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Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine
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Spirituality and Medicine: IdiotProofing the Discourse

Nancy Berlinger
a a

The Hastings Center , Garrison, NY, USA Published online: 16 Aug 2010.

To cite this article: Nancy Berlinger (2004) Spirituality and Medicine: Idiot-Proofing the Discourse, Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, 29:6, 681-695 To link to this article: http://dx.doi.org/10.1080/03605310490883037

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Spirituality and Medicine: Idiot-Proofing the Discourse

Nancy Berlinger
The Hastings Center, Garrison, NY, USA

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The field of spirituality and medicine has seen explosive growth in recent years, due in part to significant private support for the development of curricula in more than half of all U.S. medical schools, and for related residency training programs and research centers. While there is no single definition of spirituality in use across these initiatives, this article examines the definitions and learning objectives relevant to spirituality that are addressed in a 1999 report of the Medical School Objectives Project (MSOP), with special attention to their ethical implications. It concludes with several diagnostic case studies of religious consciousness from the medical literature and in literary texts, again with attention to ethical concerns. Keywords: bioethics, literature and medicine, medical education, religion and medicine, spirituality and medicine

I. INTRODUCTION Wrestling with this thing called spirituality and its relationship to that thing called religionand with what these terms have to do with that other thing called clinical medicineinvolves thinking about concepts that for centuries mystics have filed under the category of apophatic: things that can be grasped only through negation, by stating what they are not. While Americans may be familiar with that contemporary apophatic catchphrase, Im not religious, Im spiritual, this formulation fails to shed light on what spirituality is, much less on what its role ought to be in the clinical setting and in medical education. To bioethicists, humanities scholars, and social scientists who study religion, and to some clinicians as well, the discourse of the present-day spirituality and medicine movement is both intriguing and troubling. What are the sacred texts and honored practices of this movement, particularly with respect to the
Address correspondence to: Nancy Berlinger, Ph.D., M.Div., Deputy Director and Associate for Religious Studies, The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 105245555, USA. E-mail: berlingerm@thehastingscenter.org

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increasingly formal inclusion of spirituality in medical school curricula? Which definitions of spirituality are promoted, and which are excluded, suppressed, or attacked, in this discourse? Which tenets of the spirituality and education movement are verifiable, and which are matters of faith? Which concepts are clearly and consistently articulated, and which are conflated or inconsistent? And what are the possible consequencesfor the physician-patient relationship and the care of the sickof formally incorporating spirituality into medical education and clinical practice? In examining this discourse, the intent of this article is not to suggest that there is a universal or normative definition of spirituality that should be adopted within medical education and practice. Such a project is outside the scope of this exercise. There are simply too many ways to define spirituality, both within religious traditions as well as in opposition to or isolation from them, and too many different cultural contexts to consider, including contexts in which the term spirituality is never used to characterize dimensions of human experience that an observer from another cultural context might describe as spiritual. Rather, the intent of this article is to identify the ethical concerns that are attendant upon any discussion of spirituality within the culture of clinical medicine, including the incorporation of this term into formal curricula and related practices. These ethical concerns may not apply to all discussions of spirituality within the context of the care of the sickfor example, within families or in pastoral care, where there may be greater consensus around definitions, language, practices, and expectations relevant to spirituality than is possible within the complex and heterogeneous environment of a health care institution. But because of this complexity and heterogeneity; because of the inherent imbalance of power in the relationship between a hospitalized patient and a professional caregiver; and because spirituality is not a synonym for ethics, thinking constructively about spirituality as a dimension of humanistic medicine requires thinking through the ethics of spirituality as a dimension of the clinical encounter. Concerning terminology, it is worth noting at the outset that all spirituality and medicine discourses do not use this particular phrase, or intend to signify the same thing by linking these two words. As medical anthropologist Simon Lee has written concerning the role of spirituality (and religion) in the healthcare setting, Spiritual is a label strategically deployed to extend the realm of relevance to any patients belief system, regardless of his or her religious affiliation...Such a secularized professional practice is necessary to demonstrate

