Frequently Asked Questions February 2011

Frequently asked questions were obtained from CMA members and were submitted to selected experts for responses. FAQs were submitted during our national meeting or submitted to the CMA website and were discussed by the Linacre Quarterly editorial board to ascertain which experts to contact to provide appropriate answers. All answers were reviewed by the Linacre Quarterly editorial board and edited as needed prior to publication. Additional questions have been received, and we continue to seek input from CMA members for additional questions that pose common or vexing medical-ethical issues. Please submit any questions you might have to LQ@cathmed.org.—Ed.

Promoting Natural Family Planning

Richard J. Fehring, Ph.D., R.N.^*

How can a Catholic physician promote natural family planning (NFP)?¹

The Catholic Church, particularly through papal teachings, has called on Catholic physicians and other health professionals to not only promote natural family planning (NFP), but also to use, teach, develop, and re search NFP. As early as 1951, Pope Pius XII instructed Catholic health-care professionals that it was their duty to learn about natural methods of birth regulation.² In other addresses, throughout his pontificate, he stated that Catholic scientists and medical personnel should do all they can to develop scientifically sound methods of natural family planning.³ In 1968 Pope Paul VI, through his encyclical Humanae vitae, called on scientists to develop natural methods of birth regulation and asked health-care professionals to acquire knowledge on the topic of reproductive health and to provide wise consult and healthy direction in the area of natural family planning.⁴

Pope John Paul II addressed the use of NFP in his talks, allocutions, and encyclicals throughout his pontificate and in particular through his development of the theology of the body.⁵ He encouraged physicians to enhance the welfare of families and of societies in their concern to harmonize human fertility with their capabilities. He also instructed nurse midwives in the important contribution that they can make in providing advice and practical guidance to couples wishing to carry out responsible procreation.⁶ Our current pope, Benedict XVI, recently expressed gratitude to physicians and researchers who work on ways to alleviate infertility within “the aim of preventing the causes of sterility and of being able to remedy them, so that sterile couples will be able to procreate in full respect for their own personal dignity and that of the child to be born.”⁷

Therefore, the Church's charge for Catholic physicians and other health-care professionals includes the development of and research on effective NFP methods, obtaining education about these methods, providing NFP services to couples, and helping in the proper prevention and treatment of infertility. The popes have been clear that the guiding principles of this charge are the dignity of the human person, the divine law, the primary role of the family and the responsibility to married couples.

The Role of the Catholic Physician in Promoting NFP

The first role of the Catholic physician in regard to the promotion of NFP is to learn all that he or she can about this topic (and of course, if married, to use NFP in his or her married life). There are many opportunities available for this to happen through online and in-person training programs. The United States Conference of Catholic Bishops (USCCB) Department of Natural Family Planning has a listing of couple training programs in NFP (listed by states) and NFP teacher training courses.⁸ All of these programs have met the USCCB standards for NFP service and teacher training. There are special teacher training programs in all of the major methods of NFP. Marquette University has an online program specifically for health professionals wishing to provide NFP services,⁹ the Pope Paul VI Institute for the Study of Human Reproduction has an intense NFP teacher training program and a training program in how to integrate NFP into women's medical care called NaProTechnology,¹⁰ and the Georgetown University Institute for Reproductive Health has a two-hour online training course in the provision of the standard days method of NFP and other simplified but effective NFP methods.¹¹

Although many Catholic health-care institutions offer women's health and obstetric services, relatively few include NFP as part of these services.¹² Catholic physicians could be instrumental in advocating that Catholic hospitals provide NFP services and help these institutions to develop infertility programs that integrate NFP and follow Church teaching. NFP is invaluable for couples with infertility by helping them to target the most fertile days for intercourse and for the physician to time diagnostic tests, to time treatments, and to assess for menstrual cycle abnormalities. Catholic physicians could also help develop and/or sponsor teen chastity programs that could be offered in (or sponsored by) Catholic health-care institutions. There are several teen chastity programs that integrate fertility appreciation (i.e., menstrual cycle monitoring) as a means for decreasing teen pregnancies and sexually transmitted infections such as, TeenSTAR¹³ and Northwest Family Services.¹⁴ Furthermore, the American Academy of Pediatrics and American College of Obstetricians and Gynecologists have advocated that menstrual cycle tracking be used as a fourth vital sign and diagnostic tool to spot menstrual cycle pathologies among adolescents and young adults.¹⁵

Catholic physicians and health-care providers have an important role in helping to integrate NFP services into marriage preparation. Physicians and professional nurses (in particular) are appropriate persons for providing information to young couples about NFP and, by their professional status, lend credibility to NFP. Physicians and professional nurses involved with the local guilds of the Catholic Medical Association often provide NFP presentations in marriage preparation programs sponsored by the local diocese. These presentations are especially important and often difficult to present because many engaged couples are already sexually active and using contraception.¹⁶

Catholic physicians can be active in promoting NFP in Catholic parishes. Pope John Paul II felt that there should be NFP teachers in all Catholic parishes to help couples learn NFP and to help prepare those seeking marriage. He instructed faculty at the Sacred Heart Medical School (Milan, Italy) that “the moment has come for every parish and every structure of consultation and assistance to the family and to the defense of life to have personnel available who can teach married couples how to use the natural methods.”¹⁷ Physicians could be involved with individual couple preparation or with group presentations on NFP, and support the parish priest in the areas of NFP and human sexuality. The physicians could also collaborate with the Catholic parish nurse (if available in the parish) in helping to integrate NFP services in a parish. This integration of NFP services could involve organizing NFP introductory sessions, teaching NFP to couples, organizing couple support groups, and developing presentations on topics of women's health related to NFP.

Conclusion

Catholic physicians have been consistently called by their Church and Church leaders to learn about, help develop, and provide effective NFP services. Few physicians, however, have answered this call. Those who have need continued prayer and support, since they often work in systems that, at best, pay little attention to and often are hostile to their efforts. However, NFP services can help to insure that the provision of Catholic health care involving the transmission of new life is life-giving, ethical, integrative, marriage building, and family oriented. Catholic physicians can learn about NFP through the resources noted above, make their expertise available to their parish and their diocese, and promote NFP through activities such as pre-marriage preparation programs.

Is It Possible for NFP to be Used (Immorally) with Contraceptive Intent?

Richard J. Fehring, Ph.D., R.N. and Kevin E. Miller, Ph.D. cand.^*

I have heard it said that if NFP is used with contraceptive intent, it is immoral. What would constitute use of NFP with contraceptive intent?

