Christian Science and Competence to Make Treatment Choices:
Clinical Challenges in Assessing Values

International Journal of Law and Psychiatry, Vol. 10. 395-401, 1987

Anne-Marie Pavlo*, Harold Bursztajn**, and Thomas G. Gutheil***

*Staff Psychiatrist, Charles River Hospital, Wellesley, MA.
**Co-director, Program in Psychiatry and the Law, and Clinical Instructor in Psychiatry, Massachusetts Mental Health Center, Harvard Medical School, 74 Fenwood Road, Boston, MA 02115, U.S.A.
***Co-director, Program in Psychiatry and the Law, and Associate Professor of Psychiatry, Massachusetts Mental Health Center, Harvard Medical School, 74 Fenwood Road, Boston, MA 02115, U.S.A.
Reprint requests should be sent to Dr. Gutheil.
The authors acknowledge their indebtedness to Jean Jackson, Elyse Littaye, and Leslie Levi for their assistance in preparation of this manuscript.


The determination of the competency of a patient to accept or reject a psychiatrist's recommended treatment plan represents an uncertainty-laden legal and clinical decision. Courts have considered guardianship as a possible albeit problematic solution to the difficulty posed by the refusal of treatment by an incompetent patient. The complex role of the physician has only recently begun to be examined in such cases, particularly when antipsychotic medication is involved (Gutheil, 1982; Gutheil & Appelbaum, 1982; Gutheil & Appelbaum, 1980; Gutheil, Shapiro, & St. Clair, 1980; Mester, 1974).

The goal of this paper is to demonstrate through a case study how a clinical assessment of competency, especially in connection with a patient's values, may proceed in the context of an emerging therapeutic alliance (Gutheil, 1982). The case in question was especially vexing insofar as the patient, while psychotic, gave a reason for refusing treatment—belief in Christian Science—which would ordinarily be considered a valid reflection of underlying values, and a spiritual choice protected by the First Amendment.

In attempting to reach the underlying values for incompetent patients, courts have lately considered substituted judgement (Curran, 1978; Gutheil & Appelbaum, 1985; Gutheil & Appelbaum, 1980), a model of decisionmaking which seeks to determine what the incompetent patient would have chosen, were he or she competent. An implicit "thank you" test is therefore established so that an incompetent patient, when again competent, would theoretically agree with the guardian, clinician, judge, or other decisionmaker about the vicarious choice and "thank" him or her for making it (Stone, 1981; Stone, 1974).

The need for an understanding of the patient's values is obvious if this schema is to work. But how are a patient's values defined? A more crucial question here is, how may one distinguish between values considered symptomatic of a patient's psychiatric illness and premorbid "healthy" values?

Religion and Competence Assessment

Issues of religion represent an area of exquisite sensitivity at the intersection of clinical work, ethics, and law. In a country becoming increasingly sensitized to issues of religious freedom of expression, the matter of religious choice and religion is an extremely weighty one. For the clinician, the knowledge that one person's orthodoxy is another's heresy, and that one person's true belief is another's pagan superstition, makes the assessment all the more challenging.

What had to be determined was whether a religious reason for treatment refusal, offered by this patient at that time, represented a competent choice based on First Amendment freedoms, or whether it was a symptom and consequence of his psychopathology, to be given only the weight of other possibly delusional utterances of the patient. Had the "choice" of a religion occurred at a time when the patient was competent or only during an illness? What questions would this timing raise about the patient's free exercise of his religion? (Flowers, 1984) What are the implications for competence assessment?

The complexity of the competency assessment with respect to religious values has already been demonstrated in several court cases (Flowers, 1984; In the matter of the guardianship of Richard Roe III, 1981). We now examine the clinical issue.

Case History and Hospital Course

Mr. L. was a 30-year-old, Indian male raised in the Muslim faith; he had had three previous psychiatric admissions and had been diagnosed as paranoid schizophrenic. He was brought to the Massachusetts Mental Health Center (MMHC) by the police for striking a passerby on the street. He presented a psychosis with manic and paranoid features.

Mr. L.'s early development was normal. It is noteworthy that the patient reports being viewed at age eight by his parents as a "mystic" for predicting a politician's assassination. Both parents attributed the onset of his problems to corrective surgery the patient underwent at age 19 for a reportedly overly prominent jaw; interestingly, his father saw this as Mr. L.'s only masculine feature, and his mother felt it was too prominent.

Mr. L.'s first psychiatric admission followed suicidal ideation without psychosis at age 25; an episode of apparent paranoid schizophrenia led to his second admission after a job rejection for the FBI: Mr. L. then had the delusion that he was an FBI agent. Between Mr. L.'s second and third psychiatric admissions he applied for membership in the Christian Science Church (C.S.) and was rejected.

