- Email: [email protected]
Viewing the Body in the Abrahamic Faith Traditions
Educational Perspective
Viewing the Body in the Abrahamic Faith Traditions: What Radiologists Need to Know Richard B. Gunderman, MD, PhD, FACR, Christopher R. Jackson, MD
T
he best radiologists and radiology personnel aspire to care for patients as whole human beings and not just injured or diseased organs. To do so, it is important to understand the basic tenets of major faith traditions. Health professionals unacquainted with this dimension of life are liable to make avoidable blunders. By contrast, religiously informed and sensitive radiology department personnel can provide more comprehensive and compassionate care to patients and also exhibit greater understanding in their working relationships with colleagues of faith. This article focuses on key features of the three Abrahamic faith traditions: Judaism, Christianity, and Islam. It also touches on their views regarding the patient-physician relationship, including their attitude toward revealing normally hidden features of the human form.
RELIGION When asked if religion is important in daily life, 65% of Americans respond in the affirmative. This compares to 95% in Saudi Arabia, 72% in Mexico, 50% in Israel, 42% in Canada, 30% in France, and 23% in Japan. Many people view their identity as embedded in a larger religious community and see the world itself as the product of a divine creator who has a plan for human beings. Most people of faith also regard religion as an important source of ethical guidance, setting forth patterns of conduct that should be followed or avoided. These perspectives often shape health-related decisions, both for patients and providers. In general, there is an inverse correlation between a nation’s level of religiosity and its standard of living. The most economically prosperous countries generally rank among the least religious. On this score, the United States is a notable exception, with levels of religiosity about twice those of the other very prosperous nations. Of course, religiosity varies Acad Radiol 2013; 20:506–508 From the Department of Radiology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 1053, Indianapolis, Indiana 46202-5200 (R.B.G.); and Department of Surgery, Baylor College of Medicine, Houston, TX (C.R.J.). Received September 16, 2012; accepted October 4, 2012. Address correspondence to: R.B.G. e-mail: [email protected] ªAUR, 2013 http://dx.doi.org/10.1016/j.acra.2012.10.013
506
from state to state within the United States, with the highest levels (>80%) in the South and the lowest (<50%) in northeastern and far western states. Despite such interstate differences, however, the overall high level of US religiosity makes it even more important that US health personnel be religiously literate and sensitive to different religious perspectives. ABRAHAMIC TRADITIONS Judaism, Christianity, and Islam are called Abrahamic traditions because each traces its lineage back to a common origin, the patriarch Abraham. Of the three, Judaism is the oldest at 3000 years and Islam the youngest at 1400 years. In the book of Genesis, a foundational scripture for all three, Abraham is recorded as the ancestor of the Israelites through his son Isaac and his grandson Jacob. In the Christian Bible, Genesis forms the first book of the Old Testament, a modified form of the Hebrew Bible. Muslims regard Muhammad, the prophet of Islam, as a descendant of Abraham’s son Ishmael. More than half of the world’s population, some 3.8 billion people, identify themselves with one of the Abrahamic traditions, as do more than 80% of American adults. Each of the Abrahamic faiths is monotheistic, worshipping a single and exclusive personal deity who created the universe, rules over history, and has sent prophets to reveal the divine will. In each tradition, God is regarded as both the appropriate and necessary center of every human life. To put other things such as wealth, power, fame, or even health before God would be to fall prey to the sin of idolatry, the worship of false gods. JUDAISM The sacred text of Judaism is the Tanakh, which consists of the Torah (the Pentateuch or first five books of the Bible), the Nevi’im (prophets), and the Ketuvim (writings), roughly corresponding to the Christian Old Testament. To this Judaism adds the Talmudic or classic rabbinic literature as well as Midrash, a further body of writings growing out of the interpretation of scripture. Jews believe that God entered into a special covenantal relationship with Abraham, subsequently revealing His laws to the prophet Moses in the form of both written and oral Torah.
