Critical Care

Delivering Spiritual Care in Healthcare Contexts

Peter Sedgwick, Andrew Todd, Jonathan Pye

• Publisher: Jessica Kingsley Publishers
• Year: 2015
• ISBN:
  9780857009012
• Topic: Medicina
• Subtopic: Assistenza sanitaria

Providing a bridge between research in healthcare and spirituality and practitioner perspectives, these essays on chaplaincy in healthcare continue dialogue around constructing, negotiating and researching spiritual care and discuss the critical issues in chaplaincy work, including assisted suicide and care in children's hospices. Each section of the book is introduced by an academic theologian, giving the book a strong theoretical base, before serving healthcare chaplains offer their perspectives and experiences with material drawn from practice in a broad spectrum of healthcare contexts.

The integration of theory and practical application in these essays will be of interest to chaplains, healthcare practitioners, and students of theology and healthcare.

PART 1

Constructing Spiritual Care

CHAPTER 1

The Narrative of Spiritual Care

Locating Models of Spiritual Care within Contemporary Healthcare Education and Practice

Jonathan H. Pye

Why is it that I owe something more to my physician and my teacher, and yet do not complete the payment of what is due to them? It is because from being physician and teacher they become friends, and we are under an obligation to them, not because of their skill, which they sell, but because of their kind and friendly goodwill.

If, therefore, a physician does no more than feel my pulse and put me on the list of those whom he visits on his rounds, instructing me what to do and what to avoid without any personal feeling, I owe him nothing more than his fee, since he sees me not so much as a friend, as one who summons him.1 Why, then, are we so much indebted to these men? Not because what they have sold us is worth more than we have paid for it, but because they have contributed something to us personally. A physician who gave me more attention than was necessary, because he was concerned for me, not for his professional reputation; who was not content to prescribe remedies, but also applied them; who sat at my bedside among my anxious friends and hurried to me at times of crisis; for whom no service was too burdensome, none too distasteful to perform; one who was not indifferent to my moans; to whom, although a host of others sent for him, I was always his chief concern… Such a man has placed me under an obligation not so much as a physician as a friend. (Seneca, De Beneficiis, Book IV section 16)

The Stoic philosopher, Seneca writing in the 1st century CE, asks the question that lies both at the heart of this chapter and of contemporary healthcare’s search to discover why, despite all the advances in contemporary medical technology, people often remain so dissatisfied with the treatment they receive from their doctors and other healthcare professionals in increasingly target-driven and cost-orientated healthcare systems. At the heart of this dissatisfaction is the feeling that they are increasingly being regarded as simply another medical statistic, the object of care, rather than its subject and that they are no longer regarded as a ‘person’ with their own unique history but as a ‘case’, a ‘problem’ to be solved or, worse still, a medical ‘failure’ to be moved on from when cure is no longer an option.

Harvey Chochinov (2007), writing in the British Medical Journal about human dignity and the essence of medicine, begins with a quote from the late American essayist, Anatole Broyard (1992), who was facing a terminal metastatic prostate cancer, with words redolent of those of Seneca 2000 years earlier:

To the typical physician my illness is a routine incident in his rounds while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity… I just wish he would…give me his whole mind just once, be bonded with me for a brief space survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way. (Chochinov 2007, p.184)

Despite the plea for such patient individuality, many of those engaged in the practice of medicine and healthcare today complain that they simply do not have the time to listen to patients or share their stories. Some suggest that even the attentive art of taking a full patient history is a skill that has been sadly neglected, maybe even lost, in the technological busyness of contemporary medical education and practice.