Natural family planning (NFP) is simply the ability to monitor the fertile phase of the menstrual cycle with natural indicators of fertility. With knowledge of the fertile time, couples can adjust behaviors to either achieve or avoid pregnancy, i.e., avoid intercourse during the fertile phase if avoiding pregnancy and have intercourse during the fertile phase if they wish to achieve conception. Use of NFP does nothing “against” fertility. “Contraception,” on the other hand is designed to impede fertility, i.e., by suppressing with powerful chemicals, blocking with the barrier device or IUD (or avoiding with withdrawal), or destroying with sterilization. Contraception (contra-conception), properly speaking, attempts to take away the procreative meaning of the acts of intercourse in which the couples engage, and in this precise way separates the unitive (love-making) and procreative (baby-making) meanings of intercourse.¹ Use of NFP never interferes in this specifically “contraceptive” way with the unitive and procreative aspects of the coital act; NFP does nothing against the fertility of the acts of intercourse in which the couples engage, and, in fact, enables couples to better appreciate and live with their fertility, as we will further explain below. NFP is integrative of the marital act of intercourse. Couples who use NFP will remain fertile and maintain the interplay between sexuality and fertility within their relationship. Since NFP does nothing “contraceptive” against fertility and does not split the two meanings of the sexual act (as designed by God), NFP is not “in itself” immoral. However, for a human action as a whole to be morally good, not only the chosen act in itself (“object”), but also the further intention, must be good.² We must therefore consider what would constitute an immoral—“contraceptive” or otherwise selfish—intention for the use of NFP, and whether a couple using NFP is likely to have such an intention or otherwise needs to worry greatly about whether they have one.

Couples who use NFP to achieve or avoid pregnancy could be selfish in their intent, i.e., intend to have more or fewer children than they are called to have given their situations (in the extreme case, to exclude procreation entirely for the entire duration of the marriage).³ All couples are called to be generous in their decisions to have children and are asked to take many factors into account, including their relationship with God, their spouse, and children already born, in this decision, by considering their “physical, economic, psychological, and social conditions.”⁴ One of us has years of experience teaching thousands of couples NFP, and rarely sees couples make the decision to avoid conception with selfish intent; in fact, NFP seems to have a way of encouraging couples to have children because of the cycle-to-cycle interplay with their fertility and because the natural drive to procreate is not suppressed. More often, a providentialist approach to fertility is seen among couples, who say, “We will take children as they come and as God wills. He will always provide for us and our children.” This is not what the Church teaches—couples are called to “responsible parenthood” in their decisions to have children. What often results from the providentialist approach is a physically and mentally exhausted wife and a husband expecting intercourse all of the time—disregarding the fertile phase. We actually find this thinking closer to the concept of “contraceptive intent”—in that the husband is expecting the spouse to be open to intercourse all of the time. This thinking and acting, like contraception, disregards the rhythms of the fertile and non-fertile phases of the woman's cycle and avoids the development of self-mastery that is necessary in periodic continence. Pope Paul VI believed that the practice of periodic abstinence actually conferred upon the couple's relationship “a more truly human character.”⁵

Pope John Paul II defined an immoral “contraceptive intent” by stating that the values inherent in the “contraceptive mentality” are demonstrated when contraception fails and the woman (or couple) is confronted with an unwanted pregnancy and she is more likely to be tempted to abortion.⁶ He said that this attitude is very different from responsible parenthood that respects the full truth of the conjugal act. The contraceptive mentality, he said, is rooted in a hedonistic mentality unwilling to accept responsibility in matters of sexuality. It implies a self-centered concept of freedom, which regards procreation as an obstacle to personal fulfillment. He further said that the life which could result from a sexual encounter thus becomes an enemy to be avoided at all costs and abortion becomes the only possible decisive response to failed contraception. Couples could have this intent with the practice of NFP, but it is not the practice of NFP that would be immoral but rather the viewing of procreation as the enemy and abortion the answer to an unintended pregnancy. Furthermore, in all the years that one of us has taught NFP, he has never seen or heard of a couple who practiced NFP that sought abortion as a result of an unintended pregnancy. With NFP, couples take on the responsibility and the possibility of new human life; with contraception, the responsibility is placed on the contraceptive medicine or device and when those fail, abortion seems a reasonable answer.⁷

The concern about the morality of NFP might stem from early (but erroneous) thinking about natural birth regulation when the first calendar-based methods of family planning were developed and taught in the 1930s. There was little support for the promotion and development of natural methods in the early 1930s by the clergy and members of the medical profession.⁸ In fact, Leo Latz, M.D., one of the first Catholic physicians to study, develop, and write about the first calendar-based method in the United States, was dismissed from the faculty at Loyola University Medical School because he promoted its use among married couples. At this time, priests were not encouraged to promote natural methods of family planning, but, rather, only to suggest their use in the confessional when there were grave reasons for their use. There was much doubt among Catholic physicians whether these methods actually worked and whether they were moral.⁹ However, today just the opposite is taught by the Church. Pope John Paul II stated that all people should learn the use of NFP as part of preparation for marriage, and that they should not wait to do so until the final stage of preparation, “in the months and weeks immediately preceding the wedding,” but rather should do so earlier; and he was adamant that health professionals should devote themselves to the study and spread of these methods, as well to the promotion of education in the moral values which they presuppose.¹⁰

The Church thus indicates that many couples will, at some point in their marriage, have appropriate, i.e., “serious,” reason to use NFP to avoid pregnancy.¹¹ Furthermore, the Church does not encourage couples to be hyper-vigilant about making certain that they have a serious reason. Catholic teaching does not place sole or strong emphasis on the need for a serious reason. The Church encourages couples to practice “prudent generosity” rather than either selfishness or carelessness, and holds that “very wide” categories of reasons could be serious ones for avoiding pregnancy.¹²

In conclusion, NFP is based on moral values that promote the wholeness of the marital act, helps to develop self-mastery, enhances the value and acceptance of new human life, and assumes total acceptance of the spouse. Contraception, on the other hand, calls into play a dualism between fertility and sexual expression, a reliance on the drug, device, or procedure rather than the actions and self-control of the individual and couple, impedance of fertility, and a conditioned acceptance of the spouse. NFP itself is never contra-conception. It is highly unusual for couples to use NFP with a contraceptive intent, nor is it to be worried that they will use it with a selfish intent, but if either intent is present, NFP itself is not the problem and more likely would be the solution to changing the mind and heart.

