Is It Possible For a Physician To Remain Neutral When Addressing Patients’ Spiritual Concerns?

This blog is the last of a four-part series covering the topic of spirituality and healing in medicine, specifically during end-of-life care, and is based on an article by Curlin Hall.

In a pluralistic society, most authors encourage physicians to remain neutral when addressing their patients’ spiritual concerns.  However, this is based on the assumption that it is actually possible for physicians to do so.  Neutrality is defined as “not aligned with or supporting any position; indefinite.”  Any human being, physician or not, cannot separate themselves from the specific traditions of knowledge and experience that shape their lives.  Even if a physician was brought up in an atheistic culture, he is bringing with him that lens for viewing the human experience and cannot divorce himself from that when a patient voices spiritual concerns.  Furthermore, as Hall states, “feigned neutrality will never be comfortable to the devout person, for whom ‘setting aside’ ones religious commitments would be a form of unfaithfulness.”

Neutrality versus Candor

The question for physicians should not be “How do I remain neutral?”  The question should be, “How should a responsible physician address genuine disagreements regarding religious matters in such a way that he and the patient can respectfully negotiate a mutually acceptable accommodation?”  This type of dialogue requires candor.  The physician need not divulge his entire spiritual paradigm.  However, he should be aware of which judgments are part of his professional consensus and those which are derived from his personal belief system.  Moreover, that distinction must be made clear to his patients.

In conclusion, it is of my opinion that neutrality among physicians when addressing spiritual concerns is not possible.  Neutrality among physicians should not be expected or encouraged.  Instead, physicians should be encouraged to address their patients’ spiritual concerns with a spirit of wisdom and candor without neglecting their own belief system.

Does Addressing Spiritual Concerns Threaten Patient Autonomy?

This blog is part three of a series covering the topic of spirituality and healing in medicine, specifically during end-of-life care, and is based on an article by Curlin Hall.

 

The power dynamics within the patient-physician relationship have been a topic of many studies and discussions over the past few years.  Power, within relationships, has two components: the ability to form one’s will to make decisions and the ability to carry out or effect one’s will.  These components come into play within the patient-physician relationship giving the physician immeasurable authority when it comes to patients’ decisions regarding care and treatment.

In light of this, many authors state that physicians should not address their patients’ spiritual concerns because it automatically threatens their patients’ autonomy.  The only exception is if such concerns or ideas conflict with “rational, evidence-based medicine,” in which case a physician is obligated to challenge the ideas out of his commitment to beneficence.  It seems that there is a double standard or secular bias when it comes to addressing a patient’s spiritual concerns.  For example, are not physicians constantly using their power to persuade patients to stop engaging in deleterious activities such as promiscuity or smoking?  Is that any different than a physician dissuading a patient from simply praying about their treatment options and encouraging them to take the recommended path of treatment?

Autonomy versus Respect

Despite the insistence that a patient’s autonomous rights need to be upheld, it is rare that a patient does not ask and receive personal recommendations for treatment after options are presented by his physician.  If a patient voices spiritual concerns regarding treatment options, his physician should be able to engage these concerns freely in a way that promotes respect for the patient’s views while maintaining their autonomy.

Open dialogue between physician and patient where spiritual concerns are addressed should never be considered a violation of patient autonomy.  Physicians should never coerce any patient make any decision against their will, but neither should they neglect a patient’s deepest spiritual concerns.

Do Physicians Possess the Necessary Competence to Address Their Patients’ Spiritual Concerns?

This blog is part two of a series covering the topic of spirituality and healing in medicine, specifically during end-of-life care, and is based on an article by Curlin Hall.

 

Competency among physicians is governed by completion of mandatory education within a classroom during medical school, practical demonstration during residency under supervision, and continuous education and accreditation once a physician practices independently.  Because physicians are unlikely to have training in religious matters, most authors do not consider them competent to address religion.  Authors further argue that even a moderate amount of religious training would not adequately equip them to address the wide variety of religious backgrounds found among diverse patient populations.  This lack of competence, critics argue, will lead to erroneous ideas, misconceptions, and potentially harmful results; therefore, religious discussions should be left to religious professionals.  Hall’s response to critic’s stance is this: Competence is an important aspect of any technique, but when dialogue regarding religion is understood as technique, it is misunderstood.

 

Competency versus Wisdom

When a patient voices spiritual concerns to their physician, is it really appropriate to refer them to a religious professional?  For example, when a newly-diagnosed cancer patient says to her oncologist, “I am not sure if I want to receive chemotherapy or radiation; I need to pray about it and get back to you,” should the oncologist automatically refer her to a chaplain?  No.  Is the patient expecting technical competence in the response from her oncologist?  No.

The physician in this situation will best exercise her competence by understanding how her patient will come to a conclusion and attempt to navigate a way forward that contributes to the patient’s flourishing.  This type of competent navigation has nothing to do with religious training or technical expertise, but has everything to do with possessing wisdom when attempting to understand the individual’s human experience.  Technical competency allows a physician to learn medical data and the theologian to learn theology, but wisdom guides both when discerning how and when which knowledge should be applied to the patient.  The type of wisdom needed in the above situation does not come from any type of technical and/or religious training, but through natural experiences that occur within a variety of traditions and lifestyles.  Furthermore, it is my opinion that physicians should engage freely, but wisely, in this type of spiritual dialogue, when it is brought up by the patient, to provide a more holistic assessment during the clinical encounter.  What is your opinion?

Should a patient’s spiritual concerns be addressed by their physician?

I am currently enrolled in a class at Harvard Medical School called “Spirituality and Healing in Medicine” which aims to provide a framework for understanding the spiritual dimension of patients’ lives, as well as spiritual issues that arise during the practice of medicine, specifically during end-of-life care.  This class is comprised of people from a variety of backgrounds including physicians, chaplains, nurses, and medical students.  Some of the main questions discussed are:

  • Should spiritual concerns be addressed by physicians?
  • Do physicians possess the necessary competence to address spirituality?
  • Does addressing spiritual concerns threaten patient autonomy?
  • Is it necessary (or possible) to remain neutral when addressing spiritual concerns?

(These questions are outlined well in an article by Curlin Hall.)

Over the next few blog entries, I will address these questions and provide a brief overview of the different opinions discussed.  My hope is that it will provide both discussion and dialogue between my readers and their social networks, as well as my readers and myself.

Should spiritual issues be addressed by physicians?

Supporters of “spiritual inquiry” state that addressing the spirituality of a patient is simply taking the entire human experience into account and determining what factors may be relevant to their medical decision making.  Critics argue that spiritual inquiry is meddlesome, raises a threat of coercion, and is a threat to maintaining professional boundaries and patient privacy.

Despite their opposing views, supporters and critics of spiritual inquiry share a common framework which regards the interactions between physicians and their patients as strangers to one another.  The practice of medicine seems to have evolved into a discipline based solely on empirical evidence, algorithms, diagnostics and performance-based indicators. Has this technical view devalued the role of relationship in the clinical experience? When patients seek out a physician, what is more valuable to them: Expertise or interpersonal skills? How important is it to possess and exercise both confidently and competently?

In conclusion, research states the majority of patients want their spiritual concerns to be addressed by their physician. In a recent study completed in Boston by Dr. Tracy Balboni, et al, to be released in 2010, 89% of cancer patients reported that they desired for their spiritual needs to be addressed by their physician. However, only 9% of these patients reported that these needs were addressed. In my opinion, it seems that if physicians continue to view their patients as strangers, refusing to address the entire human experience, it will only make the clinical encounter unsatisfying to both physician and patient.

What is your opinion?