Although this lack of engagement is often regarded as a sequela of contemporary trends in healthcare, at least in Western industrialised societies, this displacement of the ‘person’ in the modern period is something that has been going on since at least the time of the European Enlightenment. In the 17th century, the philosophical dualism of Rene Descartes had posited an increasingly fragmented and discursive view of the human person, and the development of the first ‘secular’ hospitals in post-revolutionary France significantly changed the doctor–patient relationship, with the systematic movement from ‘patient’ to ‘case’ (Foucault 1973; Shorter 1993). This subversion of the doctor–patient relationship led, by way of germ, and then cell, theory in the 19th century and the development of molecular and nuclear medicine in the 20th, to the model of healthcare that has been characterised as the ‘medical’ or ‘bio-medical’ model. This reductionist and atomistic way of regarding the person regards human ‘being’ as no more than a biological phenomenon invaded by disease from the outside, causing changes in the body beyond the individual’s control and making the body no more than the ‘battleground’ on which the doctor’s ‘war’ on disease is waged, rather than the way in which the ‘self’ is presented to the world. This dominant and powerful discourse of disease predominated in medical practice and education until at least the last quarter of the 20th century when, having come under significant sociological, philosophical and even medical critique (Cassell 1991; Foucault 1973; Illich 1990), more holistic models re-emerged from more historic, and even ancient, characterisations of health, illness and the human person. These included what has been characterised as the bio-psycho-social model, first postulated by Engel (1962) in the early 1960s.

Cassell (1991) has argued cogently that with its focus on physical (bodily) pain, medicine was neglecting suffering, which, he argues, is not experienced simply in bodies but by persons and emerges when illness not only threatens the physical mechanism of the body but threatens the integrity of the person him or herself, seen as a whole. Indeed, Tom Driver (1991) regards suffering as a social performance that expresses the deep human search for meaning. Out of this re-integration of the self and the body, which Graham (1992) sees as ‘the primary basis…for generating our sense of selfhood’ (p.73) in which medical care is set within the context of concern for the whole person, including their wider life context, has come a rediscovery of the place of dialogue in which the narrative of the body is listened and responded to, so that the patient’s voice is once again heard. Such listening, because it fundamentally attributes value or worth to the self and therefore recognises the obligation placed upon the listener, is itself a profoundly ethical act. Indeed, the Encyclopedia of Ethics (Montgomery 1979) suggests that one of the defining characteristics of the human species is its narrative nature and, as Arthur Frank (1995), a pioneer of modern narrative method, notes, ‘in wounded story telling the physical act becomes the ethical act’ (p.xii). Thus, spiritual care, narratively expressed, requires practitioners to have a person-centred rather than task-centred orientation and to remember that their language and their actions (both of which are communicative) will seldom, if ever, be, or be construed to be, value-free.

Robinson (2008) suggests that virtues are communicated through attentive listening to the stories of others and are modelled through the development of relationship. Thus the self, including the moral self, of both care-giver and care-receiver is profoundly engaged in the construction and delivery of spiritual care; practitioners, in whatever discipline, will need to be virtue led as well as technically proficient if they are to be genuinely other-orientated. Nonetheless, as Jack Coulehan (2005), reflecting on the culture of contemporary profit-driven medicine, has argued, its ‘depleted moral imagination’ has left the profession ‘beset on all sides by the disappointment, dissatisfaction and misunderstanding of the people it is supposed to serve’ (p.892). Thus he argues for the need for a rediscovery of the virtues in medicine and medical education since it is precisely the affirmation of the person, as (to use Martin Buber’s characterisation; Buber 1944) a ‘thou’ rather than an ‘it’, which enables the dialogical engagement that confers on each individual the indispensable dignity of personhood that so many under conditions of illness feel to have been ignored, eroded or misplaced. Frank (1995) likewise notes how the temporarily broken down body (i.e. the body under the conditions of sickness) so often ‘becomes an “it” to be cured’, a diminished, even a lost, sense of self that needs to be reconstructed in the light of present circumstance. Such a self will never be the same as the one that has been ‘lost’ as such ‘selfs’ are progressive, constantly changing in the flux of experience. As McFadyen (1990) contends, the self must always transcend experience since ‘there is always an “I” beyond the “I” of present experience’ (p.100).

