Doctoring as a Human Experience: On Developing a Healing Partnership Caring for the Human Spirit, the Patient's Soul

by Ronald Banner, MD

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Introduction
In "Patients' experiences" (Banner 2001), we considered the process (stages) of becoming a patient, that suffering is much more than pain, and recognized the subjectivity of decision making by patients. All these point up the need for inputs from patients. They should be our advisors/ counselors/ teachers - these people who have experienced illness and who understand their experiences. These advisors are essential in understanding and improving patient care, as well as in medical education, policy development and research (Reiser 1993). I illustrate the notions presented in this article with the experiences I shared with a patient named Stanley, who had severe and complex illnesses.

In "The Doctor-Patient Relationship" we explored a partnership in which the physician is a consultant to patients, helping them decide on the best course for addressing their problems. Here we examine spiritual dimensions of the doctor-patient relationship (2002a).

Here, we explore the spiritual dimensions in patient care.


What is spirit?
I am reminded of a presentation I did in the 1970's on death and dying. When I described Engel's biopsychosocial model, someone suggested, "What about a biopsychosociospiritual model?" And what does it mean "to look into their hearts as well as their bodies"? Some who accept the biopsychosocial model see no separate spiritual component (to say nothing of the majority of physicians stuck in the biomedical model). I feel that these are vitally important in understanding patients in caring for them.

Let us explore here the work of some who feel that the spiritual component is a vital and essential aspect of health care.

At the University of Louisville, School of Medicine, Department of Behavioral Medicine, they developed a bio-psycho-socio-spiritual model, separating each element to facilitate inquiry and discussion (1988). They define spiritual elements as

Those capacities that enable a human being to rise above or transcend an experience at hand. . . characterized by the capacity to seek meaning and purpose, to have faith, to love, to forgive, to pray, to meditate, to worship, and to see beyond present circumstances.

These elements are related to, but are to be distinguished from, such psychological factors as emotional tone or affect, mood, thought, language, symbol formation, memory, cognition, analysis and synthesis of data, personality, intellect, judgement, perception, and coping style. Whereas. . . the mind brings a person into a problem. . . and works with or manipulates the data at hand. . . , the spirit lifts the person above it.

While the encompassing unit in Engel's systems hierarchy is the biosphere, Reiser and Rosen believe there is still another dimension (whatever one calls it) concerning the meaning of life. It gives a feeling of some order in the universe. They conclude that even if physicians do not see the relevance of such a perspective for themselves, they should realize how important spiritual concerns are for many of their patients.

"Spiritual" and "Religious" Adding to Clifford Kuhn's definition of spirituality, Patrick Pietroni (1986) has listed other words used in the definition of "spirit": "Immaterial part of man, religion/beliefs/conviction, soul - vitality, quintessence of various forms, life force, breath of life, a possession, something higher, inspired, emotional calmness, everyday ecstasy, sense of harmony, sense of belonging, knowing sure from within, transcendent force, mystical experience."

Religion on the other hand is defined in Denise McKee and John Chapel's review (1992) as "any specific system of belief, worship, conduct, etc. . . involving a code of ethics and a philosophy. . . [including] doctrine, dogma, metaphors, myths, and in a way of perceiving the world. Organized religion is one way of expressing one's spirituality."



Religion and the Physicia
Hundreds of studies showing correlations between religion and health have been gathered by Jeffrey Levin (1994a; 1994b). This research evidence confirms the common sense awareness that religion and spirituality ought to be a focus for medical attention.

Daniel Foster (1982) raises and answers three questions on religion and the physician:

1. Why must the physician deal with religion in caring for the patients?
a."Religion influences the feelings and actions of a significant number of people.

b. Patients often place the physician in the role of secular priest.

c. Illness induces serious (religious) questions.

d. Physicians' own belief systems impinge on and influence patient care."

2. What does religion demand of all physicians? "The physician must be trustworthy, treat the patient as a person, be kind, maintain hope, and assist in discovering what it really means to live."

3. How does a physician assist in discovering what it really means to live? ."..four bedrock lessons that are at once simple and profound [need to be conveyed]:

a. life must be lived day by day, and ordinary life has the potential of fulfilling beauty;

b. courage in human life is not extraordinary, but ordinary;

c. illness can sensitize one to problems of others;

d. death is not the worst thing in life."

After I was faced with, and responded to, Stanley's paraplegia, and talked with Stanley and his family - and after reviewing the above paragraphs, I realized that in between what Stanley and his family and I said, we touched every one of these elements. More on this below.

Ultimately, "It is how you live your life that bespeaks your true religion. . . so if your life is your religion, and your life changes with aging, then does your religion change as well." (Mertz 1991)

Spiritual Examination
Can we examine a patient spiritually, as we do biologically, psychologically and sociologically? If so, how do we do it?

Clifford Kuhn30 developed a seven item spiritual inventory, "manifestations of the spirit that can be measured or assessed in the examination of any patient. . . [They also learned that] a patient's general attitude in response to the observations that the physician wants to know about spiritual factors is, itself, a useful indicator of his or her spiritual health."

