Talking About Spirituality In The Clinical Setting Can Being Professional Require Being PersonalDocument Transcript
The American Journal of Bioethics, 7(7): 4–11, 2007
Copyright c Taylor & Francis Group, LLC
ISSN: 1526-5161 print / 1536-0075 online
Talking about Spirituality in the
Clinical Setting: Can Being
Professional Require Being Personal?
Mark G. Kuczewski, Loyola University Chicago Stritch School of Medicine
Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conﬂict there. As a result, the use
of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this
language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients and their families to productively engage
in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient’s religious or spiritual beliefs and successfully
translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conﬂicts regarding treatment plans, resolution may require that clinicians
become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by
rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by
offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients.
Keywords: bioethics consultation, cultural competence, ethics consultation, medicine, physician–patient relationship, religion, spirituality
THE INTEREST IN SPIRITUAL TALK cusses the limitations and ﬁnitude of the healer, generally
There is a general interest in talking about spirituality in the the physician (Sulmasy 1997, 2006).
clinical setting. It is easy to draw a crowd for a talk or a con- As disparate as these strands of the literature might be,
ference on the topic and the number of articles that discuss they seem to begin from a similar view of the clinical setting
a link between spirituality and medicine are growing at a and the problems that spirituality poses within this environ-
consistent pace. Despite this growth, however, it sometimes ment. In general, spirituality or religion becomes thematic
seems that the literature and discussion of the relationship because it is foreign to the clinical environment. It is differ-
of medicine and spirituality cannot keep pace with the de- ent or out of place there. It is not that clinicians are hostile
mand. Why this interest? And what is all this discussion to spirituality or are anti-religion. But the language of spir-
about? ituality is not the coin of the medical realm.1 As a result, its
Like most intellectual currents, this one does not seem use seems to be a solicitation that is destined to be unan-
to be a single phenomenon with one motivation. In fact, swered and to open a distance between those who speak
a quick perusal of the literature shows a number of fairly this language and those who do not.
divergent concerns. There is research that extols the beneﬁ- Of course, medicine deals with intimate and ultimate
cial health effects of spirituality and religion (Koenig 1999, matters. Birth, illness, suffering and death may be common
2002, 2004). There is literature on talking with patients who events in the clinic. But to those who experience these events
liberally lace their informed consent discussions with reli- as people rather than professionals, they are more properly
gious language, including those who seem to be making construed as among the mysteries of existence that cause us
unreasonable assertions of cure or demands for seemingly to question or to marvel at the universe in which we live.
futile treatment based on religious views (Brett and Jersild The distance between caregivers and patients can be felt
2003). And there is a small but developing literature that dis- all the more acutely because of the very profundity of the
Received 30 June 2006; accepted 12 January 2007.
Address correspondence to Mark G. Kuczewski, Neiswanger Institute for Bioethics and Health Policy, Loyola University Chicago Stritch
School of Medicine, 2160 South First Avenue, Building 120, Room 280, Maywood, IL 60153. E-mail: email@example.com
1. Many distinctions can be drawn between spirituality and religion, the former more commonly referring to a person’s sense of ultimate
meaning and connection with that meaning and the latter more typically intending discursive or theological beliefs, moral principles,
and formal practices. However, I will not specify or attribute any particular deﬁnition to either term for the purposes of this article. The
present discussion concerns the role of meaning and beliefs, and their expression, in patients’ and family members’ approaches to clinical
decision-making. It is not clear that such distinctions are always of concern to, or used by patients and families in their decision-making
processes. Thus, such a distinction would be somewhat artiﬁcial for this discussion as can be seen in the case examples.
