Keywords

Nothing in life is more wonderful than faith – the one great moving force which we can neither weigh in the balance nor test in the crucible … Faith has always been an essential factor in the practice of medicine.

William Osler [1]

Spirituality is an essential ingredient of whole person care. Although its role in health and healing is often neglected, spirituality is increasingly recognized for its relevance to personhood and creating a caring relationship with patients. As a result, its role in medical education has been emphasized to address the concerns of sick people, particularly those with life-threatening diseases, and those with diseases that affect quality of life (QOL). This chapter aims to outline the ways in which spirituality plays a role in whole person care.

Neglect of the Spiritual Dimension in Medicine

Throughout history, the healing profession has embraced the concept of mind–body and soul. In the ancient world, temples were not only places for worship but also centers for the healing of those who suffered from visible and invisible wounds of body and mind. In Middle Eastern and oriental countries, spiritual mindfulness was one of the characteristics of scholars of science and medicine. This is exemplified by the life and work of great scholars such as Avicenna and Razi.

In the West, with the rise of industrialization, technology, and science, remarkable progress has been made in the advancement of medicine. However, the growth of a materialistic view of life that has sprung up in conjunction with the advancement of science has tended to create a divide between spirituality and medicine. Descartes in his work Treatise of Man viewed the body as a machine [2].

The view of Freud and his works such as “Civilization and Its Discontent” [3] have created doubts and skepticism with regard to spirituality/religion. Many psychiatrists, psychologists, as well as other health professionals, seem to have distanced themselves from spiritual matters in academic and clinical debates. As scientific and technological advancements were not complemented by greater acknowledgement of the important role of spirituality in the healing of patients, health sciences were not adequately equipped to address the needs of whole person care in a comprehensive way. Rosen stated, “[M]odern medicine seems to have lost sight of the art, the spirit, and the intangibles such as faith, hope and compassion that are essential to the healing process” [4].

Interest in reintegrating spirituality with medicine has begun to emerge during the past twenty years in North America [5]. Extensive research studies in recent years have demonstrated the positive and beneficial effects of spirituality on health, recovery from illness, QOL, palliative care, and other fields of medicine [6].

Obstacles to Spirituality in Medical Practice

However, the subject of spirituality is often avoided because of the following three major factors, which adversely influence physicians’ pursuit of spirituality in their medical practice. One is scientific reductionism, which denies the existence of the transcendent and thus the spiritual nature of human reality. The second is a negative public impression of and attitude toward religion and spiritual beliefs due to critical publicity surrounding some organized religious institutions. This reinforces the denial of religion/spirituality as a viable phenomenon of humanity. The third is the industrialization of medicine, which reduces it to an economic enterprise, primarily concerned with efficiency and financial gain rather than the provision of compassionate care and treatment of the whole person. Put succinctly, “changes in health care are placing us under increasing pressure to become only physicians of the body and to abandon our responsibilities for the mind and soul … The current health care system is globally insensitive to the psyche of patients, whatever the infirmities of their bodies …” [7] These troubling developments in contemporary health care suggest the need to rethink the true goal of medicine with respect to saving lives and alleviating suffering. As Sulmasy stated, “no amount of scientific or economic transformation can alter the fundamental meaning and value of health care, nor can it ever eradicate the interpersonal nature of the healing relationship that begins when one person feels ill, and another highly skilled and socially authorized asks ‘How can I help you?’” [8], demonstrating the original ­meaning of the word “psychiatry”: physician/healer of the soul.

Spirituality and Healing

Spirituality is poorly understood and often avoided in the psychiatric and medical community. The word spirit is from the Latin word “spiritus” or breath and animating principle. One aspect of spirituality refers to the development of the capacity to acquire a deeper understanding of the purpose of life. Spirit is the inner reality of human beings, a nonmaterial entity that connects a material and mortal entity such as the human body to a universal transcendental power. Moreover, physical health and spiritual health are interconnected. In holistic terms, being healthy is a state of well-being of mind, body, and soul.

Healing is the art of restoration of hope and wholeness, and a healthy life goes beyond absence of disease. Some patients in palliative care and those near the end of life are overcome by a sense of hopelessness, which is not always characterized by other symptoms of clinical depression. The body may be perceived as an object that increasingly loses its meaning, and these patients may express the desire for hastened death. This strong feeling may be associated with loss of dignity and self-worth, which leads to demoralization. Demoralization is common among patients suffering from chronic medical illnesses and those with serious disabilities or who are terminally ill. It is a state of hopelessness, helplessness, existential despair, and meaninglessness, which arise from a feeling of being “trapped” and a desire to die [9]. Restoration of morale is vital in therapy.

