The role of spirituality in medical practice has sparked burgeoning interest in recent years. This has stemmed largely from arguments that spiritual activities such as belief in a deity, prayer, and various forms of meditation improve human health and well-being.1 After a century during which medicine appeared to forsake spirituality for technology, we are urged to be mindful of the ancient ties between healing and religion, and it is often pointed out that religious belief is considerably more prevalent among the general population than among physicians.2 Such claims imply that medical practice, recently a fairly positivistic and soulless discipline overall, ought to incorporate greater engagement with spiritual issues.
Objections to a more spiritual medicine begin with empirical disputes over the alleged advantages of spirituality for health; these are important arguments, but they are not my focus here. Whether or not spirituality as part of medical practice actually does improve health outcomes is irrelevant to a number of philosophical concerns. Chief among the latter has been attention to the proper scope of medicine. It has been argued that physicians are not trained to deal with numerous spiritual issues, and that to believe otherwise is to inflate the role of the physician to the point of grandiosity. It is feared that medicine, which has expanded into countless areas of modern life, will tend to appropriate religion and to degrade it into a means to medical ends.3
These are potent arguments, and religion may indeed have something to fear from medicine (as it does from all forms of encroaching modernity). However, in this paper I examine the relationship from the other side, and argue that an escalating preoccupation with spirituality may vitiate medicine itself. Maintaining a certain separation of religion and medicine is in the interest of both domains, although by separation I do not mean mutual ignorance and suspicion. On the surface this may seem a reactionary position, but as will become clear, I do not advocate a medical disregard for spirituality or a misguided attempt at value-free technique.
I wish to examine the possible implications of an increasingly spiritual medicine for physicians (and physicians-in-training) who may be agnostic, atheist, or adherents of minority faiths. After all, the difficulty arises from the plurality of beliefs in modern societies. It is often noted4 that until modern times, healing, religion, and the supernatural went hand in hand (and this is often still the case in non-Western cultures); however, such unity works only when there is a near-universality of belief shared by patients and healers, which is not the case in most contemporary societies. If the truth of religion were not to be questioned, then I would not be writing this essay. As it is, I argue that “spirituality” is a term that is inherently biased in favor of supernatural belief, and that value theory (or axiology) is the appropriate broader term for an inquiry into the goods of existence. The implication of this is that, in order to be fair to all beliefs, medicine ought to remain carefully neutral—even in the origins of its ethics—as regards religious matters. Philosophical debate about sources of value, while seen by some as reflecting the rootlessness of modern life, is preferable to invocations of spiritual authority.
THE PROBLEM WITH “SPIRITUALITY”
The medical literature on spirituality and medicine does contain distinctions between the generic notion of spirituality and the more institutionalized belief systems known as religion. Relating spirituality to anything that provides meaning, Sulmasy has asserted, “Even atheists have a spirituality.”5 Indeed, “spiritual” may be defined in plainly non-religious ways, such as “ethereal or delicately refined” and “relating to the mind or intellect.”6 However, in the medical literature “religion” and “spirituality” are sometimes seemingly conflated. For example, a recent Academic Medicine article's title contained the words “the spirituality of academic physicians,” but the text of the article described explicitly religious meetings of committed Christian physicians.7 Another recent review of the topic contained the odd amalgam “religion/spirituality,”8 which seems to imply a synonymous or interdependent relationship. Zaleski noted in a recent anthology that “spiritual” may be used to modify a host of words, yet he acknowledged that spirituality and religion are intimately related. He likened spirituality to “the inner lining of religion.”9 And what is the use of an inner lining in isolation? In fact, the problem with using “spirituality” to denote anything pertaining to meaning is its root, “spirit,” which is generally taken to refer to the incorporeal, to some supernatural entity or process.
