditions.
Exiling Catholic bioethics ignores the five-hundred year old history of Catholic efforts in bioethics per se, and the
fact that Pope Pius XII addressed contemporary issues like confidentiality, organ donation, ordinary-
extraordinary means, the principle of double effect, the physician's ethics, etc. before bioethics was "born".
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Catholic scholars worldwide have covered every imaginable topic germane to the field of bioethics. Some secularists are openly disdainful of ideas with which they do not agree, but Jürgen Habermas argued that naturalistic world views do not enjoy a prima facie advantage over competing world views or religious understandings.
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21 Ratzinger and Habermas, op. cit., p. 77.
Matthew Levering, D. F. Kelly, Paul J. Griffiths, Mark R. Hohenheimer, and John Finnis discuss the nature of desire and the thomistic realism of John Paul II's Ethics of Human Life.
According to Habermas, reason and religion are called to purify and help one another. However, there are also pathologies of reason, and Catholic bioethicists will have to settle some of their differences in interpretation of natural law.
In his conversation with Habermas, Benedict XVI questioned the notion that nature and reason overlap, and suggested that man qua man has rights simply by virtue of being human.
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obligations and limitations.23
Benedict's reflections call for a greater clarity in our use of natural law as an instrument of engagement, and a re-inspection of their interrelationships. A disciplined philosophy of science can help to keep the different orders of abstraction separated in the interests of both secular and Catholic bioethics.
In my view, Catholic bioethics satisfies the criteria of a valid university discipline and addresses the most crucial questions arising in modern biology as they affect the nature and meaning of human life. If Catholic bioethics were banished from the university, irreparable damage would occur to the university itself.
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In 1963, Muslim students in American colleges and universities formed an association, and four years later Muslim physicians in America formed IMANA. IMANA is a constituent body of the Islamic Society of North America and a member of the international Federation of Islamic Medical Associations.
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Muslim Physicians, Ethicists, Imams and scholars are asked questions about Islam's position on certain medical
dilemmas affecting the care and outcome of patient's illness and life. IMANA decided to make position papers available to those who seek our position in order to pursue further reading on their own.
Islam considers access to health care a fundamental right of the individual. A Muslim physician derives his / her conclusion from rules of Islamic laws (Shariah) and Islamic medical ethics, and upholds the four basic principles
of biomedical ethics, which are respect for the autonomy, beneficence, nonmaleficence, and distributive justice.
A Muslim physician has to make a decision based on his/her Islamic teachings, in the best interest of his/her patient, whether Muslim or non Muslim. He/she should familiarize himself/herself with the basic teachings of Islam and Islamic moral values.
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IMANA believes that terminally ill patients should be allowed to die without unnecessary procedures. They should be treated with full respect, comfort measures and pain control, and no attempt should be made to enhance the dying process in patients on life support.
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IMANA believes infertility is a disease and desire for a cure by an infertile couple is natural. IMANA believes that
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all forms of assisted reproductive technology (ART) are permissible between husband and wife during the span of marriage using the husband's sperm and the wife's ovaries and uterus.
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Muslims should not take medicines that have changed chemically, unless they are life saving drugs and no substitute is available. If you are 3 months pregnant, it is preferable that you utilize God's granted exemption and do not fast. While fasting, a Muslim patient can have a blood test, check his glucose with a finger stick, take
tablets, injections, inhalers or patches. Sick patients are exempt from fasting, and medicine of nutritional value or taken with water will break the fast. If available, female patients should seek a female Gynecologist, but in life
saving situations, a male nurse or male relative of the patient must be present. Muslim Physicians should care for AIDS patients as they would care for any patient, taking all necessary precautions to protect themselves. Muslim Physicians may not perform abortion, vasectomy or tubal ligation unless medical necessity. Surrogacy is
not permitted in Islam. If your husband is in a coma and you love him very much, you can not save his sperm to have his baby after his death. Q14: At what stage of pregnancy does the termination become abortion? A: According to Imam Ghazali, life begins at conception, but other Islamic Jurists may have different opinions. If you find out that your patient has a terminal illness, you should tell them the truth but not be dogmatic about it. You can explain the diagnosis and natural history of the disease process but do not give a time limit as you do not know for sure when the patient will die. My grandfather has diabetes and has developed gangrene in his foot. Doctors recommend amputation, but he refuses to do it, and he will be questioned about it on the Day of Judgment. A patient with cancer and bone metastasis should take pain killers, and a patient on a heart transplant waiting list should accept a heart from a criminal or an atheist. The pregnancy resulting from rape should be carried to term unless the life of the mother is in danger. A Muslim female medical student should do Masah (wadu) over her head cover before surgery. To seek cure for a disease is mandatory, so gene therapy and genetic manipulation are allowed. Embryonic stem cells can be used for this. When Prophet Muhammad got ill, he took medicine and prayed to the Healer that it works and He heals you through that medicine. The Holy Quran advises us to do the same.