Although science is able to alleviate physical pain and discomfort, it has limitations with respect to the meaning of life and the end-of-life experience. But spirituality can not only give meaning to this final stage of life but may also give a sense of hope, whatever the hope may be for the individual. This could be a specific belief that the journey of life goes beyond physical death or a more general trust or faith in life whatever the future may bring. One may perceive spirituality as a personalized feature of faith and religion as a structured and institutionalized expression of faith [6].

Prayer and Spirituality

One expression of faith is prayer. Prayer for the sick is the oldest means of alleviating anguish and suffering and is an assistance to recovery and healing used worldwide. However, it does not minimize or replace conventional treatment. In secular cultures, it may be difficult to comprehend the role of a nonmedical approach such as prayer in the healing process. Yet, there is increasing interest in the exploration of nonmaterial or nonphysical treatment as an alternative to traditional treatment. Among the 10 most frequent alternative medical procedures used in USA are prayers for oneself and for others (intercessory prayer).

Herbert Benson from Harvard University holds that prayer operates in the same way as a relaxation response [10]. It is believed that prayer can affect stress hormones, resulting in lower blood pressure and a moderation of pulse and respiration. These are physiological findings that may not necessarily be related to prayer per se; however, the power of prayer goes beyond the physiological changes for healing the illness. Belief in the effect of prayer in health or illness was and still is taken as a matter of faith by many and traditionally did not require scientific confirmation of proof for efficacy as the majority of patients were and most still are religious people. A Gallup poll of American adults showed that 94% of them had a belief in God or a universal spirit. Among those surveyed, 87% admitted that religion was important in their lives. Many of those interviewed reported that they turned to prayer for assistance in overcoming disease. In another American study, 76% of those questioned professed that they prayed daily. Many said that they turned to prayer for assistance to overcome their disease, even though they tended to avoid direct affiliation with a religion [11].

Spirituality and Personhood

The term personhood reflects a holistic view of a person as well as a state or condition that encompasses an individual’s essential meaning. Patients’ beliefs and values are expressions of personhood that play a role in the treatment process and caring relationship. Personhood is not static, but is rather an evolving phenomenon that develops through life experiences. Likewise, the meaning of our life can change from day to day as we evolve. Mount stated “Our lives are shaped not by momentous events and huge crossroad decisions but by the thousands of little decisions that occur each day … each of the little daily decisions shapes our lives to a greater extent than we may think” [12].

Maslow identified a hierarchy of needs that begin with basic biological requirements and end in self-actualization, which is the fulfillment of a human being’s highest aspirations [13]. Spirituality is related to self-actualization and fulfillment of intrinsic values. The role of the physician as a healer is to facilitate this self-fulfillment through helping the patient to draw meaning from his or her suffering. Observation as well as research in the literature shows an important relationship between spirituality and well-being [14], which may have a nurturing effect in the development of personhood. It has been reported that spiritual well-being offers some protection against despair in those nearing the end of life [15]. Indeed, spiritual issues “lie at the very centre of the existential crisis that is terminal illness” [16]. This further underlines the role of a spiritual perspective in whole person care and in alleviating human suffering and despair.

Spiritual insight into a tragic event such as the death of a loved one may give new meaning to that event, possibly alleviating some of the grief. The following anecdote is a case in point. A mother asked a great spiritual sage to see her sick child because the efforts of doctors had yielded no results and the child was gravely ill. He came and brought two roses for the little girl as he visited her. Then, turning to her mother with a voice full of love told her that she must be patient. That evening, the child passed away. The mother was devastated and asked the wise man why this had happened. He explained that the world of humanity is like a garden and the Creator is its Gardener. Human beings are like trees that grow in that garden. “When the Gardener sees a little tree in a place which is too small for its development, He prepares a suitable and more beautiful place where it may grow and bear fruit. Then He transplants that little tree. The other trees are surprised and say, ‘This was a lovely tree. Why did the Gardener uproot it’? Only the Divine Gardener knows the reason. You are weeping, but if you could see the beauty of the place where your child is, you would no longer be sad…If you could see that sacred garden yourself, you would not be content to remain here on earth. Yet, this is where your duty now lies” [17]. This spiritual perspective on the meaning of death and the life after gave that mother, who was open to this perspective, a new vision of understanding that eased her sorrow.

Spirituality and intrinsic values are interrelated and reflect the essence of ­personhood in whole person care. In today’s society, we need to reassess our concept of values to reach a deeper understanding of the meaning of life and its purpose. Intrinsic and personal values guide and propel individuals to fulfill their potential. These values are developed and nurtured through education, culture, and beliefs. According to Maslow, “human life will never be understood unless its highest ­aspirations are taken into account” [13]. Therefore, personal growth, self-actualization, and striving toward achieving a psychosocial and spiritual perspective on life are part of a universal human quest for fulfillment.

