“American medicine is spiritually sick,” begin Michael and Tracy Balboni, as they define a root issue at the heart of the malaise they see in the soul of American medicine today. They see the cause of this sickness as the neglect of spirituality and religion in the care of patients.

Michael Balboni is a Protestant minister, and his wife, Tracy, is a medical doctor. In the course of their marriage and work, they realized how much medicine and religion had to say to each other, and yet how divided these worlds actually were.

This background led them to collaborate and produce this book, calling on interdisciplinary scholarship and input from many fields, including medicine, theology, sociology, history, public policy, and others. Michael and Tracy draw parallels from their marriage to say that science and religion need each other to become a greater whole in patient care. They write to expose and illuminate the issue of the way medicine and religion are kept separate and they offer their suggestions for how to change the culture to bridge the gap and usher in a new era of respect, cooperation, and partnership in these two fields.

In part 1 of the book, the Balbonis discuss how spirituality has been shown in studies to be very important in patients’ experiences of illness and how they cope, especially with terminal illness. The authors describe how end-of-life outcomes are improved when spiritual care is incorporated. They then go on to postulate that considering this, it might be expected that spiritual care would receive serious attention in the medical field, but that this is not the case. They discuss studies done on medical personnel to show that spirituality is infrequently discussed and not as much as patients would like for it to be.

Michael and Tracy propose hypotheses for why clinicians neglect spiritual care and report that lack of training in how to offer spiritual care seems to be an important reason many do not feel comfortable offering it. They discuss how underlying beliefs and suppositions in our society and culture lead clinicians to neglect providing spiritual care, including the idea that physicians are mostly scientists practicing with technology (but avoiding religious and spiritual associations) and also that we have a death-denying culture. They also discuss the dualisms present in separating things like medicine and religion, the body and the soul, the sacred and the secular.

Part 2 of the book discusses theological perspectives on the separation of these two fields. Spirituality and religion are defined in terms of a “chief love,” what is most deeply desired and loved, what one centers one’s life around, and the structures that are built around that. The authors then discuss the theological underpinnings of medicine, especially as it is related to the Abrahamic faiths of Judaism, Christianity, and Islam. The Balbonis argue that the medicine we practice today is rooted in the deeply theological approaches of these faiths. They say that the influence of these faiths has affected the development of modern medicine and how it is practiced, even as medicine seeks to distance itself from religion. They describe that modern medicine is deeply indebted to monotheism, especially as from this worldview spring beliefs such as that God alone heals, that God is the genius of medicine, and that when healing occurs, all praise and credit are returned to God. The authors go further to postulate that the aura that medicine offers, for example, with the promise of extension of life, avoidance of pain, and a good death, is actually a promise surrounded by a religious aura. They see medicine itself functioning as a spiritual entity.

In part 3, the Balbonis address how to restore actual spirituality to the practice of medicine. They have argued that the way medicine is practiced implies a spirituality, but that it is a spirituality of imminence and thus deficient. They say that institutional forces create structures that depersonalize medicine. They hold that keeping actual spiritual forces out of the realm of medicine harms patients and clinicians. The Balbonis maintain that the approaches that will work to repair the rift and reconnect medicine and spirituality must find common ground among diverse traditions while not doing harm to the core values of each tradition.

The authors propose a structural pluralism that upholds traditions within spirituality, advocates for religious freedom against all forms of religious coercion, and creates a step-by-step approach to making the transition from imminence to pluralism. They advocate for multiple religious traditions and cultures having the opportunity to shape their practices related to patient care, creating a social compromise between moral strangers. A structural pluralism is advocated for and excesses are prevented by instructions to “follow the patient’s lead.”

The Balbonis’ book is well-researched, comprehensive, and clear in its argument. The authors used evidence-based information and objective sources to illustrate their views. I appreciate their thoughtful and well-researched approach to documenting what many of us know to be true from our experience during our medical training and practice. Their descriptions of the barriers to greater incorporation of spirituality within our current medical system ring true in my personal experience. In addition to clearly laying out their concerns, Michael and Tracy extensively propose and critique solutions that they feel could help.

In general, I agree with their conclusion, which is that authentic religion should be reconnected with modern medicine in a way that is respectful, genuine, embracing of pluralism, and not coercive or intimidating.

The authors’ description of spirituality and religion in terms of a person’s “chief love” resonated with me. As a Muslim physician, I connected with the concept of the central mark of spirituality being “what is most deeply desired and loved” (119) and how a person’s life is centered around this entity. The definition would resonate with Muslims, as Islam’s concepts of worship flow from the belief that our greatest love should be God and that this devotion affects all aspects of life and practice.

In a pluralistic society, I feel that the authors’ approach to allowing patients to identify their own chief love is a gracious way to engage the patient and better understand their perspectives on the sacred. In addition, this approach would respectfully allow for a variety of responses to this central question instead of imposing a narrow definition of the sacred on the patient.

Although I like the proposed concept of increasing religious and spiritual care for patients who want it, I am apprehensive about what the practical application of this endeavor would look like.

I would like to comment on some issues that the Balbonis themselves recognize may be a problem. These are the issues of religious intimidation, alienation, and even coercion that can occur with poorly trained personnel who may be well-meaning but greatly lack insight into how their approach to “spiritual care” might affect patients and families. I feel the authors do not go far enough in realizing how great a concern these issues are and how much of an impact they can have on patients.

The Balbonis note that there may be a fear of spiritual coercion and proselytism. In their structural pluralism model, they regard spiritual engagement that impinges on freedom or uses coercion to push a spiritual change of heart as morally intolerable. To solve this issue they advocate for “following the patient’s lead.” Listening instead of following a preset agenda is a method they recommend for following the patient’s lead. They are clear that the spiritual engagement should be freely and voluntarily chosen to safeguard against coercive influences and protect freedom of choice.

This approach sounds very respectful and appropriate. However, I do not think this can be accomplished so easily. This is where I feel the greatest drawback of the Balbonis’ book lies. In the real world, with our diversity of approaches, beliefs, and sensitivities, the application is much messier than the text would have you believe.

