Cultural competency, autonomy, and spiritual conflicts related to Reiki/CAM therapies: Should patients be informed?

Abstract

The use of complementary and alternative medicines (CAM) such as Reiki is on the rise in healthcare centers. Reiki is associated with a spirituality that conflicts with some belief systems. Catholic healthcare facilities are restricted from offering this therapy because it conflicts with the teachings of the Catholic Church. However, hospitals are offering it without disclosing the spiritual aspects of it to patients. This article will address the ethical concerns and possible legal implications associated with the present process of offering Reiki. It will address these concerns based on the Joint Commission's Standard of Cultural Competency and the ethical principles of autonomy and informed consent. A proposal will also be introduced identifying specific information which Reiki/CAM practitioners should offer to their patients out of respect of their autonomy as well as their cultural, spiritual, and religious beliefs.

Introduction

The use of complementary and alternative medicine (CAM) is on the rise. According to the National Health Statistics Report “in 2007, almost four out of 10 adults (38.3%) had used some type of CAM therapy in the past 12 months” (Barnes, Bloom, and Nahin 2008, 4). CAM consists of various non-conventional/non-Western types of therapies or practices which can be offered with (complementary) or without (alternative) conventional medicine (National Center for Complementary and Alternative Medicine 2012a). Some examples of CAM therapies include Reiki, yoga, and therapeutic touch (TT).

Reiki is a type of CAM associated with spiritual practices which according to the United States Conference of Catholic Bishops (USCCB) conflicts with Christian beliefs (United States Conference of Catholic Bishops 2009a). In March 2009, the USCCB issued a document, Guidelines for Evaluating Reiki as an Alternative Therapy, prohibiting Reiki from being offered by any healthcare facility, retreat center, or persons representing the Catholic Church (United States Conference of Catholic Bishops 2009b, sec. 12). Other hospitals are not obligated to follow these guidelines. O'Reilly in American Medical News indicated that at least one in five hospitals offer Reiki (O'Reilly 2011). Patients, however, may not be informed of the spiritual aspects associated with it. Should they be? Could lack of disclosure regarding the spirituality associated with Reiki interfere with respecting a patient's right to make an “informed” and autonomous decision when choosing healthcare options? This article will address this question based on the principles of autonomy and informed consent; the Joint Commission's Cultural Competency Standard of Care no. RI.01.01.01; and the Standards of Practice for Culturally Competent Nursing Care (nn. 3 and 5). A proposal will be introduced identifying the need to develop a spiritual consent form disclosing specific information which Reiki/CAM practitioners should offer patients out of respect for their autonomy as well as their cultural, spiritual, and religious beliefs/practices.

What Is Reiki?

Definitions from various origins are offered to present the various views regarding Reiki and help eliminate concerns related to religious or medical biases associated with Reiki. The National Center for Complementary and Alternative Medicine was established by the Federal Government to define and monitor research developments regarding the various CAM therapies and products (National Center for Complementary and Alternative Medicine 2012b). It defines Reiki as a type of CAM that utilizes an energy form of healing derived from an Eastern belief system (National Center for Complementary and Alternative Medicine 2012c). Pamela Miles, a published Reiki master, defined Reiki as a healing technique that is based on spirituality and directed towards healing the body, mind, and spirit (Miles 2006). The Reiki Foundation, an international association for Reiki, identified Reiki as originating from the “Buddhist traditions of Shingon and Tendai. … Many of our members, students, and affiliates have come to Dharma through the pathway of Reiki” (The Reiki Foundation n.d.(a)).

Mikao Usui, a Buddhist monk born in Japan on August 15, 1865, was responsible for discovering Reiki and establishing clinics offering it as an Eastern healing therapy. He studied Tendai and Shingon Buddhism, as well as kiko, a Japanese technique of utilizing “life energy” for healing (Rand 1998). After a critical illness in the 1900s, he claimed he received visions and directions regarding methods of healing from Mahavairocana Buddha, the Great Central Buddha. This led him to seek out knowledge about “the esoteric science of healing as taught by Buddha…and energy disciplines that focus on the use of ‘ki’” (The Reiki Foundation n.d.(b)). He claimed he discovered the healing powers of “ki” energy during a 21-day retreat on Mt. Kurama, after he used it on himself to heal his injured toe (Rand 1998). Usui practiced and developed this method of healing based on his study of Buddhism's healing disciplines, and called it the Usui Reiki healing technique (Rand 1998, 19).