Evangelizing the Workplace

Carolyn Laabs, Ph.D., F.N.P.^*

Any suggestions for pro-life health professionals who find themselves working alongside pro-abortion physicians, nurses, or staff, many of whom are “Catholic but pro-life personally,” claiming to separate their religion from their practice, or are simply not transparent about their beliefs? How does one evangelize the workplace?

Discussing life issues, such as abortion, is difficult, especially in the workplace. This is because life issues are very personal but also very social, and thus have become contentious to the point that discussions often degrade into emotional assertions with little hope for logical discourse. Even so, health-care professionals cannot avoid addressing the obvious contradiction between our long-standing moral duty to heal patients and the unfortunate legally sanctioned social expectation to support and even perform activities that, in actuality, can harm them. Furthermore, the social expectation that one must separate one's faith from one's work requires a hypocrisy that offends truth and violates integrity, which requires that we allow faith to shape every aspect of our lives.

We sometimes find ourselves in the midst of this contradiction in the workplace, and it can be difficult to know how best to handle the conflict. I find it helpful to reflect on the virtuous physicians that I have known who, I believe, evangelize the workplace, not so much by what they say, but by what they do. Before I explain what I mean by this, I should say a word about evangelization, a socially contested issue of its own.

Evangelizing is sometimes confused with proselytizing. Evangelizing is commonly understood as bringing good tidings.¹ The Catechism of the Catholic Church defines it as, “the proclamation of Christ and his Gospel by word and the testimony of life, in fulfillment of Christ's command.”² And according to Pope Paul VI, it is “bringing the Good News into all the strata of humanity, and through its influence transforming humanity from within and making it new.”³ Proselytizing, on the other hand, is an attempt to convert a person to another religion, denoting the use of a certain measure of zeal and earnest.⁴ This differs from evangelization, which recognizes that it is not by our power that hearts are changed, but by the power of the Holy Spirit, and that faith is not something forced upon another, but a gift of God, an invitation to the truth to which one assents freely. Hearts filled with the Holy Spirit cannot help but act as witnesses of the Gospel, thereby announcing the Good News meant for all.

That is the kind of heart that I have seen in certain physicians who, I believe, handle workplace conflicts well. There is an inner peace or serenity about them that make them stand out from others. Their hearts are full of the joy of the Good News which they share, not necessarily by word, but by example. These physicians are not only expert clinicians, respected and valued within the medical community, but also excellent people, respected for being persons of integrity. They go about their work with calmness, confidence, and courage, steadfast in their faith and clear in their moral convictions. Even when others disagree or ridicule them, they always respond with respect, speaking the truth in charity, keeping their heads, and not allowing themselves to be distracted by fallacious arguments or irrational thinking. They never compromise their integrity. I hear people comment, “I don't agree with his position on things but I really respect him as a person. There is something about him that is different, a peace and joy. I wish I had that.” What they often do not realize is that peace and joy come from knowing God, being in right relationship with him, and living the Gospel of Life.

People long for the good and desire peace and joy. So, it seems to me, that the example of these virtuous physicians touches hearts more than talking changes minds. This is because it is God who changes hearts. Many hearts are hardened to the point that even reasoning from the facts does not penetrate the wall that they have erected, and it seems like nothing we can say will change their minds. By allowing ourselves to be instruments of God, we may find that the wall can be weakened, and a channel of God's peace is opened.⁵

Reflecting on these physicians but always looking to the Divine Physician as our guide to perfection, I offer four suggestions for imitating their example and evangelizing the workplace: evangelize ourselves, know the facts, develop support systems, and prayer.

Evangelize ourselves. Since we can only share what we have received, our own hearts must first be transformed, and so, “unless we continue to be evangelized ourselves with renewed enthusiasm for our faith and our Church, we cannot evangelize others.”⁶ Receiving the sacraments, reflecting on scripture, and studying Catholic moral teaching can illuminate our minds with the wisdom and beauty of the truth, fill our hearts with the joy of the Gospel of Life, and strengthen our resolve to be faithful in service to the Author of Life.

Know the facts. Not only must we know the facts of the Catholic tradition, we also must know the facts of the social and life sciences. It behooves physicians, being experts in the science of medicine, but also all health-care professionals, to equip themselves with knowledge regarding both the untoward medical, psychological, and social effects of activities that disregard Catholic moral teaching, and the benefits of adhering to Church teaching. For example, there is a growing body of research on the negative effects of in vitro fertilization,⁷ abortion,⁸ and contraception,⁹ and the positive effects of methods of natural family planning.¹⁰ Moreover, conducting or participating in scientifically sound, morally legitimate research, when possible, can contribute to the body of knowledge in these and other areas of conflict and controversy, and provide data that support and further reveal the truth and wisdom of Catholic teaching.

Develop support systems. Professional groups, like the Catholic Medical Association and their local guilds and the National Association of Catholic Nurses and their local councils, can help provide the professional collegial support that can bolster our spirits as we share stories of faith and evangelization. It is not uncommon to feel alone in the workplace when it comes to matters of faith and morals; and so, it helps to know that there are like-minded colleagues who experience similar struggles. It is often within these groups that we find role models and mentors with the knowledge and the kind of hearts that touch us and others in the workplace.

Prayer. “Prayer is the life of the new heart.”¹¹ Indeed, the Christian life is a life of prayer, and it is the heart that longs for the Word of God and to dwell in his presence.¹² In the words of Mother Teresa, “prayer enlarges the heart until it is capable of containing God's gift of himself. Ask and seek, and your heart will grow big enough to receive him as your own.”¹³ Therefore, we need to pray without ceasing, for ourselves and for others, uniting our prayer to our work,¹⁴ so that we might be able to “radiate the joy of Christ and express it in our actions.”¹⁵ This is the joy and peace of the Good News that moves hearts and begins to break down barriers to the love of God and the Gospel of Life.

“When situations require witness to the faith, we must profess it without equivocation in action and in word, keeping a clear conscience toward God and others,”¹⁶ speaking the truth in charity. That is the mark of integrity, which requires that we allow faith to shape every aspect of our lives, including the workplace. May we evangelize ourselves, know the facts, support one another, and pray without ceasing, so that we might bear witness to the truth and bring the Good News to others with hearts filled with the joy and peace that is found only in living the Gospel of Life.

Contraception, Sterilization, and Abortion in a Office Setting

Kathleen Raviele, M.D.^*

Can a Catholic physician prescribe artificial contraception?

