Institute for Christian Teaching
Education Department of Seventh-day Adventists
TOWARD AN ETHICS OF MEDICAL
CARE
THAT INCLUDES
CARE FOR THE SPIRITUAL
Harvey A. Elder, M.D.
Professor of Medicine
School of Medicine
Loma Linda University
Chief, Infectious Disease Section
Jerry L. Pettis Memorial Veterans Affairs Medical Center
Loma Linda, California, 92354-9911
291-97 Institute for Christian Teaching
12501 Old Columbia Pike
Silver Spring, MD 20904 USA
Prepared for the
20th International Faith and Learning Seminar
held at
Loma Linda University
Loma Linda, California - June 16-26, 1997
Caring is a spiritual act,
thus, all-clinical care has a spiritual component. All health care includes spiritual care, albeit, often without
intentionality. Spiritual care provided
without diagnostic and therapeutic intent may be harmful. Many assign the harmful effects associated
with casual spiritual care to spiritual car per se. However, spiritual care, as any form of clinical care, given
without proper diagnosis and therapeutic intent can cause injury, i.e. it may
have "toxic side effects"! Spiritual care has been intentionally
ignored. For the past half-century,
religion and spirituality have been largely excluded from medical care. Spiritual car should be included as an
integral part of scientific medical care.
In fact, I argue that the absence of intentional spiritual car is
patient negligence!
I.
INTRODUCTION:
Medical care needs to
address the spiritual as well as the physical, emotional, cognitive, social and
religious for several reasons. 1) The
spiritual permeates every aspect of a person and influences health and
wellness; 2) pragmatic studies show that an active religious/spiritual life is
associated with better health and decreased morbidity; 3) unless directly
addressed, patients rarely volunteer the spiritual aspects of their illness.
Illness profoundly alters
the way people view today and anticipate tomorrow. Patients frequently deny the significance of symptoms. When denial no longer suppresses symptoms fear
emerges and patients demand health care that calms their fears and heals their
symptoms. Not symptoms per se but potential meanings cause
fear. Though patients usually deny fear
they want it eliminated. Patients need
help to face present fears and find courage for the future. Patients need care adequate for their fears,
care that assists them deal with fear.
Several illustrations follow:
Mrs. S loved to dance. She has just been diagnosed with amyotrophic
lateral sclerosis. When asked, "What do you hope for?" she answered, "I
just want to dance again!"
Alfred, a heavy smoker, had carcinoma of the lung. When asked, "Why
did you get this cancer?" answered, "I ran around with loose women
when I was young."
Peter, a heavy smoking 46-year-old truck driver, had carcinoma of the
lung. When asked, "Did you ever believe that Someone was looking after
you?" answered, "Yes, driving truck when drunk through the mountains
of Tennessee Someone took care of me. Doc, go ahead with the surgery, the same
Person is caring for me now."
When the Vietnam veteran was asked, "If you were to die at home,
who would know?" answered "Nobody!"
John, age 19, recovered from infectious mononucleosis. When asked, "What
did you learn from this illness?" replied, "I didn't know I could get
sick!"
After a prolonged drunk Bill's ex-wife had been holding and assuring
him of her care and forgiveness.
A.
Relationship between medical
care and religious/spiritual[1]
In the earliest recorded
history, priests were also the medicine men.
Hebrew priests not
only performed religious service, they also diagnosed
illness.[2] Early Christian Churches provided hospice
care for the sick and dying[3]
and at a later time, monasteries set up hospitals. Earliest medical schools were "Church related."[4]
Emerging science confronted
authoritarian religion during the renaissance.
This conflict increased during the enlightenment epitomized by the
teachings of Darwin and rationalistic philosophy. Scientists uncomfortable with a divine basis for morality
developed a utilitarian basis. "Educated"
people viewed religion as a pre-modern notion[5]
used to bring order to the pre-scientific mind, a creation of human thought
useful for comfort, but lacking in relevance.
