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No Harm Done?: Continuing the Conversation
Last month’s column on whether health care professionals in a clinical setting should endorse practices that may make patients feel better but for which there is no credible scientific evidence of efficacy – with particular attention to the characterization of prayer as a practice that “heals” – drew several thoughtful, and quite different, perspectives from readers. This month, I’m responding to the issues raised by these readers.
Joanne Bellaire, a retired chaplain in Livonia, Michigan, writes that chaplains should “stop and think about prayer and what we say and believe about it.” She describes the effect of clinical experience on her initial belief – that prayer “healed” and that it was therefore appropriate to recommend this to patients as an efficacious practice. Her experience changed the way she thought about prayer. Because prayer is not a clinical intervention in the treatment of disease, to say “prayer heals” in a clinical setting is inappropriate. She concludes that, for some patients, prayer “can bring comfort” and should be characterized in that way.
I appreciate the way this chaplain acknowledged the process of moral reflection as part of professional development. Working with patients and families caused her to rethink the way she used familiar language. Once she changed her position, she changed her practice, to avoid using language that, she concluded, could be misleading. We ask physicians to do something similar when we call on them to use clear language when talking with patients and families: meeting their obligation to provide accurate information may mean paying closer attention to the actual words they use.
Rev. Susan Weickum, a chaplain at the Indiana Heart Hospital in Indianapolis, points out that physicians frequently try different medications to see which one works. She compares her own practice, when working with recently-bereaved families, of describing the take-home materials she offers: “you may find this helpful,” but if you don’t, that’s fine. She suggests that complementary therapies are best thought of in the same way: “If it helps, use it; if not, set it aside.”
This chaplain’s careful use of language in presenting information and resources to families indicates her awareness that the words health care professionals use have ethical weight, because they have consequences for others. To suggest that there is a right way to grieve would be both insensitive and misleading: thus, a pragmatic approach – if it works for you, it’s effective –may be advisable when suggesting options that have the potential to increase well-being and cannot cause harm. However, it is important to note that when physicians use their clinical judgment to try different medications or treatment regimens, they are obligated to followed standards of care, and the evidence for a given treatment’s safety and effectiveness.
Rabbi Edmund Winter, a chaplain at Northwestern Memorial Hospital in Chicago, writes that, in his opinion, the chaplain is a member of two teams: the healthcare team, which seeks to heal the body, and G_d’s team, which seeks to heal the soul: the Jewish prayer for the sick asks for a "healing of soul and a healing of body." In the context of the work of G_d’s team, prayer is “as valid a therapeutic tool as medication and surgery,” because prayer “heals the body and forges the connection between the patient and G_d, however the patient understands G_d.”
This chaplain’s perspective demonstrates the challenges presented by the ethics of badging in a multi-faith environment that happens to be a health care institution. On the one hand, patients of any religious faith who understand prayer as a religious practice – a connection to G_d – may view the chaplain as someone who can help them support this part of their identity during their hospitalization. On the other hand, for patients who don’t already do this, or who see the badge and understandably view the chaplain as a health care professional foremost, statements such as prayer is “as valid a therapeutic tool as medication and surgery” and prayer “heals the body” are misleading. These statements cannot be justified by evidence in the same way as a statement about the efficacy of a surgical procedure or a medication regimen can be. When such a comparison is introduced – “as valid as” – then the speaker must take responsibility for justifying why the comparison is valid.
Rev. Joy Caires, a chaplain at Rainbow Babies and Children's Hospital in Cleveland, writes about the practical and theological “liminality” of her professional role: she wears “a collar and a hospital badge”; she is an “independent contractor yet part of the interdisciplinary team”; she is not a medical professional, but she is counted as “medical” staff; she views herself as a “quasi outsider,” able to “support the medical staff” because they recognize that she “understands the hospital world,” but also sought out by “families who have grown suspicious or angry with the medical staff.” With respect to the question of talking about the efficacy of prayer, she is “often asked by desperate parents what kind of miracles I have seen,” and in answering this question she must speak and act carefully: “I give no medical authority to prayer or miracles” but “I leave room for the family to find hope in both” if prayers or miracles are part of their vocabulary; she tries to “echo the words of the medical team” to help families understand the clinical picture, mindful that “the family that rejects the picture of reality laid out by the physicians” also needs support.
This response captures the reality of how chaplains, as health care professionals, may encounter families’ questions about prayer: as immediate, “desperate” pleas for reassurance that this measure will help save the life of a sick child. Families who ask physicians to tell them about other cases where a treatment has worked are also asking for reassurance, not just clinical facts. Physicians, chaplains, and others who wear badges must choose their words carefully, because, as this chaplain correctly points out, they are being asked these questions based on their perceived “medical authority.” This chaplain also nicely identifies the tension that exists among a family’s craving for reassurance, the professional’s desire to encourage hope but not to plant false hope, and the “suspicion and anger” that may result when a family does not feel reassured. While some may argue that false hope is better than none, to suggest, in the absence of evidence, that a treatment – or prayer – may result in a “miracle” may influence a decision to pursue a treatment option that confers burden without benefit, and may cause patients to suffer more. When a patient is a child or cannot make this decision independently, the ethical stakes are especially high.
I am grateful to these chaplains for the opportunity to continue thinking about the ethics of badging. While next month’s column will explore a different topic, I hope this important conversation will continue.
Editor's Note: comments that were received subsequent to the January 16 issue, are posted in TalkBack.
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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