No. A Catholic physician cannot prescribe artificial contraception and at the same time remain faithful to Church teaching. The Church asserts that “‘every action which, in anticipation of the conjugal act, or in its accomplishment, or in the development of its natural consequences, proposes, whether as an end or as a means, to render procreation impossible' is intrinsically evil.”¹ The immorality of artificial contraception remains a consistent teaching of the Church, rooted in natural law and charity. “Called to give life, spouses share in the creative power and fatherhood of God.”² “So the Church, which ‘is on the side of life' teaches that ‘it is necessary that each and every marriage act remain ordered per se to the procreation of human life.’”³ The Church does not say we must have as many children as possible. The Church does say there are legitimate reasons to postpone or prevent childbearing, even indefinitely, but this is done in a licit way only when that goal is accomplished by periodic abstinence during the fertile time. There are several natural family planning (NFP) programs that can assist the physician to transition out of a secular contraceptive practice into a medical practice in conformity with the Church's teachings, such as the Pope Paul VI Institute's FertilityCare system, the Institute for Natural Family Planning at Marquette University, and the Couple to Couple League, as well as the Billings program.⁴ The Pope Paul VI Institute has a medical consultant program that educates the physician in helping the female patient manage fertility without using oral contraceptives. Marquette's Institute of NFP has an online course that is very helpful for physicians to understand NFP; and the Couple to Couple League and the Billings' program have conferences for physicians.

Occasionally, for medical reasons, a physician may have to prescribe hormonal agents or other drugs that suppress ovulation to treat a significant medical condition in the woman, but this should be short term with the intention to restore the woman to normal function, not to prevent conception. For example, a non-pregnant woman experiencing flooding with a period, can be controlled with any combined oral contraceptive or combined menopausal hormone therapy given three to four times a day for five to seven days. The bleeding stops in twenty-four hours, saving the patient a hospitalization with intravenous hormones or a D&C. Although this does not cure the underlying pathology, it allows time to further evaluate the cause of bleeding and to treat it appropriately. In the case of ovarian cysts, it has been the recommendation to give oral contraceptives for three months to resolve them, but a recent review of the literature has shown this to be ineffective.⁵ The Pope Paul VI Institute instead recommends treating follicular and luteal cysts with progesterone in oil, 200 mg IM to resolve the estrogen dominance in the cyst, consequently a follow-up ultrasound after the next cycle usually shows resolution.⁶ Similarly hormonal contraceptives are often prescribed for acne, although other effective treatments exist (antibiotics, spironolactone, topical treatments, retinoids) which are not contraceptive. Irregular cycles, often caused by polycystic ovary syndrome, can be managed with cyclic bio-identical progesterone therapy and metformin if the woman has insulin resistance. These therapies actually treat the underlying cause, rather than mask the disorder with the regular cycles created by oral contraceptives. In the treatment with oral contraceptives for medical reasons of any female patient who is sexually active, the possibility must be considered of breakthrough ovulation with fertilization but failure to implant because of the endometrial effects of the synthetic estrogen and progestogen.⁷ Depot medroxyprogesterone acetate is least likely to have a breakthrough ovulation; and the progestogen-only “mini-pills” usually do not prevent ovulation, but none of the combined oral contraceptives prevent ovulation 100 percent of the time.⁸

So while there are specific situations where hormonal therapies that prevent ovulation can be prescribed, these are rare and should never be for the purpose of preventing conception. Given the risk of conception and subsequent failure to implant (abortifacient effects) of hormonal therapies, abstinence should be recommended for the times such therapy may be necessary.

How do I discuss artificial contraception with a patient who asks for it?

In advance of any discussion about artificial contraception with a patient, it is probably best to let the patients know before establishing care with you, that you do not prescribe any contraceptive practice, including sterilization, on the basis of moral and health reasons. One way to achieve such advance notice is to ask your appointment secretary to inform prospective patients by saying something such as: “Are you aware that Dr. XYZ does not prescribe any form of contraception?” In addition, it is important to include information about your practice in your patient information brochure, which is typically available in the waiting room. You may be surprised at the number of patients who will come to see you anyway because they appreciate a doctor who is able to stand up for his or her principles, even when they are counter-cultural. Sometimes, a patient may have seen you for awhile, but have forgotten that you do not prescribe artificial contraception, and raise the matter because of a change in circumstances. If that person is single, do not be afraid to challenge them to look at their behavior which is putting them at significant risk physically, psychologically, emotionally, and spiritually. True happiness comes within marriage and a lifetime commitment, and it is difficult to decide if someone is the right person to marry if you are already having sexual relations with them. Many who embark on illicit relationships end up devastated after acquiring a sexually transmitted disease or are abandoned by the one they thought loved them. If the person asking you to prescribe artificial contraception is married, a brief discussion of the purpose of the marital act and the complications of oral contraceptives, such as depression, blood clots, migraine headaches, and breast tumors, is helpful. Sometimes giving the patient additional information, for example, Dr. Janet Smith's CD titled “Contraception Why Not?” is useful.⁹ In addition, it may be helpful to offer the patient information on natural family planning classes by NFP providers in the area or through online courses such as those offered by the Marquette University Institute of Natural Family Planning.¹⁰ Home study courses through Couple to Couple League may also be an option.¹¹ For women with regular cycles, there is a simple method called Cyclebeads, also known as the Standard Days Method, that can be self-taught.¹² Remember, patients come to you because they trust your opinion. Therefore, do not be afraid to educate them about the dangers of contraception, the intrinsic value of each human life, and the significant meaning of marriage. Often they know these realities deep down in their hearts but cannot express it themselves, or may not have found anyone to articulate it for their benefit.

How do I work with colleagues who are pro-life but still prescribe contraceptives?

