P W Brunt, D S Short
Aberdeen
SMJ 2005 50(1): 3-4
Doctors do not ordinarily look upon themselves as having any responsibility for the spiritual state of their patients: they leave that to the chaplains. But a recent initiative from the Scottish Executive Health Department compels us to re-consider this attitude. In Guidelines, circulated to Health Boards in 2002, the SEHD required NHS organisations “to develop and implement spiritual care policies that are tailored to the needs of the local population”. The Health Minister had earlier expressed his determination to “make spiritual care a central element of the way the NHS cares for people”, and that such care should be undertaken by “the whole health care community”.1 Although this is clearly a landmark step, it does not, in fact, signal a sudden radical change in attitude: rather a further step in an ongoing process; a previous crucial step being the WHO’s addition of “spirituality ” to its definition of the word “health” a decade ago. NHS Scotland is leading the way in the UK so far as this dimension of health care is concerned, and has affirmed its intent by setting up and funding a Health Care Chaplaincy and Development Unit in Glasgow, with a national Spiritual Care Co-ordinator and a Policy Development Manager. The Unit will support NHS Boards and Trusts in planning, implementing and improving spiritual care services and standards, in training and education and research. Already, NHS Boards and Trusts have expended a considerable amount of time planning a spiritual care service, but this initiative has scarcely been mentioned in medical journals.
The case for spiritual care
It is w idely acknowledged that much current medical care is not wholly successful. It is an extraordinary paradox that at a time when the achievements and potential of medical science are higher than they have ever been, patients should be voting against it with their feet, in turning to alternative therapies of various kinds. Of course, we, as doctors, do not see this migration and, to be truthful, we are too busy to care. The steady advance in the scope and effectiveness of medical treatment has tended to blind us to the things medical science cannot do. Medical science is not the complete answer to human need. Old age and incurable cancers are obvious examples of needs for which it has little to offer. But even in younger and fitter people, many of the ills from which they suffer are not due primarily to any disease of body or mind. We are dealing with human beings whose nature is to some extent irrational and perverse. Twenty years ago, Sir Richard Doll stated, in words that are just as valid today: “The practical steps that can be taken to prevent disease mostly require changes in personal behaviour and the factors that influence it”.2 This is, of course outside the doctor’s professional competence. Carl Jung, the psychiatrist, summed up his experience in stating: “Among all my patients in the second half of life - that is to say over 35 years of age - there has not been one whose problem, in the last resort, was not that of finding a religious outlook on life”.3 And Andrew Sims, in his valedictory presidential lecture to the College of Psychiatrists, emphasised the value many patients attach to their religion and their faith, and concluded: “We need to evaluate the religious and spiritual experience of our patients in aetiology, diagnosis, prognosis and treatment”.4 Currently, many patients do not find their spiritual needs met in the NHS.5 But it is interesting to learn that in an increasing number of medical schools in the USA students are being taught to take a ‘spiritual history ’ of their patients.
Does spiritual care do any good?
As with the treatment of physical and mental disease, we should demand evidence of success before committing scarce NHA resources. The Scottish Health Minister clearly considers spiritual - and specifically religious - care to be beneficial. He accepts that research demonstrates “clear benefits in health outcomes when an individual’s religious needs are met while they undergo hospitalisation or treatment”.1 The Chief Scientist Office at the Scottish Executive Health Department evidently shared this view, or at least was sufficiently impressed by the evidence, to award research funding for a randomised controlled trial of spiritual healing in asthma.6 Most of the published evidence does not, however, relate to specific diseases, but rather to the quality and duration of life over a wide spectrum of disorders. Hence the main evidence comes from observation by psychiatrists, such as Koenig7 from the USA and Barker8 from the UK, rather than from physicians and surgeons.
But is spiritual care an appropriate role for the doctor?
Paul Tournier, a Swiss physician who specialised in helping patients with spiritual problems took the view that, although spiritual care was properly the role of the minister or priest, the vocations of doctor and minister could not be kept in watertight compartments.9 Although many doctors are likely to say that they have neither the time nor the ability to deal with this aspect of patient care, we know of a number whose personal experience of the value and importance of the spiritual dimension inclines them to help in this area. The GNC raises no objection to doctors sharing their faith with their patients, provided it is done in a non-directive and sensitive way. It is entirely appropriate for a doctor so minded to be available to the patient, to empathise with them and to be willing to help them find meaning in their illness. Even doctors with no profession of religious belief themselves frequently acknowledge its importance to many of their patients and would be prepared to accept that it is a factor in their overall well being.
What elements of spiritual care are effective?
