Religious Perspectives on Healthcare Ethics

Religion, Bioethics and Nursing Practice Marsha D Fowler Key words: faith; Native American; religion; religious ethics; sacred This article calls nursing to engage in the study of religions and identifies six considerations that arise in religious studies and the ways in which religious faith is expressed. It argues that whole-person care cannot be realized, neither can there be a complete understanding of bioethics theory and decision making, without a rigorous understanding of religiousethical systems. Because religious traditions differ in their cosmology, ontology, epistemology, aesthetic, and ethical methods, and because religious subtraditions interact with specific cultures, each religion and subtradition has something distinctive to offer to ethical discourse. A brief example is drawn from Native American religions, specifically their view of ‘speech’ and ‘words’. Although the example is particular to an American context, it is intended to demonstrate a more general principle that an understanding of religion per se can yield new insights for bioethics. Introduction Religion has been a potent and pervasive influence trans-historically, culturally and internationally. Indeed, it is hard to conceive of a nurse who has never had a religious patient. Even so, nursing has resolutely avoided the academic study of religion. While nursing has looked at religion as a variable in empirical research, and has explored non-religious spirituality, neither of these constitutes the study of religion itself. This omission ultimately obviates any claim that the profession might make to whole-person or holistic care. For the purposes of nursing ethics, the nursing profession must come to a better and more knowledgeable understanding of: the ways in which religion and ethics interact, particularly in reference to bioethics; the differing ways in which specific religions inform, critique and enlarge moral discourse within health care; and the effects of particular religious traditions on bioethical decisions. Writing about religion is fraught with pitfalls due to the very nature of religion and the ways in which adherents express their religious faith. Thus it is important to preface the discussion by identifying a few considerations basic to any discussion of religion. Address for correspondence: Professor Marsha D Fowler, Azusa Pacific University, 901 E Alosta Ave, Azusa, CA 91702, USA. Tel: +1 626 815 5402; E-mail: mfowler@apu.edu Nursing Ethics 2009 16 (4) © The Author(s), 2009. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0969733009104604 394 MD Fowler • Religious traditions are not univocal; even within one historic religious tradition there will be different streams of expression: For instance, Christianity has Eastern Orthodox, Roman Catholic, Protestant, and Radical Reformation streams and multiple subtraditions within each of these streams. Judaism finds expression among Orthodox, Conservative, Reform, Reconstructionist and Haredi branches with subgroups such as Hasidism. Buddhism has major streams such as Theravada and Mahayana; Mahayana Buddhism includes Tibetan, Zen, Pure Land, and Son forms. Although subtraditions may retain a common core with the parent tradition, that core may be interpreted, expressed and lived differently. • Religion and culture are mutually interpenetrating, reciprocating, and often inseparable: Sikhism in Vancouver, Canada, does not look identical to Sikhism in the Punjab, India.1 Portuguese Catholicism looks different from Italian Catholicism, which looks different from Mexican Catholicism. For example, a little Catholic church in Southern California, with members largely of Italian coastal descent, has an altar in the shape of a boat and the entire place of worship expresses a nautical theme found in many Catholic churches whose congregations descended from fishing communities. Religious Perspectives on Healthcare Ethics

More widely, religion and culture interpenetrate so that culture may shape the symbols of religious tradition, as in the fishing churches mentioned above. Conversely, some cultures are suffused with religious influence where adherence may not be widespread. For instance, there may be a specific underlying religious metaphysics that originally informed the shape of civil law or a constitution in a nation that no longer widely embraces that particular religion. The prevailing ethos and culture of a nation may also be reflective of aspects of a specific historic religious tradition where that religion is not or perhaps is no longer widely embraced. For instance, the communal emphasis of communism is not inharmonious with a basic communal emphasis of the Russian Orthodox Christianity that predated it. That is to say, Russia was Orthodox even when it was an atheist state. • Religious traditions often fall along a continuum of expression: This continuum may be characterized in a number of ways, including: conservative (or ultraconservative) to