Mr. Washington is a 38-year-old electrician. He arrives at the office of Dr. Martin, his psychiatrist, after a recent hospitalization for his first episode of mania. He describes a history of several depressive episodes in the past (though he never sought treatment). He says he has never abused drugs and has had no psychotic episodes.
Seven years ago, Mr. Washington reports, he experienced a dramatic conversion. Before this conversion, he was a heavy gambler and often abused his wife and 2 children. "Ever since I got saved, I haven't gambled, and I've been trying to be good to my family," Mr. Washington says. His wife, significantly less religious than he, agrees that the change was dramatic, but his heavy involvement with a local Pentecostal church since that time has been a source of tension in their marriage.
The manic episode occurred 3 weeks before, when Mr. Washington gradually noticed himself feeling energetic, very optimistic, "like I could take on the world." He began several projects at home, working long into the night, "but I still felt great in the morning and had no problem going to work." He also describes praying long into the night, and, on more than 1 occasion, he believes he heard God telling him to follow certain courses of action. For example, he sensed God directing him to give a large sum of money to a single mother in his church, and, when his wife discovered the money missing from their bank account, she was alarmed and insisted he see a doctor—"You've gone way too far this time," she said.
He was hospitalized for several days and started on a regimen of a mood stabilizer and antipsychotic medication. During his third day in the hospital, one of the nurses heard him repeating unintelligible syllables for several hours. After discussion with his wife, Mr. Washington was discharged with orders to follow up at a clinic.
At Dr. Martin's office, Mr. Washington appears significantly subdued. He makes good eye contact, and is candid and cooperative, not displaying any pressured speech or tangentiality. In attempting to assess Mr. Washington's insight, Dr. Martin asks, "So tell me, Mr. Washington, what do you understand about why you were hospitalized?"
"You know, doctor, this is something I've been thinking and praying a lot about, and, to tell you the truth, I realize this might sound kind of weird, but I think God allowed me to get sick so that I could share the gospel with you. In talking with you, it doesn't sound like you know the Lord. I may be sick, but I've gotta tell you! Jesus has made all the difference in my life. He's made me happy and given me peace inside, and I haven't wanted to gamble or hurt my wife or kids ever since I gave my life to Him. Tell me, Mr. Washington, have you ever accepted Jesus as your Savior?"
Mr. Washington's conversion brought about a dramatic change in his abusive behavior. Following in the pragmatic tradition of William James who said that the only good measure of the truth of any religious belief is whether or not its effects in the world are beneficial and healthy,1 I must support Mr. Washington's religious beliefs regardless of their ontological status or whether I would embrace similar beliefs for myself.
I see Mr. Washington's religious beliefs over the last 7 years as distinct from the manic episode that has recently led him to be hospitalized, though I certainly do not know what caused the manic episode. It may simply have been bad neurochemistry, a call from God, or something else.
The fact that the episode was replete with religious grandiosity and delusions is not surprising given the place religion occupies in his everyday life. In manic states, individuals often take their everyday concerns and issues and amplify them in some dramatic way. A musician in such a state, for example, might lock himself in his studio for days, producing little of worth but convinced he's making brilliant music that will instantly bring the music world to its knees.
Ethical Issues and Concerns
When patients agree with psychiatrists' recommendations for treatment, we rarely raise concerns about informed consent. The implicit thinking seems to be, "My patient is conforming to my recommendations and wishes, therefore he or she must be properly informed and thinking clearly." But, when a patient believes that God gave him an illness so that he might convert his psychiatrist to fundamentalist Christianity, we certainly ought to raise the issue of whether this patient understands his illness and, additionally, whether he has the ability to give informed consent about receiving treatment.
If pressed, I'd probably conclude that Mr. Washington does not fully understand the nature of his illness and therefore is not able to give true informed consent about his treatment. Even so, his understanding of the nature of his illness probably is not too much different from that of many individuals because many people ascribe religious or supernatural meaning to their suffering (or their successes, for that matter). Many of my depressed patients, for example, see every ill that befalls them as deserved because they perceive of their own nature as inherently evil. Analogously, many manic patients see any good that comes their way (whether real or imagined) as something deserved because of how special and wonderful they are.
The fact, though, that Mr. Washington's understanding of his illness jibes (to some extent) with that of the majority of humanity does not, of course, mean he is correct in his understanding recall that most of the world used to think the earth was flat and that slavery was acceptable but it does put Mr. Washington's beliefs into a broader context.
Although I question Mr. Washington's ability to act autonomously and give meaningful informed consent, I do not see autonomy as an all or nothing proposition because, in theory, full autonomy would require completeknowledge, something none of us ever has. Instead, I see us as existing along a continuum between full autonomy and no autonomy whatsoever, with some of us closer to one end and some closer to the other.
Should I refuse to treat Mr. Washington because he does not understand the nature of his illness and, moreover, is pushing his religion on me? Absolutely not! Patients are often pushy in all kinds of ways. Besides, psychiatric illness often if not always strikes at the core of one's being and in its insidious way often compromises one's ability to act reasonably and make informed decisions. Since this is the very nature of psychiatric illness, I would be forsaking my duty as a physician if I were to stop seeing Mr. Washington and reject him as a patient based on these reasons.
Handling the Question about Religion
The final ethical concern I'll raise is one of maintaining proper boundaries with patients. What should we be willing to tell our patients about ourselves? Specifically, should I answer Mr. Washington's question about my own religious belief? Besides, is my faith status even directly relevant to our work together?
It would be disingenuous of me to answer his inquiry with the standard psychiatric question, "Why are you asking?" because any remotely aware individual knows that evangelicals care a lot about the religious beliefs of those around them. More often than not our patients know far more about us than we might imagine. Whether due to our conversations with them, a Google search, or merely examining the art on our walls or the books on our shelves, patients often make highly accurate guesses about our religious or political beliefs as well as our dietary and exercise habits.
How I Would Proceed Clinically
Even though I would never take Mr. Washington's religion for myself, I would strongly support his religious belief because it has kept him from abusing his wife and away from the bottle. That same religion has him convinced he has an illness (many psychiatric patients want to deny any illness) and will probably keep him coming to appointments and taking his medication. The pragmatic utilitarian in me thus supports his belief system.
At some point I would probably tell Mr. Washington that I doubt he'd ever convert me, even though I don't think that would deter him in his mission. And that would be just fine with me, because I assume that his ongoing hope of converting me would be one of the reasons he might continue our relationship.
In some sense, Mr. Washington and I would both be using one another for our own ends. I'd be looking to keep him healthy and, in the process, feel good about my own psychiatric abilities, and Mr. Washington would be looking to convert me. This view might appear a bit cynical, but as long as we are both fairly honest about our intentions, our interactions with one another will be both more above board and more respectful than most relationships, professional or personal.
James W. The Varieties of Religious Experience. New York, NY: New American Library; 1958:308.