Academic Radiology, Vol 20, No 4, April 2013
Judaism is the oldest extant monotheistic tradition, and its adherents include both those of Jewish ethnicity and those who have converted to Judaism. It has three large branches, Orthodox Judaism, Conservative Judaism, and Reform Judaism, which exhibit differences in their interpretation of Torah. The world Jewish population is estimated at approximately 13 million, of which approximately 80% are equally divided between the United States and Israel. As with each faith tradition, estimates are complicated by disputes over who counts as a Jew. Some argue that only followers of the religion should be counted, whereas others assert that anyone born into or descended from a Jewish family should count. Judaism regards the work of physicians as holy, at least to the extent that it attends to the well being of human beings, who are made in the image of God. Because the whole person belongs to God, people should take care of themselves and one another. And because every human being is made in God’s image, physicians have a duty to respect their patients and take the time necessary to ensure that they understand their condition and its diagnosis and treatment. Physicians should tell patients the truth, but patient well-being is the highest priority, and if hearing the truth would harm the patient, the physician may tailor communication accordingly. All three Abrahamic traditions share the story of Adam and Eve in the Garden of Eden. After the first humans ate of the fruit of the tree of knowledge of good and evil, they were ashamed and covered themselves with leaves. Yet each tradition interprets the story differently, with important implications for how radiology personnel handle issues around uncovering the body and, by extension, revealing what is normally hidden beneath clothing and skin. Attitudes toward nakedness within Judaism vary among the three major traditions. In the Orthodox tradition, nakedness tends to be rather strictly regulated, extending even to encounters between spouses. In the more liberal traditions, such as Reform Judaism, nakedness is not exactly encouraged or even condoned, but the issue is left to the discretion of the individual or family involved. There are scriptural passages that seem to deal directly with the issue of nakedness, such as the Genesis 9:21-25 account in which Noah’s son Ham is cursed for seeing his father unclothed. Yet the Jewish attitude toward nakedness is grounded less in scripture than in what makes people feel ashamed. In most social and family situations, people should remain clothed, but there is nothing morally wrong or sinful about disrobing as needed for medical care. In general, modesty should be respected as much as possible. A similar attitude obtains with respect to dietary laws—an observant Jew whose only available food sources are nonKosher should eat, because saving life is a higher priority than keeping Kosher.
CHRISTIANITY The Christian sacred text is the Bible, consisting of the Old Testament, roughly equivalent to the Jewish Tanakh, and the
THE BODY IN ABRAHAMIC FAITH TRADITIONS
New Testament, which consists of the four Gospels (accounts of the life and teaching of Jesus) and other books and letters written by followers of Jesus. It is by far the most frequently produced book in human history. Christians believe that Jesus Christ (‘‘the anointed one’’) was the son of God who became human and preached a message of salvation for humanity. Jesus is seen as the Messiah, the savior prophesied in the Hebrew Bible. The three largest groups of Christians worldwide are Roman Catholicism, Eastern Orthodoxy, and various branches of Protestantism. Christianity represents the world’s largest faith tradition, accounting for more than one third of the world’s population, or about 2.2 billion people. Roughly three quarters of Americans identify themselves as Christians, with Protestants outnumbering Catholics 2 to 1. In Roman Catholicism, the largest single group of Christians in the world, the patient-physician relationship is grounded in the sanctity of human life, in which the spiritual trumps the biological. This distinction is manifest in the attitude toward suffering. Though suffering frequently involves harm to the body, it may provide opportunities for spiritual growth that should not be ignored. As stewards of life, human beings and especially physicians have an obligation to care for themselves and one another. Patients are ultimately responsible for decision-making, and thus truth-telling is of paramount importance. Health care professionals should respect a patient’s decisions, so long as they do not violate their own religious beliefs. As regards disrobing and nakedness, Christians have a wide variety of attitudes. Consider the sacrament of baptism, in which water is used to symbolize acceptance into membership in the Christian community. Early Christian writings prescribe that individuals should remove all clothing and jewelry. In later traditions, however, the sexes were separated and baptism was performed with clothing in place. On the subject of nakedness, Pope John Paul II wrote that ‘‘the human body can remain uncovered and preserve its splendor and beauty,’’ indicating that there is nothing shameful about nakedness as such. Instead the attitude toward exposure of the human exterior reflects an inner psychological and spiritual state. Nakedness becomes shameful only when it is associated with diminished value and respect for the person, as in making fun of someone or treating a human being as a mere object of sexual gratification. The art of the Christian church is replete with the naked human form. Renaissance painters and sculptors regularly depicted persons in a state of complete undress. Examples include some of the world’s most famous works of art, including Michelangelo’s paintings in the Sistine Chapel and his sculpture, David. Of note is the fact that such works of art are largely absent in the Jewish and Muslim traditions, which tend to take more seriously the scriptural prohibition against the making of images. Although there is nothing inherently shameful about nakedness, it is important to respect social conventions and avoid inappropriate relationships. 507