There is a huge popular infatuation with the spiritual life, examples of which include Zaleski's Best Spiritual Writing anthology as well as the inspirational work of Thomas Moore.10 One finds in such material no specific theological doctrine, of course, but rather a potpourri of moral endorsements, reverence for nature, mere thoughtfulness, and vague references to the unity of being. “Spirituality” is a fundamentally ambiguous and flawed term that can be made to mean anything. It is analogous to a gendered word such as “chairman,” which is often used colloquially in a neutral fashion, but which plainly exhibits the bias of its origin. “Spirituality” cannot be used in a precise fashion because, no matter how carefully it is applied to secular matters, its use raises the specter of its original link with the supernatural.
In his essay “Second Thoughts about Humanism,” T. S. Eliot made the acute observation, “Either everything in man can be traced as a development from below, or something must come from above. There is no avoiding that dilemma: you must either be a naturalist or a supernaturalist.”11 While human beliefs exist in infinite variety, they conform to two basic types. One type holds that there are any of a number of supernatural entities, places, or experiences to which humans are in some way subject or vulnerable. Examples might be God, “the gods,” ancestral spirits, heaven or hell, and an immortal soul. The other type of belief is one according to which human experience and reality are at least theoretically observable and explicable by appeal to reason alone (“theoretically” is important—a naturalist does not necessarily believe that humans can reach the level of scientific understanding that would be necessary to fathom the universe).
Certainly there are those who are unsure—the agnostics. However, most agnostics, while intellectually withholding judgment, in fact live their lives for all intents and purposes as if one or the other belief were true. This is the case even if one holds that science and the supernatural are not mutually exclusive. Either some kind of faith in supernatural forces or agents plays a significant role in a person's life, or it does not. It is important to note that not all religions are supernatural; for example, some strains of Taoism and Buddhism are more like philosophies than religions, albeit bound up with extensive communal history and ritual. Transcendence, the quest for the greatest possible significance of things, is not necessarily equivalent to faith in the supernatural.
VALUE AS CENTRAL
My argument so far has implied that atheists do not in fact have a “spirituality.” What every person does have is an underlying (often unconscious and unquestioned) system of meaning and value. I find the latter term preferable for referring to the kinds of ultimate concerns that are often of interest in medicine. “Meaning” can have a number of trivial implications related to sheer denotation, whereas “value”—in the philosophical sense and not in the debased capitalist sense—suggests a human attachment to experience. There are potentially infinite meanings, but a person must settle for a finite constellation of values in life. Also, there are many lives that contain countless pernicious meanings, but little of real value, even from the perspectives of the persons living them. Values may or may not involve appeals to what are generally agreed to be supernatural entities or experiences. Values may comprise ethics and social mores of various kinds, but they go beyond these—they signify what ultimately matters in life.
We are learning (or perhaps relearning what medicine forgot in a century of empiricism) that illness is closely bound to any number of significant values (which may or may not be “spiritual”). This has been most obvious in psychiatry and psychotherapy; many have recognized that techniques involving choices and relationships cannot possibly be divorced from values.12 In fact, it seems clear that a healthy sense of value is crucial to mental health itself. A collapse of value—that is, a withdrawal of attachment to reality—may be said to underlie experiences such as substance abuse, depression, and suicide. Mental health in turn is increasingly understood to be inseparable from physical health. So it is unsurprising that the vagaries of belief have potentially significant implications for any number of health issues.
The broad debate over the meanings and values of life is not properly called theology, or even “spirituality,” but rather philosophy. It is often pointed out that in many cultures, medicine and faith have gone hand in hand; but there is an equally ancient bond between medicine and philosophy. This does not imply that issues of ultimate concern are subject to logic alone. Mainstream philosophers—Nussbaum13 is a prominent example—are increasingly mindful of the uses of emotion and literature for understanding contextual values as they are embodied in individual lives. Camus famously wrote, “There is but one truly serious philosophical problem, and that is suicide”14; his response to that problem included fiction as well as theory. As regards mental health, works intended for the general public have advocated using philosophical concepts to increase well-being.15,16 To some extent these works revive the ancient project of the Greek Stoics, who argued that the whole point of philosophy was to improve human lives in specific ways, an idea that has been long eclipsed by more analytical trends in philosophy. In fact, until recent years mainstream medical ethics has been more concerned with discrete legalistic quandaries than with more subtle inquiries into individual values.
