Spirituality in Surgery-A Double-Edged Scalpel

Abstract

Investigating, respecting, and working with surgical patients’ spiritualities is as critical a skill as the proficient technical performance of operations. When spirituality is ignored, sacred patient values remain undiscovered, authentic trust is hindered, and healthy shared decision-making processes suffer. These are instances when the other edge of the spiritual scalpel comes back to cut us as surgeons, but more importantly, upon withdrawal of spiritual understanding, it deeply injures our patients and their families. Spiritual screening, spiritual history taking, engaged, active listening, and big-picture prognostic truth-telling while promoting hope are critical skills for efficacious whole-person surgical care and the healing of our surgical patients’ suffering—in all aspects of their humanity. These skills require surgeon introspection and vulnerability, however, as well as regular practice, and can be quite difficult; frequently leading to understandable discomfort, particularly when the surgeon does not share the patient’s spiritual orientation or religious commitments. This literature-based essay addresses all of these issues, providing surgeons with a variety of new spiritual tools for their holistic armamentarium to promote healing, rather than further injury.

Introduction

Dr. Jeremiah Turcotte once said: “Attention to spirituality can give meaning to life for both the caregiver and the patient.”¹ Surgical practice and patients’ spiritualities bleed into one another. Spirituality in surgery figuratively becomes, therefore, a double-edged scalpel. Investigating and respecting a patient’s spirituality is a sharp and ef- ficacious instrument in the surgeon’s toolkit. On the other hand, if surgical patients’ spiritualities are ignored, we fail to understand the values they hold as most sacred²; and therefore fail to practice whole-person patient-centered surgery. Ignoring religion and spirituality will also fail to generate shared decision-making that focuses on each surgical patient as a human being, with their own unique personhood, hopes, and fears. Perhaps most importantly, in ignoring spirituality we fail to build authentic trust: Trust that requires our own vulnerability as well as rec- ognizing theirs.³ These are instances when the other edge of the scalpel comes back to cut us as surgeons, but more importantly, upon withdrawal of spiritual understanding, it deeply injures our patients and their families. Thus, we ought to exercise our heart as much as we exercise our hands and our heads. Attention to spirituality is just as critical a skill as the technical performance of operations.

Twenty years ago, the father of palliative care Dr. Balfour Mount, himself an oncologic surgeon said: “We stand on the brink of the third epoch of healthcare, the epoch of Whole Person Medicine. The interdependence of body, mind and spirit calls us to look beyond the biology of disease to the broader landscape that underlies human suffering.”⁴ We are still standing on that brink. Surgeon unfamiliarity and discomfort in active listening to spiri- tuality in an honest respectful fashion is a significant barrier to bridging this human suffering gap or perhaps better, healing these subjective experiential wounds.

Spirituality, Theological Anthropology, and Spiritual Reframing

What Is Spirituality?

We subscribe to Dr. Christina Puchalski and collaborators’ national and international consensus definition of spirituality as “the dynamic dimension of human life that relates to the way persons experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant, and/or sacred.”⁵ Thus spirituality has major themes of meaning-making, pur- pose, and connection (to self, others and the transcendent, whether that be to what most of us call “God” or other sacred sources). These are very closely held values, which are largely stable, fundamental meaning-based concepts that have broad control over moral agents’ (eg, surgeons’, patients’, and pa- tients’ loved ones’) motivations and actions.⁶

What Is Theological Anthropology and How Does This Color the Discrepancy Between How We, as Surgeons, See Our Patients and How They (and Their Loved Ones) See Themselves?

Theological anthropology concerns what constitutes human persons and how those elements (if multiple) relate to the divine. Monist theological anthropologies posit a unity of body and soul (and/or spirit) and this single element relates to God. In bipartite anthropologies (eg, mainstream Christian) there is a distinction between body and soul/spirit, and yet the 2 elements remain somehow mysteriously connected during life. For those who hold to bipartite theological anthropologies, they usually believe that a person’s soul and/or spirit lives on with God after death. In contrast, surgeons typically only focus on patients’ bodies; ignoring their soul and/or spirit. This discrepancy neces- sarily devalues patients from the patients’ and families’ perspective.

How Does Our Modern Medical Culture See People?

In our materialistic focus on the body, we often embrace a Cartesian dualism without recognizing any connection between patients’ bodies and souls (or spirits). But this is not how they usually see themselves. Thus, we routinely depersonalize patients and evoke an inhospitable envi- ronment to our patients’ humanity when we ignore their spirituality.⁷ According to Drs. Tracy and Michael Balboni, this philosophy promulgates the complete separation between religion/spirituality and medicine despite lots of evidence that shows the 2 should be in- timately connected.⁸ The corollaries to and clinical implications of this philosophy are immense. We now behave as if (1) hospitals provide technologies and cures, rather than humanistic care; (2) physicians are scientists and health managers rather than whole-person healers; (3) humans are divisible into the material and immaterial, with no essential connection between body and soul/spirit, so health and well-being are not related to spiritual notions; and therefore (4) the engagement of existential fear can only be dealt with by religious communities and spiritual leaders, not clinicians.^7,8

