This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Astrow, A. B. Articles by White, M. Search for Related Content PubMed PubMed Citation Articles by Astrow, A. B. Articles by White, M. Social Bookmarking                            What's this?

Inter-Religious Perspectives on Hope and Limits in Cancer Treatment

Alan B. Astrow, Ingrid Mattson, Rabbi James Ponet, Michelle White

From the Department of Medicine and Comprehensive Cancer Center, St Vincent's Hospital-Manhattan, New York; New York Medical College, Valhalla; The Universal Baptist Church, Brooklyn, NY; The Hartford Seminary, Hartford; The Joseph Slifka Center for Jewish Life, Yale University, New Haven, CT

Address reprint requests to Alan B. Astrow, MD, Division of Hematology/Oncology, Maimonides Medical Center, 4802 Tenth Ave, Brooklyn, NY 11219; e-mail: aastrow{at}maimonidesmed.org.

HERE'S THE CASE

An 85-year-old woman, a retired nurse's aide, has advanced metastatic breast cancer to the liver and bone. She recently transferred her care to a new hospital and physician, hoping for better results. Nevertheless, her disease has worsened despite maximal hormonal therapy and several chemotherapy regimens including cyclophosphamide, methotrexate, and fluorouracil, and doxorubicin, paclitaxel, navelbine, gemcitabine, and capecitabine. In addition, she has progressive kidney failure and heart disease. She is weak and nearly bedridden. She also finds it difficult to eat.

Her oncologist has advised the patient that additional chemotherapy would not be helpful. He has attempted to shift the goal of treatment from life-prolonging interventions to comfort measures, and has consulted the palliative care team. The palliative care team has suggested referral to a home hospice program.

The patient's two sons, who, with her agreement, are directing her medical care, are unwilling to accept referral to a hospice program. They are upset that the oncologist is "giving up." At a visit with the oncologist, the patient and her sons bring an Internet printout of the investigational agents angiostatin and endostatin.

The oncologist suggests that the patient is too ill to be eligible for an experimental trial and that additional chemotherapy would not help. The patient's sons express anger. "I'm very disappointed with oncology," one son says.

The patient belongs to a religious faith. She attends religious services, but not regularly. The patient's sons appear to be very involved with their religion. They have been seen in the treatment area reading their religion's holy book.

Three scholars from the Muslim, Jewish, and Christian traditions were asked to respond to this clinical scenario by briefly introducing their faith's tradition, and then addressing the case. The question posed to them was whether, and how, a religious perspective on these issues might have helped to illuminate the patient's and the family members' understanding of the issues at stake, and potentially have lessened the degree of conflict between family and professional staff.

Ingrid Mattson, PhD, Professor of Islamic Studies and Director of Islamic Chaplaincy, Hartford Seminary
Islam, the religious affiliation of one fifth of the world's population, exhibits significant variation across cultures. Muslims from dozens of nations have some presence in the United States, with three major regional or ethnic groups almost evenly represented: African American, Middle Eastern (including Arabs and Persians), and South Asian (mostly Pakistanis and Indians). The diverse cultures of Muslims are reflected in their religious practices and expressions, although the core of Islamic worship and theology remains remarkably uniform compared with other world religions. What this means is that although we cannot claim a "typical" Muslim response to life challenges and health crises, we can identify common Islamic theologic and institutional resources for dealing with these situations.

In the Qur'an, the sacred book of Islam, respect for parents is often linked with obedience to God as a duty of the righteous. This is more than a moral obligation. Islamic law holds men and women responsible for supporting and serving their parents when they are in need. The Islamic tradition would commend the patient's sons for their diligence in seeking the best treatment for their mother. Their sense of helplessness might be alleviated if they are encouraged to attend personally to some of their mother's physical needs. This has the added benefit of allowing the sons to identify, and be less angry, with the medical practitioners who are trying to assist their mother.

At the same time, Islamic beliefs and practices constantly remind humans to be prepared for death, a death that cannot be delayed when the time has come. "Indeed you are to die," the Qur'an states. Just as death is certain, so is the resurrection of the dead, which is easy for God, who created humans "from nothing" and indeed, created the entire universe from a void. Because passages of the Qur'an must be recited in daily prayers and other ritual occasions, these verses prepare Muslims for the inevitability of death and the resurrection that is to follow. Muslims are compelled to face their mortality when writing a will, an act that is required of all adults by Islamic law. Traditionally, up to one third of the estate is willed to the poor and other charitable causes; the legacy of such contributions alleviates the sense that death closes opportunities for affecting society. In the case under consideration, the patient's sons might be encouraged to direct their desire to help their mother by assisting her to prepare a charitable legacy, even if it is modest.