Non-religious elements such as art and music may convey an immediate and powerful thrill and a feeling of peace and contentment, but do they answer the really big questions: Why am I here? What is the meaning of life? Can guilt be erased? What happens when we die? British Chief Rabbi Jonathan Sacks once made the gnomic statement: “Spirituality changes our mood, religion changes our life”.10 Most of the enduring benefits that have been reports as a result of spiritual care appear to have actually been due to the religious dimension.
A study from the USA singled out prayer and Bible readingbas being the most beneficial factors in one group of problembpatients.11 Tournier reported seeing patients experience great relief from acceptance and appropriation of a verse from the Bible - and also from the testimony of his own experience of God’s help, and his certainty of divine protection whatever happens. He described how he had seen the confession of a lie or an illicit love affair relieve symptoms such as long-standing insomnia, palpitation and headache.9 The present authors are constantly surprised at the continuing good attendance at the regular voluntary Christian Sunday Services for prayer, Bible teaching and worship in the Aberdeen hospitals, in spite of all the difficulties some of the patients have to overcome with their drip stands and bags!. These Services clearly meet a need.
The power of religion to strengthen people’s ability to cope with life threatening disease has been attributed in large measure to the availability of a supportive church fellowship and also to healthier life-styles; particularly the avoidance of smoking and moderation in the use of alcohol. Of course, other religions may be able to report similar successes.
It is important to recognise that the value of religion in healing is not confined to its direct effect in illness. Religion is even more important as a motivating force. It was Christian conviction and initiative which led to the founding of hospitals, not only in Western Europe, but later in Africa and parts of Asia. It was the Church that recognised the need for provision of healing in the context of holistic care, based on the teaching of Jesus Christ, and his linked commands to love God with all one’s heart and to love one’s neighbour as oneself. It is important to recognise also that Christianity not only gave rise to the idea but also provided the dynamic to keep it going. Other religions have provided a similar dynamic.
Conclusion and practical implications
We warmly commend the Health Minister’s initiative. There is no doubt that health care as currently practised is less effective than it might be and there is some evidence that part of this ineffectiveness is due to a lack of recognition of the spiritual and, specifically the religious dimension of life.
We recommend the following practical steps:
1 Provision of a quiet room for private reflection and counselling, and a chapel near the centre of the hospital complex, for regular services.
2 Ready availability of Bibles and other useful books - either at the bedside or in a circulating library with frequent visits to the bedside.
3 Chaplains and their assistants should be recognised as specialists in spiritual care, just as medical staff are specialists in care of the body and mind. The two should meet on terms of equality. More doctor/ chaplain interaction should be encouraged: for example the hospital chaplain could, on occasion, be invited to unit or ward meetings.
4 Spiritual provision for those who do not belong to the Christian faith - without downgrading the historic provision for Christians.
5 Teach students to include the spiritual/religious dimension in history-taking. Chaplains could be more directly involved in student teaching: for example in ethics seminars and in planning ‘spirituality ’ teaching modules.
6 Doctors could engage more meaningfully with their nursing and therapy colleagues to discuss ways in which spiritual needs may be met.
7 Doctors who themselves have little or no interest in spiritual or religious elements in their patients’ care could, nevertheless, be encouraged to countenance increased provision for these needs in their wards and units.
8 Further research should be undertaken to determine precisely which elements of spiritual care are effective.
REFERENCES
1 Chisholm M. Speech delivered at the Spiritual Care in the NHS Conference on 16th November 2001. Scottish Journal of Healthcare Chaplaincy 2002: 5:24-26.
2 Doll R. Prospects for prevention. 1983 Br Med J: 286:445-453
3 Jung C G. Modern man in search of a soul. 1933. Kegan Paul, London
4 Sims A. ‘Psyche’ - Spirit as well as mind? Br J Psychiatry 1994: 165: 441-446
5 Murray S A, Grant E, Grant A, Kendall M. Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers. Br Med J 2003: 326:368-371.
6 Smith BH.Spiritual healing and the appliance of science. Scot MedJ 2002: 47.
7 Koenig H G. Is religion good for your health? 1997 Haworth Press, N.Y.
8 Barker M G. Psychology, religion and mental health. 2000 Rutherford House, Edinburgh
9 Tournier P. A doctor’s casebook. 1954 SCM Press Ltd, London. pp11-16.
10 Sacks J. ‘Spirituality ‘ is escapist, shallow and self-indulgent. The Times, Aug 24th 2002
11 Koenig H G et al. Religious practices and alcoholism in a southern adult population. Hosp Community Psychiatry 1994 45:225-31