A diagnosis of life-threatening illness triggers existential questions in the mind of the individual as they seek to incorporate their experience into their life story. Questions such as ‘Why me?’ and ‘Is there (really) life after death?’ are common in such situations. Research has shown that if these questions are not resolved, the individual is at high risk of developing existential distress, a type of suffering that no medicine will relieve.[i] Intolerable suffering is topical at the moment, as it is an argument commonly used to justify the legislation of euthanasia. Currently research into existential suffering at the end of life is in its early stages, but it is clear that it can be treated and that management requires high levels of spiritual wellbeing.[ii]
Spirituality in healthcare is a relatively new area of academic investigation. In the last 20 years, the number of publications on the topic has risen exponentially. It began with observation of a link between attending church and improvements in health, but since then it has widened into examination of spirituality as a dimension of being human. Spirituality in this context has been defined as ‘a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.’[iii] In this literature, religion is seen as a subset of spirituality, an organised form of belief which is one way of expressing spirituality within universal human spirituality.
This is quite a radical shift in the way human beings are viewed in medicine. Since the enlightenment, science has claimed the physical body as its domain. All other domains were left to the church. However, the stress on an empirical basis for establishing truth in science has led to the situation where matters such as spiritual suffering are viewed as non-scientific and therefore not real, or else identified exclusively with bodily symptoms such as pain.[iv] And that’s what we say, isn’t it? Pain and suffering. As a result, existential suffering is often overlooked in the healthcare setting.
Spirituality may not be an important part of life for many people when they are well. They are more occupied with day to day living. However, when sickness occurs, their priorities change and spirituality becomes more important. This is even more evident in the patient who is approaching the end of life, a time when spiritual concerns are known to increase.
One way of understanding spirituality is as human beings in relationship. Generally, across the population, four types of supportive relationships have been identified—with significant others, such as family; with the environment or things, such as the arts; with self (inner strength); and with God or the transcendent. Incorporating spirituality into healthcare requires a biopsychosocialspiritual model of human beings.[v] According to this model, the intrinsic spirituality of human beings is based on a view of the human person as a being in relationship. Sickness is understood as a disruption of these relationships, both within (in physiological and psychological terms) and without (in terms of spiritual relationship with the environment etc.). This explains why severe illness is often accompanied by questions about one’s relationship with the transcendent, and why spirituality can be applied universally to all patients. ‘Healing’ (the meeting of needs) will involve restoration of right relationships. In physical terms, this means restoration of right bodily functions. In spiritual terms, healing is possible even when the body does not achieve perfect wholeness, through resolution of questions about meaning, which can be experienced by patients as a lack of anxiety, or a sense of peace.
Spiritual well-being can be measured in healthcare. And it has been clearly demonstrated that cancer patients experience a good quality of life if their spiritual wellbeing is high, even in the presence of severe physical symptoms.[vi] It is therefore possible to find a ‘healing’ of sorts as death approaches. Dying healed means you’ve dealt with those fears, guilt, shame, anger, psychological, psycho-spiritual issues that arise when your mortality slaps you in the face. It means you can die in peace.
Spirituality has always been part of the practice of palliative care. It is only now it is entering mainstream medicine that it is seen as controversial, but it is growing in influence. I think that one of the reasons why a palliative care referral can be so helpful for those facing a life-threatening illness is that spiritual needs are more likely to be addressed. It is also a reason why it is immoral to consider legalisation of euthanasia in Australia until all citizens have access to palliative care.
Dr Megan Best is a medical doctor and bioethicist at the Institute of Ethics and Society and University of Notre Dame Australia. She is the author of Fearfully and Wonderfully Made.
[i] M. Best, L. Aldridge, P. Butow, et al., ‘Conceptual Analysis of Suffering in Cancer: a systematic review’. Psychooncology Vol.24(9) 2015, pp977-86.
[ii] W. Breitbart, B. Rosenfeld, C. Gibson, et al., ‘Meaning-centered group psychotherapy for patients with advanced cancer: A pilot randomized controlled trial’. Psychooncology Vol.19(1) 2010, pp21-8.
[iii] C. M. Puchalski, R. Vitillo, S.K. Hull & N. Reller, ‘Improving the Spiritual Dimension of Whole Person Care: Reaching National and International Consensus’. J Palliat Med. Vol.17(6) 2014, pp642-56
[iv] E. J. Cassell, ‘The nature of suffering and the goals of medicine’. The New England Journal of Medicine Vol.306(11) 1982, pp639-45.
[v] D. P. Sulmasy, ‘A Biopsychosocial-Spiritual Model for the Care of Patients at the End of Life’. Gerontologist Vol.42(suppl 3) 2002, pp24-33.
[vi] M. J. Brady, A. H. Peterman, G. Fitchett, M. Mo & D. Cella, ‘A case for including spirituality in quality of life measurement in oncology’. Psychooncology Vol.8(5) 1999, pp417-28.
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