Open thread for episode #849: Spirituality in Healthcare

Today I want to mention a few more things about spirituality in healthcare.

I fully understand that someone’s personal cosmology can play a role in their health. Extreme or prolonged stress is unhealthy. And religious beliefs, as part of a person’s overall worldview, can contribute to stress or relieve it, depending on the individual. I have no problem with a patient in mental or medical treatment asking for spiritual support. And I take no issue with a facility providing them that support. When I interviewed Dr. Poole we discussed how he used referrals to religious practitioners for a number of patients, even though he is openly atheist. He became concerned, though, for a number of reasons, discussed on past shows and blogs, when there was a move to shift the spiritual and religious responsibilities to the medical/mental health professional directly—forcing patients to provide “spiritual histories” and opening the door for professional psychiatrists to pray with patients as part of standard practice. The problems and potential for abuse continue to be a topic of debate in professional journals and within these communities. Again, Dr. Poole was invited on to talk about how he specifically unwittingly became embroiled in one such dialog within the pages of the journal for the Royal College of Psychiatrists in the UK.

I’ve been looking at the arguments “for” incorporating “spirituality” more closely, and I’d like to share some of what I’m encountering.

One odd argument is the argument from tradition. It’s the idea that since “healing,” as an art, has been tied to religion (think exorcism, prayer groups, asking god to channel its power through a healing touch, and so on), it was an error to ever separate “spirituality” (in the form of religion/appeal to gods) from “medicine.” The problem is that medicine today is based on scientifically determined efficacy. It’s not the “healing art” of ancient times and non-Western cultures. Those forms of “healing” are no longer the “medicine,” we understand, today. Medical science is not a “healing art,” it’s a science—based in fact and demonstrated efficacy. I don’t want my surgeon to perform an exorcism on me prior to a surgery just because that’s how they did it in Jesus’ day, or because some shaman might be doing it in some corner of the globe today. When Russell sometimes jokes that if you pray and take an aspirin your headache will go away, I don’t think there is any confusion about which part of that situation is medicine and which part is not. If a patient wants religious support, they can get it as needed from the religious community—which is happy to provide it and available everywhere. But those using this justification, when they make references to the ancient, traditional medical oath, eerily remind me of those who appeal to “In god we trust” and “under god” as “traditional” arguments for why we should have a more theocratic government. The reality that we have founding fathers with religious views is not justification for a modern theocracy (anymore that saying they traditionally owned slaves is justification for modern slavery). In the same way, saying that people in the past were more superstitious—including healers—is not a good reason to reincorporate “treatments” that are not demonstrated medical science. If you’re a medical professional, I should be able to trust that you’re going to treat me using the modern meaning of “medicine”—that is treatments that are predicated on vetted medical science, rather than superstition.

If others prefer superstition, or want that in addition to medical treatment, so be it, and guide them to a group that can offer them prayer support or whatever they require. But I would like to have an option to see a doctor, who is not also a shaman.

Another argument for “spirituality in healthcare” is that “spiritual” is not “religious.” While it’s true that religion is tied to ritual, the situation appears to mimic Dover, where an “intelligent designer” does not necessarily have to mean a “god.” It’s true it doesn’t have to mean that, but the reason it was put forward was to promote Creationism in science classrooms. Make no mistake—Intelligent Design was put in play to promote god and religion. And “Spirituality” moves immediately to religious ritual when you start looking into the literature. Ask someone promoting spirituality in healthcare if they think that “religion” is part of “spirituality” and they can’t deny it. They will explain that “spirituality” means considering the “whole” person—which necessarily includes religious needs and perspectives. So, praying with a patient is a valid part of “spiritual” care—even though it’s obviously a religious ritual.

A strong advocate of spiritual healthcare, Christina M. Puchalski, MD, MS, wrote this in her article “Physicians and Patients’ Spirituality”:

Proselytizing by clinicians or dismissing patients’ spiritual or religious beliefs is unethical under all circumstances within the clinical encounter. Forcing a patient to share his or her beliefs or values is also discouraged…

“Forcing” a patient to share his or her beliefs or values isn’t forbidden, just discouraged? Under what circumstances should I be forced to disclose to my doctor that I’m an atheist? Why isn’t it clear that coercing this from me should be forbidden, not just discouraged? If my doctor isn’t pushing religion as an issue, how is my atheism even coming up in talks about my health?

In a JAMA article by Dr. Pat Fosarelli (“Medicine, Spirituality, and Patient Care”), the author says,

For many patients, faith in the supernatural (i.e., spirituality) is important—in health and (especially) in illness.

Those parenthetical comments are the author’s, not mine. The author also self-describes as “a physician and pastoral theologian” who teaches medical, nursing, chaplaincy and theology students. And clearly, Dr. Fosarelli advocates in the statement above, that “spirituality” directly relates to supernature.

