Religious issues in the capacity evaluation

Religious Issues in the Capacity Eva&w&km Shimon Waldfogel, M.D. and Stacey Meadows, Esq. The authors explore the difficulties present in the capacity evaluation of patients with strong religious beliefs. The article reviews the legal protection for treatment refusal on religious grounds as well as psychiatry’s approach to religion. Clinical cases encountered in an urban hospital are presented to highlight how the conflicts among psychiatric, religious, and legal issues can be resolved. Suggestions are made for incorporating an exploration of religious values into the capacity assessment. Abstract: Introduction Patients who refuse medical treatment on the basis of their religious beliefs present a complex and challenging task for consulting psychiatrists called upon to assess their capacity for medical decisionmaking. Although the psychiatric literature has rarely addressed such religiously based refusal of medical treatment [ll, the authors’ clinical experience in an urban university hospital indicates that such refusal is far from rare. The frequency of religiously based treatment refusal is not surprising given the important role that religion plays in the lives of most Americans [21 and the frequency with which psychopathology is manifested with religious content 131.For many people, religious beliefs are a central component of personal identity, and exert particular influence on their adaptation to major life events such as birth, death, and illness [4,51. In the medical setting, religious beliefs can affect patients’ understanding of, emotional response to, and ability to cope with physical illness. For the majority of patients, religious beliefs do not conflict with the treatment proposed by their physicians, and can serve to enhance their ability to cope with Department of Psychiatry and Human Behavior, Jefferson Medical College (S.W.) and Thomas Jefferson University, Philadelphia, Pennsylvania (S.M.) Address reprint requests to: Shimon Waldfogel, M.D., Department of Psychiatry and Human Behavior, Jefferson Medical College, 1020 Sansom Street, Philadelphia, PA 19107. General Hospital Psychiatry 0 1996 Elsevier Science Inc. 655 Avenue of the Americas, 18, 173-182, New York, medical illness. However, in some cases, religious beliefs can lead to the refusal of recommended medical care, including decisions about critical interventions such as resuscitation, transfusion of blood products, or amputations. Understandably, physicians who are convinced of the necessity of such procedures may question the capacity of patients who refuse them. Consulting psychiatrists often lack appreciation for the dynamic references of religion in the arena of medical decision making, as well as the legal issues implicated in religiously based treatment refusal. This is due, in part, to the fact that assessment of patients’ religious values is often overlooked during residency training [61. The failure to explore the influence of religious values on patient decision making during the capacity evaluation can lead to a number of adverse consequences, including mistaken or incomplete assessment of capacity; the failure to recommend therapeutic interventions to remove barriers to capacity and enhance coping mechanisms; and the failure to recognize maladaptive reliance upon religion and provide appropriate interventions. Many problems and pitfalls are inherent in the attempt to reconcile religious, medical, and legal issues that affect the evaluation of the patient’s capacity to make medical decisions. Below, cases encountered in the authors’ practice are reviewed to highlight how such conflicts might be resolved. Suggestions are made for incorporation of an exploration of religious values into the capacity assessment. Informed Consent and the Assessmmt of Capacity The doctrine of informed consent is fundamental to the relationship between physician and patient, and 173 1996 NY 10010 ISSN 01638343/96,‘$15.00 PTI %H6~-11~3(96~00003-5 S. Waldfogel and S. Meadows has long been ingrained in the Anglo-American legal system [7]. The principle establishes a duty on the part of the physician to disclose to the patient the risks and benefits of, and alternatives to, particular medical treatments 181. The steady expansion of the doctrine of informed consent over time illustrates the pervasive concern of American jurisprudence with the individual’s right to be free from the conduct of others that affronts bodily integrity, privacy, and individual autonomy [91. Such individual rights have become the common law and constitutional underpinnings of the doctrine, and underscore the law’s recognition of the ethical principle of autonomy. In fact, the law presumes that all adults are competent to fully participate in medical decision making [lo]. The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1111 has recommended that medical institutions formulate policies for assessing patients’ capacities to make medical decisions and obtaining their informed consent. In those situations in which a patient’s ability to participate in the informed consent process appears to be impaired, a psychiatrist is often consulted to make a determination of the patient’s capacity A patient who is judged to be incapacitated loses the right to make decisions regarding treatment, and decision making must be carried out by a surrogate, who may be the next of kin, a proxy appointed through an advance directive, a legal guardian, or a judge. Thus, the assessment of capacity is a critical juncture in the patient’s medical care, with the potential to influence all future relations between the patient and his health care providers. Neither courts nor physicians have agreed upon any single test of capacity In practice, an amalgam of criteria is usually applied, including whether the patient evidences a choice concerning treatment; whether such choice is “reasonable”; whether the choice is based on “rational” reasoning; and