World Religions for Healthcare Professionals Religious beliefs and customs can significantly shape patients’ and professionals’ attitudes toward, and expectations of, healthcare, as well as their wishes and personal boundaries regarding such daily matters as dress, diet, prayer, and touch. Undoubtedly, the sensitivity with which clinicians communicate with patients and make decisions regarding appropriate medical intervention can be greatly increased by an understanding of religious as well as other forms of cultural diversity. This second edition of a popular and established text offers healthcare students and professionals a clear and concise overview of health beliefs and practices in world religions, including Hinduism, Buddhism, Jainism, Confucianism, Taoism, Sikhism, Islam, Judaism, and Christianity. Adopting a consistent structure, each chapter considers the demographic profile of the community, the religion’s historical development, and key beliefs and practices, including views regarding health and sickness, death, and dying. Each chapter also ends with a useful checklist of advice on what to do and what to avoid, along with recommendations for further reading, both online and in print form. The book’s clear and consistent style ensures that readers with little background knowledge can find the information they need and assimilate it easily. A brand new chapter on applications and a set of new case studies illustrating issues in clinical practice enhance this wide-­ranging book’s value to students and practitioners alike. Siroj Sorajjakool has studied and taught world religions in university and healthcare settings for over 25 years. He is a professor in the School of Religion at Loma Linda University. Mark F. Carr has studied and taught in the areas of religion, theology, ethics, and bioethics for over 20 years. He holds a clinical ethics and administrative position at Providence Health and Services, Alaska. Ernest J. Bursey has studied and taught in the areas of religion, theology, New ­Testament, and healthcare for over 40 years. He teaches on these topics at the Adventist University of Healthcare Sciences. World Religions for Healthcare Professionals Second edition edited by Siroj Sorajjakool, Mark F. Carr, and Ernest J. Bursey Second edition published 2017 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2017 Siroj Sorajjakool, Mark F. Carr, and Ernest J. Bursey The right of the editors to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2009. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Names: Sorajjakool, Siroj, editor. | Carr, Mark F., editor. | Bursey, Ernest J., editor. Title: World religions for healthcare professionals / [edited by] Siroj Sorajjakool, Mark F. Carr, and Ernest J. Bursey. Description: Second edition. | Abingdon, Oxon ; New York, NY : Routledge, 2017. | Includes bibliographical references and index. Identifiers: LCCN 2016043134| ISBN 9781138189133 (hbk.) | ISBN 9781138189140 (pbk.) | ISBN 9781315641775 (ebk.) Subjects: LCSH: Medicine–Religious aspects. | Religions. | Cults. | MESH: Religion and Medicine | Spirituality | Cultural Competency | Patient Care–psychology | Professional-Patient Relations Classification: LCC BL65.M4 W67 2017 | NLM BL 65.M4 | DDC 201/.661–dc23 LC record available at https://lccn.loc.gov/2016043134 ISBN: 978-1-138-18913-3 (hbk) ISBN: 978-1-138-18914-0 (pbk) ISBN: 978-1-315-64177-5 (ebk) Typeset in Sabon by Wearset Ltd, Boldon, Tyne and Wear Contents Notes on contributors Preface Preface to the second edition Foreword to the second edition vii xi xiii xv W illiam J ohnsson 1 Introduction 1 E rnest J . B ursey 2 From conceptual to concrete 15 M ark  F . C arr and G erald  R . W inslow 3 American Indian religions 30 C arla G ober and R oy  K im 4 Hinduism 49 M anoj  S hah and S iroj  S orajjakool 5 Buddhism 66 S iroj  S orajjakool and S upaporn  N aewbood 6 Jainism 82 W hitny  B raun 7 Chinese religions 98 K wang - ­H ee  P ark 8 Sikhism A r v ind M andair 114 vi   Contents 9 Islam 133 H amid M a v ani 10 Judaism 153 D ouglas  K ohn 11 Christianity 171 D a v id R . L arson 12 Recent religious movements in America 189 J ulius J . N am Conclusion 211 Index 214 Contributors Whitny Braun, PhD, is an assistant professor of ethics in the School of Religion at Loma Linda University as well as a clinical bioethicist and public health professional who specializes in the ethics of intercultural engagement in the healthcare setting. She is also a contributor to the Huffington Post and her work has been seen on the National Geographic Channel and heard on NPR. She was formerly the director of the Center for Jain Studies at Claremont School of Theology and has been active in the legal matter of the Jain death ritual of Sallekhanā before the Indian courts. Ernest J. Bursey, PhD, is professor of religion in the department of Health and Biomedical Sciences at Adventist University of Health Sciences in Orlando, Florida. He received his doctoral degree from Yale University in the field of religious studies with a dissertation on exorcism in the Gospel of Matthew. He has had a long academic career at Walla Walla University where he served as dean of the School of Theology, and more recently at Adventist University of Health Sciences where he teaches undergraduate and graduate level courses in Spirituality and Healthcare, World Religions, Bioethics, and Biblical Studies. Mark F. Carr, PhD, served as professor of ethics in the School of Religion at Loma Linda University and the theological co-­director of the Center for Christian Bioethics at the same institution. He received his doctoral degree in religious ethics at the University of Virginia and wrote Passionate Deliberation: Emotion, Temperance, and the Care Ethic in Clinical Moral Deliberation (2001). After a brief time as chair of the Humanities and Social Sciences Department at Kettering College in Ohio, he now works in Anchorage, Alaska, where he serves as the region director of ethics for Providence Health and Services. Carla Gober, PhD, is director of the Center for Spiritual Life and Wholeness, assistant vice president for spiritual life and an assistant professor at Loma Linda University School of Religion. She holds bachelor’s degrees in nursing and religion and master’s degrees in public health education viii   Contributors and marriage and family studies. She has worked as a marriage and family counselor, a specialist in spiritual care and grief therapy, and a health educator. She completed her doctorate in religious studies from Emory University where her focus was in the area of attachment, memory, and meaning. Roy Kim, MD, is a staff physician at Riverside-­San Bernardino County (California) Indian Health, Inc. He graduated from Loma Linda University School of Medicine and completed his family medicine residency at Florida Hospital in Orlando. He went on to a faculty development fellowship at Emory University’s department of family and preventive medicine, at which time he also received his master of public health degree from Emory’s Rollins School of Public Health. He has worked with the World Health Organization in Kosovo treating the Roma, Ashkali, and Egyptian Gypsy population. He has also tended to patients in Africa, Asia, Eastern Europe, and South America. Douglas Kohn, MAHL, is senior rabbi of Congregation Emanu El in San Bernardino, California. He received his graduate and rabbinic training at Hebrew Union College-­Jewish Institute of Religion, culminating in his ordination in 1987. Prior to his current post, he served as the rabbi of Beth Tikvah Congregation in Hoffman Estate, Illinois, and assistant and associate rabbi in synagogues in Buffalo and Baltimore. He has also served as an adjunct instructor for Hilbert College in Hamburg, New York. He is the editor of Life, Faith, and Cancer: Jewish Journeys through Diagnosis (2008). David R. Larson, DMin, PhD, is professor of religion at Loma Linda University School of Religion. His specialty is in ethics from a Christian perspective, with a particular focus on bioethics. At Loma Linda University, he helped found the Center for Christian Bioethics, which has grown to be an important resource in the discipline. He received his DMin degree from Claremont School of Theology and PhD degree from Claremont Graduate University. He edited Abortion: Ethical Issues and Options (1992) and co-­edited Christianity and Homosexuality: Some Seventh-­day Adventist Perspectives (2008). Arvind Mandair, PhD, is endowed professor of Sikh studies at the University of Michigan at Ann Arbor where he holds the SBSC chair in Sikh studies. He received his PhD in chemistry from Aston University in Birmingham, United Kingdom, and PhD in philosophy/Sikh studies from the University of Warwick, also in the UK. He is the author of Religion and the Specter of the West: Sikhism, India, Postcoloniality and the Politics of Translation (Columbia University Press, 2009). He is the founding co-­editor of the journal Sikh Formations: Religion, Culture and Theory, published by Routledge. Contributors   ix Hamid Mavani, PhD, is assistant professor of Islamic studies at Claremont Graduate University, School of Religion. He obtained his graduate degrees from McGill University and received theological training from the seminaries in Qum, Cairo, and Damascus. This has enabled him to be an active contributor in both the academic and community discourses. His primary fields of interest include Islamic legal reform, women and Shi’i law, Shi’i theology and political thought, Muslims in America, Qur’anic studies, and contemporary developments in the Muslim world. Supaporn Naewbood, DrPH, is a lecturer in nursing at Narasuan University, Pitsanulok, Thailand, and a doctoral student in public health nursing at Mahidol University in Bangkok. She received her master’s degree in health education from Chulalongkorn University, her second master’s degree in community health nursing, and her DrPH from Mahidol University. Julius J. Nam, PhD, JD, received his doctorate in religion from Andrews University where he wrote a dissertation on the relationship between Seventh-­day Adventism and evangelical Protestantism in the United States. He has taught at Loma Linda University and Pacific Union College. He currently works for the US Department of Justice as an assistant United States attorney in Los Angeles, California. Kwang-­Hee Park, PhD, OMDLAC, received her doctoral degree in theology and personality from Claremont School of Theology and her doctorate in oriental medicine and acupuncture from South Baylo University in Orange County, California, where she worked as a researcher and patient counselor in the research department. She currently teaches both graduate courses in research, patient counseling, and psychology at South Baylo’s department of Oriental medicine and herbology. Manoj Shah, MD, is head of pediatrics gastroenterology division at Loma Linda University Medical Center and associate professor of pediatrics at Loma Linda University. He received his medical degree from Medical College, Baroda University in Gujarati, India and completed his residency at Cardinal Glennon Children’s Hospital at St. Luke’s Medical Center. He also served as vice president for the Federation of Gujarati Associations of North America, West Zone. He is the author of numerous peer-­reviewed journal articles. Siroj Sorajjakool, PhD, received his degree from Claremont School of Theology in the field of personality and theology and currently serves as professor of religion, psychology, and counseling at Loma Linda University. His research focus is on psychology among Asian religions. Gerald Winslow, PhD, is the founding director of Loma Linda University’s Institute for Health Policy and Leadership, and a professor of religion in x   Contributors the university’s School of Religion. Previously, he served LLU as dean of the School of Religion, vice chancellor, and vice president for mission and culture. He received his undergraduate education at Walla Walla University and his master’s degree at Andrews University. He earned his doctorate from Graduate Theological Union in Berkeley. He has also been a visiting scholar at Cambridge University, the