No Easy Answers in Bioethics Podcast

When Patients and Families Express Hope for a Miracle: Bibler and Stahl - Episode 12

February 18, 2019 Trevor Bibler photoDevan Stahl photo

How do patients, their families, or their caregivers express hope for a miracle in the clinical setting? How can medical professionals respond to these desires for a miracle to occur? Guests Dr. Devan Stahl, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and Department of Pediatrics and Human Development at Michigan State University, and Dr. Trevor Bibler, Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine, have written on this topic, with articles published in the American Journal of Bioethics and the Journal of Pain and Symptom Management. In this episode they discuss the framework for categorizing the various ways in which people hope for a miracle, while also drawing from experiences they have had as clinical ethicists. They also discuss the importance of not making assumptions when miracle language is used, emphasizing the need for all religious beliefs to be respected by medical professionals.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

Related Items

  • Bibler TM, Shinall MC Jr, Stahl D. Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists. American Journal of Bioethics. May 2018;18(5):40-51. Available online April 26, 2018. PMID: 29697329. DOI: 10.1080/15265161.2018.1431702.
  • Bibler TM, Shinall MC Jr, Stahl D. Response to Open Peer Commentaries on “Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists”. American Journal of Bioethics. May 2018;18(5):W1-W5. Available online April 26, 2018. PMID: 29697350. DOI: 10.1080/15265161.2018.1439547.
  • Shinall MC Jr, Stahl D, Bibler TM. Addressing a Patient's Hope for a Miracle. Journal of Pain and Symptom Management. February 2018;55(2):535-539. Available online October 10, 2017. PMID: 29030208. DOI: 10.1016/j.jpainsymman.2017.10.002.

Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine.

Consider the following questions: How do patients, their families, or their caregivers express hope for a miracle in the clinical setting? How can medical professionals respond to these desires for a miracle to occur? This episode features guests Dr. Devan Stahl, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and Department of Pediatrics and Human Development at Michigan State University, and Dr. Trevor Bibler, Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. Together they have written on this topic, with articles published in the American Journal of Bioethics and the Journal of Pain and Symptom Management. They join us today to discuss the framework for categorizing the various ways in which people hope for a miracle, while also drawing from experiences they have had as clinical ethicists. They also discuss the importance of not making assumptions when miracle language is used, emphasizing the need for all religious beliefs to be respected by medical professionals.

Devan Stahl: This is Devan Stahl, I'm an assistant professor of clinical ethics at the Center for Ethics and Humanities in the Life Sciences at Michigan State University.

Trevor Bibler: I'm Trevor Bibler, I'm an assistant professor of medicine at Baylor College of Medicine and a clinical ethicist at Houston Methodist Hospital Systems in Houston, Texas.

DS: Alright Trevor, so you and I have known each other for a long time now, we were both at Vanderbilt for our graduate studies.

TB: Mm-hmm.

DS: And so this project we're going to talk about today that you and I have been involved with surrounding the topic of miracles. When patients ask for specific treatments or when they invoke the term “miracle.” But I wanted to ask you first, I know this was the topic of your dissertation, right? So maybe tell me--

TB: Yep.

DS: --How you got into this topic.

TB: Oh sure, gladly. So another person we both know, Jeff Bishop, I actually got into bioethics, clinical ethics, and this topic itself through a class of his when he was at Vanderbilt. He taught a course called “theology and medicine,” and I took it while I was writing my dissertation, I'm sorry my thesis, on Augustine and infant suffering because I thought looking at suffering in the context of medicine would be an interesting, interesting aspect of it. And as part of that course, the students, including me, we rounded with the clinical ethicist and the palliative care professionals there. And during one of the, in addition to rounding, we also were part of these bi-weekly case conferences. And the first case conference that I ever sat in on was regarding a pair, a couple parents who were rejecting a liver transplant for their child because they were hoping for a miracle.

And I had lots of questions related to what that miracle might be, what was their religious faith, all of, all of the stuff that I thought was really important, and when I was asking the ethicist about this they hadn't really, they didn't dive into those aspects of it that I thought were really, really important. So I did what grad school students do, and I went and did a lit search and tried to figure out who else was--

DS: [Laughs]

TB: --Talking about this the miracle, and how complex it was in the context of medicine. And I found a couple interesting articles but overall there was no real robust conversation about the complexity. It was just more of a statement that there is complexity. And so I got extremely interested in clinical ethics and ended up staying at Vanderbilt doing my PhD work on precisely that topic, prompted by that case and many, many other cases that I had. And as part of my dissertation research I just kind of tried to understand the complexity of what this hope might be, how it relates especially to end-of-life care and adult medicine, and all of that. So that's how I both got into clinical ethics and into investigating the complexity relating to this hope for a miracle.