1. The attachment of meaning or purpose to life events - a healthy spirit reflecting hope and a relative absence of guilt. The meaning of illness or wellness usually relates directly to the patient's perception of the purpose of his/her life, with illness viewed as a "challenge, enemy, punishment, weakness, relief, strategy, irreparable loss or damage, or value." Relevant questions from Kuhn's inventory include:

Why do you think you became ill now?

Has the illness changed any attitudes you might have about the future?

Is there anything more important to you than regaining your health?

How does this illness interfere with your goals in life?

What is the purpose of regaining your health?

2. Belief is an exercise in faith, often persisting despite the availability of facts to the contrary.

What things do you believe in or have faith in?

Has this illness influenced your faith?

How do you exercise faith in your life?

How has your faith influenced your behavior during this illness?

What role does faith play in regaining your health?

3. Love - A most important indicator of a person's spiritual well being is the capacity to give and receive love; the ability and willingness to extend one's self to other persons in a non-judgmental or unpossessive manner; and the extent to which a person can identify with the joy and hardship of others as though they were his or her own.

Is there any person or group of persons that you would say you truly love?

What is the most loving thing you have ever done?

What is the most loving thing ever done to you or for you?

What is the significance of the golden rule to you?

Is there any person or group for whom you would gladly give your life?

4. Forgiveness - True forgiveness takes place when two individuals "discover together that what was estimated to be a grievous offense at a previous time is no longer so grievous and, moreover, never was. . . Forgiveness. . . is a large part of what takes place between a physician and a patient. . . [when] the patient often confesses fears, anxieties, personal shortcomings, and various symptoms, feeling isolated and alone as a result of illness. . . [and] the physician communicates acceptance, reassurance, and interest, and redefines the patient's self-denigrating confessions by means of the diagnostic process."

Are you able to forget about times when people offended you or do you hold a grudge?

Do you feel guilty about anything in your life?

Do you wish others to feel guilty about things they have done to you?

What is meant by "let bygones be bygones"?

How can a person make it up to another person when he has hurt or offended them?

5. Prayer - ."..essentially an attitude. . . reflecting the recognition of a concept or entity greater than oneself. . . [and] the attempt to be in proper relationship with. . . [it]. . . Prayer actively contributes substantially to the experience of hope and positive expectation."

Do you pray?

When do you pray?

What is your prayer?

How are your prayers answered?

What do you think is meant by "power of prayer"?

6. Meditation - the exploration of inner space: discovering and listening to the voice within, quieting the body's activities and letting go of the conscious thoughts of mind, often experienced as an act of surrender.

Do you ever spend time just being quiet?

Do you meditate?

Do you enjoy being alone in a quiet place?

Do you know how to relax your body completely?

Have you ever tried to empty your mind of all thoughts for a brief time?

7. Worship - an exercise of the spirit and an extension of prayer, often entailing a communal experience of joy and celebration with believers of like mind. Attempts to describe the full experience to non-participants often fails. A fundamental human craving is to acquire this communal relationship and to experience belonging in the deepest spiritual sense.

What is the most powerful and important thing in your life?

Upon what do you depend the most when things go wrong?

What do you worship? Do you participate in any religious activities?

What do you consider the most significant act of worship in your life?

Kuhn feels that further work is needed, including developing "spiritual prescriptions", ways to heal a sick spirit.

As we continue addressing Stanley's illnesses we will see what role each of these seven elements played for him.

Similarities of Spiritual and Medical Practices
Pietroni31 lists medical counterparts to spiritual practices. I have encountered these in my own medical practice. (See Table 3.)

Table 3. Spiritual practices and their medical counterparts (Pietroni 1986)

Spiritual Healing Craig Brown points out that everyone is capable of giving healing. A mother comforting a child after a fall by cuddling her or him and rubbing the sore area is one of the many examples of healing. Healing, like music or any other gift, can be appreciated and developed to some extent by everyone through practice. Just as there are gifted musicians, so there are people gifted in healing.

A spiritual healer laying hands on or near to the patient is thought to bring the patient's whole system back into balance, healing the patient physically, mentally, emotionally and spiritually. This type of healing is known as the "laying-on of hands". When performed by someone many miles away, it is known as "distant healing".

Most healers describe the process of healing as "channelling" of energy. In a relaxed state they will call on a higher power to direct this cosmic energy through them to the patient. Healers do not feel that they contribute any of their own energy to the patient. If they did, they would soon feel depleted (Brown 1990).

Does healing work? While there is much scepticism regarding the efficacy of spiritual healing and prayer beyond a placebo effect, let me share with you two references that establish its efficacy.

Daniel Benor's survey (2001) of the English language literature produced 191 controlled studies of spiritual healing, from enzymes to man, of which 83 showed highly significant statistical effects and 40 showed modestly significant effects. He concluded that "if healing were a drug, I believe it would be accepted as effective on the basis of this evidence. Healing is certainly more than a placebo, unless enzymes, yeasts, bacteria, plants and mice are subject to suggestion."

