(The following is from a talk Dr. Jones was asked to make to a church group)
When I was originally asked to give this talk, I declined and told Don that I would rather talk on advances in cancer treatment and not spirituality. In thinking back, I said no for several reasons. First, any talk of spirituality in medicine ultimately brings cause for a discussion of one's own spirituality and religious views, and in other words, one's feelings. So, the first reason I did not want to give this talk was the "guy" thing. The best way to totally turn off guys or run them off is to ask them to discuss their feelings. Invariably, my wife wants to do this somewhere between 12:30 and 1:30 in the morning after which she is able to fall asleep and I am left awake wondering was I really that callous a person. If you can find a guy that would willingly discuss feelings, suggest that he has his testosterone checked immediately.
The second reason is the Presbyterian thing. I was raised in a very strict Calvinist household where there is a heavy emphasis on performance, higher education, economic accomplishment, and self denial. It has only been within the last few years that I have realized what an impact this has on my view. It affects the way I deal not only with my family, but also with my patients. For those of you unfamiliar with Calvinism, you should know that among the main issues it addresses are free will, God's will for us or predestination, and the central question of evil. The view is that both good and evil reside within each of us; in other words, original sin. Moreover, there is necessarily no promise of salvation based on good works and certainly not good intentions, but rather these are decisions made by God without any puny input by man. This world view is frequently criticized by the Protestant denominations as abrogating any value for good works. As some of you know, that was actually a problem in the early Christian Church, but it does rather effectively deal with the question of why bad things like cancer happen to good people like Nina. The Calvinistic answer would be that we cannot possibly hope to know what God's will is for us, that it must be accepted, and that while we may struggle against our destiny, ultimately God will be the arbiter of that destiny. Having been raised this way, it is actually only recently that I have come to realize that no everybody else believes this. Two things led to my realization of why other people don't think this way. The first was the movie, A River Runs Through It. I saw this movie with my wife, who had absolutely no idea what they were talking about. I had been raised in exactly the same environment with the same strengths and prejudices of the Presbyterian minister and his family. In fact, one of my cousins is a Presbyterian minister whose church I had the privilege of attending when we lived in Houston. I had the unfortunate experience of attending his least popular sermon entitled, "Sometimes we have to work hard just to remain where we are socially and economically." The second experience was when my wife joined Second Presbyterian Church in Memphis. They required me to go through the communicant's class with her. As you might imagine, I strongly protested this since having done it at age 11 I saw little reason to have to repeat it again and certainly not to re-read The Westminster Confession of Faith and The Greater Catechism. Thank goodness The Greater Catechism is now considered a quasi-Catholic document, and my wife was only required to study The Westminster Confession of Faith. Nevertheless, these were two experiences which caused me to realize that I probably look at things a little differently from other people and that humility is helpful in dealing with other people's religious beliefs.
The concept of why bad things happen to good people is not new, and it has been discussed by many authors from antiquity to Dante. Remember, Dante had to explain away in The Divine Comedy what would have happened to virtuous people who had lived before Christ was born; men such as Virgil or the Roman senators Seneca, Cincinnatus, and Pliny. His answer was that they were assigned to the outer, less severe rings of purgatory, but never reached Heaven's sort of an overly warm Elysian fields for the unenlightened. These issues are of importance when discussing the role of religion and spirituality in medicine and highlight one of the main reasons I was uncomfortable discussing this. I have a number of patients who believe that if they are spiritual enough, pray enough, and do good deeds, they will be cured. Unfortunately they also believe the converse that if they are not cured, then they are "bad" or less worthy people; I have a feeling that this view may be more pervasive than even I imagined. At first, it would seem perfectly reasonable to believe this. After all, when I was five years old I was once convinced that if I prayed enough for a pony, eventually he would show up in my front yard. Could one apply a scientific approach to determining whether this would happen? Well, of course this has been tried. Dr. Benson and his colleagues at Harvard University have done extensive studies of spirituality, religion, and outcomes in disease. Outcomes are slightly better for patients who have strong beliefs; however, the nature of the religion itself did not matter. In the groups that he studied, Christians, Jews, and practicing Buddhists all benefited from their beliefs. This de-linkage from Christian faith has been noticed by others such as Engelhart at Rice University in the Institute of Religion and Medicine at Texas Medical Center. Dr. Engelhart notes that in a multi-ethnic society, de-Christianization of values has already taken place and has been replaced by so-called secular morality. Nevertheless, this is one of the founding precepts of our country. Dr. Koenig and his colleagues at Duke University have looked more deeply at the effect of religion, spirituality, and outcome. The only factor which correlated positively with outcome was the participation in organized religious activities, that is, church going. One's belief in how one is religious referred to as "internal religiosity", the frequency with which one watched television or listened to radio programs containing religious content, had no effect. In fairness however, the author's note that better physical functioning also allowed one to get to church; whereas, the sickest patients were only able to participate in religious activities by watching television. Nevertheless, from an external standpoint, those who participate in organized religious activities tend to have better social support, more cohesive family units, and a better outlook.