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the relevance and utility of spiritual care for all patients in an era of costcontainment priorities and managed care economics (Lee, 2002, p. 339). While the secularized professional practice Lee studied was that of hospital chaplaincy and Clinical Pastoral Education (CPE), his observation may also be relevant to one of the ways in which the word spiritual is strategically deployed within clinical medicine and medical education. (This particular strategy may, with apologies to Foucault, be summarized as follows: I who conduct this discourse am not conducting a religious discourse, and I am not promoting religion.) An explanation of the title may also be helpful, lest the unwary reader assume that the subject is something like spirituality and medicine for dummies. As will be discussed in the final section, Dostoyevskys idiot, Prince Myshkin, has long been, and continues to be, an influential case study of spiritualized pathology, or perhaps pathologized spirituality. The title is intended to suggest that those of us who seek to improve the care of the sick by paying attention to this thing called spirituality may need to idiot-proof our own discourse from time to time: that is to say, closely inspect it for received, romantic, or reified notions about spirituality and how it is expressed within the context of illness.

II. SPIRITUALITY AS MEDICAL SCHOOL LEARNING OBJECTIVE According to a survey reported by the Association of American Medical Colleges (AAMC) in 2000, approximately 70 medical schools in the United Statesmore than half of the totaladdress issues of spirituality in their curricula (Duenwald, 2002; Gabriel, 2000). Since 1995, approximately half of these 70 medical schools have received grants from a single private funder, the John Templeton Foundation, to support the creation of spirituality and medicine curricula.1 The Templeton Foundation also co-sponsors an annual conference on spirituality and medicine for medical educators, and underwrote the work of an AAMC task force on Spirituality, Cultural Issues, and End of Life Care whose conclusions were included in the 1999 Medical Schools Objectives Project (MSOP) Report III on Communication in Medicine.2 Another AAMC task force is currently developing Parameters for Incorporating Spiritual and Cultural Needs Assessments into Medical Treatment Plans. According to the 1999 MSOP III report, which identified learning objectives relevant to spirituality that students are required to master, spirituality is

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found in all cultures and societies and is expressed in an individuals search for ultimate meaning through participation in religion and/or belief in God, family, naturalism, rationalism, humanism, and the arts (AAMC, 1999, p. 25). Because spirituality is recognized as a factor that contributes to health in many persons (p. 25), among the explicit outcome goals of medical education are for students to be aware of the need to incorporate awareness of spirituality . . . into the care of patients in a variety of clinical contexts, and to recognize that their own spirituality . .. might affect the ways they relate to, and provide care to, patients. These goals are to be met through the completion of learning objectives that include, among others, the ability to take a spiritual history, demonstrate knowledge of research data on the impact of spirituality on health and on health care outcomes, and show an understanding of their own spirituality and how it can be nurtured as part of their professional growth (p. 26). While several other learning objectives in the MSOP III also address spirituality, religion, or related aspects of culture, this article will focus on discourses relevant to the methodology of the spiritual history, to research data on spirituality, and to the spirituality of medical students themselves. The learning objective concerning the spiritual history refers to a tool developed by Christine Puchalski, M.D., director of the George Washington (University) Institute for Spirituality and Health (G-WISH) (Puchalski, 2003; Puchalski & Romer, 2000). In taking a spiritual history, clinicians ask patients questions such as Do you consider yourself spiritual or religious? What gives your life meaning? What importance does your faith or belief have in [y]our life? What role do your beliefs play in regaining your health? Are you part of a spiritual or religious community? Is there a group of people you really love or who are important to you? How would you like me, your healthcare provider, to address these issues in your healthcare?3 The learning objective concerning research data on spirituality appears to refer to empirical research conducted by Harold Koenig, M.D., and his colleagues at Duke University Medical Center, who have conducted many studies of the effects of religious belief, practices, and observance on physical and psychological health and on health outcomes (1998, pp. 925932) among them the much-debated MANTRA (Monitoring and Actualization of Noetic TRAinings) study of the health effects of intercessory prayeras well as similar studies conducted by clinical researchers at other institutions.4 Attention to the personal spirituality of medical students and clinicians has been the focus of the influential work of Rachel Naomi Remen, M.D., of the School of