whether the patient has a generalized ability to understand [91. Appelbaum and Gutheil [121 have identified various components involved in the ability to make medical decisions, and cognitive variables that can affect them. In view of the wide variation in courts’ rulings on capacity, they suggest that psychiatrists assess all of the following: 1) communication of a choice, 2) factual understanding of the issues, 3) appreciation of the situation and its consequences, and 4) rational manipulation of information [121. Recognizing that capacity can 174 vary over time, it has been suggested that the capacity determination be viewed as a process rather than as a discrete event 1131. Thus, the determination of capacity may require more than one assessment by the consulting psychiatrist. Many courts, including the U.S. Supreme Court, have upheld the right of the competent patient to refuse unwanted medical treatment, even where death might ensue [14-161. The refusal of treatment by a patient with decisional capacity must be honored, regardless of the basis upon which it is made 1171. The Cruzan Court 1161was the first to affirm an individual’s constitutional liberty interest in freedom from unwanted medical treatment. This decision added a federal constitutional guarantee to the legal underpinnings for informed consent discussed above. However, courts continue to rely upon compelling countervailing state interests in determining whether to override patients’ rights to refuse life-prolonging treatment, including the preservation of life, prevention of suicide, prevention of the dependency of minors on the state, and protection of the integrity of the medical profession 1181. In spite of many judicial decisions and legislative attempts to address the “right to die,” it remains an area of frequent litigation and little definitive legal resolution [9]. Nevertheless, the widespread acceptance of advance directives and the passage of natural death statutes have fostered societal recognition of patient autonomy in all aspects of patient decision-making. Legal Protection for Treatment on Religious Grounds Refusal American society has long recognized the fundamental importance of freedom of religious belief to a democratic system of government, and has accorded the free exercise of religion constitutional protection under the First Amendment. Though freedom of belief is virtually absolute, courts have allowed restrictions on conduct carried out in pursuit of religious beliefs where compelling countervailing governmental interests would be served 1191. The Supreme Court’s expansive protection of religious belief is noteworthy: virtually any belief that is sincerely held, and within the practitioner’s scheme of things, religious, is constitutionally protected. In searching for an appropriate definition of religion, the Supreme Court has relied, in part, upon the writings of the progressive theologian Paul Tillich, and his view that religion is grounded in an individual’s “ultimate concern,” found in a Religious Issues in the Capacitv Evaluation particular human’s experience, rather than in some objective reality [ZOJ. Justice Douglas, commenting on the nature of religious beliefs embraced by the constitutional protection of religious free expression, stated: Men may believe what they cannot prove. They may not be put to the proof of their religious doctrines or beliefs. Religious experiences which are as real as life to some may be incomprehensible to others. The Fathers of the Constitution were not unaware of the varied and extreme views of religious sects, of the violence of disagreement among them, and of the lack of any one religious creed on which all men would agree LZll. Over time, the meaning of religion has been gradually expanded by the Supreme Court to encompass deviant Christian sects, non-Christian religions, nontheistic belief systems, essentially moral views and even nonsectarian metaphysical beliefs [201. Concomitantly, First Amendment protection of religious expression has been expanded to include not only religious practices of well-recognized religious organizations, but also idiosyncratic practices of recognized religious groups and individual religious practices that are not part of any recognized theology 1221. In light of these legal trends, the burden on physicians and institutions attempting to challenge the religiously motivated refusal of treatment by the patient with capacity for medical decision-making is substantial, and should only be undertaken following full consideration of the abiding respect with which American society treats religious beliefs. Moreover, challenging a patient’s capacity in light of such religiously motivated refusal must be seen as a potential violation of a panoply of legal rights, including both common law and constitutional privacy rights, as well as rights of religious expression protected by the First Amendment. Psychiatry’s Approach to Religion It is critical for the capacity assessment to address the patient’s beliefs, which comprise the context in which information about informed consent is received and processed. because of their training in the dynamics of thought processes, psychiatrists are in a unique position to evaluate the way in which patients’ beliefs affect their decision-making. However, the conceptualization of religion by psychiatry in general, and the individual psychiatrist in par- ticular, will have a profound effect on this evaluation. Psychiatry’s approach to religion significantly affects the ability of the psychiatrist to distinguish pathological, maladaptive, or dysfunctional modes of religious expression from normal, adaptive, and functional modes. Since determination of the existence of a mental disorder is central to the determination of capacity, diagnostic clarity in this regard is essential. Mental health professionals have tended to either ignore or pathologize the religious and spiritual dimensions of patients’ lives [23]. Unfortunately, this