Keeping the faith: What happens when religion and medicine intersect?
Like many Roman Catholic obstetrician-gynecologists, Lester A. Ruppersberger, DO, of Langhorne, Pa., prescribed birth control and performed tubal ligations, although heeding the Catholic Church’s prohibition against abortion. Then after more than two decades in practice, he had a change of heart and conscience following a life-altering conversation with a priest.
Although she cares about anti-abortion issues, Jacqui O’Kane, OMS IV, is even more concerned about the flagrant disrespect for patients she has observed on some of her clinical rotations. For O’Kane, who attends the Georgia Campus—Philadelphia College of Osteopathic Medicine in Suwanee, being a Christian physician-in-training means treating even the most difficult patients with compassion and dignity.
An orthodox Jewish family physician in Warwick, R.I., Michael F. Felder, DO, has frequently had to consult his rabbi about halakic health care law during his nearly three decades in practice.
The associate dean for clinical education at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) in Old Westbury, Abraham Jeger, PhD, advises orthodox Jewish students on how to keep Shabbat and maintain other traditions of their faith while meeting their educational requirements.
These devout members of the profession share some of their struggles to stay true to their faith every day, during the Sabbath and during religious holidays such as Passover and Easter.
Dr. Ruppersberger’s conversion story begins some 14 years ago, when he and his wife attended a Bible study class during Lent. There he met a priest who annoyed him with a seemingly intrusive question: What do you do about contraception in your practice?
“I shuffled my feet,” Dr. Ruppersberger remembers, “and in front of a bunch of people I hardly knew said, ‘You know, Father, if women who come into my practice ask for contraception, as is the culture in our society today, I prescribe it. That’s what I do. I’m trained to be an Ob-gyn.’
“His next comment to me was, ‘How can you reconcile that with receiving the Eucharist in church on Sunday?’ I became angrier and actually walked out of the meeting.”
But the following Sunday, Dr. Ruppersberger could not bring himself to receive the sacraments at mass. Tormented by his conscience, he spent the next six months in turmoil over what he should do with his practice. He felt isolated and alone because he didn’t know any other gynecologists opposed to artificial birth control.
Then on Respect Life Sunday (the first Sunday in October) in 1999, Dr. Ruppersberger listened to a homily about Catholic teachings on contraception. “I walked away from that mass deciding that I needed to change my life,” he says. “The next day, I walked into my practice and told my partners I would no longer be doing contraception or sterilizations.”
His partners said OK, but there was a hitch. “They had a meeting and decided to reduce my salary and benefits commensurate with their perception of what I would no longer be doing,” Dr. Ruppersberger says. “It was a ‘take it or leave it’ proposition.
“I could have started all over again, but I was in my 50s and had established this practice. And I have a stubborn streak. So I said, ‘I’m not leaving. I’m going to say here and practice according to my conscience.’ ”
Dr. Ruppersberger has since become a leading Philadelphia-area expert on natural family planning, in which couples seek or avoid pregnancy through the timing of sexual intercourse, identifying a woman’s fertile period by her cervical mucus and body temperature. Catholicism teaches that artificial contraception promotes irresponsible self-centered sexuality. Abstinence during a married woman’s fertile times, in contrast, does not contradict the Vatican’s position on conjugal love.
To find like-minded peers, Dr. Ruppersberger joined and now serves on the governing board of the Catholic Medical Association (CMA) and became a member of the American Association of Pro-life Obstetricians and Gynecologists (AAPLOG).
“These organizations are an excellent source of information and support,” Dr. Ruppersberger says. “Otherwise, it has been hard to find physicians of the same mind and spirit.”
Dr. Ruppersberger believes he is the sole natural family planning-only gynecologist in the five-county Philadelphia metropolitan area and knows of only a few other such Ob-gyns in Pennsylvania. Although his practice shrank as a result of his position on birth control, Dr. Ruppersberger has carved a niche for himself and receives referrals from his partners and other physicians.
“Women come from as far as an hour away and sometimes from Delaware because I’m the only pro-life authentically Catholic Ob-gyn they can find,” Dr. Ruppersberger says. They learn about him through word of mouth, the CMA’s and AAPLOG’s physician-search databases, and Google searches for Catholic obstetrician-gynecologists in the Philadelphia area.
