In my last blog entry I declared that non-compliant patients were not new to the healthcare system. It seemed pretty clear that we can find examples of non-compliance as far back as Galen, whose diet would have killed patients if they had followed it exactly. Other examples abound.
A similar but related issue is the conflict between medical advice and religious requirements. We all know about the ethical issues that arise when religious beliefs conflict with medical directives. Prescribing blood transfusion for Jehovah’s Witnesses is only the latest of these kinds of conflicts. And the tension is very great between these competing demands. Now the law is on the side of medicine – this was not always so.
In the Jewish tradition, life preservation takes precedence over religious requirements and so there are many stories, some of them no doubt apocryphal, of mischievous Christian doctors who prescribed pork products to Jewish patients as if nothing else would cure them. There was no question of not listening to the doctor’s advice; he question was how you got the pork to the patient without contaminating the whole house. For some patients this might have been a delight, but for others it was not merely unpleasant medicine. Still, for others their religion gave them good reason for non-compliance.
It turns out that not only Christian doctors made these kinds of recommendations – medieval Jewish doctors did too. Here is a complete letter from Maimonides to his royal patient. It is a good early discussion of the relation between medical advice and religious and other personal beliefs.
Maimonides’ Medical Letter
His servant is well aware that our Master, with his broad intelligence and profound understanding, will be able to conduct himself in the proper manner, in accordance with the previous treatise and these chapters. All the more so, when there stands before him [a physician] from whom he may request professional guidance or seek out practical instruction.
God, may He be exalted, is a witness, and His testimony suffices (Koran 4:79–81), that his humble servant’s great desire is to serve our Master with his own person and conversation, and not with paper and pen.
However, his poor constitution and the weakness of his natural faculties—already in his youth, and how much more so in his old age—constitute a barrier between him and many pleasures. I do not mean pleasures, rather good deeds, the most important and elevated of which is to serve our Master in actual practice. God be thanked for all the circumstances that befall us, the general and the particular, in the totality of existence and its particulars, in each and every individual, in accordance with His will, which accords with what is dictated by His wisdom, the depths of which no man can fathom. And God be thanked for every circumstance, whatever direction events may take.
Our Master should not criticize his humble servant for having mentioned in this treatise the use of wine and songs, both of which are abhorred by the religion. For this servant did not command acting in this manner; he merely stated that which is dictated by his profession. Indeed, the religious legislators know, as do the physicians, that wine has benefits for man.
A physician is bound, inasmuch as he is a physician, to present with a beneficial regimen, whether it is forbidden or permitted; the patient is endowed with the freedom to choose whether to follow or not. If [the physician] fails to mention everything that may be helpful, be it forbidden or permitted, he is guilty of acting dishonestly, for he did not offer trustworthy advice.
It is well known that religious law commands what is beneficial and prohibits what is harmful with respect to the world-to-come. The physician, on the other hand, instructs what will benefit the body and warns about what will harm it in this world.
The difference between religious commandments and medical counsel is that religion commands and coerces a person to do what will benefit him in the future, and prohibits what will harm him in the future, and punishes for it. The physician, on the other hand, counsels [a person] about what will benefit him, and warns him about what will cause him harm. He does not use coercion, nor does he punish; he merely presents the information to the patient in the manner of advice. And it is [the patient’s] choice [whether to follow that advice].
The reason for this is obvious. The harm and benefit from a medical perspective are immediate and clearly evident. Thus, there is no need for coercion or punishment. As for religious commandments, however, the harm and benefit that they bring are not evident in this world. The fool might, therefore, imagine to himself that everything that is said to be harmful is not harmful, and everything that is said to be beneficial is not beneficial, because these things are not clearly evident to him. For this reason religious law compels one to practice good and punishes for doing evil, for the good and evil will only become apparent in the world-to-come. All this is benevolence toward us, a favor to us in light of our foolishness, mercy upon us owing to the weakness of our understanding. This is the measure of what the servant saw fit to set before his Master and Ruler, may God grant him long years. I remain readily available to serve our Master. Thanksgiving and praise to God. (Quoted in Gesundheit et al. 425-426).
Here we have this tension being considered in the medieval period by a very articulate medical practitioner who will let the patient decide whether to accept the suggested regimen which is very much against the directives of his religion. It is hard to tell how much Maimonides is in league with his patient, but it is clear that this letter is for public consumption.
Reference: Gesundheit, B., Or, R., Gamliel, C., Rosner, F., Steinberg, A. “Treatment of Depression by Maimonides (1138–1204): Rabbi, Physician, and Philosopher.” American Journal of Psychiatry 165.4 (2008): 425-428. Web. 3 Mar 2014.