Volume 21, No. 2, Spring 2000

Barriers, Boundaries, & Blessings:
Ethical Issues in Physicians' Spiritual Involvement with Patients*

Clayton L. Thomason, J.D., M.Div.

Judging from the best-seller lists, television and newspapers, Americans' fascination with spirituality has grown dramatically over recent years. When pollsters ask, nine out of ten Americans consistently report that they believe in God, in the power of prayer in their lives, and even in miracles. (1) At the same time, spirituality and religion have come to be distinguishable in the lives of many people. Many have sought spiritual well being and enlightenment apart from religious traditions and institutions, and have turned increasingly toward more eclectic and personal spiritual practices.(2) Given this growing attention, perhaps it is not surprising that health and healing are central among the places that there has been a renewed interest in spirituality.(3)

Patients have generally seemed more interested than their physicians in incorporating spirituality into health care. When asked whether they would welcome inquiry regarding their spiritual or religious lives if they became gravely ill, two-thirds of patients in a recent study reported that they would welcome such a question, sixteen percent said they would not, and, significantly, only fifteen percent reported that a physician had ever made a spiritual inquiry.(4) These results are consistent with other studies that have indicated a significant difference between patients' wishes to include spiritual issues, resources, and information in their medical care and physician's practices regarding spiritual involvement with their patients.(5) At the same time that patients' interest in addressing spiritual issues in health care has become manifest, researchers have sought to assess the clinical relevance of spirituality in medicine. A mounting body of evidence suggests that religious commitment or spiritual practice may play a role in illness prevention, coping with illness, recovery from surgery, and improving treatment outcomes, among other indices. (6) A number of assessment tools have been developed to assist physicians interested in responsibly assessing spiritual issues in clinical care.(7)

In response to evidence that religious and spiritual beliefs and practices are clinically important in medicine, clinicians may wish to engage these issues in the lives of their patients. A careful consideration of some ethical questions that are sometimes perceived as barriers to spiritual involvement may help a physician choose whether and how to be involved in the spiritual life of their patients.

This paper addresses some of the ethical issues that may arise in a physician's spiritual involvement with their patients. Appealing to principles of medical ethics, some of the conceptual, methodological, structural and professional barriers to spiritual involvement are examined. Whether involvement is by spiritual assessment, through particular therapeutic interventions that are sensitive to patients' values and beliefs, or by referrals to other providers of spiritual and religious support, I consider what ethical difference the level of spiritual involvement makes. Finally, I examine some of the ethical concerns and pitfalls of spiritual involvement and how they might be addressed in practice.

The threshold question for the clinician interested in involvement with their patients' spiritual issues is whether to address these concerns at all. In a recent study of family physicians in Missouri, Ellis and colleagues report on the barriers that physicians perceive that discourage them from discussing spiritual issues with their patients.(8) This useful work suggests that while these physicians do not discuss spiritual issues frequently, most recognize a role for physicians in addressing patients' spiritual concerns, and most believe spiritual health to be important. While previous studies had speculated about the reasons for physicians' apparent reluctance to address these issues, this study provides clear evidence of just what reasons are offered to account for the observed difference between patient interest and physician involvement in addressing spiritual issues.

Of the fourteen potential barriers that were identified, lack of time was cited most often (71%), while a range of concerns associated with lack of training or experience in spiritual assessment was identified by about half the respondents as a barrier. Other barriers included concern that the physician would project their own beliefs onto patients (53%), personal discomfort with the subject (42%), and a belief that spiritual concerns are not appropriate to the physician's role (31%). While not all of the perceived barriers reported by this study were ethical objections, some which have clear implications for the ethics of the physician-patient relationship bear further examination.

The primary area of ethical barriers to spiritual involvement involves a concern for patient autonomy. If respect for patient autonomy is taken as a central moral obligation of the physician, then some of the concerns expressed by physicians in the Ellis study can be identified as affecting this obligation in the physician-patient relationship. More than half of the respondents in that study (53%), for example, were concerned that they would project their own beliefs onto patients. Like other perceived barriers, this concern can bee seen as a spectrum of spiritual involvement. On the one hand would be the careful and respectful patient-centered perspective that guards against projecting one's own beliefs onto another and allows the patient to initiate any conversation about spiritual issues. At the other extreme would be the concern that some clinicians might take the opportunity to proselytize the patient, taking advantage of their power and authority in the relationship to forcefully try to persuade the patient to accept the clinician's beliefs or values. It seems clear that this latter kind of coercion has no place in a patient-centered relationship that seeks to respect the autonomy and dignity of the patient.