In contrast, the outlook that God is in control of every event and every shape of our destiny is a kinder but more challenging point of view by Kushner in his now classic book When Bad Things Happen to Good People. Kushner's point is that God, having set up natural laws for man in the universe, does not suspend them for one person. Moreover, he feels that God is not a source of evil and that evil is not planned by God to serve another purpose, but rather, that God's construction of the universe goes on and that in the far reaches and back corners of the universe and in humanity, there are areas which he has not touched. It is these that are the source of what we call evil. Evil may take many forms, that of a man or that of a cancer cell. Moreover, he points out that which makes us human is choice, whether it is moral choice or intellectual choice. He reminds us that Adam and Eve were forbidden to eat from the Tree of Knowledge and that once having done this, it is expected that the knowledge be used to help solve the problems of the universe as well as make moral choices. He also feels that the purpose of religion is not just to put man in touch with God, but to put man in touch with man in a godly context. This, in part, explains why those who participate in organized religious activities do better because they are more in touch with their fellow man and know that there is warmth and support in the community. It is known that patients with increased social support have half the mortality and one-third of the risk of severe complications than those without (the healing bond). In the words of Rabbi Mendel, people are "the language of God". Among the choices patients can make either to be treated or not to be treated. Many times I have treated patients who have had a specific goal, and it is that goal that has helped them to do well. For example, many years ago one of my lung cancer patients was diagnosed in July, but he desired to live long enough to take his grandsons hunting. With extremely aggressive treatment, not only did he survive for one hunting season, but he was alive for three. This gave his final years purpose, meaning, and a feeling of great pride that he had participated in the raising of his grandsons. One of my breast cancer patients wished to live long enough to see her daughter graduate and marry, and another wished to live long enough to see the birth of her grandchild. In both cases, the patients lived a few months after the event.
In his book Emotional Longevity, Norman Anderson discusses this. Dr. Anderson notes that in studies of cancer, AIDS, and cardiac patients, those who do the best are those who have goals and are optimistic about reaching them, no matter how unrealistic. The one thing that both Anderson and Kushner warn as the most dangerous feeling is self blame. Many times my patients would ask me, "Is there something else I could have done? Perhaps I should have paid attention earlier or gone to the doctor more regularly." Certainly lung cancer patients say "I should have stopped smoking earlier." Nevertheless, this does not explain why each individual develops cancer or heart disease or even HIV. We all know that susceptibilities, despite risk factors, vary from person to person. Self blame will only prevent solving the problem. One way of looking at it is to separate your body from your personhood, to know that though your body may be defeated your mind, your soul, and your person will live on. They will not be defeated by a physical disease and as long as they remain intact, there is purpose to your life. When one's life changes, one must look at these as challenges and as strange as it may sound, even opportunities, to grow in a different way. Anyone who survived a life-threatening event, whether it is cancer or any other near-death experience, will tell you priorities change. Yes, some do become embittered and selfish, but many more come to appreciate life and what is important in life. As the cliché goes, ‘no longer sweat the small stuff'. One of the things most people are surprised about is the laughter in our office. We laugh at the ambiguities, the ribald comments, and the strange turns that life can take to bring every bit of joy and happiness out of so short a time because no one in our office has the right to cry, with the exception of our patients. Those who have to deal with their mortality on a daily basis soon realize that trivializes our other concerns and reduces most of the questions to mere vanity.
THE DIMENSIONS OF SPIRITUALITY
There are two dimensions of spirituality which do affect outcomes and help people. The first is external and is really provided by others. The second, internal, will be discussed later. Externally participating as a member in church affords additional support, both psychological and physical. For example, one clinic employs a full-time social worker who spends a great deal of time arranging transportation for patients to come to treatment, helping patients to fill out insurance forms including those provided by the U.S. government. Most people, including the staff, have trouble understanding them, and I doubt very seriously the people who wrote them even understand them. The social worker also helps to find support at home for both care and meals including simple things such as just bathing, bringing books, and providing companionship and concern about the patient's physical well being. One of the first questions I ask patients is what church they belong to because many of our patients, especially the elderly, are actually transported by members of their congregation. While these seem obvious, they are all too often overlooked, and they represent a major source of distress to patients who desperately try to preserve their dignity while dying or being acutely ill. Moreover, few families can cope with the magnitude of problems engendered by having an aged or dying relative at home full time without some help and relief. One of the major shortcomings of the hospice movement in this portion of the southern United States is the lack of residential hospice relief necessitating a hospital admission for so-called Respite Care. If there were one thing that organized religious groups could do to help people in our region, that would be to get past the Baptist-Methodist debate over who controls the hospice, who is going to put up the most money or lose the least money, and reach a workable relationship on how we could provide the best hospice care in a humanistic setting.
The second major area is internal spirituality. This tends to be the most important in patients who are facing the end of their lives. In studies done both at Memorial Sloan-Kettering and at the University of North Carolina, a major concern for most of us is the need for love and understanding and the feeling that our lives have amounted to something that they have been meaningful. Moreover, we want the days left in our lives to still contain meaning despite our dependence on others, our need for on-going medical care, and the ability to preserve our dignity as human beings. This may be why outcomes are de-linked from specific religious beliefs, because internal spirituality plays such a vital importance. This assumes, of course, that we come to accept the end of our life. When I was a medical student in the late 1970's, a very popular and required reading was Elizabeth Kubler-Ross' book, On Death and Dying. She pointed out quite correctly that in any sense of loss, whether it is of one's life or something important in one's life, we always go through stages. The first stage is anger and denial, which can lead to some destructive behavior such as refusing to accept care to hurting those who would try to help us. The patients I worry about the most are those to whom I give advice, and in the course of rejecting their disease, reject that advice and hurt themselves. I have always felt this was a failure on my part in not being able to convince everyone. However, that assumes I am right every time, and that is probably not always the case either. In the final stages of acceptance must come the understanding that somewhere, there are individuals who care and that somehow something in one's life made that life worth living. That would have to be true whether one leaves a physical legacy, children, or simply the knowledge that one tried to live the best life possible and hope that God agrees with our assessment.