SPIRITUALITY IN MEDICINE
AND HEALTH CARE
Thomas R. McCormick, D.Min.
Department of Medical History and Ethics
U.W. School of Medicine
Health Care in Early Times
Medicine & Religion
• Few interventions were possible
• Application of herbal medicines
• Religious concepts of cause and effect
included :
– punishment for sins
– indwelling of evil spirits
– separation of the patient from God
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 Aescleplius
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
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)
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. . .”
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
• 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,
• 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;
• Christian Scientist who refuses allopathic
health care in favor of a Reader;
• Various religions that may decry
contraception or forbid pregnancy
termination.
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 physician that
s/he be a student of religions, in addition to
medicine.
• And, what if the physician is non-religious?
Question: Should physicians
avoid talking about religion or
spirituality with patients?
• A. yes, because a physician can not be
expected to be conversant with all religions.
• B. yes,because the physician may be an
atheist or non-believer.
• C. yes, that would be an unethical intrusion
into the privacy of the patient.
• D. no, particularly when there are
indications of patient interest or need.
Distinction: Between
Religion and Spirituality
• Answer: D; no, there are indications. . .
• A particular religion or faith community is
one road to spiritual awareness and growth.
• Spirituality in this sense, may transcend 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.
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.
A Shift of focus:
from the biomedical
to the psycho-social-spiritual
• For many patients facing serious illness or
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, a Seattle surgeon’s
reflections. . .
• 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 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?
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
Meaning is related to purpose,
therefore questions might be:
• Why do you think you have become ill now
• Has this illness changed any attitudes you
might have about the future?
• Is there anything more important to you
than regaining your health?
• How does this illness interfere with your
goals in life?
• What purpose is served in regaining health?
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.
Man’s Search for Meaning
Victor Frankl
• Sometimes external circumstances in our
life situation are beyond our control.
• Frankl maintains that the attitude we choose
to take toward our life situation is within
our control.
• The spiritual journey relates to our inner
struggle to shape our attitude toward illness
and even death itself.
Frankl: the will to meaning. . .
• Aesthetic: one may find meaning in the beauty
of the sunrise, the sunset, the symphony. . .
• Relational: one may find meaning in
relationships, be they family or friends
• Creative: one may find meaning in creative
activity, work, profession, homemaking
• Attitudinal: one may find meaning in shaping
the attitude taken toward illness or death.
A Spiritual Inventory might
include questions about:
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patient’s perception of what is going on
what gives meaning and purpose to life
how, or whether belief and faith enter in
love: by whom do you feel loved-accepted?
forgiveness--need it? grant it to others?
prayer--for what do you pray?
quiet and meditation--what is off center?
worship--what restores you to center?
Taking a spiritual history. . .
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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..)
S Spiritual Belief System
• How would you describe your spiritual
belief system?
• Do you find comfort in this current illness
from your beliefs and practices?
• What in particular is helpful to you?
– Internal: private belief system
– External: participant in a community
P Personal Spirituality
• What are your most important personal
beliefs?
• The professional need not believe what the
patient believes, but must acknowledge that
the patient’s beliefs are important.
• An individual may have a profound
spirituality, but may not be overtly religious.
I Integration in a Spiritual
Community
• National Institute for Healthcare Research
report studies claiming:
• regular church attenders live longer.
• risk of diastolic hypertension ranked 40%
lower among people who actively
participate in spiritual practices.
• 93% female cancer patients said their
beliefs helped them sustain hope.
R Ritualized Practices and
Restrictions
• Patients may especially value the rituals of
their faith community:
• Baptism for a critically ill newborn
• Anointing (last rites) of a dying person
• Scripture
• Prayer
• Communion, or Eucharist Service
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Implications for Health Care
• What does the patient understand about
his/her medical condition & prognosis?
• What are the patient’s beliefs about
suffering, about pain control?
• Does the patient understand the principle of
double effect?
• What are the patient’s goals in the time that
is left?
T Terminal Events Planning
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Does the patient have an advance directive?
Attorney in fact: Durable Power of Atty.?
Curative - Palliative -Comfort Care?
How does the patient view dying?
– Is it the final end?
– Is it the beginning of life eternal?
– What is the patient’s final agenda?
Mentoring, and teaching by example, is
perhaps the most effective approach.
UWSOM is
featured for
teaching end
of life care to
medical students
Students in
preceptorships
or RUOP’s in
the pre-clinical
years, or in
the clerkships,
may gain a
deeper
appreciation of
the spiritual
needs
and resources
of
patients.
Hospice Student
Different
cultures
may have
ceremonies
and rituals of
special
importance in
coping with
illness or
preparing for
death.(Navaho)
Choice in Dying Study
• Education in spirituality should be
interdisciplinary (med/nrsng/pastoral),
expose students to dying patients, and to
caregiver mentors who model ideal
knowledge, skills and attitudes.
• Preclinical years: patient interview,
hospice elective, preceptorships
• Clinical years: Clerkships, Hospice rotation,
Simulated Patient Interviews, Patient care.
Persons with major illness or
debilitating disease find strength
and support from religious or
spiritual sources.
• Measures of religious coping can predict
outcomes of life crises, vs. non-religious.
• Use of religious coping skills by older
patients is associated with diminished risk
of depression, or of recovery from depr.
• Spiritual intervention needs a (CPT) code.
Recent surveys by NIHR find:
• 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.
5 requirements for physicians to
meet the spiritual needs of patient
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Be trustworthy,
treat the patient as a person,
be kind,
maintain hope,
assist the patient in determining what it
means to live.
Foster,DW in Religion and Medicine: the physician’s
perspective. Fortress Press, 1982
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, anti-religious, or ideologic
systems of belief on their patients. . .
Spirituality in Medicine (1 credit)
UW School of Medicine
• A multidisciplinary med school elective
• Provides a framework for students to
communicate with patients about the
patient’s spiritual connections
• Allows each student to make visitations
with a hospital chaplain--seeing patients
with serious illness or life threatening
illness
Goals of this Course:
• Heighten awareness and enhance the role
of spirituality in our own lives;
• Foster respect and appreciation for the
diversity of patient beliefs and values;
• Strengthen commitment to relationshipcentered approach to health care;
• Develop a better understanding of the role
of the hospital chaplain and clergy as
partners in caring for patients.
Spirituality Education at the UW
• Year 1: ICM, Human Behavior
• Year 2: ICM II, “Terminal Illness Seminar”
• Electives:
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SPIRITUALITY IN HEALTH CARE
HOSPICE ELECTIVE
ETHICAL ISSUES SURROUNDING DYING
PRECEPTORSHIPS & RUOP
INDEPENDENT RESEARCH PROJECTS
Contact Information
• Dr. Thomas R. McCormick
• email: mccormic@u.washington.edu
• http://eduserv.hscer.washingnton.edu/bioethics/
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Box 357120
School of Medicine
University of Washington
Seattle, WA 98195
Case examples of spiritual issues:
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a disturbing visit from the daughter
the professor’s inoperable cancer
medical student with an astrocytoma
what will my dying be like?
a patient’s lament, “please help my parents”