A Catholic physician who stands up for his or her principles, and who practices medicine in conformity with those principles provides a powerful witness to those around him or her. Other physicians and health-care personnel notice such a physician. They may be reflecting on you, thinking: Are you happy? Is your personal life peaceful? Are you a great clinician? Do you keep up with changes in medicine? Do you treat your patients and employees well? As St. Francis said, “preach often and if necessary use words.” Be friendly, cooperative, and ready to serve on a hospital committee if asked or to give a talk, but do not participate in any illicit behavior. If you are in a partnership, make sure your share of the earnings of the group does not include anything to do with contraception, abortion, or sterilization. If the situation arises, give brief explanations for why you practice the way you do, but do not force material on other physicians.¹³ It is amazing the effect of short conversations over the operating table or in the doctor's lounge where the truth is spoken quietly and in a kind way. Logic and science are frequently not the reason physicians come to embrace the Church's teaching in this area, even though both logic and science support the Church's teaching; it is through a spiritual awakening. Logic tells us that fertility is not a disease but evidence of a healthy reproductive system and therefore not in need of “treatment.” Science tells us that the use of contraceptives has negative medical, psychological, and sociological consequences.¹⁴ In spite of this evidence, physicians who embrace an NFP-only practice usually do so through the operation of God's grace. In the book Physicians Healed, by Cleta Hartman, the personal stories of fifteen physicians who changed their practices to NFP-only consistently demonstrate the power of grace working in souls and the change of hearts coming through religious conversion.¹⁵ A final thing to do is to pray and offer sacrifice for all the physicians with whom you come in contact. Grace from God comes to physicians through three movements:

The first thing he does is inspire the soul with an overpowering sense of his majesty, which fills it with awe and makes it fear and tremble at the thought of its own baseness—counting itself quite unworthy of its favors. But God cannot stop short here; for if this first feeling lasted the soul would never dare to approach him; and therefore he causes the second movement, which consists in an intensity of holy desires, producing a longing in the soul to rise up and come near to its Savior. Then, by and by, comes the third and most perfect operation of grace—namely, the full answer to these ardent wishes in the complete triumph of God's own peace within the heart, as the Apostle describes it: Pax Christi exulted in cordibus vestris.¹⁶

How do I discuss abortion with a patient who seeks one?

If a woman comes to you to discuss having an abortion, you have a limited period of time in which to impact this woman's decision making. First, develop a cordial relationship with the woman as you share the news about the positive pregnancy test. Assess her circumstances and refer to her as a mother, and the fetus as her baby. Perhaps ask her the following questions: What is the reaction of the father of the child going to be? Does she have family who will help her get through the pregnancy? How will this impact her job or schooling or her finances? If you have ultrasound in your office, show her the baby and speak of the child, perhaps pointing out parts of the child's anatomy. If she had previous abortions, discuss with her the emotions she experienced after those abortions. If she says she will have an abortion, ask her why. Offer her realistic options to overcome the obstacles that she sees are in the way of her bringing the child to term. Be sure to have educational materials that show the baby at the stages of development, and point out the stage at which her baby is presently. Discuss the complications of abortion, namely an increased risk of prematurity with subsequent children,¹⁷ the increased risk of breast cancer,¹⁸ and the psychological sequelae which can be particularly difficult to experience. The American Association of Pro-Life Ob-Gyns' website, is a wonderful resource detailing the complications from abortion.¹⁹ Never condemn your patient if she is resolved to go through with the abortion. Hopefully, she can see in your treatment of her, the love and compassion of Christ. If asked for a referral to a “safe” facility or doctor for an abortion, do not give her a referral nor assist her in any way with procuring the abortion. Such a referral makes you complicit with the immoral action through immediate material cooperation. You would not be intending that she have the abortion, but would still be providing the circumstances by which she can have the abortion. Continue to see her as a patient with great compassion if she does have the abortion, including offering her post-abortion counseling through an approved program, such as Project Rachel.

How do we explain to a patient why we do not perform or refer for sterilization (vasectomy or tubal ligation)?

From a medical standpoint, surgical sterilization is a mutilation of a normal part of the body. It is the creation of a disease process in otherwise-healthy tissues with no disease being treated. We decry the practice of female circumcision in Ethiopia, but are we not doing a similar thing in sterilization? There are consequences to this action. Tubal ligations result in premenstrual syndrome, pelvic pain, worse cramps, abnormal bleeding, heavy periods, and possible ectopic pregnancy. There is an increased risk of hysterectomy beginning at two years after a tubal ligation, particularly in women under the age of thirty.²⁰ Vasectomy can result in severe pain for the man and complications such as sperm granuloma, congestive epididymitis, an increase in anti-sperm antibodies, and psychological effects such as sexual dysfunction, impotence, or premature ejaculation. Some men develop post-vasectomy pain syndrome or chronic testicular pain.²¹ By focusing on the medical complications of these procedures, it is possible to explain to patients why you do not perform these procedures or refer them for these procedures. Make it clear that you will not perform these procedures nor refer the patient to someone else to perform them because you care for the patient, and have his best interests in mind.

The Real Risks of Oral Contraceptives

Marie-Alberte Boursiquot, M.D.^*

What are the risks for oral contracetives?

The 1960s were a time of great societal change in America. Conflicts existed among the races, and gender roles were evolving. In May 1960, the U.S. Food and Drug Administration (FDA) approved a new oral contraceptive (OCP) to regulate women's cycles, and this appeared to be a great liberator for women sexually. It is more commonly known as “The Pill.” For centuries women all over the world used a variety of methods to space having children or to avoid pregnancy altogether. The Pill is unique in that it is highly effective at preventing pregnancy and separates procreation from sexual intercourse.

In the nineteenth century, Anthony Comstock, a devout Christian, feared that American society was becoming licentious. He went to Washington, D.C., to further his cause; and in 1873 he succeeded in getting Congress to pass the Comstock Act which was aimed at stopping “obscene literature” and “immoral articles.” The Comstock Act also targeted information on birth control, abortion, and STDs.¹

Until the early part of the twentieth century, there was universal agreement among all of Christendom that contraception was morally wrong and went against God's design for humanity. Then in 1930, the Anglican Church dispensed with this tradition at its Lambeth conference.² In 1968, Pope Paul VI affirmed, in Humanae vitae, the Church's longstanding belief that artificial birth control is morally wrong. He prophetically predicted that the consequences of a culture practicing artificial birth control would result in the following: 1) an increase in conjugal infidelity, 2) in society there would be a general lowering of morality, and 3) there would be a loss of respect for women.³

Morally, “contraception is wrong because it damages our physical well-being, our psychological well-being, our marital relationships, and our relationship with God.”⁴ Ethicist William E. May assesses the situation in the following way:

Since contraception is specified precisely by the choice to impede the beginning of new human life, it is an anti-life kind of act, one expressing a contra-life will. It is precisely because contraception is specified by a contra-life will that it was … regarded for centuries as analogous to homicide by Christian writers…. Contraception is always seriously wrong because it is always gravely immoral to adopt by choice the proposal to damage, destroy, or impede the good of human life.⁵

OCPs are composed of a combination of a synthetic estrogen/progestin combination. The estrogens and progestins are two classes of female hormones secreted by the ovaries. Estradiol (a type of estrogen) and progesterone (a type of progestin) are the dominant sexual hormones. Over the years the dose of estrogen in the OCP has decreased, and different types of progestins have been added.

