AMA Journal of Ethics^®

Case

Mr. Washington is a 38-year-old electrician. He arrives at the office of Dr. Martin, his psychiatrist, after a recent hospitalization for his first episode of mania. He describes a history of several depressive episodes in the past (though he never sought treatment). He says he has never abused drugs and has had no psychotic episodes.

Seven years ago, Mr. Washington reports, he experienced a dramatic conversion. Before this conversion, he was a heavy gambler and often abused his wife and 2 children. "Ever since I got saved, I haven't gambled, and I've been trying to be good to my family," Mr. Washington says. His wife, significantly less religious than he, agrees that the change was dramatic, but his heavy involvement with a local Pentecostal church since that time has been a source of tension in their marriage.

The manic episode occurred 3 weeks before, when Mr. Washington gradually noticed himself feeling energetic, very optimistic, "like I could take on the world." He began several projects at home, working long into the night, "but I still felt great in the morning and had no problem going to work." He also describes praying long into the night, and, on more than 1 occasion, he believes he heard God telling him to follow certain courses of action. For example, he sensed God directing him to give a large sum of money to a single mother in his church, and, when his wife discovered the money missing from their bank account, she was alarmed and insisted he see a doctor—"You've gone way too far this time," she said.

He was hospitalized for several days and started on a regimen of a mood stabilizer and antipsychotic medication. During his third day in the hospital, one of the nurses heard him repeating unintelligible syllables for several hours. After discussion with his wife, Mr. Washington was discharged with orders to follow up at a clinic.

At Dr. Martin's office, Mr. Washington appears significantly subdued. He makes good eye contact, and is candid and cooperative, not displaying any pressured speech or tangentiality. In attempting to assess Mr. Washington's insight, Dr. Martin asks, "So tell me, Mr. Washington, what do you understand about why you were hospitalized?"

"You know, doctor, this is something I've been thinking and praying a lot about, and, to tell you the truth, I realize this might sound kind of weird, but I think God allowed me to get sick so that I could share the gospel with you. In talking with you, it doesn't sound like you know the Lord. I may be sick, but I've gotta tell you! Jesus has made all the difference in my life. He's made me happy and given me peace inside, and I haven't wanted to gamble or hurt my wife or kids ever since I gave my life to Him. Tell me, Mr. Washington, have you ever accepted Jesus as your Savior?"

Commentary 2

Dr. Martin has no control over Mr. Washington's initiation of a conversation about faith. Thus the ethical question we must address has to do with Dr. Martin's responsewith the appropriateness of allowing this patient to share his faith with his therapist. Simply put, "Is there room for religious discussion within the practice of medicine?"

Responding to Patients Who Share Their Faith

Dr. Martin could ethically choose between several options:

1. He could say, "Mr. Washington, you need to understand that I am a psychiatry professional. I am happy to treat your mental health, but I will not get involved in your religion."
2. He could say, "Mr. Washington, I recognize that your faith is very important to you and that it has been of significant help to you. You should understand that I, too, have my own faith (or I am not a man of faith) and just as I am not trying to change your faith, I would request that you not try to influence mine. I see the value of your faith to you and would encourage you to continue to practice it."
3. Alternatively, "Thank you. I suspect I am not personally interested in your faith, but it would help me understand you better and therefore better care for you if you did take a few minutes to explain your faith to me.
4. Finally, "Thank you. I, too, have been on a personal search for further meaning in life and I would be interested in hearing about your beliefs. It is not appropriate, however, for that to be part of our professional relationship, especially when your insurance company is paying for our time together. I would prefer to talk to your pastor to learn more about your beliefs."

Some preliminary observations are foundational to this physician's choice.

• Any response must be grounded in truth. Dr. Martin must be honest and straightforward in his response. He must not feign interest in Mr. Washington's faith in a way designed to manipulate. If he has no interest he must refuse to pursue the discussion. If he feels that Mr. Washington's church involvement is harmful to his planned treatment program, he must candidly state that. Mr. Washington may find that grounds to request a transfer of care and, in that case, Dr. Martin must comply.

• A treatment plan will, when possible, utilize many of the people and institutions influential in the patient's life. Dr. Martin should recognize that, after his conversion experience, Mr. Washington's life has significantly improved. It has not all been positive, however, inasmuch as it was through the church that the present exacerbation occurred.

It would appear likely that no matter how Dr. Martin responds to Mr. Washington's request, Mr. Washington will continue to be involved in the church. It would seem advantageous therefore to consider how to make Mr. Washington's church involvement be positive. Many churches employ counselors or have members of the pastoral staff trained in counseling. Dr. Martin may find them a useful adjunct within his therapeutic plan. Other churches foster "men's accountability relationships" for people with a variety of behavioral or social problems.

It also seems clear that there is growing tension between Mr. Washington's church and his wife. These are apparently the major influences in his life, and, for both of them to continue to have optimal beneficial effect, this tension must be dealt with. Dr. Martin should try to help Mr. Washington recognize that, though his wife does not share his faith, she can be a reality check for him.

It is increasingly difficult to distinguish between matters of body (neurochemistry), soul (the traditional domain of the psychiatric analyst), and spirit (matters of faith). Multiple studies show a genetic or biochemical basis for an interest in religion (the religion gene). Recently Koenig et al have published a twin study demonstrating a genetic influence on religious choices.¹ Do those studies contradict the validity of religious experience? No more so than would the certainty that one is genetically equipped to excel in math exclude someone as a Nobel laureate for discoveries made. Mr. Washington's biochemical imbalance may have predisposed him toward religion, but that should have no bearing on the validity of his experience with his religion. An area like this of genetic predisposition may be viewed as an asset in constructing a therapeutic plan for any patient. Without question, genetic predispositions can also lead to destructive involvements, and that is where discernment is needed.

If Dr. Martin is sincerely interested in pursuing Mr. Washington's faith for his own sake, he must be careful not to do this "on company time." He would also be well advised to speak to someone other than his patient about this to avoid any conflict of interest within their professional relationship.

Recommendations

Dr. Martin must decide whether, in his professional judgment, Mr. Washington's church involvement offers more positives than negatives. If he feels that it is essentially harmful for Mr. Washington, he must candidly say so and indicate that he will not be supportive. If Dr. Martin is open to the possibility that Mr. Washington's church involvement is helpful to him, he may choose then to find out more about the church and be able to work within the church structure to help Mr. Washington. Dr. Martin should also try to smooth out the relationship between Mrs. Washington, Mr. Washington, and the church. If Dr. Martin has a sincere interest in Mr. Washington's faith, he needs to pursue that outside of business hours.