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Medicine at the University of California at San Francisco, whose curriculum The Healers Art, which is taught at UCSF, Harvard, Yale, Stanford, and other medical schools, seeks to remedy the hidden crisis in medicine, the growing loss of meaning and commitment experienced by physicians nationwide (Remen, 2003). However, each of these learning objectives of a contemporary American medical education may fairly be described as controversial. The most controversial of the three is the reliability of the research data on the relationship between spirituality and health, and the implications of these data for the teaching and practice of medicine. Richard P. Sloan, Ph.D., a psychologist at Columbia University, is the best-known critic of this research agenda and what he argued are the faulty methodologies and selective interpretation of inconclusive data by Koenig and other clinical researchers who claim to have identified causal links between spiritual practices and health (Sloan & Bagiella, 2001; Sloan & Bagiella, 2002; Sloan, Bagiella, & Powell, 1999). Critics of this research argue that these studies are designed to find rather than test causality; that data are selectively interpreted; and that, as physician, medical ethicist, and Franciscan friar Daniel Sulmasy has noted, attempts to quantify the Infinite are conceptually flawed (2003). Even the less controversial studies, such as those that compare the longevity of churchgoers to that of nonchurchgoers,5 may hold up methodologically, but could be applied inappropriately. An epidemiologist who led a levelsof-evidence review of these and other methodologically sound studies on the relationship between religion and health was persuaded that church/service attendance confers some generalized type of protection against mortality (Powell, Shahabi & Thoresen, 2003, p. 48). (This scientist, Lynda H. Powell, was more effusive when interviewed by a reporter from Newsweek, whose cover promoted the article with a title that itself speaks to the discursive ambiguities attending this topic: God & Health: Is Religion Good Medicine? Why Science Is Starting to Believe (Kalb, 2003, pp. 4456). The finding that people who attend worship services live longer than those who dont, Powell said, blew my socks off (p. 48).) Yet Sulmasy, who agreed that the longevity studies are methodologically sound, cautions that they are of no prescriptive value to patients who dont already go to church regularly, and that the studies dont tell us enough about these particular research subjects to allow us to conclude that participants in any form of organized worship will live longer than those who attend, in Garrison Keillors phrase, the church of the brunch. Sulmasy (2000) also warned that it would be morally inappropriate,

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as well as scientifically unsound, to tell patients who want to live longer that they ought to start going to church. The Koenig-Sloan controversy, and related studies and critiques (Levin, 1994, pp. 14751482) have led to spirited exchanges in the major medical journals (Koenig et al., 1999, pp. 123131). They have also led to dismissals or over-corrections of one position by the defenders of another. Depending on which article one is reading or which conference one is attending, the connection between spirituality and medicine is clinically proven, presumed, possible, debatable, unproven, unknowable, hazardous, or downright harmful. This aspect of the discourse of spirituality and medicine has even been lampooned in the BMJs famous Christmas issue. A few years ago, a team of researchers in Israel published the results of their double-blind randomized control trial of remote, retroactive intercessory prayer, in which patients admitted to a university hospital for treatment of blood infections in the early to mid 1990s were prayed for in 2000 (Leibovici, 2001, 14501451). When the old charts were pulled, approximately half of these patients were found to have recovered, thus proving that prayereven when applied retroactivelyheals. The practice of taking and charting a patients spiritual history has also been criticized, by clinicians and by theologiansand sometimes by both in the same articleas intrusive or coercive, particularly if a clinician combines the spiritual history exercise with a recommendation to participate in religious activities (Sloan et al., 2000, pp. 19131916) or, in endeavoring to provide spiritual care to patients, appropriates a role usually associated with professional hospital chaplains or other clergy (Lawrence, 2002, p. 7476).6 Some of these critics have also advanced a theological critique of spirituality and medicine discourses that present religious spirituality as merely instrumental to health. In their recent book, Heal Thyself: Spirituality, Medicine, and the Distortion of Christianity (2002), authors Joel James Shuman and Keith G. Meador argued that the contemporary reemergence of the longstanding idea that physical health corresponds to the health of the spirit has its basis less in theological conviction than in therapeutic utility, and, that disputes over the reliability of the empirical data asidethis utilitarian approach to religion will get you into trouble in more ways than one (2003, p. 16). First, because of the distastefulness of the underlying premise that we can make God jump when we want somethingor that God will observe our research protocols and take no notice of those patients in the control group who arent being prayed for. Second, because making a religion of health creates