The first and second world war,
which documented human inhumanity, destroyed the optimism of the enlightenment. The continuing threat of nuclear
annihilation and the Vietnam war added disillusionment. Economic advances did not eliminate
poverty. Increased knowledge has not
controlled violence, decreased drug addiction or stopped epidemics of sexually
transmitted diseases. Derek Bok,
president of Harvard University commented "Relativism and individualism
have rewritten the rules of the game; they have extinguished the motive for
education – to understand the interwovenness of the facts/values and
objectivist/relativist pathologies and the cultural consequences of the loss of
purpose and meaning."[6] Because rationalism failed at the time of
need, people turned to "spirituality." This manifests in the growth of religions that highly value
spirituality, increasing interest in Native American and eastern religions, the
popularity of "new Age" and the rise of spiritism and witchcraft[7].
For many, spiritual is their
"walk" with God. For others
it is experiencing the Transcendent, or the "Ground of our Being." Alcoholics Anonymous and other 12 step
programs refer to "Higher Power."
For some, spiritual is the essence of the universe. Spirituality "has to do with man's
search for a sense of meaning and purpose in life . . .[I]t strives for
transcendental values, meaning and experience. . . .[It] is that aspect or
essence of a person . . . that gives him or her power and energy, and motivates
the pursuit of virtues such as love, truth, and wisdom . . .. Religion, on the
other hand, is any specific system of belief, worship, conduct, . . .often
involving a code of ethics and a philosophy.
It may include dogma, metaphors, myths, and a way of perceiving the
world.[8]"
In health most people give
little thought to who they are, they simply live life. With illness many questions emerge. Symptoms identify mortality and our patients
fear death.They fear the present and future.
They fear loss of identify with disfigurement, loss of Ability to
perform and earn a living. They fear
abandonment including abandonment by Life i.e. death. Memories of illness include not only the fact but also the
meanings Assigned by patients and their heritage. Patients listen to the memories assigned by meaning. They believe that their memories predict
their future.
Illness distorts patients' physical, mental, emotional, social, religious and spiritual Realities and engenders chaos. It creates neediness and patients want help; medical help, emotional and social help and help from their religious and spiritual roots. Neediness overwhelms every dimension and facet of patients' lives. They need help with the physical manifestation of illness. They need education regarding their diseases. They need help with the isolation and loneliness, with the anger, fear, loss and grief. They need help dealing with relationships. They need help with their religious heritage and their Spirituality, i.e. their self perceptions, and their encounter with the Transcendent.
1. Patients need "Spiritual Care"
For millennia, physicians
knew their patients including their cultural expectations, religious heritage,
spiritual insights and memories.
Without a useful pharmacopeia they met patients' medical needs by
optimizing cognitive, emotional, social, religious and spiritual health and
guided patients into responsible self-care.
Scientific medicine focused the medical community (as well as patients)
on the physical and molecular, and away from the religious and spiritual. However, the spiritually healthy patients
(because their life has meaning) incorporate the disciplines of responsible
self-car. Scientific medicine tries but
fails to heal irresponsible patients, instead it mutilates them with repeated
surgeries or provides drug side effects via its pharmacopeia. Patients who lathe themselves, who lack
social support, who break natural laws with impunity and who life in guilty and
shame are unable to implement change and car for their health.
2. Physicians need to be
sensitive to patients' spiritual status
The arrogant professionalism
of sophisticated scientific success offends patients. They resent the "M-Deity," the cold authoritarianism,
the exclusivity maintained by professional language. Feeling demeaned, infantilized and devalued they became
angry. Patients wish their physicians
were open, listening to their heart, hearing them as worthy reporters of
important information. Patients want
physicians to be more than mere practitioners of medical science; they want
them to practice medicine as a divine calling[9].
The demands of medicine can
become resented drudgery unless physicians have a central mission validating
their commitment to both medicine and patients. They need a purpose more grand than professionalism with its
perks, they need a mission large enough to validate the hours, the "on
call" nights, and the frequent "life or death" decisions. Physicians need a mission big enough to keep
them sensitive to and focused on patients as precious human beings.
There are multiple models of
the Physician-Patient relationship[10]. With respect to the role of spiritual care
they polarixes about two disparate foci.
1. Biotechnical models
Biotechnical models of
health describe disease in cellular terms.
Sick patients have defective cells with deranged chemicals and impaired
communication between cells. In such
models, medical care simply corrects biologic imbalances and restores or
removes malfunctioning cells. These
models have provided most of the scientific advances in medical care. Though excellent these models ignore patient
fears as well as the meaning and symbolic significance of illness – for these
do not reside in the physical domain.