is supported by psychiatry’s theoretical, methodological, and metaphysical commitments, which can blind psychiatrists to their patients’ religious experiences and preoccupations J241. The failure to address religion in the therapeutic or consultation setting is problematic. In addition to the demonstrated lack of training of residents in this area [6] and minimal research into religious variables in the person’s psychological life 1251, the theoretical and diagnostic classification systems of psychiatry contribute to the lack of appreciation of religion among mental health professionals, and as such, impinge upon the determination of capacity of the religious patient [26J. This dearth of exposure to the religious concerns of patients necessarily limits physicians’ understanding of the role religion may play in medical decision- making, and prevents the incorporation of religious themes into evaluation and treatment. The consulting psychiatrist must be prepared to encounter beliefs that are unusual, irrational, or a manifestation of a mental disorder [271, The patient who refuses treatment on religious grounds can appear to lack appropriate information-processing mechanisms. Therefore, the expression of religiously motivated behavior may cause the psychiatrist to diagnose a psychopathology, and lead to an ultimate designation of incapacity. In order to determine whether the patient who is refusing medi- cal recommendations due to religious beliefs suffers from a mental disorder that impedes his ability to make an informed decision, the psychiatrist must be aware of three categories of potentially confounding problems: 1) issues relating to diagnosis, 2) issues relating to the interaction between physician and patient, and 3) issues relating to treatment. Diagnosis Often central to the assessment of capacity is the determination ing delusional of whether the patient is experiencthinking that is interfering with the 175 S. Waldfogel and S. Meadows rational manipulation of information. However, the determination by a psychiatrist that particular supernatural and religious beliefs are delusional may be more a matter of cultural conflict than “dispassionate scientific examination” 1281. Psychiatrists employ a simplified distinction between religious beliefs and psychotic delusional thinking involving religious content, which can result in the psychiatrist confusing a particular expression of religion with psychopathology 1231. The diagnostic difficulties can be better understood by reviewing the criteria for delusional disorder in DSM-IV: “A false personal belief based on incorrect inference about external reality and firmly sustained in spite of what almost everyone else believes and in spite of what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (i.e., it is not an article of religious faith)” [29]. Two of the central features of the definition are particularly problematic: the believability of the expressed beliefs and the group context of the beliefs. The Believability of the Expressed Beliefs. Medicine is generally believed to exemplify a scientific, “rational” view of reality (i.e., based upon empirical evidence), whereas religious beliefs are based on faith. The inherent divergence in these approaches may yield fundamentally different ways of framing information in the decision-making process. For example, beliefs about the nature of death vary significantly among individuals. Though death is frequently regarded by physicians as an undesired outcome, to be avoided whatever the cost, it is viewed within certain religions as an accepted transition to an afterlife. A recent Gallup poll found that 43% of Americans believe in life after death, and 17% report contact with a person who has died 121. The belief in an afterlife mitigates the absolute undesirability of death; for some, acceptance into the benevolent embrace of God may be preferable to certain forms of earthly suffering. Religious individuals who rely on the Bible as truth, and patients preferring to die in accordance with their understanding of God’s will, may well be viewed with skepticism by scientifically oriented physicians who question the validity of patient decisionmaking based on such religious concepts. The capacity of a patient may be particularly suspect if his beliefs seem extreme to the physician, or are not part of a mainstream religious denomination with which the physician is familiar. Confronting an in- 176 dividual’s beliefs, or attempting to coerce him to act in a manner that is contrary to his religious dictates, may subject him to significant psychological harm. Such an exercise of paternalism by the physician is antithetical to the ethical concepts of autonomy and nonmaleficence. Beliefs as Part of a SubcuZture. Religious beliefs are intensely personal, even when expressed within the context of an accepted religious creed. However, individual beliefs may so deviate from accepted religious canons that they are considered heretical. When the psychiatrist is not sufficiently informed about the belief to make a determination of capacity, consultation with a member of the patient’s faith community, or other knowledgeable source, can be helpful in clarifying the religious issues involved. It may occasionally be advisable to include a religious representative in the capacity evaluation, but the psychiatrist must be cognizant of the patient’s vulnerability, which can cause him to be more susceptible to pressures from others with strong religious convictions. The patient may experience severe distress in attempting to resolve the conflict between undergoing a recommended medical treatment and foregoing such treatment based upon religious proscriptions. Such patients may have difficulty expressing a decision, or experience overwhelming anxiety, which can compromise the decision-making process. The psychiatrist must be aware of the potential for such conflict, and assist the patient in clarifying his own desires regarding