Spirituality In Medicine and
Health Care
Dr. Thomas R. McCormick
Dept. of Medical History & Ethics
U.W. School of Medicine
Adjunct Professor: Bioethics
Program, Midwestern University
University of Washington
MHE, Family Med, Soc Wk,
Pastoral Care
MHE 518 & Fam Med 547
“Spirituality in Health Care”
A QUESTION OF “MEANING MAKING”
The Golden Temple
Kyoto, Japan
2/3/05
Buddhist Tradition
• Brahma-Net Sutra:
“Sons of Buddha,
when you see all the ill
persons, you should
offer them exactly the
same as you offer the
Buddha with no
difference.”
• 2500 year tradition.
Shinto Shrine
Osaka, Japan
02/04/05
In Every Culture We Find Evidence
of the Search for Meaning
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•
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Why am I here?
What should I do with my life?
How do I order my priorities?
Where can I find guidance about the “good
life” or the “life well lived?”
When faced with sickness or the
threat of dying. . .
WHERE DO I NOW FIND
MEANING?
• In the face of loss?
• Is it temporary or
permanent?
• Mourning the loss of
the “former self”
• The unknown of a
different self.
• An uncertain future?
These Are Questions of Meaning
• Questions of meaning
and purpose are often
described as
“spiritual issues.”
• These questions are
part of being human,
they transcend culture,
religion, ethnicity,
they are universal.
Boston Marathon
Consider the case of Dax Cowart
• Dax excelled in
football, was a rodeo
rider, & a jet fighter
pilot in Viet Nam;
Burned over 65% of
his body;
• Blind;
• Facially disfigured;
• Loss of most fingers; WHAT KIND OF FUTURE?
Dax Insisted: “Please Let Me
Die”
• Early in burn rehab---should we allow him
to forego treatment?
• If he survives to mid-stage treatment and
then wants to die, should we stop treatment?
• If he is nearly finished with treatment,
discharge is on the horizon, but without
completing treatment he would become
infected and die. . . Should we stop?
• How is it some want to live, others to die?
Health Care is a Partnership
• So far we have
focused on the patient,
his values, questions
of “best interest.”
• What about the health
care provider? Our
sense of meaning, our
values, may be
challenged by the
patient.
“Complaint”
William Carlos Williams
• They call me and I go,
It is a frozen road
past midnight, a dust
of snow caught in the rigid wheeltracks.
The door opens. I smile and enter and
shake off the cold, Here is a great woman
on her side in the bed, She is sick,
perhaps vomiting, perhaps laboring.
Today’s Topic:
Spirituality in Health Care
• There are many advances in the biomedical
sciences that create new & difficult choices
for patients and their families from the
cradle to the grave.
• The topic of spirituality addresses values
and beliefs that patient’s bring to the table
about whether or not to avail themselves of
these medical advances.
Spirituality, which pertains to
ultimate meaning and purpose in
life, has clinical relevance.
• Many patients find spiritual support in
coping with illness and recovery.
• For patients experiencing suffering and
facing death, spirituality provides a context
that offers meaning, purpose and hope.
• There is a remarkable resurgence of interest
in spirituality in the United States and in its
relationship to well being and abundant life.
The divergence between
medicine and spirituality
• Modern medicine has developed marvelous
advances and interventions, relying more on
diagnostic procedures and less on patients’
conversations.
• Managed care, by limiting the time spent
with each patient, makes it more difficult to
discover the patient’s spiritual concerns and
most deeply held goals and values.
How did we get here?
• To appreciate the
current divergence
between modern
medicine and the role
of spirituality in health
care, we need to
remember our history.
Health Care in Early Times
Medicine & Religion
• Few interventions were possible
• Application of herbal medicines
• Religious concepts of cause and effect
included :
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–
–
–
punishment for sins
indwelling of evil spirits
separation of the patient from God
or the unknowable mystery of illness
Ancient medicine & religion
• 3000 BCE, early written documents show
Egyptian & Mesopotamian healers were
priests with magico-religious concepts.
• 5th century BCE in Greek medicine,
Hippocrates begins a more scientific
approach, including natural causes.
• By the 3rd century BCE, the Romans were
influenced by the Greek’s cult of Asclepius.
Greece:
The
Temple
of
Asclepius
Two views of health care
HYGEIA & ASCLEPIUS
• HYGEIA: health is the natural order of
things, fostered by prudent choices and wise
living, the goal is to find balance between a
sound body, a sane mind, and a calm spirit-medicine should discover & teach the
natural laws, so we might cooperate.
• ASCLEPIUS: the chief role of medicine is
to treat disease, the heroic intervenor.
Nursing care and natural healing processes
grow from the approach of Hygeia.
