Attitudes and Values of Three Monotheistic Religions Regarding Ethical Dilemmas in Palliative Care: Qualitative Study

Abstract

Palliative care, aimed at improving the quality of life for individuals with life-limiting illnesses, often raises complex ethical questions. This research explores the viewpoints of monotheistic faiths, namely Christianity, Islam, and Judaism, and on this matter examines how religious beliefs and values impact decision-making in the provision of palliative care, particularly when faced with difficulies. Christianity, for instance, emphasizes the sanctity of life, encouraging compassionate care while respecting patient autonomy. Islam, on the other hand, underscores the importance of relieving suffering and allowing for a natural death while upholding key principles of faith. Judaism places great value on preserving life, but this can be balanced with the consideration of human dignity and quality of life. Understanding the religious perspectives on ethical dilemmas within palliative care is vital for healthcare professionals and policymakers. It enables them to respect patients’ religious beliefs while providing appropriate care. By considering these perspectives, it is possible to find common ground and develop guidelines that ensure ethical and culturally sensitive palliative care for a diverse range of patients. This study aims to contribute to the ongoing dialog and cooperation between religious and medical communities in delivering compassionate and ethically sound palliative care.

1. Introduction

The challenges in our society, armed conflicts, and economic crises require numerous adjustments in an individual’s way of life. These changes affect not only society but also the approach to end-of-life care. Efforts to uphold the principle of respecting human life are continuously strengthening, even though we are aware that this fundamental principle is severely threatened in altered circumstances, and its respect is facing a significant test. From a medical perspective, the health crisis of coronavirus disease has increased the importance and urgency of palliative care for patients suffering from incurable diseases, their families, and all involved healthcare workers. This significance of care is most prominently exemplified in the field of intensive care, which deals with the most complex treatment goals: enabling critically ill patients to survive life-threatening conditions, improving current and future health quality, or early efforts to enhance the quality of dying and death [1, 2]. In this context, the global pandemic highlights the advantages and drawbacks of providing quality palliative care while also offering an opportunity to contemplate the capacities and opportunities that quality palliative care demands. Ethical dilemmas arise daily, many of which are related to decisions about continuing, limiting, or discontinuing life-sustaining treatment [3]. The poor prognosis of critical illness, appropriate ongoing care for these patients, and end-of-life care require a comprehensive and multidisciplinary approach [4, 5, 6]. A holistic approach in palliative care is essential as it ensures healthcare for the multidimensional needs of patients and their families [7]. Palliative care, therefore, requires a wide range of competencies, not only clinical but also relational, communicative, and ethical [8]. Interdisciplinary clinical collaboration between different professional fields signifies the realization of the standard of the highest quality of end-of-life care [9]. An essential and integral part of this approach is spiritual care. The fields of ethics, spiritual care, and treatment in palliative care often overlap, especially when making decisions about the cessation of treatment and the withdrawal of life-sustaining measures. Therefore, the role of religion and spirituality becomes increasingly important in questions related to the end of life [10, 11, 12]. Despite emerging evidence and the status of spiritual care as a central dimension of palliative care, it remains the least developed and most neglected part of care, primarily due to complications in standardizing and conceptualizing religion and spirituality and their definition within the palliative care process [13, 14]. Discussions about the end of life, which involve distinguishing the moral significance between actions and omissions, are raised in various bioethical contexts [15]. Most moral theories believe that allowing a patient to die from an ethical perspective is ethically acceptable in certain cases and fundamentally different from actively ending human life [16, 17]. On the other hand, the concept of the sanctity of life, which represents the foundation of Christian, Jewish, and Islamic ethics, emphasizes the importance of recognizing the moral equivalence between killing and letting die [18]. The intensity of the discussion increases in the context of euthanasia [19, 20, 21]. However, most ethical systems take the position that preserving human life is the highest moral duty, so intentionally causing a patient’s death cannot be ethically justified in any case [16, 22]. In today’s postmodern and secularized era, the use of the word “spirituality” is not always entirely clear, especially because it is increasingly detached from religious traditions and institutions. The relationship between spirituality and religion seems unclear due to the collective nature of religion and the individualized/subjective nature of spirituality [23]. On one hand, spirituality is an overtly religious concept, while on the other, an interest in spirituality may not necessarily arise from religious pursuits. Spirituality touches upon the meaning and purpose of life, which may not necessarily involve religious beliefs [24]. Many people today prefer to use the term “spirituality” rather than “religion,” also because it is broader, less concrete, and less tied to an institution [25]. The term “religion” (from Latin “religare”) is commonly used to denote a system of beliefs, ethical values, and actions through which a person expresses their relationship with the sacred and holy reality. On a subjective level, it signifies belief, while on an objective level, it represents a religious institution that connects a person to the supernatural and the sacred through a specific system of knowledge and practice, theology, and ethics. These two levels are complementary but can occasionally be contradictory or even mutually exclusive. Meanwhile, “spirituality” (from Latin “spiritualitas”) means the way a believer internalizes the spiritual and moral principles of faith, often referred to as prayer, asceticism, religious practice, meditation, or spiritual reading, or it signifies the dynamics of inner life, the whole lived faith at a personal and communal level (General Religious Lexicon 2007, s.v. “religion”; “spirituality”). Questions about spiritual care are particularly relevant for seriously ill and dying patients. The fulfillment of spiritual needs significantly affects patients’ health and well-being [26]. For many patients, faith in the supernatural (spirituality) is important in both health and illness. Faith gives meaning to their lives, provides security when not everything is going well, and remains even when other options are exhausted [27]. As Teoli and Kalish [28] state, it is a common misconception that healthcare and palliative care focus only on physical needs. Numerous issues related to psychological, cultural, ethical, legal, psychiatric, religious, and social needs must be considered. This is especially important when religious questions arise in the context of ethical dilemmas. The World Health Organization recognizes the significance of spiritual care in its definition of palliative care as being equally important as other activities in palliative care [29]. The European Association for Palliative Care (EAPC) defines spirituality as “a dynamic dimension of human life relating to the way individuals (individually and in community) experience, express, and seek meaning, purpose, and transcendence, and the way they connect to the moment, to self, to others, to nature, and to the significant and/or sacred” [30]. Many authors within palliative care define the concept of spirituality in the broadest sense of the word, as an intuitive, interpersonal, altruistic, and integrative expression that includes fundamental existential questions, life principles, values, beliefs, moral values, as well as the relationship with God or a higher power, or as religiously lived spirituality [30, 31]. In palliative care or at the end of life, religion and religious traditions serve two primary functions: providing a set of fundamental life beliefs and establishing an ethical foundation for clinical decision-making [32]. Both religion and spirituality support a person’s sense of security and belonging, which can be vital in end-of-life care, as they offer individuals a way to find meaning in both dying and living [32, 33]. They help patients and their families to cope with hope, the search for meaning, and purpose amidst all the adjustments and life changes required by life-threatening medical conditions [34]. On the other hand, the impact of diseases and life-threatening medical conditions on religion and spirituality can be negative due to experiences that include negative confrontations with the illness, anger, even toward God, and the loss of religious beliefs [12, 35]. The diversity of religions and religious beliefs in the modern world creates challenges in recognizing the culture of sensitivity, allowing an understanding of how patients in palliative care will comprehend their illness or ultimately their death. Religion and spirituality, in their highest form, have a significant impact on the development of human culture [25]. The broader cultural context is not only determined by nationality and ethnicity but also influenced by specific spirituality, religion, education level, gender, age, sexual orientation, country of origin, and immigrant status. Culture is an essential concept in palliative care alongside religion and spirituality since an individual’s culture also influences how they will make decisions about end-of-life treatment [36, 37].