Spirituality and Medical Education

Since the 1990s, there has been an upsurge of educational programs in the curricula of medical schools in North America to familiarize physicians with the spiritual dimensions of health and healing [18]. A growing number of medical schools across USA have been offering courses on religion and spirituality in medicine and patient care. In 1994, only 17 of the 126 accredited medical schools in the country offered courses on spirituality as part of their medical education. By 1998, this number had increased to 39 [5]. By 2004, it had risen to 84 schools. Presently, 100 of the 150 US medical schools teach spirituality in medicine courses [18]. More than 75% of American medical schools teach subjects related to spirituality and health. Likewise, hospitals are initiating spirituality programs to promote compassionate care for their patients [14]. The Faculty of Medicine at McGill University was one of the first in Canada to introduce formal courses in the curriculum on spirituality and medicine. During the past ten years, there have been two courses on this subject: one, a required introductory course for first-year medical students, and the other, a comprehensive 4-week elective course on spirituality and ethics in medicine for the fourth-year medical students. Both have been well received, the students finding the courses to have contributed to their knowledge of the spiritual dimension of medicine.

In recent years, taking a spiritual history has been included in the spirituality courses of many medical schools. This may allow clinicians to have a broader understanding of their patients with different religious backgrounds. Spirituality in this context has a wide meaning. It may be perceived as transcendent experience that is often expressed as a relationship with God, but it may also have other meanings. Puchalski and Romer suggested that spirituality is whatever beliefs and values that give a sense of meaning and purpose to life [19]. Factors that may have contributed to integrating spirituality into medical education were a greater awareness of the role of spirituality in healing and a growing number of patients, especially in USA, who wanted to share their spiritual concerns with their physicians as they sought medical treatment.

Spiritual Needs and Concerns

An increasing number of patients, especially those with chronic or life-threatening diseases, come to physicians with spiritual needs and concerns to be answered. Serious illnesses and near-end-of-life conditions provoke questions about mortality, the purpose of life, the meaning of suffering, and whether there is a greater power and life beyond death. For many of these people, religious beliefs form a basis for understanding the mystery of death and the role of prayer in life-threatening situations. Fear of the unknown often leads to disturbing questions that call for understanding and comfort by those who have assumed the role of physicians as healers. Accepting the will of God is an experience commonly observed in those who have spiritual perspective near the end of life. In light of the fact that almost 90% of the world’s population is reported to be involved in some form of religious practice [20], spiritual concerns of the patient population have worldwide implications in the work of medical and other health professionals.

In a study of hundreds of patients with advanced lung cancer, it was noted that when patients wanted to decide between different treatment options, their faith in God seems to have played an important part in making a decision, ranked second only to the recommendation of the medical oncologist. Conversely, their physicians thought that their patients’ faith in God should rank as the least important factor to consider in their decision about treatment [21]. This underlines the importance of being mindful of patients’ beliefs to make it easier for us to find a common ground for whole person care.

Spiritual/religious needs may vary across different cultures. These may include the need to be loved and remembered, to maintain personal dignity, to pray and to be loved by God, to have faith in the Creator and in the wisdom of suffering, to recognize the purpose of life, to be known to have lived a worthy and fulfilled life, to be reconciled to life challenges, to be forgiven, and to be obedient to religious principles. Patients may wish to discuss these and other needs with their caregivers and friends who can listen without being judgemental. They may want to have a safe environment where they can share some very personal thoughts of their lives. Such care may serve to fulfill real needs of the patient and is part of the healing process.

Among spiritual concerns are questions such as “Why do I have this disease?” Is it a punishment for sins of disobedience to God? “Why as a devoted believer should I suffer?” “Is there life after death?” Some terminally ill patients have a fear of dying and they wonder how to face the unknown, invisible world. Some view their imminent death as a liberation from suffering, like a bird being released from its cage. Others may wonder if death will be like a new birth into another world and if they will need to start learning again about the mystery of another world. Some may be tormented with thoughts of punishment by God for their misdeeds and transgressions. In patients with a history of mental disorder, this fear can be highly exaggerated and disturbing. Other patients who have faith in a merciful Creator may submit their will to God’s and be content with whatever their destiny will be. Therefore, this point of transition can evoke a range of emotions, from fear and anxiety to transcendence with quiet and calm submission to a greater power. This is the domain of the spiritual world on which sacred writings have shed some light.

