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If you were the consultant, what issues might you raise in the cases discussed here?
For I do not seek to understand in order that I may believe, but I believe in order to understand. For this also I believe-that unless I believe I shall not understand. - St. Anselm
Mrs. P is a 54-year-old woman admitted to the acute medical unit with uncontrolled hypertension secondary to non-adherence and a non-healing ulcer, the result of venous stasis related to high blood pressure. For the first few days of the hospitalization she is pleasant and cooperative with the medical team and nursing staff.
On a Saturday morning of her first week in the hospital, Mrs. P begins to say that she no longer needs treatment for her hypertension or wounds because “God has told her she is healed.” Despite this unusual claim, Mrs. P continues to participate in the treatment plan saying, “ I want to help the doctors and nurses, and so I will let them do what they need to do.
On Sunday Mrs. P begins to tell the team that she doesn’t need to be in the hospital because she is healed. The team is concerned that Mrs. P will try and leave against medical advice. They become seriously concerned about her decision-making capacity and advise Mrs. P that they feel she needs to stay in the hospital as her blood pressure is still not well-controlled and she needs wound care several times a day. Mrs. P says, “I cannot leave the hospital. I don’t need to be here for me as I am healed, but God wants me to remain until I have ministered to everyone in the hospital.” Mrs. P is still accepting treatment. The team is beginning to really question Mrs. P’s mental state.
The team decides to call psychiatry. Because Mrs. P believes she has been healed and has a mission, they are now sure that she suffers from a mental illness. In addition, Mrs. P increasingly says she does not need medication because she is miraculously healed. It takes considerable time and effort to persuade her to take the medication. The psychiatrist, Dr. H, sees Mrs. P on Monday morning and conducts an extensive interview as well as record review. Looking at Mrs. P’s records, Dr. H sees that Mrs. P had been seen several years earlier as an outpatient because of irritability and depressive symptoms for which antidepressants were prescribed. She stopped taking the medication and did not return for follow up. There is no history of psychiatric hospitalizations, suicide attempts, violence toward others, or psychotic symptoms. Psychosocially, Mrs. P has been married for 25-years, has no known substance use, and is working full-time as a salesperson at a department store.
Mrs. P talks freely and volubly to Dr. H about her religious beliefs. She describes herself as a lifelong Pentecostal Christian and quotes scriptures to support her faith. When contacted, her husband confirms that his wife has always been very religious and often preaches to others at church. Dr. H has had interactions with persons from similar faith traditions in her own upbringing and so does not find Mrs. P’s beliefs to be delusional but understands that they may seem so to the medical team. In Dr. H’s judgment, Mrs. P does not currently meet criteria for a serious mental illness, although she is somewhat labile, which Dr. H believes is likely due to the stress of hospitalization. Mrs. P assures Dr. H that she intends to stay in the hospital to receive needed treatment.
Two days later, Mrs. P begins wheeling herself into other patient’s rooms to save souls. She also removes the bandage from her wound. Dr. J and the medical team agree it is wise to ask the Protestant chaplain to see Mrs. P. When he comes, she politely declines to talk with him, saying she has her own pastor. Mrs. P tells the psychiatry resident the name of her church and pastor and that he can contact him. The pastor readily agrees to visit; he is a highly educated and psychologically astute minister. After more than an hour with Mrs. P he tells the psychiatry team that “our Church does believe in divine healing, but also that God heals through doctors. If you have a faith healing, there should be medical evidence. Mrs. P insists she is healed in spite of the evidence of her high blood pressure and infected leg, that is not rational. For now I have convinced her to work with the medical team.” Mrs. P’s response is that she respects her pastor but that he does not understand that God has performed a miracle.
1) At this point in her care, is Mrs. P capable of informed consent for ongoing treatment?
A. No, she is not capable of informed consent. Mrs. P is clearly suffering from religious delusions and cannot provide informed consent.
B. Yes, she is capable of informed consent. As long as Mrs. P cooperates with care, there is no reason to question her capacity to provide consent. The reasons for which she is cooperating is irrelevant.
C. Yes, she is capable of informed consent. Unless Mrs. P’s beliefs start to interfere with her treatment, they should be respected.
D. No, she is not capable of informed consent. The belief in miraculous healing is incompatible with the ability to understand and reason regarding treatment.
2) Does the health care team need to obtain further consultation? If so, from whom and why?
A. The team should call for a consult from psychiatry because Mrs. P may be psychotic and she needs treatment.
B. The health care team should call the hospital chaplain because they respect Mrs. P’s religious beliefs. This will provide the team with further guidance about how to best respond to her religious beliefs.
C. The team should call Mrs. P’s husband because she has clearly lost capacity. As such, a surrogate decision-maker is needed immediately to prevent any harm to Mrs. P.
D. The team should not call anyone. Mrs. P is still working and cooperating with the health care team, and e is not displaying any disruptive behavior. The team is just uncomfortable with her religiosity and should not overreact.
3) If you were the ethics consultant, what issue you might you raise at this juncture?
A. A chaplain or other religious professional should be the one to determine if Mrs. P’s beliefs are congruent with a recognized faith tradition and if this is outside the psychiatrist’s scope.
B. It does not matter if Mrs. P’s religious expression coheres with any organized religious group; her own personal spirituality should be respected as in accordance with a commitment to cross-cultural sensitivity.
C. Mrs. P’s religion and spiritualty are not the central concern, and she does not meet diagnostic criteria for a primary mental illness. The team may be projecting their own biases about religion.
D. It is important to empathically consider Mrs. P’s beliefs so that Dr. J can form a trusting alliance that will enable the clinician to understand her own thoughts and feelings about Mrs. P, which are key to accurate diagnosis.
4) Is there an ethical duty to reconsider the patient’s diagnosis in light of the pastor’s narrative?
A. Yes, because the pastor says Mrs. P’s beliefs do not reflect those of her religious tradition and thus it is much more likely she is psychotic.
B. Yes, because the pastor finds Mrs. P, whom he knows well, to be irrational. This further suggests she is delusional, and those delusions may be impairing her capacity.
C. No, not because of the pastor’s interaction. There is a ethical duty to reconsider on the grounds that Mrs. P’s behavior is increasingly erratic, and she is more and more difficult to engage in care.
D. No, because this is just a religious disagreement and has nothing to do with a psychiatric diagnosis.
SEND QUESTIONS AND COMMENTS TO EDITOR@PSYCHIARICTIMES.COM. DR GEPPERT WILL DISCUSS THE ETHICAL CONCERNS AND QUESTIONS IN AN UPCOMING ISSUE OF PSYCHIATRIC TIMES.