University of Virginia, and the University of Tubingen. For over 40 years, he has specialized in teaching and writing about ethics, especially biomedical ethics. His current work focuses on the intersections of social and health policy. His books include Triage and Justice (University of California Press) and Facing Limits (edited with James Walters; Westview Press). His articles have appeared in academic journals such as Western Journal of Medicine, Journal of Pediatrics, Hasting Center Report, Journal of Medicine and Philosophy, and General Dentistry. He has presented seminars and lectures at universities and for professional groups throughout North America and in Australia, Europe, Russia, Africa, and Asia. He serves as the chairperson for Stakeholder Health’s Advisory Council. He is also a member of the California Technology Assessment Forum, a public forum for the evaluation of new healthcare technologies. He has served as a consultant in biomedical ethics for major healthcare systems and for research conducted by pharmaceutical companies. Preface Teaching and publishing on the topic of world religions is not for the faint of heart. It takes courage and a bit of careless abandonment. Take, for instance, the idea that one can describe Hinduism in a single chapter – a religion that spans thousands of years, billions of adherents, and multiple continents, languages, and people groups. The same can be said for Islam, Christianity, Buddhism, Judaism, and so on. Add to this the complexity of specific elements of each of these religions that have special relevance for healthcare. This effort is multifaceted. First, we seek to identify issues emerging from an authentic, lived-­out, faith-­ based perspective on life and health. In other words, our aim is to convey information from within the religious context. Second, we must write and offer this work for the reader. Readers have specific needs – practical, educational needs that our authors must address. Third, when considering health beliefs and practices, it is difficult to make a clear distinction between faith and cultural practice. Despite these challenges, we enthusiastically offer the text that follows. We are excited about it in part because we teach it and live it out in practice in the places we live and work. Most of the authors are, in fact, involved daily in teaching and/or practice that is focused on religion and healthcare. Faith-­based healthcare institutions, both educational and service-­oriented facilities, are hard pressed to thrive in the current context in North America. In a highly competitive and intensely difficult financial context, there remain people committed to offering healthcare from a faith-­based perspective. Regardless of the context from which you offer healthcare, providers must also be purposeful in this day and age to attend to matters of religion. The religious diversity that healthcare providers face in the lives of their patients is unprecedented in world history. North America is the most religiously diverse culture ever to appear and our healthcare providers must deal with this fact routinely. We have assiduously approached this project from a non-­partisan perspective. In other words, we are not offering this book for North American Christians to learn more about non-­Christians they may face as clients and xii   Preface patients. Anyone who works in healthcare knows that as many, if not more, of the healthcare providers in North America are non-­Christians. We do not need a book of the sort that looks toward the Other from a Christian or any one privileged perspective to see what they believe and who they are. The Hindu psychologist needs to know about Latter-­day Saints as much as Catholic nurses need to know about Buddhists. The Muslim surgeon needs to know about Jehovah’s Witness beliefs as much as the Sikh pharmacist needs to know about her Jewish patient. The Shi’a public health official needs to know more about the Sunni family who lives just down the street. We find these inter-­religious conversations to be incredibly energizing and useful. Useful to a society that celebrates its diversity. Useful to a community that purposefully seeks points of commonality while respecting points of difference. We hope that you will also. There is very little storytelling in this volume, with the one notable exception of the chapter on American Indians. Although storytelling is integral to all religion, we made an exception in our format for the chapter on American Indians. The stories that will keep this volume alive in the minds of our readers, however, are those that you will share with your colleagues, friends, and families about what you have learned by reading; about what happened at work with this or that religious person or family or nurse or doctor. With our first edition, weeks prior to our deadline, we learned of a traditional Islamic practice of shaving the head of a newborn baby. As we finalized content for this edition, we are once again struck by a novel case of old believers from Russia here in America for three generations. Their death and burial rituals demanded they simply take their loved one’s body from the ICU to their vehicle for transport home. Preface to the second edition We added two chapters to this second edition (Chapter 2: From conceptual to concrete and Chapter 6: Jainism). Besides these two chapters, Ernest J. Bursey made meaningful modifications to Chapter 1 and case studies on each religion have been added. In Chapter 2, Carr and Winslow offer a chapter that describes the interaction and methodological realities of ethics and religion/spirituality. Hospital-­based clinical ethics in America (and abroad) have developed standards of case consultation the reader should know about. This need is based, in part, on the fact that ethics and religion are as intertwined and complex as is the question of culture and religion. And in the hospital context ethics have a direct bearing on how religion/ spirituality is lived out. This new chapter has a section focused on the ethics of caregiver–patient interaction with specific regard to religion and spirituality. Additionally, Whitny Braun joins us with a chapter on Jainism. Dr. Braun writes from both personal experience and scholarly expertise in Jainism. Her work on Sallekhanā, a unique Jain ritual of fasting to death, recently took her to India to participate in the ongoing battle before the Supreme Court over the legality of the religious practice. Her research was featured in the appeal to overturn the court’s decision to outright ban the practice and her testimony as an expert witness has been used by the lawyers arguing the case. Significantly high proportions of the Jain community are clinicians of allopathic medicine when compared to many of the other major religions, yet the group as a whole tends to avoid heroic measures in medicine and practice a careful ethic of not prescribing medication that may harm other life forms. I would also like to express my appreciation to my colleagues who helped me identify and write the case studies included at the end of each chapter in this second edition. I wrote some of them, I co-­authored some of them, and others authored some of them. Some of the authors I worked with were hesitant to identify themselves for fear that some involved parties might recognize elements of it. Although we masked personal identities, times, and locations out of respect for confidentiality (a subsidiary rule of the principle of respect for autonomy), a few authors did not want xiv   Preface to the second edition to be identified by name. Nonetheless, I owe them a note of gratitude and appreciation for their collaboration in this project. While this is a collection of essays such that the individuality of each author is expressed in the essay, we offer it as a textbook that has a consistent chapter structure aimed at the reader’s need for a useful reference on the various religious perspectives. These chapters illustrate the fact that the study of religion is an objective, scientific, and academic venture. We consider this academic exploration both essential and enriching. But for those who may read this text from a lived experience of faith, such an approach may be new and somewhat challenging. A special thanks to the School of Religion for special funding to make this project a success; to Brianna Taylor for excellent work on abstracts for many chapters; to Brian Loui for researching demographic data, reformatting, completing abstracts, and adding final touches to the editorial process. There is never a dull day in the offering of care to those in need. Religion is often a difficult, additional concern for already complex healthcare situations. But attending to patients’ and families’ religion is essential in our context. We commend you for your efforts and wish you well. Mark F. Carr Anchorage, July 2016 Foreword to the second edition As World Religions for Healthcare Professionals advances to a second edition, I commend the editors who compiled this useful volume. Siroj Sorajjakool, Mark F. Carr, and Ernest J. Bursey have put together a work that has quickly shown its value to students in the classroom and professionals in the office. In today’s fast-­changing society, books like this are essential for anyone who seeks to be knowledgeable of the world around. People are on the move, from East to West, immigrants or refugees. They bring with them their cultures and religions. Our neighbor, the clerk in the post office, the checker at the supermarket, the salesperson in the department store – we encounter Sikhs, Muslims, Buddhists, Hindus, and others of different faiths. Inevitably, the doctor, dentist, or healthcare provider will be thrown into close encounters with clients from a variety of religious traditions. Sheer professionalism demands that the healthcare provider has a modicum of knowledge of the religious background of every patient in order to provide care with understanding and sensitivity. For many clients, even for those whose religion is the same as the professional, a visit to the office of the doctor, dentist, physical therapist, etc. in itself arouses apprehension. How much more is this the case when the client approaches with concerns that the professional may violate religious scruples or taboos? This book meets an urgent and vital need. It is commendable, first, because those who write on each religious tradition actually practice that faith – they aren’t arm-­chair “experts.” They know what matters, what sensibilities clients of that religion bring. Thus, while each writer lays out the basic tenets of the respective religion, each also gives specific, practical suggestions to enable the healthcare provider to avoid religious taboos. While there are many works on world religion in the marketplace, this one stands apart because of its focus on health beliefs and practices. It targets, intentionally and specifically, the healthcare professional. A few other volumes attempt the same outcome, but they tend to be detailed in coverage and expensive to purchase. World Religions for Healthcare Professionals is concise, compact, and affordable. xvi   Foreword to the second edition I have assigned this book to students in my World Religions classes who are preparing for careers in dentistry, pharmacy, and other healthcare professions at Loma Linda University. They have found it useful. Now, as it is reprinted in a revised and expanded edition (a chapter on the Jain religion is added), it will be even more helpful. William G. Johnsson, PhD Loma Linda, California 1 Introduction Ernest J. Bursey Welcome to world religions from a healthcare perspective! The study of world religions offers you the opportunity to more adequately meet the needs of your patients and clients, because you will possess a more accurate knowledge of their religious beliefs and practices. Extensive research supports the claim that patients who actively participate in a religion enjoy a longer life span and shorter stays in hospital than their counterparts. In a seminal, critical review, J. Levin (1994) concluded that the available published research at that time