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Spirituality and Medicine

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Religious beliefs and practices are important in the lives of many patients seeking medical care, yet many physicians are uncertain about whether, or how, to address spiritual or religious issues. Often physicians are trained to diagnose and treat disease and have little or no training in how to relate to the spiritual side of the patient. In addition, the physician's ethic requires that the physician not impinge her beliefs on patients who can be particularly vulnerable when supplicants for health care. Complicating it further, in our culture of religious pluralism, there is a wide range of belief systems ranging from atheism, agnosticism, to a myriad assortment of religions. No physician could be expected to understand the beliefs and practices of so many differing faith communities.

At first glance, the most simple solution suggests that physicians avoid religious or spiritual content in the doctor-patient interaction. As with many issues, however, the simple solution may not be the best. This topic page inquires into the possibility that within the boundaries of medical ethics and empowered with sensitive listening skills, the physician may find ways to engage the spiritual beliefs of patients in the healing process, and come to a clearer understanding of ways in which the physician's own belief system can be accounted for in transactions with patients. Appropriate referral to the hospital chaplain will be explored as well as ways in which the physician and clergy may best work together for the good of the patient.

How pervasive is religiosity in the United States?

Surveys of the US public in the Gallup Report consistently show a high prevalence of belief in God (95%) while 84% claim that religion is important to their lives.[1] Approximately 40% of Americans attend religious services at least once a week. One survey in Vermont involving family physicians showed that 91% of the patients reported belief in God as compared with 64% of the physicians.[2] A 1975 survey of psychiatrists showed that 43% professed a belief in God.[3]These surveys remind us that there is a high incidence of belief in God in the US public. It also appears from surveys that physicians as a group are somewhat less inclined to believe in God. Whereas up to 77 percent of patients would like to have their spiritual issues discussed as a part of their medical care [4], less than 20 percent of physicians currently discuss such issues with patients.[5]
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Why is it important to attend to spirituality in medicine?

Regardless of their own belief system, physicians should not allow their own bias to blind them to the appreciation of the possibility that religion and spiritual beliefs play an important role for many of their patients. When illness threatens the health, and possibly the life of an individual, that person is likely to come to the physician with both physical symptoms and spiritual issues in mind. An article in the Journal of Religion and Health claims that through these two channels, medicine and religion, humans grapple with common issues of infirmity, suffering, loneliness, despair, and death, while searching for hope, meaning, and personal value in the crisis of illness.[6]

Persons may hold powerful spiritual beliefs, and may or may not be active in any institutional religion. Spirituality can be defined as ". . . a belief system focusing on intangible elements that impart vitality and meaning to life's events."[7] Many physicians and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of patients have a profound affect upon their experiences with illness and the threat of dying. It is generally accepted that religious affiliation is correlated with a reduction in the incidence of some diseases such as cancer and coronary artery disease. For patients facing a terminal illness, religious and spiritual factors often figure into important decisions such as the employment of advance directives such as the living will and the Durable Power of Attorney for Health Care. Considerations of the meaning, purpose and value of human life are used to make choices about the desirability of CPR and aggressive life-support, or whether and when to fore-go life support and accept death as appropriate and natural under the circumstances.

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How should I take a "spiritual history"?

In courses such as the "Introduction to Clinical Medicine," medical students learn the various components of the doctor-patient interview, often beginning with a history of the present illness, a psycho-social history, and a review of systems. Students-in-training are often hesitant to ask questions regarded as intrusive into the personal life of the patient until they understand there are valid reasons for asking about sexual practices, alcohol use, the use of tobacco or non-prescription drugs. Religious belief and practice falls into that "personal" category that students-in-training often avoid, yet when valid reasons are offered by teachers and mentors for obtaining a spiritual history, students can learn to incorporate this line of questioning into the patient interview.

Often, the spiritual history can be incorporated into what we may now want to call the "psycho-social-spiritual" patient history. Students are taught to make a transition by simply stating something like the following: "As physicians, (or, as physicians-in-training,) we have discovered that many of our patients have strong spiritual or religious beliefs that have a bearing on their perceptions of illness and their preferred modes of treatment. If you are comfortable discussing this with me, I would like to hear from you about any beliefs or practices that you would want me to know as your care giver." If the patient responds affirmatively, follow-up questions can be used to elicit the information. If the patient says "no" or "none" it is a clear signal to move on to the next topic.

In my experience as a tutor, students learning the patient interview have returned from a patient interview on many occasions with a sense of excitement and gratification in discovering that this line of questioning opened a discussion with the patient that disclosed the patient's faith in God as a major comforting factor in the face of a life-threatening illness. Some patients have described gratitude to their church community for bringing meals to their family while at least one parent was at the hospital with a sick child. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance. One patient, self-described as a "non-church-goer," described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen.

