A Balm for Gilead

Meditations on Spirituality and the Healing Arts

Daniel P. Sulmasy

• Publisher: Georgetown University Press
• Year: 2006
• ISBN:
  9781589012738
• Topic: Medicine
• Subtopic: Ethics in Medicine

Once rarely discussed in medical circles, the relationship between spirituality and health has become an important topic in health care. This change is evidenced in courses on religion and medicine taught in most medical schools, articles in journals such as the New England Journal of Medicine, and conferences being held all over the country. Yet, much of the discussion of the role of religion and spirituality in health care keeps the critical distance of only being about spirituality. A Balm for Gilead goes further, offering a work of spirituality.

Sulmasy moves between the poetic and the speculative, addressing his subject in the tradition of great spiritual writers like Augustine and Bonaventure. He draws from philosophical and theological sources—specifically, Hebrew and Christian scripture—to illuminate how the art of healing is integrally tied to a sense of the divine and our ultimate interconnectedness. Health care professionals—and anyone else involved with the care of the sick and dying—will find this series of meditations both inspiring and instructive.

Sulmasy addresses the spiritual malaise that physicians, nurses, and other health care workers experience in their professional lives, and explores how these Christian healers can be inspired to persevere in the care of the sick. Drawing on the parable of the prodigal son, for instance, Sulmasy illustrates how some physicians have put financial gain ahead of their patients, and how genuine spirituality might change their hearts. He examines both enigmatic topics such as the relationship between sinfulness, sickness, and suffering and the spirituality of more routine topics such as preventive medicine. In one especially stirring and poignant meditation, he reflects on the spirituality of dying in the light of Christian hope.

A Balm for Gilead interweaves prayer and reflection, pointing the way to a twenty-first-century spirituality for health care professionals and their patients.

CHAPTER 1
The Numinous, the Medical, and the Moral

Being Christian is not the result of an ethical choice or a lofty idea, but the encounter with an event, a person, which gives life a new horizon and a decisive direction.

BENEDICT XVI, Deus Caritas Est

FOR the last five years one of my colleagues, Dr. Alan Astrow, and I have been running a series of conferences at St. Vincent’s Hospital–Manhattan that we have called “Spirituality, Religious Wisdom, and the Care of the Patient.”¹ We have brought together clinicians and religious thinkers to discuss spiritual issues that commonly arise in clinical care. In an effort to make this a fully ecumenical, interfaith enterprise, each session features two religious speakers of different religious backgrounds. The series has been enormously successful and always draws great crowds. I have been surprised, however, by one problem that we have encountered consistently: Every clinician we involve in the program seems to conflate spirituality and ethics. When we ask for suggestions about spiritual topics for the program, they always suggest ethical topics. When we ask for suggestions about potential speakers for a series about spirituality, they always suggest ethicists. And when we ask for cases for our discussions that illustrate some of the spiritual issues that arise in practice, they always hand us crisply written clinical ethics cases, ones that are “thin” enough to be suitable for presentation at medical grand rounds. More often than not, “the spiritual problem” chosen is a case of a religiously fundamentalist family from a minority racial group praying for a “miracle” and refusing to authorize the withholding or withdrawing of life-sustaining treatments when the doctors and nurses all know that the patient will not survive to hospital discharge.

A central thesis of this book is that this approach reveals a profound misunderstanding of what spirituality means. Spirituality is not ethics. Yet the intuition that spirituality and ethics are somehow related is not entirely mistaken.

In part, the conflation of the spiritual with the ethical might reveal a deep suspicion on the part of clinicians that all ethics is actually religious. For some, this suspicion raises a troubling logical concatenation—namely, “Ethics means religion, and religion means a lot of uptight people telling me what I can’t do.” Because they do not wish to be told what to do, they reject both the spiritual and the ethical.

For another subset, the idea that spirituality implies ethics is a good thing. It may indicate an explicit belief that religion is the only true source of morality. Or it may reflect an inchoate understanding, not conscious or explicit, that their own personal moralities have been deeply influenced by their own individual religious upbringings, whether or not they actually practice that religion at present.

