By Ann Neumann
It happened again last month. Yet another journalist, working on yet another article about doctors’ religious sensitivity contacted me. Yet again, I gave my “You’re asking the wrong questions,” response. The journalists invariably deflate mid-call. They think they have an assignment with a solid, irrefutable frame, something like: the work of doctors will improve when they are better versed in a multiplicity of religious beliefs. The journalists have what they think is a practical, tolerant, liberal-minded call for reform, one very much in keeping with the post-9/11 emphasis on “interfaith dialogue.” What could be wrong with more dialogue, more sensitivity? It’s as though they’re looking to expand the collection of uplifting stories Gustav Niebuhr recounted in his 2008 book, Beyond Tolerance: How People Across America Are Building Bridges Between Faiths: Get people of different faiths together, let them discover how much they have in common, and, in this case, health care delivery will improve.
Kenneth L. Woodward wrote in his review of Beyond Tolerance for the New York Times in November 2008 that:
What gives Niebuhr’s book… its few bursts of energy, is the addition of Muslims to the conversation. Indeed, my guess is his search for interfaith understanding could not have found a publisher before 9/11. Since then, inviting Muslims to talk has become an act of mutual protection as much as one of respect for all parties to the conversation.
And so it is with much of the push for religious sensitivity among doctors. The movement for interfaith dialogue that we began as a country after September 11, 2001—for “mutual protection”—has become a tool for addressing a host of social ills, from economic disparity to unequal opportunity. Born out of an effort to dispel the (ignorant and malicious) conflation of all Muslims with the perpetrators of the 9/11 attacks, the new benevolent emphasis on religious tolerance worked much like a blind; if a representative from each of “the three Abrahamic faiths” could be brought to the table, all systemic inequality, racial prejudice, political maneuvering, economic disparity, and historic details could be obscured. “Look! We’re all talking,” became the message. “These Muslims right here at the table with us are rational and sane, so there’s hope!” Those advising interfaith dialogue, or tolerance*, get points for effort and visibility, for their intention to stabilize communication between disparate communities, but the inherent labeling, stratification, and distortion of world politics that can come from interfaith dialogue hasn’t realized true protection and equality.
And it’s certainly not always the right tool for such important tasks. In the case of medicine, it’s very much the wrong one. Here’s why:
Medicine has a diversity problem that won’t be solved by religious (or cultural) sensitivity training. African Americans and Hispanics, to take two minority groups, currently make up more than 25 percent of the population (a number that is rising fast) but only 6 percent of practicing doctors are African American or Hispanic. Which means that a vast majority of doctors are white (upwards of 70 percent).* Studies show that white doctors, for instance, don’t properly treat African Americans for pain. Greater diversity in medical schools would provide huge benefits to the diverse general population, not only by making the education experience broader and richer, but by better serving the needs of patients. Minority patients would have improved access to doctors with similar racial—and perhaps cultural—backgrounds and they would report better satisfaction with care. And here’s the kicker: medical students from diverse racial and ethnic backgrounds say they intend to work in underserved areas (51 percent of African Americans; 41 percent of Native Americans; 33 percent of Hispanics), but only 18 percent of white students intend to do the same. As the shortage of general practitioners continues, the need for more doctors who abstain from pursuing specialty areas is vital. More general practitioners, more continuity of care. But more importantly, increasing the field’s diversity goes a long way toward solving sensitivity issues, which means that the larger problem at the medical school level is not sensitivity training but diversity. When doctors are more like their patients, the need to teach them what their patients’ lives are like dissipates; patients lives are no longer othered and generalized… because diverse doctors also understand that diversity is infinite, not of describable (and limited) varieties.
That looks like I’m fudging; what does racial and ethnic diversity have to do with religious diversity? Many of the issues that religious sensitivity proponents wish to address are not just religious, they’re cultural as well. Do we really want our doctors to weigh their patient’s values and decide which ones are more important than others? I don’t.