medical treatment. It has been suggested that religious traditions only be considered in the context of the wishes of the individual being treated, and not in order to satisfy the beliefs of outside groups 1301. Patients’ beliefs can be a manifestation of psychopathology, and the refusal of recommended treatment can be a symptom of mental illness. On the other hand, the consulting psychiatrist must be sensitive to the fact that patients can assessinformalions from multiple theoretical perspectives. Though some commentators have suggested that capacity should be judged in part on whether the patient’s choice is based on “rational reasoning,” the consulting psychiatrist must be able to distinguish between irrational thoughts that reflect diminished capacity, and those that reflect merely a different cultural or religious orientation. Since James 1311first noted in his seminal work, religion can be both healthy and unhealthy [31]. Distinguishing between normal and pathological religious expression can be a complex undertaking for Religious Issues in the Capaoty Evaluation the psychiatrist. Because of the nature and emotional intensity of religious beliefs, focusing on the content of the expressed beliefs, the presence of grandiose or paranoid delusions, or perceptual distortions, is often not helpful in making this distinction. Areas to explore in clarifying whether religious content is a manifestation of psychopathology include the following: 1. The presence or absence of severe psychopathology in other domains of the person’s life 2. The temporal relationship of the religious content to clearly diagnosable psychiatric illness 3. The duration the patient has held the particular beliefs. Are the beliefs part of a recent “conversion?” Are they an intensified response to the stress of medical illness? Is the patient experiencing regression manifested by religious themes, in the face of medical problems? 4. The patient’s perception of the origins of the beliefs, their function and their consequences in interpersonal relationships and daily functioning 5. How the religious issues relate to the patient’s psychodynamics. What role does religion serve in the patient’s psychological defenses? 6. The developmental stage of the patient’s religious dimension 7. The relationship of the patient’s religious beliefs and practice to those of the larger community to which he feels an affinity [32-361 The psychiatrist about the role that life, and the beliefs community, in order must be informed religion plays in and practices of to make this latter sufficiently the patient’s the religious assessment. Interaction Between Patient and Psychiatrist Two aspects of the interaction between the patient and the psychiatrist may have an influence on the psychiatrist’s ability to accurately determine the patient’s capacity: the patient’s perception of psychiatry and the psychiatrist’s countertransference issues. The Patient’s Perception of Psychiatry. The degree of cooperation of the religious patient with psychiatric evaluation may be related to the patient’s perception of psychiatry as antireligious, or unable to encompass religious expression. The patient may choose not to disclose the religious beliefs that underlie refusal of treatment, fearing that he will be misunderstood by the psychiatrist or con- sidered “crazy.” Appelbaum and Cutheil [221 have noted that physicians assessing capacity should attempt to encourage patients to “do their best”; however, it may be difficult for a religious patient to do his best when being evaluated by a psychiatrist who is perceived to be, or is in fact, openly antagonistic to the patient’s religious beliefs. As Westmeyer [371 suggests, in the therapeutic context, it may be beneficial for the physician to receive input from individuals who are culturally and religiously similar to the patient, such as clergy or other members of the patient’s faith community. This, of course, must be counterbalanced against the need to avoid coercion of the patient by individuals with their own religious agendas. Countertransference. Psychiatrists are significantly less religious than the general population and may be influenced by their own countertransference issues in this area [381. This can be a significant obstacle to psychiatric exploration of the patient’s religious beliefs. Braun 1391argue that mental health professionals may be unable to assist religious patients within their religious frame of reference because they are unable to operate within that context. He notes that countertransference forces “may keep a therapist further embedded in barren, inaccurate theological notions and a sterile fund of knowledge from which to draw interpretations and understanding.” Treatment As discussed further below, physicians have an ethical obligation to remove barriers to capacity in the context of medical decision making. In addition, the consultation process may reveal areas in which the patient may benefit from further therapeutic intervention. Accordingly, the psychiatrist may be in a position to offer suggestions about treatment. Every effort should be made to support the patient’s coping resources, including his religiious convictions. When religion is central to the patient’s world view, choosing a psychologically based modality that ignores religious values is a biased approach [401. For a more detailed discussion of the role of religion in the treatment of medical patients, see Waldfogel and Wolpe [411. The following casesillustrate how the evaluation of capacity becomes a point of convergence for legal, clinical, and religious concerns, and how potentially problematic issues for the consutting psychiatrist can be resolved. 