The notion that all ethics is ultimately religious is, in fact, both true and false. It is false in the sense that philosophical ethics is a discipline that is independent of religion, requires no belief in any deity, and is free of any reliance on sacred texts or authoritative teachers. It is based on reasoned argument. Philosophers, in other words, “do” ethics without religion. In the Roman Catholic tradition, the natural law approach has dominated ethical thinking, and it is essentially a philosophical approach based on the trust that God has given all people the potential for good will and reason. So, Catholics also “do” ethics in a manner that is more or less independent of the beliefs of the Catholic Christian faith.² Thus, people of all faiths and of no faith can engage in philosophical ethics, and so, in this sense, religion and ethics are distinct.

In another sense, however, the notion that all ethics is religious is true. Any system of ethical theory, although based on reason, requires some basic premises. Pure reason has no content. One cannot reason about morality without having a starting point from which to begin the process. These starting premises are incredibly difficult to prove, but they are necessary even for a philosophical system of ethics. In fact, most of the time, these premises are simply accepted through the exercise of a kind of “faith.” These fundamental premises often contain a great deal of moral meaning. They express certain axiomatic (or near-axiomatic) beliefs about the meaning of life, death, good, evil, and human nature. If not frankly religious, these beliefs are at least “religion-like.” In this sense, one can say that “every ethos implies a mythos.”³ Whether one begins in the “state of nature” or the “original position” or the “Garden of Eden,” one must begin somewhere. Every ethical theory has some originating myth that has a religion-like character. Perhaps this explains why, when asked about the spiritual, some people immediately leap to the ethical.

Another reason clinicians tend to conflate the spiritual with the ethical may be that because it has been so hard for ethics to establish a beachhead in the medical arena, it is simply easier to try to line up spirituality behind the banner of ethics than to try to open a second front for spirituality. A strong minority within the medical community has persistently resisted such things as teaching ethics to students and residents, establishing ethics committees in hospitals (or cooperating with them where they exist), and enforcing codes of ethical conduct for practicing physicians and medical investigators. Organizational, procedural, and administrative resistance to allowing ethics a formal role in medicine has been common in both the academic and the practice communities. There has also been a degree of psychic resistance in the minds of some individual practitioners. In the minds of these physicians, ethics continues to be regarded as just one of those “soft” subjects. Proponents of spirituality in health care may simply believe that it is easier to lump spirituality in with ethics than to try to pick a new fight, dealing with spirituality on its own terms.

Perhaps, too, this conflation of the ethical and the spiritual represents something of a failure on the part of the various organized religions to make the distinction between spirituality and ethics clear to their members. At least this seems true of the Christian churches. Protestants, particularly fundamentalist Protestants, have always been suspicious of such spiritual practices as meditation, repetitive prayers, incense, icons, statues, and sacraments that characterize the mysticism of Catholic and Orthodox Christians. Instead, Protestants have emphasized scripture and the moral life. In the Catholic tradition since the Second Vatican Council, some of these traditional spiritual practices have been deemphasized in favor of a more psychologized approach to the inner life. This occurred along with a widespread questioning of traditional ethical teaching undertaken by some theologians, followed by a rather emphatic restatement of those traditional ethical teachings and an insistence on obedience on the part of the church. Many of these disputed ethical teachings touch on medicine. In such an environment, Catholicism has perhaps become overidentified with its ethical teaching and less identified with its spiritual practices. And this may help to explain why some clinicians conflate the spiritual with the ethical.

Last, in secularized Western societies, where people of many faiths and of no faith meet and interact daily, the moral life is a common ground of interaction among many diverse people. In such an environment, it seems that religions have sought to participate in society by emphasizing their contribution to ethical discourse. Religions “fit in” better when they are talking about ethics—the ethics of social justice, war and peace, science, and medicine. This is more acceptable in the public square than speaking frankly about prayer, spiritual experience, worship, the Buddha, or Jesus Christ. This “despiritualizing” of religion has also been turned inward within believing communities. In a sincere effort to be “relevant” to congregations that have become increasingly secularized through the overwhelming power of mass media, religions have tended to deemphasize the spiritual and have instead emphasized the ethical in their preaching. This may also partly explain why clinicians seem immediately to think “ethics” when they hear the word “spiritual.”