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an idolatry of self. If were speaking vaguely about spirituality as a synonym for wellness, this doesnt matter much, but it does point up a serious conceptual problem within spirituality and medicine discourses in which the teleology of religious belief, practice, or observance is presumed to be the bodily health of the believer. Another critique of what he terms the witches brew of spirituality and medicine is offered by Raymond Lawrence, a chaplain at New YorkPresbyterian Medical Center. In a recent article in a medical journal, Lawrence characterized the proposal that overworked physicians should [take] spiritual histories as supremely unrealistic from the perspective of institutional time and budget pressures alone (Lawrence, 2002, p. 74). Will management, he asks, really encourage doctors to undertake the major new time-consuming task of examining patients spirituality with no way to bill for the time involved? (p. 74) Or, we might ask, will management direct medical students and trainee chaplains to take on this task, given that graduate medical education, including clinical pastoral education, is Medicare-reimburseable (Lee, 2002, p. 342)? Concerning the medical school learning objective that addresses the spirituality of physicians themselves, National Public Radio recently broadcast a commentary by a student who completed The Healers Art course at Harvard Medical School, in which he explored his uneasiness with the idea that medicine itself is a spiritual practice: . . . focusing on spirituality in medicine carries the risk of creating a church of the doctor . . . I fear who I might become if I call myself a healer or try to assume any special spiritual role. Arrogance was the demon of past generations of doctors. I dont want my generation to replace it with piety (Block, 2003).

III. SPIRITUALITY AND MEDICINE: ETHICAL CONCERNS The confusing and controversial status of spirituality and its less-than-identical twin, religion, in medical education appears to have great deal to do with underlying, perhaps unacknowledged, conceptual paradigms and how they are expressed through language, definitions, and methodological tools, by advocates, critics, and skeptics on all sides of the debate. For example, it is abundantly clear that the terms spirituality and religion are still frequently conflated, by researchers, clinicians, educators, and commentators, contributing