liberal; traditional to progressive; fundamentalist to mainstream, and so on. This continuum may give rise to separatist groups or other forms of clustering of like minded adherents. The continuum is not limited to religious beliefs and practices, but also interacts with views of culture or politics. Either end of the spectrum may be associated with specific sociopolitical views. For instance, conservative (evangelical and fundamentalist) American Christians have often been associated with conservative Republican Party politics, extending to politically conservative positions on issues of justice (e.g. how health care should be organized nationally).2 • The formal tenets of a religion may not be quite the same as those expressed by an individual adherent: Individuals may differ in their beliefs from those formally expressed by the religious tradition to which they belong. That is to say that lay persons may not be aware of, may misunderstand, may modify or reject, or may culturally attenuate many of the beliefs, standards and practices of a religious tradition, including perspectives on health, bioethical issues and decisions. • Religion may find expression in ways that are sublime, and it can also find expression in ways that are toxic: The current religious wars make it necessary for the mass media to attend to the socially toxic aspects of religion, but, admittedly, religion has had a hand in colonialism, the suppression of cultures, the oppression of peoples, and the death of innocent persons.3–5 Religion can also be toxic at the individual level as Nursing Ethics 2009 16 (4) Religion, bioethics and nursing practice 395 in the ‘lethal triad’, the consequence of which is often death (e.g. Solar Temple, Jim Jones in Guyana, Heaven’s Gate).6 Any examination of religion, particularly with an interest in health care, must acknowledge but move beyond a focus on the toxic to a better understanding of what various traditions bring positively to an understanding of health and illness, and the resources they provide for patients, including guidance in bioethical decision making. • Religion may co-mingle with civil religion: Sociologically, civil religion is the ‘folk religion’ of a nation and its political culture. It often draws upon specific religious language and specific religious symbols and images to unify a people, while at the same time being devoid of actual religious content. Religious Perspectives on Healthcare Ethics

Political civil religion may include rituals and expressions specifically linked to patriotism: presidential exclamations such as ‘God bless America’, and the phrase ‘one nation under God’, evoke not so much religious faith as nationalistic fervor.7 However, some religious traditions may so co-mingle with culture that the actual religious content may, in an accommodationist syncretism, become a variant form of nationalism.8 An academic study of religions seeks to explore the theology, philosophy, sociology and other aspects of particular religions. Religious studies are intended for a broad learned audience and are neither sectarian nor evangelistic in nature. This article calls nursing to the academic study of religion and the ways in which religious faith may affect persons, whether nurse or patient, concerning their views of health, illness, caring for another who is ill, suffering, bioethical analysis, and more. Knowledge of religions and their theology will influence clinical practice. Beyond a theoretical understanding, nursing must examine the ways in which knowledge of a patient’s religion is pivotal to understanding the patient as a person. Clinical care may well need to be modified. Knowledge of a patient’s religion may also bring ethical issues into our awareness that we had previously been unable to see. Religion and ethics Bioethics in the USA has largely adopted the language and arguments of philosophy as the language of moral discourse in health care. This is in spite of the fact that, historically, philosophy has been more interested in meta-ethics than in normative or applied normative ethics. Indeed, one philosopher has asserted that bioethics (a form of applied normative ethics) saved philosophy departments from extinction.9 Historically, normative ethics has always been the domain of religions, if for no other reason than that religious persons needed ways to think about actions and relationships and to know whether or not they had erred morally. With the rise of bioethics in the 1960s it must be noted that many of the early bioethicists were trained in theological seminaries, were religiously identified, and wrote from a religious perspective (e.g. Paul Ramsey, James Gustafson, Richard McCormick, Albert Jonsen, Immanuel Jakobovits, Fred Rosner, David Bleich). It remains the case that a large number of biomedical ethicists writing in bioethics today continue to do so from an explicitly religious perspective (e.g. Elliot Dorff, Margaret Batten, Keown Damien, Robert E Florida, Vandana Shiva, Lisa Cahill, Stanley Hauerwas, Gilbert Meilander, Laurie Zoloth-Dorfman, Abul Fadl Mohsin Ebrahim). Some who have a strong religious commitment that informs their bioethics nonetheless write in completely areligious language.10 Increasingly, however, Nursing Ethics 2009 16 (4) 396 MD Fowler the medical ethical literature is devoting more attention to religious bioethics.11 Unlike medicine, writers in bioethics in nursing rarely do so from an explicitly religious bioethical perspective. Unlike medicine, nursing has made no concerted effort to explore the inter-relationships of specific faith traditions, bioethics and the discipline. Religious Perspectives on Healthcare Ethics