Despite these modifications in composition, the side-effect profile of the Pill has not changed. It includes the following conditions: cardiovascular disease/myocardial infarction (MI), cerebrovascular accidents, depression, deep venous thrombosis, pulmonary emboli, breast cancer,⁶ cervical cancer, liver cancer,⁷ inter-menstrual bleeding, migraine headaches, edema, weight gain, and yeast infections just to name a few.⁸

The 2010 edition of the Physician's Desk Reference (PDR) includes a general discussion of the side effects of OCPs under its listing for Yaz.⁹ Note that these risks are equally applicable to contraceptives by other modes of delivery such as long-acting Depo-Provera injections and the Nuva ring. A brief review of statistical terminology is in order at this juncture. The relative risk (RR), in medical terminology, is the ratio of probability of a disease occurring in the exposed group versus a non-exposed group. A RR=1 indicates that no difference between the groups (in this case, OCP users versus non-users) studied. A RR^lt;1 indicates that the disease is less likely to occur in the experimental group (OCP users) than control group. A RR>1 indicates that the disease is more likely to occur in the experimental group (OCP users) than control group. The attributable risk refers to any factor which increases the risk of suffering a particular condition.

In general the relative risk of myocardial infarction for current OCP users has been estimated to be two to six. Circulatory disease mortality per 100,000 women by age, smoking status, and OCP use is almost tripled for smokers as opposed to non-smoking OCP users as is demonstrated if one looks at the data comparing women ages 18–24, 25–34, and 35–44.¹⁰

Case control studies have found that for OCP users compared to non-users, the RR of OCP is three for the first episode of superficial venous thromboembolism, four to eleven for deep venous thrombosis/pulmonary emboli, and 1.5 to six for those with predisposing conditions for venous thromboembolic disease. The RR is not related to length of use and disappears after OCP use is stopped.¹¹

OCP use has been shown to increase both the relative and attributable risks of cerebrovascular accidents. In general, the risk is greatest among women thirty-five years of age or older and those with hypertension who smoke. The relative risk of thrombotic strokes ranges from three in normotensive women to fourteen for those with severe hypertension. The relative risk of hemorrhagic cerebrovascular accidents is 1.2 in non-smoking OCP users, and 7.6 for smokers using OCPs.¹²

The relative risk for developing breast carcinoma is 1.24, however it decreases over time after combination OCP use is discontinued; and, by ten years after cessation, the increased risk disappears. The subgroup for whom risk is significantly elevated is women who first used OCPs before age twenty.¹³

Benign hepatic adenomas are rare in the United States. Indirect calculations have estimated the attributable risk in the range of 3.3 cases per 100,000 for users. The risk increases after four or more years of use. Rupture of benign adenomas may cause death through intra-abdominal hemorrhage.¹⁴

The focus on OCP side effects is often averted by marketing OCPs for conditions other than prevention of pregnancy. Over the past recent years, for instance, the number one birth-control pill in the United States, YAZ, which is a combination of ethinyl estradiol and the progestin drospirenone, has been promoted as an effective way of treating acne vulgaris. Despite this YAZ has recently come under fire and is the subject of law suits due to the increased incidence of thromboses.¹⁵ This, in essence, is attributed to misleading advertizing of its use.

More recently, the FDA approved the Beyaz tablet, which is an estrogen/progestin combined oral contraceptive which contains a folate. Beyaz is based on the approved product Yaz which contains the same doses of estrogen and progestin, and is approved for the prevention of pregnancy, the treatment of premenstrual dysphoric disorder, and the treatment of acne vulgaris. Beyaz is additionally approved for the secondary indication in women who choose to use an OCP as their method of contraception, to raise folate levels for the purpose of reducing the risk of a neural-tube defect in a pregnancy conceived while taking or shortly after discontinuing the product.¹⁶

Despite the side effect profile of OCPs, a recent CBS poll demonstrates that over 50 percent of people believe that the Pill has improved American family life. Thirty-eight percent of Catholics share this belief while 52 percent of Protestants do. The poll also demonstrates that most people are less concerned now with the side effects of the Pill than they were in the 1960s.¹⁷

It bears mentioning at this juncture that two large British cohort studies were published recently, providing evidence that users of OCPs have less mortality than non-users. But, Dr. Richard Fehring asserts that the design of these studies, namely, a prospective cohort comparison, has the weakness of resulting in false findings.¹⁸ He points out that in large cohort studies of hormonal replacement therapy, the use of hormones was found to be healthier than not taking hormones. When a more powerful design such as a randomized control trial was conducted with the Women's Health Initiative study, in which women who were randomized into an oral hormonal group compared to a placebo group or a group that does not receive the hormones, the opposite was found: increased rates of cancer and heart disease among users of hormonal replacement therapy.¹⁹

Physicians are often consulted by women for advice on the “best” form of birth control to utilize. Often this comes up during the course of a visit because an obstetrician-gynecologist has failed to advise the patient of the risks of OCPs or, worse yet, has told the patient that she should be on birth control with, in many instances, very little to no explanation as to why. Naturally it goes against the beliefs of Catholic physicians to advise patients to take OCPs as there is clear Church teaching that contraception is morally wrong.

By focusing on the side effects of OCPs one can succeed in arming women with the information they need to make their decision. Many times after explaining the side-effect profile of the Pill, the decision will be made by the patient to be weaned off OCPs. This approach is successful in that it affords the physician an opportunity to educate the patient on the risks of this particular class of drugs and avoid the appearance of proselytizing.

We, therefore, owe it to ourselves as Catholic physicians, irrespective of specialty, to remain apprised of the risks of using contraceptives. We should consider using as many opportunities as we can to educate our patients on its ill effects. Additionally, we are blessed as Catholics to have our Church's teaching body, the Magisterium, in place to guide and instruct us in matters of morality. We should put aside time regularly to read the magisterial documents on marriage, sexuality, and contraception. And as people of faith we should not underestimate the power of prayer. We should ask the Holy Spirit for wisdom and guidance in addressing this and other morally challenging issues which arise during the normal course of our daily physician-patient encounters.

Talking about Contraception

The Catholic Physician in the Exam Room

Sister Mary Diana Dreger, O.P., M.D.^*

What does the Catholic physician do when the question of contraception is raised by the patient in the exam room? The patient may not be Catholic, although the situation is even more uncomfortable when the patient is Catholic.