DS: Yeah, well first of all, shout out to Jeff Bishop, who also got me into bioethics and clinical ethics.

TB: [Laughs]

DS: So that's funny that we share that. I actually didn't know that that was what got you into it as well.

TB: Yeah yeah.

DS: Yeah, so when you were telling me about this topic, you're totally right, we looked up all the articles we could find on the topic of miracles and medicine, and there really surprisingly was not that much. And I found that surprising because I trained as a chaplain before I got into clinical ethics, and this happens all the time. And I would say not just even for patients who you'd expect it from. The idea of a miracle is pretty, I mean it comes up quite a bit in clinical care. And it is majorly distressing to certain kinds of health care providers.

TB: Mm-hmm.

DS: So, physicians, nurses, sometimes they share that patient's faith, sometimes they do not, often they don't, and they're then not sure what to do when a patient says, "Well, I'm waiting for a miracle." Or, "I want this because I need to hold out for that miracle," or, "I don't want this medical intervention because I believe that God will perform the miracle." I actually see this in my clinical work all the time, and so the fact that there aren't more people writing about it was surprising. So I'm very glad that this was your topic because I think it's so important. So--

TB: Yeah, no, I've also found it relevant in, as, in the context, in all the contexts you said, and surprisingly even from those who don't necessarily have a strong confessional faith. Which really surprised me.

DS: Mm-hmm. Yeah I think it's just a popular word in our culture.

TB: Mm-hmm.

DS: And of course what we realized, probably you before me, is that it's not just one thing. So I think that people might think that there is just one way in which our patients might use the term "miracle."

TB: Mm-hmm.

DS: But of course, they do not. So that's how you sort of presented this to me as, you know, there, people are using the term miracle in different ways, and we might need to unpack what that means to that particular patient or their family member before we can really get into how we're going to help them work through whatever issues, or problems, or existential crisis that might follow as a result of that belief or hope in a miracle.

TB: Mm-hmm.

DS: So you came up with this wonderful taxonomy. So I wonder if you could describe that.

TB: Oh sure, gladly. So the taxonomy itself, it's kind of a framework that is based on my experience and your experience and this experiences of our colleagues and our friends, and it's really I think one way of understanding this complexity. By no way is it the way or the one way or anything like that, and I think it's primarily most helpful in contexts where the patient or the family member or the surrogate is expressing a hope and they're from, to some degree, one of the big three monotheistic Abrahamic traditions. But it's, it's also I think flexible enough to account for lots of variations. But overall the way I was kind of thinking about it, and throughout, throughout my time and my research on it, and it seems to change quite a bit with each new publication. But, the overall, I think one of the most hopeful ways is kind of, is at this point dividing the taxonomy, the typology, the framework, whatever we want to call it, between four major types of invocations.

The first as I often think about it, and I think we've called it, is those who are shaken. Their hope for a miracle is important for them, in terms of the content of it, they often themselves are not quite sure. It might or might not be affecting their surrogate decision making. They're often lacking a type of communal authority that they could rely upon to really sort things out, and the reason why I, I at least have been thinking of it as being shaken is that it really is this type of fundamental uncertainty about what the miracle might be, because of the theological or religious or spiritual struggles that you've been undergoing. And your sense of who you are, who God is, what a miracle might be, all of that has just been changed by either your sickness, or the sickness of another, or something related to medical care.

But as we have seen, not everybody who hopes for a miracle has just been completely shaken and their idea of a miracle is kind of diffuse. Some people have very long-held strong beliefs that when they or their family, their loved ones, are suffering through a type of illness especially near the end of life, they have these long-held beliefs and a sense of community support for their conception of what a miracle might be. Often their sense of who they are, what their community is, what God is, what the miracle will look like, is very heavily integrated. That's why we call them integrated, into, it's all very melded together. And they're not, they don't tend to struggle with accounting for the miracle or for--I'm sorry, accounting for sickness, they don't really struggle with that because they have a sense, this very integrated sense of who God is, what the world is, and their account of illness can then reconcile that.