GUNDERMAN AND JACKSON
ISLAM The sacred text of Islam is the Qur’an, which is considered to be the verbatim word of God (Allah) revealed to the prophet Muhammad, who lived in Arabia in the sixth and seventh centuries CE. The word Islam literally means submission, and Muslims believe that God requires complete surrender to Him as the only acceptable way of life. They hold that God has had many prophets, including Abraham, Moses, and Jesus, but that these previous revelations were changed and corrupted over time. In contrast, the revelation of the Qur’an through Muhammad represents the unadulterated and final revelation of God. Most Muslims belong to one of two denominations, Sunni Islam (85%) or Shia Islam (15%), which differ over the rightful successor to Muhammad. The largest Muslim country in the world is Indonesia. There are about 1.5 billion Muslims around the globe and approximately 6 million Muslims in the Unites States. The Islamic tradition holds medicine in high esteem, regarding someone who saves one life as saving the whole of humanity. Ultimately, Muslims see divine intent behind healing, grounded in an act of faith in God. In dealing with patients, it is important for physicians to treat everyone equally, regardless their station in life. Some Muslims regard a verbal agreement as no less binding than a written one, and may in fact take offense if pressed to sign a document, because it seems to suggest that their word cannot be trusted. A signature on a consent form is at best a mere formality— what really counts is whether the patient or family possesses sufficient understanding to make such a choice. In Islam, there are clear prohibitions against exposing certain parts of the body. For men, the prohibited region extends from the navel to the knees. In most Muslim cultures, however, men cover their upper abdomens and chests as well. For women, the scope of the prohibited region depends on the gender of those who are present. In the company of other women, it extends from the chest to the knees. Among men, it extends over the whole body, with the exception of the face and the hands. Some Muslim sects believe that a woman’s whole body should be covered in the presence of unrelated men. Moreover, women’s clothing should be both loose and opaque to obscure the contours of the body.
508
Academic Radiology, Vol 20, No 4, April 2013
Muslim attitudes toward nakedness have important implications for radiology personnel. In general, Muslims express a preference for having a physician of the same sex. The same applies even once a patient has died: clothing should be removed and the body washed by a person of the same gender. So strong is the sense of gender identity that the physician’s gender takes precedence over the physician’s faith; in general, a Muslim patient should first seek a Muslim physician of the same sex, followed by a non-Muslim of the same sex, followed by a physician of the opposite sex, and last a non-Muslim of the opposite sex. However, the priority of saving life is ultimately paramount, especially in urgent and emergent circumstances, and there is no prohibition against a physician of one gender tending to a patient of another, so long as modesty is respected as far as possible.
CONCLUSION Religious identity is an important facet of health care. Radiology personnel should be aware of the faith traditions of patients and colleagues and their implications for the patient-physician relationship. In many hospitals, patients are asked to report their religious affiliation. Clues to religious affiliation can be found in patient dress, particularly among more orthodox sects, as well as reading materials patients may bring with them. In radiology, religious identity can be especially relevant in relation to the exposure of the body and visualization of its interior. Gender-specific anatomy is often readily apparent on studies ranging from chest radiographs to cross-sectional images of the pelvis. It is important for radiology personnel to handle such images in a respectful and professional manner, addressing only those aspects directly relevant to patient care. If sensitive portions of the body need to be exposed for an imaging examination or procedure, it is appropriate to explain so beforehand, to obtain the patient’s consent, and to proceed as discretely as possible. Even if the patient has no religious affiliation, most hospitals and health care institutions have clear policies requiring the presence of chaperones for certain types of encounters, particularly those involving a female patient and a male health professional. To care well for a patient, it is usually necessary to know the patient, and faith often represents one of the deepest dimensions of a patient’s identity.