Whether the concern to avoid inappropriate proselytizing should be a barrier to any of a spectrum of spiritual involvement requires acknowledging the power differential in the physician-patient relationship and the coercive potential of the physician. This "Aesculapian power" of the physician can be turned to the patient's benefit or harm, and the potential for coercion is certainly to be resisted.(9) In their recent helpful analysis of this issue, Post and colleagues note that biomedical ethics has sought over the last three decades to demystify the authority of the old paternalistic, or "priestly", model of the physician in the interest of empowering patients through a respect for their autonomy and self-determination.(10)

A related concern that spiritual issues are not an appropriate part of the physician-patient relationship (a concern expressed by 31% of physicians in the Ellis study) seems to be belied by the consistently high interest that many patients express in having their physician be open to hearing about the spiritual concerns that impact their health and well-being.(6) Facilitating a model of patient self-determination might mean creating a safe space in the professional relationship where patients feel comfortable addressing the important values and concerns in their lives, however sensitive those may be. Clinicians are used to creating that kind of safe space for the discussion of sexual concerns, for example, by expressing empathy and a non-judgmental interest in the patient's experience and values. In training new physicians, the Association of American Medical Colleges Medical School Objectives Project suggests that physicians, "must seek to understand the meaning of the patients' stories in the context of the patients' beliefs, and family and cultural values. They must avoid being judgmental when the patients' beliefs and values conflict with their own."(10) The same non-judgmental approach to spiritual issues might lead the compassionate and empathetic clinician to be able to allow the patient room in the relationship to raise those questions of value and personal meaning that are most important to them, rather than feeling compelled to leave them outside the consulting room or away from the bedside.

A second set of ethical concerns about whether to appreciate patients' spirituality in health care has been raised about the role and usefulness of health outcomes research which suggests a positive correlation between spirituality and various indices of health. In his recent critical response to outcomes research on religious spirituality dating back over decades, Sloan and colleagues note that methodological problems afflict many such studies and challenges the conclusion that religious activity will promote health or that illness is somehow the result of insufficient faith.(11) Addressing this concern, some have suggested that this research is still in its infancy and methodological sophistication has grown over time, yielding more subtle and nuanced results showing positive correlation.(10) Sloan's concern is that physicians may actively do harm by supporting claims that, in short, religion is good for your health.

Quite apart form the scientific and methodological debates about research which seems to indicate health benefits associated with spirituality, the threshold issue is whether this uncertainty about health outcomes research needs to be a barrier to spiritual involvement for physicians. It might still be possible for the sensitive clinician to appreciate a patient's spirituality appropriately, in ways that do not rely on utilitarian or instrumental expectations of better health. Sloan and colleagues acknowledge that there can still be an important role for addressing spiritual issues in medicine, suggesting that, "Irrespective of the practitioner's religion, respectful attention must be paid to the impact of religion on the patient's decisions about health care. . . No-one can object to respectful support for patients who draw upon religious faith in times of illness."(12) Such a patient-centered perspective on spiritual involvement is entirely consistent with the approach suggested by some of the available spiritual assessment tools such as Maugans' SPIRITual History, which inquire about whether the patient wishes to make known any spiritual beliefs or issues that might impact their medical care.(13)

For the clinician who decides that some level of spiritual involvement with some patients seems appropriate to their comprehensive care of the whole person, there remain important issues of how to address spiritual concerns. As in any other aspect of the physician-patient relationship it is important to recognize the appropriate limits or boundaries of that professional relationship.

One set of ethical considerations about professional boundaries is about professional competence to address spiritual concerns. Over half of the respondents in the Ellis study were concerned that they had inadequate training or experience in taking a spiritual history, were uncertain about how to identify patients who desired discussion of spiritual issues, or were uncertain about how to manage spiritual issues that patients might raise. This concern for not overstepping the limits of their professional training seems to be addressed by the AAMC's approach to medical education, noted earlier. Training and assessment tools are available, and programs in spirituality are now part of the curriculum of many U.S. medical schools to improve clinicians' knowledge, skills, and awareness of these issues.(14) The side benefits of such training might well be to enhance the physician-patient relationship by emphasizing and developing better communication skills.

Another area of ethical consideration involves the appropriate limits of spiritual involvement. The clinician who might, for example, feel entirely comfortable inquiring about spiritual issues that could impact on medical care might well be discomfited by a subsequent request to pray with the patient. Once a clinician decides to engage in some level of spiritual involvement with patients, it is still appropriate and necessary to make referral to other sources of spiritual counsel, guidance, and support, as necessary. Whether referral is to professional pastoral care such as trained hospital chaplains or to a patient's own clergy or other spiritual caregiver, this is an important way of respecting the professional boundaries of medical and spiritual caregiving. A spiritual needs assessment and subsequent referral, when indicated, can thus be a normative part of responsible medical engagement with the patient.

The physician who desires to be actively involved in spiritual care for the patient raises a more difficult issue. T.F. Dagi, a neurosurgeon and ethicist, suggests, for example, that physicians not pray openly with a patient without the patient's explicit request and permission.(15) Even better, he suggests, is to facilitate prayer being led by an identified religious leader such as a chaplain, so as to avoid even the appearance of the kind of religious coercion discussed above.

Bioethics is sometimes accused of offering more analysis of ethical problems than practical advice about what to do. With this consideration of a few of the ethical barriers and boundaries to spiritual engagement between physicians and patients, I want to turn finally to offer some brief constructive suggestions of ways to avoid the kinds of ethical pitfalls and problems addressed here.