Talking about Spirituality in the Clinical Setting
experiences being lived there. That is, when those around us desire to understand how the patient’s beliefs impact his or
fail to relate to us during our trivial experiences, no harm is her choices and decisions (Sheehan 2003). On the simplest
done. But, when our most profound experiences take place characterization of this view, spirituality or religious beliefs
amidst people with whom we do not connect, that lack of are facts about patients that they bring to the clinical en-
connection can be glaring and painful. counter. Because these beliefs will factor into the decisions
Although there are many kinds of cases that have con- patients make, understanding these views can be helpful to
tributed to the current interest in spirituality, many of them the integrity of a sound informed consent process.
pose the issue of the chasm between provider and pa- Informed consent is the cornerstone of the contempo-
tient/family in stark terms. Most of the literature on spir- rary physician–patient relationship. In its narrowest in-
ituality is concerned with the impact of spirituality on the terpretation, it is a negative right to refuse interventions.
process of treatment decision-making, a process that has Patients must be informed of the treatment the physician
sometimes been idealistically characterized as “shared de- proposes, its risks, beneﬁts and alternatives, and the patient
cision making” between physician and patient (President’s may not be so treated unless he or she gives permission.
Commission 1982; Charles et al. 1997). That is, how can the Sometimes a patient’s religious or spiritual beliefs can lead
spirituality of the patient be successfully incorporated into to a refusal of a treatment that others commonly accept.
the clinical decision-making process? How can what seems High-proﬁle instances of such situations include Jehovah’s
to be a foreign language be successfully interpreted and its Witness patients who refuse blood transfusions (Carbon-
speaker engaged in dialogue? In other words, how can we neau 2003) or Christian Scientists who refuse a broad array
close the gap that may open when spiritual or religious lan- of medical interventions (Peel 1989). Conversely, religious
guage enters the shared decision-making process?2 or spiritual beliefs might lead a patient to desire to continue
I will illustrate and argue that there are two promis- interventions many people would consider to be without
ing approaches for engaging such language and helping beneﬁt. On this view, understanding spirituality or religious
patients and their families to productively engage in the belief is a kind of cultural competence. One wishes to know
decision-making process. First, patient-centered interview- about common belief systems among patients in order to
ing techniques can be employed to explore the patient’s understand their motivations and preferences, thereby re-
religious or spiritual beliefs and successfully incorporate specting their rights. In addition, this approach facilitates an
them into choices. Second, and more radically, I suggest understanding of religious nuances of which the patient or
that, in some more recalcitrant conﬂicts regarding treatment surrogate may be only vaguely aware. Thus, the culturally
plans, resolution may require that clinicians become more competent clinician takes steps to facilitate the inclusion of
involved and personally engage in discussion and disclo- the patient’s religious beliefs into the process of decision-
sure of religious and spiritual worldviews. I believe both making (Paasche-Orlow 2004). On a simple level, this inclu-
these approaches are supported by rich models of informed sion may involve knowing when it is appropriate to suggest
consent such as the transparency model and identify con- involving clergy or religious authorities the patient respects
siderations and circumstances that can justify such personal to sort out the full array of acceptable options.
disclosures. I conclude that we must be clear in our motiva- However, a more sophisticated view of informed con-
tions when making personal disclosures lest we succumb to sent emphasizes assisting the patient to make treatment de-
unprofessional excesses. cisions that accord with his or her values and sense of self
(Kuczewski 1996). The goal of informed consent is to help
SPIRITUALITY AND INFORMED CONSENT: A KIND the patient to make treatment choices in accordance with
OF CULTURAL COMPETENCE the long-held, stable the values that have characterized the
Most of the mainstream medical literature on spirituality is patient’s life plan. Informed consent becomes a process in
driven not by the hope of improving outcomes but by the which the physician and health-care professionals help the
patient to interpret how his or her values apply or can guide
2. I will not explore those writings that view religion as medical
the speciﬁc choices the patient faces (Emanuel and Emanuel
treatment and not simply part of the treatment decision-making 1992). As such, the patient’s religious and spiritual belief
process (Kass et al. 1991). Not surprisingly, being religious, partic- systems form part of the constellation of values important
ularly if it is expressed in spiritual practices such as church going, to the patient’s view of what is good and desirable in life.
prayer, or meditation, is often correlated with increased well-being This view of informed consent seems to form the basis of the
and better medical outcomes (Levin and Vanderpool 1987; Koenig recommendations of a prominent task force on discussing
1999). Because clinical medicine aims to produce good outcomes, religious and spiritual issues. They provide several case vi-
this literature easily suggests that such patient behaviors should gnettes to illustrate this approach (Lo et al. 2002).