Interventive Medicine has its roots in Aesclepius
Medicine in the Christian era
• Healings were attributed to Jesus, who
sometimes linked healing with the power to
forgive sins.
• The Parable of the Good Samaritan became
a formative influence on medicine.
• By the 5th century AD, virtually all
physicians were drawn from clergy in the
monastic communities. (Kuhn, Psychiatric Medicine Vol. 6 No. 2)
Medical historians claim that
the story also had a profound
affect upon the practice of
medicine.
For centuries, physicians were
recruited and trained in the
monasteries, which were
repositories of medical texts
which were preserved and
copied by the monks.
The physician’s duty was to
care for the patient, without
regard for race, religion,
gender or any other feature,
other than the patient’s need.
Secular Medicine
• Secular medicine emerged in the late middle
ages, but was still under control of church.
• 1140 AD church granted first medical
licenses, conditions, & revocations.
• 1789, the French Revolution, marked the
break down of religious control over
medicine.
• Cartesian: separation of mind and body
Separation of Medicine from
Religion
• As science began to
discover the etiology
of diseases, former
religious explanations
no longer held.
• Science and medicine
began to distance
themselves from
religion & God of the
gaps (in knowledge).
Theoretical Models Emerge
• Biomedical model in the 19th century
• Psychobiological model--after Freud
– emotional states contribute to illness
– relaxation response may reverse illness
• 20th century: bio-psycho-social model
– 1977, George Engel
– Life events & lifestyles affect health
A Current view of health care:
A BIO-PSHYO-SOC-SPIRITUAL
MODEL
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Scientific view of pathophysiology
Respect for the psychological
Perception of the social environment
Attention to the spiritual distress and the
spiritual resources of the patient
• Described by Division of Behavioral
Medicine at the University of Louisville
School of Medicine
The Spiritual
Definitions:
• The patient is not just body and mind, but a
spiritual being. --P. Tournier
• Spirituality involves the personal quest for
meaning & purpose in life and relates to the
inner essence of the self
• Spirituality: the sense of harmonious interconnectedness with self, others, nature and
an Ultimate Other (the integrating factor)
Bio-Psycho-Social-Spiritual
• Although Schools of Medicine have been
slower to recognize & appropriate this
model, Social Work has utilized this.
• The Nursing Profession has long recognized
the spiritual aspects of patient care,
• Chaplains and clergy have often assisted
patients with the spiritual aspects of illness
and the search for meaning & purpose.
Religion is seen by some to be an
impediment to medicine
• Jehovah’s Witness who refuses a life saving
blood transfusion; plight of the minor child.
• Christian Scientist who refuses allopathic
health care in favor of a Reader;
• Various religions that may decry
contraception when it appears to be
medically indicated.
• Polarization about abortion decisions or
stem cell research.
Great Diversity of Religions
• Especially in the USA, there is a great
number of religions so that one can hardly
speak of religion in general, without making
reference to a particular religion.
• It is too much to expect of a hcp that s/he be
a student of religions, in addition to
medicine.
• And, what if the hcp is non-religious?
Question: Should health care
professionals avoid talking about
religion or spirituality with patients?
• A. yes, because one can not be expected to be
conversant with all religions;
• B. yes, because the hcp may be an atheist or
non-believer;
• C. yes, because that might be an unethical
intrusion into the privacy of the patient;
• D. no, particularly when there are indications of
patient interest. . .
Distinction: Between
Religion and Spirituality
• Answer: D, no, there are indications (the Bible on
the table, the crucifix, other signs. . .)
• A particular religion or faith community is one
road to spiritual awareness and growth.
• Spirituality in this sense, transcends a particular
religion, and resides in that universal human space
where individuals seek to understand the meaning
& purpose of their lives, and what they most
value.
• Spirituality implies self-conscious living.
Many
Manifestations
“I Am Awake” (Aware)
A surgeon’s visit to the bedside
on the eve of surgery. . .
• Dr. Lester Savauge, cardiothoracic surgeon
at Providence Medical Center, described his
practice of visiting patients the evening
before their surgery in my ethics class, UW.
• He felt convinced that this “human touch”
contributed to the recovery of his patients.
• He sometimes asked, “what would you like
to do with the days that will be added onto
your life?”
Spirituality
• Thousands of alcoholic patients who found
little help from traditional medicine were
able to become sober and remain abstinent
by relying on “a power greater than
themselves” and through the support of a
twelve step program.
• Many may not adhere to a religious
institution, but have a spiritual practice.
A Shift of focus:
from the biomedical
to the psycho-social-spiritual
• For many patients facing the end of life, the
focus shifts from the biomedical to the
spiritual.
• When symptom management and pain
control are appropriately provided, patients
are set free to address their “final agenda.”