Oftentimes for these integrated folks they're hoping for a miracle in the sense of a complete recovery, or a recovery to, to baseline, of either themselves or their loved ones. And their prayers are often very petitionary, if you ask them what they're praying for they'll say they're praying to God or this miracle. Another telltale sign is that sacred objects are often ready at hand. I was recently talking with a family member of a, who was using miracle language in an integrated sense I would designate, and when I went into the room the family had eight-by-eleven-and-a-half printouts of Jesus taped to the wall, some prayer cards, and they also had a iPad that was livestreaming an altar from Alabama. That, so these sacred objects - and they were often reading the Bible, often praying – and they're often ready at hand, and there's often a great deal of community support. They have always, every, it seems like every time you go in and talk with them they had just finished talking with their pastor or Imam or rabbi or priest.

But that said, obviously not everybody who hopes for a miracle either hopes for it in this sense of their being shaken or in an integrated sense. Some use it in a strategic sense which doesn't, I don't use that term in a normative way of saying that this is a bad way of having a faith or an unjustified way of having a faith, but it is I think important that we as medical professionals reconcile and think through this complexity, because some people use the hope in a strategic sense. One of the first cases at Vanderbilt that I ever had as an independent ethicist, it involved a patient for whom she was near the end of her life, she had a neurological event, and her two daughters were in disagreement about what the plan of care should look like moving forward. One daughter saying we need to continue supportive interventions, the other daughter saying we should really concentrate on comfort. And during a family meeting, one daughter made her case for comfort care. The other daughter then made her case for supportive interventions based on a hope for a miracle. And that it would, it's her right to make that decision, and if you don't respect that right, if the care team doesn't respect that right, you're trampling all over my religious freedoms. And her sister, I'll never forget, her sister turned her head and said, "What are you talking about?" And what came out during the meeting and what that concern was based in is that this, this daughter who was using this language had never really expressed religious preferences before, she didn't really attend church or synagogue or anything like that. She didn't appear to be a person of faith as we would traditionally identify them. And so the sister was very surprised at her sister's response. And eventually through additional conversation it became quite clear that she was latching on to that language in a very justifiable attempt at having her voice being heard. She had felt neglected, she was equal in the surrogate decision making hierarchy, but the clinical care team had been going to her sister. She wasn't up to date with medical information. So she saw this hope for a miracle as a way of exerting her voice, and again, it can be very justified as in this case it was. But it's not necessarily the case as we can see, that type of hope is a very different type of hope than a person who has been part of the religious community their whole lives, isn't struggling with what this illness is, but is just hoping for a complete recovery.

The, the fourth way that I often think about this is since not everybody's shaken, not everybody has a long-held community belief, not everybody is just kind of grasping at spiritual straws and hoping for a miracle. Oftentimes, and I think this might be one of the, the most prevalent groups of folks, these are the people who are, who I have I've been calling thanks to another one of our colleagues Alex Lion, he really helped me with this language of “seeking.” People who are seeking a miracle of some sort. They themselves, it might be the case that the miracle would look like a comfortable death, the miracle would look like a complete recovery. In terms of the content of the miracle, it can be very diverse. But they're confident in their worldview, they're comfortable with who the divine is so they're not shaken, but they actually unlike the integrated invocator, they might actually disagree with some aspects of their community, so, of their community's beliefs. They might reject their own, the specific aspects of what their community would say they should be thinking through. They often see the team as well as miracle workers, because they're hoping for a miracle, and they're relying on their community, but not in the same way somebody who is completely integrated into their community might be in our sense. I'm, just, just this week I've been on call and I've been having conversations with a person who's of the Christian Science faith, and traditionally and often, people of the Christian Science faith, they favor prayer for the sake of healing and the hope for a miracle rather than medical care. Except for dentistry, ophthalmology, setting broken bones and so on, most of the time, or at least according to some of their, the Christian Scientist literature. They often hope for a miracle rather than seek medical care. But she's a person who has had a hip replacement, she's had a heart attack and received CPR, and she recently had a bleed in her stomach that resulted in her receiving life-sustaining treatment, and interventions that are, that are meant to sustain her life and save them. So I went and talked with her and she was very, she says she's very confident in her worldview, she's comfortable with who God is, but she disagrees with some aspects of her Christian Scientist community. She's hoping for a miracle that she would be able to not have to undergo any additional life-sustaining treatment and return back to her very independent baseline. She had just finished doing international travel. But you can notice with a person like that, they're seeking a miracle in a certain sense, but they're not using it in a strategic sense of just grasping at straws. They're integrated in their community to some degree but not completely dependent on their community's idea of what a miracle might be. She explicitly rejects it in some aspects, and she's also not shaken by, by what she's going through. So overall those are I think four helpful ways of distinguishing, based both on content of what the miracle might be, and on relationship to the community, that I at least to found pretty helpful in trying to sort through this complexity.

