JOURNAL OF PALLIATIVE MEDICINEVolume 4, Number 3, 2001Mary Ann Liebert, Inc.

Spirituality and Religion in End-of-Life Care

REV. JOSEPH DRISCOLL

333

AN AUDIBLE HUSH fell over the audience of 800physicians, nurses, chaplains, and other

health care professionals at this national confer-ence on spirituality and medicine in end of lifecare. Heads turned and bodies straightened upwith the rising tension as the young physicianchallenged the chaplain at the podium. “Youposit that one should pay reverence to the spiri-tuality of another person and that no one shouldproselytize. But you yourself are a Christian.How do you pay heed to the gospel mandate thatyou spread the good news of Jesus Christ?”

In an instant, all suspicion and fear inheritedfrom modernity’s long tenuous relationship of re-ligion and science came to the surface once again.

Never mind the thoughtful discussions of thelast 10 years that have carefully delineated theboundaries between religion and spirituality, tworelated, yet distinct spheres of human experienceof transcendence. Nor the clear distinction thatwhile all people have a spirituality (values andmeaning), only some people have a religion (afaith community). Not even the concise role dif-ferentiation that the rabbi, minister, iman, orpriest addresses the religious needs of peoplewho are their congregants, while the health careprofessional tends to the spiritual needs of peo-ple who are their patients.a

Walking over to the microphone that morning,the physician walked over a line that has beenconsistently drawn not only in the ethics of pro-fessional life in medicine, but in our political andsocial life as Americans as well. The privacy ofbelief—especially religious belief—is to be sepa-rate and respected in the public domain.

But wait a moment: is the push of this young

physician simply an anomaly of one fundamen-talist Christian, or is it not the case for many, if notmost physicians that personal belief and profes-sional practice are somehow inherently enmeshedin the relationship of religion to medicine?

Or to ask it another way, is the call to be ahealer predominantly a spiritual one? And if so,how does one separate out personal belief andprofessional practice?

In this issue of the Journal of Palliative Medicine,Professor David Clark brings to the fore a storyof another young physician and her similar ex-perience of wrestling with the personal and pro-fessional dimensions of religion and medicinemore than 40 years ago in London. The story ofDr. Cicely Saunders, the founder of St. Christo-pher’s Hospice, is famous for marking the begin-ning of the modern hospice movement as we nowknow it. Her contribution to the debate on the re-lationship of spirituality and medicine, however,may leave an equally important mark on thispressing issue in health care today.

Dr. Clark delves into a careful study of the let-ters of Cicely Saunders at the time she was strug-gling to find a way of living out her vocation tocare for dying persons. He debunks the revision-ists’ efforts to decry the “secularization of hospice”from its earliest religious center by uncovering justhow much Dr. Saunders herself pulled back fromincorporating many of her own religious beliefs inthe establishment of St. Christopher’s.

In fact, these letters, which were written overa critical period of a few short years, manifest aninner and outer struggle between personal reli-gious belief and professional medical practice. Inthe end, spiritual care became integrated into the

National Association of Catholic Chaplains, Milwaukee, Wisconsin.aThe role of the physician in addressing spiritual issues is given a clear boundary in both the discussion and use

of the spiritual assessment tool found in the abstract by Christina Puchalski, M.D. and Anna L Romer, Ed.D., “Tak-ing a spiritual history allows clinicians to understand patients more fully,” Journal of Palliative Medicine Volume 3,Number 1, 2000.

Editorial

care of dying persons in hospice, but did so with-out this so-called religious center, whether suchwas her initial hope for a life lived in communityor the push for an exclusive connection with herown evangelical Anglican tradition.

Her successful resolution of these conflictingthoughts and feelings occasioned a holistic ap-proach to the care of patients where in her words“the spiritual work is of paramount importance. . . [and] goes hand in hand all the time with ourmedical work . . .” (letter to Olive Wyon, 4 March,1960). This struggle resulted in a notion of spiri-tual care, while attendant to the importance ofsuch needs, at the same time left a line of sepa-ration that respected the beliefs of caregiver andpatient alike.

Not identifying spiritual care with a specific re-ligious tradition in the origins of hospice, whetherinadvertently or not, opened wide an apprecia-tion for the worth and dignity of each person andthe value and meaning that she or he attaches toher or his life. The seriously ill or dying personhas consistently indicated a need for hope in themidst of serious illness and dying.