For the Muslim, ultimate hope for eternal life rests with the merciful God. At the same time, Muslims are forbidden from wishing for death. Because they should always hope for a recovery, the Islamic tradition would advise this patient's sons to continue to pray for their mother's health even if aggressive anticancer treatment is discontinued. When they arrive at the realization that she will not improve, they should pray that their mother's death will occur with as little suffering as possible.

The literal meaning of "Islam" is "submission." Peace is found by accepting the will of God, including events that are out of our control. For this reason, Islamic theology does not accept anger at God as an acceptable response to suffering. Religious believers, however, will sometimes find it difficult to accept painful reality and acknowledge God's wisdom when suffering hits home. It is helpful for the chaplain to explore understandable feelings of anger that can lead to guilt and confusion, which can add to the family's stress in the face of grieving and loss.

At the same time, Islam recognizes free will and that God has given humans the ability to engage in scientific inquiry and develop mechanisms for relieving suffering. Frustration and disappointment in the limitations of medical interventions is acceptable, as is the desire to ensure that medical practitioners have not neglected their duties to provide the best care possible. Even if deficiencies are recognized, however, Islamic spirituality encourages forgiveness and reconciliation. To this end, it may be advisable to establish structured opportunities for those who have been frustrated by the medical treatment extended to their loved ones to meet with providers after an appropriate mourning period.

Rabbi James Ponet, Director, Joseph Slifka Center for Jewish Life, Yale University
I would like to address the spiritual concerns of the physician in this case and how the physician might best help this patient and her sons. When the physician seems to have run out of options by which to keep the patient alive, and the conversation with patient and family shifts from hopeful protocols to protocols of hope, must the physician renounce an active role and cede performance space to the chaplain, social worker, or nurse? The answer depends, I believe, on the self-understanding of the particular physician.

The range of religious metaphors by which one may describe the role of the physician extends well beyond the centrality of "healer," to include "servant," "server," "attendant," "helper," "vessel," and "instrument." The Hebrew terms best used to express this range of meaning are "eved," "oved," and "avdut," words that are often translated "slave," "servant," and "servitude." Our autonomy-obsessed culture tends to regard servitude and dignity as largely incompatible human conditions. While coerced servitude—slavery—is justly stigmatized, even voluntary servitude suffers by association, particularly when the service being rendered is simply a caring, attentive presence, a sympathetic smile, a listening ear, a hand to hold. The market does not readily reward these activities.

How does the physician, who has been my energetic ally in my war against life-snatching illness, now become my companion in surrender? How do physician and patient avoid recrimination, guilt, and feelings of failure as sickness eclipses life? Only some notion of the dignity of dying could allow these warriors to remain connected to each other as one succumbs and the other survives. The physician, as colleague in arms and fellow warrior for life, has a potentially critical role to play with a patient who is dying. The physician can now tell his patient that it is okay to give in, to let go, to die. The physician's permission to surrender, tendered at the right time and in the right way, can be a tremendous boon.

Can one find support within the Jewish tradition for this notion of "dignity of dying"? Yes, I believe, but with a significant caveat. First acknowledging the broad range of beliefs and practices that characterizes the contemporary Jewish community, most Jews of all persuasions share a deep commitment, grounded in our common textual tradition and historic memory, to the value of life on this earth. All Jews—Reform, Conservative, Reconstructionist, Orthodox, and unaffiliated alike—toast "l'chaim," to life.

While death is not necessarily viewed as a defeat in the Jewish religious imagination, it is seen as an evil, with resistance to death an unavoidable aspect to being human. Moses, known as "eved hashem," slave/servant of God, lives a long full life, vigorous until his solitary death atop Mount Nebo at the age of 120. While his death in Deuteronomy reads as a noble response to a sublime summons, "climb that mountain and die," Moses, as imagined in the rabbinic tradition, actually attempts to argue with God for his life. Moses needs to learn the hard way that deathless existence can become untenable so that he may finally choose to die. The struggle to give it up, I believe, is quintessentially (though to be sure not exclusively) Jewish, for normative Judaism understands life in the here and now as immensely precious, and every death as nearly an absolute loss. The Jewish belief in "the world to come" offers no compensation for the loss of this world, only the surety that death is not oblivion, but rather transition into a radically different order of being.

The Talmudic tradition explicitly recognizes the category of a good death, namely one that happens after the age of 80 and takes no longer than 3 days, and the Talmud describes the death of Moses as a "kiss of God." Even the cruel martyr's death of the greatest Talmudic sage Rabbi Akiba, condemned by the Romans to a horrible death in the year 132 CE, his flesh raked by red hot iron combs, is depicted in the Talmud as having brought a smile to the dying sage's face. Akiba characterized his martyrdom as an opportunity to love God with his whole body. But the sight of his amiable appropriation of pain baffled his stunned students.

Models for dying with dignity exist within the sources of Jewish religious thought and memory. But the passion for life, a passion which calls for the suspension of every religious norm in order save a life, may turn the encounter with the angel of death into a problematic, and even traumatic, experience in the Jewish understanding.

