Religion, Risk, and Medical Decision Making at the End of Life

In the past decade, studies have shown that religiousness, as variously measured, is associated with a preference for undergoing life-sustaining treatment at the end of life: Carmel and Mutran (1997a) identify in an older Israeli sample an association between religiosity and “wishes for life-sustaining treatment” in both conditions of mild and severe illness (p. S100); Cicirelli, MacLean, and Cox (2000) report that study participants high in intrinsic religiosity prefer strategies for extending life as compared to refusing treatment; Heeren, Menon, Raskin, and Ruskin (2001) provide evidence that Christians of various denominations generally show greater “willingness to undergo life saving procedures” than do persons with no religious affiliation (p. 206); and most recently, Balboni et al. (2007) report that “Religiousness was significantly associated with wanting all measures to extend life” (p. 555). These results, and others like them (Cohen-Mansfield, Droge, & Billig, 1992; True et al., 2005) from predominantly Jewish and Christian populations are consistent with the importance that Biblical traditions place on life as a gift of God and hope as a quality of religious life (Van Ness & Larson, 2002). Furthermore, the scriptures of the major Western monotheistic traditions contain stories in which health and healing are portrayed as signs of divine favor (1 Kings 17: 17–24, Psalm 41; Mark 5: 24b–34, Acts 28: 7–10; and Al Qur’ān 3: 172–174, 16: 68–70). Carmel and Mutran (1997b) supplemented their empirical study cited above with an explanatory model for the results they found in the Israeli study sample. In attempting to explain the variability in the preferences regarding potentially life-sustaining treatment in their seriously ill, older cohort, they reported that “The most powerful explanatory variable is past experience with other people’s illnesses” (p. 1725). Thus, in addition to resources of life affirmation and hope for the future, it seems that religious patients draw upon narratives of divine healing, occurring not only in scripture, but perhaps also in their own lives or the experiences of other members of their religious community who have recovered from illness. Their selective recollection of positive experiences of illness might explain why religious persons are more willing to undertake potentially life-sustaining treatment than their less religious counterparts. Another possible explanation for the apparently greater willingness of relatively religious persons to undertake potentially life-sustaining treatment at the end of life is their tendency to respect and obey physician recommendations. Koenig, McCullough, and Larson (2001, p. 405) opine that religious persons tend to “adhere to the advice of experts or authorities (such as physicians).” They offer evidence from a study coauthored by two of them (Koenig and Larson) showing that persons who attended religious services with relatively higher frequency were more likely to take medication for high blood pressure upon being told by a physician that they were hypertensive (Koenig et al., 1998). These authors acknowledged mixed results on this topic at the time they wrote this work and this pattern has continued in more recent studies with the association of religiousness and adherence varying in studies with different samples, different measures of religiousness, and different health outcomes. In a religiously diverse population in Geneva, Switzerland, Borras et al. (2007) reported that more than a quarter of nonadherent and partly adherent patients indicated some incompatibility of taking medication for schizophrenia with their religion. In a study of HIV patients in the southern United States, the authors reported positive associations between some religious predictors and adherence, and negative associations with others (Parsons, Cruise, Davenport, & Jones, 2006). More directly relevant here is a report by Benjamins that persons attending religious services with relative frequency were more trusting of both their own physicians and physicians in general (Benjamins, 2006). Furthermore, the highest levels of trust among the religious respondents was reported for mainline Protestants, Roman Catholics, and Jews—the denominations most highly represented in the sample whose results are presented in this study. If physicians recommend potentially life-sustaining treatment, then the greater trust that religious persons have in physicians might make them more willing to undertake such treatment. The research documented in this article makes new contributions to this line of work in two important ways. It compares results from multiple measures of religiousness, including two that inquire about religiousness and spirituality as reflected in the ongoing experience of illness itself. Also, people were asked about preferences for potentially life-sustaining treatments not only in different treatment-burden scenarios, but they were also asked if they were willing to undertake treatment with various increasing probabilities of death and complementary decreasing probabilities of returning to their current state of health. In effect, they were asked about their willingness to undertake the risks associated with life-sustaining treatment. Anthropologists (Douglas & Wildavsky, 1982) and sociologists (Beck, 1992) claimed that attitudes toward risk are cultural and social constructs, so it is reasonable to hypothesize that peoples’ religious beliefs and behaviors inform their attitudes toward risk, lifestyle choices, and decisions about medical treatment. Epidemiologic investigations of religious involvement and mortality have generally shown a modest, positive association between religious involvement and longevity (McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000). Part of this salutary relationship has been attributed to healthy lifestyle choices that avoid known risk factors. For instance, in a recent critical review of this literature, Lynda Powell and colleagues wrote that evidence “suggests that the relationship between religion or spirituality and cardiovascular death is, to a large extent, explained by the encouragement that religion or spirituality provides for living a healthier lifestyle” (Powell, Shahabi, & Thoresen, 2003, p. 42). To investigate whether the apparently risk-averse lifestyles of many religious persons include avoidance of medical risks at the end of life or whether views about God and authority predispose religious and spiritual persons to undertake potentially life-sustaining treatment, seriously ill older persons were questioned about religion, risk, and medical decision making.