"You just do your part. God will do the rest.": spirituality and culture in the medical encounter.

Mrs. Bennett is a 58-year-old African-American female with metastatic cervical cancer, diagnosed two years ago. She initially underwent radical hysterectomy, chemotherapy and radiotherapy. She did well until six months ago when liver metastases were detected. She then entered a Phase II clinical trial, but the cancer continued to progress. She is now hospitalized with a bowel obstruction from peritoneal carcinomatosis. Dr. Martin, a Caucasian male, talks to her about her prognosis and suggests hospice. Mrs. Bennett responds, "I don't want to discuss hospice. You just do your part. God will do the rest."

Culture may significantly impact health, influencing health-seeking behaviors, treatment decisions, and how individuals cope with and interpret illness. For some ethnic groups, spirituality is an essential component of this process. Using African-American culture as an example, this article highlights the cultural context of spiritual beliefs and offers practical considerations for clinicians.

African-Americans are one ethnic group for whom spirituality is especially important. Compared with Caucasians, African-Americans report more participation in religious activities, greater religious commitment, and a greater reliance on spirituality to cope with illness. (1,2) This increased emphasis on spirituality is thought to result from a long history of oppression and mistreatment. African-American Christian spirituality emphasizes victory over oppression and death and views suffering as redemptive. (3,4) Given past injustices and ongoing disparities in healthcare, illness may be understood as yet another struggle to overcome. As such, treatment preferences may reflect a belief in the power of Jesus Christ to "heal all manner of sickness" (Matthew 4:23) and a view that the pain and suffering of illness are not to be avoided, but rather endured as part of a spiritual commitment. (3,4)

A review of the medical literature describing the spiritual beliefs of African-Americans identified similar themes, including the belief that God is ultimately responsible for health and a belief in miracles. (2) These recurred across a range of illnesses (HIV, diabetes mellitus, hypertension, cancer) and may impact treatment decisions and health-seeking behaviors.

The case of Mrs. Bennett illustrates the potential influence of spirituality throughout the illness experience. She delayed seeking medical attention for two years after the onset of vaginal bleeding due to her belief that she was being punished for past sins. After her husband convinced her to see a doctor, she wondered if she had failed a test of faith. When she responded to the initial treatment, she rejoiced in the healing power of God. Now that her disease has reoccurred, she maintains her faith, believing that God will never "leave or forsake" her. As Dr. Martin explains the benefits of hospice in relieving suffering, Mrs. Bennett responds, "Suffering is not new to us (African-Americans). Jesus Christ suffered, and we all have a cross to bear." These beliefs are the basis for her medical decisions, not prognosis and quality of life which guide clinicians' recommendations.

Responding to spirituality within the context of an unfamiliar culture is challenging. The most effective strategy for culturally-competent care is good communication. (5) This includes asking patients about their beliefs, respecting the importance of these beliefs in understanding and coping with illness and in care preferences, and facilitating the involvement of sources of spiritual and cultural support (ie, the patient's pastor). Understanding spirituality within the context of a given culture may create an opportunity for clinicians to negotiate common goals of care when conflicts arise and improve the quality of care for patients of all ethnic groups.

After consultation with surgery and oncology, Mrs. Bennett left the hospital with a venting gastrostomy. Before discharge, she agreed to hospice because she wanted to avoid burdening her family with her care, not because of a desire to alleviate personal suffering which she saw as "God's will." As she left the hospital, she thanked Dr. Martin for doing his "part." As the U.S. becomes more ethnically diverse, the "part" of clinicians will increasingly include respectfully caring for patients whose cultural and spiritual beliefs differ from their own.

References

1. Levin JS, Taylor RJ, Chatters LM. Race and gender differences in religiosity among older adults: findings from four national surveys. J Gerontol 1994;49:S137-S145.

2. Johnson KS, Elbert-Avila K, Tulsky JA. The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature. J Am Geriatr Soc 2005;53:711-719.

3. White MD. African American Christian spirituality in the face of illness. Yale Journal for Humanities in Medicine, May 2002.

4. Crawley L, Payne R, Bolden J, et al. Palliative and end-of-life care in the African American community. JAMA 2000;284:2518-2521.

5. Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of life: "You got to go where he lives". JAMA 2001;286:2993-3001.

Kimberly S. Johnson, MD, MHS 

From the Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, and Center for Palliative Care, Duke University, Durham, North Carolina 

Reprint requests to Kimberly S. Johnson, MD, Department of Medicine. Division of Geriatrics, Center for the Study of Aging and Human Development, and Center for Palliative Care, Box 3003 Duke University Medical Center, Durham, NC 27710. Email: [e-mail]