supported an association between religion and health, that the association is valid, and that it is probably causal. Subsequent research generally supports Levin’s conclusion of a valid association between health and religion or spirituality. The Handbook of Religion and Health, a massive standard reference now in its second edition, estimates more than 2100 qualitative studies have been published, most indicating a positive correlation between religion and health (Koenig et al. 2012). A particularly important finding for our purposes is that the health benefits from religious affiliation are not restricted to one specific religion. Evidence that the financial interests of a hospital are better served when the religious needs of patients are addressed while in the hospital has led to a growing use of spiritual assessment tools by both physicians and nurses, and the introduction of spirituality and medicine into the curricula of medical schools. In 1994, only 16 out of 126 medical schools offered courses in medicine and spirituality. By 2010, more than 90 percent of medical schools in America addressed spirituality and medicine in their curricula (Koenig et al. 2010). The number of patients with religious affiliations other than Christianity has significantly increased because the general population of the United States has become more religiously diverse since 1965. That year, President Lyndon Johnson signed the Immigration and Nationality Act, which ended the national quota system that had discriminated against persons from Asia and the Middle East. In the years since 1965, preferential access in immigration has been given to applicants with scientific and medical expertise needed in the 2   E. J. Bursey United States. For example, a study by Cornell University in 2002 disclosed that one in ten Muslim households in the United States includes a physician (Allied Media Corporation 2007). One positive benefit from the study of world religions could be a better understanding of the growing number of immigrant healthcare professionals who actively embrace a faith tradition other than Christianity. Nearly all of my graduate nursing students report working alongside nurses or physicians who openly hold to a faith other than their own and who believe their faith makes them better healthcare professionals. Hopefully, as a result of reading this volume, you will become more aware of the religious minorities in your own community and perhaps more sensitive to the challenges they face in maintaining their religious practices and culture. The majority of legal immigrants, particularly from Central and South America, continue to be Christian since the largest percentage of immigrants to the United States are from Central and South America. But significant numbers of Hindus and Muslims, particularly from South Asia, have immigrated and become naturalized citizens. Mosques and temples sprout up in suburban American neighborhoods to meet the religious needs of the growing population of immigrants and their children. Funding for these projects is underwritten in part by affluent immigrant professionals, including those in healthcare and engineering. At the dedication of a new temple in Florida on June 15–19, 2005, a souvenir booklet itemized the names of donors; out of a total of 77 named devotees contributing $10,000 or more each, 42 were listed as “Dr.,” with ten of these double listed as “Drs.,” indicating both marriage partners held doctorates (Hindu Society of Central Florida 2005). On a wider front, your knowledge about the religions of the world here in North America will give you one more window into understanding current events. Predictions of futurists a generation ago that organized religions would just wither away under the advance of secularism have turned out to be wrong. In the wider world, people are as prone as ever to identify with ancient religious traditions. Religious fundamentalism is alive and even growing within most of the major religions of the world, including Buddhism, Christianity, Hinduism, Islam, and Judaism. While religious difference is usually only one of several causes of armed conflicts, it often functions to give a justification for continuing conflicts between tribes or nations. The universally recognized Dalai Lama from Tibet has brought new luster to Buddhism while being castigated by the Chinese government for fomenting a separatist movement. Muslims around the world have been judged by the actions of the terrorists who flew the two airliners loaded with jet fuel into the Twin Towers on September 11, 2001. The declaration of a worldwide caliphate in 2014 by the Islamic State of Iraq and Syria (ISIS), a jihadist military group, and the response of disaffected young Muslims around the world to join the fighting has increased the fears that Islam is inherently bent on the overthrow of all governments, in Introduction   3 spite of the denunciation against ISIS by virtually all Muslim scholars and religious leaders. Personal benefits and challenges We are more than healthcare professionals. We are, first of all, human beings who share with all human beings, including our patients, the mysteries of existence and the common experience of suffering and the certainty of death. As creatures with a bent to find meaning in our lives, we seek to cope with events that seem to defy any rational explanation. The medical explanation of an immediate cause for the death of a child falls short of explaining why we are living in a universe where this can happen. Religious people, like other humans, seek to find a conceptual framework that accounts for and even counters the apparent randomness of events. Religions attempt to answer the fundamental questions of why we have been born, the purpose of our existence, and what, if anything, lies beyond this life. It is true that when we begin to study another religion we are confronted with strange terms and even stranger practices that may give us the feeling that we are studying the beliefs of aliens quite different from ourselves. But at a deeper level, studying the religious beliefs of faiths other than your own may give you a sense of the deep bond you share with all other persons. Any medical care that fails to give homage to this common humanity dishonors the dignity of those it seeks to heal. If you consider yourself an adherent of a particular religion, you may sense the inherent challenges, and even risks, in studying other religions. Students often discover they were misinformed about what a particular religion actually teaches, as a result of taking a course on world religions. Occasionally an introductory course in world religions leads to further study into a new religion and even the change of religious affiliation. A former student described being required as a child to attend her parents’ church where she never felt at home with the ritual and loud preaching: “I often wanted to run out screaming.” When she was an adult student in a world religions course, she chose to visit a Buddhist retreat center where she felt embraced within the serene setting and calmed by the instruction in meditation that reduced her inner stress. She called me from 2500 miles away to announce that she had found her true spiritual home. Her case is an exception. Much more often students challenged in a course in world religions decide to look more closely at their own religious tradition and acquire a more accurate knowledge of its basic beliefs. As any teacher of world religions can attest, most Americans, regardless of the religious tradition to which they belong, have a limited understanding of the resources of their own religious tradition. It has often been observed that by learning a second language a person develops a more acute understanding of one’s native language. Likewise, a course in world religions often serves as a catalyst for a more mature grasp of a childhood faith. 4   E. J. Bursey While most healthcare professionals welcome the opportunity to better understand the religious perspectives of their clients and colleagues, not all are convinced, at least at the onset, of the need to spend time, effort, and expense to study the history and beliefs of various world religions. First, some are deeply convinced that their own religious faith is the only true one and that other religions teach dangerous ideas that can lead to the embrace of error, perhaps with eternal consequences. Typically persons holding this position also see it as their duty to share their beliefs with others, out of both a sense of responsibility and a concern for the welfare of others. Upon reflection, it becomes clear that any realistic attempt at sharing one’s faith requires a sound knowledge of the beliefs and practices of the other. All persuasion begins on common ground. Given that the social decorum of healthcare professionals demands appropriate restrictions upon sharing one’s faith, healthcare professionals living with a mandate to share their faith may live with an inner tension between the demands of their faith and their profession. Nonetheless, devout souls who await opportunities to speak of their faith are more likely to find receptive hearers if they are knowledgeable about the others’ beliefs. A second group that may be resistant to investing in the study of world religions are those who describe themselves as non-­religious and who are aware of what they consider to be the harmful effects of religious dogmatism and superstition – wars, religious extremists, entrenched opposition to scientific knowledge and even to beneficial health practices. Concern for their patients’ well-­being may lead them to learn enough to avoid the pitfalls that would offend a devout patient. But a study of the worldviews and distinctive practices outside of the narrow healthcare arena seems irrelevant to the curriculum of a healthcare profession. It must be admitted that the non-­religious or secular population is typically under-­represented in courses on world religions. Perhaps you are part of that group. This marginalization masks the evidence that the secular or non-­religious segment of American society, while still small, is growing in numbers and voice. Openly acknowledging the presence and the viewpoints of non-­religious students is a vital step toward greater dialogue and engagement over the negative and positive influences of religion. What is a world religion? Ask ten people on the street for a definition of religion and you may get ten different answers, some focusing on the beliefs, some on practices or rituals. Even when scholars define religion, the results can be quite diverse, depending in part on whether a scholar is a sociologist or a psychologist, an anthropologist or a theologian. If the sociologist stresses the communal nature of religious practice and the social construction of religious beliefs, the psychologist may address religion within the individual’s search for autonomy and personhood. The anthropologist stands outside the circle of Introduction   5 religious belief in describing myth and ritual within a specific cultural context, while the theologian presumes the possibility of communication with a supernatural reality. For the purposes of this book, rather than hammering out a definition of religion, our efforts can be better spent in identifying and comparing the features that are common to different religions and then to recognize the functions that religions and religious beliefs have. Where do I come from? Why am I here? What happens after death? Religion can be understood as a response to these questions of human origin, purpose, and destination, especially in the light of the certainty of death and the uncertainties of life. The mystery of our own existence and the realization that we are transient creatures attracts many to religions that claim access to the unseen beyond the senses. Each day we are immersed in a stream of events that arrive without warning. Religions typically offer the believer some sort of coherent framework of meaning to interpret these apparently random events. Religions also issue directives on how we might impose a semblance of order in our daily lives