[MOL] Food for thought... [02149] Medicine On Line

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[MOL] Food for thought...


   Author: Rabbi Elliot N. Dorff, PhD
   Affiliations: Provost and Professor of Philosophy, University of Judaism, 
Los Angeles, California, USA
Religion at a Time of Crisis
  Patients with cancer face myriad problems in the course of treatment. Some 
of these problems may be unintentionally compounded by the reluctance of 
health-care professionals to address spiritual and religious concerns. This 
article attempts to define spirituality and religion, and examines the impact 
of spiritual well-being on the patient and his or her illness. It also 
presents some ways in which healthcare professionals can address these 
concerns while still remaining true to their own beliefs. 

Silence is the Rule
 Freedom of religion in the United States has meant that Americans affirm a 
plethora of religions, and many deny any religious ties. In this author's 
view, that great American experiment in religious freedom and pluralism is an 
unqualified blessing, but it makes it difficult for caregivers treating 
patients with cancer to know how to help them with their religious needs. 
Typically, that means nurses and physicians do their best not to say anything 
at all about religion. 
Part of their silence is motivated by a fear of offending anyone. Nurses and 
physicians seldom have the time and perhaps not even the inclination to talk 
with patients about anything not directly related to the physical and 
emotional state of the patient, and even if they do, they probably would not 
talk about religion. Religion and politics are notoriously the subjects you 
do not raise in initial conversations with anyone in America, and certainly 
not someone whom you are busy treating and therefore can ill afford to 

Truth to tell, though, another important reason why health-care professionals 
do not talk about religion with their patients is that they feel inadequate 
to the task. During their training, after all, instructors usually do not 
address this element in patient care. In 1992, the UCLA School of Medicine 
instituted a new course called "Doctoring," which includes attention to the 
element of spirituality in caring for patients, but the program is very new, 
and I know of no other school training healthcare professionals which even 
broaches the subject. Fear of offending patients and fear of dealing with the 
subject in the first place, then, combine to make. silence the general rule 
on this matter. 

The Price of Silence
 While such silence is certainly understandable under some circumstances, it 
radically limits the kind of help nurses and physicians can offer their 
patients with cancer. Silence on these subjects makes it seem that 
health-care professionals do not want to be bothered with patients' religious 
urgings at such a critical time, and are coldly focused on the physical 
aspects of their being. This frankly dehumanizes both parties in the 
relationship. Health-care professionals are led to see patients as machines 
which have broken down and which they are trying to fix, and patients, in 
turn, see health-care professionals as glorified mechanics. People, though, 
are not separately body and soul; they are integrated human beings, in which 
every element has significant and often critical effects on every other 
element. Therefore, ignoring the spiritual element of patient care 
effectively means that one fails in providing adequate patient care. 
Those people whose cancer can be cured or at least brought under control by 
modern medicine usually feel grateful for the skill of their healers, but 
even they can be better served if their caregivers pay at least minimal 
attention to the religious questions they have throughout their bouts with 
cancer. They usually do not expect that the nurses and physicians who treat 
them will be expert in this area, but total silence on the matter makes 
healthcare professionals seem cold and unfeeling. 

If that is true for those patients who can be cured, how much more so is it 
the case for those who cannot be. All that health professionals can do in 
such circumstances is to help patients understand the prognosis of their 
illnesses and then be a source of comfort for them as they suffer through it. 

Nurses and (especially) physicians, though, all too often psychologically and 
even physically withdraw from such people, in some cases even failing to 
inform them about what is likely to happen, for incurable illnesses threaten 
the health professionals' sense of competence and cause them great 
frustration. Moreover, people at the point of dying sometimes transfer their 
anger to the physicians and nurses who cannot cure them. Such psychological 
transference, of course, makes no rational sense, for it is not that the 
caregivers want the patient to die, but simply that they cannot prevent that 
from happening. Despite the irrationality of it, though, patients commonly 
engage in such transference, at least for awhile. Consequently, physicians 
and nurses would much rather absent themselves from the scene in which they 
will probably be the target of the patient's anger, and will, in addition, 
have to confront their own limitations. 

That is understandable, but it is also a shame, both for the patients and for 
the caregivers. Patients, of course, feel abandoned when that happens, at 
least psychologically. It is precisely such feelings which lead to another 
kind of anger and, in extreme cases, to lawsuits. Some attention to patients' 
spiritual needs can avoid this and, on the contrary, make patients feel good 
about the health care they are getting. 