· Develop spiritual self-awareness: The clearest hedge against unwitting bias or projecting your own beliefs on others is some clarity and understanding of just what you do believe and where you are in your own spiritual journey. This is also a matter of self-care for the physician.

· Avoid value imposition: Being clear about respect for the patient's values and experience will help avoid the problems of coercion or proselytizing.

· Create a safe place in the physician-patient relationship: This safe space will allow the patient to initiate discussion of spiritual issues if they feel that the physician has indicated it is an appropriate topic by raising the question of whether spiritual or religious beliefs are important to the patient. Expressing empathy and understanding for the patient's ultimate values and personal meanings encourages trust and communication in the relationship.

· Accept your naivete of others' faith traditions and spiritual life: Don't assume that because the box for religious preference says "Catholic" or "Muslim" or "None" that you know anything about how this patient is engaged with a religious tradition or community. Let them tell you about their own spiritual life, or how they interpret the religious traditions of which they feel a part. This helps avoid the problem of stereotyping a patient according to the tradition they identify with and may lead to encounters with others that promote growth and discovery.

· Refer to pastoral care providers: Patient requests for pastoral care should be referred to an appropriate caregiver, and pastoral care professionals can be called on for consultation in situations where the physician feels uncomfortable or unprepared.

· Remain flexible in selecting the appropriate involvement, if any: If the answer to an initial question about whether spirituality is important can be "yes," then it can also be "no." Not closing the door on the subject after that patient's initial demurral can allow a subsequent interest to be expressed, as at a time of serious illness.(5)

· Build on the patient's strengths: Assessing and being willing to engage the patient's spiritual values, hopes, and beliefs may allow the physician and patient together to identify sources of spiritual support, comfort, or tools for coping or recovery.(7)

Not every physician will choose to be spiritually engaged with patients. Those who do might well encounter some of the challenges to professional boundaries addressed here. As this brief assessment of some of the ethical issues that might be perceived as barriers or boundary issues to physicians' spiritual engagement with patients suggests, the sensitivity and empathy of the patient-centered encounter of a patient's spiritual values need not fall prey to these pitfalls and objections. As health care continues to be concerned for the bio-psycho-social and spiritual well being of the whole person, the issues that have just begun to be addressed here will become even more significant for the caring and compassionate healer.

Notes
* Portions of this work were presented as part of a workshop, "Integrating Patients' Spirituality into Clinical Care," at the Society for Teachers of Family Medicine annual meeting, Orlando, Florida, in May, 2000. I am grateful to Drs. Dana King, Timothy Daaleman, Mark Ellis, Howard Brody, and Aron Sousa for their constructive engagement and discussion of many of these issues. The views and conclusions expressed here remain mine.
1. Gallup, Jr. GH. Religion in America: 1996 Report (Princeton, NJ: Princeton Religion Research Center, 1996).
2. Wuthnow R. After Heaven: Spirituality in America Since the 1950s (Berkeley: University of California Press, 1998).
3. Shea J. Health care's transformation: spirituality expands the horizons of medicine. Park Ridge Center Bulletin 1999;7:5-8.
4. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Int Med 1999; 23:1803-1806.
5. Cf. Maughans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract 1991; 32:210-213. See also, Daaleman TP, Frey B. Spiritual and religious beliefs and practices of family physicians: a national survey. J Fam Pract 1999;48. Oyama 0, Koenig HG. Religious beliefs and practices in family medicine. Arch Fam Med 1998; 431-435.
6. For a review of related research, see, Matthews DA, McCullogh ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-24. See also, National Institutes for Healthcare Research web resources at http://www.nihr.org.
7. See, e.g., Fitchett G. Assessing spiritual needs: a guide for caregivers (Minneapolis: Augsberg Press, 1993). Maugans TA. The SPIRITual history. Arch Fam Med 1996;5:11-16. Puchalski CM. Taking a spiritual history: FICA. Spirituality & Medicine Connection 1999;3:l-4. Kuhn CC. A spiritual inventory of the medically ill patient. Psychiatr Med 1988; 6:87-100.
8. Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians' attitudes and practices. J Fam Pract 1999; 48:105-109.
9. Post SG, Puchalski CM, and Larsen DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Ann Intern Med 2000;132:581.
10. Report I: Leaning Objectives for Medical School Education: Guidelines for Medical Schools. Washington, DC: Association of American Medical Colleges; 1998.
11. Sloan RE, Bagiella E, and Powell T. Viewpoint: Religion, spirituality, and medicine. The Lancet 1999; 353:664-667.
12. Editorial: Faith's Benefits. The Christian Century 1999;116(3):77.
13. Maugans TA. The SPIRlTual history. Arch Fam Med 1996;5:11-16.
14. Puchalski CM, Larson DB. Developing curricula in spirituality and medicine. Acad Med 1998;73:970-974.
15. Dagi TF. Prayer, piety and professional propriety: limits on religious expression in hospitals. J Clin Ethics 1995; 6:274-279.