through the observance of times of worship, prayer, reading of sacred texts, and meditation. The focus of this volume is the so-­called “world religions,” although Native American religions and new religious movements are included. Humans are universally religious. Yet not every religion can be called a world religion. When academics refer to world religions, the list typically includes Hinduism, Buddhism, Islam, Judaism, Taoism, Confucianism, and Christianity. Other religions occasionally included are Sikhism, Jainism, Zoroastrianism, and the Baha’i. Shinto, the national religion of Japan, and nature religions such as Wicca may be included as well. In addition to being widespread, the so-­called “world religions” typically possess scriptures or religious texts that serve to anchor religious beliefs and written collections of authoritative teachings that can be transmitted from one generation to the next. Jews revere the Tanakh and study the rulings of rabbis found in the Mishnah and Talmud. Muslims consider the Qur’an to contain the very words of Allah and draw on the preserved rulings of legal scholars familiar with the collections of sayings about and by Muhammad. But humans have been religious long before they learned to transmit knowledge through the medium of writing. Throughout the world and on every inhabited continent, indigenous peoples have feared unseen spiritual forces and sought to control them or seek their favor, often by elaborate ritual and the observance of taboos. Religion and culture This textbook focuses on religions and on the religious beliefs and practices that are characteristic of religions, not on culture and cultural practices. But religion is a part of culture. Culture includes the totality of the 6   E. J. Bursey customs and practices of a distinct group of people. So separating what is religious from what is simply cultural is not an easy matter. It might seem that the beliefs and rituals of a world religion like Buddhism or Islam or Christianity ought to be the same anywhere in the world. Yet the way a religion is actually practiced may vary considerably from culture to culture, and age to age. Labels like “fundamentalist,” “conservative,” “progressive,” and “liberal” are used to describe the variations within a religion and suggest that the individual variations in religious practices may not be isolated but part of a larger collection of specific practices and beliefs considered as “core” for groups within a given religion. Deciding what belongs under the umbrella of religion can be complicated and even confusing. Persons living in one country may include rituals or customs as part of their religious obligations that persons belonging to the same religion but living in a different country consider optional or even refuse to practice. For instance, the practice of female genital mutilation or female circumcision is widely practiced in Egypt. According to a recent study, 92 percent of Egyptian women have undergone some form of female circumcision (Ministry of Health and Population et al. 2015: 185). The Egyptian government made the procedure illegal in 2008. Yet the practice persists. A frequently cited reason is the belief that good Muslim women undergo the operation. In contrast to the societal encouragement in Egypt, the conservative Muslim society of nearby Saudi Arabia looks down upon the practice as against the principles of Islam. Saudi Arabia has legally forbidden the procedure as well. Who then decides whether a belief or practice is to be truly considered a religious obligation or simply a traditional cultural practice? In some religions, a recognized religious authority may make the decision about what is core and non-­negotiable. Roman Catholics generally consider the decisions of popes, past and present, to define what they are to believe and practice. In some religions, there may be no comparable, universally recognized figure or authoritative group. More than 50 percent of Egyptian women still consider female circumcision to be a religious requirement (Ministry of Health and Population et al. 2015: 185). High-­ranking religious leaders claiming otherwise are dismissed because they are government funded. The impact of American culture on transplanted faith traditions is often profound. Immigrants who come to the United States from a country where their religion was sponsored by the government discover on arriving that if they want to retain their religious faith they must take more personal initiative in the practice of their religion than they had taken in their country of origin. The openness and even secularization of American culture can have a double-­edge effect on religious minorities – on the one hand, leading to a deepening personal understanding of one’s faith, but on the other hand, raising legitimate concerns about the religious commitments of the second and third generation. I recall a Muslim businesswoman from Tanzania Introduction   7 telling the students in my classroom that she knew more about her faith and why she was a Muslim than her relatives who remained in Tanzania, where their religion was taken for granted and supported by loudspeakers announcing the times of prayer. Scholars of religions in America note that transported religions, including even the major world religions, tend to morph into more distinctly American forms. The openness of American culture makes isolation difficult. A continual infusion of new immigrants ensures the retention of traditional practices and views. But over time, something uniquely American or Westernized begins to emerge. Factors that drive this on-­going process include the expectation of American women to fully participate and even lead out in religious functions, the constitutional freedom to openly discuss and debate religious matters, the recognized absolute right of personal choice in matters of faith, and the acceptance of inter-­faith marriages. Debates over the physical presence of women in public worship continue to percolate in traditional Muslim and Orthodox Jewish communities. The desire of immigrants to lessen prejudice by blending into the cultural landscape and to demonstrate loyalty to an adopted country leads to changes in the practice of their religion. R. H. Seager observes an indigenous American Buddhism in the making, though the process is far from completed (Seager 2002: 118). Japanese farmers immigrated to America in the 1800s, bringing their Shin Buddhist religion with them. Over time, temples were built that outwardly imitated the appearance of Protestant churches, unlike the traditional architecture of Shin Buddhist temples in Japan. Pews replaced mats. Western musical instruments, hymns, and even choirs were incorporated into the religious services. After the Japanese attack on Pearl Harbor in 1941 and President Roosevelt’s executive order to round up citizens of Japanese descent, the name, Buddhist Mission of North America, was changed to Buddhist Churches of America. Other transplanted religions face similar developments. Santeria, a New World version of the African Yoruba religion, was twice transplanted, first as early as the sixteenth century by slaves to Cuba where they found common ground between African gods and Catholic saints and managed to continue their devotion to the orishas disguised as saints. The religion was transported a second time by exiles fleeing to the United States during Fidel Castro’s revolution. Most of the estimated adherents in the States are now light-­skinned, college educated, and middle class. Of interest to healthcare professionals is the vast healing lore involving herbalists and spiritualist mediums. Coming out from the shadows of secrecy in the more permissive and pluralistic American environment, the first Santeria church was established in Hialeah, Florida in 1974. The religion appears to be growing in numbers; estimates of devotees range from half a million upwards. Meanwhile, the previously required animal sacrifices are decreasing and drumming is avoided out of respect for neighbors (De La Torre 2004: 205–23). 8   E. J. Bursey On the other hand, the growing impact of religious beliefs and practices from immigrant religions is equally noteworthy, especially in healthcare. Payment for Chinese acupuncture treatment is widely, if not universally, accepted by insurance plans. Mindfulness, part of the Eightfold Path of Buddhism, is securely embedded in hospitals and university research centers as a legitimate therapy for stress and stress-­related illness. The impetus to introduce Buddhist mindfulness practice into secular American healthcare using non-­religious vocabulary is credited to Jon Kabat-­Zinn, former Professor of Medicine at the University of Massachusetts. Faith-­ based hospitals in the Christian tradition have resisted what has been described as “stealth Buddhism” (Brown 2014). Yoga as a way to improve one’s health is now as American as apple pie, notwithstanding protests from Hindu purists and some religious voices in the Christian and Islamic traditions. Religion, ethics, and transformation While religions have traditionally focused on how we ought to relate to the divine, all the major religions of the world also promote moral codes of conduct about how we ought to relate to each other. Whether you look in the Jewish Tanakh, the Christian New Testament, the Buddhist Dhammapada, the Hindu Bhagavad Gita, or the Muslim Qur’an, these codes of conduct are actually quite similar in forbidding murder, adultery, stealing, lying, disrespect of parents and elders, etc. The Golden Rule attributed to Jesus in the New Testament, “Do to others what you would want them to do to you,” can be paralleled by the words of Muhammad, Buddha, and other religious teachers. Some Americans fear that basic moral standards will be undermined by the growing number of the population that embrace non-­Christian religions. Such fears are groundless. Religions of the world generally place a high value on honesty, unselfishness, marital faithfulness, and the responsibility to preserve human life. Religious persons of every stripe tend to oppose abortion or the practice of active euthanasia at higher rates than more secular persons. All the major religions of the world also address the contradictions of human behavior in that humans typically live below the standards of their own moral codes, with some falling far short of basic human decency. These lapses require both an explanation and an antidote. The religions of the world tend to diverge from one another in their diagnosis of the cause for that gap between acceptable standards and actual moral conduct. It is not surprising that differing etiologies to account for moral failure lead to divergent prescriptions or strategies for closing the moral gap. Hindus and Buddhists expect reincarnation or rebirth to deal with negative karma accumulated from wrong-­doing in previous lives. Muslims practice the regimen of submissive prayer five times daily as an aid to keeping their mind on the straight path of righteousness. Christians hold to the benefits Introduction   9 from a crucified Savior to counter the consequences of a fatally flawed human nature. A note about the “nones” The percentage of Americans claiming no religious affiliation rose dramatically from 16 percent to 23 percent in the seven years from 2007 to 2014. A closer look reveals important differences among these “nones.” But every category shows a trend away from organized religion (Lipka 2016). This trend appears to follow the pattern of European secularization. Some find no interest or value in the discussion or practice of religion. In 2014, one in ten Americans fell into this simply secular category of no interest. If all persons adopted this position, books and courses about world religions would cease, except for the study of religion as a cultural artifact of the past. Age comparisons are even more alarming to those who see religious belief as a bulwark of morality. While two-­thirds of those born before 1946 claim religion to be important in their lives, the number for those born between 1981 and 1996 drops to only four out of ten (Gjelten 2015). Efforts to understand