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Religious Delusions and the Limits of Spirituality in

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The American Journal of Bioethics

Religious Delusions and the Limits ofSpirituality in Decision-Making

Thomas I. Cochrane, Harvard University

There is much to like about Kuczewskis (2007) framing ofspirituality and religion as a foreign language that re-quires translation. Religiously-framedassertions arecom-mon in healthcare, and translation of such assertions re-quires patience and concerted effort. Kuczewskis exampleof a patient contemplating do-not-resuscitate orders whosays that Death [is a] matter of when God calls is a niceillustration: it is meaningless as a response to the questionof whether cardiopulmonary resuscitation (CPR) should beperformed. God could call either with or without CPRsoshould we perform it or not? It requires a longer discussionto determine whether CPR makes sense. This discussion iswhat Kuczewski suggests, and he provides some valuable

guidance regardinghow to arrive at a common understand-ing with patients.

However, for the practitioner who does not harbor abelief in supernatural entities such as souls, spirits, orGod, Kuczewskis (2007) advice regarding transparencyand sharing of spiritual views, if taken too far, might becounterproductive. For such a clinician being too transpar-ent, too early, could irreparably harm the patientclinicianrelationship.

Recognizing two aspects of spirituality may help ratio-nalist clinicians cope with the claims of patients who have asupernatural worldview. First, even the most self-identifiedreligious or spiritual persons ethical and moral beliefs donot in fact originate from scripture or religious teachings,

and in theory can always be translated into nonreligiousethical and moral terms. Second, beliefs that directly con-tradict obvious facts are delusions, whether the beliefs arereligious in nature or not. Patience and sensitivity is re-quired to help people overcome religiously-framed delu-sions while remaining respectful of their religious and spir-itual beliefs, buttransparency on thepart of thecliniciancanbe dangerous.

SPIRITUAL AND RELIGIOUS MORAL CLAIMS ARE

NEITHER SPIRITUALNORRELIGIOUS

No one, not even a self-identified religionist, derives ethicalor moral beliefs from theteachings of God, scripture or othersupernatural instruction. Rather, the religionists moral be-liefs are selected from scripture or religious instruction, onthe basis of nonreligiousalthough often unconscious andunexaminedcriteria.

Address correspondence to Thomas I. Cochrane, Department of Neurology, Brigham and Womens Hospital, 75 Francis Street, Tower 5DEMG, Boston, MA 02115. E-mail: tcochrane@partners.org

Consider the Bible. Not even a biblical literalist can ac-cept every biblical teaching as moral instruction. It is impos-sible because all religioustexts contain somevagueand con-tradictory instructions. One must therefore interpret vaguepassages and choose among contradictory instructions onsome basis. The manner of interpretation, or the criteriaused to choose, whether conscious or not, are the real moralcodenot the instructions themselves.

For example, how does one reconcile the following con-tradictory instructions, both found in Exodus: Thou ShaltNot Kill, and [put your neighbor to death for working]on the Sabbath? (Exodus 31:1415 in Holy Bible, New KingJames Version [1985]). One could seek guidance elsewhere

in scripture, but then one must choose to follow that guid-ance and reject one of the two original alternatives. Or, onecould decide that only these passages are meant as instruc-tion,whereas those are allegorical. A choice has tobe made atsome point, and the individual must ultimately provide therationalefor thechoice.The rationalemightbe:itsnot rightto kill people except in defense of self or others, or peoplewho violate (particular) religious instructions deserve to dieand I am obligated to enact their death. Or choose the ac-tion that my priest tellsme is right. Whichever it is, it is notGod doing the choosing, and in choosing which religiousinstructions to follow, one reveals ones actual moral beliefs.And since these moral beliefs are ultimately chosen on anonreligious basis, in theory they can always be translatedinto secular terms.

Regarding the patient contemplating do-not-resuscitateorders who claims death isa matterof whenGod calls,thefirst question is whether this patients as-yet-unarticulatedmoral code requiresthat everypossibleintervention to pro-long life, even for a brief period, must be performed in allcircumstances. Usually, this is not what patients mean. Ifnot, then the patient either: 1) has not decided whether CPRis reasonable, or 2) already has criteria in mind for decid-ing whether CPR is reasonable. In the former case, the workahead consists of helping the patient with the psychologicaldifficulty of contemplating his or her own death or with un-derstanding the facts relevant to the decision. In the lattercase, the job is to discover what are the unspoken criteriafor reasonableness of CPR and whether they apply in thecircumstances.

