Spirituality, Religious Wisdom, and the Care of the Patient
B. Astrow, M.D.
Questions about meaning and purpose, hope and despair, and ultimately, about life and death are often "in the air" when doctor and patient encounter one another in the context of serious illness. Because these sorts of questions do not lend themselves to neat, evidence based responses, nor ready technical solutions, they may not be seen as worthy of sustained attention from medicine as a whole. The yearlong conference series, "Spirituality, Religious Wisdom, and the Care of the Patient," that we are hosting at St. Vincent's Catholic Medical Center, Manhattan is designed to serve as a forum for the discussion of these crucial matters for health care professionals and patients and their families.
The series hopes to explore ways in which spiritual values can be translated into practical action in health care by presenting clinical case scenarios to religious thinkers from the Catholic, Protestant, Jewish, Moslem, Hindu, and Buddhist traditions. We have chosen to focus each of the monthly interfaith dialogues around a different spiritual value: hope, dignity, healing, gratitude, suffering, faith, forgiveness, and love. The idea is to promote open-minded discussion between medicine and those humanistic disciplines that address the larger context in which medicine is practiced and illness experienced.
Why involve religion? Spiritual questions were once considered the exclusive province of organized religion. Many 21st century Americans, though, prefer to see themselves as generically spiritual rather than tied to any particular religion and may associate religion with sentimentality, prejudice, and anti-intellectualism. For physicians, religion's legacy of opposition to medical science is troubling. For our patients, while many draw strength and comfort from their religion, others feel alienated from and rejected by the faith in which they were raised. For all of us in the aftermath of the events of 9/11, religious faith unavoidably calls to mind suggestions of fundamentalism and fanaticism. On the other hand, spiritual eclecticism, so-called "new-age" spirituality, may lack the depth or rigor people need to get though life's toughest trials.
For the purposes of this series, we treat religion less as a source of unequivocal answers than as an indispensable mode of entry into a longstanding conversation about what it means to be a human being. Even those patients who deny any religious belief may be secretly deeply interested in the questions that religion raises and long for some explanatory system that will help them make sense of the experience of illness. Physicians too may sense a religious dimension to many of our most difficult clinical encounters and may find that religious wisdom has something unique to contribute in sustaining our ability to find meaning in our work and to see our patients as individuals.
The first in the series was held in November of 2001 and focused on hope and the care of the patient. Daniel Sulmasy, M.D., PhD, OFM, Chairman of the John Conley Department of Ethics at St. Vincent's and Abraham Twerski, M.D., Associate Professor of Psychiatry at the University of Pittsburgh and author of many volumes on Jewish spirituality were the featured speakers. Sulmasy, discussing what hope means for Christian patients facing death, maintained that ultimate hope for a Christian could never be placed in any finite object. "The Christian hope is in the only reality that can transcend death - it is hope in the love of God. This hope is possible for those who engage death, as they engage life, open to other persons, to the universe, and to God. And 'God's love, poured out for each individual person, and for everyone else, and filling the entire universe in all of its parts' (Eph 1:23), is enough for us. A dying Christian can hope to fall head over heels into the love of God."
Twerski's approach was less systematic, grounded in his many years experience as a psychiatrist caring for individuals addicted to drugs and alcohol and his repository of stories gleaned from his background as son of a noted Chasidic rebbe. While he agreed with Sulmasy that love of God was the ultimate end, his advice was to "love your fellow man" in the hopes that eventually that would lead to the love of God.
The speakers were asked to consider the case of a 60-year-old woman with ovarian cancer metastatic to liver and bone. The cancer has progressed through multiple chemotherapeutic regimens and the patient has grown increasingly anxious and depressed about her condition. She calls the nurse practitioner who has been helping to care for her 15-20 times a month seeking reassurance. "I don't want to die. I have to be around for my granddaughter," she will lament. "I want to see her get married."
How, the speakers were asked, can physician and nurse best respond to this patient's pleas? Should they simply reassure her, that more treatment will be given and all will be well, deferring the delivery of bad news to another time or perhaps to someone else? Or should they force the patient to confront reality: that she has an incurable disease with limited life expectancy. Is it the responsibility of the medical team to help sustain a patient's sense of hope or should the team focus on providing the best possible medical care and allow others to address those needs?
Twerski stressed the importance of listening to the patient, of viewing the patient not only as victim of illness but also as teacher. He urged the medical team to address the loneliness of the seriously ill, the fear of being abandoned and advised careful efforts to steer between giving patients false hope and totally negating their wishes. A patient who hoped to make it to a granddaughter's wedding could be told, "I certainly also hope that you will make it though naturally this is not something that I can promise you." A nurse in the audience then related her experience with a young man dying of cancer. She had helped him write a conciliatory letter to his mother, with whom the patient had been at odds. As soon as the letter was mailed, his anxiety resolved.
An honest effort to grapple with questions that in the end have no good answers may be all that one can ask of physicians. The act of listening to patients, finding out who they are, what their lives have been about, what it is they hope for and why, may over the course of a relationship help the patient to adopt realistic hopes gradually. When the spiritual dimension to illness is evaded, though, when the patient is seen as a collection of organs and parts rather than as a person, patients may be deprived of the opportunity to work through the spiritual issues that define us an individuals-to reconcile with friends and family, for instance, to complete a project that has meaning or simply to treasure and enjoy the simple pleasures of day to day existence.
When the attending physician in particular shies away from facing the spiritual situation of the patient, the morale of the health care team is threatened, with house staff, nurses and social workers unfairly left to attend to the patient's spiritual needs without acknowledgement that this is a necessary and highly valued contribution to the patient's well being. Successfully addressing these issues allows the physician to stay connected to the patient, serves as a model for physicians-in-training, and is energizing to all the professionals involved in the patient's care. When physicians are able to see their work as both a scientific and a moral discipline, they are reminded of the intrinsic value of their efforts and the likelihood of "burn-out" may be reduced. We need to remind ourselves that the medicine is a human art. Religious wisdom may help us to see it so and to see that the practice of looking at illness and healing from a religious viewpoint has a powerful intellectual lineage.
Published: January 23, 2002