Spirituality And Medicine

Spirituality And Medicine

• 1.
  JOURNAL OF PALLIATIVEMEDICINE Volume 6, Number 3, 2003 Editorial © Mary Ann Liebert, Inc. Spirituality and Medicine MYLES N. SHEEHAN, S.J., M.D. W H AT ’S UP WITH SPIRITUALITY AND MEDICINE ? Numerous articles in the medical and pop- ular press and other media have presented a va- in spiritual counseling. That is unrealistic. But, as this paper points out, talking to a person about the areas of their life affected by illness is a rea- riety of different viewpoints on the role, if any, sonable expectation of physicians. that spirituality should play in caring for pa- Third, the presentation of spiritual issues in tients.1,2 The article by Lo et al.3 in this issue is end-of-life care comes within a context of ac- an excellent example of straightforward and rea- cepted ethical analysis and good common sense. sonable recommendations for physicians and Physicians who are not comfortable with a re- other caregivers who may find themselves a bit quest for prayer should not compromise their be- bewildered and uncertain when confronted by re- liefs. Be polite, do not lie, and be straightforward quests for prayer and religious ceremonies in the about alternatives. Those comfortable with prayer context of caring for patients with life-threaten- and religious ceremonies can take part if invited. ing illness. This paper, and a recently published Physicians should facilitate the need for end of companion piece, provide practical guidelines for life religious ceremonies for patients and their physicians in discussing religious and spiritual is- families. That does not mean they need to run sues and are fine examples of solid, non-strident them! But asking patients and/or their loved ones introductions to how spirituality and medical if there is something that is important to them care can comfortably coexist.4 from their religious and spiritual tradition is not What makes this paper (and its companion) only appropriate, it is part of basic human de- worthy of attention and study? cency. Listening, caring, and consoling either in First, spirituality and religion are treated as hu- one’s own way or with a referral to a skilled chap- man experiences that do not magically disappear lain is not a conflation of religion and medical in the doctor’s office or the hospital. Persons have practice. In all contexts, Lo and colleagues make a variety of different ways in which they find, or clear that it is not appropriate to impose one’s be- fail to find, transcendent meaning. In the context liefs on patients. That obligation also extends to of life-threatening illness, those spiritualities, of- physicians and other caregivers who are atheists ten but not always expressed in particular reli- or agnostic. gious beliefs, can be extremely important for the As mentioned, this paper comes at a time of in- person and the person’s family as they try to face creasing interest in spirituality in medical care. what may be a very difficult or threatening time. There are many ways to define spirituality. But Lo’s paper gives good examples of how spiritual all the definitions aside, spirituality often in- beliefs can surface as requests for prayer or a re- cludes prayer, both spontaneous and highly for- ligious ceremony that may be considered impor- mal, and ritual, again with varying degrees of for- tant for a person who is dying. mality. Whether physicians or anyone else like it Second, this paper makes clear that physicians or not, it is clear that many persons have a need are not expected to do everything nor should they for prayer, worship, or other ways in which they compromise their own beliefs. Some caregivers, can sense the transcendent. An awareness of that especially physicians, express dismay at a per- common human need may improve the way we ceived expectation in some of the current interest care for persons in general, but particularly when in spirituality and medicine that they need to not threatened by a serious illness. “Improve” needs only excel in medical care but also be competent to be understood as patients and their families 429
• 2.
  430 SHEEHAN feel cared for, experience compassion, and find suit of treating the cancer.8 If doctors can be too some relief in the existential distress that often ac- focused on disease to attend to physical symp- companies life-threatening illness. Spirituality toms and psychological distress in caring for per- and attention to prayer and ritual can be seen as sons with serious illness, then one can extrapo- improving medical care without necessarily look- late that some physicians may be spectacularly ing to cures, regression of physical symptoms, or clueless when it comes to dealing with a patient’s something that is akin to faith healing. spiritual experience. Some patients needlessly The soundness of the approach of Lo and may suffer spiritual distress when it could have coworkers is found in striking the right note be- been recognized and resources found for help. I tween two potential extremes. For some, spiritu- would suggest that recognizing spirituality as ality can be presented as a treatment modality part of human experience affected by illness is an similar to other therapeutic agents. Thus, some integral component of caring for persons. would suggest it leads to less death, early dis- What does this suggest for orthodox, scientific charge, and other outcomes that are traditionally medicine? used to assess a new pharmacologic agent or sur- First, it means that rigor and the use of the dis- gical procedure. For others, spirituality is a dan- ease model construct for diagnosis and treatment gerous dilution of scientific progress. Any hint of continues to have a central role. There is a need it suggests Elmer Gantry is loose in the hospital. for more, though. A much-needed proposal is to And although both of these extreme positions on consider a research agenda that would look at spirituality and medicine are held by sincere, outcomes and spirituality in ways that are thoughtful, and good people, there can be a hint broader than suggesting that prayer is a thera- of religious fanaticism at times in those who see peutic agent.9 It is time to design studies to an- spirituality as a treatment modality and a pa- swer questions like whether individuals experi- tronizing, pseudo-intellectual bigotry on those ence less distress, feel they received better care, who react with horror at a seeming invasion of and adhere to standard medical regimens more the spiritual into the realm of the clinical. often if attention is paid to spiritual issues