Although he died on March 9, 1926, before Reiki was utilized in the United States, his method of healing still continues to be utilized internationally (Rand 1998, 20). This was due to Mrs. Takata, a Hawaiian native, who brought Reiki to the United States after claiming she was healed through a series of Reiki treatments offered at a Japanese hospital (Rand 1998, 21). Following this experience, she received Reiki training at a clinic which utilized a form of Usui's Reiki methods. On February 21, 1938, she became a Reiki master and began to train others on how to use Reiki on others throughout the United States (Miles 2006). The information supplied thus far regarding the origin of Reiki and its founder suggests that Reiki is linked to Buddhism.

How Are Reiki Practitioners Trained?

In order to become a Reiki practitioner, students must attend an attunement ritual led by a Reiki master. The attunement ritual is a spiritual ceremony that involves channeling Reiki energy from the Reiki master to the student while tracing invisible “sacred” symbols on their heads or hands (Rand 1998, 5, 45–46). The International Center for Training describes the process as one that is attended not only by students and the Reiki master but also by spirit guides (The International Center for Reiki Training n.d.). O'Mathuna and Larimore identified spiritual concerns associated with the spirit guide based on Christian beliefs that “contacting spirits is denounced in the Bible as sorcery, mediumship, and spiritism (Lev 19:26, 31; 20:6; Deut 18:9–14; Acts 19:19; Gal 5:20; Rev 21:8)” (O'Mathuna and Larimore, 2006). The symbols traced on students’ heads represent a covenant between a Reiki practitioner and Reiki energy. Information regarding these symbols is secretly stored by Reiki masters because it is believed that they are sacred and need to be handled with great reverence (Rand 1998, 45–46). Students have reported having visions, messages, and an increase in psychic abilities during and after the attunement ceremony (Rand 1998, 5). Are patients aware of the spiritual nature of Reiki and how students are trained when they are offered it as a form of CAM therapy? Could this information influence the patient's choice of therapy? The reports of receiving psychic abilities along with the use of “sacred” symbols to obtain power or “energy” during the spiritual attunement ceremony should be of concern to Catholic patients because it conflicts with their faith. The Catechism of the Catholic Church, numbers 2115 and 2116 clearly reject any form of occult practices or divination (Catechism of the Catholic Church 1995).

What Are Hospitals Disclosing to Patients?

The Center for Reiki Research identifies hospitals and clinics that offer Reiki (Center for Reiki Research 2003). The Memorial Sloan-Kettering Cancer Center in New York is on this list and confirms on their website that they offer Reiki. They describe Reiki as a gentle touch therapy that is used to aid in stress reduction as well as physiological and emotional well-being, but do not indicate that it is associated with spiritual practices (Memorial Sloan-Kettering Cancer Center n.d.). MetroHealth System, located in Northeast Ohio and affiliated with the Case Western Reserve University School of Medicine, offers Reiki and discloses on their website that their practitioners are volunteers who are trained in Reiki levels I, II, and III (master level), but does not indicate how they are trained (Metro Health n.d.). Portsmouth Regional Hospital offers specific details regarding the history of, origin of, and research related to Reiki. In addition, they indicate that Reiki practitioners are trained during an attunement process where they are taught the various hand positions used during a session; however, they do not indicate that it is a spiritual ritual involving the transferring of energy from a Reiki master to the student (Portsmouth Regional Hospital n.d.). Is this full disclosure? Are patients being informed that there is a lack of adequate research to indicate its effectiveness or safety because of the inconsistent results obtained from various studies? (National Center for Complementary and Alternative Medicine 2012c) This information is easily retrieved from NCCAM, the federal agency that is officially assigned to define CAM therapies and products; monitor research developments performed using CAM therapies; and identify the benefits and risks associated with them (National Center for Complementary and Alternative Medicine 2012d). Information regarding the lack of sufficient research on Reiki does not appear evident on the hospital websites identified in this article. Could this be considered lack of full disclosure and thereby affect a patient's ability to make a fully informed and autonomous decision when choosing CAM therapies?

Another concern related to Reiki is the issue of licensure and certification. According to the NCCAM, “no licensing, professional standards, or formal regulation exists for the practice of Reiki….No special background or credentials are needed to receive training” (National Center for Complementary and Alternative Medicine 2012e). Individual states are responsible for setting guidelines regulating CAM therapies. Some states require a license for some CAM practitioners, but none require it for Reiki (National Center for Complementary and Alternative Medicine 2012f). In April 2000, the Federation of State Medical Boards developed “Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice” for physicians who offer CAM or who refer patients to CAM providers (Board on Health Promotion and Disease Prevention 2005). The guidelines were developed to help ensure that standards utilized in conventional treatments were being followed in the use of CAM therapies. The board emphasized the importance of utilizing “informed consent,” and of reviewing with patients the potential or actual risk and benefits associated with CAM. However, they did not identify a need to reveal the “spiritual risks” that could be involved.