DS: Yeah, I think that this is a helpful framework, and I like that last story because I always tell medical residents and physicians that it's important not to assume. So I think a lot of times when you hear that somebody is a Christian Scientist or maybe a Jehovah's Witness, which we have a lot here in Michigan, that there's this assumption, "Oh I've learned something about this tradition, therefore this person will fit that mold."

TB: Right.

DS: And of course that's not always true because many people, either because, you know, they, they belong to a tradition, that doesn't mean they have to agree with everything from that tradition, or because in this moment of crisis they suddenly have a new way of considering what they've thought of before.

TB: Mm-hmm.

DS: So there might be some actual change in that moment, or maybe it's always been there, but to, we should never assume that we understand what somebody means when they say the word "miracle," or that we understand something about their tradition simply because they have a particular label on it. So I want to go through, so shaken, so this is, these are the folks who, you know, their world view as been turned upside down because of illness and they're really searching for something. This integrated, they have this like robust community that's there, they're following, they're helping them, they have this very concrete idea of a miracle that they're looking for. The strategic is the person who's kind of grasping at miracle language or spirituality because they need to gain some power back in the relationship with their physician. And then the seeking person who is kind of open to a lot of ideas of the miraculous, and they're searching for those. And I would say yeah, that, that category at the end makes a lot of sense to me, and makes sense with what some people will want to say is, you know, how do we shift the talk. So, you want to miracle in this way--

TB: Mm-hmm.

DS: --But might also this be a miracle?

TB: Mm-hmm, mm-hmm.

DS: And I think we've had some criticism of that, but also some openness to it. So I think the next thing I want to know is, okay, so let's say we've done kind of a diagnosis.

TB: Mm-hmm.

DS: A patient uses the term "miracle," we, we go through and try to figure out what they mean, and maybe it fits neatly into one of these categories, maybe not, but how do these categories then help us to work with that patient? Or, or maybe with that patient's family member who's bringing up the, this hope for a miracle.

TB: Sure, sure, yeah. To my, to my mind the whole point of recognizing, or not maybe not the whole point, but a really significant part of it, of recognizing this complexity is that given this complexity I think I at least as an ethicist feel as though my response to that type of hope might be slightly different. So, to my mind and what I found extremely helpful are a couple things. For those who are shaken, I've found that chaplains, grief counselors, social workers, if they're the patient him or herself, psychiatrists, psychologists, anybody who has experience working with grief, and having them talk with the patient directly or the patient's family is incredibly helpful. With the overall goal to try to be, to some degree try to minimize the type of psycho-social-spiritual angst that they're feeling. Oftentimes in terms of how this works out in the clinic, it kind of goes back and forth. I don't have any empirical data either way, but at least in my experience sometimes those who are shaken, they're shaken but then they end up reconciling what they see as their own suffering with either a past tradition, or a new tradition, or simply a rejection of all traditions, and they're able to move forward. Sometimes however they just continue to remain shaken throughout their hospitalization or throughout sickness of their loved one. And that's where I think the people like chaplains, grief counselors, and social workers, are especially, especially important. Because I as an ethicist at least, I can, to my mind I think it's within my professional scope and maybe even a professional obligation to try to think through these issues as they relate to their values and their medical courses of action. But in terms of trying to provide some type of spiritual counseling or anything like that I, I don't, I just don't have the skills, and I don't think I as an ethicist would feel comfortable doing that. But there are people, such as chaplains, who are trained in that and who do, who can do great jobs with that. In terms of medical decision making, oftentimes the hope for a shaken invocator subsides to some degree because of their own uncertainty. They're just not sure what the miracle is going to look like, so it's hard to argue that my daughter is going to have a complete recovery and therefore we should continue life-sustaining interventions when they themselves aren't sure of what, if their hope is justified.

DS: Mm-hmm.

TB: So oftentimes the, the medical decision making aspect of it dissolves to some degree because unfortunately of their own shakenness, of their own internal suffering that they're going through. For those who use miracle language in the integrated sense, I think it's very helpful to do a couple things. One is to be very clear that you're not there to necessarily question the validity of their beliefs. I've found that being very helpful, just straight up saying that.