177 S. Waldfogel and S. Meadows Case Studies Case 1. Mistaken Determination of Incapacity MS L was a 45-year-old female who presented to the emergency room complaining of extreme weakness, which she attributed to someone trying to poison her. She was found to have significant renal failure, with a creatinine of 13.5 mg/dl, BUN of 117 mg/dl, and hemoglobin of 4.4 g/dl. She was admitted to a medical service, where her attending physician recommended a blood transfusion. MS L refused to receive any blood products, claiming that she was a Jehovah’s Witness and that blood transfusions were against her religious beliefs. During her hospitalization, MS L was often hostile towards the staff because she believed they were trying to harm her. Furthermore, she believed herself to be an “empath,” with the ability to contract other people’s illness and make them well. A psychiatric consultation was requested to assessMS L’s capacity to refuse treatment. She was reluctant to undergo psychiatric evaluation, and insisted that she had no psychiatric problems. Due to the patient’s psychosis, the psychiatrist determined initially that she lacked capacity for medical decision-making regarding blood transfusions. The following day, however, she was reevaluated by her attending physician and received a more extensive psychiatric form an adaptive response to severe medical illness. Although her refusal of blood was consistent with the teachings of the Jehovah Witness church, her idiosyncratic beliefs about being an empath and concern that the staff was trying to harm her had led the initial psychiatric consultant to conclude that she was delusional, i.e., she was expressing a false, irrational belief that was not part of a subculture. Though her beliefs did appear to incorporate some psychotic content, this fact was later deemed insufficient to invalidate her right to make a medical decision about blood transfusion. In spite of her delusion, she was able to process the relevant medical information consistent with her religious framework and communicate a decision that reflected an appropriate manipulation of such information. MS L understood her illness from a spiritual, rather than a medical perspective, and her decisionmaking reflected the particular way in which she conceptualized the medical information about her illness and the necessary treatment. For her, as for many Americans who believe in an afterlife, physical death was merely a transition to an afterlife in which she would be held accountable for her behavior in this life. The hospital staff acknowledged her capacity to refuse blood products; she did, however, consent to an alternative treatment, the administration of erythropoietin. assessment. Although she maintained no formal affiliation with the Jehovah’s Witness church, MS L espoused its beliefs in an appropriate manner, and said she had asserted them in previous medical situations. She believed in an afterlife in which she would be held accountable for her sins on earth, including the acceptance of blood products from others. She was able to understand her illness, as well as the consequences of refusing treatment, although she persisted in explaining the empathic origins of her illness. Following this consultation, the psychiatric consultant changed her assessment, and determined that MS L was capable of decision-making with respect to blood transfusions. Subsequent psychiatric reevaluation revealed that MS L had become a Jehovah’s Witness during her late teens, after having been a substance abuser. Although she had not been an active member of the Jehovah’s Witness Church, she seemed to possess an integrated belief system, which satisfied the basic legal definition of religion and gave rise to certain legal protections. Her beliefs about her empathic powers, albeit delusional, allowed her to 178 Case 2. Acceptance of Treatment Religious Grounds on MS C was a 47-year-old female who had been suffering from generalized seizures since age 15. Magnetic resonance imaging (MRI) of her brain revealed a lesion in the temporal lobe, and surgical removal was recommended. Her attending physician was aware of her strong involvement in her religious community, and her general preoccupation with religious themes. Knowing of the author’s (SW) interest in religion and medicine, the attending physician requested an informal evaluation to assess the patient’s perceived “hyper-religiosity” in light of her seizure disorder. During the evaluation, MS C explained that she was very involved in her church community and felt that God played an important role in her life. She readily accepted the recommended surgery, stating that it was God’s will that she had gotten sick, and also God’s will that her faith be tested by her ability to accept the surgery. She expressed a desire to use her medical experience to help others Religious Issues in the Capacitv Evaluation who were undergoing brain surgery. Throughout MS C’s hospitalization, there was never any suggestion that her capacity to make medical decisions was compromised, even though she articulated a religious basis for her decision making. In fact, it was apparent to MS C’s physicians that her ability to place her illness in a religious context enabled her to better cope with it. From an ethical standpoint, the reasonableness of patient decision-making should not be evaluated only when the patient is refusing treatment. Patients who are compliant may also conceptualize their illness in religious terms, and may consent to recommended treatments for “religious” reasons. Although the decision-making capacity of these patients is rarely challenged, it is apparent that the religiously based acceptance of treatment recommendations can raise the same issues regarding capacity as the refusal of treatment. Physicians should be consistent in choosing when to challenge religiously based decision-making, and not be motivated solely by the fact that a patient is refusing treatment. In either case, the patient’s religious framework should be explored and integrated into the capacity evaluation, as well as treatment, where indicated. Case 3. Removing the Barrier to Decisional Capacity MS G was a 71-year-old female who required amputation of both feet due to bilateral