To illustrate my concern, I’m going to focus on one example from the book. The Balbonis cite the Christus Consolator statue at the hospital complex at Johns Hopkins University as a noteworthy example of a way in which the spiritual is successfully merged into the secular in a medical context. This replica of the original in Copenhagen was unveiled in 1896, and it is a ten-and-half-foot statue of Jesus, resurrected, with outstretched arms and pierced hands.

The Balbonis write that “many have claimed that the presence of Christus Consolator has been a source of hope and comfort, pointing people to look beyond themselves to a transcendent God who has not abandoned them.”

With regards to how this symbol may be received by non-Christians, the Balbonis say that “the iconographic predominance of the Christian religion . . . is more challenging for non-Christians, whose encounter with Christus requires the person to either ignore the symbolism or perform a private “translation” of what it may mean for them from within their own alternative spiritual worldview. Even with this challenge, Christus Consolator is at the very minimum a gesture that medicine and human material existence is not all there is or even the penultimate concern. . . . It functions as an ongoing herald that medicine and religion can operate quite seamlessly together on an institutional level, even within elite medical hospitals” (148).

I appreciate that the presence of this Christian religious symbol would offer a sense of hope and healing for those who find inspiration in the symbolism of this faith. I was, however, very concerned when I read the authors’ recommendations to non-Christians who might encounter it.

I believe that the Balbonis mean well. I don’t believe they are trying to impose Christianity on anyone or be dismissive of any challenges the statue may raise. And I do feel they are sincere in offering this advice to non-Christians and that they feel that if a non-Christian would just ignore or translate this Christian symbol then all would be able to benefit from it on some level. But I find the assumptions behind this advice to be troubling and an indication that the authors do not really appreciate the emotions that this statue may raise in some who see it, particularly those of other faiths. I feel there is a lack of insight as to how alienating and divisive such a statue can be. This example can help us appreciate how easily good intentions to include spiritual care in the practice of medicine for the benefit of patients can be derailed. The dominant religious perspective may be used or represented to appeal to and relate to the majority, the 70 percent of the country per the book that is Christian. It may be expected that the rest of the people would ignore what doesn’t fit them or translate it into something meaningful for them. But is it appropriate for us to dismiss what may be valid concerns about the effects of religious symbols? The reality of how people may respond to religious symbols is complex and not recognizing this can contribute to feelings of alienation.

Towards the end of the book, the authors acknowledge that “nor does research exist on patient desirability or health related effects of religious symbols in public hospital spaces. Similarly, little is known of how a tradition-specific religious symbol, such as the Christus Consolator at Johns Hopkins, affects patients who identify with that symbol in comparison to those who do not” (281).

For a Muslim patient, there are many complicated thoughts and feelings that can be elicited when one would see a statue of Jesus at the entry to a medical institution. I would like to offer my perspective on this question, as my own possible associations with this symbolism are complex but are likely reflective of others’ thinking as well.

I attended a Catholic high school in a small Ohio town where I was the only Muslim student. I remember my high school days, immersed with my Catholic classmates, with warmth and fondness. The symbols and statues of Catholicism were part of my school experience. The Catholic sisters who taught us were kind and caring. So the statue of Jesus would remind me of my Catholic school days and I might think the staff in the hospital would likely be people of faith who want to do right by God, as was my experience in Catholic school. I might feel that people who work in the shadow of the statue would provide care for their patients with compassion and kindness.

Another response I would have would be to the statue itself. In accordance with my faith, I do not believe that portraying an image of God is acceptable. As Christians believe Jesus was God, this is an image meant to represent the divine. Muslims entering would experience a deep discomfort with the portrayal of God in a statue, feeling it is not commensurate with his majesty to reduce him to being represented in this form.

Then with regards to the figure of Jesus, Muslims consider him to be one of the five greatest prophets of God, but not divine himself. Muslims have the greatest of love, respect, and admiration for Jesus, whom they consider to be their own prophet. But within Islam there is a belief that the prophets should not to be depicted, due to concern about people worshiping God’s creation instead of worshiping God himself. So the statue of Jesus in portraying the image of a prophet of God would also elicit deep discomfort from a Muslim.

Another significant concern I must raise is that in the shadow of such an overtly religious symbol tied to a particular faith, a non-Christian may fear that he is entering that space as an “other.” He may question if he will be treated fairly in that institution. Non-Christians might also be suspicious that a medical person who is engaging them on their religion might actually be trying to proselytize.

These are the emotions and thoughts that would weigh down on me as I led my loved one or myself into that hospital space. For these reasons, I know many people would feel safer and less an “other” in an institution that does not display prominent Christian religious symbols.

And if I honestly shared the feelings that such a statue would bring forth in me, I would fear that others would judge me without understanding the meaning behind my discomfort. I could be labeled as not valuing God, Jesus, or others’ right to religious expression. None of these labels would be true. Instead of somehow being against God, I would instead be responding based on my deep love for God and my desire to glorify him in a manner that is considered appropriate in my faith and commensurate with his majesty. For these reasons, I could not endorse or support a practice seen in my faith as being disrespectful to God.

I have spent a long time on this one example because I think it is a good analogy for my greater concerns about well-meaning people trying to implement or incorporate spiritual care in medicine. We don’t know what we don’t know about others’ beliefs and sensitivities. My own actions could very well elicit the same feelings of discomfort in others precisely because their interpretations of what is appropriate in glorifying their chief love are in direct conflict with what I feel best glorifies mine, even if we both have God as our chief love. Ensuing actions can easily result in feelings of alienation and coercion. Many practices are not easily ignored or translated if we are to be true to our consciences.

Can we as humanity ever get to a place where we know each other and each other’s beliefs well enough to avoid these barriers and pitfalls? And what is the lowest common denominator? And how do we proceed when the lowest common denominator or in-common, acceptable-to-all belief dilutes our worship such that it is no longer useful or true? Who am I to indicate to another that a statue of Jesus is not acceptable as a way to worship God when that is considered a good reminder in another faith? How do we proceed when what glorifies God in one tradition disrespects him and compromises his worship in another? Our assumptions about worship, our lack of knowledge about others’ beliefs, and our lack of safe, respectful spaces in which to share or discuss such conflicts all lead to potential minefields when considering how to practically implement the incorporating of spirituality in medicine.