1.1 Judaism

The term “Judaism” originates from the word “Iudaismus,” a Latinized form of the Greek word “Ioudaismos.” The Greek word is derived from the noun “Ioudaios,” which is typically translated as “Jew,” “Jewish,” or from the verb “ioudaizein,” meaning “to live as a Jew.” The Hebrew equivalent of “Judaism” is “Yahadut.” Judaism is the religion of the Jewish people, the oldest monotheistic religion upon which both Christianity and Islam are built. In the broadest sense, it encompasses the faith of the Jewish people from the Babylonian exile onwards, including shared history, formed mentality, and culture. When searching for a deeper answer to who a Jew is, it is crucial to understand that there is no simple response. The identity of a Jew is determined by three elements: the Torah (Law), the chosen people (collectiveness), and the promised land. These elements have developed over time and began shaping Judaism. Various forms and branches of Judaism exist due to different relationships among these three elements. Modern Judaism, despite an awareness of common Jewish culture and faith, is highly plural. The emergence of numerous denominations and divisions was influenced by several factors. Judaism has never been uniform, showing exceptional adaptability to various circumstances and societal challenges throughout the centuries. Consequently, there are three forms of Judaism: Reform, Orthodox, and Conservative Judaism. Traditional Jewish legal and ethical thinking is grounded in the interpretation and understanding of three main sources, each of which is extensive, diverse, and complex. Jewish medical ethics as a related field did not exist until modern times. Discussions on medical ethics were scattered throughout Jewish law, professional manuals, and commentaries on religious texts. With the advancement of medicine, challenges emerged in the Jewish community to consolidate existing works on medical ethics and create new ones that remain rooted in religious tradition. Patients and physicians can find works that help them explore the Jewish perspective on various medical and healthcare issues, from abortion to organ transplantation. All these works are based on the rich tradition of Jewish law. In Judaism, bioethical research and the study of halakha (Jewish law) draw their principles from other Jewish texts and their commentaries and use a developed system for explaining halakha. Among the three streams of Judaism, there is no difference in having their own legal system (halakha), but rather the level of respect for it [38]. Halakha (from the Hebrew verb “halak,” meaning “to walk”) signifies the path one should follow; that is, the legislation to be adhered to in life. Halakha represents the corpus of Jewish law, customs, and tradition [39]. Fundamental to the understanding of halakhic interpretation and the sources of Jewish law is an integral part of the discussion on Jewish medical ethics [38]. There are three sources of Jewish legal and ethical thinking: Hebrew scriptures of ancient Israel, the Talmud, and Responsa [1]. Hebrew scriptures encompass written tradition (the written Torah, also known as the Pentateuch or the Five Books, and the traditional sense of the Pentateuch) and oral tradition (the oral Torah), which dates back to Moses and was transmitted from generation to generation until it finally received its written form in Midrash, the Mishnah, and the Talmud. Jewish interpretation uses the Midrash (from the Hebrew verb “darash,” meaning “to seek, investigate, examine”) as the oldest way to pass on the oral tradition. It represents an explanation of the Holy Scriptures, aiming to delve deep into its content and extract as many shades of meaning as possible. There are two types of Midrash: Halakha (normative way, rules) and Hagada (homiletic and explanatory narrative). If Halakha explains what a devout Jew must do, Hagada tells why one must do it. Halakha and Hagada reflect the great pluralism within Judaism as they are written based on discussions and reflect contrasting opinions among different schools. The Pentateuch holds the highest level of law in Judaism. The Mishnah was enhanced with commentaries that became known as the Gemara (two versions exist: Palestinian and Babylonian). Together, the Mishnah and the Gemara constitute [2] the Talmud, the second source of law, but its influence on Jewish law and moral codes is even greater than that of Hebrew writings. The Talmud (from the Hebrew word “talmud,” meaning “study, teaching”) is a collection of laws, religious tradition provisions, discussions of legal scholars, and interpretations of the Torah. It is especially important because it sheds light on the process and structure of halakhic reasoning, which involves reasoned analysis, logic, and analogy. The Talmud is religious literature that is more extensive compared to the Holy Scripture and the Quran [3]. The third source of legal authority is Responsa literature. In Judaism, it represents a collection of responses (in Hebrew, “she’elot u-teshuvot,” meaning “questions and answers”) to complex issues related to religious law, philosophy, and related fields, which have become the most significant source of Halakha. It is actually a collection of opinions on modern matters, interpreted by Hebrew writings and the Talmud. The literature spans centuries of thought and content of opinions and represents a continuation of a 2000-year-old interpretation tradition that creates an intellectual connection with the past.