Let me be clear: I do not insist that patients must expresstheir decision in nonreligious terms or that they must not

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Talking about Spirituality in the Clinical Setting

consult scripture or religious authorities for guidance. I donot necessarily tell patients that I am trying to translate theirreligious language into secular language. I do frequently askfor help from hospital chaplains or patients spiritual lead-ers. Patients need to feel that I am not judging their reli-gious beliefs and need to feel free to express their thoughtsin whatever language feels most comfortable.

The point,however, is that oneneed notbe satisfied withan assertion such as God will decide when its time sim-ply because its framed religiously. And even when patientsgive frustratingreligious non-answers, one can be confidentthat there are secular principles underlying their religiousassertions, even if these principles are not always easy touncover.

WHENA DELUSION IS EXPRESSED AS

A RELIGIOUS CLAIM

Kuczewski writesof the pregnantHIV-positivewoman whobelieved that she had been healed by faith, and claims thatshe clearly possess[ed] decision-making capacity. This isa strange assertion, if one of the prerequisites for decision-

making capacity is the ability to understand the basic factsrelevant to the decision. This patients claim that she is HIV-negative is factually wrong, and if she fails to appreciatethis most fundamental fact regarding treatment, one cannotproperly conclude that she possesses decision-making ca-pacity for this decision. I would be willing to accept a claimthat she possessed decision-making capacity for every deci-sion except ones that required an understanding of her HIVstatus. But as the vignette is written, one must either make areligious exception to the definition of capacitysuch thatone retains capacity if ones failure to understand the factsis religiously basedor conclude that she did not possesscapacity for this decision.

In fact, this patient was suffering a delusion, and the

fact that her belief was religiously based does not make itless of a delusion. The fourth edition of the Diagnostic andStatistical Manual defines delusion as a false belief basedon incorrect inference about external reality that is firmlysustained despite what constitutes incontrovertible andobvious proof or evidence to the contrary (First 1997, 830).

But the fact that she currently lacks decision-making ca-pacity due to delusional thinking does not mean that sheis incapable ofovercoming the delusion and then obtainingcapacity. This is why one would not treat her as if she hada psychiatric illness, perhaps overriding her decision andcompelling her to take the antiretroviral zidovudine.

But how can she obtain decision-making capacity? Thisis where I can return to agreeing in part with Kuczewski

(2007). One way might be to help her see that her religiouscommunity does not share in her delusion, by asking forhelp from that community. One should also try to help herovercome thepsychological difficulty in giving up thedelu-sion. And if clinicians share some spiritual beliefs with thepatient, then I see nothing wrong with being open aboutthose beliefs, since this might be helpful. But it would notbe helpful for a nonreligious clinician to claim the belief thatGod works through medicine, because such a falsehood,if detected by the patient, would result in a loss, rather thana gain, of trust.

IMPLICATIONS FORTHE RATIONALIST CLINICIAN

Why do I insist on translating religiously framed asser-tions? First, because I would like it to be clear that it is al-most always possible to do so and that it is rare to be com-pletely stymied by religiously-framed assertions. Patience,listening skills,and a willingness to interpretpatientsasser-tions in a charitable (but secular) light will usuallyovercomeeven the most intractable language barriers. Secondly,translation results in greater clarity for both the patient

and the clinician. By uncovering and examining the pa-tients true underlying nonreligious values, patients andclinicians canbetter understand thechoices with which theyare faced.

And if I do not advocate overriding patients authoritywhen they lack decision-making capacity because of falsebut religious beliefs, why do I insist on using the word delu-sion? First, this term allows clinicians to avoid the conver-sational strain of speaking as if it is possible that deludedpersons arecorrect in their false beliefs. Second, recognizingfalse beliefs as delusions allows one to look for and over-come the real cause of the delusions (e.g., the psychologicalmechanism of denial.)

Finally, it is importantto note that oneneed notshare(or

pretend to share)religiousor spiritual beliefs to successfullyand sensitivelycare for patients facinghardshipand difficultdecisions.

REFERENCES

First, M.,ed. 1997. Diagnostic and statistical manual text revision, 4th

ed. Washington, DC: American Psychiatric Association.

Holy Bible, New King James Version. [1985]. New York, NY: Thomas

Nelson Publishers.

Kuczewski, M. G. 2007. Talking about spirituality in the clinical

setting: Can being professional require being personal? American

Journal of Bioethics 7(7): 411.

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