venous stasis ulcers. Because of her refusal to consent to the recommended treatment, consultation was requested to assess her capacity for medical decision-making. Upon examination, she was found to have an understanding of her illness, the recommended treatment, and the consequences of foregoing treatment. However, she refused to make a decision regarding amputation, stating, “God will help me make the decision . . . I pray for getting well.” The task of the consulting psychiatrist was to determine whether MS G’s refusal to make a decision, because of her reliance upon God, was an indicator of psychopathology, leading to a designation of incapacity. If so, it would have been appropriate to further assess whether therapeutic intervention could promote her capacity to make a decision, or whether substitute consent from relatives or a judge was required. Although her refusal was not based upon a particular religious prohibition, as was MS L’s, her religious identification was equally relevant to her decision-making, and deserving of consideration. Moreover, the drastic nature of the recommended treatment, as well as the grave risk of foregoing treatment, demanded a careful and complete examination of MS G’s capacity and desires. MS G’s consulting psychiatrist concluded initially that her refusal to make a decision about amputation reflected the use of religious themes as a form of denial, and saw her reliance upon religion as an inappropriate means of avoiding decision-making, She was therefore deemed incapable of making a medical decision. However, an appreciation of religious issues led the consulting psychiatrist to offer MS G the opportunity to speak with a member of the clergy. The mere offer to involve clergy led her to develop greater trust in her physicians and apparently lessened her need to use denial as a defense mechanism. Over time, empathetic exploration of MS G’s concerns about pain and dying, as well as her religious beliefs, assisted in the restoration of her capacity to make medical decisions. She became more willing to discuss her fears and the difficulties related to her medical condition, and ultimately chose to undergo the amputation. Helping to restore a patient’s capacity to make medical decisions can be a central purpose served by the capacity evaluation. Although there are some who find the offering of therapeutic interventions to be incompatible with the role of an evaluating psychiatrist, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research has recommended that those assessing capacity should, to the extent feasible, attempt to remove barriers to decisional capacity 1111. For the religious patient, sensitivity to and exploration of religious beliefs may assist in restoring capacity by promoting a sense of trust and understanding between patient and physician. Since treatment refusal may be a manifestation of idiosyncratic religious beliefs asserted in response to a stressful situation, exploring the patient’s religiosity may enhance decisional capacity by clarifying perceived conflicts between the patient’s beliefs and the recommended treatment. McLemore and Court [421 note that religious beliefs may help a patient remain functional and that the psychiatrist’s failure to acknowledge or communicate biases may interfere with the patient’s capacity to harness religious resources. In Ms G’s case, the psychiatrist’s willingness to respect the religious underpinnings of her decision encouraged her to place greater reliance on her religious resources in 179 S. Waldfogel and S. Meadows making a decision. Particularly when, as here, the proposed treatment will have permanent consequences, every effort should be made to marshal1 all of the patient’s potential resources for the restoration of capacity, including religion. Applebaum and Gutheil [121 have suggested involving staff members of similar ethnic and cultural backgrounds, having family members present, and taking appropriate account of patients’ socioeconomic and educational levels, as various means of enabling patients to perform their best during capacity evaluations. MS G’s case demonstrates the importance of establishing a therapeutic alliance involving the enlistment of available religious, cultural, and familial resources in order to promote maximum capacity for decision-making, ensuring that the process of informed consent is ethically sound [ll I. Case 4. The Therapeutic Assessing Capacity Value of Religion in MS D was a 44-year-old female hospitalized for respiratory distress and septicemia. She had a long and complicated medical history, significant for steroid-dependent asthma since age 18, a seizure disorder, and a recent stroke. The patient’s clinical condition deteriorated as she suffered from deep vein thrombosis and experienced increasing pain. She asked her attending physician to place a do not resuscitate (DNR) order on her chart, and presented him with a living will, which stated her wishes were based on her religious beliefs. She also asked nursing personnel to help her die. Psychiatric consultation was sought by the attending physician to assess the patient’s capacity to request DNR status. The referring physician and the psychiatric consultant, both of whom had been treating the patient for several years, failed initially to address the patient’s religious beliefs, even though they were prominent in her life and formed the basis for her living will. The patient was deemed capable of making the DNR request in light of her apparent understanding of the consequences of the decision, alternative treatments available, and the preferences articulated in her living will. However, the attending physician remained uncomfortable with the patient’s request for a DNR order, and consulted the hospital’s ethics committee. The committee, which relied heavily on the consulting psychiatrist’s determination that the patient was capable of making a decision about resuscitation, supported 180 her right to do so. Specific