Viewing the Body in the Abrahamic Faith Traditions: What Radiologists Need to Know Richard B. Gunderman, MD, PhD, FACR, Christopher R. Jackson, MD
T
he best radiologists and radiology personnel aspire to care for patients as whole human beings and not just injured or diseased organs. To do so, it is important to understand the basic tenets of major faith traditions. Health professionals unacquainted with this dimension of life are liable to make avoidable blunders. By contrast, religiously informed and sensitive radiology department personnel can provide more comprehensive and compassionate care to patients and also exhibit greater understanding in their working relationships with colleagues of faith. This article focuses on key features of the three Abrahamic faith traditions: Judaism, Christianity, and Islam. It also touches on their views regarding the patient-physician relationship, including their attitude toward revealing normally hidden features of the human form.
RELIGION When asked if religion is important in daily life, 65% of Americans respond in the affirmative. This compares to 95% in Saudi Arabia, 72% in Mexico, 50% in Israel, 42% in Canada, 30% in France, and 23% in Japan. Many people view their identity as embedded in a larger religious community and see the world itself as the product of a divine creator who has a plan for human beings. Most people of faith also regard religion as an important source of ethical guidance, setting forth patterns of conduct that should be followed or avoided. These perspectives often shape health-related decisions, both for patients and providers. In general, there is an inverse correlation between a nation’s level of religiosity and its standard of living. The most economically prosperous countries generally rank among the least religious. On this score, the United States is a notable exception, with levels of religiosity about twice those of the other very prosperous nations. Of course, religiosity varies Acad Radiol 2013; 20:506–508 From the Department of Radiology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 1053, Indianapolis, Indiana 46202-5200 (R.B.G.); and Department of Surgery, Baylor College of Medicine, Houston, TX (C.R.J.). Received September 16, 2012; accepted October 4, 2012. Address correspondence to: R.B.G. e-mail: [email protected] ªAUR, 2013 http://dx.doi.org/10.1016/j.acra.2012.10.013
506
from state to state within the United States, with the highest levels (>80%) in the South and the lowest (<50%) in northeastern and far western states. Despite such interstate differences, however, the overall high level of US religiosity makes it even more important that US health personnel be religiously literate and sensitive to different religious perspectives. ABRAHAMIC TRADITIONS Judaism, Christianity, and Islam are called Abrahamic traditions because each traces its lineage back to a common origin, the patriarch Abraham. Of the three, Judaism is the oldest at 3000 years and Islam the youngest at 1400 years. In the book of Genesis, a foundational scripture for all three, Abraham is recorded as the ancestor of the Israelites through his son Isaac and his grandson Jacob. In the Christian Bible, Genesis forms the first book of the Old Testament, a modified form of the Hebrew Bible. Muslims regard Muhammad, the prophet of Islam, as a descendant of Abraham’s son Ishmael. More than half of the world’s population, some 3.8 billion people, identify themselves with one of the Abrahamic traditions, as do more than 80% of American adults. Each of the Abrahamic faiths is monotheistic, worshipping a single and exclusive personal deity who created the universe, rules over history, and has sent prophets to reveal the divine will. In each tradition, God is regarded as both the appropriate and necessary center of every human life. To put other things such as wealth, power, fame, or even health before God would be to fall prey to the sin of idolatry, the worship of false gods. JUDAISM The sacred text of Judaism is the Tanakh, which consists of the Torah (the Pentateuch or first five books of the Bible), the Nevi’im (prophets), and the Ketuvim (writings), roughly corresponding to the Christian Old Testament. To this Judaism adds the Talmudic or classic rabbinic literature as well as Midrash, a further body of writings growing out of the interpretation of scripture. Jews believe that God entered into a special covenantal relationship with Abraham, subsequently revealing His laws to the prophet Moses in the form of both written and oral Torah.
