Introduction

The use of faith healing practices for the treatment of diseases is fairly prevalent in the Indian subcontinent (1, 2, 3). Such practices do not fall under a unitary concept; they can be loosely referred to as specific rituals which are accepted by the community and are carried out by designated figures with the aim of relieving symptoms of distress (4). The efficacy of these interventions is not grounded in scientific evidence, but such practices have the purported aim of relieving suffering and continue to be accepted socioculturally, at least to a certain extent (5, 6). The practices include conducting pujas and yagnas, exorcising evil spirits, and recommending amulets and rings.

People resort to faith healing practices in a wide array of scenarios. First, they may choose to visit faith healers who are available in their locality if access to or the availability of modern medical care is poor. Second, lack of awareness may impel patients and/or their family members to seek such services. Third, many Indian patients and/or their caregivers opt for faith healing for specific symptoms or diseases, according to time-honoured sociocultural belief systems which hold that these symptoms/ diseases can be treated through faith healing practices (for example, in cases of jaundice or chicken pox). Fourth, patients and/or their family members may seek such treatment if they feel that the results of modern medical care fall short of their expectations. Fifth, the family members may approach faith healers in desperation if the patient has a terminal or progressive illness and they are unable to accept it (7). Finally, members of the educated Indian elite also approach faith healers on coming across claims that such practices have improved. Claims of this sort are propagated through the social media and the personal testimonies of several faith healers are found on the Internet. Broadly speaking, faith healing treatment may be initiated either by the family members, whether by coercing the patient or with his/her acquiescence, or by the patient himself/herself. In situations in which faith healing is initiated by the family members, patients may or may not agree to undergo such treatment, ie if they are in a position to make their own decisions. This has implications for the purported benefits of the treatment as the patient’s “trust” in the faith healer may influence the outcome (8, 9).

Requests for permission to add faith healing treatment to the regular medical treatment are received by a range of medical professionals, including physicians, psychiatrists, general practitioners, surgeons, paediatricians, infertility specialists, oncologists and endocrinologists. Such requests are usually made by the patient’s family members on the recommendation of their acquaintances. The family may seek permission to take the patient away to a specific temple or faith healer for a couple of days; make a request that the faith healing practices be performed in the medical care facility itself; request the doctors to avoid specific forms of treatment; or seek the complete cessation of a treatment. A few examples of such situations are mentioned in Table 1.

The application of ethical principles varies from place to place and across time. Ethical principles need to be contextualised to the Indian setting while looking for solutions to locally relevant ethical dilemmas and conflicts (10, 11). Several options are available to medical professionals when they are required to respond to situations in which faith healing services are requested for patients under their care. We discuss four potential responses from the viewpoint of medical ethics (12). We refrain from making an all-encompassing, general exploration of medical ethics in the context of spirituality and religion – a subject which has been discussed elsewhere (13, 14). Instead, we focus primarily on ceremonial faith healing practices in the Indian context.

The options

Option 1: Outright rejection of faith healing practices

Many clinicians may summarily dismiss requests for the use of faith healing practices, terming them superstitious, useless and retrograde. Modern medical practitioners, who are rigorously trained in evidence-based medicine, find such requests irksome and consider them a waste of time. Besides, they feel that these requests interfere with their regular clinical work. Some also believe that requests for faith healing treatment reflect a lack of confidence in their ability to help the patient and make a mockery of their committed clinical endeavours. The option of outright rejection of faith healing, however, clashes somewhat with the ethical principles of the patient’s autonomy. In some cases, when the clinician is aware of the specific dangers of the proposed faith healing procedures (11), such an approach reflects beneficence. The principles of justice and non-maleficence do not really come into play in choosing this option. According to deontological principles, faith healing treatment can only be ethical or unethical, irrespective of the context or the help it can provide. From this point of view, patients should always be dissuaded from opting for faith healing practices if they are ethically incorrect.

Option 2: The “don’t ask, don’t tell” policy

Another way of dealing with a request for faith healing treatment is to not take the request into consideration. Owing to their training, medical professionals have knowledge and expertise in the field of modern medicine. However, they cannot be expected to accurately judge whether another system of medicine would be effective or not. A medical professional who displays a judgmental attitude towards a patient’s belief system runs the risk of alienating him/her. At the same time, medical professionals are likely to be quite hesitant to endorse faith healing practices, even if they fall within their belief system. In this situation, it may be acceptable to neither endorse the patient’s and/or family’s request, nor reject it. The standard response would be along the lines of, “I don’t know much about the efficacy of this procedure and it is your wish that matters.” Such an approach respects the autonomy of the patient, and is not related to beneficence. Non-maleficence and justice may also not be an issue if the clinician does not endorse any treatment.