Fox12 identifies three phases in the growth and development of bioethics in the USA. The first phase is centered on voluntary consent by participation in human research projects. Fox dates this period from the late 1960s to the mid-1970s. The succeeding period, continuing through the mid-1980s, focuses on life, death, personhood and end-of-life issues. The third phase focuses on access to care, cost containment, rationing, and the allocation of medical resources. This periodization does not exclude the continuing relevance of questions from preceding phases upon the next.12 Fox makes two observations of significant importance for the present discussion. First, she characterizes American bioethics as rationalistic, ‘intellectually provincial and chauvinistic’, and conservative, with a lack of attention to its ‘American-ness’ and an overweening emphasis on autonomy at the expense of social and relational values. She writes: The skein of relationships of which the individual is a part, the socio-moral importance of the interdependence of persons, and of reciprocity, solidarity, and community between them, have been overshadowed by the insistence on the autonomy of the self as the highest moral good. Social and cultural factors have been primarily seen as external constraints that limit individuals. They are rarely viewed as forces that exist inside, as well as outside of individuals, shaping their personhood and enriching their humanity (p. 207).12 Fox further observes that American bioethics neglects both social problems and religion. … social problems are ‘de-listed’ as ethical problems in a manner that removes them from the sphere of moral scrutiny and concern … Bioethics deals with religious variables in a comparable fashion. When questions of a religious nature arise in bioethics, there is a tendency either to screen them out, or to ‘reduce’ them, and fit them into the field’s circumscribed definition of ethics and ethical (p. 207).12 This is the situation ‘despite the significant contributions of highly esteemed religious ethicists and theologians to bioethics, the field is studiously secular in its perspective.’12 An emphasis has been placed on rational, deductive, objective/dispassionate, universalizing, secular analysis that is assumed to be ahistorical and acultural. The exclusion of social, religious and relational values, the emphasis on autonomy of the self, and the rationalism of the field are even more acutely important to consider when dealing with patients from more communitarian or tribal societies. General reasons for examining religious-ethical systems The reasons for turning nursing’s attention to religion and religious-ethical systems are practical. The first is that approximately 85.7% of the world population identifies as religious (11.92% identify as non-religious; 2.35% as atheist).13 The perception in the USA that the world is increasingly secularizing contrasts with the evidence that religious adherence is actually increasing world-wide.14 To understand a patient and to engage in whole-person care necessitates at least basic knowledge of the person’s religion. Nursing Ethics 2009 16 (4) Religion, bioethics and nursing practice 397 The second reason is demographic in nature. For example, approximately 12% or over 37.5 million residents of the USA are foreign born (2004 statistics). Religious Perspectives on Healthcare Ethics

In addition, 34% of the population self-identified as a racial or ethnic minority.15 Minority and foreignborn persons cluster around the periphery of the USA from Hawaii, California, the Southwest, Florida, to New York.15 Although 60% of the US population is ‘non-Hispanic white’, in cities such as Los Angeles this group is now a minority. The 2006 demographic estimates for Los Angeles County, California, are: population 9 948 million; Hispanic or Latino origin 47.3%; non-Hispanic White 29.2%; Asian 13.1%; Black, 9.6%; foreign born 36.2%; and language other than English spoken in the home 54.1%.15 Practically, then, sizable numbers of the US population who will become patients have not been reared in the dominant, White, western Euro-American culture and it may be found that they embrace a value complex that differs from it. At least part of this value complex will derive from religion, either directly or indirectly. In contradistinction to national