It would be naïve for us to think that instructions to provide spiritual care to patients will not result in the imposition of spiritual care with specific faith-based assumptions with a corresponding lack of insight as to how these assumptions and overtones may impact patients. That is the biggest drawback I see in the Balbonis’ approach.

We all want hospitals to be safe spaces in which patients can bring up what spiritual or religious concerns are important to them and have their struggles validated and supported. We want patients to feel equally safe to defer or refuse unwanted spiritual intervention. I agree with the Balbonis on these goals, and their book is a useful blueprint towards these aims. I fear that for many, however, the practical implementation of this ideal will remain out of reach. I hope we can get to know each other well enough to overcome the barriers so that we can incorporate meaningful patient-guided spiritual care into medical practice without alienating or intimidating patients or families regardless of faith or background.

Overall, I think this book is a well-researched, well-presented look at the current interface between medicine and religion. Despite my concerns as I discussed above, I feel the book is a valuable contribution to the field and offers many thoughtful ideas for consideration and implementation, with appropriate safeguards.

I remember taking philosopher and biostatistician Peter Van Ness’s graduate course “Religion, Health, and Society” in the fall of 2002 and feeling a moment of heightened clarity—or, at least, deep appreciation for the scope of the challenge—as we discussed different definitions of “religion” and “spirituality” epidemiologically. By the end of the course, I felt I attained more precision on the use of those words, especially in the context of how to use them as proxies for beliefs in research. So, it was with a bit of surprise some eighteen years later upon reading Hostility to Hospitality that I suddenly found myself questioning some aspects of the “spiritual” and “religious” bifurcation I had pragmatically adopted many years ago from a professor that Michael and Tracey Balboni engage at various points their discourse. On the matter of definitions, they write,

In conclusion, there are serious conceptual problems in agreeing to separate spirituality from religion. We concur with many who identify conceptual differences between these two constructs but deny that they are separable. Under our approach to spirituality, based on life centered around a chief love, this separation in neither necessary nor possible. (126)

Setting aside the epidemiologic implications of using this new construct, this is but one example of how this book actively engaged me as a reader, a physician with training in ethics and health services research, and a person of faith.

I painstakingly read Hostility to Hospitality finding myself left with an abundance of rich material for potential discussion. Anticipating some of the topics that other panelists might have chosen, I choose two topics—both less prominent themes in the book—on which to engage with the authors: health and the construct of human rights and religion/spirituality in practice outside the margins of severe illness and death.

Social Contracting and Healthcare

In Hostility to Hospitality, the authors discuss the relationship between health and human rights briefly, and as a reader, I desired further presentation and discussion around their fundamental views on if there is or is not an ideal social contract between a society and its members regarding access to and the provision of healthcare. I argue that, in fact, how the delivery of health care is arranged as a system and fundamentally understood by a society in terms of rights, privileges, or social contracts intimately impacts the individual clinical encounter as a backdrop. Regardless of the strength of the relationship between a physician and patient, a host of feelings, expectations, and vulnerabilities that impact the dyadic relationship between patient and clinician takes place before and after the encounter, and this backdrop is strong enough to sever an otherwise special relationship. As a physician who currently practices in a municipal health care system, it’s probable, through anecdote at least, that when patients a priori to their individual clinical encounter know that they will receive care regardless of ability to pay (e.g., they will not be sent to a collection agency) or immigration status, it offers the backdrop of an ease that enhances the possibility and potential of the type of physician-patient encounter as gift that the Balbonis argue for throughout their work.

The authors frame that “the source of medicine is received as a gift from God” (153). They further explain, “If medicine is framed primarily as a gift, instead of a human right or an outflow of man’s technological genius, it changes the basic framework and meaning in what takes place in the medical encounter” (153). They then elaborate that if medicine is a divine gift, it cannot be demanded as a right or treated as a commodity. They appear to attempt to hold the “gift of medicine” concept somewhere along, but not clearly outside of, a presumed rights-commodity continuum by concluding that “medicine should be freely given, motivated by human love, upheld as a gift for all to hold in generosity and compassion” (154).

In some ways, this rendering reads as a moderate rebuke of both an American politically progressive approach to universal health care steeped in rights language without condemning the idea outright, while also insipidly critiquing an American politically conservative approach where health care is a commodified privilege save by the generosity of the ethically fraught, haphazardly executed charity care models we see across the United States. Indeed, the reader is left wondering where to situate the authors’ analysis after this position: “Human participation in God’s gift should clearly include expectations of fair reimbursement of medical professionals, scientists, and institutions that offer care. Recipients of the gift of medicine should not expect it to be free of charge but should generously support all those who give their lives in service of the sick” (154). It was unclear to me what theological or Christian Testament grounds undergird the expectation of “fair reimbursement.”

In some ways, I was left with the impression that the theological underpinnings of the authors’ approach to describing health care as a gift theologically were in fact entangled with a distinctly American political belief around health care as a privilege and charity care as the solution. It would have made it clearer for the reader for understanding “gift of medicine” had the authors more fully discussed their underlying theological-political understanding of the provision of healthcare. In fact, using their framework, I would argue that in its most selfless and elemental sense, a “gift” does not demand something in return, including fair reimbursement.

If medicine is a divine gift, I suggest clinicians should serve as collaborative and necessary architects in demanding and building with society a health care system that sustainably allows that gift to be given as equitably as possible. The discourse for this might adopt a human rights framework or at least be framed in language of what is best for the common good as a form of social contract. As a clinician, I see that the cultivation of trust between clinician and patient allows for this gift to be given, but it cannot be accomplished by the clinician alone in our current healthcare system model, perhaps even for the independently practicing physician much anymore. The gift cannot be given if the patient is at risk of financial ruin and does not feel comfortable or safe seeking care in the first place for fear that it could bankrupt them and their families.