DS: [Laughs]

TB: Because it's usually assumed, but you don't want to assume it. In terms of practice I also think including the people they identify as their spiritual authorities is absolutely essential. Because it not only shows that you are respecting their faith, but it's recognizing that in terms of their conception of what is and what should be done, they rely on authorities. Their, their own designated spiritual authorities, and it's also important to note that those don't have to be part, necessarily part of their community's hierarchy. They might be a, an aunt who they've relied on heavily for their own spiritual development. So bringing that person in as well. I've found it to be--

DS: Trevor let me ask you a question.

TB: Yeah, please.

DS: Sorry. So, um. So I have also seen this, there are many people with strong religious beliefs who come to the hospital and assume that none of their health care providers will adhere to their religion, much less respect it.

TB: Hmm, mm-hmm.

DS: So what do you think that's about? I mean do you think there's a kind of defensiveness amongst some people, and maybe because they've had bad interactions in the past? Or, or where do you think that that comes from?

TB: Yeah, I don't know. I think people are justifiably suspicious of large institutions like hospitals. [Laughs]

DS: [Laughs] Sure.

TB: So I think that both, so I think that can be expressed in a couple ways. If they believe that they're part of a religious minority even if their own, for, even if that might not be accurate. If they perceive that they're part of a minority whose beliefs might not be respected, I think that might be one way that they feel, feel distrustful. If they're also part of a community that might feel marginalized in terms of their racial identity, or sexual or gender identity, or if they are people who are not well off financially, if they're homeless or itinerant. Then I think they might have good reason to suspect that they won't even be heard, they won't be respected, so they are necessarily on the defensive about that. So they would be critical or if not critical at least suspicious of people who, who might give either lip service to their spiritual beliefs, or not ask them about them at all. Or ignore them to some degree. I think that might be part of it, but, yeah, that's, that's a really good question Devan because there's, there can be so many reasons for—and so I think that's, the aspect of a loss of trust is especially seen in people who use the miracle language in a strategic sense.

DS: Mm-hmm.

TB: Because they are reacting to something. They're grasping at something to try to assert themselves as having an important voice in, in the conversation. So, to, to talk about that, they're to my mind at least helping, helping with that, having routine and interdisciplinary family meetings can be incredibly helpful. Where there's one or two single goals for the conversation, not trying to sort out everything in in a single conversation is very helpful. Also with, and I think that can be applicable to any real person who hopes for a miracle to some degree, these types of interdisciplinary family meetings, making them routine can be very helpful. For those who are integrated I also think that, who use it in an integrated sense, I should say, working to ensure that there's a unified message and being very concrete about what the likelihood of recovery is. I'll give you some, some sample language that isn't always a homerun but it's often helpful. Is, I often have heard patients, what they're envisioning, what patients and families are envisioning as a miracle would be a best case scenario. And so I often ask clinicians, I recognize their beliefs and I say that their hope for a miracle is valid, and, but, I'm wondering if that might be more of a perception of a best case scenario rather than a most likely scenario. So then I ask the clinical professionals to provide what they think is the most likely scenario, and also what might a worst case scenario look like. So, I think that type of, that type of response and again in an interdisciplinary setting can be, can be extremely helpful.

As I was saying with a strategic invocators I also think that discovering, being very explicit about what their source of distrust is and if it can be repaired can be very helpful. I had a patient and a family who I would again categorize in that strategic section who, they had undergone what they had perceived to be just straight up bad care based on their race and their, their education. They said, they explicitly said something along lines of, "We're, we are black, and we don't have as much education as everybody else." And they related that to a specific event as part of their care and were using miracle language I think in a very strategic sense. So, I specifically acknowledged that it seemed as though they had lost trust and I asked, "How can trust be repaired?” I was very explicit about that, and their response to that was, well, show us the medical records. And so, my response to that then was, well I, I can understand that that desire to have that type of information. I don't think it'd be a great idea to give you the medical records because they're hard to interpret, but what we can do is create, I can get together a clinical care team meeting and a family meeting and we can talk specifically about what your medical questions are and get a very concrete sense of the events for your father. And that was very helpful in addressing that distrust, and that was one way of moving the conversation forward.