In the case of this dying patient, there is no easy resolution to the impasse between the physician and the patient's zealous sons. But if this were a Jewish family, knowledge that the sons' actions stemmed from a deep religious commitment to the value of life on this earth might help the physician to empathize with the sons' plight. The Talmud teaches to never judge another until one has first put oneself in the other's shoes. Even if the family were not Jewish, the realization that the sons were not simply engaged in denial, but were instead struggling with issues of faith and loss, might engender a more forgiving stance on the part of the physician. With time, empathy and forgiveness might promote rapprochement with the sons.

Michelle White, PhD, Minister, Universal Baptist Church, Brooklyn, NY
Although this appears to be a very difficult and emotionally charged situation for the two sons, this is also a tremendous opportunity for their spiritual growth. I would suspect that their mother has left these men a deep well of shared memories. If they are Christians, they have undoubtedly witnessed the Lord Jesus Christ's presence in their mother's life, despite serious challenges or even persistent difficulties. Most likely they have seen their mother pray, worship, and praise the Lord Jesus despite death, separation, uncertainty, and doubt. These memories can serve as a tremendous source of strength for these men if their pastor or chaplain can capitalize on shared spiritual understandings.

If I were called in as a chaplain in this case, I would use Biblical scripture as a way to start a conversation with the patient's sons about their mother's illness and the realistic hopes and goals of medical treatment. The concept of "sola scriptura," the primacy and reliability of scripture as a source of God's intention toward humanity, is a tremendous source of comfort and confidence for those who share the Christian identity. The chaplain who respects the use of these texts will open lines of spiritual communication that may not be available to well-meaning hospital staff and others. The chaplain will begin what I expect could be a very productive exploration of the emerging relationship that the Lord Jesus Christ is inviting the brothers to develop.

God's sovereignty in the lives of his people is a very important belief among members of Christian communities and may strengthen these men in their struggle. Knowing that God sees and understands their fears and concerns can only help to sustain them through this incredibly difficult time. The scriptures are full of affirmations of God's concern, love, and presence. A further source for bolstering confidence can be found in Jesus' promise that He would remain a constant presence in the lives of His disciples. As Bible believers, they will understand that the Lord Jesus has the authority and power to accomplish His will in their mother's life and in their lives.

Finally, the chaplain might appeal to the sons' understanding of medical realities. As a retired nurse's aid, their mother has certainly had first-hand experience with the harsh realities of cancer. She had undoubtedly seen patients and their families struggle with the devastation of this disease. I suspect that given her experience, she may have elected a more grace-filled, peaceful acceptance rather than a prolonged acrimonious struggle in her final days.

A Christian minister/chaplain might serve as an intermediary between the family and the hospital staff. By participating in case conferences, the chaplain may be a valuable source of support for both the staff struggling to make appropriate medical recommendations and for the family struggling to represent their loved one.

DISCUSSION

In the case under discussion, because the patient's sons were seen reading their holy book in the cancer treatment center, it is fair to infer that religious beliefs played at least some role in their thinking. Inter-religious conversation offers the potential to expand our appreciation of the range of religious responses to a timeless human predicament: the felt anguish over the impending loss of a loved one. What religion potentially offers is not a solution, nor a substitute for psychiatry, psychology, or social work, but rather an enriching perspective developed over several thousand years of spiritual reflection and study.

The physician in this case was grappling with a dying patient and two angry sons who were openly disappointed with oncology. The physician might have attempted to redirect the sons' anger by acknowledging its legitimacy and his own disappointment that his tools were so limited. The physician needs to share the burden of the sons' anger and disappointment, and it is here that religious professionals might be helpful.

All three of our discussants empathize with the patient's sons. Rabbi Ponet cites the Jewish belief that life is "immensely precious" and every death " nearly an absolute loss." Professor Mattson notes that Islamic law requires that sons and daughters support and serve their parents when they are in need. Reverend White draws upon the relationship that these sons had with their mother and the likelihood that they have "witnessed the Lord Jesus Christ's presence in their mother's life."

All however, are also able to suggest approaches that might have moved the sons to a position more in line with their mother's real needs. Mattson finds elements within Islam that prepare for the inevitability of death. Ponet relates that God summons even Moses to die, the greatest of all prophets in the Jewish tradition (although Ponet also notes that according to a rabbinic tradition, Moses did not submit to God's summons without argument). White cites the Biblical view that God understands our fears and concerns as a way for the sons to realize that God himself empathizes with their plight. Even in the face of death, for a believing Christian, Jesus remains a sustaining presence.