“SEPARATION OF CHURCH AND MEDICINE”
If values in general are at issue, then a problem remains. Just as physicians are not trained as theologians, neither are they trained as philosophers. And even if the latter were otherwise, our society is sufficiently pluralistic that no group, philosophers included, is accorded any kind of monopoly on truth. So what stance should medicine, as an institution, take as regards the countless issues of value, both supernatural and natural, that are inseparable from the practice of working with patients? I submit that the political theory of the “separation of church and state” serves as a useful model. There is a sense in which a physician serves his patients much like a political representative serves his constituents. Patients, like voters, do have interests that they expect to be looked after, and yet there are instances in which physicians, no less than politicians, might be expected to go against the immediate desires of those they serve. Patients do vote as well, albeit individually and with their feet. The model of “separation of church and state,” ultimately noncommittal as regards religious matters, seems to avoid the evils both of theocracy and of the explicitly atheistic state. For convenience, I will call “secular” a medical philosophy that is neutral in this way with respect to religion.
First, a secular physician would neither repudiate nor ignore religion. It has been argued, convincingly I think, that respecting the full humanity of patients calls for some inquiry into their ultimate concerns, religious or otherwise.17 Analogously, a “separate” state acknowledges the importance of religion in many citizens' lives and makes allowances of certain kinds for those activities. Second, a secular physician would by no means aspire to be value-neutral or morally relativistic. Just as a “separate” state, while silent about specific religious matters, may hold dear such values as liberty, fairness, and justice, so a secular physician may be guided by certain principles deemed important for health. Some principles would be so basic as to be institutional (e.g., one should not harm a patient or needlessly break confidentiality), while many others would be open to wide interpretation.
The notion of medicine as an institution raises the question of whether medicine needs anything approaching a policy regarding the role of religion in clinical care. After all, it might be argued that the clinical role of religion will depend upon a particular patient's needs and that the matter is essentially a private one to be negotiated between patient and physician. However, I would submit that religion belongs to the group of boundary issues, such as confidentiality, privacy, and the question of amorous relationships between clinicians and patients—all of these pertain to the limits and structure that a patient or clinician ought to be able to expect from a clinical encounter. And there should be a standard of care that governs each of these. For the clinical encounter is both public and private—private as regards clinical and personal details, of course, but public inasmuch as a physician represents, and is answerable to, a profession.
Many would argue that we already enjoy an effective “separation of church and medicine”; after all, most commentators endorse a medical attitude toward religion that is curious and respectful but not proselytizing. In fact, medical practice may be as narrowly technical as ever, but excursions into “spirituality” may seem to some an easy path to a more “humane” medicine. And whenever there is a clear majority religion (as in the case of Christianity in the United States) and a recognition that belief may have benefits for an individual's flourishing, there is often a temptation to blur the distinction between public and private. Politically speaking, one sees this in some small communities that are virtually unanimously Christian: sometimes there is strong local support for posting the Ten Commandments in public buildings, despite the unconstitutionality of such. The medical analogy to this might be the physician and patient who happen to attend the same church and who decide to pray together. This may not be wrong, but there would be a temptation for such a physician to strengthen his or her belief that prayer is good for one's health. Would such a physician be as fully prepared to “represent” the interests of patients with no credence in prayer?
Religion is undoubtedly a powerful and cohesive force in many lives, and it is tempting to use religious institutions to further the general good. A recent example is President Bush's intention to support “faith-based initiatives” aimed at various social ills (including, interestingly, medical problems such as substance abuse). The medical analogy might be widespread professional emphasis on more aggressive inquiries into “spirituality,” and more pointed suggestions that belief of certain kinds may be better for health than others. This is all the more likely when patients themselves bring to the clinical encounter the conviction that their faith ought to be central to their treatment. Such a trend would be in the name of better health, of course, and therefore be the product of good intentions. However, there is the real possibility that the notion of “spirituality as strong medicine” may exert pressure on physicians and those in training to be more “inspirational,” whatever that may mean. An example of this, from the mainstream psychotherapy literature, is Karasu's “Spiritual Psychotherapy,”18 which despite its equivocations, strongly implies that such therapy is somehow advanced or “beyond” mere secular therapy. As always, it is those who adhere to minority belief systems who feel pressure from such trends.
