Weighing Religious Beliefs in Determining Competence

Hospital and Community Psychiatry, April 1987, Vol. 38 No. 4

Anne-Marie Pavlo, M.D.
Harold Bursztajn, M.D.
Thomas G. Gutheil, M.D.
Leslie M. Levi, B.A.

When this paper was written, Dr. Pavlo, now a staff psychiatrist at Charles River Hospital in Wellesley, Massachusetts, was a resident and clinical fellow in psychiatry at the Massachusetts Mental Health Center, Harvard Medical School, Boston. Dr. Bursztajn and Dr. Gutheil are codirectors of the program in psychiatry and the law at the Massachusetts Mental Health Center, where Dr. Bursztajn is clinical instructor of psychiatry and Dr. Gutheil is associate professor of psychiatry. Ms. Levi is a research associate with the program in psychiatry and the law. Address correspondence to Dr. Gutheil at Massachusetts Mental Health Center, 74 Fenwood Road, Boston, Massachusetts 02115. Spencer Eth, M.D, is editor of this column.

Dr. Eth's Introduction: Religion is a complex and important force in contemporary society. As therapists we recognize that religious beliefs exert a powerful influence on morality and behavior, that religious freedom is protected by the Constitution, and that religious delusions and religiosity may be symptoms of mental illness. Be it divine or pathological, religious experience is an unusually sensitive and controversial area for inquiry by the clinician. This month's column explores the ethical implications of evaluating the religious convictions of a psychiatric patient.

In the recent upsurge of interest in the right to refuse treatment and treatment refusal, the patient's competence to consent or refuse has played a central role [1]. Yet one particular basis for treatment refusal usually is exempt from the complexities and uncertainties of assessment of competence: refusal of treatment on religious grounds. Two examples familiar to most clinicians are refusal of blood transfusions by Jehovah's Witnesses and the more general refusal of medical treatment by Christian Scientists.

The following case example permits a review of the ethical problems that arise when treatment staff question the authenticity of a patient's religious beliefs that serve as a basis for treatment refusal.

The case

Mr. J, age 30 and single, had been raised in the Muslim faith. Previously diagnosed as a paranoid schizophrenic, he was hospitalized most recently for assaulting strangers on the street. On admission his mental status examination showed manic, delusional, and paranoid features.

When Mr. J was in his 20s, rejection from a government job triggered a psychotic episode; in a restitutive delusion he claimed to be, in fact, a government agent. Between his second and third psychiatric admissions he applied for membership in the Christian Science church and was rejected for reasons that were unclear.

One day during his most recent admission, he closed his eyes while praying that his mother would come and rescue him. When he opened them, the first person he happened to see was the Christian Science chaplain (a woman) assigned to the hospital. He interpreted this as a sign that he was now a Christian Scientist. He began seeing a Christian Scientist practitioner and refused to take his prescribed medications. However, when the practitioner opposed his longstanding alcohol and drug abuse, the patient fired the practitioner and began consulting another practitioner whose vocation was not officially recognized by the church.

After much discussion, hospital staff decided to ask the court to consider whether the patient's claimed membership in the Christian Science church was, in fact, delusional restitution after a rejection, as had occurred once before with the government job. The court found the patient incompetent and authorized treatment, and the patient recovered promptly.

After Mr. J had been in treatment for a while, he acknowledged the delusional basis of his religion and analyzed its meaning. Subsequently he joined and completed a witchcraft class given by a well-known local witch, and that, too, he opened to therapeutic exploration. Although he discontinued his treatment connection with the Christian Science practitioner, he remained on friendly terms with the practitioner [2].


In the late 1960s clinicians at large urban mental hospitals encountered an unusual diagnostic problem. That era was a high-water mark of widespread serious belief and practice in astrology and related concepts, such as out-of-body experiences. Diagnosticians were often puzzled about whether they were hearing from their patients delusions of starry influence, such as Tausk's influencing machine [3], or whether the patients were merely reciting the views of the astrologer in that morning's newspaper.

This facetious dilemma aside, religious conviction represents one of the most serious topics in American life today, as a glance at the headlines will confirm. In a country where religious freedom has always been an enduring value, religious choice and religion are an extremely weighty issue. 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.

Additional ethical tensions arise in questioning the authenticity of any religion. Theoretically any individual may have a leap of faith or a sudden conversion experience and reject his lifelong ancestral religious traditions. One could decide at a moment's notice to be a druid, for example, and practice all the rites of one's religion except for those like human sacrifice. But someone newly professing a private religion does not ordinarily have to pass a test to validate his genuine interest and commitment. While certain formal ceremonies such as catechism, confirmation, bar mitzvah, and the like are considered important to a religious group, they are not in any sense an admission examination, since many individuals practice their respective faiths without any such rites of passage.

Peteet [4] made two points in his discussion of treatment of religious patients that are relevant here. He noted that informed consent has an ethical place in the treatment of these patients as it does elsewhere. Thus a patient should have some understanding of possible effects of therapeutic exploration on religious and other beliefs. Second, Peteet stressed the "right of the patient to good treatment, which usually includes the opportunity to increase his capacity to think for himself." Both these issues bear on the present case.

