Given at: The New York City Long-Term Care Ethics Network Conference
on
Dec. 7, 1998
By Philip J. Boyle, Ph.D.
Park Ridge Center
I. Introduction
"Spirituality is an idea whose time has come--again" quipped a wag. In the rush for healthcare systems--including nursing homes--to integrate spirituality to improve care, some have lost sight of the fact that the relationship of spirituality to aging is not new. People have been thinking about spirituality and its effects on aging since the first recording of religious history. What is new, however, is the spiritual interest arising in secular areas and the rush to integrate this into healthcare, to study it as a variable, and to chart its effectiveness.
While there are great expectations for spirituality to be an elixer for the healthcare system, the hopes are nowhere greater than for the elderly. With increasing numbers of elderly who suffer greater chronicity, disabilities, dependency, and many losses--loss of family, friends, life's work, home, belongings, health, mobility, mental capacity, and meaning in life--spirituality is thought to be the missing piece in healthcare.
Yet some skepticism exists as to whether spirituality will be all that useful for the elderly. In semi-structured interviews conducted by the Park Ridge Center research staff, one respondent put it bluntly. The interviewer, in an attempt to got a picture of a resident's whole life, harmlessly asked the 76- year-old daughter about her 96-years-old frail and forgetful mother: "What about your mother's religion? Did she practice her faith?" The daughter retorted: "What good is religion going to do her now?" Her response highlights two challenges for our consideration. First, the daughter like many others who watch deterioration, dependency, and dementia, wonder how this time of life could have any meaning. Society has an unflattering--even stigmatized--social image and expectation for aging. When you are no longer a productive member of society--earning a living or filling some socially useful role--and if you have lost your autonomy, and become dependent--then how could your life have meaning and purpose? What good could religion and spirituality contribute to a person in such a state, is a question that those who want to rush to integrate spirituality into long-term care must answer.
Second, the daughter exhibits an understandable skepticism about the relevance of religion and spirituality to the experiences of aging. How can religious traditions--developed thousands of years ago when there were not the modern problems of aging--respond to the significant challenges of today's elderly and those who care for them? And what exactly is the relationship of religion to spirituality?
What the daughter's response does not address but what is nonetheless important is: how should healthcare integrate spirituality into its day-to-day fabric? What are the opportunities and challenges to such an action?
II. Characterizing Spirituality
Spirituality is the buzz word in many sectors of society--the workplace and in healthcare. But with its many, varied uses it is fairly important to establish guideposts as to its characteristics, Surely, how one characterizes spirituality will effect who will employ it in the healthcare setting, what strategies will and will not be used, and what effects are and are not to be expected.
Spirituality does not have an established place in many religious traditions and until recently, it is a word restricted to Roman Catholic circles. Some sense can be made of the term, not by defining it, but by characterizing it. One characterization can be found in a web of concerns associated with a popular statement: "I am not religious, but I am spiritual." While spirituality is obviously related to words like faith and religion, the term is used to signify some distance from religion. Some spiritualities are so deracinated of religious doctrine that there is no link to religious beliefs. These so called "secular spiritualities" are not incompatible with religious doctrine but rather stripped down versions that are characterized by eclecticism and pragmatism--whatever works.
Another characterization of spirituality can be found in a tension between concerns about transcendence versus the immanent. Some religious systems' spirituality are marked by a relationship to a transcendent. Others reject this distant, foreign relationship with a transcendent other in favor of a relationship that is marked by the immanent--a sense of indwelling or inner consciousness as some have explained it.
While there are many other features of spirituality, a quick summary would add that it is possible to be spiritual without being religious, where spiritual not sacred language is employed. And, what counts as genuine spiritual development and what is counterfeit is defined by practices (e.g., Meister Echart view of detachment, or the Cathoic understanding of "offering it up") and outcomes that are manifested in behavior such as psychological resiliency and taking responsibility.