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If a man divorces his wife by Zihar (calling her mothers), he cannot be their mother. Only the woman who gave birth to him can be their mother.
Allah creates what He wills, bestows children male or female, and leaves barren whom He will.
When believing women take the oath of fealty to you, they must promise not to associate in worship with anything but Allah, not to steal, not to commit adultery, not to kill their children, and not to disobey you in any just
matter.
Shahid Athar, Abdul Fadl Mohsin Ebrahim, Faroque A. Khan, Fazlur Rahman, Abul Fadl Mohsin Ebrahim, Hassan Hathout, Code of Medical Ethics, Jonsen, Siegler and Winslade, "Clinical Ethics" and "Health Concerns for Believers" are some of the authors that have written on medical ethics.
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Islamic Code of Medical Ethics, An Islamic Perspective on Stem Cell Research, Wahaj Ahmed's book, A.F. El-
Hazmi's book, Kamyar M. Hedayat .MD and Raya Pirzadeh's book are some of the sources that discuss Islamic
ethics in medicine. The Islamic viewpoint on new Assisted Reproductive Technologies is presented in several articles, including Peter B. Gray's article on HIV and Islam, the Medical Ethics Committee's opinion on Euthanasia, and the Guest Editorial on Gene Therapy.
Members
The Islamic Medical Association of North America is a non-profit organization that promotes the practice of medicine in the United States.
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When Patients Say, “It’s in God’s Hands.” Commentary by Keith G. Meador, MD, ThM, MPH
Mr. Adams arrived at the hospital by ambulance after a sudden onset of right-sided weakness and difficulty finding words. He was diagnosed with a transient ischemic attack and admitted to the neurology service for overnight observation.
The next day, Dr. Howard came by to have a discussion with Mr. Adams about his care going forward. He told him that to reduce his risk of having another stroke, he would need to change his lifestyle some.
“It’s your life we’re talking about,” said Dr. Howard.
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Mr. Adams thought he handled his stroke OK, and didn't see the need for a bunch of new pills. Dr. Howard, an agnostic, disagreed, saying that he had to take responsibility for his life.
Commentary
This case provides a context for considering the relationship between religion and health, ethical implications for
the physician in the practice of medicine, and the role of the chaplain in health care.
There is a clear consistent association between religion and health documented in the literature, but there is no presumption or claim to causality. Nevertheless, cultural sensitivity to the worldview represented by Mr. Adams is important in medical practice.
Dr. Howard was taken aback by Mr. Adams' response to his illness and particular worldview, and he wondered how he could engage patients genuinely and constructively without interjecting a prejudiced view of the patient.
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Sustaining the ethical integrity of the practicing clinician, while honoring the patient's worldview, is an integral part of the engagement of this issue. The outcome appears constructive, but the process by which Dr. Howard got to this outcome was not the most ethical or responsible.
Patients should expect honesty from their physicians regarding their own views and beliefs on religious and philosophical matters, and physicians should be given opportunities to examine their own religious views thoughtfully, while learning about other traditions with attentiveness to implications for the clinical setting.