details regarding the patient’s code status were placed on her chart by her attending physician. Subsequent to the ethics committee’s discussion, the author (SW) evaluated the patient’s reasons for her decision to be considered DNR, giving special attention to the role of religious beliefs in her decision-making. MS D reported feeling a desire to be relieved of the fears and pain that accompanied her medical condition. She claimed that she wanted to be in the arms of God who would protect her. In response to questions about her religious beliefs, MS D stated that she was Jewish, but had been raised with little religious orientation. She described having had a seizure 10 years prior to this hospitalization, and experiencing the presence of a “beautiful man who wiped her hair to the side and told her everything would be O.K.” She believed that she had experienced contact with the “Lord.” She subsequently became involved with “Jews for Jesus,” a messianic group, and underwent a baptism, which she described as the most wonderful experience of her life. Although she claimed to have limited religious organizational affiliation, she said that prayer was an important part of her life. In fact, she reported having received emotional comfort during this hospitalization from praying with a member of the hospital’s housekeeping staff. MS D declined the offer to consult with clergy, but acknowledged ongoing contact with members of the “Jews for Jesus” group. In discussing her decision to request DNR status, she explained that she had been very frightened as a result of her illness, and had wished to die. Several supportive discussions with the author focusing on her religious beliefs appeared to decrease her anxiety significantly. This case highlights the general lack of concern with religious beliefs, both during the capacity evaluation, and throughout the therapeutic process generally. In fact, MS D’s advance directive and later request for DNR status appeared to be completely consistent with her religious framework. Moreover, she clearly benefited from the incorporation of religious concerns into her therapy Since MS D’s mental and physical conditions fluctuated dramatically throughout her hospitalization, it was appropriate to reevaluate her capacity on numerous occasions; nevertheless, the consulting psychiatrists concluded that her capacity to make a decision about DNR status remained intact throughout her hospitalization. Although consideration of MS D’s religious concerns might not have affected the psy- Religious Issues in the Cipacitv chiatric conclusions, the intervention offered by the author allowed for a more informed understanding of the dynamics of her decision-making, the ability to forge a positive therapeutic alliance, and enhancement of her feeling of well-being. Evaluating Capacity: Suggestions The following suggestions are offered to the consulting psychiatrist to assist in the consideration of religious issues during the capacity evaluation: 1. The psychiatrist should familiarize himself with the clinical, legal, and religious issues involved. This may include consultation not only with physicians, but also with the hospital’s legal counsel, clergy, and other outside resources as needed. 2. The evaluation process should be undertaken in a “safe” environment in which the patient can do his best during the evaluation. While guarding against possible undue influence, consideration should be given to facilitating communication with the patient by enlisting the help of individuals who are culturally and religiously similar to him. 3. Remaining aware of countertransference issues related to religion, the psychiatrist should maintain neutrality, and approach the patient in a nonjudgmental manner. 4. The evaluation should include nonjudgmental questions involving the role of religion in the patient’s life generally, in response to illness, and in treatment refusal. The psychiatrist must gain an understanding of the role that religion plays in the psychological life of the patient, including the healthy and/or pathological manifestations of the patient’s religious beliefs. The psychiatrist should avoid theological debates related to dogma and ritual. 5. The psychiatrist should explore the relationship of the patient’s religious beliefs to his decisionmaking process and coping mechanisms. 6. Since informed consent is a process, and decisional capacity can be dynamic, the psychiatrist should consider whether more than one consultation is needed. 7. Treatment recommendations to remove barriers to decisional capacity should be proposed. 8. Recommendations to enhance coping and the treatment of underlying pathology should be proposed. Emlmtion 9. The psychiatrist should explore the option of providing the patient with treatment alternatives that may be more acceptable religiously. 10. The psychiatrist should expIore the impact of the patient’s refusal of treatment with other members of the treatment team, as well as the patient’s family. 11. Consultation with the hospital ethics committee should be considered when further guidance about ethical issues is needed. Review of the case with the ethics committee may serve to alleviate tension within the treatment team. 12. Because the evaluation of capacity is a clinical determination, a finding of incapacity due to a patient’s psychopathological state may require a legal adjudication of capacity, resulting in substituted decision making. Conclusion The foregoing cases illustrate how the assessment of capacity incorporating religious themes may assist the consulting psychiatrist in finding common ground among apparently conflicting medical, legal, and religious value systems. Acceptance of the premise that a patient’s religious scheme can be both adaptive and/or maladaptive will enable psychiatrists to better assesscapacity for decision making and incorporate religious themes into treatment where appropriate. The ability to explore religious beliefs should become