Cultural Competency

Should the Spiritual Aspects of Reiki Be Disclosed?

The Joint Commission (TJC) standard of care (January 1, 2012) RI.01.01.01 obligates hospitals to safeguard patient's cultural, spiritual, and belief systems when offering medical therapies to patients (The Joint Commission 2012a). It states that patients’ cultural, spiritual, and belief practices can affect their “perception of illness and how they approach treatment” (The Joint Commission 2012b). This standard confirms the need for patients to be informed of the spiritual aspects of Reiki because it conflicts with belief systems that could affect a patient's healing process. Are healthcare practitioners and facilities aware that some CAM therapies such as Reiki, conflict with patients’ spirituality or belief practices? Should they have this knowledge before offering it to their patients?

There are standards of practices that could confirm the need for healthcare facilities, as well as nurses who offer CAM, to be aware of the spiritual aspects of these therapies before offering them to their patients. Nurses are among the most frequent administers of Reiki because it is considered a therapeutic intervention that they can offer their patients without the need for a physician's order (Synder and Lindquist 2001). They are obligated by the Standards of Practice for Culturally Competent Nursing Care (n. 3) to be knowledgeable as well as supportive of their patients’ spirituality and belief systems (Expert Panel on Global Nursing & Health 2010, 7). Cultural Competence in Healthcare Systems and Organizations Standard, n. 5, states that a hospital's responsibility is to maintain cultural competency by offering their staff education about the various cultures included in the population they serve (Expert Panel on Global Nursing & Health 2010, 8–9). In 2010, TJC suggested that hospitals remove religious objects in a patient's room or cover them if they conflict with a patient's “cultural, religion, or spirituality” (The Joint Commission 2010, 21). The Standards of Practice for Culturally Competent Nursing Care, combined with TJC's standard RI.01.01.01, supports the need to disclose the spiritual aspects of Reiki to patients in order to enable them to make a fully informed and autonomous decision when choosing healthcare options.

Are There Other Spiritually Linked CAM Therapies?

Reiki is not the only type of CAM therapy that is connected with religious or specific belief systems. The Pontifical Council for Culture and the Pontifical Council for Interreligious Dialogue identified others, such as yoga and TT, as being linked to New Age practices that conflict with the teachings of the Catholic Church (Pontifical Council for Culture & Pontifical Council for Interreligious Dialogue 2003). Yoga was included in the top ten most frequently used CAM therapies by adults, according to the 2007 National Health Statistics Reports (Barnes et al. 2008, 4). The NCCAM defined yoga as “a mind and body practice with origins in ancient Indian philosophy” (The National Center for Complementary and Alternative Medicine 2013). It is often associated with exercise, but those who practice Hinduism claim that it is also spiritual in nature. Medin reported on an interview conducted with three gurus regarding yoga, and discovered that the goal of it is to purify and control one's mind and senses (Medin 2004). Many disagree that the origin or affiliation of yoga is connected to any specific religion or belief system. However, those who practice Hinduism are actually concerned that their beliefs and ties to yoga are being ignored. In fact, in 2010, there was a group so concerned that yoga was being detached from Hinduism that a campaign titled “Take Back Yoga” was developed to make all people aware of its roots in Hindu beliefs (Vitello 2010).

TT is a type of CAM therapy that resembles Reiki. It utilizes the same belief in the existence of an inner energy that when blocked, produces illnesses. Those who administer TT claim that they are able to manipulate this energy known as “prana,” in order to bring about healing or relief from symptoms caused by an illness (O'Mathuna and Larimore 2001). Dolores Krieger and Dora Kunz were responsible for developing the technique (Samarel 2006). They based TT on their own beliefs associated with Buddhism and Theosophy (Samarel 2006, 262). Despite the connections that Reiki, yoga, TT, and possibly other CAM therapies may have with specific spiritual or religious practices, patients are not informed. How can healthcare facilities and their practitioners support the ethical principles of autonomy and informed consent without disclosing information about the spiritual dimensions of CAM?