Academic Radiology, Vol 20, No 4, April 2013
Judaism is the oldest extant monotheistic tradition, and its adherents include both those of Jewish ethnicity and those who have converted to Judaism. It has three large branches, Orthodox Judaism, Conservative Judaism, and Reform Judaism, which exhibit differences in their interpretation of Torah. The world Jewish population is estimated at approximately 13 million, of which approximately 80% are equally divided between the United States and Israel. As with each faith tradition, estimates are complicated by disputes over who counts as a Jew. Some argue that only followers of the religion should be counted, whereas others assert that anyone born into or descended from a Jewish family should count. Judaism regards the work of physicians as holy, at least to the extent that it attends to the well being of human beings, who are made in the image of God. Because the whole person belongs to God, people should take care of themselves and one another. And because every human being is made in God’s image, physicians have a duty to respect their patients and take the time necessary to ensure that they understand their condition and its diagnosis and treatment. Physicians should tell patients the truth, but patient well-being is the highest priority, and if hearing the truth would harm the patient, the physician may tailor communication accordingly. All three Abrahamic traditions share the story of Adam and Eve in the Garden of Eden. After the first humans ate of the fruit of the tree of knowledge of good and evil, they were ashamed and covered themselves with leaves. Yet each tradition interprets the story differently, with important implications for how radiology personnel handle issues around uncovering the body and, by extension, revealing what is normally hidden beneath clothing and skin. Attitudes toward nakedness within Judaism vary among the three major traditions. In the Orthodox tradition, nakedness tends to be rather strictly regulated, extending even to encounters between spouses. In the more liberal traditions, such as Reform Judaism, nakedness is not exactly encouraged or even condoned, but the issue is left to the discretion of the individual or family involved. There are scriptural passages that seem to deal directly with the issue of nakedness, such as the Genesis 9:21-25 account in which Noah’s son Ham is cursed for seeing his father unclothed. Yet the Jewish attitude toward nakedness is grounded less in scripture than in what makes people feel ashamed. In most social and family situations, people should remain clothed, but there is nothing morally wrong or sinful about disrobing as needed for medical care. In general, modesty should be respected as much as possible. A similar attitude obtains with respect to dietary laws—an observant Jew whose only available food sources are nonKosher should eat, because saving life is a higher priority than keeping Kosher.
CHRISTIANITY The Christian sacred text is the Bible, consisting of the Old Testament, roughly equivalent to the Jewish Tanakh, and the
THE BODY IN ABRAHAMIC FAITH TRADITIONS
New Testament, which consists of the four Gospels (accounts of the life and teaching of Jesus) and other books and letters written by followers of Jesus. It is by far the most frequently produced book in human history. Christians believe that Jesus Christ (‘‘the anointed one’’) was the son of God who became human and preached a message of salvation for humanity. Jesus is seen as the Messiah, the savior prophesied in the Hebrew Bible. The three largest groups of Christians worldwide are Roman Catholicism, Eastern Orthodoxy, and various branches of Protestantism. Christianity represents the world’s largest faith tradition, accounting for more than one third of the world’s population, or about 2.2 billion people. Roughly three quarters of Americans identify themselves as Christians, with Protestants outnumbering Catholics 2 to 1. In Roman Catholicism, the largest single group of Christians in the world, the patient-physician relationship is grounded in the sanctity of human life, in which the spiritual trumps the biological. This distinction is manifest in the attitude toward suffering. Though suffering frequently involves harm to the body, it may provide opportunities for spiritual growth that should not be ignored. As stewards of life, human beings and especially physicians have an obligation to care for themselves and one another. Patients are ultimately responsible for decision-making, and thus truth-telling is of paramount importance. Health care professionals should respect a patient’s decisions, so long as they do not violate their own religious beliefs. As regards disrobing and nakedness, Christians have a wide variety of attitudes. Consider the sacrament of baptism, in which water is used to symbolize acceptance into membership in the Christian community. Early Christian writings prescribe that individuals should remove all clothing and jewelry. In later traditions, however, the sexes were separated and baptism was performed with clothing in place. On the subject of nakedness, Pope John Paul II wrote that ‘‘the human body can remain uncovered and preserve its splendor and beauty,’’ indicating that there is nothing shameful about nakedness as such. Instead the attitude toward exposure of the human exterior reflects an inner psychological and spiritual state. Nakedness becomes shameful only when it is associated with diminished value and respect for the person, as in making fun of someone or treating a human being as a mere object of sexual gratification. The art of the Christian church is replete with the naked human form. Renaissance painters and sculptors regularly depicted persons in a state of complete undress. Examples include some of the world’s most famous works of art, including Michelangelo’s paintings in the Sistine Chapel and his sculpture, David. Of note is the fact that such works of art are largely absent in the Jewish and Muslim traditions, which tend to take more seriously the scriptural prohibition against the making of images. Although there is nothing inherently shameful about nakedness, it is important to respect social conventions and avoid inappropriate relationships. 507