During his third psychiatric admission he described "praying with my eyes closed to my mother so that she'd come and take care of me." When he opened his eyes, he fortuitously beheld the C.S. chaplain, and he took this coincidence to mean that he was now a Christian Scientist. He began seeing a C.S. practitioner and refusing to take his prescribed medications of lithium and haloperidol, but he subsequently fired the practitioner when the latter opposed his long standing alcohol and drug abuse. He then became involved with a Christian Scientist who was not an officially recognized practitioner.

During the subject admission, Mr. L. initially refused medication because he was a Christian Scientist whose beliefs included healing only through God. By the third day of the hospitalization he accepted medication, stating, however, that, "the two of us [therapist and patient] need to stick together; undercover work is dangerous." When staff applied for guardianship (based on our conviction that Mr. L.'s claimed membership in Christian Science was, in fact, delusional restitution after a rejection, as had occurred with his application to the FBI), Mr. L.'s reaction was a combination of fear (would his therapist "trick" him into a prolonged hospitalization?), anger (had his therapist "broken his cover?"), and relief (he now could "sue the court instead of his doctor").

Mr. L. provided contradictory views when interviewed by the court lawyer (an occasion Mr. L. stated he "looked forward to"); he explained refusing medication because he was a Christian Scientist, while stating he was taking Haldol because it "helped him." Guardianship was subsequently obtained for the purpose of deciding about medication. On the guardian's consent, lithium was begun, and haloperidol was tapered. Two weeks later, Mr. L. stated the guardianship was "useful" because the "Court took control and made the decision of medication for me" which "made me think less about Christian Science and more about myself." He then questioned whether the "Mother Church of Christian Science" was "another authority figure for me."

After discharge from the hospital Mr. L. discontinued his treatment relationship with his Christian Scientist practitioner, although the latter remained a friend. After an initial acceptance of only family meetings as a treatment choice, Mr. L. gradually assumed more participation in individual therapy (2 hr./wk.). He remained in a competent status 9 months after the admission depicted above.

The course of Mr. L.'s therapy is summarized below.

Course of Therapy

The early phase of Mr. L.'s therapy explored the issues of Christian Science, particularly the role of this religion in providing a supportive social setting (though one often concordant with his delusional system) and the function of the religion as a defense against particular feelings; the defensive nature of the religion, however, was only appreciated several months later. Several joint meetings were held with Mr. L., his C.S. practitioner, and his therapist to evaluate further the role of C.S. in Mr. L.'s life; the stance of the therapist during this phase was that of participant-observer, who could side existentially with Mr. L. in his dilemma as to what could now offer him comfort as his defense of psychosis was diminishing. This period was accompanied by gradual decrease in paranoid and grandiose ideation.

Later, Mr. L. shared how comforting C.S. had been, for it apparently had a male/female deity. (Interestingly, this is also true for witchcraft in which the patient had an abiding interest; see below.) He agreed during this period, however, that should he or his therapist notice any increase in paranoia or other psychotic symptoms, he would resume his medications. Mr. L. also formulated a "living will" agreement with his therapist that—should he become psychotic in the future and experience any delusions concerning medication use (religious or otherwise)—he would like to be treated with medications in addition to milieu and individual psychotherapy. He viewed such a "living will" agreement as giving him both "independence" (which he saw as his "central problem", especially with respect to his parents), and values separate from those of his parents.

Several weeks later, Mr. L. shared a diary with his therapist in which he depicted in detail his involvement with witchcraft and C.S. He noted, "beliefs can be dangerous; strong beliefs become reality, ominous reality for the believer... for 1 ½ years I clung to a movement called C.S. I consider [it now] a delusionary religion, although I had a grand opportunity for learning Bible."

Witchcraft, in which Mr. L. had been involved before he became a C.S., was also interpreted as an escape. This "escape" function recurred when Mr. L. was undergoing another period of major difficulty involving doubts about his heterosexual identity and concern over his shyness with people. At that point he joined and completed a well known local witchcraft class. He informed the class of his psychiatric difficulties and shared with his therapist his class notes and reactions to each exercise in the class. He expressed in therapy much relief that he could find the subject interesting, without seeing himself as a witch. He stated, "I don't have to be a witch; I can be myself: shy and lonely, missing my parents and my sister." The therapist interpreted this sequence as the patient's demonstration to himself that he could deal nonpsychotically with quasi-religious issues while subjecting them to therapy exploration.


The experienced therapist knows how valuable the exploration of a patient's religious beliefs is—an exploration yielding material of great clinical richness, as demonstrated in the present case. But clinical concerns aside, the case raises multiple ethical questions directly bearing on the question of values and competence. First, the clinician had to consider whether the choice to refuse medications represented Mr. L.'s competent values (and was thus a "free choice" in the spirit of informed consent) or if it was an indication of psychiatric illness and thus of an incompetent status to make a treatment decision. Mr. L.'s religious conversion experience (seeing the C.S. Chaplain on opening his eyes) had been temporally coincident with a psychotic episode; this raised sufficient questions to lead the clinical staff to elect to petition for guardianship on the basis of the possibility that the belief was delusional. This left to the court the curious task of weighing the competency of a person to profess a specific religion whose precepts stood counter to treatment.

