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Talking About  Spirituality In The  Clinical  Setting   Can  Being  Professional  Require  Being  Personal
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    Talking About  Spirituality In The  Clinical  Setting   Can  Being  Professional  Require  Being  Personal Talking About Spirituality In The Clinical Setting Can Being Professional Require Being Personal Document Transcript

    • The American Journal of Bioethics, 7(7): 4–11, 2007 Copyright c Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265160701399545 Target Article 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: mkuczew@lumc.edu 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. 4 ajob
    • 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 July, Volume 7, Number 7, 2007 ajob 5
    • 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 6 ajob July, Volume 7, Number 7, 2007
    • 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. July, Volume 7, Number 7, 2007 ajob 7
    • 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 would want. 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. 8 ajob July, Volume 7, Number 7, 2007
    • 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 that every articulation of one’s worldview can be construed Benson, H., and M. Stark. 1997. Timeless healing: The power and biology as an invitation to embrace that view and to “convert” to of belief. New York, NY: Scribner Book Company/Simon & Shuster it. In many instances, the main point that will separate ex- Inc. planations of personal or institutional values or view from proselytization will be intent. Such matters of the heart Benson, H., J. A. Dusek, J. B. Sherwood, et al. 2006. Study of the and psyche do not easily lend themselves to hard and fast therapeutic effects of intercessory prayer (STEP) in cardiac bypass rules. patients: A multicenter randomized trial of uncertainty and cer- tainty of receiving intercessory prayer. American Heart Journal 151: 934–942. CONCLUSION Brett, A. S., and P. Jersild. 2003. “Inappropriate” treatment near Clinical medicine and religious or spiritual language are the end of life: Conflict between religious convictions and clinical from two distinct worlds and can represent two different judgment. Archives of Internal Medicine 163: 1645–1649. subcultures of our society. Medicine aspires to be objective and scientific; spirituality is subjective and faith-oriented. Brody, H. 1989. Transparency: Informed consent in primary care. Medical professionals are taught to keep a professional dis- Hastings Center Report 19: 5–9. tance; believers seek communion with the community and Carbonneau, A. 2003. Ethical issues and the religious and historical the universe. Tension between these two ways of interpret- basis for the objection of Jehovah’s Witnesses to blood transfusion ing experience would seem likely to surface, especially in therapy. Lewiston, NY: Edwin Mellen Press. regard to ultimate decisions near the end of life. Charles, C., A. Gafni, and T. Whelan. 1997. Shared decision–making I have agreed with those who have counseled that a in the medical encounter: What does it mean? (or it takes at least patient-centered approach to informed consent can accom- two to tango). Social Science and Medicine 44: 681–692. modate many typical patient needs in this regard. Tech- niques involving open-ended questions and reflective lis- Cohen, C. B., et al. 2001. Walking a fine line: Physician inquiries tening, perhaps including taking a spiritual history, can sup- into patients’ religious and spiritual beliefs. Hastings Center Report port patients in the process of interpreting their values and 31: 29–39. applying them to treatment choices. More controversially, I Curlin, F. A., et al. 2005. When patients choose faith over medicine: have tried to illustrate that personal disclosure of spiritual Physician perspectives on religiously related conflict in the medical beliefs can be helpful and may even be desirable in some sit- encounter. Archives of Internal Medicine 165: 88–91. 10 ajob July, Volume 7, Number 7, 2007
    • Talking about Spirituality in the Clinical Setting Dossey, L. 1997. Prayer is good medicine: How to reap the healing benefits Lo, B., et al. 2002. Discussing religious and spiritual issues at the of prayer. New York, NY: HarperCollins. end of life: A practical guide for physicians. Journal of the American Emanuel, E. J., and L. L. Emanuel. 1992. Four models of the Medical Association 287(6): 749–754. physician-patient relationship. Journal of the American Medical As- Lo, B., et al. 2003. Responding to requests regarding prayer and reli- sociation 267: 2221–2226. gious ceremonies by patients near the end of life and their families. Hall, D. E., and F. Curlin. 2004. Can physicians’ care be neutral Journal of Palliative Medicine 6(3): 409–415. regarding religion? Academic Medicine 79: 677–679. Paasche-Orlow, M. 2004. The ethics of cultural competence. Aca- Kass, J. D., R. Friedman, J. Leserman, et al. 1991. Health outcomes demic Medicine 79: 347–350. and a new index of spiritual experience. Journal for the Scientific Peel, R. 1989. Health and medicine in the Christian Science tradition: Study of Religion 30: 203–211. Principle, practice, and challenge. New York, NY: Crossroad. Koenig, H. G. 1999. The healing power of faith: Science explores President’s commission for the Study of Ethical Problems in medicine’s last great frontier. New York, NY: Simon & Shuster. Medicine and Biomedical and Behavioral Research. 1982. Making Koenig, H. G. 2000. Religion, spirituality, and medicine: Application health care decisions: A report on the ethical and legal implications of to clinical practice. Journal of the American Medical Association 284: informed consent in the patient-practitioner relationship. Washington, 1708. DC: U.S. G.P.O. Koenig, H. G. 2004. Religion, spirituality, and medicine: Research Puchalski, C. M., and A. L. Romer. 2000. Taking a spiritual history findings and implications for clinical practice. Southern Medical Jour- allows clinicians to understand patients more fully. Journal of Pal- nal 97: 1194–1200. liative Medicine 3: 129–137. Kuczewski, M. G. 1996. Reconceiving the family: The process of Sheehan, M. 2003. Spirituality and medicine. Journal of Palliative consent in medical decision making. Hastings Center Report 26: 30– Medicine 6(3): 429–431. 37. Sloan R. P., E. Bagiella, L. VandeCreek, et al. 2000. Should physi- Kuczewski, M. G. 2004. Re-reading On Death & Dying: What Elis- cians prescribe religious activities? New England Journal of Medicine abeth Kubler-Ross can teach clinical bioethics. American Journal of 342(25): 1913–1916. Bioethics 4(4): W19–W23. Sulmasy, D. P. 1997. The healer’s calling: A spirituality for physi- Levin, J. S., and H. Y. Vanderpool. 1987. Is frequent religious atten- cians and other health care professionals. Mahwah, NJ: Paulist dance really conducive to better health? Toward an epidemiology Press. of religion. Social Science and Medicine 24: 589–600. Sulmasy, D. P. 2006. Rebirth of the clinic: An introduction to spiritu- Lidz, C. W., P. S. Appelbaum, and A. Meisel. 1988. Two models of ality in health care. Washington, DC: Georgetown University Press, implementing informed consent. Archives of Internal Medicine 148: 2006. 1385–1389. Task Force on Standards for Bioethics Consultation. 1998. Core com- Liebman, C. B., and N. N. Dubler. 2004. Bioethics mediation: A guide petencies for health care ethics consultation. Glenview, IL: American to shaping shared solutions. New York, NY: United Hospital Fund. Society for Bioethics and Humanities. July, Volume 7, Number 7, 2007 ajob 11