While there has been substantial progress in incorporating spirituality into the curriculum in a growing number of
medical schools, the quality and depth of that instruction is quite varied. Physicians must at least commit time to
examine themselves and gain a level of comfort with the diversity of possible religious and philosophical lenses.
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A physician or other health care professional can consult with a chaplain colleague for advice on spiritual and religious issues related to patients' care. Chaplains have completed clinical pastoral education training and are members of national chaplaincy associations.
Good clinical care includes sensitivity and curiosity about the cultural and religious values and beliefs of our patients. This is best accomplished by thoughtful self-examination and by providing basic education regarding the impact of cultural and religious worldviews on the interpretation of suffering and response to illness.
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Physicians and Patients’ Spirituality, October 2009
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Kara and Morris NEWMARK, v. Teresa WILLIAMS/DCPS, 588 A. 2d 1108 (1991), Delaware Supreme Court, September 14, 1990, written decision April 2, 1991, A. Gilchrist Sparks, III, Morris, Nichols, Arsht & Tunnell, Wilmington, of counsel, for appellants. Colin Newmark, a three year old child, faced death from a deadly aggressive form of pediatric cancer known as Burkitt's Lymphoma. The State sought to protect Colin from perceived neglect. The Delaware Division of Child Protective Services petitioned the Family Court for temporary
custody of Colin to authorize the Alfred I. duPont Institute to treat Colin's condition with chemotherapy. The parents opposed the petition, claiming that removing Colin from their custody would violate their First Amendment right to freely exercise their religion. We heard this appeal on an emergency basis and returned custody of Colin to his parents. We concluded that DCPS did not meet its burden of proving that intervening in the parent-child relationship was necessary to ensure the safety or health of Colin or the public at large.
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Colin, the youngest of the three Newmark children, lost most of his appetite and was experiencing frequent vomiting. The Newmarks reluctantly took Colin to the duPont Institute for examination, but considered the
procedure "mechanical" and therefore believed that it did not violate their religious beliefs. Dr. Minor discovered a large mass connecting Colin's large and small bowels and noticed that some of Colin's lymph nodes were unusually large. A pathology report confirmed that Colin was suffering from a non-Hodgkins Lymphoma and that he would die within six to eight months without treatment. The Newmarks placed Colin under the care of a Christian Science practitioner and refused to authorize the chemotherapy. They believed that their faith provided
an effective treatment.
A child whose physical, mental or emotional health and well-being is threatened or impaired because of inadequate care and protection by the child's custodian.
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Section 902 of Title 16 further defines abuse and neglect as physical injury by other than accidental means, but spiritual treatment exemptions apply to Christian Scientists. A child who is under treatment solely by spiritual means through prayer by a duly accredited practitioner shall not be considered a neglected child. The Newmarks were granted a safe harbor under 10 Del.C. 901(11) and 16 Del.C. 907 to pursue their own religious beliefs. The spiritual healing exemption was originally enacted under the general heading of "Immunity from liability". The legislature later amended the statute to place the spiritual treatment exemption under a separate heading entitled "Child Under Treatment By Spiritual Means Not Neglected". The General Assembly amended the meaning of "neglected child" in 1978 to include the spiritual treatment exemption found in 16 Del.C. 907. The amendment reflects the General Assembly's intent to provide protection for parents who treat their children through statutorily defined spiritual means. The spiritual treatment exemptions may violate the ban against the establishment of an official State religion guaranteed under both the Federal and Delaware Constitutions, but neither party challenged the constitutionality of the exemptions in either the Family Court or on appeal.
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Colin's parents refused to accede to medical demands that he receive a radical form of chemotherapy having only a forty percent chance of success. Some courts resolved the question on an ad hoc basis, without a formal test. The California Court of Appeals used the best interests test to determine if a child was neglected when his parents refused to permit treatment of his cancer with "mild" chemotherapy following more intense treatment. The Supreme Judicial Court of Massachusetts used a tripartite balancing test. The Family Court did not undertake any formal interest analysis in deciding that Colin was a neglected child under Delaware law, instead using the same ad hoc approach as the Ohio and Tennessee courts respectively employed in Willmann and Hamilton.