As a result, it is entirely possible given the prolific cornucopia of universal health care systems across the world, that the gift of medicine framework can complement a distinct and faithful call for a social contract between society and patients and society and health care clinicians so that patients and clinicians can enter into this special dyadic relationship without (1) fear of being able to afford care or (2) fear of not receiving fair remuneration contextually relevant to the society in which one practices medicine. In American medicine, the medical-industrial complex serves as the gateway and barrier to the meaningful relationship and gift the authors see physicians as providing patients.

The Balbonis begin to account for these tensions later in their work when they write,

There is an undeniable conflict of interest between . . . hospitality and compassion . . . which at its core is a personal and costly human love, and, on the other hand, the three impersonal social forces of legal-bureaucracy, scientific-technology, and a market economy. . . . The contemporary evidence suggests, however, that if a single organization is expected to espouse and maintain both the personal dimensions of care as well as impersonal social forces, the gravitational pull draws organizations away from human-centered care and toward bureaucracy, science, and the market. This is the necessary direction for organizations that are interwoven and dependent on market forces. Health care and compassion is secondary to the organization’s basic economic survival. (231)

I wonder if this observation indeed clearly points to the need for a rights-like model for accessible and fairly remunerable health care as one mechanism to cultivate the medicine as gift relationship. Wouldn’t a human rights framework be consistent with a structural pluralistic approach (269) to letting every human know their health matters and they have dignity as well?

Using the language of “rights”—or another approach capturing what might be considered essential instrumental goods for human flourishing, e.g., health, education, housing—might best enhance how the divine gift is given by the clinician, certainly in a pluralistic society and one increasingly growing in religious “nones.” I agree with the authors rendering of the artificial sacred-secular divide that saturates society, but for this reason, I also argue that truly allowing the gift of medicine as divine cannot be a conversation disentangled from the political machinations that impact the patient-physician relationship given religious, spiritual, and political pluralism.

In summary, it was clear to me as a reader that the authors have grave concern with the setup of the medical-industrial complex and commodification of healthcare; however, I welcome further discussion on their thoughts on whether a human rights approach (or a framework of social contracting) can be consonant with the concept of Christian hospitality and human dignity without being in conflict with the fundamental essence of the “gift of medicine” as they see it.

Towards a Theological Anthropology

In the stated purpose of Hostility to Hospitality, the Balbonis explain, “The central motive behind our book is to describe why spiritual care is avoided or neglected by clinicians within the context of serious illness and then consider the large-scale, cultural consequences of this divorce between medicine and spiritualty/religion” (7). Additionally, the Balbonis describe evidence that the majority of physicians and patients espouse religious/spiritual views in a number of studies. As an extension of their discussions towards a theology of medicine, theology within the patient-clinician relationship, and the sacramental nature of medicine then, I am incredibly curious as to how they see their paradigmatic view of spirituality/religion in the patient-clinician dyad acted out in contexts of relatively good health and chronic disease; in other words, outpatient primary care and behavioral health.

Medicine, within the context of a deeply rooted theological anthropology, seeks to enable enrich human flourishing through health in all contexts. Carol Taylor proposes this operational definition for consideration here:

A rich theological anthropology provides guidance on how to (1) find meaning in the vulnerabilities that accompany birth, aging, and its developmental challenges, acute and chronic illness, and dying; (2) organize and deliver health care; (3) approach all parties receiving and providing health care, especially the most vulnerable; (4) make individual health care decisions as both patients/surrogates and health care professionals; and (5) prioritize health decisions as institutions.1

Some of the same polemics at the bedside of seriously ill people, e.g., potential coercion, not following the patient’s lead, exist in more mundane clinical encounters. Yet, perhaps other opportunities for flourishing through incorporation of spiritual/religious understandings of health do as well, such as inquiries on how religious/spiritual beliefs influence daily approaches to eating, physical activity, reactions to stressful situations, and fatalism/locus of control.

It’s also worth noting here at least one risk for understanding the relationship between health and religion in clinical context: taking an instrumental approach to the purpose of religion in health. In their own ways, medicine and religion/spirituality enhance human flourishing—medicine in the service of health and religion-spirituality in the service of meaning-making and purpose—but religion as an instrumental means to health poses a number of theological concerns. The Balbonis write, “An instrumental approach to religion understands religion’s purpose as a means or instrument to a nonreligious end, rather than the internal ends identified itself” (248). Elsewhere, I have discussed some of the promises and pitfalls when clinically applying data looking at faith, religious practice, and health and even how that data itself is interpreted.2

Building on their work in Hostility to Hospitality, what does a holistic theological anthropology look like for medicine? What does structural pluralism look like practiced in an outpatient setting where a potentially years longitudinal relationship between physicians and patients grows? What additional theological and pragmatic considerations do the authors find apply to these outpatient, non-critically ill settings when discussing religion/spirituality and health?

Medicine is sick. In their book Hostility to Hospitality: Spirituality and Professional Socialization Within Medicine, Michael Balboni and Tracy Balboni agree with the Jewish philosopher Abraham Heschel that this sickness is primarily spiritual. Heschel observes that “the crisis in the doctor-patient relationship is part of the ominous, unhealthy, livid condition of human relations in our entire society, a spiritual malaria.”1

The Balbonis explores Heschel’s pronouncement in an attempt to come up with a partial diagnosis. The problem, as they see it, is that medicine has distanced itself from religion and spirituality, and this has created a number of hostilities. These hostilities are directed against questions of ultimacy (particularly with regard to death) and against personal, patient-centered, and compassionate care. No obvious institutions exist within medicine, the authors claim, “to advocate for the personal dimensions of human compassion”—this is up to individuals (6). The result is that clinicians are left floundering. The solution, they insist, is a return to the institutions that advocate for a robust, patient-centered medicine through a renewed partnership with religion and spirituality.

As a primary care doctor well acquainted with burnout, I was particularly interested in the book’s argument that “immanence” in medicine has helped to create the dysfunctional systems in which we clinicians find ourselves. The authors define immanence as “a collective life centered on bodily health, cure, and physical comfort as chief love or ultimate concern,” and they see this immanence as a religion or spirituality in its own right (297).