certainly not be discouraged by physicians, and perhaps should be One important illustration involves a discussion con-
encouraged. Spirituality can become one more prescription (Dossey
cerning a patient’s do-not-resuscitate (DNR) status. The
1997; Benson and Stark 1997; Sloan et al. 2000). This approach to spir-
ituality is of little interest because it understands spirituality and
physician asks the patient whether he has considered a DNR
religion as medical categories rather than in their own terms with order, and the patient responds in religious terms, saying
their own distinctive contributions to the lives and decisions of pa- death is a matter of “when God calls.” However, the physi-
tients and families. As such, it will be judged by medical standards cian does not recognize this as responsive to the inquiry and
of efﬁcacy and be regarded or discarded based on these outcomes. repeats the original question. The failure to recognize that
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The American Journal of Bioethics
the patient is trying to respond to the question in terms of However, it should be noted that the model probably
his worldview and values is likely to inhibit communication works best under certain conditions. Namely, the physician–
and to make these decisions more difﬁcult than necessary. patient relationship, even if new and relatively undevel-
However, even if the physician is sensitive to the re- oped, is intact. There is no strong mistrust or palpable
sponse of the patient and knowledgeable about religious distance between the physician and patient that must be
discussions, it is not obvious whether the patient’s statement overcome. In making the initial spiritual utterance, the pa-
suggests a DNR order is or is not preferable. Recognition of tient shows openness to the clinician and is rewarded by
God’s ultimate control of life and death can support a deci- being invited to share more. Of course, if the health-care
sion to forgo resuscitation as well as to attempt it. Engaging provider fails to recognize the importance of the religious
the patient in his own terms does not immediately produce or spiritual utterances that the patient offers, such as in the
what the physician is most interested in, namely a treatment ﬁrst vignette, signiﬁcant distance could easily be created.
decision. But for the culturally-sensitive physician, supportiveness
The patient may have a clear idea what decision fol- and attempts to assist in facilitating the interpretation and
lows from his statement and all that is required is a clear application of the patient’s values and beliefs are generally
expression of his conclusion. It is just as likely, however, likely to be well received.
that he does not know exactly what he means at the time he
says it. Thus, to engage the patient in this discourse is to be- CONFLICTS IN THE CLINIC: SPIRITUAL TALK AS
come part of an interpretive process that helps the patient to CLOSING THE DISTANCE
come to reconcile his beliefs with the situation confronting
Some of the interest in spirituality and religion in the clinical
him. These authors counsel a patient-focused approach. It
encounter is motivated by physician–patient conﬂicts that
is likely that such an approach would mainly use probing
seem to be rooted in the religious or spiritual beliefs of the
questions, reﬂective listening, and expressions of support
patient (Curlin et al. 2005). Although every physician would
that foster the patient working through this process.
likely agree with the goal of improving the informed con-
Additional illustrations from these authors suggest still
sent process, conﬂicts are much more pressing and therefore
more complex situations. For instance, one vignette involves
likely to elicit more interest and attention (Brett and Jersild
a patient who seems despondent about her cancer and seems
2003). Imagine the case of an HIV-positive pregnant woman
to indicate that she sees it as a punishment from God. An-
who believes she has been healed.
other vignette describes a person who responds to questions
about treatment choices with responses about his hopes for A young woman who is HIV positive becomes pregnant and
a miracle. These scenarios make it obvious that they are presents to her primary care physician. Her primary care physi-
not advocating a simplistic model of informed consent that cian suggests a zidovudine (AZT) regimen to help prevent
takes the patient’s views as ﬁxed and given. That is, the transmission of the disease to the child. However, on a sub-
goal of asking follow up questions to these patients is not sequent clinic visit, the patient states that she participated in a
to elicit exactly which treatment options they desire. Rather, healing service at her church and had been healed of her HIV.
the treatment choices and plan will be the outcome of what The physician repeats the HIV test with the patient’s consent
might be a lengthy process of helping the patient to integrate and it shows that that patient remained HIV positive despite the
healing service. However, she continues to decline AZT and re-
the current situation with his or her larger world-view.
lated treatments as that would “show a lack of faith” on her part.