The last point is particularly noteworthy because any individual's "competence" to practice his or her established (or even idiosyncratic) religion is almost never tested or otherwise called into question. The very raising of questions about this competence might itself be considered an infringement of First Amendment rights (i.e., to practice one's religion even if "incorrectly"). As noted elsewhere (Gutheil, 1985):

. . . religious choice is often a matter of leaps of faith which are external to questions of competence to make rational choices.

Second, an argument could be raised as to whether the assessment of Mr. L.'s competency (either initially by the clinician or later by the court) was value-free, and as such, unbiased. No decision is "value-free", however, (Putnam, 1981) and the respective biases and prerogatives of the legal and psychiatric systems must be acknowledged. Here, the matter of competence had been thrust upon the doctor-patient relationship by the legal context of right-to-refuse-treatment litigation. Thus various competences were being called into question, many for the first time.

Likewise the question arises whether the clinician's evaluation of Mr. L.'s values was value-free; that is, whether such distinctions as "mature values" versus "primitive" or "premorbid" values are sufficiently objective to be clinically or legally meaningful. The patient's thanking the clinician as an outcome of treatment does not settle the issue, even though it meets the explicit "thank you" criterion described in the introduction. The "thanks" may be mere compliance or identification with the therapist. Similarly unclear is whether premorbid values can be unequivocally distinguished from psychopathological/morbid values.

The primary tool used in the assessment of Mr. L.'s values, namely the empathic stance, is not itself infallible, as Ferenczi (1941) and Buie (1981) elucidate. The clinician must test his or her own sundry value hypotheses frequently by reviewing his or her opinions collaboratively with the patient in the ongoing process of treatment (Gutheil & Havens, 1979). But the question arises, is the outcome of the therapy as well as the formulation of the problem altered by the inquiry process itself? Let us now briefly address this question with respect to the differing facets of Mr. L.'s values as they were appreciated over the 9 month period of psychotherapy.

Mr. L.'s religious values concerning C.S. and witchcraft, as illustrated in the above case history, served a variety of functions with defensive and integrative properties, including serving as a primitive superego or as defenses against underlying psychosis and depression. The highly conflictual nature of Mr. L.'s values became more apparent as a therapeutic alliance slowly evolved in the course of therapy.

But does such alliance formation contaminate the patient's value system? Is the alliance a vehicle for the therapist's imposing his or her own values on the patient, as noted earlier, through the process of identification? First, since no one's value development occurs in a closed social vacuum, "contamination" may be viewed as a normal process. Second, while identification inevitably occurs, the goal was to maximize the opportunity for Mr. L. to discover his own values, as well as create new ones; in the process he became more tolerant of experiencing feelings (particularly anger, sadness, and loneliness) rather than having to "escape into false identities." Furthermore, this approach allowed Mr. L. himself to begin to question what were his "true values"—an essential part of growing up. Lastly, the patient was able to determine in the course of his treatment how he wanted to be treated in the future, should he again become incompetent.

Thus, rather than clouding the substituted judgment (what the patient would have wanted if competent) this exploratory approach realizes that judgment's actual goal because the motivating spirit of the substituted judgment determination is the desire to individualize the vicarious decision as much as possible. This case example illustrates how the evolving therapeutic exploration within the alliance can produce the most valid empirical evidence as the basis for this determination, predicated on the state of the patient at his most mature.

Having shown that the clinical assessment of a patient's values is of particular importance in the evaluation of competence, we suggest that this assessment best occurs during the process of clinical administration and psychotherapy to ensure that an accurate picture of the patient's values is obtained. Even in the present case, the question remains as to what extent one can assess patient values without, in the process, transforming them, as growth occurs in the psychotherapeutic relationship. Given clinical realities and the length of time required to do the sort of extended competency evaluation described, our case might support use of a "best interest" model to guide immediate emergency treatment of the presumed incompetent patient (Gutheil & Appelbaum, 1985); later, should the patient continue to suffer from incompetency requiring medical intervention, the clinician may provide the court with the data for a realistic application of the substituted judgment standard. Note that both best interests and substituted judgment are time honored, common legal models for vicarious decisionmaking; our only innovation here is their sequential use as described.

Our proposed model for a biphasic assessment of competency ("best interest" standard first, later substituted judgment) (Gutheil & Appelbaum, 1982; Mills, 1980) is consistent with recent clinical (Bursztajn, Feinbloom, Ham, & Brodsky, 1981) and judicial (Harnish v. Children's Hospital, 1982) recognition of the importance of informed consent in medical treatment. Some practical advice on this process is addressed elsewhere (Gutheil, 1987). In those cases where the patient's competence begins to be restored, the second phase of competency assessment may involve the use of the therapeutic alliance to help the patient express his now competent choices in the form of a truly informed living will (Appelbaum, 1979; Gutheil & Appelbaum, 1982).