demographics, the vast majority of nurses in the USA are non-Hispanic White. According to the American Nurses Association’s most recent posted data (2004): The total number of licensed RNs [registered nurses] living and working in the United States was estimated to be 2,909,467 as of March 2004 … Of the nurses who indicated their racial/ethnic background in 2004, 88.4 percent (an estimated 2,380,639) were white, nonHispanic; 4.6 percent or 122,495 were Black/African American, non-Hispanic; 3.3 percent or 89,976 were Asian or Pacific Islander, non-Hispanic; 1.8 percent or 48,009 were Hispanic; 0.4 percent or 9,453 were American Indian/Alaskan Native; and 1.5 percent were from two or more racial backgrounds. The 2004 survey estimates that 3.5 percent of the RNs practicing in the United States (100,791) received their basic nursing education outside the United States.16 Thus, there is a higher percentage of White nurses than in the dominant culture today and their demographic characteristics are markedly different from those of the general patient population. The implications are that patients may embrace a value complex that, although differing from the general culture, may differ even more markedly from that of their nurses. The assumption here is that a significant aspect of that difference will reside in religious-ethical and cultural differences, again making an understanding of religions of great importance. Although these statistical examples are from the USA and Los Angeles County, other nations experience similar immigration patterns that affect the cultural, racial and religious balance, which can create disparities between the demographics of nurses and the patients to whom they render care.17–20 These are but two practical reasons for nursing to engage in the academic study of religion. A broader practical reason is as noted above that there has been a resurgence in religion world-wide. Thomas writes: … the global resurgence of religion … is a far more wide ranging phenomenon than religious terrorism, extremism, or fundamentalism. The world resurgence of religion taking place in the developed world … is part of a larger crisis of modernity in the West. It reflects a deeper and more widespread disillusionment with a modernity that reduces the world to what can be perceived and controlled through reason, science, and technology, and leaves out the sacred, religion, or spirituality (p. 11).14 With the escalation of technomedicine in clinical practice, combined with a worldwide nurse shortage and pressures of cost containment, for overworked clinicians it is Nursing Ethics 2009 16 (4) 398 MD Fowler easy to ‘… [leave] out the sacred, religion, or spirituality’ (p. 11)14 in clinical practice. Religious Perspectives on Healthcare Ethics

The price of this is paid by both nurses and patients. More globally, the ills of the world, including human use of the planet, will not be cured by a technofix, and the strife in the world that continues to lead to war and death cannot be understood without attention to both toxic religion (for the ill that it causes) or to irenic religion (for the good that it does). There are other, deeper reasons to take account of religion, as I will try to demonstrate. Since Christianity claims the greatest number of adherents world-wide as well as in the USA,21,22 it is important to demonstrate the significance of religiously-based ethics using a non-Christian example. An example from Native American religion and ethics A discussion of any tradition raises theoretical issues that are sensitive in nature, such as the issue of ‘representation’. No one person speaks for the whole of a tradition, and no non-member of a tradition truly represents that tradition. Thus, whenever possible, voices from those groups must be used to represent themselves, directly or indirectly, as in the quotes that follow. In the early to mid-1990s an American television station aired a program called ‘Northern exposure’, set in a fictional Alaskan town (episodes can still be seen in rerun and online). Marilyn Whirlwind, a Tlingit Indian was one of the show’s major characters. She was played by actor Elaine Miles, of Cayuse/Nez Perce Native descent, although raised as a member of the Umatilla Tribe. Whirlwind was often noticeably silent when others would speak, but when she spoke her comments were observant, incisive, pithy and sage, for example: ‘He moves nice. It’s his stillness that’s not right.’ By contrast, various reviews described her as blunt, taciturn, unsettling and cynical. Miles herself is an accomplished Native dancer with a number of dance awards to her credit. In an interview, she also acknowledged that she has a skill-set common to Native Americans who embrace their tradition: I know my Native American heritage. I can speak and understand my language, the Cayuse and the Nez Perce. I know how to bead. I can weave. I know how to process our foods … we go root digging, and we will b … Religious Perspectives on Healthcare Ethics