The evidence, however, stands in sharp contrast to our philosophy and these behaviors. For example, 96% of advanced cancer patients receiving palliative care in a New York hospital reported having spiritual pain.⁹ And 45% of ethnically diverse dying patients with no religious affiliation said they wanted their physicians to approach them spiritually.¹⁰

Healing Solutions to the Theological Anthropology Discrepancy

There are, fortunately, powerful remedies to these shortcomings. First, all surgical patients deserve a spiri- tual screening as part of their evaluation. Spiritual screening consists of 2 questions, a positive and a nega- tive.¹¹ The positive is: “Tell me about your spirituality.” Or, “What brings you meaning and joy in life?” Some- times such a positive screen requires defining spirituality, in which case the surgeon can name the major themes (ie, meaning, purpose, connectedness and transcendence, with or without a relationship with what most of us call “God”). The negative question is: “Do you have any significant spiritual suffering or struggles?” Typically, significant spiritual suffering implies a major disconnect with God (eg, feelings of divine abandonment, anger, judgment, etc.) for theists, and meaninglessness and hopelessness for non-theists and theists alike.¹² Following the spiritual screening, surgeons can explore, by saying things like “tell me more” and take a spiritual history. Spiritual screening and exploration is a skill that every surgeon should employ, from their own toolbox. When significant spiritual suffering is uncovered, however, the involvement of interdisciplinary teams with spiritual care experts (eg, chaplains and/or palliative care specialists) is warranted.

Second, particularly for those families who hold to bipartite theological anthropologies and are clinging to unrealistic miracle wishes, the surgeon can employ em- pathy and redirect their patient’s loved ones with spiritual reframing. The first clause to this statement requires that we distinguish between their loved one’s spirit and (dying) body, by acknowledging and respecting their spirit; the second expresses deep concern regarding their body. It is a modification of a wish-worry statement. This may be expressed like, “I just want to recognize how in- describably beautiful your _______’s spirit is … But I’m afraid their body is _________.” Once this has settled somewhat, the clinician can then reiterate the substituted judgment principle that the decision is not up to the surrogates,¹³ but in these instances include their con- nection to the divine—since these folks typically have a strong sense of divine providence—in order to further mitigate surrogate guilt. This can take a few forms, such as: “This isn’t a decision that we have to make for _______; … their body has really already made this decision for us.” Or: “Let’s all pray for a miracle … and let God sort out what the miracle looks like.”

Truth-Telling While Promoting Hope

Ideally, in a world of increasing patient autonomy, surgical decision-making must be a process shared with patients and their designated surrogates. When confronted with life- threatening or progressive illness, honest prognostication is an essential foundation for the spiritual work that chal- lenges very ill and dying patients. Historically and in many cultures, withholding this vital information or even overt deception has been justified as a compassionate act to preserve hope. For example, the original AMA Code of Medical Ethics states: “A physician should not be forward to make gloomy prognostications because they savour of empiricism…. The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is therefore a sacred duty … to avoid all things which have a tendency to discourage the patient and depress his spirits.”¹⁴ But what kind of hope could be preserved by lies? Dr. Balfour Mount has made a clear distinction between hope and wishing (ie, wishful thinking/denial):

“Hope is not the same as wishing. Hope is a perspective on reality, a point of view… It reflects a degree of inner peace. Hope is a child of the human spirit. It arises from an experience of personal meaning. Wishing, however, arises from a sense of need, dissatisfaction and unrest. It reflects a sense of incompleteness. Hope is the product of adversity transcended, wishing of adversity denied. Hope is linked to acceptance, the transcendent alternative to denial and the conscious attitude that accompanies in- tegration. Once we accept our givens, we are free to assume an attitude to them; to exercise our options; and to take responsibility for ourselves.”⁴

Withholding honest prognostic estimates, whether they relate to functional decline or estimates about survival time, however, deprives families of much-needed context and impedes planning, frustrating the focus on what matters most to patients and their loved ones. Speaking realism—even and perhaps especially in the face of uncertainty—is a key feature of trustworthy professionalism. In one study, 93% of 179 interviewed surrogate decision makers “felt that avoiding discussions about prognosis is an unacceptable way to maintain hope.”¹⁵ Honest prognostic discussions also allow pa- tients and families a space for meaningful communication (eg, saying goodbye and expressing love, gratitude, and forgiveness).¹⁶ It is possible to tell the truth to patients with serious illness in a compassionate manner, pre- serving individual autonomy, building trust while hon- oring cultural differences, and not wounding through deception. A pathway for truth-telling in serious illness meeting these goals can be described as follows:

Informed Consent

Delivering a grim prognosis or giving other bad news may be even more traumatic than performing an operation. Establish ground rules for disclosure of clinical in- formation with the patient’s permission. Does the patient want to be the primary recipient of clinical information? What role does the patient want family members or others to have in the disclosure/receipt of the information? How much does the patient want to know?