Option 3: Endorsement of faith healing interventions

A third option would be to endorse requests for the use of faith healing practices. This option would hold the greatest appeal for clinicians who believe that faith healing works as a form of treatment. Clinicians are social beings and hence, may tend to endorse particular procedures on account of their social conditioning. Though they may like to critically examine the nuances of any form of treatment, they are also likely to find non-invasive faith healing practices (such as wearing amulets) acceptable. Medicine does recognise the efficacy of placebo effects, and many clinicians may feel that faith healing treatments provide relief from distress in the same way that placebos do. From the ethical standpoint, this option respects the patient’s autonomy, though it does not pay attention to the principles of beneficence and justice. The issue of non-maleficence may arise if the clinician endorses potentially harmful interventions. This third option may be justified on utilitarian grounds, ie the request for a faith healing intervention may be accepted if the intervention is likely to help the patient.

Option 4: Explore the belief system and faith healing procedure suggested

Another option would be to inquire about the patient’s and/or family members’ beliefs regarding the faith healing practices concerned. There is a variety of faith healing practices, each associated with a different level of perceived promise and potential pitfalls. Exploring the patient’s and/ or family members’ views on these issues would reveal the reasons for their insistence on seeking help from faith healers, and would also help to gauge their faith in the method concerned. It would also enable medical professionals to streamline the treatment, if possible, so as not to preclude the desired faith healing practices. For example, one could schedule chemotherapy in the afternoon to accommodate the patient’s wish to visit a temple and perform a puja in the morning, rather than risk having the patient discontinue the treatment altogether. Such an approach is likely both to maintain the patient’s autonomy and extend the physician’s beneficence. This approach does not violate the principles of non-maleficence or justice in any significant manner. It may be described as being in keeping with the utilitarian principle of choosing whatever option benefits the greatest number of individuals.

Which option to choose?

There is no straight answer as to which option to choose. All four options may be considered the correct approach in specific clinical situations. The dilemma of whether to reject patients’ and/or their family members’ views or to accept them unquestioningly does remain. One needs to acknowledge the variety in faith healing practices, and the fact that the ethical conflicts and dilemmas arising from each situation may be different. Hence, the issue needs to be examined critically. Many faith healing practices may provide relief from distress, possibly due to a placebo effect, while others can be potentially dangerous (6, 15, 16). A healthcare provider could cautiously try to make the patient aware of the potential harms, if any. Another issue is that given the interdependence and close family ties characterising Indian society, the request for a faith healing intervention is very often made by the patient’s relatives and extended family members, and their wishes simply cannot be ignored. In some cases, the patient does not see eye to eye with the family. The clinician’s duty is to address the patient’s concerns, and he/she should make an effort to avoid colluding with the family members, especially when the competence of the patient is not in doubt.

The authors reckon that the four options mentioned above are not exclusive of each other. Clinical decision-making is often an ongoing process and can require the utilisation of different approaches over time, depending on the information available, the patient’s wishes and the extent to which the faith healing practice would interfere with the medical treatment envisaged. The various members of the treating team would have their own individual opinions about the best course of action in terms of ethics. The options discussed above are not allinclusive and other options might also exist (17). The judgment of the ethical aspects of faith healing treatment is likely to be context-specific, depending on the unique sociocultural milieu, and clinicians would be able to serve their patients better if they were aware of the ethical implications of a particular approach towards such treatment.

To conclude, healthcare personnel would do well to apply the principles of ethics so as to be able to take an informed decision in cases in which there has been a request for faith healing treatment. The health professional’s decision must take into account the disease per se, the acuteness of the patient’s medical condition, the proposed medical intervention and its expected benefits, the potential harm that can result from the faith healing practice, and a consideration of the patient’s social and cultural background. The ethical dilemmas regarding faith healing practices can be best resolved through a cautious and critical evaluation of the options available regarding the further course of action. Including a discussion of these issues in medical ethics, a subject which is a part of the core curriculum of health professionals in training, will help health professionals take a reasoned stance based on ethical principles when faced with such situations during their careers.

Conflicts of interest
The authors declare no conflicts of interest. This work has received no funding.