Let us consider one of these studies. To evaluate the effects of prayer in a coronary care unit (CCU), Randolph Byrd (1988) followed a prospective randomized double blind research protocol. In 393 patients admitted to the CCU, half received intercessory prayer by participating Christians outside the hospital while the other half, the control group, did not. Neither patients nor doctors knew which patients were sent distant healing. The results showed that the intercessory prayer group did significantly better than the control group. The control group had greater numbers of cardiopulmonary arrests and required ventilatory assistance, antibiotics and diuretics more frequently than the intercessory prayer group."These data suggest that intercessory prayer to the Judaeo-Christian God has beneficial therapeutic effect in patients admitted to a CCU," and since the control group was not forbidden to have prayer for themselves, or be prayed for, the results are even more strikingly significant.

Stanley's Spiritual Journey Stanley's initial hospitalizations were at the Albert Einstein Medical Center, where his spirit was cared for by the hospital priest, myself and other health care professionals and his family. Later, when his pneumonia hit hard and fast, his family drove him to Jeanes Hospital. The Board of Trustees of the first hospital is primarily Jewish; the latter hospital, Quaker. (I am a Medical Staff member at both.) Jane Brown, previously Director of Pastoral Care at Jeanes, has kindly described Stanley's spiritual journey.

When I first saw Stanley in the emergency room he and his wife were both in what we call "magical thinking". In his pain and fear, they were recounting religious acts such as a daily sprinkling of holy water from France and a tree planted in Jerusalem.

They spoke of these acts as one speaks of a good luck piece. They also were both heavily dependent on their doctor for physical, emotional and spiritual guidance. I honestly did not see much promise for spiritual movement.

However, I was wrong. Their doctor heard the patient's restless state and once more asked for pastoral intervention. Dann Ward, the associate director, responded this time and in hearing the same spiritual restlessness wisely made arrangements for the priest to hear his confession. Stanley's doctor also made sure he had a Bible and someone left a rosary by his bed. Under this team of spiritual care, Stanley appeared to have a deep conversion experience.

The next time I saw Stanley in intensive care he was in pain, knew he was going to die and was full of deep joy. He was exciting and uplifting to be with. It was a bit difficult for him to speak but he got across his amazement that after all these years, all he had to do was ask for God's love and forgiveness and it was fully his."All I had to do was ask." he said. I responded, "That's what the promise is." as I squeezed his hand. He filled the room with joy.He ad-libbed the 23rd psalm, a practice he had begun after his doctor had read it to him. He also spoke a desire to learn the rosary. Sister Marita went to him to share the rosary.His Jewish doctor had opened the door and his Catholic church gave him the means and structure to reclaim his faith. The rest of us acted as midwives.I shared with a specialist who came in to see him my joy of his joy. The doctor sceptically said that perhaps it was the drugs. I just smiled knowingly."Perhaps," I said, "but, whatever, it is good to die with peace and joy." Stanley died a good death three days later, held in the love of the God who had waited for him."

Ronald Banner will conclude this series in the next issue of the International Journal of Healing and Caring with and article titled, "The Doctor's Soul."

References

Banner, R.S. Doctoring as a human experience: On developing a healing partnership ­ Patients¹ experiences, IJHC 2001, 1(1).

Banner, R.S. Doctoring as a human experience: On developing a healing partnership ­ The doctor-patient relationship, IJHC 2002(a), 2(1)

Benor, D.J. Healing Research, Volume I - Scientific Validation of a Healing Revolution, Southfield, MI Vision Publications 2001.

Brown, C. K. Making a spiritual diagnosis in general practice, Holistic Medicine 1990, 5, 152-153.

Byrd, R. C. Positive therapeutic effects of intercessory prayer in a coronary care unit population, Southern Medical J. 1988, 81, 826-829.

Foster, D. W. Religion and medicine: the physician's perspective, In: Foster, D. W., et al (eds), Health/Medicine and Faith Traditions, Philadelphia, PA: Fortress Press 1892, 245-270.

Kuhn, C. C. A spiritual inventory of the medically ill patient, Psychiatric Medicine 1988, 6, 87-100.

Levin, Jeffrey S: Religion in Aging and Health: Theoretical Foundations and Methodological Frontiers, London/Thousand Oaks, CA: Sage 1994(a).

Levin, Jeffrey S: Religion and Health: Is there an association, is it valid, and is it causal?, Social Science and Medicine 1994(b), 38(11), 1475-1482.

McKee, D. D., Chappel, J. N. Spirituality and medical practice, J. Family Practice 1992, 35, 201-208.

Mertz, E. W. Aging and spirituality, Delaware Medical J. 1991, 63, 35.

Pietroni, P. C. Spiritual interventions in a general practice setting, Holistic Medicine 1986, 1, 253-262.

Contact
Ronald S. Banner, M.D. practices Internal Medicine in Northeast Philadelphia and is Chairman Emeritus of the Medical Ethics Committee at the Albert Einstein Medical Center.
2050 Welsh Road
Philadelphia, PA 19115

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