“It is very gratifying to me personally and professionally that there is some appreciation for what I do,” he says.
Every year, Dr. Ruppersberger gives a talk on natural family planning at the Philadelphia College of Osteopathic Medicine. “This very likely is the first time, and may be the only time, that PCOM students hear these words,” he says, noting that he had no exposure to the concept during his own medical training.
Certified as a natural family planning instructor by the Archdiocese of Philadelphia, Dr. Ruppersberger teaches classes in his practice and other locations. Through writing articles, giving lectures and granting media interviews, he aims to give natural family planning the publicity he feels it deserves.
“More people aren’t flocking to it because they don’t know about it,” Dr. Ruppersberger says. “Unlike birth control pills and other means of contraception, natural family planning is not advertised because there is no money to be made in it.”
A member of the Christian Medical and Dental Associations (CMDA), O’Kane maintains that it is easier for many Christian physicians to adhere to the profound moral mandates of their denominations regarding abortion, end-of-life care and contraception than it is to follow the teachings of Jesus in their daily professional lives.
“When someone comes in for care who has a drug addiction or is regarded as noncompliant or a hypochondriac, I have observed too often on my rotations that physicians will make disparaging remarks behind the patient’s back,” O’Kane says. And she has noticed some physicians being overtly abrupt with or condescending to patients.
“When people seek care, they are asking for our help. We need to find out why our patients are depressed or angry—why they may be seeking drugs or engaging in other risky behavior,” says O’Kane, who will serve a family medicine residency at Spartanburg (S.C.) Regional Healthcare System. “I try to get to know patients and ask, ‘How can I help you?’ I sometimes pray with patients if that is what they request.” Hospitals differ as to whether praying with patients is acceptable or frowned upon, she says.
“The overall culture of medicine in this country today encourages shorter, less meaningful patient encounters, so it is easy for physicians and medical trainees to forget what we are doing,” O’Kane says. “The Oath of Maimonides states, ‘May I never see in the patient anything but a fellow creature in pain.’ So often we forget this essential truth because we see other attributes in patients and we give them labels. We are all guilty of this regardless of our religious affiliation.”
O’Kane believes that medical schools should do more to discuss the role of spirituality in health care. Although osteopathic medicine recognizes the interplay of “body, mind and spirit” in its tenets, religious issues tend to be glossed over in school, she says. Students learn, for example, that Jehovah’s Witnesses can’t undergo blood transfusions, but students don’t have the opportunity to explore such beliefs more deeply during class time. Religious views are treated as one aspect of cultural competency rather than an integral part of a patient’s well-being and a physician’s calling as a healer.
“As a soon-to-be Christian physician, I believe it is my responsibility to care for the whole person—physical, mental and spiritual—and to honor the dignity of all patients,” O’Kane says. “One of the benefits to being in an organization like CMDA is that it reminds members of our higher calling and gives us practical tools for implementing our beliefs.”
Nuanced do’s and don’ts
In orthodox Judaism, the rules are more intricate but arguably less absolute than those in Roman Catholicism and certain Protestant denominations, says Dr. Felder, who has a master’s degree in bioethics.
“As physicians, we are not just allowed, but obligated, to break the Jewish Sabbath if it is necessary to save someone’s life,” Dr. Felder says. But which normally forbidden acts are essential remains a matter of interpretation.
For example, Orthodox Jews are not permitted to drive on the Jewish Sabbath, from sundown Friday until sundown Saturday. But a physician on call may have to drive to a hospital to provide a patient with urgently needed care.
“It may be acceptable for that physician to drive to the hospital. But can he drive home from the hospital, as he would not be saving anyone’s life at home?” Dr. Felder asks. “Over the years, I’ve needed guidance from my rabbi regarding many such situations.”
For the most part, Jewish law forbids the use of electrical appliances and many other tools on the Sabbath, which, according to Jewish and Christian scripture, honors the day God rested after creating the world in six days. Orthodox Jews regard Shabbat as an opportunity to rest, reflect, pray and spend time with one’s family and close friends. The use of mundane, worldly devices, ranging from pens to computers, is not allowed, though the Sabbath is seen as a joyful rather than somber commitment.
Given that Jewish law emerged thousands of years before the Digital Age, the relative acceptability of various modern contrivances during the Sabbath is not always clear-cut.