III. Spiritual Resources to Improve Care in Long-Term Care
While some spiritualities are stripped of their religious roots, others are tightly tied to religious foundations and it is useful to examine whether the religious moorings improve aging. Religious perspective on aging arises from a paradox: how can humans experience growth in the midst of physical decline. Spiritual traditions reconcile this paradox of loss (physical, social, or psychological) as the actual occasion for spiritual growth. Losses associated with aging are the catalyst for the beginning of a spiritual phase of life.
Despite historical and theological differences, all traditions have reflected on the aging process and the significance of the elderly for society. First, sacred texts point to late life as an honorable phase of life that presents distinct opportunities for spiritual growth and community involvement (e.g., the roshi in zen Buddhism, lama in Tibetan Buddhism, Sheikh in Islam, and the rebbe in Hasidic Judaism). (2) Each tradition describes a set of practices, handed down through unbroken lineage, that leads to self-knowledge. This self knowledge proceeds, in part, from a perspective that only longevity affords. (3) Each sees later life as a contemplation. With age the roles of work and family responsibilities diminish, causing the elderly to focus on ultimate concerns and the inner self. (4) Finally, all traditions view the elderly as bearers of valued perspective and deserving of respect e.g., "Honor your father and mother."
This wisdom from the tradition directly confronts cultural stereotypes of aging. Religious traditions create paradoxes. Aging is not seen as an indignity but as honor, not as a curse but a blessing, not a decline but a time for growth, not a period of senility but a time for wisdom, not a time of abandonment but time of covenant. The long-story-short is that religious spiritual wisdom transforms cultural stereotypes of aging.
IV. Integrating Spirituality into the Healthcare Setting: The Moral Puzzles
As positive as a picture of spirituality and aging is, it is good to wonder about the practicalities of importing spirituality into healthcare for the elderly. One caution is that the rush to integrate spirituality into health care risks reducing spirituality to one more instrumental good supporting improved health outcomes. For instance, some studies suggest that religious activity can lower blood pressure and fortify the immune system. The danger of this view of spirituality to healthcare is that it may oversimplify the value of spirituality by treating it strictly in terms of its usefulness to health. In contrast, it is wise to remember that spirituality promotes outcomes such as inner resiliency and detachment, but not necessarily cure from physical disease.
Practically considered, attempts to integrate spirituality into health care raise numerous moral questions. It is a useful thought experiment to imagine this integration through the perspective of the different moral actors who care for the elderly. Imagine yourself as a healthcare professional. If you have little interest in spirituality but are faced with the elderly who seek spiritual help, should you fake a prayer or ritual even though you don't believe? Is your integrity diminished if you merely go through the motions? On the other hand, if you are a healthcare provider with spiritual interest, should you engage the elderly patient in some spiritual practice if you don't have sufficient time or ability to deal with it? How far should the healthcare provider go if the spiritual practice does not contribute to positive health outcomes, or if the patients have different spiritual practices? Whether you engage in a spiritual practice or not, what are your professional obligations to offer it and be trained in the various spiritualities?
Alternatively, imagine yourself as a healthcare leader, such as a nursing home administrator. What should motivate your organization to spend resources on spirituality--because the organization must be sensitive to the market, improve employee and patient satisfaction, or fulfill its mission? Are you off the hook if yours is a secular, non-religious organization? Should professionals other than pastoral care staff attend to spirituality? How adept should each group be with spirituality and how should the organization go about teaching spirituality to these groups--if it can be done at all? Finally, what institutional safeguards are necessary to avoid coercive practices against residents?
Even if you cannot imagine yourself working within healthcare, as a citizen you might want to imagine what the posture of society ought to be towards spirituality through publicly funded organizations, government regulations, and incentives, supposing that spirituality is a basic human good because it helps individuals and societies flourish. What is society's obligation to promote the good of spirituality, what some philosophers term the "good of religion?" If spirituality is a basic human good like health and education, who ought to promote it?
While these are only first steps into this murky area, the initial lesson is clear. In the rush to integrate spirituality into the healthcare setting, the moral questions imbedded in the practice require us to think first so we can honor the value of primum non nocere--Above all, do no harm.
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