Most U.S. clergy reject the legalization of physician-aided dying (PAD), found a recent study.1
“There have been no adequate surveys of clergy that describe their ethical views on end-of-life issues,” says lead author Michael Balboni, PhD, ThM, MDiv, a researcher in the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute in Boston.
The researchers surveyed 1,005 clergy on controversial end-of-life ethical issues, including whether the terminally ill should ever be “allowed to die” and moral/legal opinions concerning PAD/physician-assisted suicide (PAS).
In debates on PAS, there often are clergy representing both sides of the issue. “They therefore seem to cancel each other out in the debate: The pope is against it; Bishop Tutu is for it,” says Balboni. The researchers wanted to provide actual percentages as to how many clergy are for or against PAS. “The findings held a few surprises,” says Balboni. Findings include the following:
• The majority (80%) agreed that there are circumstances in which the terminally ill should be “allowed to die.”
• A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable.
• Those reporting distrust in healthcare were less likely to oppose legalization of PAD/PAS.
• Religious beliefs associated with disapproval of PAD/PAS included “life’s value is not tied to the patient’s quality of life” and “only God numbers our days.”
• Clergy who had stronger medical knowledge of end-of-life care were more likely to be opposed to PAS.
“These clergy have a better sense of how palliative care can adequately treat pain and other physical symptoms,” says Balboni.
• Clergy were more likely to accept PAS if they thought that pain could not be addressed near the end of life.
“Clergy who understand that medicine has made considerable advancement in pain management in life-threatening illness were less likely to worry about unremitting and unaddressed pain,” says Balboni.
• Most clergy understand a moral difference between “allowing to die” and PAS.
Most reject the idea that the patient should hasten his or her own dying by introducing an outside agent intended to end the patient’s life. On the other hand, says Balboni, “Large majorities believe that patients should be allowed to die when overmastered by their disease.”
Distrust Is Concern
Policymakers should recognize that the vast majority of clergy in the U.S. are opposed to the legalization of PAS for moral reasons, says Balboni. There continues to be considerable religious resistance to PAS among Christians, Muslims, Buddhists, and Hindus. “There is a relatively significant voice of agreement that from religious viewpoints, PAS is deeply problematic,” says Balboni.
Another important factor is the distrust some clergy have in the healthcare system. “This is based on a variety of reasons, including medical hubris and disregard of religious rationales within serious illness,” says Balboni.
Distrust in healthcare may also play a role in the increased likelihood of black and Hispanic minorities receiving aggressive care at the end of life. “These minority groups are far more religious than whites, and religion is intertwined with other associated reasons leading to distrust,” says Balboni.
If PAS grows in legalization in the U.S., one potential unintended consequence is acceleration of healthcare distrust among racial and ethnic minorities, says Balboni. This, in turn, could lead to less hospice use and more aggressive care at the end of life. “Trust is likely a key problem in why many religious persons receive more expensive, aggressive care near death,” says Balboni.
State health policymakers need to carefully consider this possibility, says Balboni: “There are likely invisible and surprising connections where further loss of trust among certain at-risk health populations will almost certainly increase, not decrease, medical costs.”
1. Balboni MJ, Sullivan A, Smith PT, et al. The views of clergy regarding ethical controversies in care at the end of life. J Pain Symptom Manage 2018; 55(1):65-74.
• Michael Balboni, PhD, ThM, MDiv, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston. Phone: (617) 582-9186. Email: Michael_Balboni@dfci.harvard.edu.