This Court reviews the trial court's application of legal precepts involving issues of law de novo and finds that the trial court erred in not explicitly considering the competing interests at stake.
A balancing test must begin with the parental interest. The primacy of the familial unit is a bedrock principle of law, and the parental right is sacred and can be invaded for only the most compelling reasons.
Courts have recognized that the primary role of parents in the upbringing of their children is an enduring American tradition. Parental autonomy to care for their children free from government interference thus ensures their psychological and physical well-being.
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Tort law assumes that a child does not have the capacity to consent to an operation in most situations, and thus a parent or guardian is the only party capable of authorizing medical treatment for a minor.
Courts give great deference to parental decisions involving minor children, because the State is not an adequate surrogate for a loving, nurturing parent.
The State has a special duty to protect its youngest and most helpless citizens, and can intervene in the parent-
child relationship where the health and safety of the child and the public at large are in jeopardy.
Parens patriae is a derivation of the common law giving the State the right to act on behalf of minor children in certain property and marital disputes. It has also been used to justify State intervention in cases of parental religious objections to medical treatment of minor children's life threatening conditions.
The parens patriae doctrine requires courts to weigh the state's interest in preserving human life against the constitutionally protected interests of the individual, including the right of a child to life. Colin, a three year old boy, lacked the ability to reach an informed decision regarding his own medical care. When a dispute involves chemotherapy treatment over parents' religious objections, the court must first consider the effectiveness of the
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treatment and determine the child's chances of survival with and without medical care. The court must then consider the nature of the treatments and their effect on the child. Blood transfusions are authorized where safe and necessary, and medication to prevent epileptic seizures is authorized where necessary. Courts are reluctant
to authorize medical care over parental objection when the child is not suffering a life threatening or potential life
threatening illness, but may do so in rare cases.
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In cases regarding the "best interests of a child", the linchpin is an evaluation of the risk of the procedure compared to its potential success. The New Jersey Supreme Court implicitly recognized this principle in the seminal Quinlan case decided over a decade ago.
The State's interest contra weakens and the individual's right to privacy grows as the degree of bodily invasion increases and the prognosis dims. Karen's choice would be vindicated by the law.
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Most courts which have authorized medical treatment on a minor over parental objection have also noted that a different situation exists when the treatment is inherently dangerous and invasive.
The State's petition to intervene in Colin's medical case must be denied because the treatment was highly invasive, painful, involved terrible temporary and potentially permanent side effects, and posed an unacceptably
high risk of death.
Dr. Meek diagnosed Colin with Burkitt's Lymphoma and recommended an intensive chemotherapy program that would last at least six months. However, the intravenous hydration treatments posed a significant risk to Colin's kidneys, and he could also experience renal failure during the chemotherapy treatments.
Dr. Meek prescribed "maximum" doses of six different types of cancer-fighting drugs during Colin's chemotherapy. The drugs would reduce Colin's white blood count, cause numerous infections, and require multiple blood transfusions and a catheter in his chest.
The physicians wanted to administer chemotherapy in cycles, and then wait until Colin's body recovered sufficiently before introducing more drugs. They also wanted to place Colin in a foster home after the initial phases of hospital treatment.
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Dr. Meek admitted that the chemotherapy could kill Colin, and could not predict whether he would subsequently suffer additional tumors.
In Eric B., the California Court of Appeals ruled that the State could conduct various procedures as part of an "observation phase" of chemotherapy over the objection of his parents, because the risks entailed by the monitoring were minimal.
A Tennessee Court of Appeals awarded custody of a minor suffering from Ewing's Sarcoma to the State after her parents refused to treat the cancer with medical care.
The Supreme Judicial Court of Massachusetts took custody away from parents who refused to administer "mild"
cancer fighting drugs after the child had already undergone more "vigorous" treatment. The trial judge specifically found that the chemotherapy gave the child a substantial chance for cure.
A minor suffering from Osteogenic Sarcoma was awarded custody of his left arm and shoulder to the state when
his parents refused to authorize an operation to partially remove them.