Meakin and Kirklin (2000), although in many ways critical of recent trends in medical education to engage with the humanities, comment that,

these are exciting times for medical humanities in the UK, with artists and scientists working hand in hand to help deliver a more humanistic approach to health care… Specialists in literature, fine art, drama and medical history are bringing their expertise and enthusiasm to bear on the training of future health professionals. As a result productive and promising collaborations are taking place across traditional disciplinary boundaries. (Meakin and Kirklin 2000, p.49)

Whilst a lack of narrative acumen can be seen to have been systematically cultivated in medicine (Bleakley 2005), Rita Charon (2006), a physician with a doctorate in English and one of the pioneers of the use of narrative method in the practice and, particularly, the teaching of medicine, which she describes as ‘medicine practiced with competence to recognise, absorb, interpret and be moved by stories of illness’ (p.vii) says that, ‘patients lament that their doctors don’t listen to them or that they seem indifferent to their suffering. Fidelity and constancy seem to have become casualties of the cost-conscious bureaucratic marketplace’ (p.3). She notes that ‘sick people need physicians who can understand their diseases, treat their medical problems, and accompany them through their illness’ but that ‘a scientifically competent medicine alone cannot help a patient grapple with a loss of health or find meaning in suffering…physicians need the ability to listen to the narratives of the patient, grasp and honour their meanings, and be moved to act on the patient’s behalf’ (2001, p.1897).

Such practice makes medicine and wider healthcare an essentially relational project, rescuing medicine from the hegemony of technological dominance and restoring its place as a humane art. As Charon (2006) says, ‘A medicine practiced without a genuine and obligating awareness of what patients go through may fulfil its technical goal, but it is an empty medicine, or, at best, half a medicine’ (p.6). The dogged persistence of the epistemic distance increasingly created by post-enlightenment atomistic models, which reduce knowledge of the body to its parts rather than seeing it as an integrated whole, can be seen in recent developments in what has been characterised as ‘stratified’ or (ironically) ‘personalised’ medicine. The rise of bioinformatics, which, by combining anonymised medical information using mathematical algorithms and the consequent clustering of groups of patients to provide targeted medical care, has further alienated the patient as ‘person’ by creating another layer of distance in the doctor–patient relationship. Ironically, then, at the same time as medical technology has developed, and with it increased expectations of attaining a ‘cure’, the recipients of medical care have, in inverse proportion, become increasingly dissatisfied with the personal dimension of their care in which they feel neither ‘heard’ nor ‘seen’. Emily Martin (1992) has suggested that this alienation is particularly acute for women, while Nell Noddings (1989) argues for the primacy of a relation ethic over individualistic ethics particularly to mitigate such alienation. She argues that such a relational ethic is predicated on shared human experience, particularly that of pain and suffering and arises out of a commitment to others in caring and being cared for.

The thrust of this section is to argue that in constructing spiritual care, the starting point is an understanding of health as a performed activity in which the needs of the sick person are best met by a dialogical, holistic, person-centred, multi-disciplinary approach, that engages both virtues and skills in reflective practice. In this, the critical questions of identity, relationality and care are addressed not merely as theoretical constructs but as part and parcel of lived human experience. As the phenomenologist Maurice Merleau-Ponty (1962) observed, ‘Life is not what I think but what I live through’ (p.xviii). This takes both effort and skill and the cultivation of an attitude that is essentially agapeistic, something that Alastair Campbell (1984) sees, in itself, as a way of ‘knowing’. The philosopher Simone Weil (1951) wrote that, ‘(t)he capacity to give one’s attention to a sufferer is a rare and difficult thing’(p.59). Whilst ‘warmth of heart, impulsiveness and pity are not enough’ she argues that such neighbour-love (agape) means being able to say to him or her, ‘What are you going through?’ (p.59). This ‘extreme attention’ to others is the essence of other-orientation and, Weil (1952) argues, taken to its highest degree, is the same thing as prayer. It presupposes faith and love. Similarly, Arthur Frank (1995) in his seminal work on narrative medicine asserts that ‘one of our most difficult duti...