By David Lewellen
The biological model of medicine has reached its limits, according to Daniel Sulmasy, and must reincorporate spiritual care to make further progress.
Sulmasy, a practicing internist, Franciscan friar, and noted medical ethicist, spoke to the conference on spiritual care as the missing element in medicine. “The very fact that we are is something science cannot answer,” he said. “We do not know who a person is by knowing their genes. The double helix is wrapped around an axis of mystery.”
Illness, he said, can be seen as a disruption in relationships – diabetes involves relations of insulin, sugar and protein; a cancer cell does not respect its boundaries. But relations with the self, other people, work, and God can also be disrupted.
To the accepted “biopsychosocial” model, Sulmasy proposes adding “spiritual.” Spirituality, he said, addresses questions of meaning, values, and relationships. “Hope has more to do with meaning than with whether we will be cured,” he said, and broken bodies often remind patients of broken relationships. And at the end of life, “there is no other possible healing but spiritual healing.”
For those who wish to combine spirituality and medicine, Sulmasy said, there are three models. The parallel model is “probably what you’re used to,” in which chaplains meet patients and chart, but don’t work directly with physicians. In the doctor-priest model, the physician also takes responsibility for spirituality, thinking “we can learn this just like we learned pharmacology.”
But, he added, “MD does not stand for medical deity, much to the surprise of many physicians.” The practice raises ethical boundary issues, and patients may not be comfortable discussing spirituality with doctors.
Sulmasy’s preference is the collaborative model, common in hospice, in which the chaplain functions as part of a team. “We know it works, we know how well it works,” he said, “but why do we limit it to patients who are dying?” Doctors, he said, should be trained to do just an initial assessment before handing off to chaplains. As it is, if a patient happens to have rosary beads or a Q’uran in the room, “what’s the reaction of the clinical team in the 21st century? Silence.”
A nonreligious patient can easily be overlooked, but they also have spiritual needs, Sulmasy said. “Your job is to do the real work,” he said. He cited the examples of psychiatric patients who use religious language, and of a patient who might refuse medication because he or she thought illness was God’s punishment.
Challenges of the collaborative model, Sulmasy said, include charting vs. confidentiality, and the roles of the team members. If a doctor comes in when the chaplain is busy with a patient, he said, the doctor should come back later – which drew an approving murmur. Also, he said, chaplains need to confront the tension between value and measurement. “What you’re doing has value independent of outcome,” he said. “Use the data, but use them wisely.”
It is not a doctor’s role to encourage religious practice in patients, Sulmasy said, for reasons of power imbalance and of being patient-centered. “God is not a nostrum we put in our black bags,” he said. “We are not in charge. We are not channeling God.” But, he concluded, quoting Abraham Henschel, “To heal a person, you must first be a person.”
In table discussion afterward, Mary Heintzkill of Kalamazoo, MI, said that in the past, she has told doctors to come back later, and they consented but were surprised. “Once you’ve worked in the hospice model, you can’t go back,” she said. “I think chaplains are way too timid.”
During the question period, Sulmasy said that Catholic doctors could benefit from a formation program, and that pilot programs at various institutions should expand. “Could you do a verbatim as a physician and present it to chaplains?” he wondered. “ ‘Now, what was your agenda when you said that?’ ” The audience laughed and cheered.