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to misunderstandings and frustrations on all sides. As behavioral psychologists Carl Thoresen and Alex Harris of Stanford wrote in 2002 in a special issue of the Annals of Behavioral Medicine, which was devoted to this subject: [c]larifying this distinction is a high priority because confusion about these terms obscures understanding and impedes research (Thoreson & Harris, 2002, pp. 313). At present, the research data that the MSOP III learning objectives document describes as measuring the impact of spirituality on health and on health care outcomes focuses only on religious practices, and further, on discrete practices largely identified with Western religious traditions. (As Thoresen and Harris pointed out, there is no empirical research that attempts to measure spirituality without some reference to religion.) Even if one puts to one side the significant questions about the reliability of these data and accepts a priori that there is indeed some correlation between religionwhether construed as belief, as private practices, as social practices, as membership in a caring community, or as a combination of theseand health, it is not at all clear whether educational goals, clinical norms, and ethical practices concerning the spirituality of all patients can be extrapolated from empirical data about quantifiable Jewish and Christian religious practices. Even the suggestion by one reviewer that data on the longevity of Christian churchgoers should apply to any organized religion7 is problematic if it assumes that, in developing standards for medical education and clinical practice, research on one religion can stand in for research on any religion. On the other hand, educational goals and clinical norms that conceptualize spirituality broadly as the search for ultimate meaning, may also be confusing to clinicians, educators, students, and patients alike, and may raise significant ethical questions. For example: Does respect for patient autonomy require a physician to encourage, or refrain from condemning, all beliefs and behaviors that a patient may characterize as meaningful as a way to nurture this patients spirituality, even if these beliefs and behaviors may be harmful to the health of the patient or the health of others? Drug or alcohol abuse, other addictive behaviors, anorexia, and unprotected sex may easily be described as meaningful, even as ultimate meaning, by those whose lives are constructed around these behaviors. Similarly, racist ideologies may be overtly spiritualizedin terms of Christian identity, for example and can be assumed to be deeply meaningful to those who hold these beliefs.

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Should a physician encourage patients to embrace beliefs or practices that the physician characterizes as conducive to health or healing, or does this constitute coercion or proselytizing? One of the responsibilities of professional hospital chaplains is to protect vulnerable patients against proselytizing, so it is hardly surprising that some chaplains have been critical of what they perceive to be the proselytizing tendencies of some spirituality and medicine discourses. Even the argument that belief in and of itself is conducive to health, and should be encouraged, could be coercive within the physician-patient relationship. And is the patient who rejects this advice noncompliant, a bad patient?
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Similarly, Does conceptualizing the practice of medicine as a spiritual practice run the risk of sacralizing the physicians role, objectifying the patient, and increasing rather than decreasing the power imbalance between physician and patient? Does incorporating spirituality into clinical practice enrich a physicians relationship with her patients, or reify notions of right and wrong spirituality? If a physician, consciously or otherwise, defines religion as dogma and is interested only in non-religious spirituality, he or she may resistor fail to recognize expressions of spirituality that are defined in terms of religious belief. If a physician defines a religious person as someone who will accept a terminal diagnosis and have a good death, he or she may have difficulty understanding that some religious patients may fear or deny death. And if a physician has been taught to universalize where spirituality is concerned, he or she may fail to comprehend what is of ultimate meaning to a patient from a different culture, or may project her own norms concerning spirituality onto that patient. Whether spirituality, as a concept, ought to be compartmentalized into that of the patient, as captured and charted in a spiritual history, and that of the physician, as a professional, quasi-priestly role, is also an important question, given the lack of clarity concerning the meaning of this term and the ethical concerns it raises.

IV. SEARCHING FOR GOD IN PUBMED Like Alice in Wonderland, spirituality in the context of medical education, clinical practice, and clinical research currently seems to be either too small, when it is confined to activities such as praying or going to church, or too

