A case discussion.

A 40-year-old man came to the clinic recently for follow-up of his hypertension and reactive depression following his father's murder a couple of months prior. This day he was more upbeat and told me he had met a woman whom he believed to be "the one" for him. This was especially important as I knew he had previously gone through a painful divorce and had been wary of intimate relationships. He described his new friend as being a wonderful woman who was raising two nice teenagers, was active in her church and who lived out her Christianity rather than just talking about it like so many people he had met before. He told me this relationship was causing him to consider spiritual matters more seriously. I congratulated him on what sounded like a healthy relationship and the cautious way in which they were beginning to get to know one another.

Later during our visit, the patient told me he was concerned about his sexual performance should the relationship become intimate in the near future and would like me to write him a prescription for one of the erectile dysfunction medications he had previously used. This request required a quick decision on my part: should I write the prescription and send him on his way with a brief warning about the dangers of unprotected intercourse, or should I share with him my own heartfelt beliefs and convictions regarding what would be best for him.

This case illustrates many of the points that authors Curlin and Hall (1) have addressed in their recent article in which they propose a new approach to discussing religious and moral issues with patients, which they call an "ethic of friendship." The "ethic of friendship" is described as a combination of wisdom, candor, and respect and requires a physician to walk a fine line to avoid violation of the patient's autonomy. Scheurich (2) points out that while some patients have well-established, self-determined values that should be respected, others come to medical encounters looking for advice. In addition, many patients desire a meaningful relationship with their physician, within ethical boundaries, that involves dialogue on a variety of levels, rather than simply having their diseases treated in an excellent technical fashion. In this case, I felt a relationship of mutual respect and candor had already been established, but thought it would be paternalistic to simply state my views on a moral issue without his consent.

Returning to my patient, I proceeded by telling him I did not want to force my views on him in the area of sexual morality but was open to sharing my thoughts with him if he was interested. Surprisingly, he responded, "Doctor, that is why I came to see you--I can talk to you about these things, and I want your opinion." I then briefly explained my understanding of the Biblical teaching of reserving sexual intercourse for after marriage which would provide several potential benefits. First of all, it would protect him from sexually transmitted diseases if both partners had been tested and treated, and they remained faithful to one another from then on. Secondly, postponing intimate relations might diminish the emotional pain they would each experience if the relationship ended before a long-term commitment was made. Thirdly, their self-restraint would set an example for the teenagers for whom he might end up serving as step-father. And finally, if he suggested they refrain from sexual relations until marriage, it would show respect for his new friend's Christian convictions. He listened respectfully and said that while he would consider these factors, he would still like the prescription, which I gave him.

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After reviewing the patient's medical issues, I asked the patient if he would like me to pray for him as I had done when he was going through the pain of having lost his father, and he readily accepted. I prayed that God would bless him in every aspect of his life, including his job, his health, the care of his widowed mother, his emotions, and his new relationship that appeared so promising.

As an example of holistic medical care, this case illustrates how one can address physical, emotional and spiritual issues in one relatively brief encounter. The fact that there was already a well-established physician-patient relationship and the fact that the patient had stated he was becoming more interested in spiritual issues facilitated a more comfortable discussion. This particular visit allowed incorporation of the components of the "ethic of friendship," including candid sharing of the physician's opinion of what would be a wise lifestyle choice, while respecting the patient's ultimate right to decide how to proceed.

References

1. Curlin FA, Hall DE. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med 2005;20:370.

2. Scheurich N. Spirituality, medicine, and the possibility of wisdom. J Gen Intern Med 2005;20:379-380.

Roger D. Smalligan, MD, MPH

From the East Tennessee State University, Johnson City, TN.

Reprint requests to Roger D. Smalligan, MD, MPH, East Tennessee State University, PO Box 70622, Johnson City, TN 37614. Email: [e-mail]