Nurses and physicians should do this for themselves, too, however. Health 
professionals are not helpless when they cannot physically cure the patient; 
they can still afford substantial help if they only learn how to shift the 
focus of their concern from primarily physical matters to psychological and 
spiritual ones. Again, patients with incurable cancer, just like those with 
curable varieties, know full well that health professionals are not trained 
to be professionals in spiritual care. However, some attention to the matter 
on the part of nurses and physicians can help immeasurably in moving patients 
from their own focus on their physical being to considering how they can 
enlist the other parts of what makes them human to help themselves through 
this. Moreover, it will make the nurses and physicians involved feel much 
better about themselves, for they are continuing to care for their patients, 
albeit in a different form. After all, helping sick people is the reason why 
almost all of them selected this profession in the first place. 

Types of Spirituality
 In order to understand what nurses and physicians can do, it is important to 
spell out what we mean by spiritual life in the first place. People mean many 
different things when they refer to the "spiritual" side of life, but I would 
suggest that the various definitions generally fall into three categories: 
(1) a sense of inner wholeness and meaning; (2) moral rectitude; and (3) a 
linkage with the transcendent. 

Sense of Inner Wholeness and Meaning
 Probably the most common thing people want to denote when they speak about 
the spiritual component of life is the nonphysical parts of it--the elements, 
in other words, of their inner being, their "spirit," here used in contrast 
to their body. In this first sense of the term, people sometimes want to 
refer to their psychological state and sometimes to their moral state. Those 
are, respectively, the first and second meanings on our list of three. 
In the first sense, then, people seeking spiritual meaning are looking for a 
sense of wholeness. They want to feel that the various vicissitudes of life 
either make sense in the larger scheme of things in some way, or, if they do 
not, they want to feel that they nevertheless have the strength to cope with 
life somehow. This inner peace is not necessarily a sense of quietude, 
although it often is, at least in the end. It can, however, initially take 
the form of expressions of anger and frustration at their inability to 
overcome the limitations of their lives, whether those come from their 
bodies, their minds, their emotions, or their relationships with other 
people. They want to know that such feelings have not gone unnoticed by those 
near and dear to them, and they want such feelings to be validated as 
appropriate or at least as tolerable on the part of such people. They also 
want such people to support them in their feelings and in their attempts to 
deal with them. In this mode of spirituality, they do not want judgments from 
others and maybe not even suggestions (although some might want the latter); 
their overwhelming need is for a listening ear, an understanding presence, a 
friendly hand. They thus gain spiritual "comfort," even if they have not been 
able to resolve the problem which thrust them into turmoil in the first 

Health-care professionals used to working toward clearly definable goals of 
physical recovery and function may find this all rather spooky and maybe even 
annoying, but it is important to remember the concept of human beings 
underlying this kind of spirituality. Human beings are not just machines that 
either accomplish or fail to accomplish their ends; the pragmatics of 
resolving problems, including physical ones, is not all that matters to 
people. People are also psychological and emotional beings, who respond to 
what is happening in their lives with inner feeling and need help in dealing 
with such responses. From a practical point of view, this makes people much 
less efficient than unemotional robots would be, but on the other hand, it is 
also part of what makes them distinctly human. It is what makes them unique 
and interesting, what gives them verve, and what makes them who they are. 
Moreover, as we have learned increasingly over the years, this part of human 
beings is not separate and distinct from their physical components, but 
rather integrated with their bodies in such a way that those who would care 
for the latter must inevitably pay attention to the former as well. 

Moral Rectitude
 Another part of human spirituality is the moral side of life. A person's 
inner being is not only psychological and emotional, but moral as well. 
Therefore people stricken with traumatic illness, and especially those facing 
impending death, will inevitably ask difficult moral questions. The issue 
will not just be what they can do and what will be the consequences of the 
various things they can do; the issue will be what they should do. And that 
question will not be just an inquiry asking for practical advice, but a true 
quest for moral rectitude. They might ask, for example, "Should I (not just 
can I) fill out a Durable Power of Attorney for Health Care? If so, what may 
I include in it? I want to know not just what the law allows or what I can 
get the nurse or physician to do; I want to know what I should do because I 
want to die a good person. I may not have always succeeded in living out my 
moral commitments in my life, but I surely want to end my life 'with clean 
hands and a pure heart,' as the Psalmist says, if I can possibly do so. I 
therefore want to talk about these moral quandaries with people who care for 
me and whom I respect." 

Linkage With the Transcendent
 The psychological, emotional, and moral components of spiritual care are 
ultimately linked to a person's wider understanding of the nature of human 
life, the world, and God. The word "religion," in fact, means linkages, 
coming from the same Latin root as the word "ligament." Religions, then, link 
us to the broader context of things; they relate us to other human beings, to 
the rest of the animate and inanimate world, and, at least in the Western 
world, to God. It is precisely when people face the trauma of catastrophic 
illness that they are the most likely to ask serious questions about all 
these things, for the illness threatens all their normal ties to the world. 
Thus patients with cancer may well raise these deeper spiritual questions, 
even if they never affirmed much religion in their lives before. 