Another academic, Dr. Mary Elizabeth O’Brien, has provided research which has been used to create a list of manifestations for the nursing diagnosis of “spiritual distress.” Another strong advocate of spirituality in healthcare, O’Brien shares this story in one of her books, “A Sacred Covenant: The Spiritual Ministry of Nursing,” about a nurse who reads the Bible to a stroke victim, with whom she is having difficulty communicating:

Pattie told about caring for an elderly gentleman who had suffered numerous strokes and had not regained full mobility of one arm and leg. He was feeling very sad and depressed over his physical losses. He was grieving the loss of the health and strength that he once possessed. Pattie reported that she was not always sure if her patient was understanding her, but one day she took his hand and squeezed it and read him a biblical message: ‘Blessed are they who mourn for they shall be comforted.’ Pattie added, ‘I had to repeat this quote several times but I knew that I had struck a chord.

Let this sink in. The patient can’t communicate with the nurse, and his nurse takes that as her cue to start reading the Bible aloud to him. Is this fine? The book uses this story as a shining example of how wonderful and helpful nursing can be.

Ultimately it turns out that the patient was all right with this event. However, that’s hardly the point. The question is why a nurse would be promoting her religious views to a patient she admits she’s having difficulty communicating with to the point she’s not sure he is even processing what she’s saying. What if that was an atheist in that bed? Or worse, a Muslim? For me it would be an annoyance and violation of my religious freedom. For someone of another faith, it could be blasphemy and heresy forced upon them, as well.

After my airing of the segment with Dr. Poole, I was contacted by a number of viewers relating stories of how mental and medical healthcare providers promoted and thrust religion upon them and their families during treatment. I’m not sure how aware people are that this is happening. Dr. Poole serves in a capacity where he is tasked with investigating ethical complaints brought against his peers by patients. While he is clear that complaints about sexual misconduct are not rampant, he stated during an interview with me on Godless Bitches that complaints about religious violations easily outnumber accusations of sexual misconduct. Additionally, the Secular Therapists Project was created to respond to the need for non-religious providers. The program was so in-demand they had to recruit volunteer operators to help with incoming calls.

Now imagine how complicated Dr. Poole’s investigative job would become if a movement began to promote “sexuality in healthcare.” Imagine that forcing a patient to share their sexual experiences and views is “discouraged,” but not forbidden. Imagine that a nurse initiating sexual contact with a patient unable to communicate or move, is praised by professionals advocating for this position. And imagine that the argument “for” it was simply that sexuality is part of being a whole human, which gives medical and mental health professionals a right to integrate discussions on the patient’s sexuality, and even incorporate sexual practices into therapy settings, where the problems presented are not tied to sexual behaviors in any way more compelling than “sexuality is part of who we are as whole human beings.”

Even today when religion is not routinely integrated into healthcare, and where spirituality is not considered a standard part of practice, we know there are professionals who are not able to identify healthy boundaries. We are aware there are complaints and abuses. To suggest that relaxing these standards, and, further, telling students entering the field that integrating this into treatment is perfectly acceptable, can only be an invitation for more and greater violations. When a solid boundary is not sufficient to stop the abuse, how can anyone reason that a fuzzier boundary might be a better solution?

I’m still looking at this issue, but, so far, it seems to be the same old theme we’ve seen repeatedly. Religious people want to promote their religion and thrust it onto nonadherents, blind to the violation of religious freedom. They go to court and say “in god we trust” is a tradition, not a religion. But as soon as the case is ended, they run the “we’re a Christian nation” flag right up the pole and fly it as high as they can. They go into schools to say that “intelligent design” is not religion, just an alternative view of cosmology that should be considered. But we saw the evidence at Dover. And so we know. We know, and they know, the drill. You take the religious items, you package them in secular wrapping paper, and you hand it out to society at large hoping that enough people won’t look inside the box, so that you can saturate the market of ideas with your religion before anyone realizes you’ve slid it through the door.

So, is it a well-meaning, but misguided secular initiative being infiltrated by religious parties? Or is it a well-packaged religious initiative being bought up by unaware secular parties? In the end, since the potential for abuses is present either way—does it matter? The benefit to the patient can be had using referrals to religious practitioners. The medical and mental health communities can continue to partner in teams to assist patients. There is no reason professionals in the medical or mental health communities need to start incorporating, or even re-incorporating, religious rituals into their therapeutic settings. The “benefit” it provides is already available to patients in the form of pastoral referrals. On the flip side, the risks are undeniable and abuses already occuring. Why invite significantly greater risk where it doesn’t offer significantly greater benefit?

Something about this math just doesn’t seem to add up. And when an explanation fails to make sense, that’s often a sign of justification after the fact—of a subtext in play.