The Spiritual

But the spiritual aspects of health care cannot be supplanted by bio-ethics. Hospitals, outside of the obstetric wards, are not usually happy places. As one walks down the corridors early in the morning on arrival at work, half awake, most of the other people one sees are fellow employees. Sometimes, however, one encounters a stranger—the woman without an identification badge, dressed not in scrubs but in a rumpled dress, walking slowly down the hall, her features barely discernible in the dim fluorescent light, biting her lip, fighting back the tears.

Did she just lose a husband? A mother? A son? Perhaps she was just told she has multiple sclerosis or cancer of the pancreas.

In the hospital the best it generally gets is relief—relief that the chest pain one experienced was not a heart attack; that one’s prematurely born daughter, now on a ventilator, is likely to survive her harrowing first ninety days of life. Suffering shadows the work of health care professionals—a pervasive, profound, and persistent presence.

If health care professionals were honest, they would admit that they are just like most of the rest of secular society. They avoid eye contact. They demur at the thought of explicitly acknowledging suffering or their failure to make it all go away. They just keep walking.

If one is a Christian health care professional, however, one denies one’s own creed by doing so. Sunday after Sunday Catholic Christians recite by rote, “He suffered, died, and was buried.” If Christian health care professionals really knew Christ or understood what Christianity asks them to believe, they would understand immediately and intimately the spiritual dimension of their work that stares them in the face. Spirituality is not an ethical dilemma. It is the substance of what health care professionals do.

He suffered, died, and was buried. Just as our patients suffer, die, and are buried. Just as we suffer, die, and are buried. Ethics can make no sense of this. The way health care professionals behave in response to the reality of suffering may raise plenty of questions for ethics. But ethics itself will not help them to see their way through this. They can walk away. But the spiritual will be there again the next morning. In the corridor. Weeping.

Spirituality and Ethics

Simply put, spirituality describes one’s relationship with the transcendent. Ethics, by contrast, can be defined as the systematic, critical, reasoned evaluation and justification of one’s notions of right and wrong, good and evil, and of the kind of person one ought or ought not strive to become. By definition, these would appear to be quite distinct concepts. What, then, is the relationship between these two?

To answer this question, I must first make a further distinction between ethics and morality. Although these two words are often used interchangeably, ethics is, in a very formal way, the study of morality. Morality is the actual living, discerning, and doing of right and wrong, good and evil, and the actuality of either being or not being the kind of person one ought to be. Ethics is the effort to explain morality. But morality is where we live as human beings.

Thus understood, spirituality has much more to do with morality than it does with ethics (although trying to explain the relationship between morality and spirituality is an exercise in ethics). Spirituality is to theology as morality is to ethics. Human beings, by virtue of being the kinds of things that they are, are both spiritual and moral. One lives a human life as a spiritual and moral being. Explaining the spiritual and moral dimensions of human life are the tasks, respectively, of the disciplines of theology and ethics.

The good is known in the moral life in its individual instances—Mary’s good and John’s good. There is certainly a universal aspect to this good, depending, as it does, on the fact that both John and Mary are individual examples of the same kind of thing, that is, that both are human beings. What is good for each depends in large part on this fact. But one cannot promote the good of humankind concretely. One can only promote the good of John, or the good of Mary, or perhaps the good of their community. In the clinical world, this concrete good is the good of each particular patient. The health care practitioner has sworn to promote the good of particular patients.

Likewise, what is right is known in the moral life only in its individual instances—the right decision to forgo cardiopulmonary resuscitation or the right decision to build extra safety features into a research protocol, for example. Again, this is not to deny that some things are right and wrong for everyone. Establishing such principles is the task of ethics. But in the moral life, we decide what we think is right by making particular decisions in particular circumstances.

