Medical spirituality: defining domains and boundaries.

ABSTRACT: The rapidly accumulating evidence that personal spirituality has important influences on health care outcomes is somewhat difficult to integrate into daily medical practice, in part because accepting it requires adjustments to the standard biomedical worldview, and in part because it challenges established boundaries between chaplaincy and evidence-based medicine. We propose that the recognition of medical spirituality as a distinct, interdisciplinary field of interest, with its own well-developed body of clinical evidence, clinical skill, clinical ethics, and with well-defined clinical boundaries, can help overcome much of the current confusion about how to integrate the new knowledge, and help pre-empt developing "turf" issues. The new field would contribute significantly to refraining the worldview of healing practice, consistent with the evidence-based approach.

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REGENT DECADES have seen rapid expansion of evidence that personal spirituality has important influences on health care outcomes, as summarized and tabulated in a recent textbook of some 700 pages with 1,200 references. (1) Effectively integrating the evidence into daily medical practice is problematic, however, in part because the evidence is voluminous and has accumulated rapidly, but also because the results are unpredicted by the dominant molecular worldview of biology and medicine. Accepting the new evidence requires adjustments to the standard reference frame of medical practice.

The strain has already begun to show. Sloan et al (2,3) have taken strong exception to incorporating spirituality concerns into medical practice. Koenig et al (4) have replied to the substantive arguments, but in reply to correspondence, Sloan (5) acknowledged that turf issues also are a concern. Indeed, many disciplines contribute to knowledge about the complex relationships between health and spirituality, and each would thus have some claim to "turf." This knowledge provides the basis for courses relating religious faith and medicine in an increasing number of medical schools. (6,7)

The growing diversity of population, especially in the United States, makes it important that medicine and its allied professions develop approaches to health and spirit which are sensitive to patients' personal beliefs, but are theologically neutral.

For all of these reasons, we propose that presently there is sufficient weight of information to justify defining medical spirituality as a special area of interest within medical and allied health practice. We offer definitions and language which we hope will define the domains and boundaries for appropriate, cooperative clinical practice and research, consistent with the evidence-based approach.

DEFINITIONS

The current literature offers no consensus about definitions for religion or spirituality, nor about a name for this field of medical interest, or the bounds of its subject domain. For purposes of this discussion, we offer the following: Spirituality is defined as that personal function which relates life's meaning to transpersonal reality. Spirituality is an element of a person's individuality and is not necessarily defined by association with a certain tradition or by organizational affiliation. It is multidimensional and operates (to varying degrees) in acknowledgment of the unconscious self, the needs of others, and the realm of the sacred. Such awareness varies among individuals and throughout a person's lifetime. Waldfogel (8) has summarized the elements of spirituality as they relate to medical practice. Transpersonal reality here refers to those levels of "world" beyond the ordinary bounds of ego-consciousness. It includes the level of transcendence as used by Waldfogel (8) and Cassel. (9) Religion is defined, for our purposes, as the set of beliefs and practices shared by a community in reaching toward the transpersonal reality. This also is a broad term, but describes a more collective element. Each religion has its own historical tradition with a rich and complex symbolic language by which to interpret its central symbol of the deepest level of transpersonal reality. Such language may easily be misunderstood by people outside the tradition.

In proposing a name for this field, we considered the term spiritual medicine, to parallel such terms as physical medicine, internal medicine, and behavioral medicine. While that would be appropriate in the context of physicians and the practice of medicine, we offer medical spirituality as a more general term, better to reflect the broad and complex interconnectivity of many disciplines within this domain. While health care spirituality would be a possible name for this field, we admit a bias toward retaining a reference to medicine, whose rich symbolic connection to its hippocratic, and thus aesculapian (ie, spiritual), origin is still reflected in its iconography (eg, the seal of the American College of Surgeons). (10) We define medical spirituality as that area of spirituality studies which generally relates to health effects. It is spirituality seen from a medical point of view. It is the space defined by the overlapping spheres of action, as health care and spiritual care seek together to relieve all le vels of suffering. (9)

SUBJECT AREAS

Medical spirituality, as a domain of special clinical interest, education, and research within the health care field, should encompass at least the following subject areas.