A case study by Cohen and Smith [5] is even more specifically relevant to the one discussed here. They described a patient whose obsessions about disease appeared fueled by Christian Science principles and whose successful treatment was accompanied by disavowal of Christian Science principles.

In a discussion of the case, London [6] challenged the causal role of Christian Science in producing the disorder and noted that psychotherapy directed at undermining a patient's religious faith is ethically justified only if the convictions sustain a disorder. Halleck [7] suggested that a change in values is both a risk and a goal of treatment and stated that Cohen and Smith's "pretense of neutrality is illogical"; that is, the choice of psychotherapeutic treatment, rather than Christian Science healing, is at the outset a confrontation of and challenge to the patient's beliefs.

In another discussion of the Cohen and Smith case, McLemore and Court [8] noted that religious beliefs, even bizarre ones, may help the patient remain functional and that therapists face several dangers in treatment like that described by Cohen and Smith. The dangers include failing to acknowledge or communicate biases, slipping into an antireligious position, and interfering with the patient's capacity for "harnessing . . . religious resources."

While the patient in our case claimed to be a Christian Scientist, he might have claimed that his personal practice of any religion— for example, his Muslim faith— rejected the use of medication as treatment. Although that is not a principle of Muslim doctrine, individual variation in religious practices is also protected by the First Amendment. It is possible, however, that the court in this case was influenced by the fact that the patient's religious practice was not authenticated by the Christian Science church and that he was a chronic mental patient.

Another concern is the staff's questioning of the authenticity of the patient's claimed religion. Despite the final judicial resolution, it might be argued that ethically the staff should not question any patient's religious claims, that even to raise that question, with its implication that the patient doesn't have "the right religion," has a "crazy religion," or is "not religious enough," is already a violation of ethical principles. (It should be noted, however, that in this case staff were not denying the patient his religion, merely questioning it.)

The staff's challenging of the patient's religion might be partly justified by the claim that staff members felt they understood the psychological significance of the patient's religious conversion experience. Unfortunately, since everyone's religious choice has psychological implications and "reasons," this argument seems weak. Nor is the simple presence of reality testing a durable guide. If someone claims that under certain circumstances his blood is being turned into wine, he is likely delusional; if he claims under other circumstances that certain wine is being turned into blood, he may be merely devout. Similarly one who talks to God is praying, but if God talks back, one is hallucinating.

To balance the ethical analysis here, we must ask what good for the patient might balance or outweigh the good of honoring the patient's religious belief, no matter how idiosyncratic. If his religious choice was indeed a product of the illness for which he had been remanded to the hospital for treatment, then, once treated, he would still, in theory at least, be free to exercise any and all religious choices with the added benefit of being out of the hospital and in an improved mental state.

Latent in this reasoning, however, is the idea that values—in this example, spiritual values—may have a "sick" and "healthy" dimension or meaning depending on the patient's condition of sickness or health. A corollary might be that staff efforts to get the patient to replace Christian Science principles with medical ones could be a form of proselytizing in that the patient is being urged to exchange one belief system for another. A case could still be made, however, for the good of maximizing a patient's competence to weigh the choices.

In the case discussed here, the "goods" of treatment, restoration to health, preservation of freedom to make competent choices when well, and release from the hospital were counterposed against the "goods" of idiosyncratic religious freedom and practice. After the court's intervention, the former were given primary expression, and the patient himself eventually confirmed the wisdom of that ruling. The case illustrates some of the ethical complexities in assessing religious values in the clinical setting.


The authors thank Jean Jackson and Elyse Littaye for their assistance in preparing earlier versions of this manuscript.


  1. Gutheil TG, Appelbaum PS: Clinical Handbook of Psychiatry and the Law. New York, McGraw-Hill, 1982
  2. Pavlo AM, Bursztajn H, Gutheil TG: Christian Science and competence to make treatment choices: clinical challenges in assessing values. International Journal of Law and Psychiatry (in press)
  3. Tausk V: On the origin of the "influencing machine" in schizophrenia (1919), in The Psychoanalytic Reader: Anthology of Essential Papers With Critical Introductions. Edited by Fliess R. New York, International Universities Press, 1948
  4. Peteet JR: Issues in the treatment of religious patients. American Journal of Psychotherapy 35:559-564, 1981
  5. Cohen RJ, Smith FJ: Socially reinforced obsessing: etiology of a disorder in a Christian Scientist. Journal of Consulting and Clinical Psychology 44:142-145, 1976
  6. London P: Psychotherapy for religious neuroses? Comments on Cohen and Smith. Journal of Consulting and Clinical Psychology 44:145-146, 1976
  7. Halleck SL: Discussion of "socially reinforced obsessing." Journal of Consulting and Clinical Psychology 44:146-147, 1976
  8. McLemore CW, Court JH: Religion and psychotherapy: ethics, civil liberties, and clinical savvy: a critique. Journal of Consulting and Clinical Psychology 45:1172-1175, 1977