ONCOLINK (UNIV OF PA)
http://www.oncolink.upenn.edu/psychosocial/qol/qol_6.html
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
alienate.
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
place.
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
different.
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
care.
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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