GUNDERMAN AND JACKSON
ISLAM The sacred text of Islam is the Qur’an, which is considered to be the verbatim word of God (Allah) revealed to the prophet Muhammad, who lived in Arabia in the sixth and seventh centuries CE. The word Islam literally means submission, and Muslims believe that God requires complete surrender to Him as the only acceptable way of life. They hold that God has had many prophets, including Abraham, Moses, and Jesus, but that these previous revelations were changed and corrupted over time. In contrast, the revelation of the Qur’an through Muhammad represents the unadulterated and final revelation of God. Most Muslims belong to one of two denominations, Sunni Islam (85%) or Shia Islam (15%), which differ over the rightful successor to Muhammad. The largest Muslim country in the world is Indonesia. There are about 1.5 billion Muslims around the globe and approximately 6 million Muslims in the Unites States. The Islamic tradition holds medicine in high esteem, regarding someone who saves one life as saving the whole of humanity. Ultimately, Muslims see divine intent behind healing, grounded in an act of faith in God. In dealing with patients, it is important for physicians to treat everyone equally, regardless their station in life. Some Muslims regard a verbal agreement as no less binding than a written one, and may in fact take offense if pressed to sign a document, because it seems to suggest that their word cannot be trusted. A signature on a consent form is at best a mere formality— what really counts is whether the patient or family possesses sufficient understanding to make such a choice. In Islam, there are clear prohibitions against exposing certain parts of the body. For men, the prohibited region extends from the navel to the knees. In most Muslim cultures, however, men cover their upper abdomens and chests as well. For women, the scope of the prohibited region depends on the gender of those who are present. In the company of other women, it extends from the chest to the knees. Among men, it extends over the whole body, with the exception of the face and the hands. Some Muslim sects believe that a woman’s whole body should be covered in the presence of unrelated men. Moreover, women’s clothing should be both loose and opaque to obscure the contours of the body.
508
Academic Radiology, Vol 20, No 4, April 2013
Muslim attitudes toward nakedness have important implications for radiology personnel. In general, Muslims express a preference for having a physician of the same sex. The same applies even once a patient has died: clothing should be removed and the body washed by a person of the same gender. So strong is the sense of gender identity that the physician’s gender takes precedence over the physician’s faith; in general, a Muslim patient should first seek a Muslim physician of the same sex, followed by a non-Muslim of the same sex, followed by a physician of the opposite sex, and last a non-Muslim of the opposite sex. However, the priority of saving life is ultimately paramount, especially in urgent and emergent circumstances, and there is no prohibition against a physician of one gender tending to a patient of another, so long as modesty is respected as far as possible.
CONCLUSION Religious identity is an important facet of health care. Radiology personnel should be aware of the faith traditions of patients and colleagues and their implications for the patient-physician relationship. In many hospitals, patients are asked to report their religious affiliation. Clues to religious affiliation can be found in patient dress, particularly among more orthodox sects, as well as reading materials patients may bring with them. In radiology, religious identity can be especially relevant in relation to the exposure of the body and visualization of its interior. Gender-specific anatomy is often readily apparent on studies ranging from chest radiographs to cross-sectional images of the pelvis. It is important for radiology personnel to handle such images in a respectful and professional manner, addressing only those aspects directly relevant to patient care. If sensitive portions of the body need to be exposed for an imaging examination or procedure, it is appropriate to explain so beforehand, to obtain the patient’s consent, and to proceed as discretely as possible. Even if the patient has no religious affiliation, most hospitals and health care institutions have clear policies requiring the presence of chaperones for certain types of encounters, particularly those involving a female patient and a male health professional. To care well for a patient, it is usually necessary to know the patient, and faith often represents one of the deepest dimensions of a patient’s identity.