This focus on the physical—this immanence—leads to clinician burnout through what they describe as the “corporate socialization of impersonal factors including bureaucratic, technological, and market-driven forces” (285). The question that most interests me, then, is can the proposed solutions actually work to solve the burnout problem—which studies show affects more than half of all practicing doctors?2

The authors tell us that the solution is structural pluralism. For those not familiar with the term, the book defines “structural pluralism” as tradition-specific, that is, “a coexistence of multiple communities within shared medical structures consisting of different religions, moral systems, and worldviews” (299). Such a system provides opportunity for patients and clinicians to partner transparently with the tradition of their choice without fear of penalty or coercion.

This might sound reasonable enough, but what does it mean? Under structural pluralism, patient-clinician-tradition triads are to develop over time their own visible social structures, such as tradition-specific chapel space or medical student training programs for professional socialization. Practically speaking, this means that a Catholic or a Muslim medical student, for example, can voluntarily choose to align with their respective Catholic or Muslim clergy, chaplains, and clinicians as they traverse medical training. The authors suggest that this process might even follow the six domains of clinical competency identified by the Accreditation Council for Graduate Medical Education (ACGME), the organization responsible for accrediting most physician training programs in the United States.

The hope as I understand the book is twofold. First, that “overt spiritual partnership within tradition-dependent communities” will form “clinicians as healers” who will have had sufficient training and modeling to have grasped “the necessary virtuous capacities to wisely engage patient spirituality and who hold professional resilience grounded in virtue rather than technique” (285). Second, that these partnerships will restore person-centered hospitality to medicine and collectively resist “the social powers of the market, bureaucracy, and science, refusing to allow these concerns to dictate or undermine patient-centered care” (286). The authors conclude with concrete steps for implementing structural pluralism and the vision of hospitality for clinicians, medical educators, patients, health systems leaders, researchers, hospital chaplains, and community clergy.

I agree with a substantial portion of this book. But my concern is that neither the diagnosis nor the treatment goes far enough. We start from the claim that medicine’s sickness is primarily spiritual. This claim is valid. But does it mean simply that medicine has distanced itself from religion and spirituality as the authors suggest? Or does Heschel push us further with his imagery—medicine’s “spiritual malaria” is part of the “ominous, unhealthy, livid condition of human relations in our entire society”—that is, the whole system is spiritually bankrupt?

My sense is that to summarize the problem as making a wrong move—we turned right when we should have turned left; or, doctors distanced themselves from religion when they should have stayed close—is to underdiagnose. Medicine is spiritually sick because it is practiced in a society suffering from an ominous, unhealthy, livid condition of malaria-infested relationships, to borrow from Heschel.

Perhaps a more suitable analogy than Heschel’s for the wayward medicine portrayed by the Balbonis is that of the wandering Israelites—at times following the good path of God’s law and at other times worshipping the golden calf. If I read the book correctly, the authors are suggesting that the profession has veered wayward, and it needs to get back on the right path.

I suggest an alternative diagnosis: the whole medical enterprise is Egypt. Health care professionals are either slaving away to generate more relative value units (RVUs) for Pharaoh’s coffers or they are in various levels of the hierarchy cracking the whip. The whole system is oriented around production and money. Yes, treating illness is a good. Yes, storing grain in the event of future famine is good. But what happens when curing disease becomes an obsession, and those in power hold clinicians to ever more severe productivity requirements while telling them that they must at the same time collect their own straw to make bricks?3

But perhaps I am exaggerating the diagnosis. Perhaps invoking the need for an exodus overstates things.

Softening the critique slightly we might assume that the authors are correct, and that change is possible from within. But then there is a point that needs to be made more clearly. The authors hint at it but they do not state it explicitly: there is a strong, perhaps increasingly irreconcilable tension between pluralism and consumerism. Consumerism plagues American medicine leading to burnout—which the authors state. Pluralism is the solution. Can the two be reconciled?

The theologian Mirsolav Volf explores the tension with regard to the decline of pluralism in the university.4 The university, he contends, has evolved to have two primary aims: to produce research and to train people for jobs. Gone are the days of deliberate conversation about what makes life worth living and what values should guide it.

What does Volf believe has replaced the art of conversation? The art of consuming. “Decisions about a life worth living are increasingly shaped by the way we make decisions about consumer goods,” he writes. He continues:

Consumption is squeezing out individual reflection about a life worth living by insinuating itself into the place of such reflection. A new consumer good offers itself to our imagination before we can ever grow dissatisfied with the old one, and the endless stream of new goods and services, a veritable opiate for the people, becomes for us as a cornucopia of mystery, protection, and salvation.

To the extent that we reflect on the good life—or, we might say, to the extent that we reflect on good medical care—we reflect on our choices, our preferences, like choosing between a Honda and a Ford, Volf says.

Volf notes that our current use of the word “preference” belongs to what the sociologist and theologian Peter Berger in his book A Far Glory calls “the language of consumerist culture.” This belongs not, Volf says, “to the language of deep and informed commitments, and certainly not to the language of ways of living that matter to us more than life itself.” He continues:

“Preferences” are not formed in prayerful contemplation, through careful reading of sacred texts, or through judicious processes. . . . They emerge as a blend of inchoate longings and calculations of benefits directed at sleek and cleverly advertised goods. You don’t read and discuss Socrates, Buddha, and Jesus, or Luther, Spinoza, and Nietzsche to determine your “preferences;” you listen to what your gut tells you and read consumer reports.

Consumer choice has replaced thoughtful deliberation.

We might apply Volf’s analysis to health care as follows: medicine has become about research and training people for jobs that generate money. No longer do its practitioners deliberate about a vocation worth practicing and the values that should guide it. Instead, decisions about medicine are shaped by the way we make decisions about our consumption of health care goods. Medicine offers a constant stream of new goods and services, veritable opiates for the people, a cornucopia of mystery, protection, and salvation (to paraphrase Volf). The reigning ethical principle in medical practice is patient autonomy; we simply defer to patient preferences to know how to practice our profession.

With regard to the university, Volf says that not only do students and society lose out, but universities themselves become “servants of these reflexively opaque desires and preferences.” The same could be said of the profession of medicine. Not only do medical students, patients, and clinicians lose out on experiencing a robust healing profession, but medicine itself becomes a servant of the opaque desires and preferences of health system administrators, researchers, and patients.