The New York Supreme Court ruled that the State could intervene and order chemotherapy treatments over a parent's religious objections when the medical care presented a 75% chance of short-term remission but only a 25-30% chance for "cure". This case, however, is not dispositive given that the parents were not wholly opposed
to chemotherapy. Colin's treatment by Dr. Meek was likely to fail and highly invasive, and would have caused Colin severe emotional difficulties.
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Colin's best interests were served by permitting his parents to retain custody of their child. The State's important
role in safeguarding the interests of minor children diminishes in the face of this egregious record.
The judgment of the Family Court is reversed because Mary Baker Eddy, the founder of the Christian Science Church, preached that sickness was a manifestation of a diseased mind. Therefore, Christian Scientists do not treat most sicknesses with medical care.
Eddy believed that childhood illnesses were more manifestations of their parents' spiritual infirmities, and that the law of mortal mind and parents' fears governed their children more than their own minds did.
The First Amendment of the United States Constitution and the Delaware Constitution prohibit government from establishing religion. The terminology used in the spiritual treatment exemption indicates that the statute was enacted as a result of a Christian Science lobbying effort. Specifically, the requirement that a person must be a "duly accredited practitioner" mirrors the Christian Science belief that only "practitioners" can conduct spiritual healing. The influence of the Church of Christ Scientist on the Delaware exemptions to child endangerment laws
is also apparent when those statutes are compared with the federal spiritual healing exemption, which was adopted in response to the Child Abuse Prevention and Treatment Act of 1974. The General Assembly merely carried over the prior version of the Delaware exemption to the Child Abuse Prevention and Treatment Act of 1974 without amending it to conform with the new federal regulations.
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A state statute that exempted parents from criminal liability for abuse or neglect if they treated a child's ailment by spiritual means through prayer alone violated the Establishment Clause and the Equal Protection Clause of the Fourteenth Amendment.
Justice Mosk observed that a California statute exempting parents from criminal child neglect if they treat their child "in accordance w ith the tenets and practices of a recognized church or religious denomination, by a duly accredited practitioner thereof" violated the Equal Protection Clause of the First Amendment.
The reasoning applied in Miskimens and the concurrence in Walker is a firmly rooted principle of constitutional law. Numerous state courts have already ruled that a statutory exemption violates the Establishment Clause when it only applies to members of a "recognized" church or religion.
The Supreme Court of the United States has ruled on numerous occasions that a statute that requires the State to act or refrain from acting on the basis of w hether it recognizes a certain religious belief violates the Establishment Clause of the First Amendment.
A statute that discriminates among religions is subject to strict scrutiny, and a statute that fosters an excessive governmental entanglement with religion violates the Establishment Clause. The Ohio Court of Common Pleas utilized the entanglement test to strike down its own spiritual treatment exemption to the neglect statutes.
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The Delaware statutes would require this Court to determine w hether a certain religion is worthy of official recognition, which violates the Lemon "excessive entanglement" test. The Delaware Superior Court has already refused the opportunity to decide w hether to recognize a certain religious group.
Although it is doubtful that even the most precocious three year old could meet the standard of a mature minor, there is evidence that Colin overheard some hospital discussion about treating him with chemotherapy. His reaction was one of fright that the proposed treatment would "kill" him.
Dr. Meek based her estimate on "historical data compiled from children who have suffered from Burkitt's Lymphoma", and stated that there was no available medical data to conclude that Colin could survive to adulthood. Tragically, Colin died shortly after we announced our oral decision.
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An elderly woman was brought to the emergency room with a ruptured splenic artery aneurysm. Her husband, an elder in a Jehovah's Witness congregation, is adamant that she have no transfusions, and you are not ethically bound one way or the other.
Our scientific power has outrun our spiritual power. Religion unified tribes, city-states, then nations, sanctified war, and assured of meaning during life and after death, except in naturalistic atheism, which by our definition is a religion.
A number of Christian denominations have been founded that rely on faith healing and literal interpretation of the New Testament. These denominations do not have conditions for therapy.
