Commentary

Spiritual care, as a feature of the care of the whole person, is integral to the values of hospice, and hospice organizations offer guidance to their members on the delivery of spiritual care in hospice programs.[1]

Spirituality and religiosity are very personal facets… these serve to modify a person's understanding, beliefs, and outlook to life and to what he holds sacred. However, one must also understand that although a person might appear to be religious outwardly, he might not attribute much "significance" or "meaning" to it. Furthermore, just merely by focusing on social and cultural factors, one must not arrive at any hurried conclusions about the persons religious and spiritual concerns… a direct question might often be helpful.

Ethical dilemmas can thus arise when one remains uncertain as how to act in the patients best interest, which would confirm to their religious and spiritual values that they had cherished when the patient's wishes cannot be determined. To further add to the confusion, comes the role of the "professional first responders," in hospitals, which in India, are most often the doctors, who have been taught mostly how to sustain life… for death is often viewed on as a failure of medical treatment. Unfortunately though, autonomy of the patient is hardly an issue in these situations. India still does not legally acknowledge advance directives.

In such confusing times, I believe, that the health-care professional must stick to the first principle of medical ethics of primum non nocere. However, the concept of harm would be judged on an individual basis by each individual, which would be influenced by his culture and beliefs. However, ethically speaking, a medical professional should honor the decision of a capacitated patient. In an incapacitated patient, surrogate decision-making, in the absence of written advance directives (which currently have no legal sanction in India), one must carefully determine if the surrogate's decision-making is based on the surrogate's interest ahead of the patient's interest.

Medical professionals often have to encounter religious sounding statements such as "it's in God's hands," or "God will show the path" which often reflects ambivalence on the part of the patient, surrogate, and even the medical professional. Some major religions view the end of one person's bodily life as part of a continuous cycle of life, death and rebirth, and suggest that it is wrong to use technology to confine a person in a body that is dying.[2] On the other hand, for many religious persons, the integrity of their own faith may seem to be at stake in a decision to forgo treatment.

These situations put them at crossroads in medical decision-making. Good communication, informed decision-making, involving the family and any religious head that the family should need to consult can be very helpful in these trying times.

It thus becomes a balancing act… on one scale is the patients right to compassion and dignity and on the other scale lies heavily the burden of "safe" medical practice. It is a gray zone and most health-care professionals would want to be on "safe grounds."