Spiritual beliefs may provide an existential framework through which grief is rapidly resolved. In a 14-month follow-up study of a population after the death of a loved one, the survivors and friends who had a stronger spiritual belief seemed to overcome their grief more rapidly and adequately as compared to those who had no spiritual belief [22].

In dealing with suffering due to life crises and disease, a spiritual outlook can be invaluable. In recent years, I have been in contact with a number of individuals who have gone through major crises in their lives. Among them were those who suffered from cancer. Some have risen above their pain and limitations, demonstrating a unique spirit of faith and resilience that surprised even their family and friends. Among them was a mother of two children who, at age 42 and at the height of her career, was diagnosed with breast cancer. She was devastated by this horrible news and could not believe what was happening to her. The surgeon advised a radical mastectomy to prevent relapse. After the surgical operation and chemotherapy, instead of feeling defeated or shattered, she decided to make a change in her life by becoming closer to her family and living life to the fullest. She wanted to discover her true purpose in life and move from resignation to affirmation.

A few years later, as she was recovering, she and two other cancer survivors created a support group called Hope to help and empower women cancer patients to see “the bright side of life.” Her fear of dying was transformed into a celebration of life. Their Hope retreat became a success, attracting and inspiring many other cancer survivors.

After this organization was in existence for a few years, she and her coworkers received an award of distinction for their outstanding contribution in helping cancer patients to live with hope and to have a better QOL. About 10 years after her first cancer was diagnosed, she was shocked to learn that her cancer had returned in another form. She went through radiation treatment and persevered with faith and hope. Again, she recovered and was happy to resume the Hope project and become very active in promoting hope for cancer survivors. Her group won an award of recognition in the category “Health, Well-Being and Spirituality.” This was another confirmation of her creative resilience helping others to fulfill their potential to the best of their ability. Unfortunately, a few years later further complications and metastasis revisited her, but her spirit remained unshaken.

In a letter she wrote that after 23 years of cancer and its challenges, she still tries to never give up hope and to be positive. Even though she had stage 4 cancer, she still responds to invitations from the College of Medicine in Saskatchewan to speak with medical and nursing students, telling them about the importance of hope in cancer patients.

In 2009, she wrote and published a book about her life and struggle with cancer called “A Rose Grows – Fighting Cancer, Finding Me.” Like project Hope, her book became another source of inspiration that encouraged scores of cancer survivors to strive for a meaningful life. She wrote, “Cancer gave me a chance to become who I was really meant to be....There was a purpose in facing the challenges I faced. I have learned so much through my experience.” She discovered what she was capable of after enduring cancer. Believing in spiritual strength she wrote “This was God’s way of redirecting my life and making me see what life is really all about … and I will eternally be grateful for this journey” [23].

Her story shows how suffering can inspire people to pursue a creative life and to fulfill their latent potential and capacity of which they may not be aware. It also reflects how one can remain grateful for what one learns from adversity.

An illness can have different meanings: personal, social, and cultural. It can also have different meanings to the same person at different stages of life or in different circumstances. Our sociocultural beliefs about disease influence our perception of and attitude toward it. For example in some cultures, people’s attitudes toward patients suffering from AIDS or mental illness are charged with negativism, stigma, and discrimination. On the contrary, a sickness can consume a patient’s attention and like a sponge soak up his/her personal and social importance if there is no reliance on other forces of life that would give a deeper vision of meaning and purpose of creation [24]. Awareness of this dynamic may help a therapist to recognize the value of the patient as a whole person. Reflecting on the spiritual reality of the patient will make it easier for the physician to accept the patient unconditionally and to honour the essence of personhood within the person.

Spiritual Perspective on Death

Expectation for recovery and cure is not the only hope that seriously ill patients cherish. When cure is no longer possible, some patients reflect and hope that there will not be undue pain and suffering or that they will not be left abandoned. They strive to draw meaning from life crises and possibly to enjoy whatever time they have left with family and loved ones. They expect to be remembered by relatives and friends after death. During the near-end-of-life period, a sense of hopelessness and loss of meaning may precipitate depression. But for those who have found a spiritual perspective on life and its ultimate destiny, there is less likelihood of total despair and hopelessness. They may believe that the soul is not affected by physical and biological infirmities generated by disease, and therefore, they may be more prepared to let go. Death may be perceived as a transition to another world as was birth a transition into this world. They may envisage the journey of life as an organic process moving from one stage of growth to another and death as a gate to a new beginning. Death may also be viewed in the context of the evolution of the soul, leaving behind the physical frame as its vehicle while continuing its journey in a spiritual world. A metaphor that may be helpful to some people is the relationship between the computer (body) and the programmer (soul). The programmer, although closely associated with the computer, is not part of it and has a life of his own [25]. As the human soul or spirit is not a material entity, it is believed to be eternal and independent from the body. But human spirit is fully aware of the condition of the body, which is its instrument, just as the programmer is aware of the condition of the computer.

