Separation Anxiety Between
Religion and Medicine:
Reclaiming the Sacred Dimensions of Healing
By James D. Campbell,
Ph.D. and David A. Fleming, M.D.
A patient with pancreatitis
is found to have a large pancreatic mass.
A subsequent CT-guided needle biopsy reveals
pancreatic carcinoma. Pancreatic neoplasm
may originate from either exocrine cells
that produce digestive enzymes or endocrine
cells that produce insulin, but both are
quite lethal. Ninety percent of pancreatic
neoplasms are malignant and incurable and
have a 90 percent one-year mortality.
What
the physician says… "The biopsy shows that you have cancer.
Unfortunately, we cannot surgically remove
the cancerous tumor. Chemotherapy and radiation
therapy are available, but usually they
are not effective. Inoperable pancreatic
cancer has a very high mortality within
one year."What
the patient hears… "The biopsy that we did two days ago
shows that you have cancer…cancer…cancer."
From the white-coated
authority, you, the patient, have heard
the dreaded "C-word." A needle has penetrated
deep into ancient fears. Your mind is spinning.
Your pulse quickens. You start to shake
as if the foundations of your very life
have been uprooted and tossed into chaos.
A void opens in your gut. The landscape
of the clinic becomes alien and surreal.
Sounds and colors fade into the background
except for the white, metallic sound of
the physician's voice. Cold. You are now
like a distant observer of your fate. Questions
abound: What is going to happen to me? Why
me? Where will I go? What do I do now? To
whom do I turn?
Likewise, the health
practitioner is challenged at such times
with self-awareness of unbuffered human
frailty and undeniable human finitude. A
finely tuned intellect, skilled hands, and
access to an expanding arsenal of medical
technology are frequently no match for nature
in such malignant circumstances. The physician
qua human being must also come to grips
with the realities of personal limitation
and the inevitability of death and will
ask, "Why me" and "What can I do for this
patient now?" The loneliness and desperation
of observing suffering and the inevitable
death of a patient, with whom they share
a covenant relationship, can likewise lead
the physician to ask, "To whom can I turn?"
The often unanswerable and transcendental
"why" is fundamental to religion and the
spirit. Such questions are often asked of
ancient healers and modern medical professionals
alike.
Healing's
sacred dimension
Although this example
is severe in its rendering, it does bring
into focus the precarious balance between
religion, spirituality, and medicine. Examining
issues of life and death are seen as the
province of both religion and medicine,
albeit from different perspectives. Both
religion and medicine preside over many
of life's important transitions-birth, development,
illness, and death. Even in the commonplace,
they are counterpoised to consider the well-being
of the individual in physical, mental, and
spiritual health.
Practitioners of both
religion and medicine are concerned with
sustaining and regaining health. The very
definition of health and healing exemplifies
the duality of restoring both the body and
the spirit. Historically, these two elements
of healing were often embodied in the same
practitioner, such as a shaman. The practitioner
did not consider the separation of mind,
body, and spirit but would treat the "whole"
patient.
Even today, many cultures
and traditions still regard the separation
of mind, body, and spirit as illusory. However,
the emergence of modern Western medicine
and the attendant biomedical model has generally
placed a premium on distinguishing between
these parts of the individual, focusing
primarily on the secular, physical body.
Advances in biotechnology and the objectification
of medical science have further exacerbated
this division to the point that there is,
currently, a separation anxiety in the medical
profession and an attendant loss of the
sacred dimension.
In the modern paradigm
of health care, the good of the patient
is defined in biomedical terms. When these
goals no longer can be achieved, the health
care provider often has a sense of frustration
and angst. Feeling defeated, the physician
may withdraw psychologically and emotionally
because "nothing further can be done" for
the patient.
Shifting
attitudes?
Evidence of separation
anxiety between health and religion in the
practice of medicine is clearly shown in
a Newsweek cover story entitled Faith
& Healing. Claudia Kalb, in the November
10, 2003, issue examined the debate over
whether religion is good for medicine. She
noted that many in the medical profession
now seek more ethical and effective ways
to combine patients' spiritual and religious
beliefs and practices with high-tech treatment.