Health care that ignores personal, relational and spiritual needs misses
the human aspects of disease.
2. Virtue based
altruistic models
Virtue based altruistic
models are more humanistic. They assume
that clinicians are moral people with nurtured and trained character. These models supports patients' desire for
virtuous people they can hold "morally accountable for … [their] actions[11]." Within the limits of science and clinical
arts, patients expect their physicians to do what is best for them. These models say that a clinical "need
… constitutes a moral claim on" physicians[12]. They describe patients as uniquely
dependent, vulnerable, exploitable and relatively powerlessness before their
physicians. They are "forced to
trust" physicians. According to
these models, physicians hold "knowledge in trust for the good of the
sick." Virtue-based altruistic
models call physicians to include physical, mental, emotional, social,
religious and spiritual dimensions in their clinical care.
D. Who is the patient?
Integrated wholeness
characterizes person-hood. For
millennia, each person was seen as an integrated multi-dimensional,
multi-faceted whole. More resent poets
speak of "body, soul and spirit" while the more pedantic refer to
physical, cognitive, emotional, social, religious and spiritual facets of life
significantly modify health. To speak
of "body, mind and spirit" is to speak of different perspectives of a
person not different parts. The
perspectives are interactive, none can be dissected out, none function separate
from the other. They are foci, not
parts. They physical, cognitive,
emotional and social affect the religious and spiritual. The religious and spiritual affect the
physical, cognitive, emotional and social.
Patients are more than physical structures with cells integrated by
neurons, hormones and other effectors molecules. Patients want their physicians to be aware that symptoms have
multidimensional complexity.
Jewish Scripture says that
God made humans "in His image[13]." Other ancient perspectives use similar terms
to identify humans by their relationship with "God." The universality of notions of God suggests
that these are useful[14]. However, illness complicates a person's
relationship with their God. The sick
become very self-centered while loathing their own bodies! They attend to the ever-present screams of
disease rather than their relationship with God.
E. What is illness?
Illness is multidimensional
brokenness with loss of integration.
The sick suffer physically, have unreasonable thinking and unreasonable
expectations based on deficits in knowledge and illogical thoughts about cause
and effect. Frequently fear,
loneliness, anger, loss, and grief accompany illness. Often illness strains social relationships[15]
and threatens cultural and family expectations. It stresses peoples' belief in a loving and beneficent God
causing crises of religious faith.
Illness dehumanizes and destroys person-hood. It clouds the future, hiding meaning and purpose thereby
threatening spiritual health. Sick
people wonder if their illness was caused by past actions. Many believe, "I am being punished!"
Illness raises frightening
questions that demand answers: "Given these symptoms, who am I? I will be useless (and therefore
worthless)! What is the meaning of
this? What should I expect? Am I loosing it? Do I need help, or do I need to calm down?" Patients what more than physiological
homeostasis they wan answers, words that restore meaning, hope and purpose[16].
Patients see themselves on
multiple spectra between positive and negative foci: between worthwhile and
worthless, in community and isolated, in harmony with and exception to natural
law, peace with and condemned by their past.
Illness usually damages self-perceptions shifting them towards negative
foci. With jaundiced hindsight patients
see themselves as useless and worthless.
Dependent on, though separated from, those who love them they feel
alone. When illness follows specific
risk behaviors patients often say, "I thought it wouldn't happen to me!" That is, "I thought I was an exception
to natural law!" Many patients
find it difficult to forgive their own past, some blame others for untoward
consequences of their behavior while rejecting personal responsibility. Patients want and need more than just
physical help[17].
F. What is healing?
Classical Greek, the
language of medicine's birth, does not differentiate "healing" and "saving"
or "health" and "salvation." Translators interpret the Greek verb sozo as "to heal" of "to save" and the noun soteria as "health" or "salvation"
depending upon the setting[18]. Salvation notions such as "rescue from
death," "restoration to relationship" and "wholeness"
also apply to healing and health. From
recorded history until the first half of this century healing restored
thinking, emotions and social relationships.