Clinical Basis

Correlations between measures of spirituality and health outcomes (1) provide the foundational knowledge base for the field. Primary clinical skills include recognition and assessment of patient concerns as a screening function for. appropriate referral, (11,12) and recognition of the faith-specific needs of patients and families as they seek to cope with illness. Spirituality concerns are especially likely to be encountered in chronic and progressive disease, critical care, oncology, end-of-life care, bereavement, stress management, and mental health practice.

Philosophic Basis

There is growing research in physics, (13,14) biology, (15,16) and psychology, (17) which points to an abstract realm of nonlocal reality, a realm "beyond" the physical for which science generally lacks descriptive language. Clinical evidence for nonlocal effects of intentionality is beginning to emerge in preliminary studies, (18-20) and though the scope of existing studies is limited and important questions remain, the results so far cannot readily be accommodated within a mechanistic view. (4) Practitioners attuned to medical spirituality concerns are well positioned to provide new data about relationships between physical and psychical ("experiential") realities. All such evidence must be integrated in the refraining of the worldview of medical practice. (21)

Professional Activity

Medical spirituality seeks, first of all, to foster professional awareness of patients' spiritual needs. Waldfogel (8) wrote, "Of course, to engage patients effectively in the spiritual realm, and thereby to offer better and richer support to ill persons and their families, the health care provider must possess a personal and spiritual maturity" Thus, an important concern for medical spirituality is providing practitioners appropriate, nonsectarian peer support and encouragement of personal spiritual development, and fostering among ourselves the rediscovery of personal meaning in healing practice.

Ethical, Legal, Social Implications

Medical spirituality at all levels will be concerned to be evidence-based, nonsectarian, and theologically neutral. It will also need to deal with boundary issues among practitioners of various types, and between practitioners and patients, for as Sloan et al (2,3) report, medical spirituality is not without its own special set of concerns and cautions. A special ethical concern is that practitioners restrict themselves to doing what they do well, and make appropriate referrals.

INTERFACING DISCIPLINES

The knowledge base and skill base of medical spirituality develop through the interactions of many disciplines, which include, at a minimum, the following:

* Medical specialties 

* Nursing and allied health professions

* Psychology, including transpersonal (depth) psychology

* Pastoral care/health chaplaincy

* Philosophy: bioethics, consciousness studies, ontology 

* Medical anthropology anti sociology

* Health education

* Community services: faith-based service groups, hospice, parish (congregational) nursing

* Clergy (identifying faith-specific patient needs)

Each discipline contributes a special perspective on human experience, which taken together can lead to a deepening general understanding of the many levels involved in healing process. Further development of medical spirituality as a field will benefit from recognizing and respecting the unique contributions of each.

DISCUSSION

Examination of the list of interfacing disciplines reveals a variety of boundaries which must be respected if optimum cooperation is to be achieved. Each discipline's field of action is defined variously, for example, by academic or clinical licensing or credentialing. Such boundaries have ethical, legal, arid social implications; in one sense, they limit action, but they can also serve to identify opportunities for cooperative action. Some of the disciplines, though not involved in clinical work, make important contributions to the knowledge base.

There is a more general boundary between health care and spiritual care, defining respective areas of expertise for appropriate consultation and/or referral. An important need of the new field is to identify ethical ways to communicate essential patient-care information across this important boundary, especially when one or the other party has information critical to the successful work of the other, in the patient's behalf.

There is also an important boundary defining two modes of spiritual care. A nonsectarian approach is essential in general health care programs, where spiritual needs are served by a credentialed pastoral-care team (health chaplaincy), and perhaps by pastoral counselors licensed for psychotherapy. Their doctrinally neutral approach must be distinguished from the faith-specific spiritual care offered in the general community, such as by clergy to members of their congregations, or by spiritual directors (as in the monastic model). Consultations and referrals across this boundary often require an even more careful assessment than that needed before consultations between health care and spiritual care providers in health facilities.

The key to effective, cooperative functioning of health care and spiritual care teams is good communication. Those in the field must devise and evaluate explorative models for cooperative caregiving at various levels of care. Accredited hospitals generally have health chaplaincy services available to inpatients and in their affiliated hospice programs. However, in many communities there is a notable gap in nonsectarian spiritual assessment and care for outpatients. For example, breast cancer now is usually treated entirely on an outpatient basis; any such patients not affiliated with a faith community may have few opportunities for spiritual care consultations.