"There's been
a tremendous shift in the medical profession's
openness to this topic," Kalb writes. This
openness is not universal, which is exemplified
by the article's juxtaposition of two leading
scholars, Harold G. Koenig, director of
the Center
for the Study of Religion/Spirituality and
Healthat Duke University, and Richard
Sloan, director of behavioral medicine at
Columbia-Presbyterian Medical Center.
Koenig suggests that
medical students ought to learn about religion
and health and that physicians should take
spiritual histories on their patients. "As
we've moved into the later 20th century,
we recognized that there are questions of
meaning and purpose that science just doesn't
have very good answers to. Also, patients
want to be talked to. They are tired of
[being] treated like bodies, just physical
bodies. Plus, older adults in America today
are a very religious population," Koenig
says in the article.
Sloan, however, has
concerns about merging religion and health
care matters. (See The
Critic: ‘Religion Is a Private Matter’.)
Although Sloan agrees that physicians should
understand the various dimensions of their
patients' lives — including the religious
and spiritual ones — he believes that
too closely aligning religion and health
could cause harm. "It's bad enough to be
sick, it's worse still to be gravely ill,
but to add to that the burden of remorse
and guilt for some supposed failure of religious
devotion is unconscionable," he says.
Doctor-patient
relationships
While scholars debate
the issues and the medical practitioners
ponder what to do, patients also exhibit
evidence of this separation anxiety. Would
our patient with pancreatic cancer want
to have his physician address spiritual
or religious issues? Would patients welcome
their doctors asking about their religion
or spirituality? Here, too, there is controversy.
Although some (most) patients feel that
physicians should be aware of their patients'
beliefs and practices, others clearly do
not. Then again, like physicians, some patients
would only want these considerations addressed
under certain circumstances, particularly
during a serious illness.
Because not all physicians
and patients find communication about religious
issues acceptable and because many would
rather have medicine focus on physical issues,
physicians are faced with a dilemma. Should
the profession encourage all medical schools
to require students to be knowledgeable
about religious and spiritual issues? And
should physicians be encouraged to take
spiritual histories?
A similar dilemma arises
when considering the closely linked subject
of cultural diversity. It is expected that
sensitivity to cultural issues will improve
the delivery of health care, and medical
schools and physicians have been encouraged
to develop cultural competence. Are questions
relating to cultural issues an invasion
of privacy or are they a component of a
good patient evaluation? Are such discussions
harmful or will they be helpful? How is
developing sensitivity to a patient's cultural
background, particularly in the situation
of a life-threatening disease, any different
from gaining knowledge about a patient's
religious or spiritual beliefs and practices?
Both figure prominently in patients' perceptions
of illness and health by interpreting these
experiences and by providing a sense of
meaning to life. Neither should be taken
for granted.
Some medical schools
and physicians have decided that it is important
to address religious and spiritual issues
in the doctor-patient relationship. According
to the Association
of American Medical Colleges, more than
half of all medical schools in the United
States either have a required or elective
course in religion, spirituality, and health
or have integrated these topics across the
curriculum, with a focus on taking a spiritual
history. AAMC's
Medical School Objectives Project has
recommended that students be trained to
understand the spiritual dimension of people's
lives.[1] The medical profession
has begun to acknowledge that religious
and spiritual dimensions, like cultural
differences, can affect health and illness.
Clinical studies are beginning to clarify
how spirituality and religion can contribute
to the coping strategies of many patients
with severe, chronic, and terminal conditions.
Chechinov, among others,
discovered a few years ago that a positive
mindset and a supported sense of "self"
tend to have a positive impact on clinical
outcomes for patients approaching the end
of life.[2] Now there is
indication that spirituality may promote
longevity, protect against cardiovascular
disease, and improve recovery from acute
illness. An extensive review of the literature
by Post, Puchalski, and Larson indicated
that patient expressions of spirituality
and religious belief are important to health
outcomes and that recognition of these expressions
by physicians, with appropriate response,
is important.[3]
It is precisely because
physicians don't often know what patients
are thinking or feeling after being given
bad news that they should at least inquire
about spiritual needs. Although some acknowledge
the importance of these discussions and
the concept that this knowledge may benefit
the doctor-patient relationship and enhance
medical decision-making, most physicians
are uncomfortable with actually doing it.[4,5]
Much of this discomfort may be due to the
underlying separation anxiety caused by
the focus on physiology, pathology, and
anatomy—to the exclusion of the mind
and spirit—as well as a fear of projecting
one's own beliefs on a patient.