It moved religious ideation towards truth and restored patients' sense
of value and community. It provided
forgiveness and reinforced patients' laws and taboos. Today, healing should reestablish person-hood and restore a sense
of value, saving people from being "nobody" and establishing them as "somebody." Healed people become "whole." They accept their past, live in the present
and look to the future with hoe and courage, regardless of problems. They know they are precious and share their
precious-ness in caring loving relationships.
Healed people provide responsible self-care and do what is right for
their community and planet earth.
For health care to be
healing, it must improve and integrate the multiple facets of life. When cure only improves the physical, then
broken people simply have stronger bodies in which to experience their
brokenness! Physical improvement passively received via pharmaceuticals or
surgery often increases dependency on others allowing patients to abandon
health laws and ignore responsible self care.
Ambroise Pare the famous
medieval surgeon said, "I dressed him and God healed him[19]." Many patients are awed by healing's
magnificent mystery. To them scientific
medicine provides conditions that allow or encourage healing.
At is noblest, physicians
minister to the suffering of frightened people. They support them with science, comfort them with presence and
care for them as precious human beings.
The world describing physician-patient relationships have significant
derivations. "Physician" means
healer, "doctor" means teacher and "patient" identify one
who suffers. These words speak of body,
mind and spirit. They imply more than
anatomic and physiologic repair of malfunctioning cells. To be healers, physicians must evaluate and
treat the whole patient, body, mind and spirit. Physicians must responsibly apply science in the care of their
patients. Even when they cannot cure,
they are expected to encourage, comfort and relieve pain.
Physicians should know the
religious ideation patients use to cope with illness. Some religious ideas destroy patients' spirituality, including
their self-esteem and hope. Physicians,
who usually lack theological training, can support patients seeking freedom
from destructive ideas[20].
Physicians need to listen
while patients story how illness altered their perception of what is
ultimate. Physicians need to know how
illness affects not only their patients' relationship with "God" and
but also their view of self and their world.
Only then can physicians assist in healing the whole person.
B. Serve their communities
Society provides medical education and licenses physicians. These are provided so society's members can receive caring and timely medical services of high quality. For several millennia, model physicians have been those who serve at the call of their communities incorporating available science into clinical art[21]. Society expects physicians to do more than care for cells and chemistry[22]. Society calls physicians to care for each patient as a person of infinite worth, to validate hope and help patients live lives of dignity with self worth despite anatomic brokenness. Society calls physicians from professionalism to be healers (physicians) of the sick, comforters of those who suffer (patients), teachers (doctors) of those who do not know how to live healthful lives, and comfort for those worrying about symptoms or grieving from loss. Society calls physicians, individually and collectively, to guide to health: physical, mental, emotional, social, religious and spiritual health. Physicians must value society's call.
A. Reasons:
1.
Illness
has great symbolic significance
Previous experiences modulate
patients' interpretations of illness[23]. Spirituality integrates and focuses
interpretations and gives meaning.
People respond to the meanings altering personal identity and future
plans being willing either to hope and trust or refusing such. Spiritual interpretations of physical facts
dominate patients' expectations and their responses to illness, diagnosis and
therapies. To answer society's call
physicians must learn the spiritual meaning patients give illness.
2.
Physicians
need to take and active interest in their patients' spiritual health
Most patients do not know how to
deal with guilt and shame, how to find meaning in the present or how to restore
hope for their future. Physicians best
treat patients' shame, intimidation, distorted meanings and destroyed hope by
examining their spiritual domain.
Physicians need to investigate the spiritual as well as the physical
components of illness. The spiritual
significance may be grater than the physical significance of symptoms. Physicians need[24]
to help patients deal with meaninglessness, despair, shame and guilt. When compassionate physicians provide
non-judgmental treatment with integrity and courage patients are empowered to
deal with spiritual disease. Physicians
lacking training and experience to deal with spiritual needs should consult
with those possessing these skills.
Physicians providing primary care need the expertise to provide
spiritual care.
In earlier times spiritual care
was relatively simple for physicians were part of their patients' heritage and
ethos. No longer is this true. Only rarely do physicians share either their
patients' heritage or their community[25]. Physicians need to learn the source of
patients' spiritual strength. Those possessing
spiritual care skills more effectively guide patients to responsible
self-care. Whether or not they want
their physician to understand them, patients do not volunteer their social,
religious and spiritual relationships.