1.2 Catholicism

Catholicism, in a general sense, emphasizes the universality of the Christian gospel message, which is intended for every individual, nation, language, culture, civilization, and society. In a narrower sense, it represents the shared dignity of all Christians based on equality among believers, in both communal and hierarchical (ministerial) or sacramental service context. The foundation of the Catholic Church, as referred to in the following paragraphs, is the primacy of the pope, who holds leadership and jurisdictional primacy over the entire Church. The Catholic Church is organized as a visible Christian community with hierarchies and laypeople. There are three hierarchies: the clergy, the canon law, and the honorary hierarchy. The Catholic Church does not represent a monarchy, an oligarchy, or a democracy, but it is a hierarchically organized community, where each member has a role and a task for the benefit of the whole. According to Catholic doctrine, nature and the supernatural, human free will, and God’s grace presuppose and complement each other. Therefore, in Catholic morality, three theological virtues (faith, hope, and love) and four natural virtues (prudence, justice, temperance, and fortitude) are complementary. The sources of Catholic morality are the Old Testament (the Ten Commandments, personal responsibility), the New Testament (love for God and neighbor), and natural ethics. It is systematically studied by moral theology, and within the community, it is carefully regulated by canon law. Pope John Paul II officially expressed the Church’s position on the value and inviolability of human life in 1995 in the encyclical Evangelium vitae – The Gospel of Life. Likewise, the document titled “Samaritanus bonus” by the Congregation for the Doctrine of the Faith, published in September 2020, provides doctrinal foundations and pastoral guidelines for the care of people in critical and final phases of life. These documents are among the most important ones addressing ethical issues, including end-of-life ethical decisions. Within Catholic ethics, moral theology, or Catholic bioethics, two fundamental values exist: human dignity and the interconnectedness of every individual in terms of responsibility toward one another. All other values stem from these two. It is minimalistic to define human dignity, which is protected in democratic legal systems and is legally enforceable, as it does not encompass.

According to German moral theologian Schockenhoff [40], the core of human dignity is directed toward what makes a person human, their capacity for free action, and responsibility for self-determined autonomy. In other words, it means discovering a common living space that allows people to mutually respect each other as rational beings.

1.3 Islam

Islam is a monotheistic religion founded in the seventh century in Arabia by the Prophet Muhammad. It encompasses the belief in one God (Allah) and a comprehensive way of life, including religious, moral, and legal guidance. The primary sources of Islam are the Quran, the teachings, and practices of the Prophet Muhammad (Sunnah), consensus among Islamic scholars (Ijma), and reasoning by analogy (Qiyas). These sources provide the basis for Islamic jurisprudence and ethics [41]. Islamic belief is based on the concept of Tawhid, the absolute oneness of God, and the acknowledgment of Muhammad as the final prophet. The five pillars of Islam include the Shahada (declaration of faith), Salat (prayer), Sawm (fasting), Zakat (almsgiving), and Hajj (pilgrimage to Mecca). Islamic law, known as Sharia, is derived from the Quran and Sunnah, and it governs various aspects of life, including personal morality, family law, and criminal law. Islamic ethics emphasize justice, compassion, and mercy, and these principles have significant implications for end-of-life care. In Islam, the preservation of life is considered one of the highest values. Taking a human life is strictly prohibited, and euthanasia is not allowed. However, the alleviation of suffering is encouraged, and palliative care is seen as an important aspect of medical ethics in Islam. The decision to withdraw or withhold treatment must be made with a focus on relieving suffering rather than hastening death. There are differing opinions within the Islamic community on specific issues related to end-of-life care, and these differences can be influenced by cultural and regional factors. Despite these differences, the fundamental principles of compassion, justice, and the preservation of life remain core values in Islamic medical ethics [42, 43]. It’s important to note that Islamic beliefs and practices can vary among different schools of thought within Islam, and individual interpretations may also play a role in end-of-life decisions. Islamic bioethics has its complexities, and the application of these principles may differ among individuals and communities. In Islamic ethics, guidance is found through idĵtihad, with fundamental principles, rules, and regulations from the main sources shaping the Islamic way of life. Together with idĵtihad, they provide a comprehensive moral and legal framework to address and adapt to human circumstances [44, 45]. Islamic jurisprudence, in its judicial practice, must consider five fundamental principles in resolving any issue: the preservation of life, the protection of individual freedoms or beliefs, the preservation of intellect, the protection of honor and integrity, and the safeguarding of property.

The purpose of our research was to assess the importance of ethics, religion, and spiritual care in palliative care, with an emphasis on religious perspectives on ethical dilemmas at the end of life and the importance of religious beliefs in medical care and healthcare at the end of life. We focused on three monotheistic religions, namely Judaism, Christianity, and Islam. We wanted to identify similarities and differences in the concept of understanding the importance of palliative care and ethical dilemmas in end-of-life treatment decisions.