The goal for these authors is to be a supportive pres- The physician sought the help of the ethics committee and
ence and allow the patient to express his or her beliefs. This several consultants spoke with the patient. The patient clearly
patient-focused approach assumes that the patient usually possesses decision-making capacity. She repeatedly explains
works through the issues over time if he or she is allowed to that she understands the physicians think she is still HIV posi-
verbalize and make transparent his or her thought process tive but she knows differently from her faith. As she possesses
(Puchalski and Romer 2000). It is quite possible that there is decision-making capacity, she has the right to refuse treatments
something inherently therapeutic about explaining beliefs for herself.
at time of stress or crisis, perhaps doing so repeatedly over The attending physician and the ethics consultants were
a short period of time (Cohen et al. 2001). at a loss concerning what to do. The physician believed that
he should honor the patient’s refusal and continue with all
This patient-centered approach seems to be motivated
other pre-natal care. He would, of course, follow AZT protocols
by common situations encountered in the clinic and the best for the child once the child was born. The ethics consultants
traditions of the physician–patient relationship. The physi- pondered whether it would make sense to have the patient
cian fosters communication by encouraging exploration of bring her minister for a conference with pastoral care where
the patient’s belief’s and values. The physician also facili- these religious beliefs might be explored further.
tates the patient’s integration of the particular medical deci-
sions into the patient’s worldview. By helping the patient to Such conversations concerning “healings” or potential heal-
resolve the conﬂicting tendencies and competing interpreta- ings for which patients or their families are waiting are
tions of the patient’s beliefs and values, the physician treats fairly common in contemporary medical centers. It is easy
the whole patient, not simply the patient’s disease (Koenig to see why they are so problematic for health-care profes-
2000). sionals. The patient’s religious belief, in effect, prevents the
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Talking about Spirituality in the Clinical Setting
physician from doing what the physician does, i.e., practic- cian in order to bridge the interpersonal gap that can emerge
ing the standard of care. It is also easy to see how difﬁcult when patients raise matters of faith (Hall and Curlin 2004).
dialogue with the patient will be. The present example illustrates that this can involve quasi-
The conversation will typically be construed as pitting personal disclosures in that the physician may be explaining
science against faith. The physician will likely be in the his general worldview. However, once we acknowledge that
position of telling the patient that she is wrong. From the engagement on a somewhat personal level may be helpful
patient’s perspective, the physician is likely to be seen as rep- in the treatment decision-making process, i.e., to bridge an
resenting a faithless perspective and resisting her interpreta- interpersonal gap, we might ask whether such disclosures
tion may be seen as a test of that faith. As a result, additional may go beyond that of general worldviews and be more
conversations in which each summarizes his or her position particular in nature.
may actually exacerbate the problem and increase the dis-
tance between them. Although the physician would do well
to continue treating the patient and determine if caring for PERSONAL AND SPIRITUAL CONNECTIONS
the patient allows them to form a decision-making partner- IN CLINICAL ETHICS CONSULTATIONS
ship, there seems to be no conversational way to overcome Clinical ethics case consultations often evidence the char-
their difﬁculties if the physician continues to operate within acteristics of conﬂict and interpersonal distance in an exag-
the normal conventions of informed consent. gerated form. When an ethics consultation is requested, a
One member of the ethics committee suggested that the difference of opinion regarding treatment plan usually ex-
physician might translate his views into a spiritual world- ists and multiple efforts to resolve the conﬂict have usually
view. He could suggest that he understands the patient’s po- proven fruitless. As a result, the tensions between the health-
sition and that maybe the patient’s faith will prevent her and care team and the patient and/or patient’s family may be
her child from suffering the ravages of AIDS. But, the physi- strong and the sense of distance heightened. As we noted in
cian can explain that he believes that God works through the case of the HIV-positive woman, the patient or her fam-
medicine and that it is respecting creation to use what God ily may be speaking the language of religion or spirituality
has given us. This position need not be said in a challenging while the health-care team is talking solely in clinical termi-
way or be an attempt to argue the patient out of her position; nology. Of course, unlike that case, most ethics consultations
however, in explaining his worldview more fully, the physi- involve end-of-life decision-making, decisions that are most
cian is simply disclosing how he views the situation and hu- commonly associated with religious or spiritual discourse.