Instead patients elaborate on peripheral issues and are pleased when
their physicians pick up on cues and explore withheld information. Respect and cooperation increase. Disappointed when physicians do not pursue
cues they often ignore their advice[26].
3.
Spiritual
care decreases the cost of patient care
Physicians who do not evaluate
patients' spiritual domain miss the spiritual brokenness. Often these patients are treated for
depression because of their despair, loss of meaning and hopelessness. Though their physiology may improve, they do
not "feel better" causing many physicians to order additional test,
medication or both. This adds to the
cost of medical care and may increase morbidity. Such patients will not "feel better" while their
spiritual brokenness is ignored. They
need spiritual help.
4.
Pragmatic
science documents that attention to the religious and/or spiritual improves
health
A review of 212 articles
examining the role of religion in health found that 75 percent showed a
positive benefit of religious practices on health[27]. Religion has a profound positive effect on
the treatment of substance abuse, mental illness and quality of life. In a study of college students[28]
those who were highly religious enjoyed better health, had less illness and
fewer injuries. In addition they had a
better lifestyle. Byrd showed that
intercessory prayer for post-myocardial infarction patients in a coronary care
unit in San Francisco was associated with less frequent complications[29]. Church members had significantly lower
mortality rates than non-church members in Alameda County, California[30]. When, because of illness, elderly people
were forced to leave their homes, those with most religious commitment had less
mortality[31]. Survival from coronary artery bypass surgery
is higher among regular church attenders[32]. Intensity of religious practices predicted
decreased depression among patients with severe disability[33].
B. What
ethical issues are involved?
Some physicians believe that
patients do not want physicians to bring religion into their clinical practice[34]. However, nearly half of hospitalized
patients want their doctors to pray with them[35]. Patients are dependent, vulnerable and
exploitable. It is wrong to dominate
and control patients so that they think, believe and follow their physicians'
will. It is also wrong to ignore the
human domain. Skipping the spiritual
dimensions of illness is just as wrong as skipping the physical, mental
emotional or social domains. As
physicians learn the spiritual aspects of patients' illness they understand the
anatomy of their suffering and are able to respond with wisdom and
courage. They will know gentle words to
speak to a hurting friend. When
physicians intentionally provide spiritual car for illness, they empower
patients to responsibly solve their own needs and intelligently follow valid
therapies.
1. Bioethical principles
Four principles dominate
biomedical ethics[36]. These are 1) autonomy – respect for each person's capacity to make informed
decisions and the right to be held accountable for them. 2) The principle of non-maleficence expands Hippocrates' aphorism, "First, do no
harm." 3) Beneficence requires
physicians to do good to use their clinical skills benefiting patients. Society expects physicians to render
clinical assistance when that is within their purview and when such help is not
provided this is called negligence. 4) Justice requires equal opportunity for
all. This means that physicians give
competent care equally to each patient.
2. Autonomy
Autonomy requires that patients
be able to make free informed decisions.
They need to understand the meaning of their illness and the possible
treatments. Only when physicians and
patients dialogue openly including the religious and spiritual dimensions of
the illness can they acquire the critical information necessary to make
informed and free decisions. Spiritual
care increases patient autonomy and enables patients to move toward wholeness
despite their physical abnormalities.
Without attending to the spiritual, medical advice I limited in focus
and may unanswered questions remind causing patient uncertainty and
anxiety. This limits their ability to
make appropriate heath car decisions. Patients,
who know that their physicians will accompany them as they explore their
illness, including the spiritual implications, become wiling to take
responsibility for their needs. Not
providing spiritual care limits patient autonomy.
3. Non-maleficence
When physicians do not evaluate
the spiritual dimension they limit their knowledge of their patient's illness
and miss major aspects of patient suffering.
When physicians prescribe therapy after evaluating only the physical or
emotional dimensions of symptoms they teat without identifying underlying
causes. This is akin to the outmoded
practice of using analgesics for abdominal pain without appropriate evaluation
or plans for such. By neglecting
spiritual dimensions, physicians break the principle of non-maleficence and may
harm their patients.