and counter these trends are evident in every faith tradition. Factors toward the marginalization of religion and the drop in religious affiliation include a sense that science conveys truth while religion may peddle tradition; the lack of confidence in the relevance of religious organ­ izations; the publicized moral corruption of religious leaders; and, in the case of Christianity and Islam, a rejection of an angry or vengeful God. The plurality of religions can create a disbelief that any of them can claim to provide the exclusive avenue to the Divine. Seven percent of the population are not affiliated with a specific religion but believe a religious or spiritual perspective to be important. These are typically categorized as “spiritual but not religious” (SBNR). Often they “have rejected a God stereotyped as a judgment overseer and instead have substituted the idea of a sacred force which is impersonal and benevolent” (Mercadante 2014: 230). A self-­declared former SBNR, Mercadante notes that many will in time move from the category of “none” to affiliate with a religion. The search for a coherent meaning to human existence and for religious practices to counteract a self-­centered spiritual experience and for the strength that comes from belonging can lead them to a religious community. Ideally, that community is able to portray a loving God and offer a counter view to the values of a market-­driven culture. Another 3 percent polled considered themselves atheists, double the percentage in 2007; while self-­identified agnostics also almost doubled at 4 percent in 2014. Two out of three atheists are males, with a median age of 34, compared with a median age of 46 for the general public. Deep suspicion of atheists shows up, with 51 percent of Americans viewing atheism as a personal deterrent when voting for the President, down from 10   E. J. Bursey 63 percent in 2007. Recently the strident calls of prominent atheists like Richard Dawkins and Christopher Hitchens to eliminate religious belief and abolish religious privileges have found a widespread audience. But other atheists recognize the social value of religion and seek to establish corresponding non-­theistic or humanist communities that can work with religious organ­izations in bettering human life (Stedman 2013, cited in Krattenmaker 2016). Religion and healthcare One of the distinctive features of this textbook on world religions is the focus on healthcare. Historically, virtually all religions have been concerned with illness and the maintenance of health. Some offer explanations for the presence of sickness and death. Some paradigms for treating illness are theoretically tied to particular religions. Ayurveda, a form of medical care widely practiced in India and to some extent in North America as an alternative to Western medicine, is closely associated with Hinduism. Traditional Chinese medicine, including acupuncture and moxibustion, has theoretical roots in Taoist thought. On the other hand, the missionary religions of Buddhism, Christianity, and Islam have not been so closely tied to a particular medical paradigm, but their followers have accommodated to a variety of medical practices. For thousands of years, religion has been involved in bringing physical and mental healing. Illness has been widely considered as caused by negative or even hostile spiritual forces that need to be appeased or even banished to restore health. Jesus, the founder of Christianity, healed the sick, often by means of exorcism, alongside his preaching. His enemies attributed his particular effectiveness as an exorcist to an alleged alliance with Satan. A key factor in the spread of Christianity was the perceived effectiveness of Christian missionaries in banishing evil spirits in the name of Jesus. Yet today physicians in the west who call themselves Christians typically do not include demonic possession as a diagnosis. Florida Hospital, a faith-­based Christian hospital with the motto “Extending the healing ministry of Christ,” does not have a department of exorcism but follows the protocols of Western biomedical healthcare. Yet many devout believers continue to put their confidence in prayers and rituals to address what they consider to be the spiritual causes of their illness. Whether or not you hold such views, you will need to become aware of the differing understandings of illness in order to more skillfully assist your patients in their recovery. The rapid growth of medical knowledge has raised profound challenges to the ethical norms of all the world religions. Religious leaders have struggled to keep up in providing the faithful with guidance regarding life-­ creating, life-­extending, and life-­denying technologies that were previously unimaginable but now are readily available. Rather than automatically Introduction   11 embracing the latest life-­enhancing miracle or simply denouncing the new outright, they have more often turned to their scriptures, the ancient texts held to contain the essential wisdom, in order to provide a rationale for embracing or denying each medical advance. Shall sperm donors be denounced as adulterers? Does in vitro fertilization blur the distinction between the Creator and the human creature? Is the circulation of blood through external cleansing equipment during surgery a violation of the Bible’s prohibition against ingesting blood? If God is the source of human life, under what circumstances then, if any, may a pregnancy be terminated? Muslim and Catholic theologians differ on when an embryo receives a soul or is deemed a person, and consequently they issue different rulings regarding the use of drugs that impede implantation of the embryo in the lining of the uterus. When is the removal of artificial life support justified? Religions typically place a high value on human life and stand almost united against active euthanasia or physician-­assisted suicide. Yet limits to the utilization of life-­extending technology have to be drawn somewhere. In most religions, the authority of a religious leader will be recognized by only a portion of the faithful and so conflicting views may be offered as options. The Orthodox Jewish belief that the soul of a person gradually withdraws from the body and may remain with the body even when higher brain function appears to cease can put end-­of-life decisions on a collision course between medical personnel and the dying person’s family. These conflicts make graphic headlines in newspapers eager to boost reader interest: “Catholic godson of woman on life support fights to get proxy back” (Saul 2014) and “Hasidic boy in legal fight over life support buried” (Furse 2008). Chayim Aruchim, a program of the ultra-­conservative Agudath Israel of America, appeals to Jews to seek the guidance of a rabbi trained in Jewish law or halakha when navigating end-­of-life issues. For a comprehensive guide to the range of Orthodox halakha reasoning, see Shabtai (2012). Less conservative Jews in the Reformed and Conservative branches of Judaism are more likely to end life support when no brain activity can be detected and the beating heart is dependent on a mechanical ventilator. The importance of preserving the body intact for a future resurrection of the deceased has often stood in the way of Muslim, Jewish, and Catholic families granting permission for medical autopsy for potentially valuable medical knowledge. Autopsy itself has seemed to some to be like the desecrating of the fallen warrior on the field of battle, forbidden by the sacred text of the Qur’an. Yet when organ transplantation offered the gift of life to persons dying from organ failure, theologians and religious leaders reconsidered long-­held positions and took up the questions of when organs could be harvested, who should receive them, etc. When the faithful accept the gift of an organ for the sake of preserving their own lives, fairness calls for reciprocity by allowing them to offer that gift to another person. 12   E. J. Bursey A recommendation to enhance your learning This text was carefully prepared by knowledgeable experts to offer you a reliable overview of the several recognized world religions. Yet I recommend that you supplement a careful reading of this text with face-­to-face conversations with persons from other religious traditions who are active in the practice of their own religion. I know of no other experience to better awaken your awareness of what you have been reading. Reading a chapter in this book about a religion other than your own will serve to introduce you to that tradition. It would require years of careful study and experience for a Christian, for instance, to know the vast range of views and practices that are held among so-­called Hindus. Should you interview a person from another religious tradition, you may discover that this person holds views about their religion that differ somewhat from what is found in the chapter on that religion in this textbook. On the other hand, if you read the chapter carefully in advance of the interview, you may discover that you know specific information about that religion or its history that the person you interview did not know about their own religion! Most importantly, you will learn not so much about the religion’s beliefs and history but how another person actually practices the religion they love. That is a treasure worth seeking. Conclusion As you study each of the religions, picture in your mind four concentric circles. In the outer and largest circle, you will find the basic information about a world religion’s belief system and resources, as well as how it is practiced with some variations around the world. Then picture inside that larger circle a smaller circle to represent how that religion is practiced here in the United States where religious freedom is practiced but where Christianity is the dominant religion. The inevitable impact of American culture produces accommodations and innovations in each incoming religion. Conversely, incoming religions enrich American culture. In this textbook, you will find some attention to this circle of cultural immersion. Likely you will find further evidence of accommodation if you take up the suggestion of interviewing a person from another religious tradition. Now envision a still smaller circle to represent American healthcare. Here the religious beliefs and practices of patients and healthcare practitioners interact with one another. When faced with medical issues, patients from every religious tradition draw from their own spiritual wells. A significant part of every chapter will be spent considering that inner circle of the intersection of healthcare and religion. Finally, you can imagine an even smaller circle to represent your own religious traditions, practices, and beliefs. In this course on the major religions Introduction   13 of the world, you will have the opportunity to reflect on your own religious traditions, practices, and beliefs, should you wish to do so. I hope that you will take advantage of this opportunity. Studying and working in the field of healthcare prompts one to see that we are living in a time of change. Buddhist, Christian, Hindu, and Muslim healthcare professionals are caring for patients of all faiths and denominations in American hospitals and clinics. Not everywhere yet. But the tides of change continue to spread. Will we learn how to work together with our cultural and religious differences? Will we be able to hold on to our old exclusionary ideas of “us” and “them?” Or will we make larger inclusive circles of commitment and care that respect and even value this religious diversity? Your study of world religions from a healthcare perspective will give you the confidence you need to join the larger circle. Bibliography Allied Media Corporation (2007) “American Muslims.” Available online at: www. allied-­media.com/AM (accessed December 8, 2008). Brown, C. G. (2014) “Mindfulness: Stealth Buddhism for mainstreaming meditation?” The Huffington Post, December 2, 2014, updated February 1, 2015. Available online at: www.huffingtonpost.com/candy-­gunther-brown-­phd/ mindfulness-­stealth-buddh_b_6243036.html (accessed June 