Role of Nurses and Physicians in Spiritual Care
 What should nurses and physicians do with all this? They may well feel out 
of their league, for their medical and nursing training did not prepare them 
to help people with such problems. Moreover, as we noted above, on such 
questions America is blessed with a plethora of views. If silence is not the 
answer, then, how should health-care professionals treat these issues? 

Sense of Inner Wholeness and Meaning
 The first form of spirituality is probably most amenable to at least some 
intervention on the part of nurses and physicians. People needing to vent can 
be helped by any other caring human being, and so can those needing a 
reassuring word, a sympathetic hand, a listening ear. Clearly, there are 
limits of time, energy, skill, and ultimately, willingness which will be 
operative here. Furthermore, the primary burden of providing such spiritual 
care properly falls on family, friends, and clergy; but for reasons developed 
above, this does not relieve nurses and physicians from this kind of care 
entirely. On the contrary, health-care professionals should be on the lookout 
for these emotional needs and should see it as their duty to provide for 
them, at least to some extent, as part of their calling to heal the person, 
and not just the physical machine, in their care. 

Moral Rectitude
 When it comes to the moral component of spiritual care, one is immediately 
aware of the varying conceptions of what is ideal behavior and even what is 
minimally acceptable action. Consequently, health-care professionals may well 
refrain from being too actively involved in the moral decisions that must be 
made for fear of imposing their own moral views on their patients. The 
patient's priest, minister, or rabbi, if he or she has one, should clearly 
be, consulted if there are major moral questions about the person's care, for 
then the patient can make such decisions with the help of the expert in the 
vision of life he or she has chosen. 
Nurses and physicians must at least be aware of this dimension of life in 
helping cancer patients, as the medical decisions that must be made are not 
simply a function of the physical realities of what is possible and what is 
pragmatically most effective. When one has a serious disease like cancer, the 
choices regarding appropriate patient care also entail the patient's 
understanding of how people ought to live and die. The patient's conception 
may be radically different from that of the attending health-care 
professionals. For that matter, the latter may differ among themselves on 
such issues. They therefore should certainly not assume that the patient 
would choose what they would choose, as their moral values might be 

That, however, does not mean that nurses and physicians should be totally 
silent about these matters. They should indicate that they are keenly aware 
of the value issues inherent in many of the decisions that must be made, and 
they should encourage the patient to think them through with appropriate 
family, friends, and clergy. 

Health-care professionals, of course, are also people with moral convictions. 
If some forms of potential therapy violate their own values, they must let 
the patient know that, too. Assuming that the therapy in question is legal, 
even if it is morally controversial, the objecting physicians or nurses must 
also assure the patient that they will refer him or her to other health-care 
professionals who find it morally permissible to carry out the course of 
therapy the patient wants. This, too, is part of what it means to attend to 
the patient's spiritual well-being. 

Linkage With the Transcendent
 If variation is the name of the game with regard to moral questions, that is 
all the more the case when it comes to the broad matters of context generally 
treated by religion. As a result, family, friends, and clergy are certainly 
the ones appropriately and primarily responsible for this kind of spiritual 
Nevertheless, here, too, nurses and physicians have a role to play. They can, 
at the very least, make sure that the patient has someone appropriate with 
whom to talk about these issues. They might mention, for example, the 
patient's need to talk about these matters when members of the family or 
friends visit, or they might call the clergy member with whom the person is 
most familiar to alert him or her of the patient's need to talk about these 
issues. They might also call the relevant hospital chaplain for such 
discussions. This is especially important for those patients who are not 
visited very often, for then their loneliness compounds their spiritual needs 
on all three levels. 

Those health-care professionals who feel comfortable with religion and 
spirituality may even broach the issues themselves. The goal, of course, 
would not be to impose one's own ideas on the patient, but rather to get the 
patient to voice his or her spiritual needs and questions, and perhaps even 
to share some of one's own search. In general, asking the patient questions 
is a better method than making declarative statements, for through the 
questions the nurse or physician is validating the patient's spiritual needs 
without skewing them towards their own ideas and values. 

God's Partner in Creation
 The Jewish tradition, my own and the one I know best, has a most 
appreciative understanding of the role of health-care givers, one which 
depicts their role not only in terms of the obligation to heal the person's 
physical being, but also in broader, more spiritual terms. Along with one's 
parents, God is one of the progenitors of each one of us, and God continues 
to own our bodies through- out our lifetime. Therefore, Jews may not live in 
a town where there are no physicians, for that would be to put God's property 
at undue risk. On the other hand, those who tend to the sick, the Talmud 
says, are God's partners in the ongoing act of creation. 
While nurses and physicians come from many religious backgrounds, just as 
patients do, all, I think, can acquire a much better view of themselves if 
they begin to think in such religious terms. The patient is not just a 
machine, and caregivers are not just mechanics. Both are human beings created 
in the image of God, and both are performing divinely ordained acts in 
seeking and affording medical care. 

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