4.
Beneficence
The principle of beneficence
requires physicians to do the good of which they are capable. Physicians who do not provide this good are
negligent. To arbitrarily limit patient
evaluation and therapy to the physical or emotional ignoring the religious or
spiritual is to neglect patients' deepest needs. All physicians can offer spiritual care regardless of their
belief system either by skillfully responding or by calling an appropriate
consultant. Physicians who ignore areas
of brokenness that they (or available consultants) could help break the principle
of beneficence. In this they are
negligent.
5.
Justice
The principle of justice demands
that all patients receive equal opportunity for car of the physical, cognitive,
emotional, social, religious and spiritual aspects of their illness. Justice is
not swerved when the religious and spiritual needs of some patients are
neglected.
6.
To be
ethical
Physicians (healer) are called to
treat patients (sufferers). In this
they supervise the total care of their patients. The multidimensional requirements for healing oblige physicians
(healers) to address spiritual needs.
They may not ignore major areas of suffering just because they lack
training and skill in that area.
Ethical physicians are obliged to identify all areas of brokenness
whether physical, cognitive, emotional, social, religious or spiritual. When they dentify religious or spiritual
brokenness, what then? They are obliged
to offer rational effective therapy.
Those unable to provide religious or spiritual care should consult with
other physicians, chaplains, patient's spiritual counselor; someone who can
meet the patient's spiritual needs.
Primary care physicians, and others, will want to obtain additional
training so they can better meet patients' religious and spiritual needs.
V. INITIAL RELIGIOUS AND SPIRITUAL
QUESTIONS
Asking religious and spiritual
questions is straight forward and readily accepted by patients. The following questions are part of the
author's initial patient work-up. I ask
the following without any special permission: 1) after "Pat Medical
History," I ask, "Ho si your glue holding? What sustained you during
these crises?" Sometimes I include
a modification "What was your source of strength? How has this illness altered the way you see
yourself? Answer to these questions evaluate
patients spiritual strength. 2)
Classics social history includes social, cultural, and religious heritage. I add "Have these helped you? How have
they helped you deal with your illness?" 3) After I finish examining the
patient I ask, "What are you famous for?" Patients respond with demur
"Nothing," and then share. By
taking an extra 10-30 seconds I learn something about my patients' religious
practices, the source of their spiritual strength and how they see themselves.
Patients do not expect physicians
to query and may prefer not to expose parts or all of their religious r
spiritual lives. Therefore, I asked and
receive specific permission before follow up to their responses or asking
additional questions. Requests for
permission are of the nature, "You said..., I was wondering . . . Would
you like to discuss that further? For
example, "You said that you attend church regularly, but did not indicate
that it was a source of strength during this illness. Would you like to say
more?" I seek to understand my
patients' journey prior to this illness and how this illness affected their
life. In this manner I learn about the
destruction to their person-hood brought by illness. When I learn their values and concerns, I can discuss therapy and
expectations in the "language" of my patients and help them set
realistic goals.
VI. CONCLUSION
To be truly human, physicians
need to give spiritual care. In
addition, physicians need to give spiritual care because their patients need
spiritual car. The face of illness is
very complex. It includes more than
physiologic, immunology and anatomic disruption. It also threatens the cognitive, emotional, social, religious,
and spiritual life.
For millenaries physicians,
without scientific medicine, met patient needs by meeting their emotional,
social, religious and spiritual needs. "Scientific
medicine" left these valuable therapies because it forgot its
history. "Scientific medicine,"
divorced from patients' spirits and souls may improve patients physically but
leaves them emotionally, socially, religiously and spiritually bereft. In this chaos, patients attack scientific
medicine and seek healing through alternative medicine and new age
enlightenment.
In this paper I argue that people
are multi-dimensional, actually have multiple foci. They cannot be dissected into multiple parts. Based on a virtue based model of patient
care, I show that physicians are obliged to treat the "whole patient,"
i.e. not only the physical but also the mental, emotional, social, religious
and spiritual. I conclude that when
physicians neglect intentional spiritual care they run afoul the principles of
biomedical ethics and are guilty of patient abandonment. In fact, the absence of intentional
spiritual car is tantamount to patient neglect.
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