Some Catholic physicians have ways of making it known in advance that they will not “do” contraception. Others may excuse themselves apologetically and suggest that gynecologic care should be sought with a specialist in the field. How many Catholic physicians see this potentially stressful moment as an opportunity to promote good health care, independent of religious beliefs? The Catholic teaching in the area of contraception is perfectly equated with sound medical care. And there is no reason to apologize for it.

Health care is the evaluation and treatment of disease states, and the promotion of appropriate preventive services to decrease risk of illness. To say contraception is a form of health care would mean one of two things. Either the patient's fertility is a disorder, and therefore needs to be evaluated and treated. Or a future pregnancy is an affliction, and therefore appropriate preventive measures should be taken to decrease risk of this morbidity.

The truth is that fertility is not a disease. And bearing a child is not an illness.

In modern medicine, contraception is the only “treatment” that is given because the patient is healthy. A well-functioning system is rendered malfunctional by chemical or mechanical means. The precise reason for intervention is that the organs involved are working properly. In no other instance in medicine is a physician permitted to damage healthy tissue intentionally to prevent its function. In all other cases, this would be assault. Yet current medical teaching permits and encourages direct impairment of the reproductive system in a consenting patient.

Vasectomy, tubal ligation, and newer methods of blocking passage of gametes through the reproductive tract intend to damage permanently these normally functioning tissues. There is no other case in medical care in which definitively blocking the lumen of organs would be allowed ethically. Cardiologists and vascular surgeons do not tie off arteries or veins transporting blood to or from healthy tissues. A gastroenterologist or general surgeon does not create a permanent bowel obstruction for any purpose. Such actions are criminal.

Intrauterine devices and barrier methods of contraception involve the use of non-sterile foreign bodies within body spaces. The medical world allows for foreign objects to be used invasively only with proportionate reason, carefully weighing the risks and benefits to the patient. Central venous lines and urinary catheters are discouraged without clear, evidence-based, medical need.¹ When they are used, time limits are set with the knowledge that infection risk increases with extended use.² Yet little consideration is given to a copper or plastic device inserted into the uterus with strings extending into the vagina. Yet these projections from a non-sterile area to a relatively sterile one provide direct access for microorganisms to the uterus.³ Further, medicine is convinced that chronic inflammatory processes in the body lead to long-term damage.⁴ Yet the inflammatory response set up by the IUD is accepted as an appropriate mechanism of action to achieve the end of infertility.⁵

Chemical contraception using estrogen- and progesterone-derived compounds function in a combination of ways, suppressing oocyte development at the level of the ovaries, promoting atrophic changes of the uterine lining, and interfering with normal changes of the cervical mucus.⁶ While prevention of ovulation is considered to be the usual contraceptive effect, medical texts and pharmaceutical companies report that a second effect is to alter the endometrium sufficiently to exclude effective implantation of an embryo should conception occur.⁷ Some argue that this abortifacient effect is so unlikely that it should be excluded from the contraception debate. Others maintain that even if there is a possibility that the Pill can result in abortion,⁸ this point should be in the forefront of public discussion, as more non-Catholics are likely to oppose abortion than to oppose contraception.

The Catholic physician, however, need not shy away from discouraging the use of oral contraceptive pills out of concern for uncertainty of its role as an abortifacient. Again, ingestion of a chemical substance that directly interferes with normal, healthy organs with the specific intent to prevent their functioning is opposed to the tenets of health care. This principle is independent of possible contra-implantation effects of the pill. In addition, health-care professionals are always cognizant that secondary unintended effects are possible with the use of any medication. The side-effect profile of oral contraceptives is wideranging from the recently reported decrease in sexual satisfaction, to the well-known risks of metabolic disorders, hepatic adenomas, and thromboembolic disease among others.⁹ Physicians are obliged to discuss these with patients as part of the informed consent process. It would be interesting to know how honestly these discussions take place as oral contraceptives are prescribed.

So how do we, as Catholic physicians, engage our patients in a thoughtful evaluation of contraception and explain to them why we cannot act in any way that would support these surgical, mechanical, or chemical interventions?

My own practice is in a charity clinic operated within a Catholic health-care system. My patients typically have little formal education, and we are often communicating through a translator, with their limited English, or in my limited Spanish. Even in this setting, patients understand quite clearly the concerns about contraception when they are invited to consider them.

One young man, at the end of his appointment, asked me to refer him for a vasectomy. I explained to him that this procedure was one that destroyed parts of his body that were working normally, that were actually healthy. I told him that if he asked me to cut off his finger because he did not want it, when there was nothing wrong with it, I could not assist his request. Similarly I could not support his interest in sterilization, whether for himself or for an analogous procedure for his wife. I stepped out of the exam room for a few minutes and then returned, expecting he would not want to continue this conversation. However he brought it up again immediately, and said that he recognized the truth of my arguments. He asked about alternative ways of avoiding another pregnancy, as he and his wife had three children and were in a limited economic situation. I provided a simplified explanation of natural family planning, and he was very open to receiving further information for consideration with his wife.

Several of my patients have IUDs placed by providers at the local public health clinics. When I hear this, I open a conversation with them asking if they understand how an IUD works. The patient typically shrugs her shoulders and says she just knows it is a contraceptive. I explain that as a foreign body it creates an inflammatory response in the uterus¹⁰; and while it may simply prevent conception, it has another effect in preventing implantation.¹¹ If a sperm fertilizes an egg in the fallopian tube, the embryo would not be able to stay in the uterus, but would be eliminated from the body. Nearly every patient's response is, “They never told me that”; and several have offered the observation that this would be an abortion.

Again, when patients are taking oral contraceptives prescribed by others, or ask if I will prescribe them, I explain why I cannot acquiesce to their request. My role as a health-care provider is to promote the proper functioning of the body. I would not give a pill to stop the functioning of the heart or lungs, and so I cannot prescribe a pill that stops the function of the ovaries. That is not legitimate medical care. Again, if they ask for options, I speak about the scientific basis for natural family planning, or sometimes offer that information on my own initiative.

Patients want physicians who will be true advocates for care of their health. No patient has argued against my concern for their well-being. It is not necessary for me to say that surgical, mechanical, and chemical contraceptive methods are in opposition to my religious or moral beliefs, or that they raise conscience problems for me. It is enough, and even better, that I instruct my patients about what I, as their primary care physician, believe is true medical care. Promoting health of the human person is not dependent on religious denomination. Catholic physicians need to understand that the truth of the evil of contraception is not relative to personal beliefs. And they can begin to educate the world on this issue with the patients whom they meet in their exam rooms.