29, 2016). Chayim Aruchim. Website of the Chayim Aruchim, Center for Culturally Sensitive End-­of-Life Advocacy and Counseling. Available online at: www.chayimaruchim.com/Pages/aboutUs (accessed June 15, 2016). De La Torre, M. (2004) Santeria: Beliefs and Rituals of a Growing Religion in America, Grand Rapids, MI: Wm. B. Eerdmans. Furse, J. H. (2008) “Hasidic boy in legal fight over life support buried,” New York Daily News, November 17, 2008. Available online at: www.nydailynews.com/ ny_local/brooklyn/2008/11/16/2008-11-16_hasidic_boy_in_legal_fight_over_ life_sup.html (accessed June 29, 2016). Gjelten, T. (2015) “Poll finds Americans, especially millennials, moving away from religion,” The Two Way: Breaking News from NPR, November 3, 2015. Available online at: www.npr.org/sections/thetwo-­way/2015/11/03/454063182/poll-­ finds-americans-­especially-millennials-­moving-away-­from-religion (accessed June 29, 2016). Hindu Society of Central Florida (2005) MahaKumbabhishekam and Prathistapanam Celebrations, June 15–19, 2005, Souvenir and Directory, Casselberry, FL: Hindu Society of Central Florida. Current lists of trustees and patrons are available at: www.hindutempleorlando.org. Koenig, H. G., Hooten, E. G., and Lindsay-­Calkins, E. (2010) “Spirituality in medical school curricula: Findings from a national survey,” International Journal of Psychiatry in Medicine, vol. 40, no. 4: 391–8. Koenig H. G., King, D. E., and Carson, V. B. (2012) Handbook of Religion and Health, 2nd edn, New York, NY: Oxford University Press. Krattenmaker, T. (2016) “The ‘nones’ are becoming somethings,” Reflections Yale Divinity School, Spring, 2016: 44–5. Available online at: http://reflections.yale. 14   E. J. Bursey edu/article/all-­together-now-­pluralism-and-­faith/nones-­are-becoming-­somethings (accessed June 29, 2016). Levin, J. (1994) “Religion and health: Is there an association, is it valid, and is it causal?,” Social Science and Medicine, vol. 38, no. 11: 1475–82. Lipka, M. (2016) “Ten facts about atheists,” Pew Research Center, June 1, 2016. Available online at: www.pewresearch.org/fact-­tank/2016/06/01/10-facts-­aboutatheists/ (accessed June 2, 2016). Mercadante, L. A. (2014) Belief Without Borders: Inside the Minds of the Spiritual but not Religious, New York, NY: Oxford University Press. Ministry of Health and Population, El-­Zanaty and Associates, and ICF International (2015) Egypt Demographic and Health Survey 2014, Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International. Available online at: http://dhsprogram.com/pubs/pdf/FR302/FR302.pdf (accessed June 29, 2016). Saul, J. (2014) “Catholic godson of woman on life support fights to get proxy back,” New York Post, March 20, 2014. Available online at http://nypost. com/2014/03/20/catholic-­godson-of-­woman-on-­life-support-­fights-to-­get-proxy-­ back/ (accessed June 29, 2016). Seager, R. H. (2002) “American Buddhism in the making,” in Prebish, C. S. and Baumann, M. (eds) Westward Dharma: Buddhism beyond Asia, Berkeley, CA: University of California Press. Shabtai, D. (2012) Defining the Moment: Understanding Brain Death in Halakah, New York, NY: Shoresh Press. Stedman, C. (2013) How an Atheist Found Common Ground with the Religious, Boston, MA: Beacon Press. 2 From conceptual to concrete Mark F. Carr and Gerald R. Winslow Some people are more inclined to broad, theoretical views of life while others are more concerned with the practical matters and particular details of everyday life (Jonsen 1991: 14–16). Both patterns of thought are essential in religion and healthcare. The methods of decision making and patient care detailed below take this into account. Nationally and internationally, these two modes of thought are associated with two methods of clinical decision making in healthcare. Principles-­based reasoning, or what has come to be called principlism, as well as case-­based reasoning, or casuistry, are both highly influential in the field of ethics and morality in healthcare decision making. Principles-­based patient care There are four principles that are widely accepted as essential for morally appropriate patient care. Respect for autonomy, beneficence, nonmaleficence, and justice have emerged from centuries of religious, social, and cultural attention to religion and morality. The institutions of our civilization have been significantly shaped by shared conceptions and applications of these four principles. Though there is debate about exactly how many principles suffice to capture the essence of this common morality, with some arguing for as many as seven, the most influential advocates of principlism assert that these four are sufficient (Beauchamp and Childress 2013: 2–13). Before proceeding to a discussion of how the principles may be applied in the clinical setting, it will be helpful to provide a brief definition for each of the four: • • Respect for autonomy: respecting the choices of the patient. In recent decades, especially starting in the 1970s with the promulgation of the “Patients’ Bill of Rights,” much greater emphasis was placed on the ethical importance of honoring the patient’s expressed values and decisions. Beneficence: ensuring the patient receives significant benefit from healthcare interventions. Patients generally trust their professional 16   M. F. Carr and G. R. Winslow • • caregivers to give priority to the good of the patient over other potentially competing concerns. Seeking the patient’s good is what the healthcare professions, in their codes of ethics, all profess. Nonmaleficence: guarding against harming the patient. One of the most time-­honored commitments of healthcare professionals is captured in an oft-­repeated Latin expression – primum non nocere – which means “first of all, do not harm.” Justice: treating patients equitably, without unfair discrimination. The essence of this principle is a commitment to human equality with differences in treatment based on morally relevant considerations. According to the most prevalent view of principlism, the four principles are not hierarchical; they are not to be considered in rank order since one is no more or less important than the others. Rather, they move in and out of relevance in any given case as details of the case are discovered and capture our attention. Based upon the case details, typically one of the principles will supersede the others. The careful work of figuring out which of the principles should take priority in any particular case is the responsibility of caregivers and the people for whom they are caring. Let us illustrate: A two-­car accident involving a 24-year-­old male alone in his vehicle and a family of five in a minivan brings out the paramedics. Upon arrival at the scene the family is found to have only minor injuries, but the young man has passed out from shock primarily due to a compound fracture of his left femur. He has lost a lot of blood. Paramedics do their best to revive him, and upon further assessment they believe that he probably also sustained a number of internal injuries. They rush him to the emergency room (ER) while trying to contact his family. As principles-­based reasoning goes, thus far in the case the paramedics have correctly responded under the principle of beneficence; they clearly are doing good for the patient, trying to keep him alive. Doing good for persons in distress is an immediate, intuitive, and also learned response for both lay and professional people in our society. In the ER, these beneficent responses are well established. Thus, it would seem rather odd, given this brief case description, for anyone in the emergency setting to appeal to other principles, such as justice. Nor is anyone likely to wonder if we are actually harming this young man (nonmaleficence). Since he is unconscious, it would also be nonsensical to ask him for his informed consent under the principle of respect for autonomy. Imagine, however, that the details of the case shift rather quickly. Within the next couple of hours, the man’s wife and extended family arrive at the ER with his advance healthcare directive in hand. The directive From conceptual to concrete   17 clearly indicates that he does not want any blood products in the event of a serious accident or critical illness. This is because he is a Jehovah’s Witness and he holds religious convictions that forbid the use of blood products for medical care. Within the next hour of treatment in the ER, the young man’s condition continues to decline. While the fracture and associated bleeding are managed, the internal bleeding continues. His wife and family refuse to give consent for surgery, again citing the use of blood products. After considerable argument between the ER physicians and the family (the patient was still unconscious), the physicians and hospital administrators decide to seek a court order to allow them to take the young man to surgery and use the full measure of blood products and methods at their disposal. Thus, the hospital risk management team takes a request to the judge on call in the hope of getting an injunction that will allow them to use blood products. The judge rules in favor of the patient’s family, thus effectively giving priority to respect for the patient’s autonomy as expressed through his advance directive. Principles-­based reasoning is again at work here. One of the important reasons for an advance healthcare directive is to honor the personal choices of patients. Of course, these personal choices are routinely, deeply influenced by our religion and spirituality. Thus, respect for autonomy comes to the fore as an important principle to consider in this specific case at this specific time. In light of the patient’s religious desire to avoid the use of blood, the principle of beneficence is now in conflict with the principle of respect for autonomy. Additionally, if the ER team were to simply override the family’s desire to honor his advance directive, one could argue that they would actually be harming the patient, thereby breaking the principle of nonmaleficence (avoiding harm) in the process. While the family members are clear that they do not want their loved one to die, they do not want to override his clearly expressed religious convictions. And with frustrated reluctance, the ER team accepts the judge’s decision to honor the young man’s advance directive. There will be no surgery without the family’s consent, and the ER must not use any blood products in caring for the young man. Despite their best efforts, the young man dies within the hour following the judge’s decision. The process of specifying and balancing the four principles is a crucial skill in the principles-­based method of caring for patients (Beauchamp and Childress 2013: 17–24). Critical thinking skills and self-­reflective practices are essential tools for any clinician seeking to care appropriately for patients. It is part of clinicians’ professional responsibility to evaluate the relevance of each of the principles and determine which of them will take priority over the others at any given point in the case. For nearly four decades, through several editions of Principles of Biomedical Ethics, the four principles just mentioned have continued to be extensively influential. Meanwhile, international attention to a principles-­based approach 18   M. F. Carr and G. R. Winslow has also generated guidance worth noting. For example, in 1998 the “Final Report to the European Commission on the Project, Basic Ethical Principles in Bioethics and Biolaw, 1995–1998” was published. Occasionally referred to as the Barcelona Declaration, the document details a different set of four principles: autonomy, dignity, integrity, and vulnerability. Seven years later, the United Nations (UNESCO division) offered the “Universal Declaration of Bioethics and Human Rights.” Using a far more expansive list of 15 principles, this document now serves the international community on matters of religion and ethics in clinical medicine. Of particular usefulness to our concern for religion and healthcare, Articles 8, 11, and 12 are noteworthy. Article 8, “Respect for human vulnerability and personal integrity,” acknowledges patients’ vulnerability but also includes personal integrity. Below, we will detail further how these two concerns are closely linked in attending to patients’ religious and spiritual needs and resources. Article 11, “Non-­ discrimination and non-­stigmatization,” and Article 12, “Respect for cultural diversity and pluralism,” further express a commitment to care for patients in ways that are fully respectful of their personhood, including their religious identity, or lack thereof. Closely associated with principlism is another prominent method of attending to religion and morality, referred to as “casuistry” or the “four-­ box” method. For ease of memory, we refer to it as “case-­based” as it is compared and contrasted to the principles-­based approach. Case-­based patient care The proponents of the case-­based approach, Albert Jonsen, Mark Siegler, and William Winslade, offered their model in stark contrast and opposition to the principles-­based model (Jonsen et al. 2015). Over time, however, both camps have conceded some points, and both have incorporated some of the more persuasive elements of the others’ arguments. For the case-­based group, the method consists of attending to four crucial details of the actual case; they want to know (1) the medical conditions, (2) the patient’s preferences, (3) the patient’s quality of life, and (4) contextual features of the patient’s case. The authors have depicted these four considerations in a four-­quadrant table, with medical conditions and patient’s preferences in the upper two quadrants, and quality of life and contextual features in the lower two quadrants. Early on, the authors expressed the belief that more than 90 percent of all cases could be resolved within the medical conditions quadrant, followed by sequential progression through the other three quadrants, as described above. Over time, however, the proponents have modulated this sequential, four-­box approach in favor of giving more holistic attention to the entirety of the quadrants. At the back of their book, they have even provided a removable card-­stock page in order to facilitate having the four quadrants, with their accompanying questions, readily available. From conceptual to concrete   19 Given the pragmatic and often fast-­paced context of inpatient care, this case-­based approach has gained popularity with medical doctors when treating complex cases, including those in which the patient’s religion represents a significant consideration. The hefty, in-­depth volume of the Principles of Biomedical Ethics makes it the preference of professors and philosophers of medical humanities and ethics. While both publications express respect for religious convictions and diversity, neither of them gives extensive attention to religion and spirituality. Beauchamp and Childress (2013) argue that religion and spirituality are so pervasive throughout the entirety of our common morality that treating them as standalone topics would be disingenuous. Jonsen, Siegler, and Winslade, on the other hand, simply embed religion in their fourth box, “Contextual Features,” with the following question: “Are there religious factors that might influence clinical decisions?” (Jonsen et al. 2015). When resolving difficult clinical cases, including those with significant religious factors, healthcare professionals will be well-­served by either method described above, or by some combination of methods in what some refer to as “reflective equilibrium” (Rawls 1971: 20). This expression, coined by philosopher John Rawls, points out the reality that our reasoned judgments, guided by established principles, are routinely adjusted by the specific details of any given case (Beauchamp and Childress 2013: 404–410). In similar fashion, our understanding of principles matures over time as we gain experience in their application to specific cases. In essence, this argument says that justification for a normative position taken in response to a religious or ethical quandary is found in the reasoning of both principles-­based and case-­based methods. The two are better understood as complementary rather than as competitors. The need for more There are three additional approaches to clinical ethics that need careful consideration if we are to create a comprehensive and ethically effective response to religious and spiritual concerns in the clinical setting. We address these under the rubrics of narrative ethics, virtue ethics, and care ethics. The additional insights and practical guidance from these approaches have considerable value in the clinical care of patients. Narrative ethics Have you ever asked someone a clear and pointed question only to have her or him respond by telling a story? A former student referred to being angry at her father when she was young because every time she asked him a hard question, he would sit back and tell her a story. She never really understood, until she heard the description of narrative faith and ethics. This approach features the central importance of stories – stories that form 20   M. F. Carr and G. R. Winslow the essence of our religion, ethics, and spirituality. These are not limited to an individual’s own personal stories, but they may also be the stories of one’s family, community, church, school, state, nation, and so forth. Human beings are so deeply embedded in such stories that it would be impossible to resolve religious and moral dilemmas in ways that do not attend to the stories that shape the involved person’s understanding of the context. People hear, interpret, and repeat meaningful stories every day. Among the most powerful of these are the religious stories that thoroughly shape the lives of billions of people. Without the story of Siddhartha, what would Buddhism be? Without Muhammad, how would we understand the story of Islam? Christianity without Jesus is unthinkable. And lest anyone think this approach works only for religion, we might ask what of the United States of America, without George Washington? Or the Republic of South Africa without Nelson Mandela? Hilde Lindemann Nelson identifies at least five things we do with stories that may profoundly affect how we live our lives: (1) reading stories, (2) telling stories, (3) comparing stories, (4) analyzing stories, and (5) invoking stories. All five of these, according to the author, are part of the process of making sense of life (Nelson 1997: x–xii). In the realm of health and illness, it is often the case that the power of religious and spiritual stories is dramatically enhanced. It is hard to overstate the thoroughgoing nature of this approach to life and religion. One narrative theorist in medical contexts, Kathryn Montgomery Hunter, insists that “narrative is the primary way of organizing and communicating” what it means to be human in our world. At the “heart of human knowing” lies an “interpretive process integral to shaping and understanding” our lives through story (Hunter 2004). Indeed, from this perspective, religion is unintelligible without thoroughgoing engagement in telling stories. Young people may often be bored or annoyed with having to sit through the stories their parents or grandparents tell, some of which may be told over and over again. Yet, as those same young people themselves grow older, they often find themselves remembering and perhaps even recounting the same stories. Whether or not it is realized, the subconscious effects of stories shape the way we live and function in the world. Often the intention of telling religious stories is to lead the hearers (or readers) to accept practical lessons. “Now boys and girls, the moral of the story is . . .” is the oft-­used transition away from the details of the story itself to the lessons that children are supposed to learn from the story. Narrative religionists are prone to point out that the stories, in and of themselves, are strong enough to convey the lessons. There is no need to moralize at the end of the story. A crucial task for responsible humans, who share a concern for enhancing the spiritual and religious lives of their community, is simply to tell the stories well (Hauerwas and Jones 1989: 158–190). From conceptual to concrete   21 In clinical care, much may be learned about patients by listening attentively to their stories. In particular, when patients reach the end of their lives, families often need to retell the stories that have been important to them through the years. As much as possible, caregivers may help provide time for this process. Additionally, those caring for dying patients and their family members can use stories to help them understand and process what is going on in their dying process. Attending to patients’ life stories highlights respect for autonomy. Listening to family stories about their religion and the proper practice of it near the end of life brings ongoing meaning in family life. One of the case studies used in this text dramatically highlighted this reality for palliative care nurse practitioner Marianne Johnston-­Petty. Thinking she understood how a 34-year-­old Christian man would go about making decisions as he struggled through his final stages of cancer, she found out rather quickly that she had the wrong conception of both family and autonomy. The autonomy practiced in the Eritrean culture of the young man was markedly different than she had thought. It was through his telling and her listening about the fabric of this man’s “family” that Marianne learned a new way of conceiving of “family.” Not only was autonomy extended beyond himself as a patient, but the notion of family was dramatically different. One of the important decision makers in his case was a stranger to the patient. The patient and his genetic family wanted Marianne to grant equal weight and credibility to this stranger as a member of his family, making decisions on behalf of the patient. The focus on narrative highlights the character of the participants in the story. The actors in the story portray characters of a certain sort. Almost any story has good guys and bad guys; persons with virtue and persons with vice. And so we turn to what is called “virtue” or “character-­based” approaches to religion and ethics. Virtue ethics The way of virtue is usually intimately connected to religion and spirituality, though it is true that one need not be either to be virtuous. Religion and spiritual practices shape human character traits more effectively throughout history than most other human institutions. One of the ways the virtues accomplish this is through the practice of upholding an exemplar to mimic and model. Traditions within every one of the world’s religions routinely appeal to moral and religious exemplars. Indeed, it would be virtually impossible to imagine Christianity without Jesus, Islam without Muhammad, or Buddhism without Siddhartha. Those of us charged with imbuing the religious values and convictions of a faith tradition use reinforcing techniques to encourage our children to behave as our religious heroes have in the past. And again, this sort of reinforcement method is not limited to religion. You may recall the old Nike brand shoe 22   M. F. Carr and G. R. Winslow commercials that said, simply, “I want to be like Mike” (Sommers and Sommers 2004: 209–276). This character-­based approach has bearing on both sides of any clinical religious scenario. The patient and the patient’s family and friends do well when they practice the virtues of courage, insight, openness, and vulnerability. Similarly, there are key virtues that caregivers practice so as to provide the best possible healthcare to patients and their families. According to physician-­philosopher Edmond Pellegrino, fortitude, compassion, integrity, practical reason, and self-­effacement, among others, are essential to remain true to the history of both healthcare and religion (Pellegrino and Thomasma 1993). To single out one virtue prevalent in religious communities that is essential to caregiving in our view, we will highlight self-­ effacement or altruism below. Virtues are not easily developed or perfected. Some believe that our personal character traits are primarily genetic rather than something that one