How should caregivers deal with the issue of spirituality?
Divergence exists among chronic care providers
Shamans — the oldest known healers — were physicians/ priests who catered to the needs of patients on every level according to the available wisdom. Whether consciously or not, shamans knew that healing occurred on three levels: body, mind, and spirit.
Few modern health care professionals would disagree that this is a basic need of all humans. Yet there is a great divergence of opinion about how this should take place. Should today’s physician, nurse, or patient advocate also play the role of priest or priestess, minister, or rabbi?
Some say health care professionals should remain sympathetic, empathetic, but clinically detached from the spiritual needs of their patients, referring them to the professionals for spiritual succor. Others insist the shaman’s way must return, and to heal the patient, we must address all the patient’s needs — physical, emotional, and spiritual. The divergence may not be as wide as it might first seem. Just as no responsible health care professional would suggest a primary care physician should treat a serious psychological disorder or attempt complex surgeries, few, if any, would argue that serious spiritual crises are best left in the hands of specialists.
Numerous studies show the positive effects of belief systems on the course of illness, healing, and even mortality, although there are varying opinions on their quality and value.
A 1993 patient survey reported in the Archives of Physical Medicine and Rehabilitation1 showed:
• 74% considered their religious and spiritual beliefs important.
• 54% desired pastoral counseling.
• 45% thought health care professionals paid too little attention to their spiritual and religious concerns.
• 73% said no one on staff ever inquired about these matters.
• 16% of physicians on staff, according to patients, ever inquired about spiritual or religious matters.
Clinicians on the front lines are faced every day with ethical dilemmas that are demanding more answers as American society turns more and more to matters of religion and spirituality:
Consider these situations:
• Should you agree to a patient’s request for prayer just before surgery?
• Should you recommend, as recent literature suggests, that a patient might find peace, and perhaps healing, through faith?
• Do patients want you to discuss spiritual issues with them?
• Is it ever appropriate to encourage or discourage religious beliefs for the "benefit" of the patient?
There are no clear answers.
Complementary Therapies in Chronic Care spoke to experts on both sides of the issue who offered their viewpoints. (For additional viewpoints, see related stories, pp. 27-29.)
Stay away from religion
A cross-disciplinary team of physicians and clergy from a variety of faiths created a sensation in June when they wrote to the New England Journal of Medicine2 questioning "the implications of making religious and spiritual matters part of medical care."
While conceding that recent research suggests that religious faith and practice are positively associated with health status, the authors wrote, "We are concerned that broad generalizations are being made on the basis of limited, narrowly focused and methodically flawed studies of the place of religion in medical practice."
The letter was signed by Richard P. Sloan, PhD, associate professor of psychiatry at Columbia University College of Physicians and Surgeons in New York City, as well as seven members of the clergy affiliated with the ecumenical HealthCare Chaplaincy in New York City. That organization is the country’s largest freestanding chaplains’ organization, which contracts pastoral services to hospitals, nursing homes, and hospices. The clergy who signed the letter represent six different faiths: Roman Catholic, Protestant, Jewish, Islamic, Buddhist, and Greek Orthodox.
"It is never appropriate for a doctor to offer to pray with a patient," says Sloan. "The patient ought to be free to practice religion in whatever way he wants without interference."
Furthermore, he says, the physician, nurse, or other health care professional should refer a patient to a chaplain when asked about spiritual matters about which they have no expertise. "At the same time, physicians should be nice people. They shouldn’t treat people like a piece of meat, but they also don’t have to be counselors."
Sloan’s group made three basic points in the letter:
1. Empirical evidence for the idea that religious activities promote health is "generally weak and unconvincing since it is based on studies with serious methodological flaws, conflicting findings and data that lack clarity and specificity." They concede that two recently reported "well-conducted" studies show that attendance at religious services is associated with reduced mortality.
2. Physicians should not recommend religious activity as a way of providing comfort. Since physicians have considerable influence with patients, Sloan and colleagues argue, "physicians and patients, alike, are on dangerous ground if they believe that advice about religious matters has the same medical support as a recommendation about an antibiotic treatment." Such assumptions have a ring of coercion and raise ethical questions about patient autonomy in religious matters, says Sloan. Furthermore, the signers argue, physicians are not properly trained to engage in in-depth conversations with patients about their spiritual concerns.
3. Finally, Sloan and his group note that only a minority of patients say they want a spiritual or religious component as part of their medical care, and those results appear to be derived from studies of patients in a family care setting. "The degree to which patients express an interest in incorporating religion and spirituality into medical care depends on the clinical setting, the interpersonal and communication skills of the physician, the nature of the specific physician-patient relationships, and the characteristics of the patient," Sloan wrote.
Given the time constraints that are well known to health care providers, Sloan comments, "We question the assumption that this interest justifies the incorporation of religious matters into medical practice. Patients often ask for things that are unrealistic or may not be in their best interests."
One of the letter’s authors, Larry VandeCreek, DMin, director of pastoral research for the HealthCare Chaplaincy in New YorkCity, says, "From the chaplain’s point of view, we are not interested at all in protecting our professional turf. There’s enough sin and sickness in the world to keep everybody busy.
"Yet, VandeCreek contends, "Religion is a very private issue, and patients and physicians alike have enormous amounts of feelings."
What should a surgeon do if a patient on the operating table requests a moment of prayer?
"I think there will always be patients who raise religious and spiritual issues with their physicians and there will be times, perhaps, like in a situation where the two have known each other for a long time or are members of the same religious congregation, in which is it appropriate for the physician to respond," he says.
References
1. Anderson J, Anderson L, Felsenthal G. Pastoral needs and support within an inpatient rehabilitation unit. Arch Phys Med Rehabil 1993; 74:574-578.
2. Sloan R, Bagiella E, VandeCreek L. Should physicians prescribe religious activities? N Engl J Med 2000; 342:1,913-1,916.
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