Praying with Patients

Patricia Fosarelli, M.D., D. Min.^*

I pray for my patients on my own, but there are times that I would like to pray with some of my patients. Yet, I don't even know how to begin. Should I ask them if they'd like me to pray, or should I wait until they ask me to pray? And what kind of prayer should I pray?

According to Gallup and D.M. Lindsay, the vast majority of U.S. citizens believe in God, attend religious services regularly, and pray regularly, even daily, and believe their prayers are answered.¹ Furthermore, another Gallup poll, conducted in 2001, found that 47 percent of U.S. adults would like their doctors to pray with them during an illness, adding weight to a previous Gallup poll from 1997 which found that 70 percent of adults said that it was important to have a doctor who was “spiritually attuned” to them.² However, H. Koenig and colleagues found that compared to nurses, patients, and patients' families, physicians were less likely to believe in God, attend religious services, and consider religious beliefs highly important in coping with stress.³ Nearly twenty years later, in their study of academic pediatricians, E. Catlin and colleagues found almost the same results.⁴ Making matters more complicated is the fact that many doctors who graduated from medical school prior to the last fifteen years or so never heard a presentation in medical school or during their training on praying with patients.

Yet, because many patients find solace in prayer when they are ill, the chances of a physician being in a situation in which prayer is offered or one in which a request for prayer is made is increasing. Furthermore, some physicians themselves will desire to initiate prayer. As the question makes clear, a physician is free to pray for his or her patients away from them at any time. The challenge is praying with patients, and the challenge exists for several reasons.

First, physician and patient may be of different faith traditions, and a prayer highly significant to the one might not be embraced by the other. This is not only true because of the beliefs themselves (e.g., one person believes in Jesus Christ while the other does not) but also because of the types of prayers offered. In some faith traditions, spontaneous, colloquial prayers are not preferred, while ritualized, formal prayers are and vice versus.⁵

Second, there is a power differential between physician and patient, especially during times of illness; and in some patients, this might be heightened when there is a gender difference between physician and patient. Because of the vulnerability that an illness confers upon a patient, he or she has less control than does a physician. Because a physician will have more power than a patient, a patient might be reluctant about asking his or her physician to pray or, on the other hand, be unable to decline a physician's offer of praying. In the former case, a patient might think, “Will my doctor think I'm crazy to bring up prayer? After all, many doctors don't even believe in God.” In the latter case, a patient might think, “Will my doctor be offended if I don't pray with him or her? I just don't feel comfortable doing it. But I don't want to lose my doctor.” Of course, the longer-standing the physician-patient relationship, the more likely the two parties know something about each other's beliefs—but not always. A patient who requests prayer from his or her physician risks alienating a physician who is uncomfortable with the practice. A physician who suggests prayer risks alienating a patient who construes the suggestion as proselytizing. A physician who insists on praying with a patient, especially one who has not requested, suggested, or even mentioned prayer, in essence, reminds the patient how little control he or she has.

There are several spiritual assessment tools to help medical professionals determine whether religious or spiritual beliefs play a role in a patient's life and the extent of that role, especially as such beliefs relate to medical decisions.⁶ These include the CSI-MEMO, ACP Spiritual History, FICA, and the HOPE questionnaire, among others.⁷ A comparison of the various tools is available.⁸ Keep in mind that no instrument is perfect, but each permits a medical professional to gauge the importance of religious or spiritual beliefs in a given patient, which can be very helpful, especially when a patient is not well known to the medical professional.

Just as there are multiple spiritual assessment tools, there are many opinions about physicians praying with patients; the guidelines below summarize these opinions.

• 1)Physicians should always take their lead from patients. If a patient mentions prayer in the midst of a conversation (e.g., “the folks at my church are all praying for me,” “my family is praying for me,” or “I keep praying that everything will turn out OK”), one can safely assume that prayer is part of that patient's experience. If a patient never mentions “God,” “prayer,” “church” (“synagogue,” “temple,” or “mosque”), there is probably a reason related to his or her comfort in broaching such topics.
• 2)Physicians should only do what makes them comfortable. They should not feel as if they are expected to suggest prayer if that is not their style of relating, because doing so will come across as tentative, stiff, or forced. In addition, physicians should not feel as if they must take active part in a prayer that is foreign to their ways of belief. Even chaplains are more likely to pray with someone of their own faith tradition.⁹
• 3)Physicians should not pretend to be something that they are not. For example, instead of taking active part in a prayer of a faith tradition not his or her own, the wise physician stands quietly as the prayer is prayed.
• 4)Even if a physician is of the same faith tradition as a patient, the physician should not assume that his or her way of praying is the patient's way of praying. If and when a physician decides to pray with a patient, it is always good to ask the patient which prayer means the most to him or her, gently suggesting that he or she lead the prayer. For example, most Christians know the Lord's Prayer, but that might not be the prayer that a given Christian patient finds most comforting at a particular moment. On the other hand, if a physician prefers extemporaneous prayer, and the patient prefers a formal, structured prayer, it is advisable to accept the patient's preference.
• 5)Asking the patient if he or she would like to lead the prayer is a gentle reminder to the patient that physicians do not have an “in” with God just because they are physicians. Naturally, the patient's response as to whether he or she would like to lead the prayer should be accepted without further discussion.
• 6)A physician should not enter into a debate (friendly or otherwise) with a patient about the meaning of a given prayer or given Scripture passage. Different faith traditions might interpret a prayer or Scripture passage in a way commensurate with their beliefs and polity. In fact, even persons of the same faith tradition can interpret prayers and Scripture differently. All too often, debates end up being less friendly and more insistent.
• 7)When a physician feels that he or she cannot pray with a patient, the physician should acknowledge (to the patient) his or her difficulty in this area and offer to assist the patient in other ways that may bring comfort.
• 8)Physicians should become acquainted with local chaplains or clergy of various religious traditions who can assist them when a patient requires spiritual assistance or requests prayer when a physician is unable to participate in the manner that the patient would prefer. No physician is expected to be an authority on world religions, or even various Christian denominations, and that is why chaplains and clergy have so much to offer both patients and their physicians.

Summary

Studies have found that patients would like their physicians to pray with them, but many physicians might be uncomfortable doing so. Physicians should always take their lead from their patients in whether they pray or not and the type of prayer that is said, but physicians should not be reluctant to seek assistance from chaplains or other clergy if they are uncomfortable with praying aloud or if they are unfamiliar with a particular patient's faith tradition.