Volf calls for a university that understands itself as pluralistic rather than exclusively secular. With Nicholas Wolterstorff, he sees a legitimate place at the university for thinking out of a particular faith tradition. And this is what the Balbonis also see for medicine.

If health care professionals are not in Egypt, but are in fact in Chicago or New York or Boston or any of the other major research centers, how do we get past the dominance of consumerism to the practice of conversation that asks what is a medicine worth practicing? I am not entirely persuaded it will start with the introduction of structural pluralism. Something must precede it.

In reflecting on the occasion in the temple when Jesus overturned the money changers’ tables, Augustine asked, “Who are they who sell the oxen? Who are they who sell the sheep and doves? They are those who seek their own interests. . . . Those who have no desire for redemption have everything for sale.”5 Augustine implies here that those who are wholly committed to maximizing their own gains cannot at the same time reflect on what makes life worth living. Until there is an awakening of the need for redemption, consumerism will prevail.

Consumerism drives out pluralism. A recognition of the need for redemption invites pluralism.

The Balbonis’ Hostility to Hospitality is a compelling read for any medical professional who senses that medicine has lost its way. Their diagnosis could be pushed further perhaps, but on the whole it strikes me as accurate. The introduction of structural pluralism as treatment, however, will doubtless amount to little more than a checklist of ACGME competencies unless they first address the need to cultivate a desire for redemption. When we can awaken in patients, colleagues, and health care administrators a hunger to understand what is meant by a life worth living or a vocation worth practicing, then we can start to introduce the thoughtful dialogue that makes structural pluralism possible. And the Balbonis offer many helpful ways to realize that vision.

Eighteen months ago, my stomach became upset on the way home from the gym. I assumed that I had eaten something that did not agree with me and would be fine in the morning. At 2 a.m., the pain was so severe I drove myself to Duke Medical Center’s emergency room, almost in tears. Scans and tests were ordered. At 6 a.m., full of fear, I called an old friend, a pastor who also worked for Duke, and who I knew would know how to find me. At 8 a.m., I called my parents who lived a few hours away to let them know I was in the hospital awaiting results. My father told me to call my aunt, who was a physician in New York and an atheist, before making consenting to anything. The surgical fellow arrived in the ER to tell me that my intestine was full of blood clots, I called my aunt and handed the phone to the fellow, who explained the details of my situations. My aunt advised me the situation was grave, and surgery necessary. Duke’s chief of gastro-intestinal surgery was called in and performed both operations. I was in the ICU for four days. When I he visited me in the stepdown unit, I did not ask him about his faith. Grounded in Lutheran tradition, I remembered Luther’s quip that he did not care about his physician’s faith, only their skills. I thanked my surgeon for his skill, and success; I also thanked God for him. I do not know if he prayed before operating. I really did not care.

While I was in the hospital, my faith was supported by several sources. Someone placed a referral to Duke’s Pastoral Services Department on my behalf. I received a visit from the unit’s staff chaplain, who was a friend and fellow Lutheran. Another friend, who had had been a Clinical Pastoral Education resident with me and was now Chief of Chaplains at Durham’s Veterans Affairs Hospital, came on his lunch break to pray and provide support. We attended the same congregation in Durham, where I had been his pastoral successor. My congregational pastor and several members visited. A beginning Clinical Pastoral Education intern stopped by to offer a nervous, awkward, but well-intentioned prayer. I told him I was a chaplain and had been in his shoes. My chaplain colleague from work, an African American Pentecostal stopped by to pray. We always told our colleagues that we both believed in Jesus, but then our theology parted ways. I was moved she stopped by. I went home nine days later. Thoroughly shaken, I spent weeks recovering, and in follow-up strengthened by the religious communities of which I am a part. Despite a decade of chaplaincy work and an advanced degree in medical ethics, my illness shapes my work, ministry, and reading of this book.

From Hostility of Hospitality combines Michael Balboni’s experiences and expertise as a pastor and theologian with Tracy Balboni’s experiences and expertise as a radiation oncologist and builds on their joint empirical research. It explores a host of religious, social, and structural forces that they believe exiled religious practice from contemporary medicine then makes practical proposals in an attempt to make contemporary medicine respectful and inclusive of the claims of faith. While I can only do partial justice to the book’s detailed and complex arguments, the book’s theological and practical proposals gave me pause. I begin with the Balbonis’ theological proposal about God’s role in healing, and the attendant relationship between faith and science. Then I want to turn to two practical issues. The first is the book’s proposal that physicians engage in assessing patient religious belief, exploring the dangers of that proposal that the book only partially recognizes and does not fully address. I want to press the Balbonis to name the role faith plays in a physician’s clinical reasoning how faith might really matter in treatment decisions? I explore what I believe is one of the book’s most significant contributions, its skillful discussion and dismantling of the much brandished but often carelessly theorized concept of spirituality in contemporary pastoral care. Finally, I want to affirm the Balbonis’ critique of hospital chaplaincy and think about how theological education might better prepare pastors to engage the medical system in providing rich, tradition-based care to patients.

First, I want to look at the book’s theology and its argument that God is the source of all healing. That simplifies the historical acknowledgment within much of Christian tradition, that physicians and medicines are agents of healing. If healing is God’s responsibility, why do even religious patients seek care at renowned cancer centers? Faith does not mean that we cannot consider how a physician’s knowledge and skills can change outcomes. Religious patients are victims of medical error showing the real agency physicians have in healing. If we deny that, the only theological recourse we have would be some sort of providential account of God’s action in medicine, which seems to lurk behind some of what the book argues, but it is never explicitly named.