Todd Maugans offers a mnemonic in the Archives of Family Medicine as a technique to assist students in framing an approach to spiritual history taking:

S  Spiritual Belief System
P  Personal Spirituality
I   Integration and Involvement in a Spiritual Community
R  Ritualized Practices and Restrictions
I   Implications for Medical Care
T  Terminal Events Planning (advance directives)

A group at Brown University School of Medicine has developed a slightly different teaching tool to help begin the process of incorporating a spiritual assessment into the patient interview which they call the HOPE questions. (footnote C.   Anandarajah, G. and Hight E., “Spirituality and Medical Practice: Using the HOPE Questions as  a Practical Tool for Spiritual Assessment”  American Family Physician, 2001: 81-88.)

     H   Sources of hope, meaning, comfort, strength, peace, love and connection.
     OOrganized religion
     P:   Personal spirituality and practices
     E:   Effects on medical care and end-o-life issues

One possible advantage of the HOPE questions is the fact that they begin with open ended questions related to one’s support systems without immediately focusing on the word “spirituality” or “religion. This allows a conversation to begin with a variety of patients and is inclusive of those who may be nontraditional in their spirituality.  (Footnote: IBID)

These mnemonics are of course suggestive of a broader line of questioning that may follow from open ended questions organized around the topics identified above.

How can respect for persons involve a spiritual perspective?

The emphasis on listening to the patient and learning of the patient's beliefs and values as well as the signs and symptoms of illness is timely. A variety of features related to cost containment seem to work adversely against the patient's needs. The typical office visit grows shorter and more curtailed as physicians are pressured to see more patients within a working day. In managed care organizations the physician is responsible for a pool of patients, not just the individual patient who is standing before the physician at this particular moment. Increasingly, the physician is the "gatekeeper" in terms of referral to specialists and to expensive diagnostic procedures or hospitalization decisions. These pressures toward economy have been created by the upward spiraling of health care costs. However, they must not come at the sacrifice of respect for persons, a fundamental moral obligation in the profession of medicine.

The principle of respect for persons leads to actions designed to safeguard the autonomy of the patient, to limit the risks of harm while providing a medical benefit, and to treat persons fairly in the allocation of health care resources. Such respect for persons is a guiding principle of the healing profession and flows from the professions fundamental ethical commitment in serving the sick and injured. This principle is reinforced for the physician with a religious perspective, who in most religions, views the patient as a part of the creation of God. Likewise, it is reinforced in religious hospitals where the mission is to care for persons individually and equally as "children of God."

How should I work with hospital chaplains?

It is heartening to know that the physician is not alone in relating to the spiritual needs of the patient, but enjoys the team work of well trained hospital chaplains who are prepared to help when the needs of the patient are outside the competence of the physician. Many of today’s hospital chaplains have undergone specialized training in listening to and talking with patients, Clinical Pastoral Education (CPE). Consultation frequently may involve clergy serving the patient and his family. The onset of serious illness often induces spiritual reflection as patients wonder, "what is the meaning of my life now?". Others ponder questions of causation, or "why did this happen to me?". Still others are concerned as to whether the physician's recommendations for treatment are permissible within the faith community of the patient. Practical questions concerning the permissibility of procedures such as in vitro fertilization, pregnancy termination, blood transfusion, organ donation, or the removal of life supports such as ventilators, dialysis, or artificially administered nutrition and hydration, arise regularly for persons of faith. In many cases, the chaplain will have specialized knowledge of how medical procedures are viewed by various religious bodies. In each case, the chaplain will first attempt to elicit the patient's current understanding or belief about the permissibility of the procedure in question.

The chaplain is also a helpful resource in providing or arranging for certain rituals that are important for patients under particular circumstances. Some patients may wish to hear the assurances of Scripture, others may want the chaplain to lead them in prayer, and still others may wish for the sacrament of communion, baptism, anointing, or the last rites, depending upon their faith system. The chaplain may provide these direct services for the patient, or may act as liaison with the patient's clergy person. In one case, the surgeon called for the chaplain to consult with a patient who was inexplicably refusing a life-saving surgical procedure. The chaplain gently probed the patient's story in an empathic manner, leading the patient to "confess" to a belief that her current illness was God's punishment for a previous sin. The ensuing discussion revolved around notions of God's forgiveness and the patient's request for prayer. In this case, the chaplain became the "embodiment" of God's forgiveness as he heard the patient's confession, provided reassurance of God's forgiving nature, and offered a prayer acknowledging her penitence and desire for forgiveness and healing. In another case, the neonatologist summoned the chaplain to the NICU when it became apparent that a premature infant was not going to live and the parents were distraught at the notion that their baby would die without the sacrament of baptism. In this case, the chaplain was able to discuss the parents beliefs, to reassure them that their needs could be met, and to provide an infant baptism service with the parents, the neonatologist and the primary nurse all in attendance. The chaplain also notified their home town pastor and helped make arrangements for the parents to be followed back home in their grieving process.