“I’ve asked my rabbi, ‘Is it better to talk to a patient using a cellphone than a landline?’ ” Dr. Felder says. “ ‘Probably yes,’ he said, ‘because a cellphone doesn’t use electricity.’ ”
Dr. Felder notes that a Sabbath-friendly phone has been developed that has a delayed reaction to the user’s actions. The indirectness makes this phone more permissible; in relinquishing control, observant Jews show reverence for God’s power and authority.
“Women come from as far as an hour away and sometimes from Delaware because I’m the only pro-life authentically Catholic Ob-gyn they can find.”
Even on major moral issues, Jewish law is less rigid than many non-Jews might expect, Dr. Felder says. For example, orthodox Judaism does allow for pregnancy termination to save a mother’s life. “A husband and wife will ask for guidance from their rabbi on this issue,” he says.
Genetic testing prior to marriage to determine whether a potential husband or wife has the gene for Tay-Sachs disease—a disease most common among European-descended Jews that can result in deafness, blindness, paralysis and severe cognitive deficits—is not just tolerated but recommended, Dr. Felder says. If both carry the gene, Jewish law discourages them from getting married.
All physicians must navigate a wide range of bioethical questions when advising and treating orthodox Jewish patients, according to Dr. Felder.
Jewish law regarding handling of the dead, for example, is complex and sometimes misunderstood, he says. While autopsies are not allowed except under certain circumstances, such as in a homicide investigation, most orthodox Jewish medical students may work on cadavers in anatomy lab. However, the Kohanim, a specific subgroup of orthodox Jews who descend from a priestly class, are bound by additional restrictions and may not touch cadavers.
Less eligible for dispensations, orthodox Jewish medical students—who are not yet saving lives—are expected to adhere to Sabbath and holiday rituals and restrictions if they wish to comply with Jewish law, says NYITCOM’s Dr. Jeger. “When these students are on clinical rotations, I will authorize their absences for religious reasons as long as the hospitals let them make up the time,” he says.
Dr. Jeger also has helped students secure Sabbath-observing residencies in hospitals with a relatively high proportion of orthodox Jewish patients and staff.
“Certain hospitals have a ‘Shabbat elevator’ that stops on every floor, so it isn’t necessary for the rider to push a button,” he notes. Orthodox Jews are supposed to avoid elevators during the Sabbath. But if it is necessary to ride in an elevator, it should be one that doesn’t require user activation.
As is the case with Muslim women, orthodox Jewish women are expected to dress modestly, which can be a challenge in osteopathic manipulative medicine lab, where female students typically wear halter tops or sports bras and shorts. At NYITCOM, reasonable accommodations are made that don’t compromise curriculum objectives, so that these students need only reveal whatever part of their body is being worked on, Dr. Jeger says.
An orthodox Jew himself, Dr. Jeger observes all of his religion’s dietary restrictions, which include eating only kosher-slaughtered beef and not consuming shellfish or pork. “Kosher food is accessible at NYITCOM, but it does not have to be offered at official campus functions,” he says. “Often I’ll just eat fruits and vegetables.”
When attending conferences outside of New York, he travels with his own food.
“Once I was flying to Phoenix on a Friday morning. I had my clothing in one suitcase and my food in another,” he remembers. “I wasn’t worried about Sabbath travel restrictions because of the time difference.
“But my luggage didn’t arrive with me. After reporting my lost suitcases, I went to my hotel. Meanwhile two, three, four hours go by, and I still have no luggage and no food.
“So I start scrounging around the hotel gift shop, thinking I would have to make do with a bag of pretzels. Then at the bottom of the shop’s refrigerator, I stumble on a package of kosher-certified bagels. I couldn’t believe my luck. There is a Jewish tradition of eating two pieces of bread with each meal during the Sabbath. And here I had my six bagels—this was great.”
His luggage arrived the next day. “I open the door and see a man carrying my suitcases,” Dr. Jeger remembers. “And guess what? I look at his name badge and see that his name is ‘Sundown.’ ”
At least Dr. Jeger hasn’t experienced hostility for keeping kosher. “If anything, people respect me for it,” he says.
In 2012, The DO published an article on the issues Muslim DOs and medical students face in medicine.