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No matter how principled, the denial of butter cookies to a bedridden woman--one of the few joys of her life--appears at first blush to be a form of cruel and unusual punishment. Nevertheless this choice may have to stand, unflinchingly brutal, in a society that aspires to the norm of religious toleration. No doubt restricting long-term care residents' choices on the basis of an institution's religious practice seems as unsavory as forcing a religiously affiliated institution to act against a core practice. In settings where religious diversity creates conflict, is there a course of action that at once respects individuals and institutions?

From an administrative perspective, the course of action may seem straightforward: an institution's raison d'etre is to provide an environment and practices consistent with its religious beliefs and mandate, and forcing it to do otherwise would be to gut the very soul from the institution--it would exist in name only.

From a religious accommodationist perspective, a "give the lady her butter cookies" argument might be justified by reducing the issue to informed consent. If, for example, Mrs. X had not been told upon admission of the restriction, then she would have been justified in requesting and receiving the contraband cookies. Similarly, if Mrs. X had no alternative choice in institutions because of nursing home bed shortages, then some might conclude she is under no obligation to comply with the religious practice of the home.

Yet to resolve the issue one way or the other too quickly, without paying attention to the particulars bearing on religious diversity in the nursing home environment, is to short-circuit moral reasoning. One feature we must examine is the home's resident population, frequently impaired--sensorially, cognitively, and functionally--which inhibits residents' personal exercise of autonomy. Add to this the fact that the higher portion of residents are women and poor--creating a power differential--and one may conclude that residents are in a vulnerable position. It would be important to examine whether Mrs. X is denied butter cookies principally based on strong religious commitment, or because unquestioning religious reflex will encounter little resistance from Mrs. X, who is weak and incapable of fighting.

Another facet of the problem is long-term care regulations, which are often adversarial in response to former scandalous practices of the nursing home industry. While the deference of the regulators for the Jewish dietary laws has led to a blanket restriction against any nonkosher food, an adequate moral analysis demands an exploration of the gradation that is admitted in a significant portion of rabbinic teaching on kashrut. It is essential that the regulators understand the weight of the teaching--how long it has been taught, by whom, and how centrally it is tied to the belief system.

The complexion of the nursing home staff also bears on considerations of religious diversity because nursing home staff often have less professional education than those in acute-care settings (some 70 percent of chronic care is supplied by nurse's aides), are less likely to practice with professional discretion, and are more apt to follow orders. Routines, devised to promote efficiency, at the same time drive patterns of care that may go entirely unquestioned. Restricting nonkosher foods is easier and more efficient than questioning whether there are gradations in religious law. Again, it would be important to examine whether denying Mrs. X her butter cookies was a religious conviction masquerading as something else--for example, the staff's selective enforcement of the restriction as a means of punishing Mrs. X for previous uncooperative behavior.

These particulars are not decisive in determining whether Mrs. X should have the butter cookies. Once a rich, sensitive discussion has taken place, it well might be the case that to retain its identity a home will have to insist on a totally kosher environment. Alternative environments to meet the needs of those who do not follow kashrut must be explored.

More important, however, is looking beyond which alternative course of action should be adopted--both seem unsavory--to whether the moral analysis has attempted at once to respect individuals and institutions. Such investigation of particulars brings a fuller meaning to ethics; it is a realization that the very act of moral struggling makes us more human. Only by paying attention to all the subtleties through sensitive moral analysis do we fully honor others and become more fully human ourselves.
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Title Annotation:religious tolerance in nursing home policies; Please Pass the Butter Cookies
Author:Boyle, Philip J.
Publication:The Hastings Center Report
Date:May 1, 1993
Previous Article:Am I my brother's warden? Responding to the unethical or incompetent colleague.
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