Finally I think with those who use it in a seeking sense, they don't often have a agonizing spiritual struggle, but sometimes they're not completely in agreement with the care plan. So again this is another area where I think chaplains and whoever they identify as their own spiritual resources would be extremely helpful. They often end up making medical decisions that are in alignment with the care team's idea of what good medicine is, but they're in this sorting out process. What, in terms of concrete practices for seeking invocator, I think probably the most helpful is being very concrete and setting time limited trials. So this idea that, okay, well, if you're hoping for a miracle, but you're not quite sure what that would look like, but it does sound like your mother would be willing to accept vent support and trach support if it was short-term, if she could return to her life, but if it was long-term and she was unable to talk with y'all, then that would be unacceptable to her. So why don't we try out the trach, try out dialysis, try out this vent support, try out this life-sustaining intervention for a couple weeks. And then these are the three markers for improvement, these are the three markers for deterioration, and then at the end of that time we can get back together and see, and see where we're at at that point. So I've found for seeking invocators time limited trials to be extremely helpful as well.

DS: I think that's a really helpful sort of way—and I love all the cases that you've brought to it to help sort of illustrate—way that we might think about how we're intervening. And I think some people might say, well gosh, as clinical ethicists, what are you doing in these conversations at all, because shouldn't this be the role of the chaplain? And I would say--

TB: Mm-hmm.

DS: --You know, I have tons of respect for chaplains, trained as a chaplain. They're probably important in all of these scenarios.

TB: Mm-hmm.

DS: But as clinical ethicists we're called in because there's some sort of conflict, typically. Or there's a, you know, someone who's labeled as a "difficult patient." Which is language that can be criticized for all sorts of reasons. But so, you know, we're coming in, and, and there's some sort of situation we're entering into. We're trying to facilitate better conversation between the care team and this patient and their family. And that's why, you know they come up in our, in our role quite a bit. So if anyone's sort of wondering what a clinical ethicist does, this is some of the work that we do. And so this framework that we've developed, and we'll put some links to the papers that we've written on this topic, I think can be helpful to providers and people working in the hospital. But I also want to say to anybody listening who's not part of the health care system, you might be a patient one day, or you might be a family member, and if you do have some sort of understanding of a miracle, it'd be great to sort of talk with your pastor about that, or, or figure it out. Because I think sometimes patients come to the hospital and they'll say this, and actually they're not as clear as they thought they were.

TB: Mm-hmm.

DS: On what that miracle means. I think that there's some education to be done in local congregations and, and houses of worship on what we really mean by this and what we might expect from our medical care as a result of this particular belief. I don't think that people talk about that enough. What do you think?

TB: Yeah! Yeah, I agree completely. I think that in terms of what a miracle might look like, what good end-of-life care that is consistent with your values and your own idea of what a good death would look like. If there are people—I shouldn't say it like that—since there are people who rely very heavily on their religious communities and their, or their own ideas of who God is, what God might be or anything in between. Who gods are, all of that. I think it's very, very important that there are formal efforts to try to not necessarily standardize what a response should be, but to think through what the hope for a miracle might look like in certain contexts. And then have some sense of what that might mean before people get so sick that they're unable to communicate their own beliefs. Because you mentioned our role as ethicists. I think another, another especially, especially important area for us as ethicists is investigating the distinction between what, when a patient might hope for a miracle, and when a surrogate or a family member might hope for a miracle. Because it doesn't always have to be the case, but not all family members, not all surrogates share the same religious beliefs and might not hope, or might hope for a miracle in a different way than the, than the patient him or herself might. So really delving into the distinctions between what the patient might have believed, and what the surrogate invocator might believe can be another way that I think ethicists can be very helpful. And that, that case of the Christian Scientist who I just mentioned, it was unique for many reasons, but one of them is that the consult came from family. And we don't routinely get consults from families. Because the patient's family member was very much wrestling with her idea of what her mother would want. Hope for a miracle, what a miracle might look like, and her desires for her mother. Her own, that she very, that she recognized very quickly her own ideas as to what she would want her medical, her mother's medical care to look like. So, so I think that another area where ethicists can be helpful is having that conversation and sorting through these issues about who's hoping for what, and what that might look like. It's another area where I think we can be especially helpful.

DS: Yeah. So, shout out to advance directives. If you have particular beliefs, by all means write them down, tell your family about it. That will help our jobs go so much easier, and will help you get hopefully the care that you actually wanted based on your own values, instead of maybe what somebody else thinks is your value without having talked to you about it ahead of time. So plug always for advanced directives.

TB: [Laughs]

DS: So, we are gonna continue writing on this topic, and speaking on this topic. But I thank you so much Trevor for joining me for this podcast.

TB: No, you're very welcome. No, thanks for the invitation, I appreciate having a chance to chat with you.

DS: Alright.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.