And where does hope reside? In a recent sur-vey of more than 7,500 patients, 70.6% indicatedthat it was faith/God/Higher Power contrastedwith 28.5% who saw their treatment as a sourceof hope.1 If the general public identifies the spir-itual as the primary resource of hope in dealingwith their illness, would the physicians them-selves score much differently in their own re-sponses?

Spiritual care is so much more than religiouscare. Spiritual care discovers, reverences andtends the spirit—that is the energy, or the placeof meaning and values—of another human being.A person’s energy may her religious beliefs, as inthe case of Dr. Cicely Saunders. But a person’senergy or what he values may not be religious.Take the example written by a nurse who soughtto offer spiritual care to a dying man with onlythe slightest indication of what he valued andwhat held meaning for him.

One winter night a man was brought to theemergency room of a Denver hospital in respira-tory distress. As they were admitting him he wasreluctant to let go of his cowboy hat and boots.The staff reassured him that they would bebrought with him to his room. Two weeks passedand it became evident that he had no family mem-ber or friends to visit. One of the nurses was dis-tressed to see him so alone. She sensed his sad-

ness and asked him if he would like to hold hishat. He nodded his head and was visibly relievedwhen she handed it to him. When a few days laterhe was dying, the same nurse asked him if hewould like the hat on his head, he nodded tak-ing great comfort, and he died peacefully shortlythereafter. After he died, she even went so far asto tie the hat on his head and keep the boots byhis side in her postmortem care.2

Spirituality is focused on meaning and value,which in the above instance, was not identifiedwith religion.

In the growing climate where spirituality andmedicine more often walk “hand in hand,” it isimperative that physicians learn from the exam-ple of Dr. Cicely Saunders to carefully distinguishtheir own spirituality (which may or may not con-tain religious beliefs) and the spirituality of thepatients they care for (which likewise may or maynot contain religious beliefs). Not to do so risksgreat harm to the doctor-patient relationship, in-tended or not.

Perhaps not surprisingly, the person who ismost able to help the physician or other healthprofessional in establishing this boundary is theboard-certified chaplain on the team. She or heemerges from a religious tradition and yet istrained in a clinical setting to offer spiritual careto all patients of any or no religious tradition. Thechaplain is the health care professional whose pri-mary focus is the spiritual needs of patients, fam-ilies and staff, and differs from the parish clergy,rabbi, or other congregational minister whose pri-mary focus is the religious needs of her or his con-gregant. The chaplain too needs to separate hisor her own personal beliefs from his or her pro-fessional practice.

An apparent irony unfolded before 800 peopleas a physician said he felt the need to spread thegood news of Jesus Christ to his patients, while achaplain, a Christian and a priest, said that neitherhe nor the physician should ever do such a thing.

Pushed further on the issue of religion’s call to“evangelize,” the chaplain paused long and hard.“If by ‘evangelize’ you mean ‘proselytize,’ no,never.” The chaplain continued on, “How thendo I ‘evangelize’? The only way is by witness.People will know by my actions the beliefs that Ihold.”

Witness seems the way for healers who seek tolive within the ethical lines of personal belief andprofessional practice in religion and medicine.Anything else is a violation of patients’ rights and

DRISCOLL334

a breach in a code of ethics. Chaplains would losetheir board certification if they ever went in thedirection of the young physician at the podium.

Witness is what Dr. Cicely Saunders gave theworld with the institution of hospice. And wit-ness is what she gives her physician colleaguesin a view into the struggle that led to this legacy.

REFERENCES

1. Rodrigues B, Rodrigues D, Casey DL: Spiritual Needsand Chaplaincy Services: A National Empirical Study

on Chaplaincy Encounters in Health Care Settings.Medford, OR: Providence Health System, 2000.

2. Christensen A: His boots and hat were at his side whenhe died. In: Sacred Stories. Denver, CO: The CatholicHealth Initiatives, 2000.

Address reprint requests to:Rev. Joseph Driscoll

President and Chief Executive OfficerNational Association of Catholic Chaplains

3501 South Lake DriveMilwaukee, WI 53207-0473

E-mail: jdriscoll@nacc.org

SPIRITUALITY AND RELIGION IN END-OF-LIFE CARE 335