Process

Understand that the disclosure of the truth about the illness is a process that will unfold through multiple encounters, as the situation and considerations affecting treatment change over time. Don’t ever lie to a patient, but it is not necessary to bludgeon a patient with information s/he is not ready to hear. Because it is necessarily a process, be patient in communicating with the patient.

Trust

Reassure the patient (and family) that no lies will be told, but the patient’s right to refuse to hear more information will also be respected. If the patient refuses to hear di- agnostic and/or prognostic information essential for in- formed consent regarding proposed treatment, the patient may need to authorize a surrogate decision maker to receive the information and make treatment decisions on the patient’s behalf. As the disease progresses, gently offer information about the prognosis repeatedly without forcing the issue. “I respect your wish to avoid hearing more about your illness, but I also believe that the in- formation is so important for you to hear and consider, that I will keep offering to tell you.”

Hope

Encourage and support hope based on a realistic as- sessment of the current condition and likely prognosis of the patient. Understand that the patient may misinterpret further offers of disease-focused treatment, even though explicitly “palliative.” Balance the patient’s (and family’s) expectations with use of language like: “we will hope for the best, but also prepare for the worst.”¹⁷ Remember that hope is not based on an outcome or an event (eg, surgery). Rather, “hope is a positive, empowering, transcendent attitude, which reveals the underpinnings of deep- meaning construction that are based on acceptance of realistic prognostication, no matter how foreboding.”⁶

Handling Spirituality that Isn’t Your Own

Engaging with a patient’s spirituality can often be un- comfortable for physicians, especially when the doctor does not share the patient’s spiritual orientation or religious commitments. Our default mode in a pluralistic society is to treat spirituality and religion as intensely personal and not appropriate for engagement from the outside. When faced with a situation where the topic of spirituality cannot be avoided, such as when a patient’s request for medically inappropriate care stems from a religious justification, this default stance of avoidance cannot be maintained, but we are generally poorly equipped to engage with spirituality that is not our own. These situations demand that we engage with patient spirituality, but we must be mindful of our obligation to respect patient beliefs and not impose our religious beliefs on others.

The academic field of religious studies can provide a helpful model of constructive, respectful engagement with spirituality that is not shared. Religious studies conceives of itself as a humanistic discipline and approaches religion and spirituality as human activities that are directed to human ends. Religion and spirituality can therefore be studied by outsiders. Religious scholars seek to understand and ex- plain religious phenomena as parts of human cultures. Looking at religion and spirituality as cultural phenomena means that engaging with them is fundamentally similar to engaging with other aspects of a patient’s culture that is different from our own. It requires respectful listening to the other person and an earnest effort to understand how a spiritual belief or practice fits into their life.

One helpful metaphor in this endeavor is to think of a person’s religion or spirituality as a toolbox, containing tools that they use to navigate life.¹⁸ The tools may not form a coherent system (there may be some metric wrenches and some English unit wrenches), but they belong together in the toolbox because they serve some purpose. It is only by observing how someone uses the tools that we come to know what the tool is for (a screwdriver in a toolbox might be used primarily to open paint cans rather than for screws). There may be tools in the toolbox that are not currently being used but could be helpful in a given situation (the Phillip’s head screwdriver may be lying in the bottom of the box while the user struggles with a flathead screwdriver on a Phillip’s head screw).

Just so, an individual’s religion or spirituality may contain incongruous or even contradictory elements that have each proved useful in different situations. From the outside we cannot necessarily deduce or predict how one aspect of a patient’s spirituality leads to another. Instead, we must observe how the patient deploys their spirituality to understand it. Finally, the patient may have untapped resources within their spiritual toolbox that chaplains or religious leaders from their communities can help them discover.

Conclusion

Routine spiritual screening and exploration begins to bridge the gap as well as heal the wounds of our inhospitable medical culture. Understanding our patients’ fears and religious and/or spiritual sources of support is also critical, as is honest prognostication, delivered with compassion. Redirecting those with unrealistic miracle wishes to harsh prognostic realities with spiritual reframing requires that we step into the scary or unfamiliar place alongside our patients and families with hospitality.

Incorporating their bipartite theological anthropologies (when appropriate) can help. Recognizing their spiritual struggles—as well as when spiritual care experts, such as local faith community leaders or chaplains can help—also promotes whole-person healing. Finally, we must never underestimate the power of presence. This requires that we completely subsume our “fix-it” mindset¹⁹ and simply listen. Supporting patients and their loved ones with active, engaged empathic listening by its very nature cultivates healing and provides compassionate holistic care.^4,5,20

Key Takeaways.

• When spirituality is ignored, patients are devalued and depersonalized, rapport and trust is hindered, and a hostile-rather than hospitable-environment is promulgated, promoting further suffering.

• Respectful whole-person patient-centered care requires spiritual screening, engaged, active listening, and big- picture prognostic truth-telling while promoting hope.

• Tools for honoring patient spirituality when the surgeon does not share their spiritual orientation or religious commitments are illustrated.