an essential tool of the psychiatrist practicing in the consultation and liaison setting. This is in keeping with APA Ethics Guidelines regarding the physician’s professional competence, as well as specific guidelines concerning the respect for religious beliefs in the psychiatric setting [431. Training psychiatrists in the expforation of religious values, and further research in, this area are needed. Physicians and medical institutions attempting to challenge the religiously motivated refusal of treatment should adhere to the APA Guidelines in order to foster medical decision making that accords appropriate respect for the patient’s autonomy as well as the medical aims of the treatment team. Addressing the patient’s religious beliefs in the context of the capacity evaluation represents sound ethical process; it may also assist physicians in enhancing both patient capacity and well-being. 181 S. Waldfogel and S. Meadows References 1. Pavlo A, Bursztajn H, Gutheil TJ, Levi LM: Weighing religious beliefs in determining competence. Hosp Community Psychiatry 38:350-352, 1987 2. Gallup G, Castelli J: The People’s Religion: American Faith in the 90’s. New York, McMillan, 1989 3. Meissner WM: The phenomenology of religious psychopathology Menninger Clin 55:281-298, 1991 4. Pressman P, Lyons JS, Larson DB, Strain JJ: Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 147:758760,199O 5. Whitehead PL, Stout RJ: Religion as ego support. In Treatment of Psychiatric Disorders: A Task Force Report of the APA, Vol. 3. Washington DC, American Psychiatric Association, 1989 6. Sansone RA, Khatain K, Rodenhauser I’: The role of religion in psychiatric education: a national survey. Academic Psychiatry 14:34-38, 1990 7. Schloendorff v. Society of New York Hospitals, 211 N.Y. 125, 105 N.E. 92 (1914) 8. Salgo v. Leland Stanford Jr. University Board of Trustees, 154 Cal Stanford App. 2d 560, 317 P.2d 170 (1957); Cobbs v. Grant, 8 Cal. 3d 229,502 I?2d 1,104 Cal. Rptr. 505 (1972) 9. Roth LH, Meisel A, Lidz CW: Tests of competency to consent to treatment. Am J Psychiatry 134:279-284, 1977 10. In re Farrell, 108 N.J. 335,529 A.2d 404 (1987); In re Roe, 383 Mass. 415,421 N.E. 2d 40 (1981) 11. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Patients Who Lack Decision-making Capacity Washington DC, 1983 12. Appelbaum I’S, Gutheil TJ: Clinical Handbook of Psychiatry and the Law, 2nd ed. Baltimore, Williams and Williams, 1991, pp 214-258 13. Lidz CW, Appelbaum S, Meisel A: Two models of implementing informed consent. Arch Intern Med 148:1385-1389,1988 14. Superintendent of Belchertown State School District v. Saikewicz, 373 Mass. 728, 370 N.E. 2d 417 (1977) 15. Matter of Quinlan, 70 N.J. 10, 355 A.2d 647 (1976) 16. Cruzan v. Director, Missouri Department of Health, 110 U.S. 2841 (1990) 17. Id.; Bouvia v. Sup. Ct., 179 Cal. App. 3d 1127, 225 Cal. Rptr. 297 (1986); Norwood v. Munoz, 409 Mass. 116,564 N.E. 2d 1017 (1991) 18. Swartz M: The patient who refuses medical treatment: a dilemma for hospitals and physicians. Am J Law Med 11:147-194, 1985 19. Burdens on the Free Exercise of Religion: A Subjective Alternative, 102 Harv L Rev 1258 (1989) 20. Towards a Constitutional Definition of Religion, 91 Harv L Rev 1057 (1978) 21. United States vs. Ballard, 322 U.S. 78, 80 (1944) 22. Bowen v. Roy, 476 U.S. 693, 695 (1987) 23. Lukoff D, Lu F, Turner R: Toward a more culturally sensitive DSM-IV psychoreligious and psychospiritual problems. J Nerv Ment Dis 180:673-682, 1992 182 24. Wallace IV ER: Psychiatry and religion: toward a dialogue and public philosophy. In Smith JH, Handelman SA (eds), Psychoanalysis and Religion. Baltimore, The Johns Hopkins University Press, 1990, pp 195-210 25. Larson DB, Pattison EM, Blazer DG, Omran AR, Kaplan BH: Systemic analysis of research on religious variables in four major psychiatric journals, 19781982. Am J Psychiatry 143:329-334, 1986 26. Post SG: DSM-III-R and religion. Sot Sci Med 35:8190,1992 27. Brock DW, Wartman SA: When competent patients make irrational choices. NEJM 332:1595-1599, 1990 28. Hufford DJ: Paranormal experiences in the general population. J Nerv Ment Dis 180:362-367, 1992 29. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV. Washington, DC, American Psychiatric Association, 1994 30. Medical Ethics Advisor 6:11, November, 1990 31. James W: The Varieties of Religious Experience. New York, The Modern Library, 1929 32. Barnhouse RT: How to Evaluate Patient’s Religious Ideation in Psychiatry and Religion: Overlapping Concerns. Robinson LH (ed), Washington, DC, APA Press, 1986 33. Julian R: Spiritual discernment in psychiatric patients. J Rel Health 26:125-130, 1987 34. Lukoff D: The diagnosis of mystical experiences with psychotic features. J Transpersonal Psycho1 17:151181, 1985 35. /Greenberg D, Witzbum E, Bucbinder JT: Mysticism and psychosis: the fate of Ben Zoma. Br Jr Med Psychology 65:223-235, 1992 36. Fallon BA, Howarth E: Asceticism: creative spiritual practice of pathological pursuit? Psychiatry 56:310320, 1993 37. Westermeyer J: Clinical considerations in crosscultural diagnosis. Hosp Community Psychiatry 38: 160-165,1987 38. Bergin AE: Values and religious issues in psychotherapy and mental health. Am Psycho1 46:394-403, 1991 39. Braun JA: Ethical issues in the treatment of religious persons. In Rosenbaum M (ed), Ethics and Values in Psychotherapy. New York, The Free Press, 1982, pp 131-162 40. Sider RC: The ethics of therapeutic modality choice. Am J Psychiatry 141:390-394, 1984 41. Waldfogel S, Wolpe PR: Using awareness of religious factors to enhance interventions in consultationliaison psychiatry. Hosp Community Psychiatry 44: 473477‘ 1993 42. McLemore CW, Court JH: Religion and psychotherapy: ethics, civil liberties and clinical savvy; a critique. J Consult Clin Psycho1 45:1172-1175, 1977 43. American Psychiatric Association: Guidelines regarding possible conflicts between psychiatrists’ religious commitments and psychiatric practice. Am J Psychiatry 147:542, 1990