2. Methods

In this study, we used qualitative methodology and employed a semi-structured open interview as the research instrument. Each interview was labeled as “IN,” and a corresponding number was added to indicate the conducted interview, ranging from 1 to 9. The process of data acquisition was standardized among all participants in the study. We included six structured questions with sub-questions, as described below. We conducted interviews with nine participants, each representing one of three major religious communities: Catholic, Jewish, and Islamic. The research participants were purposefully selected after careful consideration by both researchers. The inclusion criterion was affiliation with a religious community and employment in healthcare for participants who were not spiritual leaders of the selected religious communities. A prerequisite was that they agreed to participate in the study and the recording of the conversation. Within each religious community, we ensured the inclusion of an official representative, such as a rabbi for the Jewish community, a priest for the Catholic community, and an imam for the Islamic community. We also considered that other participants from the religious communities involved in the study were employed in healthcare institutions, either as physicians, registered nurses, or pharmacists. This approach aimed to ensure the relevance of their professional and expert knowledge in the field of palliative care, impartiality, and an equal objective presentation of data. We also considered the criterion that the participants involved in the study were limited to the territory of the Republic of Slovenia. Due to the relevant sample size, we had to expand this criterion to the nearest Jewish community in the Zagreb area, based on the historical connection between the two communities before the establishment of the Jewish community in the Republic of Slovenia.

3. Results

In the conducted interviews and qualitative data analysis, we identified four main themes or content areas: (1) recognition of the significance of religion and spirituality in palliative care, (2) the provision of spiritual (religious) care in palliative care, (3) the importance of religion in ethical questions and dilemmas in palliative care, and (4) awareness of recognizing cultural and religious differences in palliative care. The main themes and their categories and codes are presented in Table 1.

Theme	Categories	Kode
Recognition of the significance of religion and spirituality in palliative care.	Human dignity	Sanctity of life; Quality of life; Right and duty to treatment
	Spiritual care as part of comprehensive patient care in palliative care	Spirituality as a dimension of relationships; Spirituality as a dimension of redemption; Spirituality as an equal approach in comprehensive palliative care
The provision of spiritual (religious) care in palliative care.	Institutional provision of spiritual (religious) care in palliative care	Religious communities in public and private institutions
	Non-institutional provision of spiritual (religious) care in palliative care	Family, friends, relatives, and; other institutions
The importance of religion in ethical questions and dilemmas in palliative care.	Palliative care without a religious perspective is insufficient	Multidisciplinary patient care; Human and professional care
	Religion as a challenge for quality palliative care	Clash of values between religious and medical ethics; Diverse cultural and value environments
Awareness of recognizing cultural and religious differences in palliative care.	Individual responsibility	Personal competencies; Professional competencies
	Social responsibility	Importance of religious communities; Importance of educational institutions

Table 1.

Main themes, categories, and codes.

3.1 Recognition of the significance of religion and spiritual care in palliative care

Based on the conducted interviews, it can be highlighted that the participants recognize the significance of religion and spirituality in palliative care primarily as guardians of the principles of (1) human dignity and the indispensable role of (2) spirituality in the comprehensive patient care. A participant from the Islamic faith said: “In Islam, life is sacred and must not be shortened in any way” (IN8). Some participants in the study also used the term human dignity: “Palliative care cares for the dignity of human life until the last moment” (IN1); similarly, we can observe that palliative care is “a reflection of care for the dignity and health of the individual” (IN5) or “the provision of palliative care significantly contributes to the preservation of human dignity” (IN6). One of the participants in the discussion emphasizes the important distinction when he says, “In the public discourse, we rarely talk about the sanctity of life but rather about the dignity of the human person and human life” (IN1). This means that even within our research, it is possible to determine the polemical use of the term or principle of “sanctity of life.” Reconstructing the history of religious ideas to understand their original meaning is one thing, advocating fundamental religious arguments is quite another, as one of the participants notes when highlighting the necessity of recognizing and understanding religious traditions in ethical questions: “When it comes to ethical dilemmas, it is, of course, necessary to maintain a wide spectrum and view (Christian) ethics as something rational, often much more rational today than the ideology of unlimited freedom, which thinks that everything that is possible in medicine today is also right. If Christianity ever sets a limit to what is acceptable in ethical dilemmas, it is not ideological opposition but a rational argument against the ideology of misunderstood freedom that would sacrifice anything, even human life, just to confirm itself” (IN1).

In palliative care, religion recognizes the principle of human dignity in ensuring the principle of quality of life. A participant from the Catholic faith states, “In the Catholic Church, the absolute value is the sanctity of life, meaning the inviolability of life from conception to death” (IN2). Similarly, a participant from the Jewish faith says, “It seems to me incredibly important to provide people with a dignified life until the end” (IN6), and one from the Islamic faith adds, “Each religion has different views or rules that somehow influence the quality of palliative care” (IN9). It is important to note that participants in the interview, while recognizing the importance of maintaining the quality of life, oppose the contemporary anthropological utilitarian perspective, which is mainly linked to economic possibilities, well-being, beauty, and the enjoyment of physical life, and which deems life worthwhile only if it reaches an acceptable level of quality. Participants highlight that, from the perspective of monotheistic religious beliefs, the basis of human dignity, besides advocating the principle of the sanctity of life and ensuring the maximum quality of life, also includes the realization of the right and duty to treatment. Participants from the Islamic faith mention that “[A] Quranic rule applies: ‘Whoever kills one man, it is as if he killed the entire world, and whoever saves one man, it is as if he saved the entire world.’ Therefore, it is necessary to fight for every life since it is God’s gift we have received. Thus, as believers, we are obligated to care for our health” (IN7). They also emphasize that “In our religion, there are no specific instructions/rules that would specifically prescribe that a believer should renounce or refuse a specific medical procedure. On the contrary, a Muslim is obliged to seek treatment” (IN8). Similarly, a participant from the Jewish faith describes such an obligation as the task of providing spiritual care: “I come from my spirituality, religion, faith. ‘In the suffering, let one brother give his hand to another.’ Even when everything fails, even when all medicine fails, or all possibilities are exhausted, in fact, even professionally, there’s nothing more to ‘do,’ you can always do that” (IN2). Participants recognize the importance of spirituality in palliative care as an indispensable part of comprehensive patient care.