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big, when it must stand for ultimate meaning. Extricating the discourse of spirituality and medicineor, perhaps, spirituality in medicinefrom this dualism is an ongoing project. By way of conclusion, I will return to my title and suggest some possible applications of the tools of literary and religious studiesof attention to texts and to practicesto this project of idiot-proofing, beginning, naturally, with the case of The Idiot and its creator. What many readers (and non-readers) of The Idiot know about Prince Myshkin, the sacred fool, is that he is Christ-like and suffers from epilepsy, and that his spirituality has something to do with his temporal lobe epilepsy and vice versa, a heightened religious consciousness being understood as the mark of this disorder. We find a contemporary version of Prince Myshkin in a much, much shorter novel, Mark Salzmans Lying Awake (2000). Salzman told the story of a cloistered nun, Sister John of the Cross, whose ecstatic visions of God, which she translates into poetry, filling notebook upon notebook, are diagnosed as temporal lobe epilepsy, caused by a tumor. The condition is treatable; remove the tumor, and the visions, which are triggered by the underlying neurological problem, will cease. Here is Sister John in the consulting room as she receives the diagnosis: Sister John had come prepared to hear bad news about her health, but not about the state of her soul. She knew quite well that one of the first questions asked of anyone wishing to become a cloistered nun was, Have you ever been treated for mental illness or epilepsy? If the answer to either was yes, the candidate was automatically rejected. Epilepsy was particularly feared because of its reputation for producing compelling but false visions. Doctors and clergy alike had referred to the disease for centuries as holy madness . . . From the materials the doctor had given her, she learned that temporal-lobe epilepsy sometimes caused changes in behavior and thinking . . . includ[ing] hypergraphia . . . an intensification but also a narrowing of emotional response, and an obsessive interest in religion and philosophy. The novelist Dostoyevsky...followed this model so closely that the syndrome was . . . named after him (Salzman, 2000, pp. 120121). The materials given to Sister John by her physician mention some of the other usual suspects for a diagnosis of temporal lobe epilepsy, based on this model: St. Paul, St. Teresa of Avila, Van Gogh. And, indeed, there is an intriguing body of medical literature, accessible via PubMed, that is devoted to the retroactive diagnosis of this condition in persons described in literary and historical texts. Many of these case studies involve accounts by or about

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religious figures: titles include A differential diagnosis of the inspirational spells of Muhammad (Freemon, 1976, pp. 423427), and Joan of Arc, creative psychopath (Ratnasuriya, 1986, pp. 234235). As such, these studies may offer some insight into how religiosity, as a form of religious spirituality, may be viewed by clinicians and clinical researchers. Consider the case of the prophet Ezekiel. In a recent article that appeared in a psychiatric journal, the author, a physician and neuroscientist, diagnoses Ezekiel as suffering from temporal lobe epilepsy, and even proposes him as a memory aid, a mnemonic zebra to help students and clinicians remember the signs and symptoms associated with a comparatively rare condition (Altschuler, 2002, pp. 561562). Ezekiel is diagnosed as suffering from this condition based on the following symptoms: hes obsessed with the minute particularities of religion; he talks a lot about harlots; he talks a lot, full stop. Now, granted, the Book of Ezekiel is not an easy read, but these three symptoms do seem to go with the prophets job description. Also, as Tod Chambers has pointed out, the process of telling and retelling a story in accordance with genre conventions whether they are the conventions of the prophetic narrative or the bioethics case studyfictionalizes the story to the point where it is no longer possible to determine what the facts of the case are, even though it is still being presented and read as a real case (Chambers, 1999). More to the point with respect to using Ezekiel as a diagnostic zebra is the longstanding disagreement among neurologists as to whether an obsession with religion should even be regarded as a sign of temporal lobe epilepsy, no matter how useful the trophe of the sacred fool, suffering from holy madness, has been for writers of fiction. A 1987 study that tested the hypothesis that excessive religious preoccupation is a consistent . . . personality trait of persons with this condition did not find that this longstanding belief held up, and suggested two reasons: earlier studies had been conducted on institutionalized mental patients, whose excessive religious preoccupation may not have been linked to this or any other neurological disorder; and the definition of hyperreligiosity relevant to temporal lobe epilepsy has not been consistent over time (Tucker, Novelly, & Walker, 1987, pp. 181184). Indeed, the term hyperreligiosity is not to be found in the DSM, even though it is often used as if it were a meaningful diagnostic category. There is an old joke with a grain of truth, to the effect that a promiscuous person is one who has had at least one more sexual partner than the person using the term. Similarly, the clinical use of the term hyperreligious may at times simply reflect a patient who is more religious than his physician.