It is not a doctor’s role to decide what patient preferences are cultural, religious or simply preferences. In the abstract for her paper, “Doctors and Diversity: Using Interfaith Literacy and Interfaith Dialogue to Improve Patient Care,” Concordia College’s Interfaith Scholar, Leslie Bellwood, uses this example: “What if a doctor who is ignorant of Islam’s prohibition of the consumption of pork prescribes a Muslim patient Heparin, a porcine product? Would the patient unknowingly defile themselves, become noncompliant, or even pursue litigation?” Bellwood assumes that any Muslim patient would oppose using Heparin, or any porcine product, because they are Muslim, and therefor jeopardize either themselves or their doctor (litigation) by prescribing it. While patients’ non-religious objections to ingesting certain products may carry less weight for Interfaith scholars, they well may not for patients. The argument for religious sensitivity then is not for full disclosure of prescribed medications’ contents but for doctors to make assumptions about particular patients based on their faith’s doctrines. Neither she nor other advocates are telling doctors to make patients’ decisions for them, but giving doctors a shorthand—faith is a series of categories—lifts the responsibility for full disclosure and places the emphasis on only some.
Bellwood concludes that “interfaith dialogue” works best in educating doctors about religious diversity, “because it is non-conversional at its core and allows for patients to describe their own experiences and expectations, both of which may have a substantive impact on the care that they need or are willing to accept.” But even this statement, that patients and doctors must better discuss “experiences and expectations,” should hold true for all doctor-patient relationships, not just among those with different faiths. By placing the emphasis on a doctor’s understanding (gathered during medical school in what I would assume is a unit or semester-length course that includes an instructor’s summary of the doctrine of primary faiths?) of religious tenants, the patient’s preferences are blurred, subsumed by a survey of their beliefs and practices that may well have little to do with how they live their lives or what they want.
Every faith is riddled with compromise, every believer’s life is an exercise in interpretation, accommodation and choice. By empowering doctors to make assumptions based on broad strokes, we risk the chance that patients’ decisions will be further compromised.
Doctors, according to informed consent and general medical practice, have an obligation to tell patients what all their options are. It’s the role of the patient to decide accordingly. The movement for informed consent in medicine grew out of the 60s and 70s, an era when doctors’ paternalism left limited or no choice to the patient about what treatments they were willing to undergo. Women particularly led the charge to take control over their medical decisions; they were horrified by stories from women who were scheduled for biopsies and came out of anesthesia will full mastectomies, no questions asked, no options given. But medical paternalism will only be eliminated when doctors are required to fully inform patients of what their options are, without bias, without profiling, without assumption. If the movement for religious sensitivity training were to rather focus on a more robust version of today’s informed consent, I would be all for it. But simply pushing doctors to tailor information according to their understanding of their patient’s beliefs is a recipe for less information, not more.
The threat of racial or religious profiling is real and dangerous. In today’s medical delivery environment, doctors’ visits are shorter because of time and financial constraints. Gone are the days of long-term doctor-patient relationships, wiped out by the complications of health insurance, a more transient population, and increased use of hospital emergency rooms and clinics. These shifts in contact between doctors and their patients mean that doctors have little time to parse the intricacies (and idiosyncrasies) of individual belief. Nor should they have to. Their role is to diagnose a problem, recommend and explain all the available treatments, and work with the patient to find a suitable solution.
Yes, patient narratives are lost in today’s examination room hustle. Yes, patient care suffers because doctors don’t have long-term knowledge of conditions and causes. Yes, patients’ stories about seemingly unrelated things can enlighten doctors about underlying ailments. But giving doctors the burden of doing this work from survey-like data on religious beliefs won’t change the dialogue problems that the medical field currently suffers from. Only rebuilding an unbiased doctor-patient dialogue can do that. And it must include much more than sensitivity to varying need, beliefs and viewpoints or we’re simply providing doctors with crib notes on what really matters.
* Listen to this fantastic, 14-minute interview with Wendy Brown, talking about her 2006 book, Regulating Aversion: Tolerance in the Age of Identity and Empire: http://ec.libsyn.com/p/0/4/8/0480036f3ef28a33/Wendy_Brown_on_Tolerance.mp3?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d06ce873ed9cf5adadf&c_id=1779543
** A minority percent are also Asian. Socioeconomic class of medical school applicants is also a problem, but one that I’ll leave to another day. You can read more here.
Past “The Patient Body” columns can be found here.
Ann Neumann is a contributing editor at The Revealer and Guernica magazine and a visiting scholar at The Center for Religion and Media, NYU. Neumann is the author of The Good Death: An Expl