• This may be seen as the last chapter in one’s
spiritual journey. (Mary Levine)
R.M. Mack, MD “Occasional notes: Lessons learned
from living with cancer.” NEJM 311:1642, 1984
• “Simply accepting this prognosis was
completely intolerable for me. I felt I was
not yet ready to be finished. I still had not
seen and done and shared with the people I
love. . . I could sit back and let my disease
and my treatment take their course, or I
could pause and look at my life and ask,
What are my priorities?
Dr. Mack,continuing. . .
• How do I want to spend the time that is left?
I began to focus on choosing to do things
every day that promote laughter, joy, and
satisfaction. . . I began to make choices to
do the things that felt good to me.”
• One person, opening to the meaning of life
in the face of imminent death. . .
What do patients nearing the end
of life say?
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fear of uncontrolled pain & neg. symptoms
worry about becoming a burden on family
concern about financial costs of care
uncertainty about the dying process
anxious anticipation of surrendering the
known for the unknown
• Concern for the “unfinished business of
life”
Patients in Rehab Medicine face
issues of Loss
• Case of a university student with a spinal
injury from a skiing accident, leaving him
paraplegic---committed suicide in the
earliest stages of stabilization and rehab.
• Conversely, many quadriplegic patients
choose to live in the face of even greater
losses of function and independence
(Christopher Reeves)
Patients raise spiritual questions
• Who am I, now that I am sick or dying?
• What is the meaning of my life when I am
no longer productive and independent?
• Where am I connected to others who value
me and see me as a person of worth?
• What is my relationship to the Ultimate?
• What do I now value most in the time that is
left to me? Am I ready to die?
Epictetus: a question of meaning
• “It is not as important
what happens to a
person, as to the
meaning that the
person gives to what
has happened.”
• Assignment of
meaning is a spiritual
function.
Lipowski: how we view illness
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Illness a challenge
Illness as enemy
Illness as punishment
Illness as weakness
Illness as relief
Illness as strategy
Illness as having value
Where does spirituality fit?
• Patients may have
coping mechanisms
related to their belief
• May be supported by a
community of caring
others.
• May feel themselves
to be in the company
of the Divine.
Well designed studies are
revealing a beneficial relation
• Religious commitment, practices and
attitudes are related to:
• Patient well-being, stress reduction,
recovery from illness, reduction of
depression, substance abuse prevention and
recovery, prevention of heart disease and
high blood pressure, mitigation of pain, &
adjustment to disability. (Annals of Internal
Medicine Vol. 132.No.7 4 April 2000)
Focus on human hope. . .
Emerging Data:
• U.Michigan study of 108 women with
gynecological cancer: 93% indicated their
religious lives helped them sustain hopes.
• American Cancer Society study found 85%
of women with breast cancer indicated
religion helped them cope with illness.
• Sloan-Kettering study found religious
beliefs of patients provided a helpful active
cognitive framework in dealing with illness.
Studies of 203 patients in
Kentucky and North Carolina. . .
• 77% wanted physicians to consider their
spiritual needs;
• 37% wanted physicians to discuss these
needs more frequently;
• 48% wanted their physicians to pray with
them if they could;
• 68% said their physicians never discussed
religious beliefs with them at all.
• 74% felt spirituality to be important.
Association of American Medical
Colleges
• “Physicians must seek to understand the
meaning of the patients’ stories in the
contexts of the patients’ beliefs, and family
and cultural values. They must avoid being
judgmental when the patients beliefs and
values conflict with their own.”
Different
cultures
may have
ceremonies
and rituals of
special
importance in
coping with
illness or
preparing for
death.
Taking a spiritual history. . .
(Todd Maugans, MD)
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S Spiritual Belief System
P Personal Spirituality
I Integration in a Spiritual Community
R Ritualized Practices and Restrictions
I Implications for Health Care
T Terminal Events Planning (advance
directives, DNR wishes, DPOA etc..)
HOPE Model
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H
O
P
E
Sources of hope, meaning, comfort
Organized religion
Personal spiritual practices
effects on medical care and EOL issues
Recent surveys by NIHR find:
(National Institute for Health
Research)
• 43% of physicians pray for their patients,
• 90% of doctors at the American Academy of
Family Physicians 1996 meeting agreed that
“a patient’s spiritual beliefs can be helpful
in his or her medical treatment”
• 58% have actively pursued information on
spirituality and healing.
American Psychiatric Association
• Physicians should maintain respect for their
patient’s beliefs. It is useful for physicians
to obtain information on the religious or
ideologic orientation and beliefs of their
patients. . .
• Physicians should not impose their own
religious, antireligious, or ideologic systems
of belief on their patients. . .
Doctors, and patient stories. . .
• Doctor’s duty, to
provide a diagnosis, a
pathophysiological
plot explaining signs
and symptoms.
• Doctor’s reward, to
behold the life journey
of patients and
apprehend their
meanings.