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Of course, some practices can be understood to be excessive within the context of a given religious tradition. And neurological or psychiatric problems can be manifested in terms of religious language and behaviors. But it is a clinical and ethical problem if strong religious conviction itself is viewed as a symptom of pathology, particularly when the evidence for either correlation or causation may be far less conclusive than has been assumed, as in the case of temporal lobe epilepsy. Its also a problem if hyperreligiosity is code for a wrong way to express spirituality. Yet this is a hazard of spirituality and medicine discourses that define the word spiritual only apophatically, as not religious, or as no more religious than I am.
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V. HEROIC CRIPS: AN ETHICAL CAUTION And finally, one last ethical caution, which concerns the notion that illness and other suffering makes a person more spiritually inclined, or even makes one into a heroic crip, a morally superior person, ennobled by suffering. The importance of tending to patients spiritual needs at end of life, when further curative care is futile, is a central tenet of the hospice movement and of other efforts to improve the care of the dying. Yet for patients who are not at end of life (and even for those who are) there may be a hazard in focusing overmuch on the things of the spirit, if this means assuming that this is what all patients want, or all that they want. My dearest friend was recently treated for cancer at a major academic medical center offering an extensive menu of spiritual, integrative, complementary, and wellness services to patients. While she was aware of these services, she told me that she really didnt care whether her physicians were concerned about her personal spirituality, or their own spirituality, for that matter. What mattered most to her was being given an incorrect dosage of medication, resulting in an extra night in the hospital after surgery. What mattered most to her was the alarming shortage of nursing staff. Describing another mistakeone that was emotionally distressing as well as potentially dangerousmade by one of her physicians, she said, It wouldnt have mattered if hed asked me about God. Hed still have made the mistake. My friends observations, while anecdotal, point up the fallacy of assuming that all patients want spirituality to be a tangible dimension of their medical careand also, of presuming that spirituality in medicine is any guarantor of safety or quality in medicine. Grappling with the definition of spirituality

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and its role in humanistic medical education and clinical practice may be difficult and important tasks, but integrating these concerns into quality improvement efforts that, in a different way, honor the humanity and dignity of patients and clinicians may still need to be recognized as a larger ethical obligation of the spirituality and medicine movement.

ACKNOWLEDGMENTS
Versions of this article were presented at the Religion and Spirituality in Medical Education Panel at the American Society for Bioethics and Humanities Annual Meeting in October 2003, and to the Religion and Science Group at the American Academy of Religions Annual Meeting in November 2003. I am grateful to these audiences, and, in particular, to Tod Chambers, Greg Peterson, and Dan Sulmasy, for their questions, comments, and suggestions. Conversations with Mary Ann Baily, Julia Boltin, Eric Cassell, Bruce Jennings, and Josephine Johnston, and with participants in an exploratory meeting on spirituality and medicine held at The Hastings Center in December 2002, have been essential to the development of this article. Research assistance was provided by Michael Khair and Alissa Lyon. Research support was provided by grants from the Pettus-Crowe Foundation and the Fannie E. Rippel Foundation.

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NOTES
1. 1999 Curricular Awards Course Summaries. The John Templeton Spirituality and Medicine Award for Undergraduate Medical School Curricula, (2003, June 17). 2. Association of American Medical Colleges, Medical Schools Objectives Project Report III: Contemporary Issues in Medicine: Communication in Medicine, (1999). Referred to below as MSOP Report III. 3. Puchalski, FICA [website] 4. See, for example, R.C. Byrd (1988). 5. For a review of these studies, see Powell, L.H., Shahabi, L., & Thoresen, C.E. (2003). 6. Clinical Pastoral Education, the clinical phase of training for professional hospital chaplains, uses a similarly-named methodology, the spiritual assessment, to help students identify patients core spiritual needs. See Lee (2002), p. 344. 7. Powell, quoted in Kalb (2003), p. 48.

REFERENCES
1999 Curricular Awards Course Summaries. The John Templeton Spirituality and Medicine Award for Undergraduate Medical School Curricula. (2003, June 17). [On-line]. Available: http://www.gwish.org/courses/id43.htm.

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