Most patients welcome
an opportunity to discuss their religious
beliefs and practices with their physician.[6]
There continues to be disagreement as to
the extent to which physicians should engage
in discussions about religion and faith
with their patients. Many physicians are
just not comfortable going there.[7]
The Oslerian tradition of medical training
tends to encourage professional detachment
and repression of feelings and personal
beliefs in the interest of unencumbered
clarity of clinical judgment and a desire
for uncoerced patient choice. After all,
personal bias may unfairly influence our
ability to think clearly and objectively
when considering the evidence, the holy
grail of medicine. Physicians are conditioned
to maintain a comfortable and objective
distance from patients, no matter how long
and rich the relationship, by protecting
themselves with the symbols of their station:
the long white coat and a well honed "doctor-speak",
undecipherable to the common person, if
not to each other. When these barriers are
breached physicians tend to squirm, realizing
that they too are vulnerable.
For both the physician
and the patient, then, an important question
becomes, "What do I do now?" From the perspective
of the physician, "What is my own sense
of spirituality?" and "Should I address
religious and spiritual issues with my patient
if we are of a different faith? And, if
I broach these issues with my patient, how
can I do so without imposing my own attitudes?"
From the perspective of the patient, "Do
I want my physician to be aware of my beliefs
and practices and, if so, when and how would
I like my physician to talk about these
issues?"
Next
steps
Clearly, there are no
easy answers to the questions faced by both
physicians and patients as to how to handle
spiritual issues related to life's major
transitions and the influence of disease.
One approach that can be useful for physicians
is to incorporate open-ended questions into
the clinical interview with patients that
can assess the impact of spiritual issues
and patients' interest in discussing spiritual
issues. For example, a physician might inquire
of the patient with pancreatic cancer about
the impact of the news of a life-threatening
disease in terms of the patient's spiritual
life and/or views. The patient, then, can
receive from the physician the permission
and encouragement to talk about the delicate
interplay between spirituality and medical
issues if the patient so desires.
Many people who work
with patients have noted that open-ended
questions let the patient decide whether
to pursue a discussion of spiritual issues.
Patients often will indicate quickly to
physicians by comments and comfort level
whether they wish to discuss their situation
in terms of their spiritual views or not.
Such an approach, when used with other areas
of investigation, can be an effective way
to open a conversation on such topics and
can let the patient know that his or her
views about questions of life's meaning
are pertinent and acceptable to discuss.
Simply asking, "Are there any spiritual
needs or concerns that we should talk about?"
may be all that is needed to inform the
patient that the physician is aware and
ready to deal with these issues if and when
the patient is ready.
Attention to patients'
spirituality and religious practices will
help the physician reclaim the sacred dimension
of healing by fortifying the primacy of
patient respect and autonomy. Such action
confirms patient-centered care and places
on the medical profession the responsibility
of developing heuristic methods and training
programs that will facilitate sensitivity
to patients' religious beliefs and practices,
spiritual needs, and cultural orientation.
This also will encourage physicians to be
in touch with their own spiritual identity.
Physicians who are self-reflective and willing
to communicate in this realm can do so without
fear of harm if they sustain a strong and
trusting partnership with their patients.
References
Post
S, Puchalski C and Larson D. Physician
and Patient Spirituality: Professional
Boundaries, Competency and Ethics. Ann
Int Med 2000; 132(7): 578-583
Chinball
JT, Brooks CA. Religion in the clinic:
The role of physician beliefs. Southern
Med J 2001;94:374-80.
Ellis
MR, et al. Addressing spiritual concerns
of patients: Family physicians' attitudes
and practices. J Fam Pract 1999;48:105-9.
Ehman
JW, et al. Do Patients Want Physicians
to Inquire about Their Spiritual or Religious
Beliefs if They Become Gravely Ill? Arch
Int Med. 1999; 159: 1803-1806
Ellis
M, et al. What do Family Physicians
Think about Spirituality in Clinical Practice?
J Fam Practice. 2002; 51(3):249-254
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