The Christian belief that medicine can be a means of divine healing long predates the emergence of a “spirituality” of immanence. The assertion that an adequate theology of medicine requires viewing “physical healing is a gift that is mediated through but ultimately located outside of human knowledge, scientific expertise or technological capacities” (154) is problematic. Though that theological claim may fit within some versions of a Reformed theology and providence, it is not in accord with all of classical Christian tradition. The claim also sits in uneasy tension with the book’s claim that human reason is a divine gift. In the sixteenth century, when plague struck the city of Wittenberg, Martin Luther argued that “God created medicines and provided us with the good intelligence to guard and take good care of the body so that we can live in good health.” God gave human beings reason to help them develop medicine and follow what reason commands about the perseveration of health. Furthermore, Luther argues that it is unfaithful to reject scientific medicine in the belief that God will protect them without using available knowledge or medical knowledge, and that to do so is not the result of “trusting God but tempting [God].”1 The Balbonis’ proposal to locate healing outside of medicine, rather than through medicine, separates God’s action from medicine’s means, or at least makes medicine irrelevant. If healing comes from God, why is medicine necessary? This theology does also not address theologically the issue of medical error. If God is working through medicine and through the physicians, how are we to understand the failures inherent in medicine because of human error? Which is to say, for this account of God’s relation to medicine.

The book argues that medicine now functions as religion, noting, among other things, the use of religious language in hospital fundraising. Duke Medicine’s motto is “Where Miracles Happen.” Duke physicians provide good patient care and engage in meaningful research. However, I have never heard a Duke physician claim miraculous powers. Patients undergoing treatment often interpret medical success as a sign of divine action, and also attribute treatment failures to the absence of the divine, or more unhelpfully a patient’s lack of faith. Yet how Christians understand the work of the Triune God is always changing. Theologian Regina Schwartz argues that “the gods departed with the rise of modernity; here, a medieval universe full of sacramental meanings gave way to the notion of the infinite mechanization of the universe. They left again with the rise of modern industrial civilization and the secular political order: at the end of the nineteenth century, in the epoch of nihilism signaled by Nietzsche’s God is dead. And again when postmodernity claimed the end of big narratives.”2

Nor am I convinced that medicine’s death anxiety exiled religion, since palliative and hospice care continue to expand, even in academic medical centers. Some argue that hospice and palliative care are marginalized in the modern hospital, but I do not think this a full explanation. I do think that the rise of for-profit hospitals and hospices might have contributed to religion’s exile. Any chaplaincy department director in a modern American hospital will tell you that they fear for their existence because they cannot bill for their services, and so exist as the “ugly stepchild” in the clinical departments. How might these changes to the structures of medicine make the rapprochement between medicine and religion more difficult?

I am not sure that a “spirituality of immanence” disconnected faith and medicine. For physicians, faith may motivate one’s entrance into medicine and sustain the practice of medicine over time. For patients, faith shapes their hopes and expectations for medicine, and helps set what they think are possible goals of care. Patients who cannot express these theologically rooted hopes are at the mercy of scientific medical power which leaves no room for divine action. Some people of faith reject what medicine sees as common sense. Christian Scientists refuse all medicine, Jehovah’s Witnesses refuse blood transfusions. This does not mean that faith has been removed from medical practice, it only acknowledges that religion shapes what people seek from medicine. Christian Scriptures clearly portray Jesus’ profound concern with illness, a concern he commands his followers to share. Empirical studies show that physician religiosity shapes how physicians act especially in end-of-life care. The impact of religious faith on other practices is less clear. Religiously based hospital systems refuse to provide specific treatment options. Roman Catholic hospitals often refuse to provide abortions.

The book fails to articulate how religion changes a physician’s clinical reasoning after establishing goals of care. Physicians can use conscience clauses to not participate in theologically controversial procedures such as abortion or gender reassignment surgeries on the basis of faith. More important is how faith might change clinical reasoning on an everyday basis. Does Tracy use her faith to establish what radiation protocols she prescribes patients? If the answer is yes, what source does she use for theological grounding? Scripture is obviously silent about radiation oncology. Would a radiation oncologist that goes to Saint Paul’s Roman Catholic, Old Cambridge Baptist, or University Lutheran (I am working around Harvard Square and left out a few non-Christian options) prescribe a different protocol than an oncologist who goes to Park Street Church? Can two physicians who attend the same congregation apply their faith in different ways? The lived appropriation of religious traditions is not uniform even in the same community. If treatment protocols are dictated by scientific reason not by faith, then does not this challenge how faith is apparent in medical practice?

The book is clear that religion does shape medicine in unacknowledged ways, arguing that “medical advice, with its potential moral implications, or spiritual care, with its implicit theologies, no longer rests solely on perceived neutral scientific evidence on unbiased values. Yet it also claims that reason is “God-given”? How is the clinician’s reason about ethics, or other matters (not medical treatments), related or not related to tradition? This is the larger question about reasoning in medicine and its relationship to faith. If reason is God’s gift, how does that impact the way we think about scientific evidence in medicine as opposed to simply relying on faith healing?

“Patients can more clearly judge a clinician’s ethical counsel or spiritual care since clinicians have identified with a particular spiritual tradition with openness and candor” (275). Sometimes a physician’s religion is visible, such as when Jewish personnel wear skullcaps or Christians wear crosses. However, much of medicine is not based on faith, but on reason and science. When the Duke Fellow talked to my atheist aunt, prescribing a treatment based on science, my aunt, needed no faith understand the logic of the procedure being advocated for. Achieving patient-provider religious congruence is increasingly difficult because hospitals are no longer run by religious organizations to serve their own members, as was once the case for hospitals such as Barnes Jewish Hospital in Saint Louis or the Lutheran Medical Center outside Chicago or Baptist Hospital in Winston-Salem, North Carolina. Even systems retaining a religious affiliation now serve religiously diverse populations. Baptist Hospital is the major hospital for Winston Salem, North Carolina, and a training site for the now secular Wake Forest University School of Medicine.

The concept of “spirituality” is foundational in interfaith chaplaincy. The Balbonis rightly question if the concept is as neutral as it claims to be. Rather they assert that one must adopt some form of a theological stance to claim that spirituality is “rooted in a person prior to religious or theological formulation.” Many individuals claim to be “spiritual” and not “religious. The Balbonis argue that “all spiritual practices have underlying presuppositions regarding the nature of humanity and the universe that can be considered theologies, even if they are latent and unacknowledged” (125). However, their assertion that spiritualities “hold to beliefs that are effectively doctrines and submit on some level to a social organization and hierarchy” (126) is contestable. Many “spiritualities” lack communal gatherings, and both authoritative leaders and texts. One can see the way individuals make meaning as “theological” in form even when individuals label it as only “spiritual.” I hope that researchers on medicine and religion can use this insight when they design metrics and scales to employ in quantitative and qualitative research.