manizes himself. The physician, of course, incurs the risks The ethics consultant arrives in this scene in an unusual
associated with making himself vulnerable through sharing situation. The strength of the consultant’s position may be
his worldview and values. Should the patient not receive the lack of involvement in previous discussions and the op-
this disclosure in the spirit it is offered, it could seem hurt- portunity to bring a fresh perspective. Additionally, simply
ful on a personal level. However, this approach attempts to because of the presence of the consultant and the explana-
bridge the conversational chasm by working with a broader tion of the consultant’s function, the participants may grasp
model of informed consent, a transparency model (Brody the gravity of the situation in a new way and become more
1989). receptive to moving the decision-making process forward.
The transparency model, ﬁrst proposed by physician- However, the consultant also has several obstacles to over-
ethicist Howard Brody, eschews the view that information come. First, the consultant has no established rapport with
ﬂows unidirectional, from physician to patient. The trans- the patient or family. Thus, the consultant is a stranger to
parency model sees the goal of informed consent as the pa- them and can easily seem to be an employee and, there-
tient and physician each making his or her own thinking fore, an agent of the hospital or health system. Whereas
transparent to each other. They “mutually monitor” (Lidz ethics consultants commonly see their primary role as that
et al. 1988) each other as each discloses more information. of “facilitator” to the decision-making process, (Task Force
It is possible to argue that one can interpret a transparency on Standards for Bioethics Consultation 1998) the patient or
model as restricting disclosures to the diagnostic and pre- family is unlikely to see the consultant as a neutral party
scriptive thoughts of the physician and the values of the (Leibman and Dubler 2004). As a result the consultant may
patient. However, a more subtle and realistic interpretation inherit the distance that separates the clinicians from the pa-
would acknowledge that the physician’s values and assess- tient and family while having no history with the latter upon
ments of the beneﬁts of potential treatments often guide which to draw. Thus, establishing even the kind of minimal
the physician’s thought process. The medical facts are not connection necessary to facilitate productive discussion can
givens; what facts are uncovered is due in part to a value- present a great challenge.
laden thought process that directs the diagnostic testing pro- The case that follows is one in which I used a per-
cess. Such values may simply come from the standard of care sonal disclosure in order to further a bond with the patient
and the clinical culture, but they will sometimes be colored or surrogate decision maker in the course of conduct-
by the physician’s own experiences and, quite possibly, per- ing clinical ethics consultations. The consultation and the
sonal values. disclosure seem to have turned out well. However, de-
The transparency model of informed consent may pro- parting from standard operating procedure and having
vide a justiﬁcation for a self-reﬂective disclosure by a clini- positive outcomes does not constitute having scientiﬁc data.
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The American Journal of Bioethics
Nevertheless, I believe that a framework begins to emerge fortable. The treatment plan included keeping the patient on
from our consideration of the previous case can be used to the ventilator and maximal comfort measures. However, a do-
evaluate these actions. Consider this case: not-resuscitate order was written and no additional invasive
measures were initiated. The patient died within two days.
I was called to provide ethics consultation in a case involving
I conferred with the unit’s social worker who assured me
a patient who seemed to be dying but whose adult son was
she had talked with Mr. J and provided him with referrals to
conﬂicted concerning the best course of treatment for her. The
shelters and other social services.
patient had a long history of chronic obstructive pulmonary
distress (COPD) and had been in the hospital’s medical inten- This case ﬁts the general pattern of our previous case, that
sive care unit for several days. Her condition was deteriorating.