This is not to suggest that the physician here should attempt to engage in theologic debate. Patients consult physicians primarily for their medical expertise. The physician's first obligation is to be certain that there are no reasonable therapeutic alternatives that might return the patient to health—to leave no stone unturned on the patient's behalf. But physicians also need to have available to them the resources to respond to difficult human dilemmas in an empathic manner. The sons' decision to bring their holy book to the cancer center might be seen as an invitation to the physician to inquire compassionately and respectfully about the sons' spiritual beliefs. Rough familiarity with the variety of religious responses to suffering and loss might help the physician to feel more comfortable engaging in a dialogue with patients and families about their spiritual concerns. Given the range of responses to these issues, though, even within a single religious tradition, the physician might best simply listen without preconceptions. By taking the sons' religious views seriously, and perhaps calling in a chaplain to assist, as White suggests, even a nonreligious physician might have been able to open up levels of trust and communication that might not otherwise have been available.

Religious views sometimes complicate the task of caring for the terminally ill, and a chaplain might also have had a difficult time reasoning with this family.¹ But a skilled chaplain could potentially explore a patient's and family's understanding of their religious commitments and direct them, within their own tradition, to a more subtle and complex understanding of end-of-life care issues. At the very least, involving a chaplain in these kinds of cases allows the physician to share some of the burden of dealing with dying patients and their grieving families.

By placing this trying encounter in a larger context, religious wisdom might help address some of the oncologist's sense of isolation. Clearly, in this case, the anger and guilt of the sons is the primary issue. But the oncologist's frequent proximity to suffering and death, and to the emotions that accompany them, may also lead to feelings of anger, guilt, and burn-out on the part of the oncologist. When medical science is promoted as the only response to human suffering, patients and their families may come to understand future promise as present fact and may unfairly blame the oncologist when treatment is unsuccessful. The oncologist may feel beleaguered and unappreciated, and lacking in an adequate support system or explanatory framework to sustain himself in the presence of so much sadness.

Religious perspectives offer a means of understanding our role in caring for cancer patients that supports our efforts to understand and treat disease, but that does not, in the end, depend upon our ability to master the material world. If we are to prepare patients adequately for loss, we health care professionals are obliged to discuss not only medical science's promise, but also its limitations. Unqualified faith in scientific progress leaves us as prisoners of expectations and does not meet the needs of patients and of health care professionals in the here and now. Religion acknowledges both hope and limits and so connects us to others, past and present, who have struggled to find meaning in the experience of suffering and death.

Because patient and family decision-making may be informed by religious understandings,² physicians who know something about different religious traditions may gain an added dimension of understanding into their patients' plight, and so form more effective bonds with their patients. This may help physicians to better guide patient choices. In addition, case-based conversation with religious thinkers may promote honest reflection among physicians about meaning at the end of life, and about their role as witnesses to profound human experience.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

NOTES

Authors' disclosures of potential conflicts of interest are found at the end of this article.

REFERENCES

1. Brett AS, Jersild P: Inappropriate treatment near the end of life: Conflict between religious convictions and clinical judgment. Arch Intern Med 163:1645-1649, 2003[Abstract/Free Full Text]

2. Silvestri GA, Sommer K, Zoller JS, et al: Importance of faith on medical decisions regarding cancer care. J Clin Oncol 21:1379-1382, 2003[Abstract/Free Full Text]

Submitted July 27, 2004; accepted January 20, 2005.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				A. B. Astrow, A. Wexler, K. Texeira, M. K. He, and D. P. Sulmasy Is Failure to Meet Spiritual Needs Associated With Cancer Patients' Perceptions of Quality of Care and Their Satisfaction With Care? J. Clin. Oncol., December 20, 2007; 25(36): 5753 - 5757. [Abstract] [Full Text] [PDF]

				S. Ruzicka, S. Sanchez-Reilly, and M. Gerety Holistic Assessment of Chronic Pain Among Elders American Journal of Hospice and Palliative Medicine, September 1, 2007; 24(4): 291 - 299. [Abstract] [PDF]

				R. T. Penson, F. Gu, S. Harris, M. M. Thiel, N. Lawton, A. F. Fuller Jr., and T. J. Lynch Jr. Hope Oncologist, September 1, 2007; 12(9): 1105 - 1113. [Abstract] [Full Text] [PDF]

				D. P. Sulmasy Spiritual issues in the care of dying patients: ". . . it's okay between me and god". JAMA, September 20, 2006; 296(11): 1385 - 1392. [Abstract] [Full Text] [PDF]

				J. Corbett-Hemeyer Inter-Religious Perspectives on Hope and Limits in Cancer Treatment: One Buddhist Chaplain's Response to the Case J. Clin. Oncol., November 1, 2005; 23(31): 8140 - 8141. [Full Text] [PDF]

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Astrow, A. B. Articles by White, M. Search for Related Content PubMed PubMed Citation Articles by Astrow, A. B. Articles by White, M. Social Bookmarking                            What's this?