Autonomy and Informed Consent

Autonomy is demonstrated when a patient makes a decision based on a “substantial degree of understanding and freedom from constraint” (Beauchamp and Childress 2009, 101). Could lack of disclosure regarding the spiritual aspects of Reiki be considered a restraint or barrier, preventing patients from making truly informed and autonomous choices? Informed consent is a process that supports the patient's autonomy, enabling a person to freely choose healthcare options. There are three aspects to this process: patient competency and decision-making capacity; disclosure of risks and benefits, as well as identifying possible alternatives (Sugarman 2003). This article's primary concern is the need for practitioners to disclose the “spiritual” risks associated with Reiki. Sugarman agrees that the spiritual aspect of some CAM therapies should be included in the informed consent process, because it may conflict with some patients' beliefs (Sugarman 2003, 248). It was interesting that he made this suggestion even before the USCCB developed their report on the spiritual conflicts between Reiki and Christian beliefs in March 2009. Despite Sugarman's suggestion, there is no indication, at least among the hospitals identified in this article, that spiritual aspects of Reiki are disclosed to patients. Even basic information regarding the risks and benefits associated with CAM therapies (Reiki) may not be addressed adequately. Caspi, Shalom, and Holexa conducted an interview in 2011 of twenty-eight CAM practitioners who offered a variety of CAM therapies. The results demonstrated: inconsistent disclosure of information; suggestions of therapies based on opinions versus specific standards or studies; and a lack of concern about obtaining informed consent. Spiritual components of CAM were not identified as risks or benefits. In addition, many practitioners indicated that they often elected not to focus on the risk of CAM with patients, due to concerns that it would interfere with their healing (Caspi, Shalom, and Holexa 2011). Could this be interpreted as a paternalistic viewpoint?

Lack of Spiritual Disclosure and Liability

Could physicians be held liable if they refer a client to a CAM practitioner (i.e., Reiki master) without obtaining an informed consent that includes the risks and benefits of the therapy? (Cohen and Eisenberg 2002). In 1957, the courts in the Slago v. Leland case ruled that they can be liable if they omit facts that are necessary for patients to make an informed decision when choosing health treatments.¹ Cohen and Eisenberg (2002) identified a potential malpractice liability risk associated with CAM that dealt with the degree of benefits compared to the potential risks reported in evidence-based studies. They emphasized that if the evidence does not support a high degree of benefits associated with a particular CAM therapy, there may be reason to be concerned about a liability claim (Cohen and Eisenberg 2002). There was no discussion of the actual risks or benefits associated with CAM, nor did they differentiate between physical, emotional, and “spiritual” risk.

Berg, Appelbaum, Lidz, and Parker indicated that a decision–causation rule can be applied if it is determined that a patient would have changed a decision if he or she were fully informed regarding the spiritual aspect of Reiki. Terry Ruhl, M.D., identified a concern regarding the spiritual aspects of some CAM therapies and emphasized, “one should not introduce a therapeutic method with spiritual implications to a religious patient without informing the patient of potential conflicts” (Ruhl 2002).

The National Council Against Health Fraud posted an article by William Jarvis, Ph.D., regarding Reiki. He also agreed that patients should be fully informed of the spiritual aspects of Reiki, since it can conflict with patients’ beliefs (Jarvis 2000). Jeremy Sugarman, M.D., a professor of bioethics and medicine at John Hopkins Berman Institute, is responsible for intensive contributions dealing with ethical issues associated with informed consent (John Hopkins Bloomberg School of Public Health n.d.). He agreed that physicians should obtain informed consent when offering alternative therapies such as Reiki, especially if the therapy is associated with risk (Sugarman 2003). Is the spiritual risk associated with Reiki substantial enough to warrant its disclosure in the consent? Who decides if it is? TJC stated that patients’ spirituality was important and emphasized that it should be respected, not ignored (The Joint Commission 2012a). Studies have also been conducted which demonstrated its importance in relation to health. McCord et al.'s (2004) study of 921 adults discovered that 87 percent wanted their physician to discuss spirituality and 62 percent thought that it may affect their treatment. Yuen, in The American Journal of Medical Quality, identified the importance of understanding the difference between religion and spirituality. She emphasized that religion was associated with a particular set of beliefs whereas spirituality was more of an individual's independent search for something divine, but not necessarily linked to a certain belief system. She also stressed that spirituality is an important aspect of healing and should be respected (Yuen 2007). Koenig, George, and Titus (2004) studied the importance of religion and spirituality for elderly patients who were hospitalized. Their study also confirmed the correlation and importance of patients' religious beliefs, spirituality, and the healing process.