The study found that spirituality in palliative care is expressed in three ways: as a dimension of the relationship, as a dimension of salvation, and as an equal approach within holistic palliative care. Participants understand the role of spirituality in palliative care in a way that it originates from religion itself, and religion provides fundamental identity. Therefore, the spirituality they describe represents not only fundamental existential questions, principles, values, and beliefs but also primarily the relationship with God and its eschatological dimension. A participant from the Catholic faith describes it as follows: “A sense of reconciliation with loved ones and God, a sincere review of one’s own life from the perspective of eternity, deep spirituality that often accompanies the person at the end of life” (IN2).

“In their final moments, all of this and much more are elements of spirituality in palliative care” (IN1), and concludes: “For a Catholic, the reason human life has such great value is manifold, including the belief that life on this Earth continues in some other form in eternity” (IN1). A participant of the Jewish faith similarly states: “Spirituality is very important in the final stage of life. Judaism views life as a cycle, a beginning, and an end. At the end of life, it is important, especially for palliative patients, to have someone with them who will understand their religious and cultural needs” (IN6). Similarly, a participant of the Islamic faith adds: “Faith gives us a sense of hope, so for a believer in palliative care, it is important to have the opportunity to devote oneself to God or to have someone assist them in doing so. People in this condition can have only hope” (IN7). Participants in the study highlight spirituality as a concept rather than focusing on the characteristics of spirituality itself. Spirituality, often, is not integrated into palliative care due to the lack of training, time constraints, and a lack of vocabulary surrounding spiritual matters among healthcare professionals. As one participant notes, “we have not yet developed the field of palliative care units and experts, so talking about spirituality as an equal and professional approach to the dying is something that is seen from a distance” (IN3). While participants emphasize spirituality as an approach equal to all other aspects of palliative care, it is necessary from a professional standpoint for healthcare workers to differentiate between institutional, religious, and, ultimately, political influences of spirituality in all modern secularized societal sectors where complex spiritual issues are encountered.

3.2 The provision of spiritual (religious) care in palliative care

In the study, we formulated another highlighted topic as spiritual (religious) care in palliative care. Using categories, we identified as institutional and non-institutional arrangements for providing spiritual (religious) care in palliative care, we created three forms of delivering spiritual care: (1) religious communities in public and private institutions, (2) family, friends, and relatives, and (3) other institutions. Catholic, Jewish, and Islamic religious communities have developed ethical obligations, legal guidelines, and religious positions concerning individual ethical dilemmas, particularly those related to a patient’s religious affiliation. On the other hand, the legal regulation of palliative care in Slovenia is still non-systemic, so the aspect of religiosity or spirituality in the broadest sense is inadequately incorporated into legal regulations and health codes. In Slovenia, Catholic, Jewish, and Islamic religious communities have different experiences, either positive or negative. For the Catholic religious community, spiritual care is primarily provided in practice by priests as (formal) representatives of the religious community: “In the Catholic Church, the largest religious community in Slovenia, I can proudly state that we have very well-organized spiritual care, not only for the seriously ill and dying in palliative care and the hospice, but also for all other patients. We have several chaplain priests who are responsible for visits, administering sacraments, and accompanying all patients in all hospitals” (IN3). On the other hand, the Islamic religious community, where a similar spiritual (religious) care is provided by an imam, a representative of the religious community, highlights a negative experience, with a participant stating, “We have never succeeded in securing a small space in the largest clinical centers or hospitals for prayer in the same way as a chapel is arranged. There was no understanding for addressing this issue” (IN7). The Jewish religious community emphasizes that, being numerically smaller than other religious communities, the extent of such care depends primarily on the size of the community and the scope of assistance: “The Chief Rabbi of Slovenia is authorized to address these issues within the public healthcare in the Republic of Slovenia. The level of addressing these issues usually reflects the population density of any Jewish community” (IN4). A positive example in one of the hospice institutions is provided by a participant of the Catholic faith when they say, “In 2016, at the initiative of the director, five religious communities - the Catholic Church, the Islamic religious community, the Serbian Orthodox Church, the Protestant religious community, the Macedonian Orthodox Church - signed an agreement committing to always have their religious representatives available if the dying need them” (IN2). It is recognized that this form of providing spiritual (religious) care is carried out within the framework of individual initiatives of certain institutions, meaning that the current palliative care in Slovenia does not ensure uninterrupted comprehensive palliative care, also because there are no systematically established connections between different healthcare and other institutions. Study participants emphasized the importance of family, friends, and other forms that come into play in this context to provide spiritual (religious) care because “in Judaism, it is crucial.”

“It is not necessary that a rabbi is always present at the end of a person’s life. Representatives of religious communities, family members, or others can also be present and perform the final rites. In Judaism, there is a specific organization called ‘Chevra Kadisha’ that plays this role” (IN 6). Similarly, another participant states, “There are various groups of mourners that anyone in need can join during this difficult time” (IN 3).