of the HIV-positive woman. The decision maker in this case,
Several of her organ systems had begun to fail and she would
soon need dialysis to prolong her life. The patient had a vari-
a surrogate for the patient, raises spiritual or religious con-
ety of very aggressive measures in place, but the dialysis team cerns and the conversation with the health-care team reaches
believed this next intervention would be unwarranted. The an impasse. However, the case is multi-layered. Mr. J’s reli-
team said that gaining appropriate access for dialysis would gious beliefs are not necessarily the cause of the impasse, al-
be very difﬁcult and would cause the patient much discom- though they may be contributing. After reviewing the teach-
fort. Although no one was sure how much longer the patient ings of the Catholic Church on care of the dying with the
would live, none of the physicians involved in the patient’s care chaplain, Mr. J did not seem to think his religion required
believed she would ever recover sufﬁciently to be discharged him to delay his mother’s death through dialysis or other in-
from intensive care. vasive measures. His hesitance to make a decision appeared
The patient’s surrogate decision maker was her son, Mr.
to be based more on personal factors such as the gravity and
J. He was a middle-aged man who seemed very devoted. He
responsibility of his decision. These factors seemed to isolate
sometimes stayed around the clock in the chair at her bedside
but sometimes left at night. Either way, Mr. J was there every him and cut him off from the health-care team.
day for many hours. Many of the clinicians on the unit believed I would hope to say that my decision to speak personally
he was homeless and lived in his car. The basis of this belief was to Mr. J was a strictly logical decision and that I was simply
not entirely clear. following a mental protocol. In one sense, this is true. In
Mr. J talked with the unit’s chaplain, a Roman Catholic particular, it seemed to me that the more times we reviewed
priest. Mr. J was also Catholic and asked how the Church’s the situation and met the same response of “You don’t know
teachings applied to his mother’s situation. The chaplain ex- what it’s like; it’s not your mother,” the more isolated Mr. J
plained the traditional teachings of the Church and how they was becoming; the chasm that separated the team and me
might apply. Despite several conversations, Mr. J had made no from him was growing wider. It was not clear how we would
decision regarding the dialysis question.
make progress toward a care plan. However, this assessment
I convened a conference that included Mr. J, the chap-
and the decision to try to cross that chasm clearly involved
lain, the attending physician and several other members of the
health-care team. The meeting proceeded in a normal fashion empathy and subjective judgments.
with discussions of the medical facts, various treatment options For whatever reason, I related to and liked Mr. J. I
being outlined, and inquiries concerning the patient’s wishes can speculate why—he was caring toward his mother; he
and values. However, when it seemed the appropriate time for seemed to be of Polish descent; despite what seemed to be
Mr. J to make a decision, he would decline saying, “You don’t modest means, he tried to dress neatly and to show respect
know what it’s like; it’s not your mother.” We left the ﬁrst meet- when visiting the hospital; and he seemed concerned to un-
ing without resolution and agreed to reconvene the next day. derstand his religion. Although the circumstances of our
The meeting the next day proceeded in a very similar fash- lives were very different, I felt I understood much of how
ion. Mr. J continued to reiterate “You don’t know what it’s like; he thought and felt. At the point when I decided to discuss
it’s not your mother.” After this had been said a number of
these decisions in terms of my own personal experience, it
times, I said, “Well, actually, most of us have to make these
decisions for our parents at some time and I can tell you that
was because I instinctively believed that the professional
we’re not asking you to do anything we would not choose for norms by which we proceeding were artiﬁcially preventing
our own parents. A couple of years ago, my father was diag- us from relating on a very human level, the level on which
nosed with cancer . . .” I went on to explain how my family Mr. J was going to make these decisions.
made these decisions and the role of our religion and spiritu- Religious and spiritual language was a way of relating.
ality in our thinking. I added that this was difﬁcult and sad, It provided a common idiom but probably also served a
but that I believed we had done the right thing. In particular, psychological and moral function. That is, it placed each of
I noted certain roles in the process that had been difﬁcult for us, and our decisions, within the context of a much larger
me but which I carried out as I thought it was what my father tradition. It provided terms for communication between us
in a language that had been spoken by many other “good
After the case conference discussion went on for a short
sons” making similar decisions for many years before us,
time further, Mr. J again turned to me and said, “Tell me that
stuff about your father again.” I retold the story. and overcame Mr. J’s sense of being isolated with his respon-
Mr. J agreed that the physicians should not initiate any new sibilities. The religious and the psychosocial dimensions are
invasive measures on his mother. He asked that the physician intertwined and addressed through the same means, mutu-
talk again with him the next day about stopping things that ally constructing a narrative that places these decisions in a
were already started that might be making his mother uncom- broader context.