Not everyone, patients included, would be happy with secular medicine. There are definite tensions between naturalism and supernaturalism that do not disappear in the context of official neutrality. For instance, many of fervent belief may feel that a secular medicine, by not explicitly supporting faith, implicitly repudiates it (such individuals would likely oppose separation of church and state as well). A similar problem arises when secular theorists, perhaps in an effort to appear tolerant, describe ways in which religion may be a normal developmental step or serve particular psychological needs—an example would be psychoanalytic “justification” of faith.19 Believers naturally mistrust attempts to explicate in naturalistic terms what is ultimately uncanny. Tolerance and mutual respect are of course possible, but there is an irreducible tension between supernaturalism and naturalism, as there would have to be between two such different ways of viewing the world.
WHAT IS A PHYSICIAN TO DO?
What is a physician to do? It should be clear that, just as the United States government does not oppress religious groups or pretend that religion doesn't exist, I do not advocate the denigration or disregard of patients' spiritual concerns. However, to inquire about patients' spirituality is very different from encouraging or even validating belief (e.g., through praying with patients). The much-exercised “biopsychosocial model” of health care should not be used as a pretext for endless intrusions of medicine into personal life. After all, sexuality is part of the “biopsychosocial model,” but we physicians should not be having sex with patients, even if they invite it. Obviously even active proselytizing is a far cry from sexual involvement with patients, but both, to my mind, represent misuse of medical authority for non-medical ends. But health cannot be isolated from countless other facets of life, so how can holism not lead to grandiosity? The answer would seem to be referral to a religious authority. The physician may well inquire into a patient's finances (and there is little doubt that avoiding poverty is good for one's health), but the physician would not act as investment counselor; rather, he or she would refer the patient to the proper resources. The physician may well inquire about a patient's legal situation, but would not offer legal advice beyond the most basic sort. Similarly, the physician is not a member of the clergy. Definite limitations to the physician's role do not amount to scientism, but rather reflect humility. The issue boils down to how entirely candid, in their clinical encounters, physicians should allow themselves to be. In very small towns and primitive cultures, it may be fine for healer and patient to be mutually transparent because of congruence of beliefs, but in a pluralistic world considerable discretion is sometimes called for in public encounters.
IMPLICATIONS FOR EDUCATION
What are the implications for training and education? Medical value theory, a broad understanding of the roles of meaning and belief and their negotiability in clinical encounters, should occupy a greater portion of medical ethics curricula than is generally the case (values in practice are more relevant to the average physician than are the great institutional quandaries of medical ethics). In an age of ever-increasing data and technology, it seems quaint to try to rehabilitate the figure of the physician as “Renaissance man” (or woman), but this remains a worthy if lofty goal. It is as vital now as ever that physicians have a broad appreciation of human understanding. Individuals such as William Osler, whose example remains honored more in the breach than in the observance, embody a more potent example than do notions such as the physician as “spiritual healer.” Within a framework of humanism (which unfortunately, like “spirituality,” seems an infinitely elastic term), it must be possible for an agnostic physician to be every bit as ethical, caring, and understanding as a devout one.
Having a superficial regard for religious beliefs does not compensate for a medical education that is shallow and technological. Obviously it should be recognized that religious and supernatural beliefs are prevalent types of values that patients hold dear. But a separate discipline of “spirituality and medicine” tends to indefensibly lionize the physician with a particular understanding and sympathy for otherworldly matters. For better or worse, the purview of medicine ought to be our sufferings and triumphs in this world, not the next. A medicine that neither exalts nor demeans religious belief, but rather situates the latter among the countless values persons may hold, should be the goal.