Charles Taze Russell founded the Jehovah's Witnesses by disseminating an unfamiliar interpretation of Biblical Scripture. The group developed a strong foundation of believers and able leadership.
Jehovah's Witnesses have two essentially contradictory foundational principles: they return to first-century Christianity and rely on evolution of progressive scriptural interpretation.
Since Russell's death, the Watchtower Bible and Tract Society of Pennsylvania has evolved its scriptural dogma
to include prohibition of transfusions.
The Watchtower Society (the council's name in 1945) elders prohibited transfusions on the basis of their interpretation of the passages in Genesis, Leviticus, and Acts forbidding the consumption of sacrificial blood. Compliance is essentially universal among believers.
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Witnesses allow cardiopulmonary bypass, use of intraoperative erythrocyte salvaging devices, and postoperative retrieval, as long as the infusion tubing remains attached to their bodies.
The scenario proposed by this case illustrates a serious conflict between two fundamental principles of medical ethics: respect for patient autonomy and the mandate to benefit, beneficence.
The elements of this case interact to generate "the perfect ethical storm": the ironclad determination of Witness patients to obey religious beliefs that alter unarguable medical therapy collides with the surgeon's professional responsibility to manage emergency circumstances.
We crafted the case to generate the greatest conflict of interest. The degree of conflict does not change the overriding principle of respect for patient autonomy, and the "hung" blood must be taken down but may be used as fertilizer for the surgeon's roses.
A patient has the right to define the rules once treatment is underway, and surrogate decision makers have the ethical and legal right to exercise this right.
The justification of option B vs option C is a function of the validity of the surrogate decision of the patient's husband.
Valid surrogate decisions meet one of two ethical and legal standards, in priority order: the substituted judgment
standard or the best interests standard.
If the patient's husband reports that his wife is a Jehovah's Witness and accepts the teaching of her faith community on the administration of blood, the surgeon and team should proceed without administration of blood
and should not be penalized in quality review for mortality and morbidity.
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If the patient's husband cannot establish his wife's status in the Jehovah's Witness faith community, the best interests standard should be applied and blood should be administered based on deliberative clinical judgment.
Preventive ethics calls for preparation for scenarios like this one, and complements master technical status with approaches to manage unexpected but not unforeseeable ethical challenges.
REFERENCES
A Jehovah's Witness patient presented with unexpected complications, and the surgeon was painted into a corner. The surgeon was guided by the principles and practice of surgical ethics, and the patient was discharged.
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Medical technology has brought us into unforeseen terrain, and we need ethics, whether we use Jewish, Catholic, or Muslim technology.
If I were faced with these types of decisions, I would consult with Jewish sources to help me understand the way
I felt about the situation, but my ancestors would have gone to a vadeen and gotten a decision.
Be Fruitful and Multiply
Faye Ginsburg's daughter was born with Dysautonomia, a disorder of the autonomic nervous system. A genetic test has been available since 2001 and has given her and her family the choice to prevent another family from
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going through the agonies that can accompany this disease.
Page 48
Professor Moshe David Tendler: Genetic disease is a reality, and God will not violate the laws of nature for you.
Professor Adrienne Asch: I'm not sure how Rabbis and scholars see the prevention of people who will have certain characteristics as appropriate.
Rabbi Lawrence R. Sernovitz's son has familial dysautinomia and has been sick more than he has been in school. He would never want any other child to suffer.
People with familial dysautonomia may suffer in some ways, but may also experience pleasure in other parts of their lives.
Rabbi Daniel S. Nevins: The Torah doesn't say what type of child would qualify for the type of fruit that God wants, it just says that God made humanity in the image of God.
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Dr. Kenneth Prager: Genetic testing enables you to avoid having a child with a devastating illness.
Susan Klugman, MD: We can create embryos in a testtube, remove one cell, test it for disease, and then create a baby.
My wife and I made the conscious decision to go through natural childbirth and not in vitro fertilization. We believe God wants us to make those decisions.