3.3 The importance of religion in ethical questions and dilemmas in palliative care

As the third major theme in the study, we emphasize the significance of religion in ethical questions and dilemmas in palliative care. We identify two distinct approaches that raise the question of whether palliative care can be of sufficient quality without including a religious perspective. They also address how religion, spirituality, or spiritual care as part of an equitable approach to comprehensive palliative care can present a significant challenge. The religious perspective undoubtedly brings quality multidisciplinary teamwork and humane, professional end-of-life care. One participant notes, “If we take a holistic view of the patient, if we address them on all levels, then the team can find the best solution collectively” (IN 3). They continue, “If a physician in palliative care approaches the patient not only as a professional but as someone who wants to offer help… if we are all humans first, if the patient is at the centre of our team, then religion is not an obstacle to working in palliative care” (IN 3). On the other hand, there can be clashes between religious and medical ethics, especially when doubts arise about the correctness or incorrectness of individual decisions, and when legally sanctioned procedures and interventions are in conflict with the principles of a particular religious or ethical system. Legislation in Slovenia is framed in a way that, in general, religious communities do not see contradictions with official medicine, especially when it comes to euthanasia. A Catholic participant states, “In our country, there are no issues because our legislation aligns with ethical standards. If euthanasia were legalized, for example, this would change, and religious beliefs would play a significant role, but not because of the faith itself, but because of reasonable arguments against ethically questionable medical practices” (IN1). Similarly, a participant from the Islamic faith mentions, “Ethical concerns regarding Islam are never in conflict with official medicine, at least not in our Slovenian context and the legislation in this area, such as euthanasia” (IN 7). However, a participant from the Jewish community highlights that during the treatment of a patient, doctors may encounter doubts about the justifiability of administering certain medications to an individual. “In such cases,” they say, “doctors should always discuss these issues with a rabbi” (IN 4). All monotheistic faiths have clear positions against euthanasia. “The Catholic Church is against euthanasia in any form, but it does not oppose the withholding of treatment, which varies from case to case” (IN 2). “Judaism considers human life and its preservation an absolute value, and patients must be kept alive” (IN 4). “In Islam, we must fight for every life, as it is a gift from God that we have received. Therefore, as believers, we are obligated to take care of our health” (IN 7). Misunderstanding the concept of compassion can raise ethical questions that are theoretical but significant in understanding a particular religious perspective. One participant reflects on this in relation to Christian compassion: “Due to Christ’s example, His teaching of love, and my personal experience of this love in my life, I want to be like Christ in my relationship with people, especially the most suffering. He shapes my life, my work, my behavior. The patient may not necessarily emphasize spirituality in their life. If they are open to it and express specific questions, we can have direct conversations (with them or their family). However, many questions, answers, and conversations remain unspoken” (IN 2).

3.4 Awareness of recognizing cultural and religious differences in palliative care

As the final theme, we emphasize the importance of awareness when recognizing cultural and religious differences in palliative care. We divided this theme based on interviews into two parts: individual and societal responsibility in recognizing cultural and religious differences in palliative care. On one hand, recognizing these differences reflects personal orientation and individual engagement in understanding or recognizing the religious, spiritual, or cultural aspects. On the other hand, this question is raised as a matter of social responsibility both within religious communities and other educational institutions. Within individual responsibility, participants first highlight the importance of personal competencies. A Catholic participant emphasizes that “a priest or another spiritual collaborator should not view the patient merely as a person of faith but as a human being in need of assistance” (IN 3). Similarly, a participant from the Jewish community states, “Providing palliative care requires an exceptional commitment from the person providing it, provided that they want to do their work honorably” (IN 5). An Islamic participant also stresses the need for healthcare professionals to be more open to religion, as the quality of palliative care depends on it (IN 9). However, participants also note the importance of professional competencies in recognizing the spiritual and religious needs of patients. Participants from all three faiths agree that there is a lack of practical knowledge in the field of cultural and religious issues. A Catholic participant argues, “I believe that, in general, there is a lack of cultural and religious education in Slovenia. This is a broad framework that goes beyond the specific topic, but it is a fact that we know too little about our country, our culture, and are, therefore, less receptive to any profound understanding of culture, let alone religion” (IN 1). Similarly, a participant from the Jewish community adds, “In my opinion, healthcare workers are not well-informed about individual religious beliefs, and some of them are very resistant to this information” (IN 9). Therefore, the need for adequate education and regulation on this subject is evident. A participant from the Jewish community points out, “Patients expect to be treated with respect, including respect for their religious beliefs and other beliefs and opinions. Generally, a Jewish healthcare worker who is also a believer always treats the patient with due respect… while considering the absolute value of human life and its consequences. It is necessary to promote it in every way through appropriate education and legislation” (IN 4). In the Slovenian professional literature, there is a lack of published material that would systematically profile the profession’s fundamental competencies or competencies based on training programs specific to specialized spiritual care in palliative care, for both healthcare workers and other pastoral workers and collaborators in providing spiritual care. Therefore, for the professional community, it is a clear challenge to focus and unite national guidelines and clinical and professional standards in a framework that encourages the discussion and development of the competence framework for spiritual care in palliative care, including religious practices as performed by certain pastoral workers from specific religious communities under the current conditions. In addition to individual engagement, the development of a competence model or standards for recognizing people’s religious or faith orientation in palliative care is essential. Participants in the research emphasize the significance of religious communities and educational institutions and their role in shaping a framework for recognizing cultural, religious, and spiritual diversity in the context of a pluralistic and global setting. The Healthcare professionals work in different healthcare settings. Recognizing one’s own cultural and spiritual foundations is the first step toward open exploration, as one of the participants states: “In Slovenia, due to its sad recent history, this is not obvious, but worldwide, it’s clear that one of the fundamental parts of faith is also life in charity and diakonia, which means benevolence. These are the oldest Christian principles. Therefore, as we know from history, the Church has always cared for the poor, established schools, hospitals, alms-houses, and all kinds of institutions for the weakest. After what happened in our local history, the Church is somewhat hindered in this respect, but fortunately, this only applies to the (un)normality of our region. Nevertheless, despite everything, the Slovenian Church has greatly increased the number of elderly homes in recent decades. This is a typical measure that is usually overlooked when faith compels Christians to care for the poorest” (IN1). On another note, it is worth mentioning the guidelines of the EAPC, which specifically address the issue of education on spiritual care for all professionals involved in palliative care. Educational competencies in spiritual care for all providers of palliative care are guided by models of best practice and research evidence, which also encompass various developmental stages of palliative care services in the European region. Education on religious, spiritual, or cultural diversity can help healthcare professionals to avoid their own biases or reservations. In this way, the EAPC encourages high-quality, multidisciplinary, and academic education on spiritual care for all stakeholders in palliative care [30].