that There are serious issues at stake in the consid- arise in their illness. eration of spirituality in medicine. Taking prayer Second, it is time to avoid bigotry. Bigotry, in and religion seriously, as Lo and his colleagues academic medicine? I am afraid the answer is yes. have done, is an important step in recognizing Large numbers of Americans describe themselves that physicians and other caregivers not only as spiritual and many are formally religious.6 I treat disease but care for persons who are suffer- believe that this may make some physicians and ing in a variety of ways. Kleinman 5 notes that dis- other highly educated caregivers very uncom- ease is the biomedical grid that physicians use in fortable and lead to responses that are inappro- the diagnosis and treatment of illness. As such, it priate. Let me give two examples. Several years is extremely useful. But when people get sick, ago, at a conference on communication skills and they suffer in ways that go beyond disease and end-of-life care, I was scheduled on the confer- that makes up the experience of illness. Physi- ence’s third day to give a presentation on spiri- cians and other caregivers can always use some tuality. Of the roughly 100 participants, I found guidance in looking how best to care for persons. myself stunned to have approximately half come Sulmasy 6 suggests a model of the human person up at breaks or during social gatherings to tell me that combines the biological, psychological, so- that they were atheists. Why they felt a need to cial, and spiritual realms of the person. There is make such a confession was unclear to me. But it ample evidence that doctors sometimes do not do made me uneasy as to how open they would be a real good job in caring for any of these realms, to the distress of a person who expressed himself so intent is their focus on treating a disease. in spiritual or frankly religious terms. Another ex- Woman with early stage breast cancer frequently ample occurred at a conference at a major med- seek alternative medicine in the setting of psy- ical school and one of the powerhouses of aca- chological distress not attended to by their physi- demic medicine in the United States. I gave a cians.7 Children with malignancies treated at an presentation on assisted suicide and used the pre- academic teaching hospital were perceived by sentation to review ethical arguments for and their parents to have suffered from a variety of against medically assisted suicide as well as to symptoms that the doctors ignored in their pur- present a differential diagnosis of the meaning of
• 3.
  SPIRITUALITY AND MEDICINE 431 a person’s request for assistance in suicide in the deep roots in the hospice movement, has recog- setting of a serious illness. At the end of the pre- nized the need to attend to spirituality in assess- sentation a faculty member commended me for ing the suffering of persons with life-threatening the reasoned, balanced nature of the talk and illness. This recognition should extend more praised my insight into some of the reasons why broadly through health care. individuals might request suicide. Then he ended with a set of questions: “But you are a physician and a Jesuit, right? How can you be reasonable REFERENCES and thoughtful and be a Roman Catholic priest?” These anecdotes may not prove much more than 1. Gunderson L: Faith and healing. Ann Intern Med 2000; the obtuseness of the individuals involved. But 132:169–172. the discomfort of some doctors and other care- 2. Sloan RP, Bagiella E, VandeCreek L, Hover M, Casa- lone C, Jinpu Hirsh T, Hasan Y, Kreger R, Poulos P: N givers at things religious or spiritual does not Engl J Med 2000;342:1913–1916. mean it is appropriate to neglect the suffering and 3. Lo B, Kates LW, Ruston D, Arnold RM, Cohen CB, needs of others in the spiritual domain. Faber-Langendoen K, Pantilat SZ, Puchalski CM, Quill Third, an awareness and openness to spiritual TR, Rabow MW, Schreiber S, Sulmasy DP, Tulsky JA: and religious experience does not mean that Responding to requests regarding prayer and religious physicians and other caregivers should willy- ceremonies by patients near the end of life and their nilly think they need great expertise in this realm. families. J Palliat Med 2003;6:409-415. 4. Lo B, Ruston D, Kates LW, Arnold RM, Cohen CB, In many hospital settings, as well as in hospice, Faber-Langendoen K, Pantilat SZ, Puchalski CM, Quill chaplains are available who are skilled in assist- TR, Rabow MW, Schreiber S, Sulmasy DP, Tulsky JA: ing persons from a variety of spiritualities and JAMA 287 749–755. 2002. faiths. Recognizing the need for these individu- 5. Kleinman A: The Illness Narratives: Suffering, Healing, als at a time of ongoing cutbacks is important. and the Human Condition. New York. Basic Books, Professional chaplains are not just clergy who 1988 visit folks in the hospital. They are individuals 6. Sulmasy DP: A biopsychosocial-spiritual model for the with a minimum of a master’s degree in theology care of patients at the end of life. Gerontologist 2002;42: 24–33. or an allied discipline who have undergone a pro- 7. Burstein HJ, Gelber S, Guadagnoli E, Weeks JC: Use of longed residency program in what is known as alternative medicine by women with early-stage breast Clinical Pastoral Education. Physicians should cancer. N Engl J Med 1999;340:1733–1739. consider how and when to refer to these profes- 8. Wolf J, Grier HE, Klar N, Levin SB, Ellenbogen JM, sional chaplains and whether they are missing an Salem-Schatz S, Emanuel EJ, Weeks JC: Symptoms and opportunity to improve the care of their patients Suffering at the End of Life in Children with Cancer. by ignoring this resource. Doctors must develop N Engl J Med 2000;342:326–333. 9. Marwick C: Should physicians prescribe prayer for an awareness that those persons who come to health? Spiritual aspects of well-being considered. them have a variety of needs. Recognizing those JAMA 1995;273:1561–1562. needs is crucial. It is unrealistic to expect the doc- tor to meet and treat them all. But just as I as an internist and geriatrician can make a diagnosis of Address correspondence to: cancer—even though I do not perform surgery, Myles N. Sheehan, S.J., M.D. or administer chemotherapy, or provide radia- Department of Medicine/Geriatrics tion therapy—so all physicians should be able to Loyola University Chicago get a sense of a person’s need for spiritual help Stritch School of Medicine and respond with respect and, if necessary, ap- 2160 South First Avenue propriate referral. Palliative medicine, with its Maywood, IL 60153