can learn, practice, or perfect. Character traits like open-­mindedness or stubbornness seem to be things we come by naturally, whereas virtues like compassion and courage are qualities we may learn and practice over time (Borba 2002). Indeed, at the outset of learning a virtue like courage, we may have to fake it (Herdt 2008: 23–32). In a stressful situation, we may be scared to death, but externally no observer would be able to discern that about us. Internal motivation and disposition are essential to the authentic exercise of the virtues. An external observer cannot tell when they see me engage in an apparently compassionate act whether or not I am actually compassionate. A duty-­based perspective on the life of faith stresses that one engages in an act that God or the gods have demanded. When I compassionately help an old person across the street, you may see me as a virtuous person, but I may simply be doing my duty according to my interpretation of what God requires. This is not the way of virtue. The way of virtue calls for personal authenticity and consistent, practiced intention to care for others out of the compassion in your heart and soul. Habituating such character is the way of virtue, and religion is part and parcel of any such habituation. There are many influences of personal development for those seeking religious and character growth in the way of virtue. Yes, one’s genetics makes a difference. So also, the family, friends, and communities within which one is raised make an immense difference. Healthcare itself has a certain cluster of virtues that are emphasized and practiced throughout the education and professional development of caregivers at every level of patient care. One of the most important virtues in the history of healthcare professionalism is called altruism. Altruism is the prioritizing of the needs of the other (in this case, the patient) over one’s own needs. In this relational orientation, matters of consequence, duty, and even virtue become lost in the intensity and importance of the caring. In the past 50 years or so, this attention to relationships has come to be known as “care ethics.” From conceptual to concrete   23 Care ethics The care ethic demands that the primary concern of religion and the moral life is the relationship among all involved parties. If, for instance, I am pondering whether or not to lie to someone who asks me how I like their new tie, a care ethic founded upon the relationship I have with this person would prioritize the depth and details of that relationship over any sense of duty or concern for consequences. To use a more difficult example, if I held deep moral convictions that abortion should never be allowed and my closest friend asked me to accompany her to an abortion clinic for emotional care and support, a care orientation to religion and spirituality may compel me to go with her. But what is it about the relationships with others that provides such a strong orientation to clinical interactions with patients? Traditionally, relational or caring aspects of patient interactions are associated with nursing. Nurses are the warm, fuzzy, caring ones while medical doctors and surgeons are the technicians who do the hard analysis and decision making. Curing aspects of patient interactions are traditionally associated with physicians (Jecker 2004: 371). With the present-­day ascendance of a more relational approach to medical care, this traditional dynamic is breaking down and should continue to do so. One central teaching of the care ethic is to realize and act upon the fact of human interdependence as opposed to human independence and individualism. As Nel Noddings puts it in the introduction to the second edition of her seminal work, “Virtually all care theorists make the relational more fundamental than the individual” (Noddings 2013). All individual actions have immense ripple effects in the lives of others in relationship to the person. Recognizing and accounting for this interdependence is essential. The force of personal autonomy is somewhat blunted by this emphasis if autonomy is taken to be atomistic and individualized. And the extent and influence of one’s personal moral actions are highlighted in this approach. Again, the point here is not to completely discount other elements important to religion and the moral life, but to prioritize relationships with others. To additionally highlight the narrative approach to religion, a care approach wants to account for the influence of the story of one’s life and relationships. A narrative approach is an important element of a robust concern for others in a relationship-­based religious life. If the stories that you and your family have always told about abortion, for instance, are condemnatory then the request from your friend to accompany her will make for a particularly difficult decision. On the other hand, if those stories have always sought to extend understanding and grace, then you will be more positively disposed toward attending to your friend. Further, when someone is hospitalized, those of us who care for patients realize our care is extended to that patient’s family precisely because of the relationships within that family. Those relationships may be functional or 24   M. F. Carr and G. R. Winslow dysfunctional, pleasant or unpleasant, but we intuitively recognize this important approach to the manner with which we reach out to the family. Let this focus on the interdependence of our moral lives launch us into our final concern, namely, how we manage our religion in relation to the religions of those we care for in clinical healthcare. Historically, religion and politics are topics that we all agree not to fight about. In healthcare, particularly in pluralist America, we enter a world where our interactions with others of different faiths challenge us daily. What do we make of this challenge? What are the key areas of religious instruction on ethics and morality that enable us to honor and respect all persons we care for? Religion and spirituality It has become increasingly common in contemporary Western culture to distinguish between religion and spirituality. Religion is typically associated with the belief systems and practices of established faith traditions. Spirituality, in contrast, is typically associated with the personal search for meaning of individuals. Of course, one’s personal spirituality may be linked to a religious tradition. But in many of today’s cultures, the linkage between individual spiritual journeys and organized religious traditions has been diminished. For our purposes in this chapter, we note this distinction, but we have chosen to include both religion and spirituality in our discussion of spiritually nurturing and respectful patient care. Perceptive healthcare professionals often notice their patients’ faith or spirituality can be among their most important resources for coping with serious illness or injury. Failure to take these resources into account represents less than optimal care for many patients. On the other hand, spiritual care of patients who may come from many different faith traditions, as well as those who would benefit from spiritual attention but have no identifiable religious commitments, requires following some carefully chosen norms. Here, we discuss five such guides for compassionate care (Winslow and Wehtje-­Winslow 2007: 63–66): 1 2 3 4 5 Understand the patient’s religious needs and resources. Follow the expressed wishes of the patient, to the extent this is feasible. Do not prescribe or pressure patients to adopt new practices or convictions. Do not proscribe the patient’s religious practices or resources. Understand your own religious convictions, practices, and resources. Understand the patient’s religious needs and resources Most of us live in highly pluralistic cultures when it comes to religion and spirituality. This means that no single faith tradition or religious vision will From conceptual to concrete   25 have dominance. Given this reality, it is important to permit patients to self-­identify whatever they wish to have known about their spiritual needs and resources. Non-­intrusive conversations that welcome such exploration are best facilitated in a context that carefully avoids stereotyping based on a patient’s apparent ethnicity or perceived cultural heritage. People differ. And even within a named faith tradition, there may be a wide range of personal beliefs and practices. All of the major religions have numerous, distinctive iterations of their faith. We suggest finding thoughtful ways to welcome patients’ expression of their own spiritual journey and its significance at this point in their lives. We offer the following script as one example of a way to open such a conversation: “Faith is often important to people when they need healthcare. Is there anything you want us to know about your faith or spiritual practices that might be helpful in your care?” The hope is to open a pathway of discovery with the patient. No particular script will be suitable for all occasions, all patients, or all caregivers. A better method is for the caregiver to develop an approach with which he or she feels confident. The goal of such conversations is to help the patient identify her or his own spiritual resources and then permit the patient to express to caregivers how these resources may be helpful in planning for the best possible care. The purpose of these conversations should not be an attempt to bring about a patient’s conversion to a new religious tradition. Follow the expressed wishes of the patient, to the extent this is feasible As noted earlier, it is often difficult to find the best balance among the principles of respecting the patient’s autonomy, providing significant health benefits, and avoiding harm to the patient. Traditionally, the practice of medicine has been shaped by the expectation of paternalism, or the belief that the important decisions about the patient’s care should be made unilaterally by the healthcare professionals, especially the physician in charge. After all, it is the physician who is expected to have the greatest knowledge of the science and art of medical care. So whose judgment should govern when caregivers perceive that the patient’s beliefs, decisions, and practices may be harmful to his or her health? This question may be peculiarly perplexing when the patient, influenced by strongly held religious beliefs, makes decisions that seem inimical to the usual goals of healthcare. Those goals were usually informed by clinical considerations that had little, if anything, to do with the patient’s religious convictions. Learning to navigate the caregiving territory that includes clinical goals of the healthcare team, the personal spiritual goals of the patient, and the established norms of society requires artfulness, creativity, and balance. In finding the balance, it is the settled ethical conviction of our society that we begin with the competent patient’s expressed wishes. 26   M. F. Carr and G. R. Winslow The priority our culture gives to patient autonomy is tempered, however, by the professional responsibilities of healthcare providers to offer only those reasonable treatment alternatives for which there is adequate evidence. Healthcare professions are never required to offer or to provide treatment alternatives that, in their professional judgment, are unwarranted in light of scientific evidence. It is imperative for caregivers to maintain personal integrity within the boundaries of their professional knowledge and ethical commitments. If the values of caregivers and care recipients clash, honest attempts to preserve the personal integrity of all those involved can help to reduce moral distress. Such distress may arise from a dissonance of values in a variety of healthcare settings. Specifically, religious convictions sometimes do generate conflicts associated with relatively high levels of distress. Occasionally, such distress may be ameliorated by the caregiver’s reassignment to care for other patients with whom there is no dissonance. Healthcare organizations...
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