Proposal for a Spiritual Consent Form

Practitioners and healthcare facilities that offer Reiki may not be aware of the spiritual conflict attached to this therapy or the pertinent information that should be disclosed when offering it. A spiritual consent form could help prepare the practitioner to disclose specific information regarding Reiki or other spiritually associated CAM therapies. It would also help ensure that all patients are given the same basic information obtained from specific resources, such as the NCCAM and the USCCB.

Suggestions on what should be disclosed in a spiritual consent form when offering Reiki include: identifying the spiritual origin of Reiki; discussing how Reiki practitioners obtain energy from a Reiki master; reviewing how Reiki students are trained via a “spiritual” ritual (attunement); and offering information regarding Reiki. This author also suggests offering the USCCB's guidelines regarding Reiki and how it conflicts with Christian beliefs. The USCCB's guidelines are referred to in the spiritual informed consent form provided (Figure 1), which could also be used or other CAM therapies associated with spiritual or religious beliefs/practices. Utilizing a spiritual informed consent form will assist hospitals and healthcare practitioners to respect the spiritual and religious beliefs of their patients, while abiding by the standards of TJC and cultural competency for nursing care. Respecting patients’ cultural, spiritual, and religious beliefs facilitates the healing process, according to TJC (The Joint Commission 2010, 21). Is not medicine's goal to facilitate healing, to do no harm (nonmaleficence) and promote benefits (beneficence)?

Figure 1.

Spiritual Consent Form for CAM Therapy Treatment

Patient's Name (please print):__________________________________

Type of CAM therapy (circle one): Reiki, TT, yoga, other ______________________

Practitioner's Name (please print):__________________________________

Credentials/License (Circle one or NA). Name of Institution of Training ________________________ (NOTE): If a spiritual attunement or initiation was involved, offer a brief description of the process to the patient including how the energy is obtained- transferred from a Reiki master; use of sacred symbols and the presence of spirit guides._________ Identify the spiritual or religious origin of the therapy offered- (circle one) Buddhism, Hinduism, Catholic, Other.

Offer websites to allow the patient the opportunity to further research CAM therapies (check one or both)

National Center for Complementary and Alternative Medicine (NCCAM) __________________http://nccam.nih.gov/health/whatiscam

United States Conference of Catholic Bishops website, Guidelines for Evaluating Reiki as an Alternative Therapy ________

http://www.usccb.org/comm/archives/2009/09-067.shtml

I (Signature required):___________________have been informed of the spiritual aspects and specific beliefs and/or religions associated with _____________ (Identify the CAM therapy). The practitioner identified their credentials/license and/or training associated with the CAM (note: not all states obligate CAM practitioners to obtain credentials or a license to administer CAM). Information regarding the CAM practitioner's training was offered. The practitioner gave a brief explanation of what the attunement process/ritual involved: its association with spirit guides, sacred symbols and the transferring of energy from a Reiki master. Material/websites from both (NCCAM) and the USCCB were offered.

Witness (Signature required):____________________________________________

Conclusion

The evidence offered in this article (standards of cultural competency, standards to safeguard patient's spirituality and beliefs identified by TJC, and the USCCB's document on Reiki) support the need for healthcare practitioners to supply patients with information pertaining to the spiritual aspects of Reiki. If hospitals or Reiki practitioners are unaware that Reiki conflicts with certain belief systems, such as the Catholic faith, they should seek out knowledge to educate themselves according to the Cultural Competence in Healthcare Systems and Organizations Standard No. 5. The hospitals identified in this article offer information regarding Reiki, but they do not include details regarding the spiritual aspects of it and how it is obtained through a spiritual ritual. One hospital offered information that Reiki practitioners were trained in hand positions during an attunement process. However, they did not indicate that this process is actually a spiritual ritual versus a classroom session. This author's belief is that this information could affect patients’ decisions when considering Reiki.

Hospitals are already familiar with how a religious belief can interfere with healthcare options when offering blood products to Jehovah Witness patients. They have policies that address this issue, and how best to administer care to patients while safeguarding their patients' religious and spiritual beliefs as well as respecting their autonomy. Perhaps a similar policy needs to be developed to address the spiritual concerns related to Reiki, yoga, TT, and other CAM therapies which are associated with spiritual or religious practices. These therapies may conflict with Christian spiritual/religious beliefs and practices. This will enable them to abide by the Standards of Cultural Competency as well as the standards developed by TJC regarding patients’ rights.

Biography

Maria Marra Arvonio, R.N., B.S.N., M.A. Ms. Arvonio is a graduate student of the Institute of Catholic Bioethics, St. Joseph's University, Philadelphia, Pennsylvania. Her email address is: elishaspirit2003@yahoo.com.