Yet the good and the right also have a transcendent dimension. Metaphorically speaking, the good and the right are the “wormholes” by which the parallel universes of the moral and the spiritual communicate. The person who is spiritually alive affirms that there is a Good beyond the sum of the good of each person and a Right beyond the sum of all morally correct decisions. The Good beyond all good and the Right beyond all right are not the abstract notions of good and right in ethical theory. Neither should this Good and this Right be identified with Platonic forms. I am invoking, instead, the moral horizon. Finitude and concreteness characterize human life, and these features of life are so explicit in the health care setting that clinicians and patients come to the brink of their deepest desires: Is there any meaning that is absolute? Any goodness that is infinite? Any relationship that is perfectly harmonious? Are there actual answers to these questions anywhere in the space and time of the universe or beyond it? To accept the possibility that these transcendent questions have an affirmative transcendent answer is to understand, in the first instance, how the spiritual passes over into the moral and the moral passes over into the spiritual.

The Numinous and the Medical

Rudolf Otto, in The Idea of the Holy, called the direct experience of transcendence an experience of the “numinous.”⁴ He invoked the notion of the mysterium tremendum—the apprehension of the transcendent, holy, and wholly other.⁵ The numinous, as Otto pointed out, cannot be reduced to the morally good. The experience of the numinous is the experience of the awesome mystery that is so beyond human telling that it is what makes goodness good; it is an experience of goodness so vast and powerful that we shudder in shame, acutely conscious of our humanity and moral fallibility. Human beings have been describing such experiences for millennia and have named these as experiences of the divine. Such experiences most often occur in special times and places—on mountaintops, in religious shrines, on watching one’s wife give birth, in meditation, while reading sacred scripture, while pondering a particularly profound theological work, or during a liturgy. These are the “oceanic” experiences of eternity and oneness with the universe that Freud deemed illusions and massive collective neuroses.⁶ Freud denied that he had ever had such experiences, but it is my guess that he (the father of the theory of psychological repression), like many people, merely repressed his experiences. As the poet T. S. Eliot said, “We had the experience but missed the meaning.”⁷

Such experiences are natural to humans. Human beings live their lives in relation to the infinite. We know the infinite reach of our desire. As Luigi Guissani put it, one must therefore either affirm oneself infinitely or affirm for oneself the infinite.⁸ If one is sufficiently self-aware that one understands one’s own finitude, only the latter makes sense. Put more simply, it has been said that Alcoholics Anonymous really has only two spiritual rules: (1) there is a higher power, and (2) you are not it.⁹ These are the starting points of a spiritually informed moral life.

A Good Friday

The following is but one example of how spiritual experience can happen for a clinician. Once, during Holy Week, I attended the Good Friday liturgy at St. Francis of Assisi Church in New York City, where I was living at the time. I was thinking no particular thought, simply trying to be present to the Word of God proclaimed in my hearing; to the simple actions of procession, prostration, veneration; and to the sound of the organ and the smell of the incense. My gaze turned to the San Damiano crucifix in our church. This crucifix is a reproduction of the one from which Christ spoke to St. Francis in the ruined chapel of San Damiano. It is Byzantine in style. Although this image of the Crucified is very familiar to me, I noticed consciously for the first time that the belly of the Christ depicted on this crucifix is, oddly, a bit protuberant. My thoughts drifted, and I began to wonder why. Perhaps it was the artist’s way of depicting Jesus’s slumping body. Perhaps it was symbolic, meant to represent spiritual fecundity. Perhaps the artist just was not very good. Suddenly, however, another thought entered my mind. I saw there the protuberant belly of a patient I had seen the day before—a hospice nurse with a belly distended by cancerous fluid, a woman otherwise gaunt, obviously ill, and in profound denial, who had continued to work with hospice patients up to two weeks before her own hospitalization. She had told me of her eclectic background—ethnically Irish, English born, raised as an Anglican, and, on moving to New York, regularly attending both Episcopal church services and a Buddhist meditation group. She was unmarried and seemed very much alone in the world. She had attributed her sixty-pound weight loss, jaundice, swollen abdomen, troubled breathing, and rock-hard liver to “working too hard.” The Passion narrative was being proclaimed from the pulpit, and my daydream and the Gospel intersected as I heard the cry from the cross, “My God, my God, why have you forsaken me?” In the painful site of this woman’s thoracentesis (where a needle had been inserted to draw out fluid from around her right lung), I saw the lance that pierced the body of Christ on that same side. In her complaints about her dry mouth, I heard the words o...