4. Discussion

The research illustrates the importance of ethics, religion, and spirituality in palliative care, with an emphasis on religious perspectives on ethical dilemmas at the end of life. Participants in our study recognize the significance of religion in palliative care, especially in providing spiritual care as part of comprehensive patient care. They emphasize that religion perceives palliative care as a means of ensuring and preserving the inalienable dignity of patients. This is consistent with the understanding of the sanctity of life upheld by all selected religious communities, which recognizes the importance of a dignified death in relation to ensuring the highest quality of life. The study further identifies that despite various legal mechanisms protecting fundamental rights and freedoms, including religious freedom, in the Republic of Slovenia, the provision of specific spaces for prayer and other religious rituals in various public healthcare and hospital institutions is inadequately regulated, for instance, for the Jewish (even though they are a small community) and Islamic religious communities. In the study, it is found that religious communities define their positions on specific ethical dilemmas through their ethical codes, a point also affirmed by participants. The study does not highlight any instances where religious beliefs conflict with the practice of medical professionalism, as Slovenian legislation does not oppose the ethical standards advocated by religious communities. Participants point out that religious ethical foundations are not arbitrary, capricious, or random, but they introduce ethical dilemmas to the progress of medicine and science that do not have simple right or wrong answers. Participants in the research identify that awareness among healthcare professionals in Slovenia regarding cultural and religious differences is insufficient. The reasons cited for this lack of awareness are numerous, encompassing both societal and individual factors. The challenge of understanding different value systems and beliefs of patients, sensitivity to cultural and religious differences, demands greater awareness from both religious communities and the state, as well as the broader social community. The theoretical overviews and research results presented provide a basis for further development in this field—in recognizing the interconnection of ethics and religion and in fostering a more inclusive and holistic practice of assuming responsibility for people. In healthcare, this process can be partially facilitated by introducing appropriate educational content into the curriculum, offering the opportunity to acquire specialist knowledge in ethics, religion, and spirituality, and conducting professional assessments of individual spiritual needs. It is nearly impossible to provide a comprehensive overview of the monotheistic view on end-of-life decisions, especially because there exist different theological and philosophical methodologies that intersect at various points on specific questions. In our discussion, we have highlighted important stances that characterize the Jewish, Catholic, and Islamic faiths.

Some methodological limitations of our study may relate to our open research question, and the explanatory character of the study may have been hampered by the inductive creation of codes and categories [46]. In the context of the latter, a potential criticism would be that the study was subjective, which is the most frequent criticism of qualitative research [46, 47]. However, all co-authors relied on a careful, deliberate research strategy, and respect for the basic characteristics of qualitative research during the data collection and analysis stages.

4.1 Judaism

In modern Jewish medical ethics, particularly in the 1960s and 1970s, the emphasis was predominantly from Orthodox Judaism, where divine authority expressed through the Torah and Talmud forms the foundation of the consultative process [38]. Much of Jewish bioethical literature is based on this perspective, assuming that with the appropriate interpretation of Talmudic texts and commentaries, answers to the most challenging questions can be found. In practice, a rabbi, whose opinion is sought for ethical guidance, serves as a “professional advisor” who interprets halakhic law for the specific situation, assisting both the doctor and the patient. In complex cases, a local rabbi or chaplain may consult more learned halakhic authorities. While traditional Jewish texts express numerous ethical principles worthy of consideration, there are a few fundamental principles that underpin a significant part of the Jewish bioethical tradition. These include:

1. Human life has infinite value.

2. Aging, illness, and death are natural parts of life.

3. Improving a patient’s quality of life is a constant commitment.

4. People are “responsible caretakers” in preserving their bodies, which ultimately belong to God.

5. Individuals are obligated to violate any other law to save a human life, except for murder, incest, or idolatry.

Compared to secular values, these principles indicate a lesser role for patient autonomy. The duty to treat illness or preserve health takes precedence over any perceived right to refuse treatment or commit suicide. The principle of sanctity of life means that any decision that could indirectly or directly hasten death is prohibited. Traditional Judaism generally forbids suicide, euthanasia, withholding or withdrawing treatment, and abortion when the mother’s life or health is not at risk, as well as many traditional “rights” associated with a strong concept of autonomy. The challenge Jews face in end-of-life decisions is typically not in determining appropriate halakha; the greater challenge is deciding the moment when hope for further life is lost, and the process of dying begins. Jewish law is relatively clear that one should not take life before the natural time of death. Regarding the issue of withholding and withdrawing life-sustaining treatment, Jewish law allows such actions only if the treatment is futile and repetitive, and provided the patient has given clear consent. This includes refraining from any activities that prolong life, such as intubation, surgery, chemotherapy, or dialysis, even after the treatment has begun because such an action is considered an omission rather than a withdrawal. For continuous forms of maintenance treatment, such as a respirator or a pacemaker, removal is prohibited. The strictest position in Judaism limits permission for withdrawal or discontinuation of treatment to cases where physicians anticipate the patient will die within 72 hours. Patients and physicians can discontinue clinical treatment in cases where the patient has a diagnosis of an incurable chronic illness if it is in the patient’s best interest. Furthermore, halakha defines oxygen, food, and fluids as essential components of life, which every individual is entitled to. Therefore, a dying patient cannot be denied these basic necessities, and the withdrawal of artificial nutrition and hydration is not permitted as it constitutes an action leading to death. In cases where the continued provision of artificial nutrition and hydration causes suffering and complications to a patient approaching death, such support can be withdrawn upon the patient’s request or if it is determined to have been the patient’s wish. As for palliative sedation, there is a consensus in Jewish law that it is permitted, despite the risk that such medications may shorten life based on the principle of double effect (Padella).