We believe that recognizing medical spirituality as a distinct, interdisciplinary field of interest, with its own well-developed body of clinical evidence, clinical skill, and clinical ethics, can help overcome much of the current confusion about how to integrate new knowledge about the influences of spirituality on health care outcomes. The new field would also contribute significantly, with other disciplines, to refraining the worldview of healing practice; more immediately, however, it could help pre-empt developing turf issues about spiritual care.

Almost 100 years ago, Sir William Osler wrote, "Linked together by the strong bonds of community of interests, the profession of medicine forms a remarkable world-unit in the progressive evolution of which there is a fuller hope for humanity than in any other direction." (22) That view of medicine (and the now vastly expanded health care enterprise) as an evolving world-unit is an essentially spiritual vision of the calling to heal on many levels. The 20th century saw great progress in molecular understanding of disease. We believe that a formal embrace of the field of medical spirituality would represent a significant evolutionary step and help us collectively take those understandings to new levels.

References

(1.) Koenig HG, McCullough ME, Larson DB: Handbook of Religion and Health. New York, Oxford University Press, 2001

(2.) Sloan RP, Bagiella E, Powell T: Religion, spirituality and medicine. Lancet 1999; 353:664-667

(3.) Sloan RP, Bagiella E, Van de Greek L, et al: Should physicians prescribe religious activities? N Engl J Med 2000; 342:1913-1916

(4.) Koenig HG, Idler E, Kasl S, et al: Religion, spirituality and medicine: a rebuttal to skeptics. Int J Psychiatry Med 1999; 29:123-131

(5.) Sloan RP: (Reply to correspondence). N Engl J Med 2000; 343:1341-1342

(6.) Barzansky B, Jonas HS, Etzel SI: Educational programs in US medical schools, 1999-2000. JAMA 2000; 284:1114-1120

(7.) Puchalski CM, Carson DB: Developing curricula in spirituality and medicine. Acad Med 1997; 73:970-974

(8.) Waldfogel S: Spirituality in medicine. Prim Care 1997; 24:963-976

(9.) Cassel E: The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639-645

(10.) Stephenson GW: Of Aesculapius and the medicine man: some comments on the College Seal. Available at: http://www.facs.org/about_college/seal.html. Accessed May 2001

(11.) Puchalski C, Romer AL: Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med 2000; 3:129-137

(12.) Lo B, Quill T, Tulsky J: Discussing palliative care with patients. Ann Intern Med 1999; 130:744-749

(13.) Aspect A: Bell's inequality test: more ideal than ever. Nature 1999; 398:189-190

(14.) Rowe MA, Kielpinski D, Meyer V, et al: Experimental violation of a Bell's inequality with efficient detection. Nature 2001; 409:791-794

(15.) Denton M, Marshall C: Laws of form revisited. Nature 2001; 410:417

(16.) Kirschner M, Gerhard J, Mitchison T: Molecular 'vitalism'. Cell 2000; 100:79-88

(17.) Clarke CJS: The nonlocality of mind. J Consciousness Studies 1995; 2:231-240

(18.) Byrd RC: Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988; 81:826-829

(19.) Harris WS, Gowda M, Kolb JW, et al: A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med 1999; 159:2273-2278

(20.) Schlitz M, Braud W: Distant intentionality and healing: assessing the evidence. Altern Ther Health Med 1997; 3:62-73

(21.) Bessinger CD: Reflections on reality healing and consciousness. Altern Ther Health Med 1996; 2:40-45

(22.) Osler W: Unity Peace and Concord [c.1905]. Aequanimitas. With other Addresses to Medical Students, Nurses, and Practitioners of Medicine. Philadelphia, P. Blakiston's Son and Co, 2nd Ed, 1925, p 453

KEY POINTS

Medical spirituality is defined as an interdisciplinary field in medical and allied health practice, which integrates new knowledge of complex relationships between health and spirituality.

* Recognizing well-defined clinical boundaries between health care and spiritual care can help foster communication, education, and research.

* The new field includes clinical evidence and skills, philosphy of medical practice, and ethical, social, and legal issues.

* Medical spirituality at all levels will be concerned to be evidence-based, non-sectarian, and theologically neutral.

From Palmetto State Surgical Associates and Emmanuel Unit, St. Francis Hospital System, Greenville, SC.

Reprint requests to Donivan Bessinger, MD, MS, 10 Brookside way, Greenville, SC 29605.