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What role should my personal beliefs play in the physician-patient relationship?

Whether you are religious, or areligious, your beliefs may affect the doctor-patient relationship. Care must be taken that the nonreligious physician does not underestimate the importance of the patient's belief system. Care must be taken that the religious physician who believes differently than the patient, does not impose his or her beliefs onto the patient at this time of special vulnerability. In both cases, the principle of respect for the patient should transcend the ideology of the physician.

It is clear that religious beliefs are important to the lives of many physicians. Some physicians attest to a sense of being "called" by God to the profession of medicine, a definite sense of vocation in the religious sense of a calling. In fact, in a much earlier time in the history of the world, the priest and the medicine man were one and the same in most cultures, until the development of scientific medicine led to a division between the professions. Modern physicians wonder whether, when and how to express themselves to patients regarding their own faith.

In one study reported in the Southern Medical Journal in 1995, physicians from a variety of religious backgrounds reported they would be comfortable discussing their beliefs if asked about them by patients.[8] The study shows that physicians with spiritual beliefs that are important to them integrate their beliefs into their interactions with patients in a variety of ways. Some devout physicians shared their beliefs with patients, discussed the patients beliefs, and prayed either with or for the patient. These interactions were more likely in the face of a serious or life-threatening illness and religious discussions did not take place with the majority of their patients.

Four guidelines are offered for physicians regarding religious issues:

  • physicians may enter such a dialogue, but they are not obligated to do so.
  • the dialogue must be at the invitation of the patient, not imposed by the physician.
  • physicians must be open and nonjudgmental in claiming that their beliefs are personally helpful, without claiming ultimate truth
  • the guiding principle should be "do no harm," the purpose of the dialogue should be burden-lifting, not burden-producing.[9]

Some physicians find a number of reasons to avoid discussions revolving around the spiritual beliefs, needs and interests of their patients. Reasons for not opening this subject include the scarcity of time in office visits, fear of imposing upon the patient, lack of familiarity with the subject matter of spirituality, or the lack of knowledge and experience with the varieties of religious expressions in our pluralistic culture. On the other hand, some physicians do incorporate spiritual history taking into the bio-psycho-social-spiritual interview, and others find opportunities where sharing their own beliefs or praying with a particular patient in special circumstances has a unique value to that patient. Certainly issues in modern medicine raise a host of questions such as whether or not to prolong life through artificial means, whether it is licit to shorten life through the use of pain medications, or what duty one has to a new born with fatal genetic anomalies. These and a myriad of other questions have religious and spiritual significance for a wide spectrum of our society and deserve a sensitive dialogue with physicians attending to patients facing these troubling issues.

How can I approach spirituality in medicine with physicians-in-training?

In one approach at the University of Washington School of Medicine, the elective course "Spirituality in Medicine" goes beyond teaching the spiritual history taking. The purpose of this interdisciplinary course is to provide an opportunity for interactive learning about relationships between spirituality, ethics and health care. Some of the goals of the class are as follows:
  • To heighten student awareness of ways in which their own faith system provides resources for encounters with illness, suffering and death.
  • To foster student understanding, respect and appreciation for the individuality and diversity of patients' beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.
  • To strengthen students in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.
  • To facilitate students in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.
  • To encourage students in developing and maintaining a program of physical, emotional and spiritual self-care which includes attention to the purpose and meaning of their lives and work.

Until recently, there were all too few medical schools that offered a formal forum to discuss humanistic aspects of medicine for medical students and residents. This situation is changing. Like the University of Washington, nearly fifty medical schools around the country have recently added new courses addressing spirituality in medicine. Increasingly, residency programs, particularly those with a primary care focus, are also incorporating this view in the training of residents. In addition, CME has been offered to practicing physicians through a series of annual conferences on "Spirituality in Medicine," the first of which was hosted by Harvard Medical School with Herbert Benson, MD, as facilitator.

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Core clerkship material for: General Curriculum

Thomas R. McCormick, DMin
Faculty, Department of Medical History and Ethics

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Last date modified: October 25, 2010