4.2 Catholicism

In line with this, Christianity primarily emphasizes the importance of autonomy and the patient’s presence in ethical decision-making or treatment [43]. The question of withholding or withdrawing treatment is permitted if it is burdensome, dangerous, extraordinary, and disproportionate to the expected results of medical procedures [48]. This is the so-called “refusal of therapeutic obstinacy,” which means that the responsible person does not want to hold back death but rather accepts the fact that they cannot prevent it. The decision should be made by the patient if they are competent or capable of making it. If not, those who have the legal right to do so make this decision, always respecting the patient’s reasonable will and their legitimate interests. In 1980, the Declaration on Euthanasia allowed pain relief with medication or the use of analgesia and sedation in dying patients, including the shortening of life as an unintended side effect (the principle of double effect). However, it is important to emphasize that the issue of pain and suffering holds special significance for Catholic bioethics, as it also represents an opportunity and the meaning of participating in Christ’s suffering [48, 49]. In Catholic tradition, pain and suffering are not seen as goods in themselves. At this point, we recall the statement of Pope Pius XII when a group of anesthetists asked him whether pain relief medication should be offered to a patient, even if this unintentionally shortened the patient’s life. The Pope replied that pain relief should be offered if no other means exist, even if it leads to unconsciousness and an inability to fulfill the patient’s moral duties and family obligations. This judgment reflects the principle of double effect, which plays a crucial role in end-of-life care. It establishes that an act with a double effect, one good and one bad, is morally permissible if the act: 1) is not intrinsically evil, 2) is done with the intention of achieving a possible good effect, without intending the possible bad effect, although foreseeing that it is possible, 3) does not bring about a good effect through a bad effect, and 4) is done for a proportionate reason [48].

4.3 Islam

Ethical considerations regarding end-of-life issues in Islamic bioethics revolve around the sanctity of human life. This judgment is defined in the Quran with the following verses: “Do not take life, which God has made sacred, except in the course of justice” [50]. In line with this, it is forbidden for anyone to intentionally end their own life: “If anyone kills a person, it is as if he kills all of humanity, except those who commit murder or spread corruption in the land” [50]. Preserving life is one of the greatest merits and imperatives in Islam. Doctors are obliged to do everything in their power to prevent premature death. However, this imperative no longer applies when death is inevitable and clinical treatment is clearly futile. Islam acknowledges that people must sometimes recognize their limitations and allow nature to take its course [50]. Resorting to unwarranted treatment to avert death is unacceptable in Islam [49]. Muslim jurists agree that a doctor, patient, and family members can make a collective decision, based on informed consent, to reject medical interventions and discontinue treatment if these procedures in no way improve the patient’s condition or quality of life [48]. If invasive treatment has been initiated to save a patient’s life, Muslim jurists have determined that the medical equipment maintaining the patient’s life should not be switched off unless the doctor is certain of the inevitability of death [51]. Islam advocates the stance that even at the end of life, patients should not be deprived of their right to nutrition and hydration. This is due to the fact that withholding such necessities would hasten death, which is prohibited in Islam [48]. However, the use of palliative sedation to alleviate end-of-life suffering is permitted, even if it expedites death. Islam teaches that “actions are to be judged by their intentions” [48, 51]. In Islam, pain is regarded as a test of faith and spirituality [50]. Therefore, Muslims should endure it patiently.

To endure pain patiently, this does not mean they are prohibited from seeking means to alleviate suffering. The Quran states that “good deeds will surely drive away evil deeds [that cause suffering]” [50]. This means that an individual should strive to overcome pain [51]. In Islamic ethics, an individual’s well-being is closely tied to their family and community [51]. Therefore, neither autonomy nor paternalism are decisive factors in deciding on the course of end-of-life care; instead, it is a collective decision involving all parties connected to the patient, which may also require the involvement of religious authorities if necessary [48, 51]. It is worth noting that the two main branches of Islam, Sunni and Shia, may have some differences in interpretations, methodologies, and authoritative systems but not significantly in bioethical judgments. However, it should be noted that most Islamic communities will follow the views of their recognized religious scholars because the Islamic faith is not monolithic and encompasses diverse viewpoints [48].

Importance for everyday practice

1. We recognize the need for adequate regulation of specific spaces for prayer and other religious rituals in various public healthcare and hospital institutions for all religious groups.

2. Participants in the research identify that awareness among healthcare professionals in Slovenia regarding cultural and religious differences is insufficient and recognize the need of improving the curriculum in education regarding this topic.

3. Religion is not the common basis for ethics, but rather a rational reflection on human life, its value, and dignity.

5. Conclusion

The question of how to understand the place of religion between the patient and healthcare personnel is not straightforward. In contemporary Europe, there are various religious affiliations in every country and community. Within each religious community, divisions exist, such as between Shiite and Sunni Muslims, Orthodox and Reformed Jews, as well as Catholic, Orthodox, and Protestant Christians. In addition to these divisions, there is also diversity in the degree of religious affiliation, beliefs, and religious practices. The complex context reveals the space in which healthcare professionals work; each patient is unique in terms of their religious beliefs, and each healthcare professional is unique in terms of their religious affiliation. Every interaction between a patient and a healthcare professional takes place in the light of profound and evolving religious diversity [52]. Different ethnic, racial, and religious identities within the patient population lead to countless value systems present in clinical practice [38, 53]. Religious values shape ethical codes present not only in every religion but also often expressed in various cultural norms in society. Therefore, it is important to understand the religious values that can shape such a cultural encounter [28]. The fact is that no religion in the Western world can serve as a common basis for ethical reflection. Religion is not the common basis for ethics, but rather rational reflection on human life, its value, and dignity. However, the fact that religion is not a common foundation for ethics does not mean that religion cannot contribute to ethical discourse in a pluralistic society. A pluralistic society, religious pluralism, encourages us all involved in healthcare to be more aware and understand the different value systems and beliefs of patients entering the healthcare system. Sensitivity to cultural and religious differences leads to increased trust between medical staff and patients, resulting in a compassionate and high-quality environment for providing healthcare or end-of-life palliative care. Many ethical dilemmas require a structured approach through the various value systems of each individual or patient. One of the main ethical issues in the world today—how to provide palliative care to all patients regardless of their background and location—is a challenge that surpasses all ethical dilemmas and requires us to consider how to provide a structure of high-quality palliative care that will be accessible to as many patients as possible. The future research should focus on the possibility how to integrate the knowledge about the religiosity and spirituality in the curriculum of medical health staff and emphasize the young generation of healthcare providers for a culturally sensitive work, especially in palliative care.