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Talking about Spirituality in the Clinical Setting
While the connection between the patient’s son and me spiritual or religious language is a mode that many pa-
was personally satisfying, that satisfaction was not an end tients use to express their thoughts, feelings, beliefs and
in itself. The motivation for the interpersonal connection values. Mere cultural sensitivity and competence requires
was clearly to help with this surrogate’s decision-making that patients and families be welcomed and respected in
process. It was shared decision-making in a robust sense of expressing themselves in the terms that are most comfort-
that term. As noted in the discussion of the transparency able for them rather than have to translate or reframe their
model of informed consent, certain values regarding what thinking in the idiom of the clinic. Finally, informed con-
is thought to be best direct what information the health-care sent is probably best conceived as entailing not only that
team chooses to present or represent. For instance, we were the patient’s values and preferences are made transparent,
holding these meetings with Mr. J because we valued limit- but that physicians and clinicians contributing to the plan
ing the patient’s pain and suffering and limiting the indig- of care also make clear the values that are guiding their
nities of further invasive procedures over the possible ex- recommendations.
tending of life a few more days or perhaps several weeks. In Of course, the case illustrations we have examined
making an interpersonal connection through personal dis- also strongly suggest a secondary justiﬁcation. Namely, the
closure, I was taking explicit responsibility for these values bonds of human connectedness and interpersonal trust can
and making them transparent. My motivation was simply be fostered by discussing momentous conditions in human
to support the shared decision-making process. While it is and spiritual terms rather than simply in the language of
always difﬁcult to be self-critical, I think this motivation can choices and preferences. This approach may simply be a part
potentially justify such actions, especially when supported of a salutary caregiver-patient relationship. In fact, it may
by speciﬁc facts of a situation such as Mr. J’s statements that be an important element in transforming it from a provider–
seem to be requesting such a disclosure. consumer relationship into a caregiver–patient relationship.
This justiﬁcatory framework responds to the concerns
TOWARD A FRAMEWORK AND PRACTICE GUIDELINES of possible excesses by placing them in perspective. That is,
FOR ENGAGING SPIRITUALITY once we examine the justiﬁcations for clinicians exploring
When we reﬂect on the cases we have considered, the ironies or engaging the patient’s spirituality, we understand that
of contemporary medical care may seem to jump off the concerns about excesses cannot be used as reasons to pro-
page. We ﬁnd vulnerable persons facing difﬁcult situations hibit such discussions or for restricting them to chaplains.
and tragic choices. The details of their own or their loved Physicians and virtually everyone who engages in patient
one’s biological functioning are sometimes very apparent, care at a health-care facility should be culturally compe-
potentially embarrassing elements of their social history tent, and it would be nonsense to say that that any discus-
may be clear, yet we commonly approach such things as sion of cultural beliefs or their impact belongs solely to one
spiritual or religious history and beliefs with some trepida- specialty. Similarly, while cultural sensitivity typically will
tion. To be fair, this is not without reason. be patient-focused, it would be strange to argue that there
There are at least two realistic concerns. First, physicians are no circumstances under which health-care professionals
are not chaplains and may incompetently handle such dis- can disclose their cultural beliefs and worldviews. In other
cussions with patients or families. Second, physicians may words, we have probably established that medicine has too
use the new emphasis on spirituality and relating personally long erred in wrong direction, the direction of value-neutral
to patients to inappropriately shift the focus to themselves language and professional distance.
and their beliefs, perhaps, to engage in proselytizing. Although we may accept that discussion of spirituality
To respond to these concerns, it is not clear whether should become more common in the clinical setting, it is
we best address these issues by way of the justiﬁcatory realistic to ask if there can be any guidelines to help curb
framework that supports physicians engaging their patient excesses. Three guidelines seem to follow from our illustra-
in discussion of the patient’s spiritual history and beliefs tions and may form part of a protocol or practice pattern in
or through practice guidelines that might help a physician these discussions.
