Until last October, Tyrell Dueck was a normal eighth grader living in Saskatchewan, Canada, hoping that his favorite hockey team, the Detroit Red Wings, would win a third Stanley Cup. Then, on October 1, he slipped climbing out of the shower and discovered a lump on his leg. Eventually, Tyrell was diagnosed with bone cancer.

After receiving two rounds of chemotherapy, and after being told that further treatment would include amputating his leg, Tyrell said he wanted to stop treatment. With the support of his fundamentalist Christian parents, he was going to leave his health to God and seek treatment at a Mexican alternative health clinic. This decision sparked a pitched court battle with Saskatchewan's health officials, who sought a court order compelling Tyrell to have his leg amputated and the chemo restarted. That battle ended in late March when doctors said the bone cancer had spread from his leg to his lungs and there was nothing more they could do for him.

This sad development spared his doctors the ethically dubious duty of amputating his leg against his and his parents' wishes. But it has spared no one else, particularly the Dueck family, the fallout from four months of legal wrangling over questions of children's rights, alternative medicine, and religious freedom.

In some ways the story is a familiar one, whether involving Christian Scientists, Jehovah's Witnesses, or Hmong Buddhists. When children are in medical crisis and clinicians feel that the parents are making bad choices in the name of religion, those caregivers frequently seek help from government authorities.

Judges in these cases often intervene to protect the child, basing their decisions on some understanding of the child's best interests, the demands of informed consent, and the seriousness of the child's condition. As the ethicist Loretta Kopelman writes, "Parents who, even for religious reasons, endanger their children's health or well being may find the courts willing to take custody temporarily or permanently to serve the best interests of the child."

Caregiver's frustration
Physicians, nurses, even hospital chaplains can become frustrated when patients and families make important healthcare choices based on religious beliefs. Healthcare practitioners frequently don't know how to respond and feel torn between a desire to respect the patient's religious beliefs and an impulse to do what they think is right. It may be easier to engage the legal system to settle the issue.

Public debates, private consequences: Sketches of Two Barristers, by Honoré Daumier

Yet such showdowns can sometimes be avoided with careful diplomacy in the clinical setting. It is important to pay attention to religious language and symbolism, as they frequently convey vital information about patients' and families' inner experience, what they are going through emotionally, mentally, and spiritually.

Ideally, there would be adequate time for conversation between the parties, to reach a plan of treatment agreeable to all. Often, however, these cases erupt because death may be imminent: the child's fever is dangerously high; the bone cancer may spread if not treated quickly. Recommending that participants in these disputes create an atmosphere conducive to cultivating trust seems easier said than done. Some rules of thumb for keeping the conversation going:

Set aside intellectual judgments about the truth or falsity of the patient's religious claims. Make the assumption that if you shared their life experiences, you might embrace such beliefs. Rather than argue that medicine knows best, clinicians can present their knowledge and expertise in a way that accommodates the patient's beliefs and builds the common ground on which to base a mutually agreed-upon care plan.

Treat religious assertions or requests as code or symbolic communications. A universal human tendency is to cry out for supernatural help in times of extreme distress. However a 13-year-old like Tyrell understands cancer and survival rates, what child wants to lose a leg? Relying on parents and a belief in God's protective power in these circumstances seems, in one sense, completely natural. Rather than challenge Tyrell's belief system in court and remove him from his parents' care, is there a way to enlist these resources to strengthen Tyrell's hope?

Speak to the other person's religion, not your own. Asking questions to further your understanding is a good way to keep the conversation going, as it conveys respect and an interest in maintaining the connection. The primary purpose of conversation is not to win an argument, but to learn, grow spiritually, and help the other person. While Tyrell's parents and the clinicians may have espoused his best interests, the participants used different vocabularies and manifestly have not understood each others' language and motivation. A willingness to talk, no matter what, signals a commitment to the therapeutic relationship.