I think the book rightly argues that at some level medicine has come to serve a quasi-religious function. However, the relationship between medicine and religion is broader and wider than the religious congruence or incongruence of physicians and patients. A childhood friend of mine, a devout Baptist, recently underwent a thirteen-hour surgery for cancer. The Covid-19 pandemic meant he could have no visitors other than his wife. She set up a CaringBridge site so his church and friends could follow his medical progress. We posted prayers and Bible verses. The interaction between his faith and his medical treatment was upheld and supported by his fellow believers outside the hospital. He was thankful (and gave God praise) that he had a skilled surgeon. I was thankful for the skill of my surgeon, too, whose worked save me from long-lasting health effects of my clots. Do I revere the surgeon? Maybe a bit, but I can refer that thanks to God; but that does not mean I do not recognize the time, effort, and energy the surgeon spent to become an excellent master of the art of surgery.

The book argues physicians acting as scientists “implies an in-person model of caregiving, one constructed on a scientific paradigm, in which the physician-patient relationship is transformed into an object-observer relationship” (165). This seems like an overly simplistic phenomenology of the patient-physician encounter. The use of scientific knowledge does not foreclose compassionate presence or theological engagement. I have seen numerous visits from congregational clergy that lack compassionate engagement. The many ways we are present to patients, in speech, in body language, in touch, in disposition, not simply the disclosure of religious faith, helps patients not be seen as objects.

The Balbonis argue that physicians should both inquire about a patients’ faith traditions and disclose their own. I am skeptical that this question can be routinely asked by physicians without intimidating patients. While admitting that the task is complex, the book is silent about how such an inquiry can be extricated from imbalances of both power and knowledge in physician-patient relationships. They support their claim using a Boston-based religion and cancer support study, but the generalizability of that study is questionable. After completing seminary and a Clinical Pastoral Education residency in New England, I did post-graduate work and a second year of Clinical Pastoral Education residency in North Carolina. Southern Christianity impacts medical care. Southern Christianity’s form challenged residents who arrived from Duke from outside the South. Duke Medicine’s motto is “Where Miracles Happen,” but many residents remember when they could not be admitted for a “miracle” because of the color of their skin.

Even a skillful inquiry about a patient’s faith can harm a treatment alliance. Patients may fear mistreatment or mistrust if they express a religious position discordant with that of their physician. Even the fear of bias may prevent a patient from disclosing information that is important for treatment, such as being in a same-sex relationship, or a lack of faith. If I know my physician is a devout Southern Baptist, or Catholic, or Orthodox Jew. Finding a physician who shares my religious values would be ideal, but it is not always possible. Even in religiously discordant physician-patient relationships, physicians would provide appropriate care for patients in most situations. Unless a patient freely discloses their faith, a physician risks being perceived as invasive if the patient believes the physician is seeking a certain answer. Finding a physician whose values and religiosity more closely match the patient would be ideal but is not always possible. Physicians often abide by codes of professional ethics, and physicians can and do provide excellent care for a diverse patient situation. The Balbonis believe that when physicians are open about their faith, patients can seek a religiously congruent doctor. In Boston, with its thousands of physicians and numerous hospitals, this may be possible. One rural community where I do hospice work has only one family physician. Most community hospitals have a limited variety of staff. I did not have time to find a Lutheran gastrointestinal surgeon.

Congregational clergy and hospital chaplains deal with power dynamics. Theologian Stefan Gartner notes, “Pastors have, and still have power because they are pastors. Their ministry makes them respected persons with authority—whether they like it or not and whether they are aware of it or not.”3 Individuals often relate to health care chaplains and hospital chaplains in different ways despite their overlapping roles. Chaplain Mark LaRocca Pitts observes that “whereas local faith representatives from the surrounding communities have little to no input in the patient’s overall plan of care, chaplains—as clinical members of the health care team—can advocate effectively for the patients’ spiritual, pastoral, and religious needs through interdisciplinary rounds and charting.”4 HIPAA laws make it difficult for congregational clergy to participate in medical team meetings.

Community clergy are vital to helping hospitalized and homebound patients stay connected to their religious communities. Denominational clergy can help patients who are away from their religious communities stay connected to their particular traditions. As an ordained pastor in the Church of the Brethren, I am called by Duke Medical Center to anoint Brethren patients according to our tradition’s rite. Anointing in the Roman Catholic tradition requires a priest, the Brethren are non-sacramental, and it would be acceptable to be anointed by any Christian. Still, patients feel important to be connected to their own tradition, and hospitals must build relationships with local religious communities.

As a chaplain, the book’s critique of interfaith chaplaincy resonated with me. If anything, the Balbonis underestimate the ways that hospital systems attempt to deploy chaplains to ensure that patients are compliant with medical team goals. Jeff Bishop notes that “the great high priest who promotes social function within biopsychosocialspiritual medicine is the doctor, and his chief altar boy is the generic chaplain.”5 However, denominational seminaries need to better prepare parish pastors for engaging medical ethics. Some university-based divinity schools offer classes on theological medical ethics, but many free-standing Protestant seminaries do not. Roman Catholic seminaries teach students authoritative magisterial statements about medical ethics issues. Clergy should be grounded in their own theological tradition; however, effective advocacy and engagement in medical contexts is an additional skill. Because parish clergy are not enmeshed in hospital systems and power structures, parish clergy have an easier time being a prophetic presence in medicine.

This book’s theological questions and practical proposals challenged me to think carefully about my practice. The authors “understand that many readers will not share with us key theological assumptions, this will not ultimately undermine the direction we encourage readers to deliberate” (124). I disagreed with the book’s theology, which is heavily grounded in Reformed Christian thought. I question the practicality of some of the books proposals. Still, the book should help all readers engage religion more carefully and respectfully, as clinicians seek to engage religious patients and maintain their own faith amid the powerful and complex economic, political, and social forces that give shape to medicine in the United States.