avoid committing such errors. Perhaps an effective response First, it is important to discuss spiritual or religious mat-
requires addressing these concerns from each perspective. ters with patients who welcome it or invite it in some manner
The main justiﬁcation is simply a series of three impli- and to avoid doing it with patients who are uncomfortable
cations of the doctrine of informed consent. First, procur- with it. Simply asking as part of an initial history whether the
ing the informed consent of a patient or a decision based person considers him- or herself a spiritual or religious per-
on the substituted judgment of an appropriate surrogate son or a person of faith and whether the patient is comfort-
decision maker entails that the patient’s values and life able talking about such matters with health-care providers
narrative be part of the care plan. As we have noted, this will immediately provide a context for meeting the needs of
often requires assisting the patient and family to inter- patients for privacy or for dialogue. Similarly, in the cases
pret how their values might apply in the particular situa- we considered, the patients introduced the terminology of
tion they ﬁnd themselves. Within this frame of reference, spirituality and religion and thereby laid the foundation to
a spiritual history may be seen as a form of a values his- explore these matters further.
tory, an uncontroversial but underutilized mechanism to Second, self-disclosures can only be made if they are
facilitate the treatment decision-making process. Second, responses to patient/family wishes or are important to
July, Volume 7, Number 7, 2007 ajob 9
The American Journal of Bioethics
the transparency of the informed consent process. In other uations. To fail to engage the patient’s or family’s spirituality
words, physicians and other clinicians, including ethics con- directly can seem disrespectful by standard conversational
sultants, can respect direct requests from patients or their and interpersonal norms and thereby turn professional dis-
family members or less direct ones as in the case of Mr. J. Fur- tance into an unbridgeable chasm.
thermore, I have also suggested that disclosures of values What remains a question for additional exploration is
and world-view that underpin recommendations should be the interpersonal and spiritual connection between physi-
disclosed. In many cases, this may seem superﬂuous be- cian and patient or any clinician and the patient or family,
cause providers and patients share worldviews. But, con- even when particular decisions are not at stake. The pro-
ﬂicts can reveal differences of viewpoints and that chasm fessional norms may be becoming relaxed as we hear that
may only be bridgeable by interpersonal dialogue that in- some physicians attend patients’ funerals and the question
cludes speciﬁc narrative details as well as worldviews. of praying with patients has been receiving attention (Lo
Third, medicine and educational institutions such as et al. 2003). Are these connections to be encouraged and
medical and nursing schools must help professionals to in- exactly how far should they extend? I have justiﬁed some
corporate habits of reﬂection and develop forums for feed- efforts to make the interpersonal connection and speak the
back and self-care. We cannot possibly develop a sufﬁciently patient’s language in an effort to resolve conﬂict. But, where
nuanced list of “do’s and don’ts” to govern discussions be- no conﬂict exists, are we simply too squeamish owing to
tween physicians and patients that will exactly hit the mark the traditional professional norms we have embraced? Af-
between appropriately discussing spirituality and inappro- ter all, from a lay perspective, clinicians routinely deal with
priately shifting the focus from patients to providers or very intimate patient matters but become very uncomfort-
self-indulgently directing conversations in ways that meet able when it comes to simple spiritual matters.
provider needs more than those of patients. Forums for re- I have tried to suggest that we are a bit too cautious.
ﬂection should help caregivers in their spiritual and emo- However, we must never fail to be self-critical and ask
tional self-care so that self-indulgent excesses do not need to whether we are actually serving patient needs or are serving
seek an outlet in the clinic. And, in sharing their clinical ex- ourselves. Protocols and rules of thumb that can guide us
periences and receiving feedback, providers can reﬁne their to avoid self-serving impulses are needed. Similarly, ways
intuitions regarding how to be a caring and facilitative pres- of caring for ourselves that can nurture such dimensions of
ence to their patients. ourselves and help us to cope with dealing with such per-
These protocols probably do not provide the rules that sonal, ultimate matters in an antiseptic environment should
many would like. For instance, a rule such as “Don’t pros- be developed. (Kuczewski 2004)
elytize” may seem more appropriate. While such rules of
thumb certainly have their place, it is probably also true REFERENCES
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