Viktor Frankl believed that traditional psychotherapy, which aimed at restoring one’s capacity to work and enjoy life, was not sufficient and it should also include enabling the patient to regain his/her capacity to accept unavoidable suffering and to discover a meaning in it. “Man’s main concern is not to gain pleasure or to avoid pain, but rather to see a meaning in his life” [26]. Frankl wrote about his interview with an elderly general practitioner who came to his office for treatment of a severe depression. He told Dr. Frankl that his depression began after the loss of his wife whom he loved dearly and who had died two years earlier. Dr. Frankl wondered how he could help this man and asked him the following question: “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” The man replied that this would have been terrible because his wife would have suffered so much. Then, Dr. Frankl commented, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering, but now, you have to pay for it by surviving and mourning her” [26]. This explanation comforted and satisfied the patient because it gave a meaning to the tragic loss of his wife, which was consuming his mood and mind. Dr. Frankl wrote, “Suffering ceases to be suffering in some way at the moment it finds a meaning, such as the meaning of a sacrifice” [26].

When patients are valued as no more than physical entities, a disabling illness brings an end to their productivity and usefulness. In such an environment, patients are also deprived of the spiritual dimension of the therapeutic relationship and feel as though they are being treated like an object that is no longer of any value for society. This adds to patients’ feeling of guilt for being a burden to family and friends. Living a life judged to be unproductive, sick, and useless is a recipe for hopelessness and self-destruction. Such patients may ask distressful questions such as what am I living for? What is the purpose or meaning of merely surviving? What is my value in a world immersed in selfish materialism? When I am disabled and no longer functional, what am I good for? These questions may lead to an impression that the physical body is a broken machine, a commodity or a product to be discarded if one so wishes. Such a pessimistic view becomes fertile ground for seeking out euthanasia or suicide. A spiritual perspective on life as a process of acquiring the capacity to learn from life struggles with faith and resilience gives a sense of hope to rise above limitations and to accept what cannot be changed.

Spirituality and Quality of Life

Although the QOL of individuals has been the subject of extensive studies, the spiritual dimension of that quality has not been explored as much as it deserves to be. This is partly because conducting research on spirituality is very complex, since it is concerned with the inner realm of human consciousness. Science has its limits with respect to exploring certain qualities that are not of a material nature such as the intrinsic values of an individual, the purpose and ultimate meaning in life, and the QOL based on personal values. These are issues that are deeply embedded in human consciousness and are influenced by spirituality.

In spite of the dearth of material on this subject and the complexity of studying it, there is a growing body of research findings and published reports on spirituality and QOL that suggest that spirituality and a better QOL are interrelated [6]. The US National Institutes of Health reported that in a study of population health, a 25% lower mortality rate was noted in those who attended religious services at least once a week. Some features of these services included meditation, social networking, and values that would discourage risky and unhealthy behaviour such as substance abuse, violence, and infidelity [6]. In addition, spiritual support and mindfulness enhanced coping skills in the face of anxiety and depression in believers.

In another study on international university students, it was noted that spirituality/religion was significantly correlated with psychological aspects of QOL. It was furthermore noted that spirituality/religion contributes to the development of the coping mechanisms of these students in dealing with cultural stressors [27]. However, the relationship between religiosity and QOL requires further exploration.

Spirituality not only influences QOL of individuals but also impacts quality of care and attitude of health professionals toward patients. In a large-scale survey on this subject, individuals were asked if they were to need treatment for cancer, what were the most important characteristics they would like to see in their treating physicians. A large majority of these individuals stated that it would be most important for them to have a doctor who would care about them, would recognize them as a person, and would be “spiritually attuned” to them. They valued these qualities more than technical medical expertise. This finding further supports the role of attitude and empathy in the doctor–patient relationship, especially at a time when patients face grave and life-threatening disease [28].

Conclusion

In conclusion, this chapter explores the importance of a spiritual perspective and intrinsic values in whole person care. Integrating spirituality into the mainstream of health sciences remains a challenge. This is partly because of misconceptions regarding spirituality among a large number of health professionals as well as the complexity of defining an abstract phenomenon such as spirituality. Nevertheless, there are a growing number of research studies and clinical observations that support the need for a role and implication of spirituality in addressing the well-being and QOL of patients [29]. Moreover, there are encouraging signs ­suggesting that science and spirituality could have complementary roles in enabling health professionals to have a more comprehensive approach to whole person care in society.