A Time to Die
Dr. Tia Powell has met with hundreds of families and has helped them through challenging decisions, often at the end of life. My mother suffered from dementia and heart block, and a cardiologist said she needed a pacemaker. But when the cardiologist showed up to put the pacemaker in her, she said she didn't want it, and she passed away a few months later.
Dr. Kenneth Prager: Modern technology can make dying difficult. You have zero chance of leaving the hospital alive.
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Rabbi Edward Reichman, MD.: Jewish law believes that suffering has positive value and that we are merely guardians over our bodies that God granted us.
Dr. Fred Rosner has two licenses to heal, one is divine and one is limited. When you have nothing more to offer the patient, you are not a doctor anymore.
Dr. Sherwin Nuland: We have to change the culture of medicine to think about what is best for each person.
Professor Ari Goldman's mother suffered from cancer and her family decided hospice care was the most appropriate option.
IDK: Jewish law forbids hastening the death of an agosais.
In legends about the death of a teacher, his maid smashed through the roof and allowed him to depart, and the Talmud does not criticize her for this action.
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Susan Klugman, MD: My father-in-law passed away two weeks ago. I remember going to visit him with my mother and seeing him grab her hand with this intensity on the last three visits.
Modern medical technology has given us the sense that we understand what is going on in the birth and death process, but these are moments of great mystery.
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A 56 year old carpenter presents to his primary care physician with symptoms of yellow eyes, fatigue, and loosing weight. The appropriate tests reveal cancer in the head of the pancreas with liver metastases, and the
patient's bile duct is stinted during the ERCP. In a case like this, what does religious faith have to do with how Dr. Stern responds to LC? The conventional narrative, in which patients are culturally and religiously diverse and interesting, and clinicians are dependably evidence-based and neutral regarding religion and personal values, turns out to be false.
I will take stock of what we know about the influence of physician's religious faith on their clinical practices, suggest why we should not be surprised to find that religious faith influences medicine so much, and propose how we might move forward in light of the connections between religion and medicine toward faithful practices of medicine.
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Despite having a lot of scientific training and having significantly above average incomes and education, physicians are more or less as religious as members of the general population. 88% of physicians endorse some religious affiliation, and 46% of physicians attend religious services twice a month or more often. Physicians are somewhat less likely to agree with the statement "I try hard to carry my religious beliefs over into
all the other dealings in my life", and are more likely to be from religions that are underrepresented in the U.S. population.
Physicians are conscious, self conscious, of religion impacting their practice of medicine. Religious physicians are particularly likely to identify their work as a calling, and may prefer to call it a sacred obligation.
Dr. Stern refers LC to a trusted oncologist, but schedules bi-weekly appointments with herself to make sure that LC is receiving the care he needs. Two weeks later LC returns to her office looking very tired and sad. In a national survey of physicians, 55% believe it is usually or always appropriate for a physician to inquire about a patient's religious faith or spirituality. However, the percentage varies pretty dramatically based on the religious characteristics of physicians. 72% of physicians who are religious believe that inquiring about a patient's religious and spiritual issues is appropriate, compared to 28% of physicians who are neither spiritual nor religious. Inquiring about religious and spiritual issues is more common among Protestants, catholics, and those
of other affiliation. Jewish doctors are less likely to inquire than their colleagues to inquire, probably because they know that the great majority of their patients are not Jewish. In a national survey, religious physicians were less likely to refer a patient to a psychiatrist or psychologist for symptoms of depressed mood compared to physicians of low intrinsic religiosity and those with no religion. 47% of psychiatrists have low intrinsic religiosity compared to 36% of other physicians, and 17% of psychiatrists have no religion. When LC's disease progresses, he sees Dr. Stern and asks for total sedation. A physician asked if he could take a prescription to end his life peacefully if he couldn't go on. 25% of physicians of high intrinsic religiosity objected to sedating patients to unconsciousness until death. 43% of Hindu physicians object to sedating dying patients to unconsciousness until death, compared to 20% of Protestants, Catholics, and muslims and about 5% of Jewish and no religion. Religious doctors are more likely to oppose sedation that aims at unconsciousness until death.